# thePlasticsFella > One platform for everything Plastic Surgery - independent, evidence-based & verified educational tools for all stages of your plastic surgery career.. Public Ghost content for AI and LLM tooling. This file includes a bounded export of public pages first, then recent public posts. Append `.md` to any post or page URL to get the content in Markdown (for example, `/example-post.md`). ## Pages ### Take your pick! URL: https://www.theplasticsfella.com/membership/ Last updated: 2021-03-20T18:01:56.000Z _No content available._ ### Bookmarks URL: https://www.theplasticsfella.com/bookmarks/ Last updated: 2021-03-06T13:06:17.000Z _No content available._ ### Sign up URL: https://www.theplasticsfella.com/signup/ Last updated: 2022-03-08T18:23:20.000Z _No content available._ ### Sign in URL: https://www.theplasticsfella.com/signin/ Last updated: 2021-03-07T12:01:10.000Z _No content available._ ### Account URL: https://www.theplasticsfella.com/account/ Last updated: 2023-01-11T12:09:27.000Z _No content available._ ### P'Fella's Mission URL: https://www.theplasticsfella.com/about/ Last updated: 2024-04-30T21:15:42.000Z ## A proudly independent platform for evidence-based Plastic Surgery ****In the summer of 2019, thePlasticsFella came to life with a clear mission: to provide quick, reliable access to evidence-based knowledge in Plastic Surgery. What started as a humble project, aiming to craft a small set of educational tools, has grown into something much more significant.thePlasticsFella is built on 3 principles**Evidence, Independence, Open Sourced. 0:00 /0:08 1× Today, thePlasticsFella is an independent, open-source haven where Plastic Surgeons and Trainees come to sharpen their skills and deepen their knowledge. From its modest beginnings, the platform has grown organically, fuelled by a community passionate about pushing the boundaries of medical education. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/Zones-of-the-Hand-Journal-Club.png) ## ****Independence** ****This isn't just a buzzword; it's our ethos.** We stand apart, not tethered to any organizations, societies, or academic institutions. thePlasticsFella has freedom in the educational landscape, providing unbiased, unfiltered knowledge directly to our community. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/About-Us---Ghost-1.png) This independence isn't just about standing alone; it's about standing for something—integrity, trustworthiness, and a unique charm that resonates with the plastic surgery community. ## This created a self-sustaining ecosystem. Every dime we generate is diligently reinvested into the platform, fueling the creation and enhancement of a vast, free educational library. We're not just a resource; it's an ecosystem where quality education and community engagement thrive together. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/About-Us---Ghost-2.png) Every interaction contributes to a virtuous cycle. More engagement leads to more resources, allowing us to reinvest in creating superior content. It's this collaborative spirit that ensures thePlasticsFella is a continuously evolving community. ## So, open-source? This is not the "open journal" concept. Originally a term from the software world signifying a collaborative method of creating programs, "open-source" for us symbolizes a broader commitment. It's about championing values like open exchange, joint effort, clear visibility, and development driven by a community's pulse. ![thePlasticsFella, about, mission, education, plastic surgery, study notes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/About-Us---Ghost-3.png) thePlasticsFella does not copyright its evidence-based content. Instead, we embrace a culture of open contribution and collective improvement. All public work is distributed through the creative commons license. It's about being part of an evolving, transparent educational journey, openly nurtured and collectively enriched by a community. ## If this mission resonates with you [Become thePlasticsPro](https://www.theplasticsfella.com/join/) ## Also, here's a fun fact. This is the inspiration behind the logo 👇 ![thePlasticsFella, about, mission, education, plastic surgery, study notes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/About-Us---Ghost-2.png) --- Here is also some of the finer detail - [Privacy](https://www.theplasticsfella.com/privacy/), [Terms and Conditions. ](https://www.theplasticsfella.com/terms-and-conditions/) ### Privacy URL: https://www.theplasticsfella.com/privacy/ Last updated: 2021-03-07T17:33:13.000Z ThePlasticsFella takes data privacy seriously. This privacy policy explains who we are, how we collect, share and use Personal Information, and how you can exercise your privacy rights. We recommend that you read this privacy policy in full to ensure you are fully informed. However, to make it easier for you to review the parts of this privacy policy that apply to you, we have divided up the document into sections that are specifically applicable to Members (Section 2), Contacts (Section 3), and Visitors (Section 4). Sections 1 and 5 are applicable to everyone. If you have any questions or concerns about our use of your Personal Information, then please contact us using the contact details provided at the end of Section 5. To the extent we provide you with notice of different or additional privacy policies, those policies will govern such interactions. ![TRUSTe](https://www.theplasticsfella.com/ghost/) ## **1\. The Basics** ###### **A. About Us** ThePlasticsFella is an online educational platform a company headquartered in the Ireland (“**we**,” “**us**,” “**our**,” and “**ThePlasticsFella**“). Our Service enables our Members to, among other things, send and manage email campaigns across channels, serve advertisements, and create Websites and Landing Pages. We also provide other related services, such as real-time data analytics and insights to help our Members track and personalize their marketing activities. Find out more about our Service here. ###### **B. Key Terms** In this privacy policy, these terms have the following meanings: **“Mobile App(s)”** means any one or all of the ThePlasticsFella applications available for Members to use on their mobile devices. “**Contact**” is a person a Member may contact through our Service. In other words, a Contact is anyone on a Member’s Distribution List or about whom a Member has given us information. For example, if you are a Member, a subscriber to your email marketing campaigns would be considered a Contact. “**Distribution List**” is a list of Contacts a Member may upload or manage on our platform and all associated information related to those Contacts (for example, email addresses). “**Member**” means any person or entity that is registered with us to use the Service. “**Personal Information**” means any information that identifies or can be used to identify an individual directly or indirectly. Examples of Personal Information include, but are not limited to, first and last name, date of birth, email address, gender, occupation, or other demographic information. **“Service”** has the meaning given to it in our Standard Terms of Use. **“ThePlasticsFella Site(s)”** has the meaning given to it in our Standard Terms of Use. “**Visitor**” means, depending on the context, any person who visits any of our ThePlasticsFella Sites, offices, or otherwise engages with us at our events or in connection with our marketing or recruitment activities. “**you**” and “**your**” means, depending on the context, either a Member, a Contact, or a Visitor. ## **2\. Privacy for Members** This section applies to the Personal Information we collect and process from a Member or potential Member through the provision of the Service. If you are not a Member, the Visitors or Contacts section of this policy may be more applicable to you and your data. **In this section, “you” and “your” refer to Members and potential Members.** ###### **A. Information We Collect** The Personal Information that we collect depends on the context of your interactions with ThePlasticsFella, your ThePlasticsFella account settings, the products and features you use, your location, and applicable law. However, the Personal Information we collect broadly falls into the following categories: (i) **Information you provide to us**: You (or your organization) may provide certain Personal Information to us when you sign up for a ThePlasticsFella account and use the Service, consult with our customer service team, send us an email, integrate the Service with another website or service (for example, when you choose to connect your e-commerce account with ThePlasticsFella), or communicate with us in any other way. This information may include: - Business contact information (such as your name, job title, organization, location, phone number, email address, and country); - Marketing information (such as your contact preferences); - Account log-in credentials (such as your email address or username and password when you sign up for an account with us); - Troubleshooting and support data (which is data you provide or we otherwise collect in connection with support queries we receive from you. This may include contact or authentication data, the content of your chats and other communications with us, and the product or service you are using related to your help inquiry); and - Payment information (including your credit card numbers and associated identifiers and billing address). (ii) **Information we collect automatically**: When you use the Service, we may automatically collect or receive certain information about your device and usage of the Service (collectively “Service Usage Data”). In some (but not all) countries, including countries in the European Economic Area (“EEA”), this information is considered Personal Information under applicable data protection laws. We use cookies and other tracking technologies to collect some of this information. If you are using our Mobile App, we may collect this information using our software development kits (“SDKs”) or APIs the first time the SDK or API is initiated on your Mobile App. For further information, please review the section below and our Cookie Statement available here. Service Usage Data may include: - **Device information:** We collect information about the device and applications you use to access the Service, such as your IP address, your operating system, your browser ID, and other information about your system and connection. If you are using our Mobile App, we may also collect information about the cellular network associated with your mobile device, your mobile device’s operating system or platform, the type of mobile device you use, your mobile device’s name and unique device ID, and information about the features of our Mobile App that you accessed. - **Log data:** Our web servers keep log files that record data each time a device accesses those servers and the nature of each access, including originating IP addresses and your activity in the Service (such as the date/time stamps associated with your usage, pages and files viewed, searches and other actions you take (for example, which features you used)), device event information (such as system activity, error reports (sometimes called ‘crash dumps’)), and hardware settings. We may also access metadata and other information associated with files that you upload into our Service. - **Usage data:** We collect usage data about you whenever you interact with our Service, which may include the dates and times you access the Service and your browsing activities (such as what portions of the Service you used). We also collect information regarding the performance of the Service, including metrics related to the deliverability of emails and other communications you send through the Service. If you are using our Mobile App, we may collect information about how often you use the Mobile App and other performance data. This information allows us to improve the content and operation of the Service, and facilitate research and analysis of the Service. (iii) **Information we collect from other sources**: From time to time, we may obtain information about you from third-party sources, such as public databases, social media platforms, third-party data providers, and our joint marketing partners. Examples of the information we receive from other sources include demographic information (such as age and gender), device information (such as IP addresses), location (such as city and state), and online behavioral data (such as information about your use of social media websites, page view information and search results and links). We use this information, alone or in combination with other Personal Information we collect, to enhance our ability to provide relevant marketing and content to you and to develop and provide you with more relevant products, features, and service. ###### **B. Use of Personal Information** We may use the Personal Information we collect or receive through the Service (alone or in combination with other data we source) for the purposes and on the legal bases identified below: - To bill and collect money owed to us by you to perform our contract with you for the use of the Service or where we have not entered into a contract with you, in accordance with our legitimate interests to operate and administer our Service. This includes sending you emails, invoices, receipts, notices of delinquency, and alerting you if we need a different credit card number. We use third parties for secure credit card transaction processing, and those third parties collect billing information to process your orders and credit card payments. To learn more about the steps we take to safeguard that data, see the “Our Security” section of this privacy policy. - To send you system alert messages in reliance on our legitimate interests in administering the Service and providing certain features. For example, we may inform you about temporary or permanent changes to our Service, such as planned outages, or send you account, security or compliance notifications, such as new features, version updates, releases, abuse warnings, and changes to this privacy policy. - To communicate with you about your account and provide customer support to perform our contract with you for the use of the Service or where we have not entered into a contract with you, in reliance on our legitimate interests in administering and supporting our Service. For example, if you use our Mobile Apps, we may ask you if you want to receive push notifications about activity in your account. If you have opted in to these push notifications and no longer want to receive them, you may turn them off through your operating system. - To enforce compliance with our Standard Terms of Use and applicable law, and to protect the rights and safety of our Members in reliance on our legitimate interest to protect against misuse or abuse of our Service and to pursue remedies available. This may include developing tools and algorithms that help us prevent violations. For example, sometimes we review the content our Members send or display to ensure it complies with our Standard Terms of Use. To improve that process, we have software that helps us find content that may violate our Standard Terms of Use. We may or our third-party service provider may also review content that our Members send or display. This benefits all Members who comply with our Standard Terms of Use because it reduces abuse and helps us maintain a reliable platform. Please do not use ThePlasticsFella to send or display confidential information. - To meet legal requirements, including complying with court orders, valid discovery requests, valid subpoenas, and other appropriate legal mechanisms. - To provide information to representatives and advisors, including attorneys and accountants, to help us comply with legal, accounting, or security requirements in reliance on our legitimate interests. - To prosecute and defend a court, arbitration, or similar legal proceeding. - To respond to lawful requests by public authorities, including to meet national security or law enforcement requirements. - To provide, support and improve the Service to perform our contract with you for the use of the Service or where we have not entered into a contract with you, in reliance on our legitimate interests in administering and improving the Service and providing certain features. For example, this may include sharing your information with third parties in order to provide and support our Service or to make certain features of the Service available to you. When we share your Personal Information with third parties, we take steps to protect your information in a manner that is consistent with our obligations under applicable privacy laws. For further information about how we share your information, refer to Section 5 below. - To provide suggestions to you and to provide tailored features within our Service that optimize and personalize your experience in reliance on our legitimate interests in administering the Service and providing certain features. This includes adding features that compare Members’ email campaigns, using data to suggest other publishers your Contacts may be interested in, or using data to recommend products or services that you may be interested in or that may be relevant to you or your Contacts. Some of these suggestions are generated through analysis of the data used in our data analytics projects, as described below. - To perform data analytics projects in reliance on our legitimate business interests in improving and enhancing our products and services for our Members. Our data analytics projects use data from ThePlasticsFella accounts, including Personal Information of Contacts, to provide and improve the Service. We use information like your sending habits and your Contacts’ purchase history, so we can make more informed predictions, decisions, and products for our Members. For example, we use data from ThePlasticsFella accounts to enable product recommendation, audience segmentation, and predicted demographics features for our Members. If you or your Contact prefers not to have their data used for this purpose, you can alter the settings on your account (as described [here](https://mailchimp.com/help/set-account-security-options/?ref=theplasticsfella.com)) to opt out of data analytics projects, or your Contact can opt out of data analytics projects at any time by emailing us at personaldatarequests@ThePlasticsFella.com. As always, we take the privacy of Personal Information seriously, and will continue to implement appropriate safeguards to protect this Personal Information from misuse or unauthorized disclosure. - To personalize the Service, content and advertisements we serve to you in reliance on our legitimate interests in supporting our marketing activities and providing certain features within the Service. We may use your Personal Information to serve you specifically, such as to deliver a product or service according to your preferences or restrictions, to provide more personalized features or for advertising or targeting purposes in accordance with this privacy policy. ###### **C. Third-Party Integrations** We may use the Personal Information we collect or receive through the Service, as a processor and as otherwise stated in this privacy policy, to enable your use of the integrations and plugins you choose to connect to your ThePlasticsFella account. For instance, if you choose to connect a Google integration to your ThePlasticsFella account, we’ll ask you to grant us permission to view and/or download, as applicable, your Google Sheets, Google Contacts, Google Analytics and Google Drive. This allows us to configure your Google integration(s) in accordance with your preferences. For example, if you wanted to use the Google Contacts integration to share the templates in your ThePlasticsFella account with contacts in your Google address book, we would need to access your Google Contacts to share your templates. ###### **D. Cookies and Tracking Technologies** We and our third-party partners may use various technologies to collect and store Service Usage Data when you use our Service (as discussed above), and this may include using cookies and similar tracking technologies, such as pixels, web beacons, and if you use our Mobile Apps, through our SDKs deployed on your mobile device. For example, we use web beacons in the emails we send on your behalf, which enable us to track certain behavior, such as whether the email sent through the Service was delivered and opened and whether links within the email were clicked. Both web beacons and SDKs allow us to collect information such as the recipient’s IP address, browser, email client type and other similar data as further described above details. We use this information to measure the performance of your email campaigns, to provide analytics information, enhance the effectiveness of our Service, and for other purposes described above. Reports are also available to us when we send email to you, so we may collect and review that information. ###### **E. Member Distribution Lists** In order to send an email campaign or use certain features in your account, you need to upload a Distribution List that provides us information about your Contacts, such as their names and email addresses. We use and process this information to provide the Service in accordance with our contract with you or your organization and this privacy policy. A Distribution List can be created in a number of ways, including by importing Contacts, such as through a CSV or directly from your email client. We do not, under any circumstances, sell your Distribution Lists. If someone on your Distribution List complains or contacts us, we might then contact that person. You may export (download) your Distribution Lists from ThePlasticsFella by accessing the “Audience” tab from within your account. If we detect abusive or illegal behavior related to your Distribution List, we may share your Distribution List or portions of it with affected ISPs or anti-spam organizations to the extent permitted or required by applicable law. If a Contact chooses to use the Forward to a Friend (FTF) link in an email campaign a Member sends, it will allow the Contact to share the Member’s email content with individuals not on the Member’s Distribution List. When a Contact forwards an email to a friend, we do not store the Contact’s email address or their friend’s email address, and no one is added to any Distribution List as a result of the FTF link. The Member who created the email campaign only sees an aggregate number of times their email campaign was forwarded by a Contact and does not have access to the email addresses used to share or receive that forwarded content. ###### **F. Your Data Protection Rights** Depending on the country in which you reside, you may have the following data protection rights: - To access; correct; update; port; delete; restrict; or object to our processing of your Personal Information. - You can manage your individual account and profile settings within the dashboard provided through the ThePlasticsFella platform, or you may contact us directly by emailing us at personaldatarequests@ThePlasticsFella.com. You can also manage information about your Contacts within the dashboard provided through the ThePlasticsFella platform to assist you with responding to requests to access, correct, update, port or delete information that you receive from your Contacts. Note, if any of your Contacts wish to exercise any of these rights, they should contact you directly, or contact us as described in the “Privacy for Contacts” section below. You can also contact us at any time to update your own marketing preferences (see Section 5\. General Information, C. Your Choices and Opt-Outs below). ThePlasticsFella takes reasonable steps to ensure that the data we collect is reliable for its intended use, accurate, complete and up to date. - The right to complain to a data protection authority about the collection and use of Personal Information. For more information, please contact your local data protection authority. Contact details for data protection authorities in the EEA and UK are available [here](https://ec.europa.eu/justice/article-29/structure/data-protection-authorities/index%5Fen.htm?ref=theplasticsfella.com) and Switzerland are available [here](https://www.edoeb.admin.ch/edoeb/en/home/the-fdpic/links/data-protection---switzerland.html?ref=theplasticsfella.com). - Similarly, if Personal Information is collected or processed on the basis of consent, the data subject can withdraw their consent at any time. Withdrawing your consent will not affect the lawfulness of any processing we conducted prior to your withdrawal, nor will it affect the processing of your Personal Information conducted in reliance on lawful processing grounds other than consent. If you receive these requests from Contacts, you can segment your lists within the ThePlasticsFella platform to ensure that you only market to Contacts who have not opted out of receiving such marketing. We respond to all requests we receive from individuals wishing to exercise their data protection rights in accordance with applicable data protection law. We may ask you to verify your identity in order to help us respond efficiently to your request. If we receive a request from one of your Contacts, we will either direct the Contact to reach out to you, or, if appropriate, we may respond directly to their request. ## **3\. Privacy for Contacts** This section applies to the information we process about our Members’ Contacts as a data controller. Our Service is intended for use by our Members. As a result, for much of the Personal Information we collect and process about Contacts through the Service, we act as a processor on behalf of our Members. ThePlasticsFella is not responsible for the privacy or security practices of our Members, which may differ from those set forth in this privacy policy. Please check with individual Members about the policies they have in place. **For purposes of this section, “you” and “your” refer to Contacts.** ###### **A. Information We Collect** The Personal Information that we may collect or receive about you broadly falls into the following categories: (i) **Information we receive about Contacts from our Members:** A Member may provide Personal Information about you to us through the Service. When a Member uploads their Distribution List or integrates the Service with another website or service (for example, when a Member chooses to connect their e-commerce account with ThePlasticsFella), or when you sign up for a Member’s Distribution List on a ThePlasticsFella or other signup form, the Member may provide us with certain contact information or other Personal Information about you such as your name, email address, address, or telephone number. You may have the opportunity to update some of this information by electing to update or manage your preferences via an email you receive from a Member. (ii) **Information we collect automatically**: When you interact with an email campaign that you receive from a Member or browse or purchase from a Member’s connected store, we may collect information about your device and interaction with an email. We use cookies and other tracking technologies to collect some of this information. Our use of cookies and other tracking technologies is discussed more below and in more detail in our Cookie Statement available [here](https://mailchimp.com/legal/cookies/?ref=theplasticsfella.com). - **Device information:** We collect information about the device and applications you use to access emails sent through our Service, such as your IP address, your operating system, your browser ID, and other information about your system and connection. - **Usage data:** It is important for us to ensure the security and reliability of the Service we provide. Therefore, we also collect usage data about your interactions with campaigns (and/or emails) sent through the Service, which may include dates and times you access campaigns (and/or emails) and your browsing activities (such as what pages are viewed and which emails are opened). This information also allows us to ensure compliance with our Standard Terms of Use and Acceptable Use Policy, to monitor and prevent service abuse, and to ensure we attain certain usage standards and metrics in relation to our Service. We also collect information regarding the performance of the Service, including metrics related to the deliverability of emails and other electronic communications that our Members send through the Service. This information allows us to improve the content and operation of the Service and facilitate research and perform analysis into the use and performance of the Service. (iii) **Information we collect from other sources:** From time to time, we may obtain information about you from third-party sources, such as social media platforms, and third-party data providers. ###### **B. Use of Personal Information** We may use the Personal Information we collect or receive about you in reliance on our (and where applicable, our Members’) legitimate interests for the following purposes: - To enforce compliance with our Standard Terms of Use and applicable law. This may include utilizing usage data and developing tools and algorithms that help us prevent violations. - To protect the rights and safety of Members, third parties, or ThePlasticsFella. For example, sometimes we review the content of our Members’ email campaigns to make sure they comply with our Standard Terms of Use. To improve that process, we have software that helps us find email campaigns that may violate our Standard Terms of Use. We, or our third-party service provider, may review those particular email campaigns, which may include your contact information. This reduces the amount of spam being sent through our servers and helps us maintain high deliverability. - To meet legal requirements, including complying with court orders, valid discovery requests, valid subpoenas, and other appropriate legal mechanisms. - To provide information to representatives and advisors, including attorneys and accountants, to help us comply with legal, accounting, or security requirements. - To prosecute and defend a court, arbitration, or similar legal proceeding. - To respond to lawful requests by public authorities, including to meet national security or law enforcement requirements. - To provide, support and improve the Service. For example, this may include sharing your information with third parties in order to provide and support our Service or to make certain features of the Service available to our Members. When we share Personal Information with third parties, we take steps to protect your information in a manner that is consistent with applicable privacy laws. For further information about how we share information, refer to Section 5 below. - To perform data analytics projects. Our data analytics projects use data from ThePlasticsFella accounts, including your Personal Information, to provide and improve the Service. We use information, like your purchase history, provided to us by Members, so we can make more informed predictions, decisions, and products for our Members. For example, we use data from ThePlasticsFella accounts to enable product recommendation, audience segmentation, and predicted demographics features for our Members. If you prefer your data not to be used in this manner, you can opt out of data analytics projects at any time by completing this [form](https://mailchimp.com/dsar-requests/?ref=theplasticsfella.com) or emailing us at personaldatarequests@ThePlasticsFella.com. - To carry out other business purposes. To carry out other legitimate business purposes, as well as other lawful purposes about which we will notify you. ###### **C. Cookies and Tracking Technologies** We and our third-party partners may use various technologies to automatically collect and store certain device and usage information (as discussed above) when you interact with a Member’s email campaign or connected store, and this may include using cookies and similar tracking technologies, such as pixels and web beacons or if a Member is using our Mobile App, we may collect this information through our SDKs deployed on our Members mobile device. For example, we use web beacons in the emails we send on behalf of our Members. When you receive and engage with a Member’s campaign, web beacons track certain behavior such as whether the email sent through the ThePlasticsFella platform was delivered and opened and whether links within the email were clicked. Both web beacons and SDKs allow us to collect information such as your IP address, browser, email client type, and other similar data as further described above. We use this information to measure the performance of our Members’ email campaigns, and to provide analytics information and enhance the effectiveness of our Service, and for the other purposes described above. Our use of cookies and other tracking technologies is discussed in more detail in our Cookie Statement available [here](https://mailchimp.com/legal/cookies/?ref=theplasticsfella.com). ###### **D. Your Data Protection Rights** Depending on the country in which you reside, you may have the following data protection rights: - To access; correct; update; port; delete; restrict or object to our processing of your Personal Information. - For more information about how you can exercise these rights, please see our Data Subject Requests [form](https://mailchimp.com/dsar-requests/?ref=theplasticsfella.com). You also have the right to complain to a data protection authority about our collection and use of your Personal Information. For more information, please contact your local data protection authority. Contact details for data protection authorities in the EEA are available [here](http://ec.europa.eu/justice/data-protection/article-29/structure/data-protection-authorities/index%5Fen.htm?ref=theplasticsfella.com). As described above, for much of the Personal Information we collect and process about Contacts through the Service, we act as a processor on behalf of our [Members](https://mailchimp.com/legal/privacy/?ref=theplasticsfella.com#2.%5FPrivacy%5Ffor%5FMembers). In such cases, if you are a Contact and want to exercise any data protection rights that may be available to you under applicable law or have questions or concerns about how your Personal Information is handled by ThePlasticsFella as a processor on behalf of our individual Members, you should contact the relevant Member that is using the ThePlasticsFella Service, and refer to their separate privacy policies. If you no longer want to be contacted by one of our Members through our Service, please unsubscribe directly from that Member’s newsletter or contact the Member directly to update or delete your data. If you contact us directly, we may either forward your request to the relevant Member or provide you with the identity of the Member to enable you to contact them directly. We respond to all requests we receive from individuals wishing to exercise their data protection rights in accordance with applicable data protection laws. We may ask you to verify your identity in order to help us respond efficiently to your request. ## **4\. Privacy for Visitors** This section applies to Personal Information that we collect and process when you visit the ThePlasticsFella Sites, and in the usual course of our business, such as in connection with our recruitment, events, sales and marketing activities or when you visit our offices. **In this section, “you” and “your” refer to Visitors.** ###### **A. Information We Collect** (i) **Information you provide to us on the ThePlasticsFella Sites or otherwise:** Our ThePlasticsFella Sites offer various ways to contact us, such as through form submissions, email or phone, to inquire about our company and Service. For example, we may ask you to provide certain Personal Information when you express an interest in obtaining information about us or our Service, take part in surveys, subscribe to marketing, apply for a role with ThePlasticsFella, or otherwise contact us. We may also collect Personal Information from you in person when you attend our events or trade shows, if you visit our offices (where you will be required to register as a visitor and provide us with certain information that may also be shared with our service providers) or via a phone call with one of our sales representatives. You may choose to provide additional information when you communicate with us or otherwise interact with us, and we may keep copies of any such communications for our records. The Personal Information we collect may include: - **Business contact information** (such as your name, phone number, email address and country); - **Professional information** (such as your job title, institution or company); - **Nature of your communication**; - **Marketing information** (such as your contact preferences); and - **Any information you choose to provide to us** when completing any ‘free text’ boxes in our forms. (ii) **Information we collect automatically through the ThePlasticsFella Sites:** When you visit our ThePlasticsFella Sites or interact with our emails, we use cookies and similar technologies such as pixels or web beacons, alone or in conjunction with cookies, to collect certain information automatically from your browser or device. In some countries, including countries in the EEA, this information may be considered Personal Information under applicable data protection laws. Our use of cookies and other tracking technologies is discussed more below, and in more detail in our Cookie Statement available [here](https://mailchimp.com/legal/cookies/?ref=theplasticsfella.com). The information we collect automatically includes: - **Device information**: such as your IP address, your browser, device information, unique device identifiers, mobile network information, request information (speed, frequency, the site from which you linked to us (“referring page”), the name of the website you choose to visit immediately after ours (called “exit page”), information about other websites you have recently visited and the web browser you used (software used to browse the internet) including its type and language) - **Usage data**: such as information about how you interact with our emails, ThePlasticsFella Sites, and other websites (such as the pages and files viewed, searches, operating system and system configuration information and date/time stamps associated with your usage). ###### **B. Use of Personal Information** We may use the information we collect through our ThePlasticsFella Sites and in connection with our events and marketing activities (alone or in combination with other data we collect) for a range of reasons in reliance on our legitimate interests, including: - To provide, operate, optimize, and maintain the ThePlasticsFella Sites. - To send you marketing information, product recommendations and non-transactional communications (e.g., marketing newsletters, telemarketing calls, SMS, or push notifications) about us, in accordance with your marketing preferences, including information about our products, services, promotions or events as necessary for our legitimate interest in conducting direct marketing or to the extent you have provided your prior consent. - For recruitment purposes if you have applied for a role with ThePlasticsFella. - To respond to your online inquiries and requests, and to provide you with information and access to resources or services that you have requested from us. - To manage the ThePlasticsFella Sites and system administration and security. - To manage event registrations and attendance, including sending related communications to you. - To register visitors to our offices for security reasons and to manage non-disclosure agreements that visitors may be required to sign. - To improve the navigation and content of the ThePlasticsFella Sites. - To identify any server problems or other IT or network issues. - To process transactions and to set up online accounts. - To compile aggregated statistics about site usage and to better understand the preferences of our Visitors. - To help us provide, improve and personalize our marketing activities. - To facilitate the security and continued proper functioning of the ThePlasticsFella Sites. - To carry out research and development to improve our ThePlasticsFella Sites, products and services. - To conduct marketing research, advertise to you, provide personalized information about us on and off our ThePlasticsFella Sites, and to provide other personalized content based on your activities and interests to the extent necessary for our legitimate interests in supporting our marketing activities or advertising our Service or instances where we seek your consent. - To carry out other legitimate business purposes, as well as other lawful purposes, such as data analysis, fraud monitoring and prevention, identifying usage trends and expanding our business activities in reliance on our legitimate interests. - To cooperate with public and government authorities, courts or regulators in accordance with our legal obligations under applicable laws to the extent this requires the processing or disclosure of Personal Information to protect our rights or is necessary for our legitimate interest in protecting against misuse or abuse of our ThePlasticsFella Sites and Service, protecting personal property or safety, pursuing remedies available to us and limiting our damages, complying with judicial proceedings, court orders or legal processes, or responding to lawful requests. ###### **C. Public Information and Third-Party Websites** - **Blog.** We have public blogs on the ThePlasticsFella Sites. Any information you include in a comment on our blog may be read, collected, and used by anyone. If your Personal Information appears on our blogs and you want it removed, contact us [here](https://mailchimp.com/contact/?ref=theplasticsfella.com). If we are unable to remove your information, we will tell you why. - **Social media platforms and widgets.** The ThePlasticsFella Sites include social media features, such as the Facebook Like button. These features may collect information about your IP address and which page you are visiting on our ThePlasticsFella Site, and they may set a cookie to make sure the feature functions properly. Social media features and widgets are either hosted by a third party or hosted directly on our ThePlasticsFella Site. We also maintain presences on social media platforms, including Facebook, Twitter, and Instagram. Any information, communications, or materials you submit to us via a social media platform is done at your own risk without any expectation of privacy. We cannot control the actions of other users of these platforms or the actions of the platforms themselves. Your interactions with those features and platforms are governed by the privacy policies of the companies that provide them. - **Links to third-party websites.** The ThePlasticsFella Sites include links to other websites, whose privacy practices may be different from ours. If you submit Personal Information to any of those sites, your information is governed by their privacy policies. We encourage you to carefully read the privacy policy of any website you visit. - **Contests and sweepstakes.** We may, from time to time, offer surveys, contests, sweepstakes, or other promotions on the ThePlasticsFella Sites or through social media (collectively, “Promotions”). Participation in our Promotions is completely voluntary. Information requested for entry may include Personal Information such as your name, address, date of birth, phone number, email address, username, and similar details. We use the information you provide to administer our Promotions. We may also, unless prohibited by the Promotion’s rules or law, use the information provided to communicate with you, or other people you select, about our Service. We may share this information with our affiliates and other organizations or service providers in line with this privacy policy and the rules posted for our Promotions. ###### **D. Cookies and Tracking Technologies** We use cookies and similar tracking technologies to collect and use Personal Information about you, including to serve interest-based advertising. For further information about the types of cookies and tracking technologies we use, why, and how you can control them, please see our Cookie Statement available [here](https://mailchimp.com/legal/cookies/?ref=theplasticsfella.com). ###### **E. Other Data Protection Rights** Depending on the country in which you reside, you may have the following data protection rights: - To access; correct; update; port; delete; restrict or object to our processing of your Personal Information. You can exercise these rights by emailing personaldatarequests@ThePlasticsFella.com. - You may also have the right to complain to a data protection authority about our collection and use of your Personal Information. For more information, please contact your local data protection authority. Contact details for data protection authorities in the EEA are available [here](http://ec.europa.eu/justice/data-protection/article-29/structure/data-protection-authorities/index%5Fen.htm?ref=theplasticsfella.com). - Similarly, if we have collected and processed your Personal Information with your consent, then you can withdraw your consent at any time. Withdrawing your consent will not affect the lawfulness of any processing we conducted prior to your withdrawal, nor will it affect the processing of your Personal Information conducted in reliance on lawful processing grounds other than consent. You can also contact us at any time to update your marketing preferences (see Section 5\. General Information, C. Your Choices and Opt-Outs below). We respond to all requests we receive from individuals wishing to exercise their data protection rights in accordance with applicable data protection laws. We may ask you to verify your identity in order to help us respond efficiently to your request. ## **5\. General Information** ###### **A. How We Share Information** We may share and disclose your Personal Information to the following types of third parties for the purposes described in this privacy policy **(for purposes of this section, “you” and “your” refer to Members, Contacts, and Visitors unless otherwise indicated):** (i) **Our service providers**: Sometimes, we share your information with our third-party service providers working on our behalf for the purposes described in this privacy policy. For example, companies we’ve hired to help us provide and support our Service or assist in protecting and securing our systems and services and other business-related functions. Other examples include analyzing data, hosting data, engaging technical support for our Service, processing payments, and delivering content. We use YouTube’s API services in connection with our Service to provide certain features. As such, you acknowledge and agree that by signing up for an account and using the Service, you are also bound by [Google’s Privacy Policy](http://www.google.com/policies/privacy?ref=theplasticsfella.com). In addition to the rights set forth in Section 2, you may manage your YouTube API data by visiting Google’s security settings page at [https://security.google.com/settings/security/permissions](https://security.google.com/settings/security/permissions?ref=theplasticsfella.com). In connection with our Service, we also use a third-party service provider, Twilio, Inc. We use Twilio’s API, which allows us to build features into our ThePlasticsFella application to enable us to communicate with our Members through texting and calling, and their “Authy” product, which we use for two-factor authentication for our application. If you are a Member, Twilio may need to collect and process certain Personal Information about you as a controller to provide such services. To learn more about Twilio’s privacy practices, please visit [https://www.twilio.com/legal/privacy](https://www.twilio.com/legal/privacy?ref=theplasticsfella.com). (ii) **Advertising partners**: We may partner with third-party advertising networks, exchanges, and social media platforms (like Facebook) to display advertising on the ThePlasticsFella Sites or to manage and serve our advertising on other sites, and we may share Personal Information of Members and Visitors with them for this purpose. We and our third-party partners may use cookies and other similar tracking technologies, such as pixels and web beacons, to gather information about your activities on the ThePlasticsFella Sites and other sites in order to provide you with targeted advertising based on your browsing activities and interests. For more information, please see our Cookie Statement available [here](https://mailchimp.com/legal/cookies/?ref=theplasticsfella.com). (iii) **Any competent law enforcement body, regulatory body, government agency, court or other third party where** we believe disclosure is necessary (a) as a matter of applicable law or regulation, (b) to exercise, establish, or defend our legal rights, or (c) to protect your vital interests or those of any other person. (iv) **A potential buyer (and its agents and advisors)** in the case of a sale, merger, consolidation, liquidation, reorganization, or acquisition. In that event, any acquirer will be subject to our obligations under this privacy policy, including your rights to access and choice. We will notify you of the change either by sending you an email or posting a notice on our ThePlasticsFella Site. (v) **Any other person with your consent.** ###### **B. Legal Basis for Processing Personal Information (EEA and UK Persons Only)** If you are located in the EEA or UK, our legal basis for collecting and using the Personal Information described above will depend on the Personal Information concerned and the specific context in which we collect it. However, we will normally collect and use Personal Information from you where the processing is in our legitimate interests and not overridden by your data-protection interests or fundamental rights and freedoms. Our legitimate interests are described in more detail in this privacy policy in the sections above titled “Use of Personal Information”, but they typically include improving, maintaining, providing, and enhancing our technology, products, and services; ensuring the security of the Service and our ThePlasticsFella Sites; and supporting our marketing activities. If you are a Member, we may need the Personal Information to perform a contract with you. In some limited cases, we may also have a legal obligation to collect Personal Information from you. If we ask you to provide Personal Information to comply with a legal requirement or to perform a contract with you, we will make this clear at the relevant time and advise you whether the provision of your Personal Information is mandatory or not, as well as of the possible consequences if you do not provide your Personal Information. Where required by law, we will collect Personal Information only where we have your **consent** to do so. If you have questions or need further information concerning the legal basis on which we collect and use your Personal Information, please contact us using the contact details provided in the “Questions and Concerns” section below. ###### **C. Your Choices and Opt-Outs** Members and Visitors who have opted in to our marketing emails can opt out of receiving marketing emails from us at any time by clicking the “unsubscribe” link at the bottom of our marketing messages. Also, all opt-out requests can be made by emailing us using the contact details provided in the “Questions and Concerns” section below. Please note that some communications (such as service messages, account notifications, billing information) are considered transactional and necessary for account management, and Members cannot opt out of these messages unless you cancel your ThePlasticsFella account. ###### **D. Our Security** We take appropriate and reasonable technical and organizational measures designed to protect Personal Information from loss, misuse, unauthorized access, disclosure, alteration, and destruction, taking into account the risks involved in the processing and the nature of the Personal Information. For further information about our security practices, please see our Security page available [here](https://mailchimp.com/about/security/?ref=theplasticsfella.com). If you have any questions about the security of your Personal Information, you may contact us at privacy@ThePlasticsFella.com. ThePlasticsFella accounts require a username and password to log in. Members must keep their username and password secure, and never disclose it to a third party. Because the information in a Member’s ThePlasticsFella account is private, account passwords are hashed, which means we cannot see a Member’s password. We cannot resend forgotten passwords either. We will only provide Members with instructions on how to reset them. ###### **E. International Transfers** (i) **We operate in the United States** Our servers and offices are located in the United States, so your information may be transferred to, stored, or processed in the United States. While the data protection, privacy, and other laws of the United States might not be as comprehensive as those in your country, we take many steps to protect your privacy, including offering our Members a Data Processing Agreement available [here](https://mailchimp.com/legal/data-processing-addendum/?ref=theplasticsfella.com). (ii) **Data transfers from Switzerland, United Kingdom, or the EEA to the United States** ThePlasticsFella participates in and has certified its compliance with the EU-U.S. Privacy Shield Framework and the Swiss-U.S. Privacy Shield Framework. We are committed to subjecting all Personal Information received from EEA member countries, United Kingdom, and Switzerland, respectively, in reliance on each Privacy Shield Framework, to each Framework’s applicable Principles. To learn more about the Privacy Shield Frameworks, and to view our certification, visit the U.S. Department of Commerce’s Privacy Shield website available [here](https://www.privacyshield.gov/welcome?ref=theplasticsfella.com). A list of Privacy Shield participants is maintained by the Department of Commerce and is available [here](https://www.privacyshield.gov/list?ref=theplasticsfella.com). ThePlasticsFella is responsible for the processing of Personal Information we receive under each Privacy Shield Framework and subsequently transfer to a third party acting as an agent on our behalf. We comply with the Privacy Shield Principles for all onward transfers of Personal Information from the EEA, United Kingdom, and Switzerland, including the onward transfer liability provisions. With respect to Personal Information received or transferred pursuant to the Privacy Shield Frameworks, we are subject to the regulatory enforcement powers of the U.S. Federal Trade Commission. In certain situations, we may be required to disclose Personal Information in response to lawful requests by public authorities, including to meet national security or law enforcement requirements. If you have an unresolved privacy or data use concern that we have not addressed satisfactorily, please contact our U.S.-based third-party dispute resolution provider (free of charge to you) at [https://feedback-form.truste.com/watchdog/request](https://feedback-form.truste.com/watchdog/request?ref=theplasticsfella.com). Under certain conditions, more fully described on the Privacy Shield website, [here](https://www.privacyshield.gov/article?id=How-to-Submit-a-Complaint&ref=theplasticsfella.com), you may be entitled to invoke binding arbitration when other dispute resolution procedures have been exhausted. Members located in Switzerland, United Kingdom, and the EEA are subject to our Data Processing Addendum available [here](https://mailchimp.com/legal/data-processing-addendum?ref=theplasticsfella.com), as described in our Standard Terms of Use. (iii) **Members, Contacts and Visitors located in Australia** If you are a Member, Contact or Visitor who accesses our Service in Australia, this section applies to you. We are subject to the operation of the Privacy Act 1988 **(“Australian Privacy Act”)**. Here are the specific points you should be aware of: - As stated in our Acceptable Use Policy available [here](https://mailchimp.com/legal/acceptable%5Fuse/?ref=theplasticsfella.com), sensitive personal information is not permitted on ThePlasticsFella’s platform and Members are prohibited from importing or incorporating any sensitive personal information into their ThePlasticsFella accounts or uploading any sensitive personal information to ThePlasticsFella’s servers. - Please note that if you do not provide us with your Personal Information or if you withdraw your consent for us to collect, use and disclose your Personal Information, we may be unable to provide the Service to you. - Where we collect Personal Information of our Visitors, the Personal Information we ask you to provide will be information that is reasonably necessary for, or directly related to, one or more of our functions or activities. Please see [Section 4](https://mailchimp.com/legal/privacy/?ref=theplasticsfella.com#4.%5FPrivacy%5Ffor%5FVisitors) of this privacy policy for examples of the types of Personal Information we may ask Visitors to provide. - Where we say we assume an obligation about Personal Information, we will also require our contractors and subcontractors to undertake a similar obligation. - We will not use or disclose Personal Information for the purpose of our direct marketing to you unless: - you have consented to receive direct marketing; - you would reasonably expect us to use your personal details for marketing; or - we believe you may be interested in the material but it is impractical for us to obtain your consent. You may opt out of any marketing materials we send to you through an unsubscribe mechanism. If you have requested not to receive further direct marketing messages, we may continue to provide you with messages that are not regarded as “direct marketing” under the Australian Privacy Act, including changes to our terms, system alerts, and other information related to your account as permitted under the Australian Privacy Act and the Spam Act 2003 (Cth). - Our servers are located in the United States. In addition, we or our subcontractors may use cloud technology to store or process Personal Information, which may result in storage of data outside Australia. It is not practicable for us to specify in advance which country will have jurisdiction over this type of offshore activity. All of our subcontractors, however, are required to comply with the Australian Privacy Act in relation to the transfer or storage of Personal Information overseas. - We may also share your Personal Information outside of Australia to our business operations in other countries. While it is not practicable for us to specify in advance each country where your Personal Information may be disclosed, typically we may disclose your Personal Information to the United States, Canada and the European Union. - You may access the Personal Information we hold about you. If you wish to access your Personal Information, please contact us directly by emailing us at personaldatarequests@ThePlasticsFella.com. We will respond to all requests for access within a reasonable time. If you think the information we hold about you is inaccurate, out of date, incomplete, irrelevant, or misleading, we will take reasonable steps, consistent with our obligations under the Australian Privacy Act, to correct that information upon your request. If you find that the information we have is not up to date or is inaccurate or incomplete, please contact us in writing at dpo@ThePlasticsFella.com, so we can update our records. We will respond to all requests for correction within a reasonable time. - If you are unsatisfied with our response to a privacy matter, you may consult either an independent advisor or contact the Office of the Australian Information Commissioner for additional help. We will provide our full cooperation if you pursue this course of action. ###### **F. Retention of Data** We retain Personal Information where we have an ongoing legitimate business or legal need to do so. Our retention periods will vary depending on the type of data involved, but, generally, we’ll refer to these criteria in order to determine retention period: - Whether we have a legal or contractual need to retain the data. - Whether the data is necessary to provide our Service. - Whether our Members have the ability to access and delete the data within their ThePlasticsFella accounts. - Whether our Members would reasonably expect that we would retain the data until they remove it or until their ThePlasticsFella accounts are closed or terminated. When we have no ongoing legitimate business need to process your Personal Information, we will either delete or anonymize it or, if this is not possible (for example, because your Personal Information has been stored in backup archives), then we will securely store your Personal Information and isolate it from any further processing until deletion is possible. ###### **G. California Privacy** The California Consumer Privacy Act (“CCPA”) provides consumers with specific rights regarding their Personal Information. You have the right to request that businesses subject to the CCPA (which may include our Members with whom you have a relationship) disclose certain information to you about their collection and use of your Personal Information over the past 12 months. In addition, you have the right to ask such businesses to delete Personal Information collected from you, subject to certain exceptions. If the business sells Personal Information, you have a right to opt-out of that sale. Finally, a business cannot discriminate against you for exercising a CCPA right. When offering services to its Members, ThePlasticsFella acts as a “service provider” under the CCPA and our receipt and collection of any consumer Personal Information is completed on behalf of our Members in order for us to provide the Service. Please direct any requests for access or deletion of your Personal Information under the CCPA to the Member with whom you have a direct relationship. Consistent with California law, if you choose to exercise your applicable CCPA rights, we won’t charge you different prices or provide you a different quality of services. If we ever offer a financial incentive or product enhancement that is contingent upon you providing your Personal Information, we will not do so unless the benefits to you are reasonably related to the value of the Personal Information that you provide to us. ###### **H. Do not Track** Certain state laws require us to indicate whether we honor “Do Not Track” settings in your browser. ThePlasticsFella adheres to the standards set out in this Privacy Policy and does not monitor or follow any Do Not Track browser requests. ###### **I. Changes to this Policy** We may change this privacy policy at any time and from time to time. The most recent version of the privacy policy is reflected by the version date located at the top of this privacy policy. All updates and amendments are effective immediately upon notice, which we may give by any means, including, but not limited to, by posting a revised version of this privacy policy or other notice on the ThePlasticsFella Sites. We encourage you to review this privacy policy often to stay informed of changes that may affect you. Our electronically or otherwise properly stored copies of this privacy policy are each deemed to be the true, complete, valid, authentic, and enforceable copy of the version of this privacy policy that was in effect on each respective date you visited the ThePlasticsFella Site. ## What personal data we collect and why we collect it ### Comments When visitors leave comments on the site we collect the data shown in the comments form, and also the visitor’s IP address and browser user agent string to help spam detection. An anonymized string created from your email address (also called a hash) may be provided to the Gravatar service to see if you are using it. The Gravatar service privacy policy is available here: https://automattic.com/privacy/. After approval of your comment, your profile picture is visible to the public in the context of your comment. ### Media If you upload images to the website, you should avoid uploading images with embedded location data (EXIF GPS) included. Visitors to the website can download and extract any location data from images on the website. ### Cookies If you leave a comment on our site you may opt-in to saving your name, email address and website in cookies. These are for your convenience so that you do not have to fill in your details again when you leave another comment. These cookies will last for one year. If you have an account and you log in to this site, we will set a temporary cookie to determine if your browser accepts cookies. This cookie contains no personal data and is discarded when you close your browser. When you log in, we will also set up several cookies to save your login information and your screen display choices. Login cookies last for two days, and screen options cookies last for a year. If you select “Remember Me”, your login will persist for two weeks. If you log out of your account, the login cookies will be removed. If you edit or publish an article, an additional cookie will be saved in your browser. This cookie includes no personal data and simply indicates the post ID of the article you just edited. It expires after 1 day. ### Embedded content from other websites Articles on this site may include embedded content (e.g. videos, images, articles, etc.). Embedded content from other websites behaves in the exact same way as if the visitor has visited the other website. These websites may collect data about you, use cookies, embed additional third-party tracking, and monitor your interaction with that embedded content, including tracking your interaction with the embedded content if you have an account and are logged in to that website. ### Analytics ## How long we retain your data If you leave a comment, the comment and its metadata are retained indefinitely. This is so we can recognize and approve any follow-up comments automatically instead of holding them in a moderation queue. For users that register on our website (if any), we also store the personal information they provide in their user profile. All users can see, edit, or delete their personal information at any time (except they cannot change their username). Website administrators can also see and edit that information. ## What rights you have over your data If you have an account on this site, or have left comments, you can request to receive an exported file of the personal data we hold about you, including any data you have provided to us. You can also request that we erase any personal data we hold about you. This does not include any data we are obliged to keep for administrative, legal, or security purposes. ## Where we send your data Visitor comments may be checked through an automated spam detection service. ### Terms and Conditions URL: https://www.theplasticsfella.com/terms-and-conditions/ Last updated: 2024-07-18T21:56:37.000Z By clicking the “accept” button (or opening and using the software/content package if applicable), you agree to become bound by the terms of this Subscription and License Agreement (the “Agreement”). If you do not agree to these terms, click “decline” (or do not open the package and promptly return it if applicable). READ THE FOLLOWING TERMS IN THIS AGREEMENT CAREFULLY BEFORE INDICATING YOUR ACCEPTANCE. In this Agreement, the term “you” refers to: (i) an entity entering into this Agreement for use of its employees, (ii) an individual purchasing an ThePlasticsFella subscription under this Agreement, either on his or her own behalf (or as agent for a corporation or other entity or organization); or (iii) an individual entering into this Agreement as a condition of using ThePlasticsFella through a subscription purchased by a hospital, medical school, or other institution (“Institution”), where the individual is employed by or affiliated with the Institution. 1. Refund policy - at any stage you would like a refund please contact support@theplasticsfella and we would happy to oblige. 2. LICENSE: ThePlasticsFella, Inc. (“ThePlasticsFella”), in consideration of the subscription fee paid to ThePlasticsFella and your acceptance of this Agreement, grants you a non-exclusive, non-transferable license and right to use and access the ThePlasticsFella database and software (the “Licensed Materials”) in accordance with the applicable subscription terms (as may be further provided in ThePlasticsFella’s separate invoice terms or any additional subscription and license terms entered into by and between ThePlasticsFella and you and/or the Institution): 3. INDIVIDUAL: An individual subscription permits one individual to access and use the Licensed Materials for his or her own use only by loading the software on a single computer (i.e., within a single CPU) at a fixed location, by loading the PDA software on a single Personal Digital Assistant (PDA), by loading the ThePlasticsFella Application on a mobile device (e.g., a tablet or smartphone) (a “Mobile Device”), or by using his or her unique user name and password to access the Licensed Materials from any location via the Internet. 4. STANDALONE WORKSTATION: A standalone subscription permits multiple users employed by or affiliated with you to access and use the Licensed Materials only for a purpose related to your business by loading the software on a single computer (i.e., within a single CPU) owned or controlled by you, with a hard drive owned or controlled by you connected directly to such computer. You may not install the software on more than one computer. A standalone workstation license does not include Internet access to the Licensed Materials. 5. INSTITUTIONAL SUBSCRIPTION: An institutional subscription permits only certain individuals who are employed by or affiliated with the relevant Institution to access and use the Licensed Materials at any Internet-connected computer or on any Mobile Device validated for such use by ThePlasticsFella, but only for the clinical, educational or research purposes of the Institution. Further, access may be restricted to particular websites per the applicable invoice or additional subscription and license terms. 6. OWNERSHIP: The Licensed Materials, including without limitation all copyrights and other intellectual property rights therein, are the sole and exclusive property of ThePlasticsFella (or its parents, subsidiaries, affiliates, or designees) or its suppliers. By indicating that you accept these terms, you do not become the owner of the Licensed Materials but are entitled to use them only according to the terms of this Agreement. All content with author's name appearing on the image has not been created by thePlasticsFella. This is the sole ownership of those medical illustrators. This is not for monetisation or commercial purposes. It is purely for educational purposes and those images have been used under Google's Image Policy, Wikipedia's Image policies, and other respective policies. Any acknowledgment of an infringement of the article will be immediately unpublished and a thorough review will be perfromed. No images can be downloaded from the website without prior review from thePlasticsFella or the original illustrators. 7. PERMITTED USES: You may occasionally print out individual articles for personal clinical, educational or research use and/or email individual articles to a colleague, provided that the articles printed and emailed by an individual Authorized User contain in aggregate only insubstantial portions of the Licensed Materials and include a source reference to ThePlasticsFella and its copyright notice. Under no circumstances may Authorized Users print or email large numbers of articles from the Licensed Materials. 8. PROHIBITED USES: Except as expressly permitted in this Agreement, any copying, printing, distributing or modifying of the Licensed Materials is strictly prohibited. No part of the Licensed Materials may be copied for resale or other commercial use, or posted on public bulletin boards, web sites, Internet domains, or online chatrooms, or hyperlinked, indexed, or otherwise utilized by automated software means, including: search engines, robots, spiders, crawlers, data mining tools, or any other software that aggregates access to, or the content of, the Licensed Materials. The Licensed Materials may not be combined with other content in knowledge banks or through similar technologies. No part of the Licensed Materials may be reverse engineered or included in other software. ThePlasticsFella electronically monitors compliance with this Agreement (or may otherwise audit your use of the Licensed Materials for compliance with these terms), and reserves the right in its sole discretion to change and or cancel an individual’s user name and password or to disable an IP address without notice in the event of multiple concurrent logins, excessive search quantities or excessive download traffic volumes. You agree to comply with all applicable laws, including all US export laws and regulations, in connection with Your access and use of the Licensed Materials. 9. SUBSCRIPTION TERM: You have obtained the right to use and access the Licensed Materials for the subscription period for which you or your Institution have agreed to pay subscription fees. At the end of this period, your license and your associated rights, such as technical support, will expire automatically, unless you or your Institution have renewed your subscription on ThePlasticsFella’s then-current terms. ThePlasticsFella may embed technology in the Licensed Materials causing them to become inaccessible after your subscription period. The Agreement and your license to use the Licensed Materials will also terminate if you fail to comply with any term or condition in this Agreement. 10. RESTRICTION AGAINST TRANSFER: You may not sublicense, assign, share, sell, rent, lease, or otherwise transfer your right to use the Licensed Materials (including your username and password) whether by merger, operation of law, or otherwise. You cannot email another person linking to this website without written permission from thePlasticsFella. 11. USE OF PROFESSIONAL JUDGMENT: The editors and authors of the Licensed Materials have conscientiously and carefully tried to create the identified diagnosis measures, treatment alternatives and drug dosages in the Licensed Materials that conform to the standards of professional practice that prevailed at the time of publication. However, standards and practices in medicine change as new data become available and the individual medical professional should consult a variety of sources. For this reason, only the most current release of the Licensed Materials should be consulted when information is sought. New updates of the Licensed Materials are issued periodically; do not rely on older versions. In addition, when prescribing medications, the user is advised to check the product information sheet accompanying each drug to verify conditions of use and identify any changes in dosage schedule or contraindications, particularly if the agent to be administered is new, infrequently used or has a narrow therapeutic range. The Licensed Materials describe basic principles of diagnosis and therapy. The information provided in the Licensed Materials is no substitute for individual patient assessment based upon the healthcare provider’s examination of each patient and consideration of laboratory data and other factors unique to the patient. The Licensed Materials should be used as a tool to help the user reach diagnostic and treatment decisions, bearing in mind that individual and unique circumstances may lead the user to reach decisions not presented in the Licensed Materials. 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Should you have any questions regarding this Agreement, you may contact ThePlasticsFella at the email address set forth below. ThePlasticsFella, Inc. support@ThePlasticsFella.com ### Authorship Program URL: https://www.theplasticsfella.com/become-an-author/ Last updated: 2021-03-11T22:02:00.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/1-2.png) ThePlasticsFella has a certified authorship program. This allows the plastic surgery community to create **written and video** **content** relevant to Plastic Surgery. All content undergoes and **independent 3-step validation** process to ensure high standards and evidence-based practice. You will recieve certification of authorship, which is great for your own personal development but also the development of your CV/Portfolio. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Purple-and-White-Week-Goals-List-Maker-Interactive-Instagram-Story.png) **Submit a topic today!** ### NEW: Audio Library URL: https://www.theplasticsfella.com/audio-library/ Last updated: 2021-04-18T14:42:15.000Z **QuickCuts** is your audio companion to an evidence-based library of Plastic Surgery knowledge. This podcast is available here on [all major podcast platforms](https://anchor.fm/jakemarksmd?ref=theplasticsfella.com). [![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/04/-New-Episode-Design.gif)](https://www.theplasticsfella.com/audio-library/#liposuction) Every week, **new content** is added to the audio library. Voiced and produced by Jake Marks MD ([Instagram](https://www.instagram.com/jakemarksmd/?ref=theplasticsfella.com), [Twitter](https://twitter.com/jakemarksmd?ref=theplasticsfella.com)). If you have any requests or suggestions, let us know [here](https://www.theplasticsfella.com/contact/). --- ## An Evidence-Based Audio Library > **In this Library (updated weekly)** > > - [Cleft Palate](https://www.theplasticsfella.com/audio-library/#cleft-palate) > - [Facelift](https://www.theplasticsfella.com/audio-library/#facelift) > - [Syndactyly](https://www.theplasticsfella.com/audio-library/#syndactyly) > - [Gynaecomastia](https://www.theplasticsfella.com/audio-library/#gynaecomastia) > - [Breast Reduction](https://www.theplasticsfella.com/audio-library/#breast-reduction) > - [Orbital Floor Fractures](https://www.theplasticsfella.com/audio-library/#orbital-floor-fractures) > - [Upper Lid Blepharoplasty](https://www.theplasticsfella.com/audio-library/#upper-lid-blepharoplasty) > - [Lower Lid Blepharoplasty](https://www.theplasticsfella.com/audio-library/#lower-lid-blepharoplasty) > - [Lower Extremity Reconstruction](https://www.theplasticsfella.com/audio-library/#lower-extremity-reconstruction) > - [Breast Augmentation](https://www.theplasticsfella.com/audio-library/#breast-augmentation) > - [Lymphedema](https://www.theplasticsfella.com/audio-library/#lymphedema) > - [Cleft Lip](https://www.theplasticsfella.com/audio-library/#cleft-lip) > - [Pressure Ulcers](https://www.theplasticsfella.com/audio-library/#pressure-ulcers) > - [Carpal Tunnel Syndrome](https://www.theplasticsfella.com/audio-library/#carpal-tunnel-syndrome) > - [Liposuction](https://www.theplasticsfella.com/audio-library/#liposuction) Browse the topics below or see the directly embedded in their relevant topics throughout this platform. ### Cleft Palate --- ### Facelift --- ### Syndactyly --- ### Gynaecomastia --- ### Breast Reduction --- ### Orbital Floor Fractures --- ### Upper Lid Blepharoplasty --- ### Lower Lid Blepharoplasty --- ### Lower Extremity Reconstruction --- ### Breast Augmentation --- ### Lymphedema --- ### Cleft Lip --- ### Pressure Ulcers --- ## Carpal Tunnel Syndrome --- ## Liposuction ### Welcome URL: https://www.theplasticsfella.com/welcome/ Last updated: 2022-03-12T11:58:42.000Z --- --- \_\_\_\_ ### P’Fella’s Diary URL: https://www.theplasticsfella.com/diary/ Last updated: 2021-04-19T20:52:34.000Z --- ## A personal insight into P'Fella and a behind-the-scenes look at content creation, team management, and platform development. --- ### 19th April 2021 - Really improve the efficiency of content creation and content marketing last week. I have now got the handle of Notion, which allows me to keep track of all the tasks and makes every more streamlined. - Built more personal relationships with future content creators. Currently have 6 open-sourced articles in progress. - Developed my thoughts on what it means to be open-sourced and for people to be able to access content without even having to put in their email address. This is one of the key themes that I want to address in my upcoming talk that I was asked to give at the HLA conference. --- *forgot to write stuff for a few days! (sorry!)* --- ### 7th April 2021 - Worked on next stage of content creation for future articles and also the upcoming saturday content release with QuickCuts - Thought of an interesting concept. Instead of people paying for premium content, they can have the option to create an evidence-based review topic. This will encourage learners to become teachers and will also remove a barrier for entry for those with financial difficulties. This is a work in progress. - Cemented the new rule for P'Fella: 6 weeks of content creation, 2 weeks of idea creation. This will allow greater focus and efficiency ### 5th April 2021 - Forgot to diary for the past few days. but fear not, work was being done. published the written and audio versions of carpal tunnel and also sent out the easter edition of theplasticspaper - chatted to a couple more future authors and excited to see what they have in store - thinking lots about the next step in growing the platform. could be a SAAS product, watch this space! _This page is for subscribers only._ ### Medical Illustrator Program URL: https://www.theplasticsfella.com/medical-illustrator-program/ Last updated: 2021-12-13T20:23:24.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Orange-Illustrative-People-Events-and-Special-Interest-Presentation.png) We promote and support independent medical illustrators. Your illustrations are embedded throughout the platform and promoted on social media, audio, video, and email. If you want your work promoted, and link to a personal website where you sell your skillset then that is also an option. If you are interested in working with thePlasticsFella, drop us an email at **support@theplasticsfella.com**. Looking forward to hearing from you! ### Current Research URL: https://www.theplasticsfella.com/current-research/ Last updated: 2021-03-18T21:41:02.000Z This is a page dedicated to promoting collaborative research projects to help promote evidence-based practices. Here is some ongoing research that you can help support. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Search-and-Answer-for-Business-Instagram-Post.png) If you want to promote your current research, then email **support@theplasticsfella.com** and P'Fella will take care of the rest. ## Burns QEH Birmingham are doing a survey to look at External referrals in burns and plastics surgery. I would appreciate your help in spreading this survey across burns&plastic units. This will help us check how other units receive referrals to facilitate better communications among speciality over the United Kingdom. The COVID-19 pandemic has had a profound impact on the way we communicate and manage patients. With ongoing issues such as national bed crises, we must have a robust communication method within our speciality. We would appreciate it if you could spare a couple of minutes to complete this survey consisting of 5 questions that will help us capture how Burns and Plastics units across the country are communicating with their external referrals. [External referrals in burns and plastics surgeryPlease take the time to complete our survey. Your feedback is important.![](https://www.smartsurvey.co.uk/img/ss_logo_twitter.png)](https://www.smartsurvey.co.uk/s/3vrogu?ref=theplasticsfella.com) --- If you want to promote your current research, then email **support@theplasticsfella.com** and P'Fella will take care of the rest. ### Raw Data URL: https://www.theplasticsfella.com/raw-data/ Last updated: 2022-04-16T22:34:36.000Z _No content available._ ### The Simplest Way to Stay Updated in Plastic Surgery URL: https://www.theplasticsfella.com/theplasticspaper-newsletter/ Last updated: 2024-08-22T21:29:39.000Z ## Join 3000+ reading ***thePlasticsPaper** every Sunday. The Simplest (& Most Popular) Way to Stay Updated in Plastic Surgery Read the Next Edition Email sent! Check your inbox to complete your signup. No spam. Unsubscribe anytime. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/thePlasticsPaper-Logo-20204.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/A-weekly-digest-from-your-favourite-plastic-surgery-resources-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/1-3.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/2-2.png) ## This is the most read Plastic Surgery publication in the world Rated 9.6/10 from 300+ Reviews ## Read the Next Edition Curated Plastic Surgery content direct your inbox. Read Every Sunday Email sent! Check your inbox to complete your signup. No spam. Unsubscribe anytime. ### Spend less time studying... URL: https://www.theplasticsfella.com/coach/ Last updated: 2021-05-03T18:24:21.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/COMING-SOON.-3.png) [Request Early Access](https://forms.app/form/609031cff974c36f5bc587c4?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/COMING-SOON.-6.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/3-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/4-2.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/5.png) ### [I would like to request early beta-access](https://forms.app/form/609031cff974c36f5bc587c4?ref=theplasticsfella.com) --- ### Coach · thePlasticsFella URL: https://www.theplasticsfella.com/testingggggggg/ Last updated: 2024-02-02T10:06:38.000Z _No content available._ ### rasa project (testing) URL: https://www.theplasticsfella.com/rasa/ Last updated: 2021-05-09T19:06:22.000Z _No content available._ ### Interview with P'Fella (Updated) URL: https://www.theplasticsfella.com/plastic-surgery-interview/ Last updated: 2022-03-01T12:01:12.000Z [![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/08/Plastic-Surgery-Interview---Landing-Page-3.png)](https://www.google.com/?ref=theplasticsfella.com) Each year the Plastic Surgery application process seems to be getting more and more **competitive**. Although the quality of the applicant increases, the interview remains relatively standard. This is why **successful interview** preparation period is a great way to **optimize your** application. Every future Plastic Surgeon goes through the same emotional journey of stress, fatigue, self-doubt, and anxiety. This online digital course removes all those emotions with a purposeful and well-planned step-by-step digital course that puts the interviewee in safe hands. [![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/08/Plastic-Surgery-Interview---Landing-Page-4.png)](google.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/08/3-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/08/4-1.png) ## Posts ### Grassroots Webinar Series, 5 Burn Management Tips, The Sunday Quiz is Back! URL: https://www.theplasticsfella.com/october-11th/ Last updated: 2026-10-10T10:07:33.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/october-11th/#a-letter-from-pfella) Something new is coming to Grassroots 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-11th/#the-sunday-quiz) Welcome to the first round 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/october-11th/#image-of-the-week) Jackson’s 3 zones of burn injury 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/october-11th/#technique-tip) Split-thickness skin grafting guide 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/october-11th/#what-does-the-evidence-say) When should a burn be excised and grafted? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-11th/#articles-of-the-week) Burn depth assessment, laser Doppler imaging, & early excision. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/october-11th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Something New Is Coming to Grassroots* 👋 A while ago, we started ****Grassroots** with a pretty simple idea: good plastic surgery teaching shouldn’t depend entirely on where you train, who happens to be around you, or whether you can travel to the right course. We started small, with an in-person teaching organised locally in Malaysia. Now we’re trying to see how far we can take it. ![Grassroots Event in Malaysia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/10/WhatsApp-Image-2026-05-02-at-09.50.19-1.jpeg) Grassroots Event in Malaysia - May 2026 Over the past few weeks, we’ve been expanding our Grassroots team to bring a new **international live teaching series**. The plan is to bring together trainees from different parts of the world for a series of webinars on a designated sub-specialty, with a different sub-topic each week. One thing we are putting a lot of effort into is making sure these do not feel like another webinar where you log on, listen to someone speak for an hour, and disappear. We’re working on ways to make the sessions much more hands-on. You might be asked to mark your operative plan, work through a clinical decision before hearing how an expert approaches it, or compare your answer with everyone else in the room. We’ll then keep the conversation going between sessions with shorter teaching, clips, and useful resources from what came up that week. There are still a few things being worked out. We’re choosing the sub-topics, testing some of the interactive parts, and building an international team around the project. So I won’t give too much away just yet. But I wanted to ask, what would actually make you want to turn up to a webinar during the weekend? Is there a topic you’d like us to tackle, a surgeon you’d like to learn from, or an activity you think would make the sessions genuinely useful? **Send us your ideas**, and we’ll take them into the planning for the first Grassroots series. If you’ve followed Grassroots since the early days, this is a much bigger version of what we originally hoped it could become: **people learning plastic surgery together, wherever they happen to be training.** P’Fella ❤️ ## The Sunday Quiz **Welcome to the First Round* You asked for it, and we're bringing it back! ****Are you ready for a fresh round of The Weekly Quiz?** Each week, we'll put your plastic surgery knowledge to the test with a new question designed to challenge you and keep you thinking. Join in every Sunday, keep your wits about you, and compete for the top spot. The winner at the end of eight rounds will receive **6 months of Plastics Pro**, on us. ## Image of the Week **Jackson’s 3 Zones of Burn Injury* 🖼️ ****Image of the Week** A burn isn't a single area of uniform tissue damage. Jackson's model describes three concentric zones, each with a different potential for recovery. At the ****centre** is the ****zone of coagulation**, where tissue damage is irreversible. Surrounding it is the ****zone of stasis**, where reduced perfusion leaves tissue injured but potentially salvageable. The outer zone of ****hyperaemia** has increased blood flow and typically recovers without permanent damage. The critical zone is ****stasis**. Without adequate perfusion and appropriate burn care, this tissue can progress to ****necrosis**, deepening the original injury. This is why early burn management is not just about treating the damage already present, but preventing further tissue loss. ![Jackson’s 3 Zones of Burn Injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/10/eplasty-24-QA5-g005.jpg) Jackson’s 3 Zones of Burn Injury - [Source](https://pmc.ncbi.nlm.nih.gov/articles/PMC10948199/?ref=theplasticsfella.com) ## Technique Tip **Split-Thickness Skin Grafting Guide* 🚑 ****Technique Tip of the Week** Split-thickness skin grafting (STSG) is a fundamental technique in burn reconstruction, providing wound coverage following excision of non-viable tissue. Successful graft take depends on a well-vascularised wound bed, adequate haemostasis, and close contact between the graft and recipient site, with minimal shear or fluid accumulation. ## What Does the Evidence Say? **When Should a Burn Be Excised and Grafted?* For burns that are clearly ****full-thickness**, early excision and grafting is well established. The more difficult decision is the ****deep partial-thickness or indeterminate-depth burn**, where the key question is whether the wound is likely to heal spontaneously within about ****3 weeks**. Healing time matters because hypertrophic scarring rises sharply as epithelialisation is delayed: classic burn-scar data found hypertrophic scarring in about ****one-third of sites healing within 14-21 days**, increasing to ****78% when healing took longer than 21 days**. Later paediatric burn data showed the same pattern, with hypertrophic scarring increasing progressively beyond 3 weeks. Randomised clinical evidence also supports early excision in appropriately selected deep burns. In indeterminate-depth burns involving less than 20% TBSA, early excision and grafting shortened hospital stay and time away from work and reduced the need for later grafting compared with conservative treatment. In major burns, early excision has also been associated with improved outcomes in selected patient groups. However, early assessment is not perfect: in indeterminate scald burns, delaying excision allowed some wounds to declare themselves and heal without surgery, reducing the amount of tissue excised. The practical takeaway is therefore not simply ****“graft early.”** Full-thickness burns generally require excision and grafting, while deep partial-thickness burns should be judged by ****depth, anatomical site, functional importance, and expected healing time**. If a wound is unlikely to epithelialise by around ****21 days**, the balance increasingly shifts toward excision and grafting to reduce prolonged healing and hypertrophic scar risk. ([Engrav](https://pubmed.ncbi.nlm.nih.gov/6355500/?ref=theplasticsfella.com), 1983); ([Herndon](https://pubmed.ncbi.nlm.nih.gov/2650643/?ref=theplasticsfella.com), 1989); ([Deitch](https://pubmed.ncbi.nlm.nih.gov/6632013/?ref=theplasticsfella.com), 1983); ([Cubison](https://pubmed.ncbi.nlm.nih.gov/16901651/?ref=theplasticsfella.com), 2006); ([ISBI Practice Guidelines Committee](https://pubmed.ncbi.nlm.nih.gov/27542292/?ref=theplasticsfella.com), 2016) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****How Accurate Is Clinical Burn Depth Assessment?**](https://www.lotusmdc.com/upresimler/easyldi/2008easyldi1.pdf?ref=theplasticsfella.com) Clinical assessment correctly identifies burn depth in only 60-75% of cases, compared with approximately 95% accuracy using laser Doppler imaging, which can better predict healing potential and guide decisions on excision and grafting. ✅ [****Can Laser Doppler Imaging Predict Which Burns Need Grafting?**](https://www.lotusmdc.com/upresimler/easyldi/2009easyldi2.pdf?ref=theplasticsfella.com) A review of burn assessment techniques found that laser Doppler imaging can predict healing potential up to 2 days earlier than clinical judgement, helping surgeons identify wounds requiring excision and grafting while avoiding unnecessary operations. ✅ [****Does Early Excision Improve Survival in Severe Burns?**](https://pmc.ncbi.nlm.nih.gov/articles/PMC1494069/pdf/annsurg00183-0051.pdf?ref=theplasticsfella.com) In a randomised study of adults with burns covering over 30% TBSA, early excision reduced mortality from 45% to 9% in patients aged 17-30 without inhalation injury, although no significant survival benefit was demonstrated in older adults or those with inhalation injuries. ## Feedback ### I hope you enjoyed it 😄 --- ### Make the Call First, 3 Cleft Palate Repair Tips, What's Next on How I Operate? URL: https://www.theplasticsfella.com/october-4th/ Last updated: 2026-10-04T06:17:52.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/october-4th/#a-letter-from-pfella) Before you read the answer, make the call 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/october-4th/#image-of-the-week) Rebuilding the palatal sling 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/october-4th/#technique-tip) Furlow double-opposing Z-plasty 4. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/october-4th/#how-i-operate) Next season of How I Operate - Guest recommendations 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/october-4th/#what-does-the-evidence-say) Ideal timing for cleft palate repair 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-4th/#articles-of-the-week) Genetic link in cleft lip and palate, impacts on speech after palate repair, & 3 goals of cleft palate repair. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/october-4th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Before You Read the Answer, Make the Call* 👋 I think most of us have read a case, looked at the answer and thought, yes, I knew that. I’ve been wondering how often we would have reached the same answer without it in front of us. Once someone has laid out the reasoning, everything can seem fairly obvious, including the finding we might have overlooked on our own. Being asked what you would do next is a different experience. You might be able to name several flaps that could cover a defect, but choosing between them means thinking about the patient, the available tissue, and what you’re trying to achieve. Sometimes you get halfway through explaining your choice and realise you need more information. That’s a useful moment in teaching. You’ve found the exact point where your understanding needs a little more work. I’d like us to be more comfortable with those moments. It can feel awkward to put forward an answer when you’re unsure, especially in front of colleagues. But saying how you arrived at it gives someone a chance to help with the part you’re struggling with. They might agree with your choice but question the reasoning, or suggest an alternative you hadn’t considered. Even when experienced surgeons disagree, hearing what each person is giving more weight to can be more useful than simply being told the preferred operation. There’s something practical to take from that when we’re reading, too. Before opening the explanation, spend a moment deciding what you would do and why. Be honest about what you’re uncertain about. Then compare the reasoning, rather than just checking whether you picked the right option. You might have reached the right answer for the wrong reason, or made a reasonable choice based on an assumption the case never addressed. Both are worth noticing. We have been working on bringing the **Sunday Quiz** back to *The Plastics Paper*, which is what got me thinking about this in the first place. I’d like each question to give you a reason to pause, make a decision, and consider someone else’s approach. And when an explanation leaves you unconvinced, I hope you’ll reply and tell us why. There’s a good chance a discussion would help not only you, but many others to see perspectives they didn't consider before. P’Fella ❤️ ## Image of the Week **Rebuilding the Palatal Sling* 🖼️ ****Image of the Week** In a normal soft palate, the ****levator veli palatini muscles form a transverse sling**, elevating the palate during speech and swallowing. In cleft palate, these fibres can instead run abnormally towards the posterior edge of the hard palate, compromising velopharyngeal function. This image shows the principle behind ****revision intravelar veloplasty**. Through a midline incision, the abnormal muscle attachments are released and the velar muscles are dissected before being ****re-repaired transversely across the midline**, recreating a more functional muscular sling. ![Revision Intravelar Veloplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/10/nihms-1931867-f0001.jpg) Revision Intravelar Veloplasty - [Source](https://pmc.ncbi.nlm.nih.gov/articles/PMC10787042/?ref=theplasticsfella.com) ## Technique Tip **Furlow Double-Opposing Z-Plasty* 🚑 ****Technique Tip of the Week** The ****Furlow palatoplasty** uses opposing Z-plasties on the oral and nasal surfaces of the soft palate to ****lengthen the velum** and reorient the **levator musculature into a more transverse position**. In secondary palatoplasty, these principles can be used to address persistent velopharyngeal insufficiency (VPI) following previous cleft palate repair. In this operative video, a secondary Furlow palatoplasty is performed in a patient with VPI. The procedure demonstrates flap design and elevation through previously scarred tissue, transposition of the opposing Z-plasties, reconstruction of the velar musculature, and layered closure to restore palatal length and configuration. ## How I Operate **Next Season of How I Operate - Guest Recommendations* [How I Operate — the plastic surgery podcast by thePlasticsFellaPlastic surgeons at the top of their field, walking you through exactly how they operate. New episode every month.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/favicon-5e572945-4611-4e6c-9a6f-fa521a7710ae.png)thePlasticsFellaDr Ryan Sugrue![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/og-f24f20a8-34f8-4b1f-b8e5-4685e6ac51e6.jpg)](https://howioperate.com/?ref=theplasticsfella.com) With all episodes of ****How I Operate** now released, we’re already planning the next season 🎙️ We’re thinking through the topics we want to cover, the conversations we want to have, and the people we’d love to bring into the discussion. So we’d love to hear from you. Who would you like to hear from next? Leave your suggestions below 👇 ## What Does the Evidence Say? **Ideal Timing for Cleft Palate Repair* The traditional debate around cleft palate timing has always balanced two priorities: ****earlier repair** may support **speech development**, while ****later repair** has historically been thought to ****reduce interference with maxillary growth**. Until recently, however, much of that trade-off was based on retrospective and highly heterogeneous studies rather than strong comparative evidence. The best contemporary evidence comes from the international TOPS trial, which randomised 558 medically fit infants with ****nonsyndromic isolated cleft palate** to primary repair at either 6 or 12 months. At 5 years, insufficient velopharyngeal function was significantly less common after ****6-month repair (8.9%) than after 12-month repair (15.0%)**, with postoperative complication rates remaining low and similar between groups. Earlier PRS work also found better phonologic development after repair at 6 months, although velopharyngeal insufficiency rates were similar between groups. The important caveat is growth. Systematic reviews examining hard-palate timing and maxillary development have not produced a consistent answer: most available studies are retrospective, heterogeneous, and at high risk of bias. So the evidence currently supports a real ****speech advantage to earlier repair in appropriately selected infants**, without proving that one age is universally optimal for every cleft phenotype or surgical protocol. Timing should still be integrated with cleft type, technique, airway, anaesthetic considerations, and the experience of the multidisciplinary cleft team. ([Gamble](https://pubmed.ncbi.nlm.nih.gov/37646677/?ref=theplasticsfella.com), 2023); ([Ysunza](https://pubmed.ncbi.nlm.nih.gov/9727430/?ref=theplasticsfella.com), 1998); ([Liao](https://pubmed.ncbi.nlm.nih.gov/16986982/?ref=theplasticsfella.com), 2006); ([Rodrigues Salgado](https://pubmed.ncbi.nlm.nih.gov/31677987/?ref=theplasticsfella.com), 2019); ([Cornefjord](https://pubmed.ncbi.nlm.nih.gov/38095226/?ref=theplasticsfella.com), 2023) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****How Strong Is the Genetic Link in Cleft Lip and Palate?**](https://pmc.ncbi.nlm.nih.gov/articles/PMC3925974/pdf/nihms530566.pdf?ref=theplasticsfella.com) First-degree relatives of someone with cleft lip have an estimated 32-fold higher risk, while identical twins show 40-60% concordance, supporting a strong, but not exclusively genetic, basis for nonsyndromic clefting. ✅ [****Does Cleft Type Affect Speech After Palate Repair?**](https://www.jprasurg.com/article/S0007-1226%2800%2993599-9/pdf?ref=theplasticsfella.com) Despite similar final speech outcomes, 37% of children with isolated cleft palate required secondary pharyngoplasty compared with none of those with unilateral cleft lip and palate, suggesting isolated cleft palate may be more challenging to correct with primary surgery alone. ✅ [****What Are the 3 Goals of Cleft Palate Repair?**](https://web.archive.org/web/20190223234207id%5F/http://pdfs.semanticscholar.org/4f3a/8c4035615d1f58da93732d14ce4df883e1f2.pdf) Successful cleft palate repair centres on three goals: separating the oral and nasal cavities without fistula, achieving sufficient velar length, and restoring the levator muscle sling to a functional transverse orientation. ## Feedback ### I hope you enjoyed it 😄 --- ### 3 Plastic Surgery Research Insights, Building a ST3 Prep Guide, & How I Operate Season Finale URL: https://www.theplasticsfella.com/september-27th/ Last updated: 2026-09-25T12:53:43.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/september-27th/#a-letter-from-pfella) ST3 prep: What would help you the most? 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/september-27th/#image-of-the-week) How an editor judges your paper 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/september-27th/#technique-tip) What makes a study methodologically strong? 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/september-27th/#building-in-public) Did you like last week’s Aesthetic Decisions? 5. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/september-27th/#how-i-operate) That’s a wrap on this season! 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/september-27th/#what-does-the-evidence-say) Can AI be used safely in scientific writing? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/september-27th/#articles-of-the-week) RCTs, struggles in publishing research, & AI in aesthetics. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/september-27th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **ST3 Preparation: What Would Help You the Most?* 👋 Preparing for ST3 can become a fairly long list of things. There’s the portfolio to organise, clinical knowledge to revisit, and interview practice to fit around work. Even deciding where to start can take time, particularly when the advice you’re getting comes from people who applied in different years. We have an existing Plastic Surgery[**ST3 interview guide**](https://www.theplasticsfella.com/st3-plastic-surgery-interview/) on the website, and we’re working on an updated version with a few supporting articles. We’re expanding the preparation material to cover more of the application process, including eligibility, portfolio evidence, the interview itself, and how to work out where you need to spend your time. One thing we try to pay attention to is the gap between having done the work and being able to explain it. Take an audit: you might know the project inside out, but could someone looking at your portfolio quickly establish what you contributed and what changed? Could you then discuss its limitations in an interview? Those are useful things to prepare, and they’re much easier to work on when you have specific examples of what to check. The same goes for clinical preparation. Reading an answer and explaining your own approach aloud are quite different experiences. Because of this, we would like to include tips like trying a timed mock early, so you can find out whether you need to work on your knowledge, prioritisation, or simply getting to the point. “Revise burns” is a big task. “Practise giving a clear assessment and escalation plan for a burns referral” gives you something specific to do and get feedback on. That’s the level of practical detail we'd like to include in the updated guide. We’re also being careful to distinguish published recruitment guidance from details that still need confirmation for the next application cycle. Before we finalise the articles, though, **what would help you most?** You might need a clearer explanation of portfolio scoring, worked clinical scenarios, or a manageable revision plan. And those of you who have already been through ST3 selection may remember something you wish you’d understood earlier. Let us know below 👇 P’Fella ❤️ ## Image of the Week **How an Editor Judges Your Paper* 🖼️ ****Image of the Week** Before your paper reaches peer review, an editor has to decide whether it is worth sending any further. That first impression starts with the ****title and abstract**. Is the research question clear? Can the editor quickly understand what was done and why it matters? Then comes the ****methodology**. A striking result will not rescue a study if the methods cannot properly answer the question. In our latest [****How I Operate**](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) episode, JPRAS Editor-in-Chief Adam Reid walks through what actually happens after you hit submit, including how editors screen manuscripts, what they look for in the methodology, and why ****good research starts with a strong question and a study designed to answer it**. ![How an Editor Judges Your Paper](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/09/reel-2-img-1--1--1-1.png) How an Editor Judges Your Paper ## Technique Tip **What Makes a Study Methodologically Strong?* 🚑 ****Technique Tip of the Week** When a paper reaches a journal editor, impressive numbers alone aren't enough. Editors look at ****how the study was designed, how the data were collected and analysed,** and whether the **conclusions are actually supported by the methodology**. A large dataset can still raise important questions about sample size, outcome events, patient selection, and study design. In our latest episode of [****How I Operate**](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com), Adam Reid breaks down a study with 500 free flaps and nearly 30,000 images and explains the questions an editor would ask before being persuaded by those numbers. For anyone conducting research, this episode sheds light on **what you should be thinking about before you submit yours.** 0:00 /1:34 1× ## Building in Public **Liked Last Week’s Aesthetic Decisions?* [Special Edition: Blepharoplasty vs Brow Lift & the 60-Second Periorbital AssessmentLearn to read the periorbital region as one aesthetic unit, recognise findings that change your plan, & avoid three common assessment traps.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/Logo-Small-2-08ae7bbf-f1c8-4c36-8836-3d235e4ed257.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/ChatGPT-Image-Aug-26--2026--01_56_08-PM-a004b487-ea0d-49f5-b39d-40b54ad9ecee.png)](https://www.theplasticsfella.com/aesthetic-decisions-1/) 💌 Last Sunday, we turned **The Plastics Paper* into the first edition of ****Aesthetic Decisions**, our new monthly newsletter focused entirely on aesthetic surgery. Our goal: Each edition takes one area of aesthetic surgery and focuses on the decisions behind it, including how you assess the patient, what findings actually change your plan, and the evidence worth knowing. Our first edition looked at the ****periorbital region**, with the 60-second assessment, blepharoplasty vs brow lift, and how to think about the region as one connected aesthetic unit. If you enjoyed the first edition, **Aesthetic Decisions mailing list is open below.** ## How I Operate **That’s a Wrap on This Season!* On Monday, we released the final episode of this season of ****How I Operate**. Across the season, we’ve sat down with plastic surgeons who have helped shape techniques, classifications, and ideas that are now part of everyday practice to ask them how those ideas actually came about. If you haven’t listened yet, you can find it [here](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com). Now that the full season is out, we’d really like to hear what you thought. We'd love to know which conversations you enjoyed most, who you'd like us to sit down with next, and, most importantly, what we could do better next season. ## What Does the Evidence Say? **Can AI Be Used Safely in Scientific Writing?* AI can help researchers ****edit language, structure drafts, summarise material,** and **generate ideas**, but the evidence shows why it should not be trusted as an independent scientific author. Studies testing large language models on medical and scientific writing have repeatedly found ****fabricated or inaccurate references**, even when the prose itself sounds convincing. In one study of ChatGPT-generated medical papers, only ****7% of 115 references were both authentic and accurate**; another analysis of 636 citations generated by GPT-3.5 and GPT-4 found that fabricated citations remained a substantial problem, although newer models performed better than earlier ones. Current editorial guidance, therefore, draws a clear line between ****assistance and accountability**. The ICMJE states that AI tools cannot qualify as authors, that their use should be ****disclosed**, and that human authors remain responsible for the accuracy, originality, attribution, and integrity of everything submitted. It also warns reviewers and editors not to upload confidential manuscripts into AI systems where confidentiality cannot be assured. WAME and COPE take the same position: AI use should be transparent, but responsibility for the manuscript stays with the human authors. The practical takeaway is not ****“don’t use AI.”** It is to use it for tasks where the output can be checked: editing, organisation, brainstorming, or language support. ****Do not rely on an LLM to supply evidence, references, data, or scientific conclusions without independently verifying them against the original sources.** AI can improve the workflow; it cannot take responsibility for the study. ([Bhattacharyya](https://pubmed.ncbi.nlm.nih.gov/37337480/?ref=theplasticsfella.com), 2023); ([Walters](https://pubmed.ncbi.nlm.nih.gov/37679503/?ref=theplasticsfella.com), 2023); ([Zielinski](https://pubmed.ncbi.nlm.nih.gov/38089825/?ref=theplasticsfella.com), 2023); ([ICMJE](https://www.icmje.org/recommendations/browse/artificial-intelligence/?ref=theplasticsfella.com)); ([COPE](https://publicationethics.org/guidance/cope-position/authorship-and-ai-tools?ref=theplasticsfella.com)) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****How Good Are RCTs in Plastic Surgery?**](https://www.sciencedirect.com/science/article/abs/pii/S1748681512006298?ref=theplasticsfella.com) Among 57 plastic surgery RCTs, methodological quality was low, with only 4% using intention-to-treat analysis, 23% reporting patient blinding, & 25% adequately handling and reporting withdrawals. ✅ [****What Stops Plastic Surgeons From Publishing Research?**](https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2025.1640588/full?ref=theplasticsfella.com) Among 188 respondents across 21 LMICs, the leading barriers to publishing were clinical workload (46%), lack of mentorship (38%), and publication charges (35%), while half also reported difficulty accessing plastic surgery journals. ✅ [****How Is AI Being Used in Aesthetic Plastic Surgery?**](https://link.springer.com/article/10.1007/s00266-024-04421-3?ref=theplasticsfella.com) Across 18 studies, AI and machine-learning models were used for applications including surgical planning, image-based assessment, & predicting postoperative complications, although the authors caution that AI-generated simulations may create unrealistic patient expectations. ## Feedback ### I hope you enjoyed it 😄 --- ### Special Edition: Blepharoplasty vs Brow Lift & the 60-Second Periorbital Assessment URL: https://www.theplasticsfella.com/aesthetic-decisions-1/ Last updated: 2026-09-21T20:00:40.000Z ### #### In This Edition 1. [****The Overview**](https://www.theplasticsfella.com/aesthetic-decisions-1/#the-overview): The 60-second periorbital assessment. 2. [****The Case**](https://www.theplasticsfella.com/aesthetic-decisions-1/#the-case)****:** Make your call. 3. [****The Assessment**](https://www.theplasticsfella.com/aesthetic-decisions-1/#the-assessment)****:** Findings that change the plan. 4. [****The Decision**](https://www.theplasticsfella.com/aesthetic-decisions-1/#the-decision)****:** How would I approach this patient? 5. [****What to Avoid**](https://www.theplasticsfella.com/aesthetic-decisions-1/#important-to-avoid)****:** Three classic traps. 6. [****Take it to the Clinic**](https://www.theplasticsfella.com/aesthetic-decisions-1/#take-it-to-the-clinic)****:** The 60-second assessment. 7. [****The Evidence**](https://www.theplasticsfella.com/aesthetic-decisions-1/#3-papers-worth-reading)****:** If I could recommend only three papers. A quick note before we start 👋 This Sunday, you are receiving our first ****Aesthetics Decisions** as a special edition of **The Plastics Paper*. From October onwards, Aesthetics Decisions will be its own monthly newsletter. [If you’d like to receive it, subscribe here ](https://tally.so/r/PdN470?ref=theplasticsfella.com) ## The Overview **The 60-Second Periorbital Assessment* 0:00 /0:54 1× THEMES for This Edition 1. ****Beauty is harmony over perfection:** Individual features don’t exist in isolation. It’s the relationship between features that matters. 2. ****The eyes as a whole:** Brow height, eyelids, and surrounding features work together. 3. ****Changing one feature changes the balance:** Isolated correction can affect overall harmony. 4. ****Beyond perfect measurements:** There’s no single formula for the ideal eye. ## The Case **How to Read the Periorbital Region as One Connected Aesthetic Unit* The Case ****A 52-year-old woman presents requesting an upper blepharoplasty**. Her concern is simple: her upper eyelids feel heavier, she looks tired, and she wants to know whether removing the excess skin will make her look more refreshed. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/unnamed--4--1-1.jpg) *The answer will be revealed in the next edition.* ## The Assessment **Findings That Change Your Plan* The key A practical consultation framework for deciding what truly needs correcting. Focus on the details, then take a step back. **Focus on the Details** Look at the **forehead** before you look at the eyelid. At first glance, this patient appears to have a straightforward upper-lid problem. But there is one finding that should make you pause: **frontalis recruitment**. Frontalis recruitment can partially mask brow ptosis and make the upper eyelid appear to be the primary problem. Ask the patient to fully relax the forehead and reassess. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/unnamed--4--2-1-1.jpg) TIP! Once the frontalis relaxes, the brow settles into its true resting position. In this patient, the lateral brow descends, and the upper lid appears more crowded. ****The eyelid has not changed. Your assessment has.** **Now step back: Think in terms of the orbital unit** Brow position alone does not determine whether the periorbital region looks attractive, youthful, or balanced. The brow, upper eyelid, eye, and lower lid-cheek junction need to be read together as a single aesthetic unit. The **Orbital Oval Balance Principle** reframes the assessment away from an absolute ideal brow height and toward the relationship between the structures surrounding the eye. Both narrow and wide orbital ovals can be attractive when their components remain balanced. This changes the question from **“Is the brow low?”** to **“Is the periorbital region balanced?”** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/09/ChatGPT-Image-Jul-9--2026--01_59_00-AM.png) TIP! A low brow is not, by itself, an indication for a brow lift. The aim is not to create a higher brow, but to identify which component, if any, is disrupting the overall balance. ## The Decision **How to Approach This Patient* The key Once the brow has been assessed at rest, the decision becomes clearer.In this patient, frontalis relaxation reveals true brow ptosis, particularly laterally, while genuine upper-lid skin excess remains present. My preference would therefore be a **combined approach: brow repositioning** with a **conservative upper blepharoplasty.** Treating the eyelid alone would address the skin excess, but not the brow component contributing to the imbalance. Conversely, a brow lift alone would improve brow position but leave true dermatochalasis untreated. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/unnamed--14--1.png) ## Important to Avoid **Three Classic Traps in These Patients* The key Even a technically well-performed operation can disappoint if the initial assessment is incomplete. Before choosing the procedure, avoid these three common traps. 1. **Missing frontalis compensation:** Assessing the brow while the frontalis is active can hide its true resting position. Relax the forehead before judging brow position or upper-lid excess. 2. **Treating one structure instead of the orbital unit:** A brow or eyelid may look acceptable in isolation, but still be out of balance with the rest of the periorbital region. Step back and assess the orbital oval before deciding what, and how much, to change. 3. **Choosing the operation before defining the anatomy:** Starting from “blepharoplasty or brow lift?” risks matching a procedure to a complaint rather than identifying the structures responsible for it. Define the anatomical problem first. Let the diagnosis determine the operation. ## Take it to the Clinic **The 60-Second Periorbital Assessment* Before deciding on the procedure, run through these seven checks. It takes less than a minute and can change the plan. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/unnamed--15-.png) Checklist Before discussing an upper blepharoplasty or brow lift, run through these seven checks. 1. ****Forehead:** Is the frontalis active at rest? 2. ****Relax the brow:** Reassess its true resting position. 3. ****Brow position:** Assess medial, central, and lateral brow. 4. ****Upper-lid skin:** How much true dermatochalasis remains? 5. ****Crease-platform:** Is the brow-crease-pretarsal relationship balanced? 6. ****Step back:** Assess the entire orbital frame. 7. ****Final Thought:** What anatomical change actually improves this patient? ## 3 Papers Worth Reading **Evidence & Further Reading* #### The Orbital Oval Balance Principle Shifts periorbital assessment from isolated brow height to proportional balance across the orbital frame. [Read the Article](https://pure.rug.nl/ws/portalfiles/portal/67166965/00006534%5F201810000%5F00010.pdf?ref=theplasticsfella.com) #### The Brow-Eyelid Continuum Shows why brow and upper-eyelid position should be assessed together before choosing either procedure. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/23186753/?ref=theplasticsfella.com) #### The Influence of Brow Position on Perceived Facial Expression Reminds us that changing brow position alters not only anatomy, but how facial expression is perceived. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/18454005/?ref=theplasticsfella.com) ## Before You Leave **The best surgeons don't collect operations. They collect better questions.* **This month, I hope you'll leave with one:* ***Am I treating the patient's request, or the anatomy in front of me?** **See you in the next edition.* ### 4 Rhinoplasty Tips, Inverted-V Deformity, & Aesthetics Newsletter Releasing Soon URL: https://www.theplasticsfella.com/september-13th/ Last updated: 2026-09-13T09:24:50.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/september-13th/#a-letter-from-pfella) A little more time for aesthetics 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/september-13th/#image-of-the-week) Supporting the nasal tip 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/september-13th/#technique-tip) Lateral osteotomies in rhinoplasty 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/september-13th/#building-in-public) Updates with our on-call team 5. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/september-13th/#how-i-operate) Air bubbles in the arterial anastomosis 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/september-13th/#what-does-the-evidence-say) Preventing the inverted-V deformity 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/september-13th/#articles-of-the-week) Aesthetic nasal tip, nasal tip support, & open rhinoplasty. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/september-13th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **A Little More Time for Aesthetics* 👋 The conversations I enjoy most in surgery start with a fairly ordinary question: What would you do with this patient and someone notices a detail you hadn’t paid much attention to... suddenly there’s a much more interesting discussion to have. I’d like our monthly Aesthetics newsletter to give you a little of that experience. The first edition is nearly ready, and there’s one part of the format I’m particularly pleased with. You get to consider the case before reading through the assessment. **In this upcoming first edition, you’re invited to think about what you would recommend for a patient with a specific request,** including whether you have enough information to recommend anything yet. As you read on, we introduce the findings and explain how they influence the proposed approach. You can see where your thinking agrees, where it differs, and what you might have wanted to examine more closely. This is a more effective way of teaching. It’s easy to read an explanation after being given the answer and think, yes, that makes sense. Having a go yourself first makes it a different read. You have a reason to pay attention to the assessment because you’ve already started forming a view. And I hope that even someone with years of experience would find things to discuss. We’re presenting a clinical perspective, with the reasoning behind it, so there should be room to consider how it compares with your own practice. **Putting the edition together has also meant making some decisions about how much to include.** Certain clinical decisions could easily fill several issues. For this one, we’ve kept returning to the patient in front of us and the details that would affect the consultation. **Having a dedicated Aesthetics Department gives us room to develop something a little different alongside the weekly thePlasticsPaper.** We are excited to keep returning to the specialty each month, work through another case or question, and hear what *you* think we should cover next. There’s plenty still to work out as we go, but I’m looking forward to getting the first edition into your hands and hearing how you find it. **The Aesthetics mailing list is open below.** P’Fella ❤️ ## Image of the Week **Supporting the Nasal Tip* 🖼️ ****Image of the Week** These images show two different ways of creating structural support during rhinoplasty. On the left, a ****columellar strut graft** sits between the medial crura, reinforcing the existing tip-support mechanism. On the right, a ****septal extension graft** is fixed directly to the septum, creating a more rigid framework from which tip position can be controlled. The distinction matters. A columellar strut primarily ****supports the tip**, whereas a septal extension graft gives the surgeon greater control over ****tip projection and rotation** by effectively extending the caudal septal framework. ![Supporting the Nasal Tip](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/09/gr1_lrg--3-.jpg) Supporting the Nasal Tip - [Source](https://www.jprasurg.com/article/S1748-6815%2822%2900095-X/abstract?ref=theplasticsfella.com) ## Technique Tip **Lateral Osteotomies in Rhinoplasty* 🚑 ****Technique Tip of the Week** ****Lateral osteotomies** allow controlled mobilisation of the nasal bones and are commonly used to narrow the bony vault, correct asymmetry, or close an open-roof deformity following dorsal reduction. Precise osteotomy placement and controlled fracture are important for maintaining smooth dorsal aesthetic lines while avoiding unintended comminution or irregularity. This operative video demonstrates lateral osteotomies using an endonasal approach, showing how the nasal bones are mobilised and repositioned to achieve a narrower, more symmetrical bony vault. ## Building in Public **Updates with Our On-Call Team* 🌐 We caught up with the On-Call Team again this weekend, and there’s quite a bit happening behind the scenes. One of our longest-running issues is finding good clinical images we can actually use, and we are currently planning on adding a new team role to help us create custom images for the Library. We also gave the team an early look at the new learning platform we’ve been building, which brings articles, images, videos, and notes into one workspace, and they’ll be testing it out over the next few weeks. Last but not least, we discussed what’s coming from the Aesthetics Department, including our first specialist newsletter, webinars, and more to come. ![P'Fella's On-Call Team](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/09/Screenshot-2026-09-12-at-15.38.08.png) P'Fella's On-Call Team ## How I Operate **Air Bubbles in the Arterial Anastomosis* 🎙️ If you haven’t listened yet, Episode 5 of ****How I Operate** is out now In this clip, Pedro Cavadas talks about a small detail that can have a big consequence: ****air bubbles in the arterial anastomosis**. His point is that some cases we call “no-reflow” may not be mysterious at all. They may be tiny air emboli blocking flow in a small perforator or replant. Before tying the final stitch, he makes sure the air is flushed out. 0:00 /1:37 1× [Listen Now](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## What Does the Evidence Say? **Preventing the Inverted-V Deformity* The inverted-V deformity is not simply a cosmetic contour problem. After dorsal hump reduction, loss of support at the junction between the ****upper lateral cartilages and dorsal septum** can allow the middle vault to narrow and the upper lateral cartilages to fall medially. This produces the characteristic inverted-V shadow on frontal view and can also narrow the ****internal nasal valve**, creating functional obstruction. The landmark work by Sheen introduced the spreader graft specifically to reconstruct this disrupted middle vault and restore support between the septum and upper lateral cartilages. Later work reinforced the same principle: preserving the upper lateral cartilages during dorsal reduction and reconstructing the middle vault when necessary helps maintain both ****dorsal aesthetic lines and internal nasal valve function**. However, the evidence does not support one mandatory technique for every patient. Systematic reviews comparing ****spreader grafts and spreader flaps** show broadly similar functional and aesthetic outcomes, with no clear difference in overall complication rates. The practical takeaway is therefore not “everyone needs a spreader graft,” but that ****middle-vault support must be actively assessed and preserved after dorsal reduction,** using spreader grafts, spreader flaps, or another appropriate reconstructive technique when the upper lateral cartilages are at risk of collapse. ([Sheen](https://pubmed.ncbi.nlm.nih.gov/6695022/?ref=theplasticsfella.com), 1984); ([Rohric](https://pubmed.ncbi.nlm.nih.gov/15457053/?ref=theplasticsfella.com), 2004); ([Gruber](https://pubmed.ncbi.nlm.nih.gov/17440373/?ref=theplasticsfella.com), 2007); ([Keyhan](https://academic.oup.com/asj/article/42/6/590/6449481?ref=theplasticsfella.com), 2022); ([Fallahi](https://pubmed.ncbi.nlm.nih.gov/35165759/?ref=theplasticsfella.com), 2022) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****What Defines an Aesthetic Nasal Tip?**](https://www.ovid.com/jnls/plasreconsurg/abstract/00006534-199202000-00002~the-nasal-tip-anatomy-and-aesthetics?ref=theplasticsfella.com) Analysis of 50 primary open rhinoplasties identified three key nasal tip angles: tip rotation, domal definition, and domal divergence that can be defined anatomically and deliberately shaped during surgery. ✅ [****Which Ligaments Support the Nasal Tip?**](https://academic.oup.com/asj/article-abstract/38/4/357/4816879?redirectedFrom=fulltext&ref=theplasticsfella.com) Cadaveric dissection consistently identified five ligamentous structures around the nasal tip, supporting preservation of these ligaments to help control tip projection, position, and rotation during rhinoplasty. ✅ [****Does Open Rhinoplasty Reduce Nasal Tip Support?**](https://www.ovid.com/jnls/plasreconsurg/abstract/00006534-199901000-00040~anatomic-basis-and-clinical-implications-for-nasal-tip?ref=theplasticsfella.com) Open rhinoplasty produced significantly greater loss of tip projection than the closed approach (3.43 mm vs 1.98 mm), supporting active measures to maintain tip support when ligamentous structures are disrupted. ## Feedback ### I hope you enjoyed it 😄 --- ### Bridging Nerve Gaps, 5 Nerve Repair Tips, & How I Operate with Pedro Cavadas URL: https://www.theplasticsfella.com/september-6th/ Last updated: 2026-09-06T02:49:07.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/september-6th/#a-letter-from-pfella) Operations that start as a bad idea 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/september-6th/#image-of-the-week) Bridging a nerve gap 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/september-6th/#technique-tip) Digital nerve repair with acellular nerve allograft 4. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/september-6th/#how-i-operate) At the limits of reconstruction with Dr Pedro Cavadas 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/september-6th/#what-does-the-evidence-say) Autograft vs allograft 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/september-6th/#articles-of-the-week) Nerve transfers, autografts, & processed nerve allografts. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/september-6th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Operations That Start as a Bad Idea* 👋 Every new operational procedure starts with someone saying...bad idea. Or at least, quite a few of the interesting ones probably sounded like one at first. Recently, I've been looking into these cases more and more. Replant a completely amputated limb or transplant somebody else’s hands.... temporarily attach an amputated part somewhere else on the body to keep it alive. Use a free flap from the opposite leg when the usual reconstructive options have run out. There’s a strange point in surgical innovation where the difference between *impossible* and *possible* is **simply that nobody has worked out how to do it reliably yet.** Plastic surgery has always lived quite close to that line. It’s one of the things I love about the specialty. We don’t always have the luxury of choosing from a neat list of operations. Sometimes the defect in front of you doesn’t fit the algorithm, and the operation has to be worked out from first principles. Of course, the textbooks tend to make innovation look much cleaner than it really is. We see the operation that worked, the paper that was published, and the technique that eventually became accepted. We don’t see nearly as much of the uncertainty beforehand....the failed ideas, anatomical work, the modifications between patient one all the way up to patient twenty. Or the years it can take before something unusual becomes something other surgeons can reproduce. We’ve been hearing a lot about this while recording [*How I Operate*](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com). Our recent conversation with Pedro Cavadas probably sits at an extreme end of it. We spoke about reconstruction when the usual options have run out, and how he breaks those problems back down into tissue, vessels, timing, and sequence rather than beginning with whether an operation has been done before. **But one thing I’m beginning to appreciate from these conversations is that the surgeons who move the specialty forward don’t necessarily start by trying to do something extraordinary. Usually, they’ve just found a problem they think can be solved better.** And sometimes, a few years later, everyone forgets it was ever considered impossible. We’ve just recorded another conversation that looks at this from a slightly different angle: not only how new ideas begin, but how we actually investigate them, prove them, and decide whether they deserve to change practice. More on that one soon! P’Fella ❤️ ## Image of the Week **Bridging a Nerve Gap* 🖼️ ****Image of the Week** When a nerve injury leaves a gap that ****cannot be closed without tension**, direct end-to-end repair is no longer appropriate. The damaged ends must first be trimmed back to healthy fascicles, leaving a defect that requires another reconstructive strategy. This image shows how that decision can extend beyond simply placing a graft. A ****lateral antebrachial cutaneous nerve graft** bridges the sensory component of a proximal median nerve injury, while distal nerve transfers restore motor pathways closer to their targets. The principle is to ****match the reconstruction to the function that needs restoring**: graft where a viable proximal source can support regeneration, and consider nerve transfer when the distance to the motor target makes regeneration less favourable. ![Management of Nerve Gaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/09/1-s2.0-S0014488609001228-gr7.jpg) Management of Nerve Gaps - [Source](https://www.sciencedirect.com/science/article/abs/pii/S0014488609001228?ref=theplasticsfella.com) ## Technique Tip **Digital Nerve Repair with Acellular Nerve Allograft* 🚑 ****Technique Tip of the Week** The central principle of ****peripheral nerve repair is a tension-free reconstruction**. When a nerve gap prevents primary end-to-end repair, reconstruction may require an autograft, nerve conduit, or processed acellular nerve allograft, depending on the characteristics of the defect and clinical context. In this video, an ****8 mm ulnar digital nerve defect** is reconstructed using an acellular nerve allograft. The technique demonstrates preparation of the proximal and distal nerve ends, selection of an appropriately sized graft, and microsurgical coaptation at both interfaces to restore continuity without tension. ## How I Operate **At the Limits of Reconstruction with Dr Pedro Cavadas* 🎙️ If you haven’t listened yet, Episode 5 of ****How I Operate** is out now! Below is a snippet where Dr Pedro Cavadas challenges one of the classic rules in microsurgery: ****one artery, two veins**. His argument is simple: when you plan for two veins, you may start accepting small technical mistakes. But when you only have one, you know it has to be perfect. One perfect anastomosis is better than two imperfect ones. 0:00 /0:47 1× [Listen Now](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## What Does the Evidence Say? **Autograft vs Allograft* When a peripheral nerve gap cannot be closed primarily without tension, ****nerve autograft** remains the benchmark reconstruction. It provides native Schwann cells, extracellular matrix, and viable biological architecture, but requires sacrificing a donor nerve and carries morbidity including sensory loss, neuroma, and additional operative time. Processed nerve allograft avoids that donor-site cost and has therefore become an increasingly attractive alternative, particularly for sensory and smaller mixed-nerve defects. The clinical results are encouraging. A 2023 meta-analysis found ****no significant difference in meaningful sensory or motor recovery between autograft and processed allograft** across the nerve gaps examined; both also performed better than conduits for short sensory gaps. Large multicentre allograft series have similarly reported meaningful recovery in roughly ****80% or more** of repairs, including sensory, mixed, and motor nerves. However, those results need an important qualification: much of the allograft literature consists of uncontrolled observational studies and industry-associated registry data rather than direct randomised comparisons with autograft. A separate systematic review specifically assessing the quality of this evidence concluded that certainty was ****very low** and that the existing literature could not reliably establish equivalence between processed allograft and autograft. The practical takeaway is therefore not that allograft has replaced autograft. ****Autograft remains the most established option when reliable regeneration is critical**, particularly for larger, mixed, or motor nerve gaps, while ****processed allograft is a valuable donor-sparing alternative** in appropriately selected defects. ([Lans](https://pubmed.ncbi.nlm.nih.gov/36728885/?ref=theplasticsfella.com), 2023); ([Frostadottir](https://pmc.ncbi.nlm.nih.gov/articles/PMC10299771/?ref=theplasticsfella.com), 2023); ([Brooks](https://pubmed.ncbi.nlm.nih.gov/22121093/?ref=theplasticsfella.com), 2012); ([Safa](https://pmc.ncbi.nlm.nih.gov/articles/PMC7496926/?ref=theplasticsfella.com), 2020) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Why Are Nerve Transfers Useful in Proximal Nerve Injuries?**](https://onlinelibrary.wiley.com/doi/full/10.1155/2014/698256?ref=theplasticsfella.com) Nerve transfers shorten the distance required for axonal regeneration and typically require only one neurorrhaphy, enabling faster reinnervation of denervated motor targets compared with longer nerve graft pathways. ✅ [****Can a Nerve Conduit Replace an Autograft for Short Gaps?**](https://www.ovid.com/jnls/plasreconsurg/abstract/00006534-199003000-00015~clinical-nerve-reconstruction-with-a-bioabsorbable?ref=theplasticsfella.com) For digital nerve gaps up to 3 cm, bioabsorbable PGA conduits produced good-to-excellent sensory recovery in 86% of reconstructions, while avoiding the donor-site morbidity of nerve grafting. ✅ [****Can Processed Nerve Allografts Restore Meaningful Function?**](https://onlinelibrary.wiley.com/doi/abs/10.1002/micr.20975?ref=theplasticsfella.com) Across sensory, mixed, and motor nerve defects measuring 5-50 mm, processed nerve allografts achieved meaningful recovery in 87% of repairs, with no graft-related adverse events reported. ## Feedback ### I hope you enjoyed it 😄 --- ### 3 Lymphovascular Principles, ICG Mapping, & Our Specialist Edition Is Almost Here URL: https://www.theplasticsfella.com/august-30th/ Last updated: 2026-08-30T02:20:36.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/august-30th/#a-letter-from-pfella) Our first specialist edition is almost here 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-30th/#image-of-the-week) Reading ICG lymphography 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-30th/#technique-tip) ICG-guided lymphatic mapping 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-30th/#what-does-the-evidence-say) Reverse lymphatic mapping in VLNT 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-30th/#articles-of-the-week) Lymphoscintigraphy & lymphedema patterns for LVA. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/august-30th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Our First Specialist Edition Is Almost Here* 👋 A while ago, we mentioned that we were working on something a little different from **The Plastics Paper*: a monthly newsletter focused entirely on one area of plastic surgery. And, the first edition is almost ready! We're starting with **Aesthetics**, and putting this together has helped us work out what we actually want these monthly editions to be. We didn't want just an email filled with links to papers or a long overview of a huge topic. There are already plenty of places to find information. We wanted to build something that you could read in 10-15 minutes and come away thinking a little differently about a problem you might actually see in clinic. The first edition is a good example. We're focusing entirely on **periorbital assessment**. First, we bring up a clinical question with context. From there, we work through the findings that might change your plan, how to do the assessment, the common misconceptions you might fall into, and eventually the decision itself ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/ChatGPT-Image-Aug-26--2026--01_56_08-PM-1.png) Coming Soon! With these specialist editions, we planned on going in the direction of recreating a clinical scenario you will likely come across. Each month, we want to take **one useful clinical problem and properly work through it**, with input from P'Fella's specific department. Our current structure is: The case, assessment, thinking behind the decision, what to avoid, and evidence worth knowing. Aesthetics is where we're starting, and if this format works, there's plenty of room to take it into the other departments we're building too. Each specialty has those decisions and principles that are difficult to pick up from reading facts alone, and I'd love for these editions to become somewhere we can unpack them properly. For now, we're doing the finishing touches on Edition 1. If this **specialist aesthetics newsletter** is something you're interested in, join the mailing list below, and we'll send you the first edition when it goes live. Hope you enjoy what we've been building. P’Fella ❤️ ## Image of the Week **Reading ICG Lymphography* 🖼️ ****Image of the Week** These four ****Indocyanine green (ICG) lymphography** patterns show the progression from normal lymphatic flow to **increasingly abnormal dermal backflow**. A ****linear pattern** represents normal collecting lymphatics. With lymphatic dysfunction, this changes to ****splash**, then ****stardust**, and eventually a ****diffuse pattern** as lymphatic damage becomes more severe. These changes can appear ****before obvious swelling develops**, making ICG lymphography particularly useful for detecting early lymphatic dysfunction. It also provides real-time mapping of superficial lymphatic flow, which can help identify suitable lymphatics for LVA. ![Reading ICG Lymphography](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/Untitled-design--11-.png) Reading ICG Lymphography - [Source](https://www.jvsvenous.org/article/S2213-333X%2812%2900013-3/pdf?ref=theplasticsfella.com) ## Technique Tip **ICG-Guided Lymphatic Mapping* 🚑 ****Technique Tip of the Week** ****ICG lymphography** uses near-infrared fluorescence to provide real-time visualisation of superficial lymphatic drainage. Following injection, movement of ICG through afferent lymphatic vessels can be followed towards the regional nodal basin, allowing lymphatic channels and sentinel nodes to be identified intraoperatively. In this operative segment, ICG demonstrates ****defined lymphatic transit towards the axilla**, with an afferent lymphatic channel leading to two fluorescent sentinel nodes. The fluorescence overlay allows these structures to be localised relative to the surrounding surgical anatomy during dissection. ## What Does the Evidence Say? **Reverse Lymphatic Mapping in VLNT* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. One of the main concerns with groin-based vascularized lymph node transfer (VLNT) is ****donor-site lymphedema**. The key anatomical problem is that the groin contains lymph nodes draining both the ****lower limb** and the ****trunk**. Reverse lymphatic mapping was developed to distinguish between these drainage territories, allowing surgeons to harvest trunk-draining nodes while preserving nodes responsible for lower-extremity lymphatic drainage. The original prospective PRS description used differential tracers to identify limb-draining versus trunk-draining nodes during VLNT harvest. Subsequent work refined the technique using ****indocyanine green (ICG) and blue dye**, showing that ICG mapping identified the same key lower-extremity draining nodes as technetium-99 mapping in all 39 patients studied, with no donor-site lymphedema reported. More recent prospective JPRAS data are similarly reassuring: among 51 patients undergoing groin VLNT with reverse lymphatic mapping, ****none developed a lower-extremity volume difference greater than 10% at 12 months**. The practical takeaway is that reverse lymphatic mapping should be viewed as a ****risk-reduction strategy, not a guarantee**. The evidence is still based mainly on prospective cohort studies rather than randomized trials, but it consistently supports the same principle: if lymph nodes are being harvested from a basin that also drains an uninvolved limb, identifying and preserving those limb-draining nodes is one of the most defensible ways to reduce the risk of creating a new lymphedema problem while treating another. ([Chang](https://pubmed.ncbi.nlm.nih.gov/35919888/?ref=theplasticsfella.com), 2022); ([Schaverien](https://pmc.ncbi.nlm.nih.gov/articles/PMC5891655/?ref=theplasticsfella.com), 2018); ([Pajula](https://pubmed.ncbi.nlm.nih.gov/39226714/?ref=theplasticsfella.com), 2024); ([Pons](https://pubmed.ncbi.nlm.nih.gov/33565822/?ref=theplasticsfella.com), 2021); ([Dayan](https://pubmed.ncbi.nlm.nih.gov/25285683/?ref=theplasticsfella.com), 2015) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****When Lymphoscintigraphy Changes the Diagnosis**](https://jnm.snmjournals.org/content/44/1/43.full?ref=theplasticsfella.com) Quantitative lymphoscintigraphy detected abnormal lymphatic function in all 308 affected limbs in one cited series, including mild cases missed by qualitative imaging, highlighting its value when early lymphedema is clinically subtle. ✅ [****When Swelling Isn’t Lymphedema**](https://www.jvascsurg.org/article/0741-5214%2893%2990331-F/pdf?ref=theplasticsfella.com) Lymphoscintigraphy distinguished lymphedema from other causes of limb swelling, with 80% sensitivity and 94% specificity, and excluded lymphedema in approximately one-third of referred patients. ✅ [****Which Lymphedema Pattern Is Best for LVA?**](https://onlinelibrary.wiley.com/doi/10.1002/micr.20772?ref=theplasticsfella.com) Among 142 limbs classified by lymphoscintigraphy, type III - dermal backflow involving both the thigh and leg - was identified as the most favourable pattern for lymphaticovenous anastomosis. ## Feedback ### I hope you enjoyed it 😄 --- ### Breaking the Rules, 4 Replantation Tips, & the 6-Hour Principle URL: https://www.theplasticsfella.com/august-23rd/ Last updated: 2026-08-22T21:27:19.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/august-23rd/#a-letter-from-pfella) When should you break the rules? 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-23rd/#image-of-the-week) When you cannot replant yet 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-23rd/#technique-tip) Multiple digit replantation 4. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/august-23rd/#how-i-operate) Snippet from ep 4: A small anatomical detail with a big impact 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-23rd/#what-does-the-evidence-say) Can digital replantation wait until morning? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-23rd/#articles-of-the-week) Temporary ectopic replantation, & replant survival vs functional recovery. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/august-23rd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **When Should You Break the Rules?* 👋 Surgery is full of rules. Mark this many centimetres from that landmark. Raise the flap this way. Preserve this structure. Close it in this order. Most of them are necessary, especially when you’re starting out. They give you a safe way to think before you’ve built enough experience to know why these rules are in place. They give you something reproducible to fall back on when you don’t yet have the experience to make every decision for yourself. But at some point, you start noticing that the best surgeons don’t follow every rule blindly. That comes up repeatedly whenever I sit down with an expert for a recording of [*How I Operate*](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com). Over the last few months, we’ve had the chance to sit down with Elizabeth Hall-Findlay, JP Hong, Fouad Nahai, Claudio Angrigiani, and most recently, Pedro Cavadas. Five very different surgeons with five very different careers. And there’s something they seem to have in common. At some point, each of them looked at something they had been taught and asked: **Does it actually have to be done this way?** Elizabeth Hall-Findlay spoke about first learning the accepted way to perform breast reduction, then gradually changing her approach as her own experience and understanding developed. Foad Nahai made a similar point from a different angle: plastic surgery gives us enormous freedom to innovate, but that freedom has to sit alongside knowing your limitations and remembering who lives with the consequences. Our next conversation with Pedro Cavadas (releasing on 30th August!) probably brought this idea out more than any other. There were several moments where Pedro described doing something differently from how many of us are taught. His approach to venous anastomoses is one example. Rather than accepting that two veins must always be better than one, his preference is often to concentrate on making one anastomosis as good as it can possibly be. His sequence for replantation is different too, because over thousands of cases he has found an order that works better in his hands. None of this means the rules are useless. Quite the opposite. You probably need to understand them extremely well before you can recognise when there might be a better way. So, the takeaway is: **The goal isn’t to become confident enough to ignore the rules. It’s to become experienced enough to understand why they exist.** P’Fella ❤️ ## Image of the Week **When You Cannot Replant Yet* 🖼️ ****Image of the Week** This week's image shows ****temporary ectopic replantation**, where amputated digits are attached to a different part of the body to keep them viable until definitive reconstruction is possible. Here, the middle, ring, and little fingers were temporarily replanted onto the ****dorsum of the foot**, using the dorsal foot vasculature to restore circulation. Severe crush, avulsion, and soft-tissue injuries can leave the original recipient site unsuitable for immediate replantation. Ectopic replantation effectively ****“banks” living tissue**, buying time to debride and reconstruct the injured hand while preserving potentially salvageable digits. ![Ectopic multiple digit replantation salvage of hand torsion injury following anterolateral thigh perforator flap coverage](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/gr2_lrg.jpg) Temporary Ectopic Replantation - [Source](https://www.jprasopen.com/article/S2352-5878%2823%2900069-4/fulltext?ref=theplasticsfella.com#fig0002) ## Technique Tip **Multiple Digit Replantation* 🚑 ****Technique Tip of the Week** This operative video demonstrates ****five-digit replantation**, including bone fixation, tendon, nerve, and vessel repair, followed by postoperative recovery. Replantation following ****amputation of multiple digits and the thumb** requires systematic reconstruction of the key skeletal, tendinous, vascular, and neural structures, with microsurgical vessel repair critical to restoring perfusion to each replanted digit. The challenge extends beyond survival of the digits to achieving meaningful functional recovery. ## How I Operate **Snippet From Ep 4: A Small Anatomical Detail With a Big Impact* 🎙️ Snippet from Episode 4 of ****How I Operate:** A small anatomical detail with a big impact. Dr. Elizabeth Hall-Findlay breaks down the thinking behind the ****true superomedial pedicle** in breast reduction. She explains why preserving the second and third interspace vessels matters, why the blood supply is more superficial than many surgeons assume, and why the parenchyma itself is not what keeps the nipple alive. 0:00 /1:43 1× [Listen Now](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## What Does the Evidence Say? **Can Digital Replantation Wait Until Morning?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Ischaemia time has traditionally driven the urgency of digital replantation, with commonly quoted limits of approximately ****6 hours warm and 12 hours cold ischaemia**. However, the evidence behind these rigid cut-offs is surprisingly weak. Digits contain very little muscle and therefore tolerate ischaemia considerably better than major limb amputations, particularly when the amputated part is promptly and correctly cooled. Pedro Cavadas and colleagues tested this directly in ****597 digital replantations**. Carefully selected injuries presenting in the evening were delayed until the following morning if they had less than 12 hours of preceding ischaemia and no major contamination. Survival was ****93.4% after overnight-delayed replantation versus 91.2% after immediate replantation**, with no significant difference between groups. Similar results have been reported with delayed or staged replantation, while newer pooled evidence suggests that ****cold preservation substantially extends the tolerated ischaemic window**. Conversely, prolonged **warm* ischaemia remains important: survival is better within the first 6 hours than after 6-12 hours of warm ischaemia. The practical lesson is therefore not that ****time no longer matters**, but that it should not be considered in isolation. Injury mechanism, appropriate preservation, smoking, vessel quality, and the reconstructive requirements of the digit also influence survival. This evidence should ****not** be extrapolated to proximal limb amputations containing substantial muscle, where prolonged ischaemia carries very different consequences. ([Cavadas](https://pubmed.ncbi.nlm.nih.gov/29751978/?ref=theplasticsfella.com), 2018); ([Harbour](https://pubmed.ncbi.nlm.nih.gov/34376294/?ref=theplasticsfella.com), 2021); ([Fijany](https://pubmed.ncbi.nlm.nih.gov/38725110/?ref=theplasticsfella.com), 2024); ([Li](https://pubmed.ncbi.nlm.nih.gov/18766047/?ref=theplasticsfella.com), 2008); ([Woo](https://pubmed.ncbi.nlm.nih.gov/25746146/?ref=theplasticsfella.com), 2015) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Temporary Ectopic Replantation as Salvage After Replant Failure**](https://pubmed.ncbi.nlm.nih.gov/16516743/?ref=theplasticsfella.com) When infection threatened an initially successful arm replantation, temporary transfer to the groin preserved the limb until the recipient site was suitable for definitive replantation. ✅ [****Ectopic Replantation to Enable Definitive Testicular Reattachment**](https://www.jprasurg.com/article/S1748-6815%2807%2900225-2/abstract?ref=theplasticsfella.com) Following traumatic testicular avulsion, temporary forearm replantation preserved the testis while enabling creation of a longer vascular pedicle for subsequent microsurgical transfer back to the perineum. ✅ [****Replant Survival Does Not Equal Functional Recovery**](https://www.sciencedirect.com/science/article/abs/pii/0363502389900543?ref=theplasticsfella.com) Among 261 replanted or revascularized hands and digits, survival reached 82%, yet intrinsic muscle recovery remained poor, highlighting the important distinction between successful tissue salvage and meaningful functional restoration. ## Feedback ### I hope you enjoyed it 😄 --- ### Bringing Plastics Education Live, 5 Lower Limb Recon Principles, & The 72-Hour Rule URL: https://www.theplasticsfella.com/august-16th/ Last updated: 2026-08-14T12:40:04.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/august-16th/#a-letter-from-pfella) Beyond articles: Bringing Plastics education live 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-16th/#image-of-the-week) Extending the reach of reconstruction 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-16th/#technique-tip) Anterolateral Thigh (ALT) free flap harvest 4. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/august-16th/#how-i-operate) How I Operate with Dr. Elizabeth Hall-Findlay 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-16th/#what-does-the-evidence-say) Does the 72-hour rule still matter? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-16th/#articles-of-the-week) The superficial femoral artery, pedicled vs. free flaps, & ALT vs. latissimus dorsi free flaps. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/august-16th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Beyond Articles: Bringing Plastics Education Live* 👋 As you already know, we're constantly brainstorming ways to make plastics education more accessible. So, we've been thinking, what comes after the articles and the Foundations textbook? For years, our focus has been on building resources that you can come back to whenever you need them. Articles, illustrations, podcasts, newsletters, and now we're expanding into department-based resources. That's still at the heart of what we do. But the more we speak to people around the world, the more we realise that there's something those resources can't fully replace: learning together. There's something different about being able to ask a question in real time. To hear why a consultant made one decision over another. To spend an hour diving into a single topic instead of trying to piece it together from ten different sources. That's the direction we've started thinking about. At the moment, it's just an idea. But it's an idea we're quite excited about. We're exploring the possibility of running live, department-based webinars with our department heads and the experts we're already working alongside. Rather than trying to cover everything at once, we'd focus on one subject at a time. It could be a single evening webinar on facelift planning. Eventually, we'd like to turn it into something longer-term, like a small cohort spending five evenings working through facial aesthetics together. We don't want to conduct lectures for the sake of lectures, but sessions that are practical, interactive, and centred around what people actually want to learn. Naturally, our plan is to start with the Aesthetics Department. We've already built an incredible group of people around it, and it feels like the right place to begin. If it works well, we'd love to gradually bring the same format to lymphovascular surgery, hand surgery, burns, and the other departments we're building. We're still very much at the drawing board, so we're not looking for detailed feedback just yet. We'd simply like to know whether this is something you'd actually attend. If a live cosmetics webinar sounds interesting to you, let us know. We'll keep you updated as the idea develops and let you know when we're launching the first session. P’Fella ❤️ ## Image of the Week **Extending the Reach of Reconstruction* 🖼️ ****Image of the Week** This case demonstrates one of the most challenging scenarios in lower limb reconstruction: ****when the defect extends beyond what a single free flap can reliably reach.** In patients with devastating lower limb trauma and ****no usable recipient vessels**, the healthy limb can temporarily provide the blood supply needed for reconstruction. Once the transferred tissue has established its own circulation, the bridge is divided, leaving durable soft tissue coverage where conventional reconstruction would otherwise be impossible. ![Recipient Vessel Selection for Vessel-Depleted Lower Limbs](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/gr3_lrg--1-.jpg) Recipient Vessel Selection for Vessel-Depleted Lower Limbs - [Source](https://www.jprasurg.com/article/S1748-6815%2825%2900663-1/abstract?ref=theplasticsfella.com) ## Technique Tip **Anterolateral Thigh (ALT) Free Flap Harvest* 🚑 ****Technique Tip of the Week** The ****anterolateral thigh (ALT) flap** is the workhorse free flap for lower limb reconstruction, providing a long vascular pedicle, reliable perforators, and ample soft tissue with minimal donor-site morbidity. Its versatility allows reconstruction of traumatic defects ranging from exposed bone and tendon to complex Gustilo IIIB fractures. This operative video demonstrates the key steps of ALT flap harvest, including ****perforator identification**, ****intramuscular pedicle dissection**, and ****flap elevation**. ## How I Operate **How I Operate with Dr. Elizabeth Hall-Findlay* 🎙️ If you haven’t listened yet, the new episode of ****How I Operate** is out now! Ryan Sugrue sits down with ****Elizabeth Hall-Findlay** for a conversation on breast reduction, mastopexy, and the evolution of modern breast surgery. This episode explores how surgical ideas develop over time, through anatomy, experience, honest reflection, and the willingness to question long-held assumptions. 0:00 /1:18 1× [Listen Now](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## What Does the Evidence Say? **Does the 72-Hour Rule Still Matter?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Marko Godina’s landmark 1986 PRS paper established the principle that ****early free-flap reconstruction after severe extremity trauma improves outcomes**. In his 532-patient series, reconstruction within 72 hours was associated with markedly lower flap failure and infection than reconstruction performed later. This became the foundation for modern orthoplastic practice and the “fix-and-flap” philosophy. Subsequent evidence has largely supported the principle of ****early definitive coverage**, even if the exact 72-hour threshold is less absolute than once thought. Meta-analysis has shown that reconstruction within 72 hours is associated with lower flap failure, infection, and need for additional procedures compared with delayed reconstruction. More recent pooled data in open lower-extremity fractures similarly found that coverage within 72 hours was associated with a ****52% lower risk of infection**, while coverage within 7 days was also associated with a ****50% reduction in infection** and lower nonunion risk. The practical message is therefore less “72 hours or failure” and more ****cover early once adequate debridement, fixation, and patient optimisation have been achieved**. Contemporary series suggest that reconstruction between 72 hours and roughly 7-10 days can still produce good outcomes, but prolonged delay is consistently associated with increasing infectious and wound complications. ([Godina](https://pubmed.ncbi.nlm.nih.gov/3737751/?ref=theplasticsfella.com), 1986); ([Gopal](https://pubmed.ncbi.nlm.nih.gov/11041582/?ref=theplasticsfella.com), 2000); ([Haykal](https://pubmed.ncbi.nlm.nih.gov/29536455/?ref=theplasticsfella.com), 2018); ([Tiongco](https://pubmed.ncbi.nlm.nih.gov/40487829/?ref=theplasticsfella.com), 2025); ([Habarth-Morales](https://pubmed.ncbi.nlm.nih.gov/39191415/?ref=theplasticsfella.com), 2025) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Distance Shouldn't Deter You from the Right Recipient Vessel**](https://www.jprasopen.com/article/S2352-5878%2824%2900123-2/fulltext?ref=theplasticsfella.com#fig0002) Despite its distance from the defect, the superficial femoral artery provides reliable anatomy, robust blood flow, and excellent outcomes, making it a valuable option for complex knee reconstruction when local recipient vessels are compromised. ✅ [****Pedicled Flaps Deserve First Consideration**](https://www.sciencedirect.com/science/article/abs/pii/S174868150600101X?ref=theplasticsfella.com) This review found that pedicled flaps achieved outcomes comparable to free flaps with fewer and less severe complications, supporting them as the preferred first-line option for many distal leg and foot soft tissue defects. ✅ [****ALT Flap Delivers Better Cosmetic Outcomes**](https://pubmed.ncbi.nlm.nih.gov/29078226/?ref=theplasticsfella.com) Both ALT and latissimus dorsi free flaps achieved similar long-term functional results for distal lower limb reconstruction, but the ALT flap offered better aesthetics and lower donor site morbidity. ## Feedback ### I hope you enjoyed it 😄 --- ### Updating Plastics Pro, 3 Breast Reconstruction Decisions, & Hall-Findlay on How I Operate URL: https://www.theplasticsfella.com/august-9th/ Last updated: 2026-08-07T12:33:26.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/august-9th/#a-letter-from-pfella) Help us build the next version of Plastics Pro 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-9th/#image-of-the-week) Preoperative planning and dermal flap design for breast reduction 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-9th/#technique-tip) C-V flap for nipple reconstruction 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/august-9th/#building-in-public) Monthly specialist newsletter: Aesthetics department 5. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/august-9th/#how-i-operate) Upcoming episode of How I Operate: Elizabeth Hall-Findlay 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-9th/#what-does-the-evidence-say) Is a free nipple graft still necessary? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-9th/#articles-of-the-week) Breast reduction, pedicle choice, and superomedial pedicle safety. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/august-9th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Help Us Build The Next Version of Plastics Pro* 👋 If we were building Plastics Pro from scratch **today*, what would it look like? It's an exciting question because the landscape of digital education is very different from when we first started. Back then, the goal was simply to create better educational articles. Since then, we've added podcasts, newsletters, illustrations, visual learning tools, and the Foundations textbook with its annual updates. What started as a library of articles has gradually become something much bigger. Now we're at another one of those moments where we need to stop at think before we move forward. There are lots of directions we want to take. We could focus entirely on the articles themselves, making them more visual and interactive. We could build out every specialty department so articles are continually reviewed and updated by dedicated teams of experts and trainees. We could expand the podcast, create comprehensive flashcard decks for exam preparation, or come up with entirely new ways of learning that we haven't even thought of yet. The reality is that we can't build everything at once. That's why we'd like to hear from the people who use Plastics Pro every day. Rather than deciding what the future should look like ourselves, we'd much rather build around those who use the platform regularly. If one feature would genuinely make a difference to your training, we'd love to know and build it for you. Another thing we're considering is the best way to structure subscriptions in a way that's fair, flexible, and sustainable for everyone. So, let us know your thoughts below. Thank you for helping us build this together. P’Fella ❤️ ## Image of the Week **Preoperative Planning and Dermal Flap Design for Breast Reduction* 🖼️ ****Image of the Week** This image demonstrates preoperative marking and pedicle planning for breast reduction. The superomedial pedicle is outlined along the breast meridian, preserving reliable vascularity to the NAC, while the Wise pattern markings define the final skin envelope. Importantly, the dermal flap design can be extended medially and laterally, allowing the surgeon to tailor resection and shaping to the patient’s anatomy. ![Breast Reduction Preoperative Markings ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/08/Screenshot-2026-08-07-at-01.09.32.png) Breast Reduction Preoperative Markings - [Source](https://www.researchgate.net/publication/336650978%5FModification%5Fof%5Fthe%5FSuperomedial%5FPedicle%5Fin%5FWise-Pattern%5FBreast%5FReduction%5FNew%5FSling%5FSuspension%5FTechnique%5Fto%5FPrevent%5FPseudo%5FPtosis/fulltext/5da9e68f92851c577eb83b82/Modification-of-the-Superomedial-Pedicle-in-Wise-Pattern-Breast-Reduction-New-Sling-Suspension-Technique-to-Prevent-Pseudo-Ptosis.pdf?ref=theplasticsfella.com) ## Technique Tip **C-V Flap for Nipple Reconstruction* 🚑 ****Technique Tip of the Week** The ****C-V flap** is one of the most widely used techniques for nipple reconstruction following breast reconstruction. By combining local skin flaps to create nipple projection with a ****full-thickness skin graft** for the areola, it provides reliable contour, colour match, and long-term aesthetic outcomes. This operative video demonstrates the key steps of C-V flap design, flap elevation, nipple inset, and full-thickness skin graft application for reconstruction of the nipple-areolar complex. ## Building in Public **Monthly Specialist Newsletter: Aesthetics Department* 🌐 One project we've announced on a previous Plastics Paper and have been working on is a new monthly specialist newsletter. Unlike **The Plastics Paper*, which covers different plastics topics each week, this will be dedicated to ****one subspecialty every month**. We want to bring together landmark papers, expert insights, clinical pearls, and practical ways of thinking about a specialty. And we're starting with ****Aesthetics**. We're now opening a waiting list while we build the first edition. If you'd like to receive the ****monthly Aesthetics newsletter**, join the mailing list below. ## How I Operate **Upcoming Episode of How I Operate: Elizabeth Hall-Findlay* In this clip, Dr. Elizabeth Hall-Findlay explains one of the key shifts in her approach to breast reduction and mastopexy: stop relying on skin to hold shape, and start thinking about the parenchyma. Remove the excess where it is. Rearrange what needs support. Episode release on Monday! 0:00 /1:04 1× [Subscribe & Stay Tuned!](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## What Does the Evidence Say? **Is a Free Nipple Graft Still Necessary?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Free nipple grafting was traditionally recommended for extreme breast hypertrophy because shortening the pedicle was thought to reduce the risk of nipple-areola complex necrosis. It remains a useful option when pedicle perfusion is genuinely unreliable or when patient and operative factors make a shorter procedure preferable. However, grafting disconnects the nipple-areola complex from its nerves, ducts, and native blood supply, leading to loss of breastfeeding potential and less predictable sensation, pigmentation, and projection. Modern evidence increasingly challenges the idea that breast size, resection weight, or a long sternal-notch-to-nipple distance should automatically trigger free nipple grafting. Nipple-sparing reductions using inferior, medial, or superomedial pedicles have been successfully performed in patients with severe ptosis and very large resections, with low rates of complete nipple loss. A contemporary systematic review found complete nipple-areola complex necrosis to be uncommon after nipple-sparing gigantomastia reduction, although the underlying studies were mostly retrospective and used inconsistent definitions of gigantomastia. Direct comparative evidence also favours considering an elongated pedicle when technically feasible. In patients with gigantomastia, extended-pedicle reduction produced a similar overall safety profile to free nipple grafting, but better patient-reported nipple satisfaction and superior assessed breast and nipple aesthetics. Free nipple grafting should be treated as a selective or rescue technique rather than an automatic response to a large breast or long pedicle. The decision should instead reflect intraoperative perfusion, pedicle anatomy, comorbidities, smoking, previous surgery, and the patient’s priorities regarding sensation, lactation, pigmentation, and breast shape. ([Courtiss](https://pubmed.ncbi.nlm.nih.gov/847026/?ref=theplasticsfella.com), 1977); ([Chang](https://pubmed.ncbi.nlm.nih.gov/8988769/?ref=theplasticsfella.com), 1996); ([Zelko](https://pubmed.ncbi.nlm.nih.gov/36796050/?ref=theplasticsfella.com), 2023); ([Chetty](https://pubmed.ncbi.nlm.nih.gov/28272856/?ref=theplasticsfella.com), 2016); ([Talwar](https://academic.oup.com/asj/article/43/2/NP91/6717638?ref=theplasticsfella.com), 2022) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Breast Reduction Is as Much Geometry as Surgery**](https://www.sciencedirect.com/science/article/abs/pii/S0007122654800464?ref=theplasticsfella.com) Classic breast reduction principles support avoiding excessive undermining and staging large reductions as key to preventing nipple necrosis and achieving symmetrical, aesthetically balanced outcomes. ✅ [****Pedicle Choice Determines Both Shape and Survival in Vertical Breast Reduction**](https://www.plasticsurgery.theclinics.com/article/S0094-1298%2802%2900008-1/abstract?ref=theplasticsfella.com) Modern vertical breast reduction hinges on selecting a pedicle that reliably preserves NAC vascularity while allowing effective reshaping, reflecting an evolution from staged safety-focused techniques to single-stage procedures that balance blood supply, projection, and scar minimisation. ✅ [****Superomedial Pedicle Safety Depends on Preserving Superficial Neurovascular Anatomy**](https://www.sciencedirect.com/science/article/abs/pii/S1748681509000680?ref=theplasticsfella.com) In Hall-Findlay breast reduction, the NAC blood supply and innervation run superficially within the pedicle, so aggressive thinning or de-epithelialisation risks necrosis and denervation, making deep-plane resection the safer strategy for large-volume reductions. ## Feedback ### I hope you enjoyed it 😄 --- ### Teaching Surgery Visually, 4 Hand Surgery Principles, & Zone II Repair URL: https://www.theplasticsfella.com/august-2nd/ Last updated: 2026-07-31T11:46:45.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/august-2nd/#a-letter-from-pfella) Teaching plastic surgery is becoming more visual 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-2nd/#image-of-the-week) Retrograde venous flap for dorsal finger reconstruction 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-2nd/#technique-tip) Zone II flexor tendon repair 4. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/august-2nd/#how-i-operate) Designing the perfect PIA flap with Professor Claudio Angrigiani 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-2nd/#what-does-the-evidence-say) Dupuytren’s treatment: Recovery vs durability 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-2nd/#articles-of-the-week) Hand vascular anatomy, and metacarpal & phalangeal fractures 7. 💕 [****Feedback**](https://www.theplasticsfella.com/august-2nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Teaching Plastic Surgery Is Becoming More Visual* 👋 Lately, we've spent a lot of time thinking about recently is how difficult it can be to explain a three-dimensional operation using two-dimensional resources. You can describe an anatomical relationship in a paragraph, but sometimes a single illustration communicates the idea instantly. That's always been one of the challenges in surgical education. Not every concept has a good image to accompany it. Even when one exists, using it isn't always straightforward. Clinical photographs require consent and meticulous attention to patient confidentiality, while illustrations and published figures are often protected by copyright. By the time you've navigated permissions, documentation, and licensing, creating educational content can become a project in itself. Over the last few months, we've been building a new image generation platform by The Plastics Fella. It's something we've experimented with for a while, and the technology has improved dramatically over the past three months. We're now at the point where it can generate clinically accurate anatomy and patient illustrations that are useful for teaching and learning. The actual challenge isn't creating the images. It's making them educational. We're currently developing tools that allow us to label structures, highlight anatomical landmarks, compare clinical photographs, and annotate illustrations in a way that's accurate and easy to understand. Instead of simply looking at an image, you'll be able to create it, test yourself, and understand how a clinical concept actually works. I'm excited to share a few early examples of what we've been working on. We currently have a range of simplified anatomical illustrations to clinical photographs paired with interactive labels. They're still works in progress, but this is making impressive progress and I'm hoping to share it with you soon. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/WhatsApp-Image-2026-07-30-at-10.13.56-1.jpeg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/WhatsApp-Image-2026-07-31-at-01.15.05.jpeg) Visual Tool for Plastic Surgery Learning Our goal has always been the same: make plastic surgery easier to learn. If better tools help someone understand anatomy a little faster or remember an operation for longer, then they're worth building. P’Fella ❤️ ## Image of the Week **Retrograde Venous Flap for Dorsal Finger Reconstruction* 🖼️ ****Image of the Week** This case shows a complex dorsal finger defect following trauma, with tendon adhesions and joint pathology requiring tenoarthrolysis and joint replacement. The key reconstructive step is the use of a ****retrograde free venous flap** harvested from the forearm. Unlike conventional arterial flaps, this technique uses a ****venous conduit that is arterialised**, with the vein anastomosed to a digital artery to provide inflow. This allows thin, pliable tissue coverage, which is ideal for the dorsum of the finger while preserving contour and enabling tendon gliding. The sequence highlights the principle clearly: restore function first (joint and tendon), then provide ****appropriate soft tissue coverage** that won’t compromise movement. ![Retrograde Venous Flap for Dorsal Finger Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/medicina-58-01065-g004b-550.jpg) Retrograde Venous Flap for Dorsal Finger Reconstruction - [Source](https://www.mdpi.com/1648-9144/58/8/1065?ref=theplasticsfella.com) ## Technique Tip **Zone II Flexor Tendon Repair* 🚑 ****Technique Tip of the Week** ****Zone II** remains one of the most technically demanding regions for ****flexor tendon repair**. Success depends on meticulous tendon handling, a strong core suture construct, preservation of the pulley system where possible, and a repair that permits early controlled mobilisation without excessive bulk or gapping. This operative video demonstrates a Zone II flexor tendon repair, highlighting ****tendon retrieval**, ****core and epitendinous suturing**, and ****techniques** to achieve a smooth repair that glides freely within the flexor sheath. ## How I Operate **Designing the Perfect PIA Flap with Professor Claudio Angrigiani* Episode 3 of ****How I Operate** is out! 🎙️ Professor Claudio Angrigiani challenges the way we describe “fasciocutaneous” flaps. His point is simple: a flap is skin and subcutaneous tissue transferred while preserving its vascularisation. The fascia may help with dissection or handling, but it is not necessarily what carries the blood supply. So, include the fascia if it helps the operation, but don’t confuse fascia with the flap. [Listen Now!](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## What Does the Evidence Say? **Dupuytren’s Treatment: Recovery vs Durability* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Treatments for Dupuytren’s contracture correct the deformity but do not cure the underlying disease. The main decision is therefore a trade-off between ****rapid recovery and long-term durability**. Percutaneous needle fasciotomy and collagenase injection can be performed without open excision and generally allow an earlier return to hand use. Limited fasciectomy requires surgery and a longer recovery, but removes the affected fascia rather than simply dividing or dissolving the cord. Long-term evidence favours limited fasciectomy for durability. In a randomised comparison, recurrence at five years was ****84.9% after needle fasciotomy versus 20.9% after limited fasciectomy**, although many patients still preferred the minimally invasive procedure because of its quicker recovery and lower treatment burden (van Rijssen et al., 2012). More recent randomised evidence found that collagenase produced ****worse patient-reported hand outcomes** than limited fasciectomy at one and two years and was associated with more recurrent contractures requiring reintervention (****8% vs 1.7%**). However, moderate-to-severe complications were less frequent after collagenase (****2% vs 5%**). The practical takeaway is that there is no universally superior treatment. Minimally invasive procedures may suit older patients, those seeking rapid recovery, or those willing to accept repeat treatment. Limited fasciectomy offers a more durable correction and appears particularly valuable for more advanced contractures, but this must be balanced against its greater surgical and recovery burden. Treatment choice should therefore be based not only on the initial correction, but on how the patient values ****recovery time, procedural risk, and the likelihood of recurrence**. ([van Rijssen](https://journals.lww.com/plasreconsurg/abstract/10.1097/prs.0b013e31823aea95~five-year-results-of-a-randomized-clinical-trial-on?redirectionsource=fulltextview&ref=theplasticsfella.com), 2012); ([Dias](https://www.nejm.org/doi/10.1056/NEJMoa2312631?ref=theplasticsfella.com), 2024); ([Hurst](https://www.nejm.org/doi/full/10.1056/NEJMoa0810866?ref=theplasticsfella.com), 2009); ([Rodrigues](https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010143.pub2/full?ref=theplasticsfella.com), 2015) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Understanding Hand Vascular Anatomy for Flap Design**](https://www.sciencedirect.com/science/article/pii/S0749071219300873?ref=theplasticsfella.com) This review maps the radial, ulnar, and interosseous arterial systems and their perforators, showing how their interconnected arches and digital branches underpin the design and reliability of local and regional hand flaps. ✅ [****Metacarpal and Phalangeal Shaft Fractures: Treatment**](https://journals.lww.com/jaaos/abstract/00124635-200003000-00005~operative-treatment-of-metacarpal-and-phalangeal-shaft?redirectionsource=fulltextview&ref=theplasticsfella.com) Stable fractures can be managed nonoperatively, but when fixation is required, outcomes depend less on the hardware and more on preserving soft tissue and restoring precise rotational alignment to maintain hand function. ✅ [****Function Over Radiographic Perfection in Metacarpal Fractures**](https://www.sciencedirect.com/science/article/abs/pii/S0894113003800091?ref=theplasticsfella.com) Metacarpal fracture management should prioritise function over radiographic perfection, as operative fixation can improve alignment but risks stiffness, making careful patient and fracture selection critical. ## Feedback ### I hope you enjoyed it 😄 --- ### Angrigiani on How I Operate, 3 PIA Flap Principles, & Team Updates URL: https://www.theplasticsfella.com/july-26th/ Last updated: 2026-07-26T11:01:14.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/july-26th/#a-letter-from-pfella) What makes someone an expert? 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-26th/#image-of-the-week) PIA flap pedicle identification 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/july-26th/#technique-tip) Reverse posterior interosseous artery flap 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/july-26th/#building-in-public) This month at The Plastics Fella 5. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/july-26th/#how-i-operate) New episode coming this Monday! 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-26th/#what-does-the-evidence-say) Preventing venous congestion in the reverse PIA flap 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-26th/#articles-of-the-week) Posterior interosseous artery flap: making it more reliable & “reverse” PIA flap 8. 💕 [****Feedback**](https://www.theplasticsfella.com/july-26th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **What Makes Someone an Expert?* 👋 One of the unexpected things about recording **How I Operate* has been realising that the conversations rarely end up being about operations. You go into them expecting to talk about flap design, anatomy, or techniques. However, you also end up talking about the way experts think. The principles they come back to. The questions they asked decades ago that they're still asking today. There seems to be a common thread running through all of them. When we spoke to Professor JP Hong, the conversation wasn't only about the SCIP flap. It was about understanding anatomy well enough to simplify reconstruction and make it more reliable. With Professor Foad Nahai, it wasn't simply how the Mathes and Nahai classification came to life. It was about taking something incredibly complex and turning it into a framework that thousands of surgeons could immediately understand and apply. Our next episode, releasing on Monday with Professor Claudio Angrigiani, felt remarkably similar. Although he's well known for developing the Posterior Interosseous Artery (PIA) flap, much of our discussion wasn't about the flap itself. It was about the years spent studying anatomy, questioning accepted ideas, and refining a concept until it became dependable enough that another surgeon could reproduce it with confidence. The ideas that stand the test of time all seem to share a few characteristics. They aren't necessarily the most complicated or the most technically impressive. They're grounded in anatomy. They're logical, reproducible, and most importantly, teachable. Perhaps that's what expertise really looks like. Not simply knowing more than everyone else, but being able to organise knowledge in a way that makes other people better surgeons. The people who shape our specialty don't just contribute new techniques. They create frameworks, refine principles, and simplify complex ideas until they're accessible to everyone else. That's what allows good ideas to spread, evolve, and remain relevant for decades. If these podcast recordings have taught me anything, it's that the most valuable lessons rarely come from hearing *what* someone does. They come from understanding *why* they think the way they do. P’Fella ❤️ ## Image of the Week **PIA Flap Pedicle Identification* 🖼️ ****Image of the Week** This intraoperative image captures the key step that made the PIA flap reliable: identification of the pedicle within the septum between the extensor digiti minimi (EDM) and extensor carpi ulnaris (ECU). The ****septocutaneous plane** consistently contains the ****posterior interosseous artery** and its perforators. Here, the fascia is opened to expose the pedicle, with small perforating branches visible. This anatomical basis allows safe flap elevation without sacrificing a major vessel to the hand. ![Posterior Interosseous Artery Flap Pedicle Identification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/gr1_lrg--1-.jpg) Posterior Interosseous Artery Flap Pedicle Identification - [Source](https://www.jprasurg.com/article/S1748-6815%2818%2930284-5/abstract?ref=theplasticsfella.com) ## Technique Tip **Reverse Posterior Interosseous Artery Flap* 🚑 ****Technique Tip of the Week** The reverse PIA flap is a reliable option for reconstructing dorsal hand and first web space defects while preserving the radial and ulnar arteries. Successful harvest depends on identifying the posterior interosseous artery within the septum between the ****ECU** and ****EDM**, preserving the posterior interosseous nerve, and maintaining the distal pivot point approximately ****2 cm proximal to the distal radioulnar joint**. This operative video demonstrates flap design, septal dissection, pedicle elevation, and safe transfer of the reverse PIA flap. ## Building in Public **This Month at The Plastics Fella* 🌐 This month, we caught up with our On-Call Team to review what's working and where we can improve. Over the last month, we have refined our reviewer workflow and worked on new image tools to provide visual aid in our articles. We're also looking to plan a webinar series, with the first session expected later this year. We're excited for more of these conversations with the team because they shape the platform and ensure we're building in a direction that's truly useful for the community. ![This Month at The Plastics Fella Team](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/Screenshot-2026-07-25-at-15.23.14.png) This Month at The Plastics Fella Team We're currently building our ****Lymphovascular Department** and would love to welcome more reviewers to the team. If you are interested in getting involved, let us know below 👇 ## How I Operate **New Episode Coming This Monday!* Episode 3 of ****How I Operate** is coming this Monday 🎙️ In this episode, we sit down with ****Professor Claudio Angrigiani** to discuss the anatomy, design, and surgical thinking behind one of the most important local flaps for hand and wrist reconstruction. From cadaveric studies in Argentina to 40 years of clinical experience, Professor Angrigiani reflects on how the PIA flap was developed, why its middle perforators matter, and where surgeons commonly get into trouble when raising it. ****Designing the Perfect PIA Flap, with Prof. Claudio Angrigiani**: Out this Monday. [Subscribe & Stay Tuned](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## What Does the Evidence Say? **Preventing Venous Congestion in the Reverse PIA Flap* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Venous congestion** remains one of the principal limitations of the reverse posterior interosseous artery flap. Retrograde arterial inflow is usually dependable when the ****distal interosseous anastomosis** is intact, but venous return must overcome valves within the venae comitantes. This helps explain why ****congestion** and ****distal-edge necrosis** can occur even when the flap appears to have adequate arterial inflow. Technical studies suggest that reliability depends less on simply including more tissue and more on ****preserving an effective venous pathway**. In smaller flaps, including a single well-positioned perforator was associated with less venous congestion than incorporating several perforators, possibly because excessive pedicle dissection, twisting, or compression can impair outflow. Other clinical series have reported low congestion rates when the flap is raised with a generous cuff of fascia and subcutaneous tissue, avoiding skeletonisation of the pedicle and preserving communicating veins. Where congestion risk is particularly high, adding a superficial venous anastomosis, or “superdrainage,” has also been used successfully to provide an additional route for venous return. The practical lesson is that a reverse PIA flap should not be judged by arterial inflow alone. A broad, untwisted pedicle, preservation of the surrounding fascia and venous communications, a tension-free tunnel, and selective venous superdrainage may be more important than maximising the number of included perforators. Persistent postoperative congestion should be treated as a mechanical outflow problem until proven otherwise. ([Reyad](https://pmc.ncbi.nlm.nih.gov/articles/PMC5222658/?ref=theplasticsfella.com), 2016); ([Sönmez](https://pubmed.ncbi.nlm.nih.gov/30380168/?ref=theplasticsfella.com), 2018); ([Puri](https://pubmed.ncbi.nlm.nih.gov/17716962/?ref=theplasticsfella.com), 2007); ([Acharya](https://www.jhandsurg.org/article/S0363-5023%2811%2901631-5/abstract?ref=theplasticsfella.com), 2014); ([Kelada](https://pubmed.ncbi.nlm.nih.gov/35820834/?ref=theplasticsfella.com), 2013) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****PIA Flap Publication by Zancolli & Angrigiani**](https://www.sciencedirect.com/science/article/abs/pii/0266768188901210?ref=theplasticsfella.com) The posterior interosseous artery flap provides thin, well-vascularised dorsal hand coverage without sacrificing a major artery, with reliable reach based on distal interosseous anastomoses and primary donor closure possible if kept under 3-4 cm in width. ✅ [****Making the Posterior Interosseous Flap More Reliable**](https://www.ovid.com/jnls/jtrauma/abstract/00005373-199809000-00027~posterior-interosseous-flap-and-its-variations-for-coverage?an=00005373-199809000-00027&redirectionsource=fulltextview&ref=theplasticsfella.com) Adding simple intraoperative modifications such as venous supercharging, converting to a free flap, or widening the pedicle can prevent necrosis and significantly improve the safety of posterior interosseous flaps in difficult anatomy or compromised limbs. ✅ [****The “Reverse” PIA Flap May Not Be Reverse After All**](https://journals.lww.com/plasreconsurg/abstract/00006534-199308000-00014~posterior-interosseous-reverse-forearm-flap-experience-with?ref=theplasticsfella.com) Anatomical and clinical evidence suggest the reverse PIA flap is actually supplied by direct flow via the recurrent anterior interosseous system, with safe design limited to the distal forearm and proximal extensions risking flap loss. ## Feedback ### I hope you enjoyed it 😄 --- ### Perioral Rejuvenation: Assessment, Treatment Selection, & Complications URL: https://www.theplasticsfella.com/perioral-rejuvenation/ Last updated: 2026-07-24T19:30:09.000Z #### Summary Card [****Indications and Suitability**](#indications-and-suitability) Perioral rejuvenation treatment should be modified or deferred for functional, inflammatory, dental, infectious, or unrealistic-expectation problems. [****Applied Anatomy and Ageing**](#applied-anatomy-and-ageing) Safe perioral rejuvenation depends on layered lip anatomy, orbicularis function, dermal ageing, dental support, labial arterial course, sensory nerves, and lymphatic swelling tendency. [****Assessment and Treatment Planning**](#assessment-and-treatment-planning) Assess history, skin type, rhytid pattern, volume deficit, dynamic movement, mucosa, dentition, previous treatments, HSV and scar risk, medications, and photographs before committing to a staged plan. [****Treatment Selection**](#treatment-selection) Choose the modality by dominant pathology: filler for volume and border, toxin for dynamic pull, resurfacing or peel for skin quality, fat for broader autologous volume, and surgery for structural lip length or commissure problems. [****Lipofilling and Fat Processing**](#lipofilling-and-fat-processing) Use perioral lipofilling when the dominant problem is soft-tissue deflation or contour depletion, and process fat gently to preserve viable graft while matching parcel size to the recipient plane. [****Procedure-Specific Treatment Rationale**](#procedure-specific-treatment-rationale) Choose the modality by the dominant perioral problem: filler for volume or border support, toxin for dynamic pull, resurfacing or peeling for texture and rhytides, biostimulation for skin quality, fat or surgery for structural deficiency. [****Injectable Procedures**](#injectable-procedures) Injectable safety depends on conservative product choice, correct plane, small-volume delivery, preservation of oral function, vascular risk reduction, and immediate rescue readiness. [****Facial Expression Preservation**](#facial-expression-preservation) Use toxin to soften excessive muscle activity while preserving speech, smile, oral competence, and the patient’s recognisable facial mimicry. [****Resurfacing and Chemical Peeling**](#resurfacing-and-chemical-peeling) Choose resurfacing or peel depth by rhytid depth, dyschromia, Fitzpatrick type, downtime tolerance, HSV risk, and the patient’s ability to perform wound care. [****Lipofilling and Surgical Procedures**](#lipofilling-and-surgical-procedures) Fat grafting and surgery are appropriate for structural volume loss, elongated upper lip, vermilion deficiency, commissure deformity, or selected mounds, but the design must preserve mobility and close without tension. [****Pre- and Post-Treatment Care**](#pre-and-post-treatment-care) Safe care requires pre-treatment risk control, HSV planning, appropriate anaesthesia, antisepsis, swelling management, wound care, sun avoidance, scheduled review, and early escalation for vascular, infectious, or functional concerns. [****Procedure-Specific Precautions**](#procedure-specific-precautions) Pre- and post-treatment care should be matched to the modality: injectables need vascular and swelling surveillance, resurfacing needs barrier and pigment protection, and surgery or lipofilling needs wound, infection, and oedema control. [****Complications**](#complications) Complications range from expected swelling, erythema, bruising, pain, and temporary sensory change to urgent vascular occlusion, infection, necrosis, ocular symptoms, HSV reactivation, scarring, functional impairment, nodules, pigment change, asymmetry, and revision need. [****Energy-Based, Toxin, and Peel Complications**](#energy-based-toxin-and-peel-complications) Laser resurfacing, botulinum toxin, and chemical peeling add modality-specific risks, including pigmentary change, burns or scarring, infection or HSV reactivation, toxin-related functional weakness, and peel-depth injury. [****Outcomes and Counselling**](#outcomes-and-counselling) Perioral rejuvenation usually gives staged, partial improvement rather than perfection; durability varies by modality, ageing recurs, maintenance is common, and evidence is strongest for selected HA fillers but weaker for many surgical and regenerative options. --- ## Indications and Suitability ****Key Point** Perioral rejuvenation is suitable for rhytids, volume loss, border effacement, dyschromia, dynamic lines, commissure descent, lip lengthening, and selected perioral mounds, but treatment should be modified or deferred for functional, inflammatory, dental, infectious, or unrealistic-expectation problems. Perioral ageing is rarely a single-problem presentation. Decide whether the patient needs isolated correction of lip hypotrophy, perioral skin treatment, structural lip surgery, or staged combination treatment. ### Patient Selection Treat the dominant ageing change, not the most visible request. - **Lip enhancement:** isolated thin lips may be suitable for filler-based augmentation when proportion and dental support are acceptable. - **Combined ageing:** treat lip volume and surrounding wrinkles together when both are clinically relevant [2](#ref-2). - **Lip lengthening:** consider lip lift strategies when the upper lip is elongated or dental show is reduced [3](#ref-3). - **Commissure descent:** downturned oral corners may need commissure support, depressor modulation, resurfacing, or surgery. ### Treatment Boundaries Defer treatment when rejuvenation will not address the real pathology. - **Dental support:** assess occlusion, dentition, vertical dimension, and prostheses before adding volume. - **Active disease:** defer injectable, laser, peel, or surgery for active infection, dermatitis, ulceration, or mucosal inflammation. - **Functional symptoms:** dysarthria, drooling, oral incompetence, or unexplained pain require diagnosis before aesthetics. - **Expectation mismatch:** decline treatment when the requested result is anatomically unsafe or disproportionate. --- ## Applied Anatomy and Ageing ****Key Point** Safe perioral rejuvenation depends on layered lip anatomy, orbicularis function, dermal ageing, dental support, labial arterial course, sensory nerves, and lymphatic swelling tendency. The perioral region is mobile, vascular, expressive, and unforgiving. Small technical errors can alter speech, smile, oral seal, contour, or skin colour. ### Layered Anatomy Choose the plane according to whether you are treating skin, border, volume, muscle, or structure. - **Skin:** epidermal pigment, actinic change, and dermal elastosis drive resurfacing and peel choice. - **Dermis:** intrinsic ageing, sun exposure, and genetics contribute to angular, radial, and vertical perioral lines alongside orbicularis activity [1](#ref-1). - **Orbicularis oris:** repetitive activity contributes to angular, radial, and vertical perioral lines [1](#ref-1). - **Mucosa:** wet-dry border swelling is obvious and should be treated conservatively. ### Ageing Changes Perioral ageing results from progressive skeletal remodelling, soft-tissue volume loss, skin ageing, and repetitive muscle activity. Together, these changes reduce lip support, alter lip proportions, and contribute to perioral rhytids. - **Upper lip:** ageing may produce lip lengthening, philtral flattening, Cupid’s bow inversion, vermilion thinning, and reduced dental show [3](#ref-3). - **Lip lift planning:** specifically document philtral elongation, vermilion thinning, and upper incisor show [4](#ref-4). - **Skeletal support:** progressive maxillary resorption reduces support for the upper lip and contributes to deepening of the nasolabial and perioral folds, while diminished dental support may exaggerate lip inversion and reduce incisor show. - **Proportions:** reviewed estimates describe female philtral height increasing by about 5.5 mm with ageing, supporting measurement-based counselling [4](#ref-4). ### Blood Supply Treat the red lip as a vascular danger zone and inject with an arterial rescue plan. - **Labial arteries:** superior and inferior labial arteries most often lie submucosally, less often intramuscularly, and rarely subcutaneously [5](#ref-5). - **Red lip risk:** arterial probability is higher in the red lip than the cutaneous lip during augmentation [5](#ref-5). - **Danger signs:** blanching, severe pain, livedo, delayed capillary refill, or dusky skin require immediate action. - **Plane discipline:** keep product superficial when appropriate and avoid forceful bolus injection. ### Innervation and Lymphatics Preserve sensation and oral function while anticipating swelling. - **Sensory nerves:** infraorbital and mental nerve territories explain numbness, dysaesthesia, and regional blocks. - **Motor function:** orbicularis, depressor anguli oris, depressor labii, and levator balance determine smile and competence. - **Lymphatic oedema:** lips swell readily after filler, resurfacing, peel, fat grafting, or surgery. - **Counselling:** expected swelling can mimic overcorrection during the first review. --- ## Assessment and Treatment Planning ****Key Point** Assess history, skin type, rhytid pattern, volume deficit, dynamic movement, mucosa, dentition, previous treatments, HSV and scar risk, medications, and photographs before committing to a staged plan. Assessment should end with a written plan: what is treated first, what is deferred, and what complication rescue is available. ### History Identify contraindications, risk factors, and previous interventions before selecting a modality. - **Treatment history:** record previous fillers, implants, surgery, resurfacing, peels, complications, and HA dissolving episodes; repeated hyaluronidase use may signal prior overfilling, nodularity, migration, vascular concern, or dissatisfaction that should change product choice, volume, and consent. - **Disease screen:** check active perioral disease, HA allergy, non-HA implants, and recent interfering facial procedures before HA filler [6](#ref-6). - **Risk history:** ask about HSV, keloid tendency, isotretinoin exposure, pigment problems, autoimmune disease, and immunosuppression. - **Medication review:** anticoagulants, antiplatelets, retinoids, photosensitisers, and immunomodulators alter planning. ### Examination Map static anatomy and dynamic movement separately. - **Lip metrics:** document philtral height, vermilion height, and dental or incisal show for lip lift planning [4](#ref-4). - **Filler planning:** assess the whole lip and perioral region, select product and technique to patient need, and plan safety issues [7](#ref-7). - **Dynamic lines:** observe speech, smile, pursing, oral seal, and depressor activity before toxin. - **Skin type:** Fitzpatrick type, dyschromia, telangiectasia, actinic damage, and thickness guide resurfacing intensity. ### Documentation Use repeatable measurements and images when the outcome is millimetric. - **Photography:** take frontal, oblique, lateral, repose, smile, and animation views. - **Scales:** validated lip fullness scales can support HA filler planning and touch-up assessment [8](#ref-8). - **Resurfacing metrics:** wrinkle severity ratings, objective imaging, and satisfaction scores can support laser follow-up [9](#ref-9). - **Individualisation:** lip ageing procedures should use objective preoperative analysis rather than one-size-fits-all design [4](#ref-4). --- ## Treatment Selection ****Key Point** Choose the modality by dominant pathology: filler for volume and border, toxin for dynamic pull, resurfacing or peel for skin quality, fat for broader autologous volume, and surgery for structural lip length or commissure problems. Do not choose a treatment you cannot rescue. HA filler is reversible; resurfacing, deep peel, fat grafting, and excisional surgery require stricter selection and consent. ### Procedure Selection Match each treatment to the anatomical problem it actually solves. | Dominant problem | Best-fit option | Main limitation | | ----------------------------- | ----------------------------- | ------------------------------------ | | Thin vermilion or border loss | HA filler | Swelling, vascular risk, maintenance | | Dynamic vertical lines | Small-dose toxin ± filler | Smile change, oral incompetence | | Static etched rhytids | Laser or peel | Downtime, pigment risk | | Generalised volume loss | Fat grafting | Variable take, delayed judgement | | Long upper lip | Lip lift | Scar and revision risk | | Downturned commissure | Filler, toxin, or corner lift | Does not shorten philtrum | ### Non-Operative Management Use reversible or lower-downtime options first when the deformity is mild or uncertain. - **HA fillers:** select product and technique according to patient profile to improve predictability [7](#ref-7). - **Combination therapy:** consider botulinum toxin plus HA filler when volume loss and dynamic muscle activity coexist [10](#ref-10). - **Laser choice:** erbium:glass may fit superficial lines and pores, while combined Nd:YAG/Er:YAG may fit deeper perioral wrinkles [9](#ref-9). - **Polynucleotides:** consider for skin quality when volume change is not the primary goal. ### Operative Management Choose surgery when the problem is structural, length-related, or unlikely to be corrected naturally with injectables. - **Lip lift:** excisional lip lift is longer-lasting but leaves a planned scar; scarless volume options include HA filler and autogenous fat grafting, which are less invasive but temporary or less predictable [3](#ref-3)[7](#ref-7)[10](#ref-10). - **Technique choice:** select lip lift design by deformity, not by a supposedly universal best method [4](#ref-4). - **Commissure surgery:** corner mouth lift is adjunctive and should not replace philtral shortening when the upper lip is long [4](#ref-4). - **Perioral mounds:** selected mound surgery may be combined with lower-face contour adjuncts for harmony [11](#ref-11). --- ## Lipofilling and Fat Processing ****Key Point** Use perioral lipofilling when the dominant problem is soft-tissue deflation or contour depletion, and process fat gently to preserve viable graft while matching parcel size to the recipient plane. Lipofilling is a structural rejuvenation tool, not a substitute for resurfacing, toxin, or vermilion-border definition. It is most useful when volume loss contributes to perioral hollowing, lip-body depletion, or poor soft-tissue support, while fine rhytides and etched lines still need skin-directed treatment [1](#ref-1)[2](#ref-2). ### Fat Graft Handling Harvest, process, and inject fat atraumatically because graft survival depends on viable adipose-derived tissue and recipient-bed contact. - **Harvest:** use low-pressure aspiration and small cannulas to reduce mechanical trauma to the graft [19](#ref-19). - **Processing:** decantation, washing, filtration, or gentle centrifugation may be used; avoid over-processing that desiccates or fragments the graft. - **Parcel size:** use microfat for structural lip and perioral volume, and consider finer emulsified fat only for superficial contour or skin-quality adjuncts. - **Placement:** inject small aliquots in multiple tunnels to maximise surface-area contact and reduce lumpiness, overfilling, and irregularity. ### Treatment Boundaries Choose fat when autologous volume restoration is the goal, but counsel that predictability is less immediate than hyaluronic acid filler. - **Best fit:** global perioral deflation, thin soft-tissue envelope, recurrent filler burden, or preference for autologous tissue. - **Poor fit:** dominant dynamic lines, severe photodamage, active infection, unrealistic demand for exact millimetric correction, or need for fully reversible augmentation. - **Combination planning:** pair with resurfacing for etched rhytides or with lip lift when the problem is excessive cutaneous upper-lip length rather than volume loss. - **Counselling:** explain swelling, possible undercorrection or overcorrection, contour irregularity, and the potential need for staged refinement; adverse reactions have been reported across laser, fat, and hyaluronic-acid perioral rejuvenation literature [18](#ref-18),[26](#ref-26). --- ## Procedure-Specific Treatment Rationale ****Key Point** Choose the modality by the dominant perioral problem: filler for volume or border support, toxin for dynamic pull, resurfacing or peeling for texture and rhytides, biostimulation for skin quality, fat or surgery for structural deficiency. Perioral rejuvenation reads best as a manual when each procedure is linked to the anatomical problem it solves. Avoid offering a treatment simply because it is available; explain why its mechanism matches the patient’s deficit. ### Treatment Selection Match product, energy, or operation to the tissue target rather than treating every perioral ageing pattern with filler. - **Hyaluronic acid filler:** choose softer, flexible products for mobile lip and perioral units where integration, expression, and low palpability matter; HA evidence supports lip and perioral enhancement, but product choice should respect mobility and tissue thickness [1](#ref-1)[6](#ref-6),[8](#ref-8). - **Botulinum toxin:** use small, conservative doses when the dominant issue is orbicularis-driven vertical rhytides, commissure depression, or a hyperactive perioral pattern; combination treatment with HA may be appropriate when both dynamic and volume problems coexist [12](#ref-12),[13](#ref-13). - **Lasers and resurfacing:** prefer ablative or fractional ablative platforms for etched rhytides and actinic texture when downtime is acceptable, while non-ablative fractional lasers suit milder texture change or lower downtime tolerance; comparative studies support framing ablative treatment as more intensive rather than universally preferable [15](#ref-15). - **Chemical peels:** choose depth by pathology and risk: superficial peels for dyschromia and mild texture, medium-depth peels for more established perioral photodamage, and deep peels only in carefully selected patients because depth increases both effect and risk. - **Biostimulators and polynucleotides:** consider these as skin-quality adjuncts rather than substitutes for precise volume restoration or resurfacing; current perioral planning should present them cautiously because evidence is less established than for HA filler, toxin, fat grafting, and laser resurfacing. - **Fat grafting or lip lift:** reserve structural procedures for durable volume deficiency, upper-lip lengthening, poor tooth show, or ageing patterns unlikely to be corrected safely with injectables alone [9](#ref-19),[21](#ref-21). --- ## Injectable Procedures ****Key Point** Injectable safety depends on conservative product choice, correct plane, small-volume delivery, preservation of oral function, vascular risk reduction, and immediate rescue readiness. Injectables are not interchangeable. Decide whether the aim is hydration, shape, projection, line softening, collagen stimulation, or neuromodulation before opening a syringe. ### Filler Technique Use HA filler where reversibility and fine control matter most. - **Indication:** HA restores lip volume, supports borders, and can soften selected perioral folds [10](#ref-10). - **Plane:** superficial injection keeps the product away from the common intramuscular or submucosal course of the labial arteries during lip volumisation [5](#ref-5). - **Approach:** a perpendicular cutaneous approach may be safer because labial arteries are commonly within the red lip [5](#ref-5). - **Volume:** inject incrementally, reassess frequently, and avoid chasing immediate swelling. ### Neuromodulation Use toxin as a functional treatment, not a substitute for volume or resurfacing. - **Target:** small-dose toxin can soften dynamic perioral rhytides [10](#ref-10). - **Combination:** toxin plus cohesive HA produced greater lower-face and perioral improvement than either alone in a trial population [12](#ref-12). - **Microbotox:** counsel onset around 5–14 days and duration around 3–6 months when used for facial rejuvenation [13](#ref-13). - **Safety:** preserve speech, oral seal, smile symmetry, and drinking competence. ### Biostimulation Reserve biostimulators, polynucleotides, and platelet products for skin quality rather than precise lip shaping. - **Biostimulators:** avoid high-risk mobile wet lip placement where nodules would be visible and symptomatic. - **Polynucleotides:** use superficial conservative techniques for crepey texture, not vermilion projection. - **Platelet products:** PRF lip injections may last up to 3 months, but should not be counselled as durable volumisation [14](#ref-14). - **APC dosing:** reviewed guidance describes 0.2–0.5 mL per lip quadrant for APC lip injections. --- ## Facial Expression Preservation ****Key Point** Use toxin to soften excessive muscle activity while preserving speech, smile, oral competence, and the patient’s recognisable facial mimicry. Perioral rejuvenation should not trade static lines for an unnatural or unfamiliar animated face. Assess the lips at rest and during speech, smiling, pursing, and laughing before deciding whether toxin is appropriate. - **Functional indication:** use small, targeted doses when orbicularis overactivity, downturning, or dynamic rhytides are the dominant problem. - **Treatment boundary:** do not use toxin as a substitute for volume replacement, vermilion support, skin resurfacing, or correction of structural lip length. - **Expression risk:** excessive weakening can alter smile shape, speech animation, oral seal, and the patient’s self-recognition in movement. - **Practical endpoint:** aim for softened movement, not paralysis; review animation before escalating dose or combining with filler. --- ## Resurfacing and Chemical Peeling ****Key Point** Choose resurfacing or peel depth by rhytid depth, dyschromia, Fitzpatrick type, downtime tolerance, HSV risk, and the patient’s ability to perform wound care. Energy and chemical treatments improve skin surface, not lip length or dental support. They require endpoint control and postoperative surveillance. ### Laser Resurfacing Use ablative lasers for etched rhytids when downtime and morbidity are acceptable. - **CO₂ laser:** CO₂ resurfacing gives greater perioral wrinkle reduction and satisfaction than IPL through 12 months, but morbidity must be considered [15](#ref-15). - **Trade-off:** erythema, dyspigmentation, and milia occurred after CO₂ laser in the comparative trial, whereas IPL had no observed side effects [15](#ref-15). - **Fractional CO₂:** choose fractional CO₂ when seeking cosmetic improvement with a lower stated complication rate than non-fractionated ablative laser [16](#ref-16). - **Er:YAG:** useful where precise ablation and less thermal coagulation are desired. ### Non-Ablative Lasers Use non-ablative or combined devices when downtime, pigment risk, or wound-care burden limits ablative treatment. - **Superficial lines:** erbium:glass improved supralabial lines and hyperpigmentation in Fitzpatrick III–IV women [9](#ref-9). - **Corner wrinkles:** significant improvement in corner lip wrinkles occurred only with combined Nd:YAG/Er:YAG in that comparative study [9](#ref-9). - **PDT adjuncts:** fractional resurfacing plus ALA-PDT evidence is limited to very small samples, so counsel cautiously [17](#ref-17). - **Escalation:** start lower intensity in darker skin or uncertain compliance, then reassess. ### Chemical Peels Match peel depth to the defect and stop when the endpoint is reached. - **Superficial peels:** useful for dyschromia and texture with lower downtime and repeated sessions. - **Medium peels:** TCA-based protocols can address moderate photodamage but increase pigment and scarring risk. - **Deep peels:** phenol-based peeling may fit severe perioral rhytids in selected lighter skin, with strict systemic and wound-care precautions. - **Technique:** degrease, protect mucosa, feather edges, and avoid uncontrolled overlap. --- ## Lipofilling and Surgical Procedures ****Key Point** Fat grafting and surgery are appropriate for structural volume loss, elongated upper lip, vermilion deficiency, commissure deformity, or selected mounds, but design must preserve mobility and close without tension. These procedures trade reversibility for durability. Mark conservatively and respect the layered mobile lip. ### Fat Grafting Use autologous fat when broader, softer volume replacement is preferred over precise reversible shaping. - **Indication:** fat administration is a recognised perioral rejuvenation modality with published complication data [18](#ref-18). - **Processing:** the Lopasce technique uses low-pressure aspiration and slow centrifugation for harvesting and processing [19](#ref-19). - **Placement:** use small aliquots in multiple tunnels, avoiding bulky deposits in the mobile vermilion. - **Dermis fat:** upper-lip augmentation can use strip grafts from presacral, pre-abdominal, or suprapubic donor sites [20](#ref-20). ### Lip Lift Surgery Shorten the cutaneous upper lip when proportion and incisor show are the main defects. - **Goal:** upper lip lift shortens cutaneous lip height and increases maxillary incisor show [3](#ref-3). - **Design:** bullhorn or wavy-ellipse excisions hide the scar in the nasal crease [3](#ref-3). - **Counselling:** consider lip lifting when volume enhancement alone risks an unnatural central facial result [21](#ref-21). - **Closure:** mobilise in layers, avoid tension, and align the nasal sill and philtral columns carefully. ### Commissure Surgery Correct oral corner descent without distorting the sphincter. - **Commissuroplasty:** use conservative excision and layered closure to avoid notching or lateral migration. - **Vermilion advancement:** useful for border deficiency, but overadvancement creates tightness and visible scarring. - **Mound surgery:** one described intraoral option combines mucosal resection, buccinator stripping, buccal fat pad sculpting, and focal radiofrequency [11](#ref-11). - **Revision risk:** defer aggressive excision when asymmetry, scarring tendency, or poor tissue quality dominates. --- ## Pre- and Post-Treatment Care ****Key Point** Safe care requires pre-treatment risk control, HSV planning, appropriate anaesthesia, antisepsis, swelling management, wound care, sun avoidance, scheduled review, and early escalation for vascular, infectious, or functional concerns. Preparation is procedure-specific. A patient having ablative resurfacing needs different instructions from a patient having small-volume HA filler. ### Pre-Treatment Preparation Reduce avoidable risk before creating wounds, injecting product, or operating. - **Training and governance:** safety depends on adequate clinician training, careful patient selection, and appropriate regulation [18](#ref-18). - **Consent:** explain downtime, swelling, bruising, pigment risk, scarring, asymmetry, recurrence, and rescue options. - **HSV:** document history and prescribe antiviral prophylaxis according to local protocol for ablative resurfacing, deep peel, or high-risk patients. - **Medication plan:** manage anticoagulants, antiplatelets, retinoids, photosensitisers, and immunosuppression deliberately. ### Anaesthesia and Antisepsis Choose anaesthesia that permits safe treatment without masking complications. - **Topical anaesthesia:** useful for laser, peel, and superficial injections, but requires adequate dwell time. - **Regional block:** improves comfort for lips but can distort movement and early symmetry assessment. - **Infiltration:** useful in surgery, but volume can obscure lip lift design. - **Antisepsis:** cleanse skin and mucosa-adjacent areas carefully; avoid dragging oral flora through injection tracks. ### Early Aftercare Match aftercare to tissue injury depth and review before complications mature. - **Filler:** use cold compresses, head elevation, gentle activity restriction, and reassessment around 4 weeks for possible touch-up [6](#ref-6). - **Swelling:** a 12-hour betamethasone valerate plaster reduced next-day swelling after HA-based facial rejuvenation injections in one study [22](#ref-22). - **Laser or peel:** use emollient occlusion, appropriate antimicrobial ointment where indicated, strict hygiene, and avoid picking. - **APC adjuncts:** when combining APCs with laser, perform laser first and apply APCs afterward. ### Surveillance Review early enough to rescue vascular, infectious, pigmentary, or wound-healing problems. - **HA protocol:** optional 30-day touch-up was built into a randomized HA lip and perioral enhancement protocol [8](#ref-8). - **Lip lift:** remove cutaneous sutures between days 5 and 7 to reduce suture track marks [4](#ref-4). - **Scar care:** use strict photoprotection for at least 3 months after lip lift [4](#ref-4). - **Ablative wounds:** monitor fractional CO₂ wounds closely so complications are recognised early and sequelae avoided [16](#ref-16). --- ## Procedure-Specific Precautions ****Key Point** Pre- and post-treatment care should be matched to the modality: injectables need vascular and swelling surveillance, resurfacing needs barrier and pigment protection, and surgery or lipofilling needs wound, infection, and oedema control. Procedural success depends on precision more than volume, but recovery depends on disciplined aftercare. Give written instructions before treatment so the patient knows what is expected and what should trigger urgent review. - **Injectables:** use topical, local, or regional anaesthesia selectively; lidocaine-containing fillers can improve comfort but do not remove the need for slow injection, aspiration-aware technique, and vascular vigilance [23](#ref-23). Apply ice briefly for bruising or swelling, avoid massage unless specifically instructed, and review immediately for disproportionate pain, blanching, livedo, or visual symptoms. - **Laser and peeling:** start antiviral prophylaxis when herpes risk is relevant, protect the barrier with bland emollient ointment, and avoid sun exposure until re-epithelialisation and erythema have settled; HSV reactivation is a recognised concern after fractional ablative laser treatment [16](#ref-16). Use strict photoprotection afterwards to reduce post-inflammatory hyperpigmentation risk. - **Surgery and lipofilling:** use local anaesthesia with or without sedation according to procedure extent, anxiety, airway access, and haemostasis needs. Post-treatment care should prioritise head elevation, cold compresses early, incision ointment when appropriate, oral hygiene for intraoral wounds, and early review for haematoma, infection, dehiscence, or fat necrosis. - **Excessive swelling:** distinguish expected oedema from allergy, infection, haematoma, or vascular compromise before treating. Corticosteroids may be considered for troublesome inflammatory swelling after facial rejuvenation procedures, but should not delay escalation when pain, skin colour change, fever, or visual symptoms are present [22](#ref-22). --- ## Complications ****Key Point** Complications range from expected swelling, erythema, bruising, pain, and temporary sensory change to urgent vascular occlusion, infection, necrosis, ocular symptoms, HSV reactivation, scarring, functional impairment, nodules, pigment change, asymmetry, and revision need. Separate normal inflammatory response from pathology. The dangerous perioral complication is the one dismissed as routine swelling. ### Expected Reactions Reassure only when the pattern is symmetrical, improving, and consistent with the procedure. - **Common reactions:** laser ablation, filler, and fat grafting mainly cause mild-to-moderate oedema, erythema, bruising, and temporary sensory change [18](#ref-18). - **HA filler:** SPHAL commonly causes lip bruising, swelling, and pain, usually mild and transient [23](#ref-23). - **Skin of colour:** HA filler injection-site responses usually resolve within 2 weeks [24](#ref-24). - **Mobile zones:** reported HA events include oedema 28%, haematoma 20%, irregularities 14%, and pain 14% [25](#ref-25). ### Urgent Complications Act immediately for vascular, visual, infectious, or rapidly progressive symptoms. - **Vascular occlusion:** severe pain, blanching, livedo, dusky skin, or delayed refill requires immediate HA rescue and escalation. - **Ocular risk:** visual disturbance after filler is an emergency; stop injecting and activate emergency pathway. - **Severe events:** rare severe perioral complications include infection, scarring, and vascular compromise [18](#ref-18). - **Readiness:** clinicians must recognise adverse events promptly and initiate remedies without delay [26](#ref-26). ### Modality Complications Look for the complication pattern typical of the treatment delivered. - **Botulinum toxin:** upper-lip lifting can cause perioral muscular palsy and mouth incompetence [3](#ref-3). - **Laser and peel:** burns, delayed healing, infection, HSV, dyspigmentation, milia, and scarring require early review. - **HSV:** reactivation can occur after perioral fractional CO₂ laser even with peri-treatment valacyclovir prophylaxis [16](#ref-16). - **Biostimulators:** nodules, inflammatory masses, granuloma-like reactions, and visible irregularity are poorly tolerated around the mouth. ### Late Problems Revise only after swelling, scarring, and tissue remodelling have declared themselves unless urgent harm exists. - **Lip lift scar:** visible incision scarring is the most common long-term lip lift complication, reported at 4.36% [3](#ref-3). - **Revision:** reviewed lip lift revision rates range from 0.6% to 6.7% [4](#ref-4). - **Asymmetry:** assess at rest and animation before deciding whether filler, toxin, steroid, laser, or revision is appropriate. - **Necrosis sequelae:** tissue loss may need wound care, delayed reconstruction, scar treatment, and psychological support. --- ## Energy-Based, Toxin, and Peel Complications ****Key Point** Laser resurfacing, botulinum toxin, and chemical peeling add modality-specific risks, including pigmentary change, burns or scarring, infection or HSV reactivation, toxin-related functional weakness, and peel-depth injury. Counsel patients that perioral rejuvenation is not risk-free when treatment moves beyond filler or surgery. Risk is reduced by matching treatment depth to skin type, rhytid severity, healing capacity, and willingness to follow antiviral, photoprotection, and wound-care instructions. - **Laser resurfacing:** erythema, oedema, crusting, acneiform eruption, infection, post-inflammatory hyperpigmentation, hypopigmentation, burns, delayed healing, and scarring are the main counselling points; ablative treatments carry greater wound-care burden than non-ablative resurfacing [15](#ref-15). - **HSV reactivation:** perioral laser treatment can reactivate herpes simplex, so document history and use prophylaxis when clinically indicated [16](#ref-16). - **Botulinum toxin:** excessive dose, poor placement, or diffusion around orbicularis oris can cause smile asymmetry, oral incompetence, speech difficulty, drooling, or difficulty using a straw; conservative dosing is safer in the mobile perioral unit [12](#ref-12),[13](#ref-13). - **Chemical peeling:** complications depend on peel depth and patient selection; persistent erythema, pigmentary disturbance, infection, demarcation lines, delayed epithelialisation, and scarring should be discussed before medium or deep perioral peeling. --- ## Outcomes and Counselling ****Key Point** Perioral rejuvenation usually gives staged, partial improvement rather than perfection; durability varies by modality, ageing recurs, maintenance is common, and evidence is strongest for selected HA fillers but weaker for many surgical and regenerative options. Counselling should be practical: what changes first, what swells, what lasts, what needs repeating, and what cannot be safely corrected. ### Aesthetic Outcomes Counsel in proportions, texture, and millimetres rather than idealised lips. - **HA durability:** Juvéderm Volbella with Lidocaine showed effectiveness for lip and perioral enhancement lasting up to 12 months in a randomized trial [27](#ref-27). - **VYC-15L:** lip fullness responder rates remained above 60% through 1 year in a randomized adult study [8](#ref-8). - **Perioral lines:** VYC-15L improved perioral line severity in 65.4% at Month 3 and 66.2% at Year 1 [8](#ref-8). - **Topicals:** twice-daily peptide therapy improved perioral wrinkles by at least 1 unit in 59% at 6 months in an RCT [28](#ref-28). ### Durability and Maintenance Explain that reversible treatments need maintenance and structural procedures still age. - **Single HA session:** without touch-up, 18-month success was 32% for lips, 74% for nasolabial folds, and 82% for marionette lines in one study [25](#ref-25). - **Surgery:** upper-lip lift satisfaction is generally favourable in reported studies, but comparative certainty is limited by heterogeneous outcome measures [3](#ref-3). - **Evidence quality:** lip lift estimates come from limited observational evidence without randomized trials, blinded assessment, or prospective power calculations [4](#ref-4). - **Fat grafting:** dermis fat grafting improved vermilion show and projection at 12 months in a small study [20](#ref-20). ### Consent Themes Make the patient accept trade-offs before treatment, not after swelling starts. - **Combination planning:** staged filler, toxin, resurfacing, and surgery often looks more natural than maximal single-modality treatment. - **Downtime:** resurfacing, deep peel, fat grafting, and surgery need more recovery than small-volume injectables. - **Limits:** dental support loss, severe elastosis, scarring tendency, and unrealistic proportions limit correction. - **Maintenance:** recurrence of rhytids, volume loss, pigment, and commissure descent is expected with ageing. --- ## References **\[1\]** Pascali M, et al. 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An Objective, Quantitative Assessment of Flexible Hyaluronic Acid Fillers in Lip and Perioral Enhancement. Dermatologic Surgery. 2021\. doi:10.1097/DSS.0000000000002917 **\[7\]** Díaz-Aguayo M, et al. Aesthetic Management of Lips and Perioral Region With Hylacross® and Vycross® Hyaluronic-Acid-Based Fillers: A Document of Recommendations. Journal of Cosmetic Dermatology. 2024\. doi:10.1111/jocd.16358 **\[8\]** Geronemus RG, et al. Safety and Effectiveness of VYC-15L, a Hyaluronic Acid Filler for Lip and Perioral Enhancement: One-Year Results From a Randomized, Controlled Study. Dermatologic Surgery. 2017\. doi:10.1097/DSS.0000000000001035 **\[9\]** Mohamadi S, et al. Comparative Analysis of Erbium:Glass 1550 nm and Combined Erbium:YAG and Nd:YAG Lasers for Perioral Rejuvenation: A Prospective Study. Lasers in Medical Science. 2025\. doi:10.1007/s10103-025-04540-6 **\[10\]** Michaud T, et al. Global 3-Dimensional Approach to Natural Rejuvenation: Recommendations for Perioral, Nose, and Ear Rejuvenation. Journal of Cosmetic Dermatology. 2013\. doi:10.1111/jocd.12035 **\[11\]** Caughlin BP, Abud BT. Modified Buccal Fat Pad Reduction as a Component of Perioral Mound Rejuvenation: “The Mouth Pouch.” Facial Plastic Surgery. 2025\. doi:10.1055/a-2622-2896 **\[12\]** Carruthers J, et al. Multicenter, Randomized, Parallel-Group Study of the Safety and Effectiveness of OnabotulinumtoxinA and Hyaluronic Acid Dermal Fillers Alone and in Combination for Lower Facial Rejuvenation. Dermatologic Surgery. 2010\. doi:10.1111/j.1524-4725.2010.01705.x **\[13\]** Iranmanesh B, Khalili M, Mohammadi S, Amiri R, Aflatoonian M. Employing Microbotox Technique for Facial Rejuvenation and Face-Lift. Journal of Cosmetic Dermatology. 2022;21(10). doi:10.1111/jocd.14768 **\[14\]** Davies C, Miron RJ. Autolougous Platelet Concentrates in Esthetic Medicine. Periodontology 2000\. 2025;97(1):363–386\. doi:10.1111/prd.12582 **\[15\]** Hedelund L, et al. Ablative Versus Non-Ablative Treatment of Perioral Rhytides: A Randomized Controlled Trial With Long-Term Blinded Clinical Evaluations and Non-Invasive Measurements. Lasers in Surgery and Medicine. 2006\. doi:10.1002/lsm.20216 **\[16\]** Zaouak A, et al. A Case of Herpes Simplex Virus Reactivation After Fractional Ablative Carbon Dioxide Laser to Treat a Burn Scar. Journal of Cosmetic and Laser Therapy. 2019\. doi:10.1080/14764172.2018.1481513 **\[17\]** Ruiz-Rodriguez R, et al. Enhanced Efficacy of Photodynamic Therapy After Fractional Resurfacing: Fractional Photodynamic Rejuvenation. Journal of Drugs in Dermatology. 2007\. PMID:17763613 **\[18\]** Ozkaya O, et al. Long-Term Clinical Outcomes of Fat Grafting by Low-Pressure Aspiration and Slow Centrifugation (Lopasce Technique) for Different Indications. Journal of Plastic Surgery and Hand Surgery. 2014\. doi:10.3109/2000656X.2013.771585 **\[19\]** Tabrizi R, et al. Dimensional Changes of the Upper Lip Using Dermis Fat Graft for Lip Augmentation. Journal of Oral and Maxillofacial Surgery. 2016\. doi:10.1016/j.joms.2015.03.040 **\[20\]** Jalalabadi F, Lisiecki JL, Chiodo MV, Rohrich RJ. Lip Lifting: The Missing Link in Central Facial Rejuvenation. Plastic and Reconstructive Surgery. 2024;154(1):79e–84e. doi:10.1097/PRS.0000000000010735 **\[21\]** Iannitti T, et al. Corticosteroid Transdermal Delivery to Target Swelling, Edema, and Inflammation Following Facial Rejuvenation Procedures. Drug Design, Development and Therapy. 2013\. doi:10.2147/DDDT.S45722 **\[22\]** Beer K, et al. A Randomized, Evaluator-Blinded, Controlled Study of Effectiveness and Safety of Small-Particle Hyaluronic Acid Plus Lidocaine for Lip Augmentation and Perioral Rhytides. Dermatologic Surgery. 2015\. doi:10.1097/DSS.0000000000000199 **\[23\]** Taylor SC, et al. Lip and Perioral Enhancement With Hyaluronic Acid Dermal Fillers in Individuals With Skin of Color. Dermatologic Surgery. 2019\. doi:10.1097/DSS.0000000000001842 **\[24\]** David S, et al. Long-Term Efficacy and Tolerability of a Medium G′ Hyaluronic Acid Filler With Tri-Hyal Technology on the Rejuvenation of the Mobile Facial Zone. Clinical, Cosmetic and Investigational Dermatology. 2023\. doi:10.2147/CCID.S395353 **\[25\]** Sayan A, Gonen ZB, Ilankovan V. Adverse Reactions Associated With Perioral Rejuvenation Using Laser, Fat, and Hyaluronic Acid: Systematic Review. British Journal of Oral and Maxillofacial Surgery. 2021;59(9):1005–1012\. doi:10.1016/j.bjoms.2021.02.027 **\[26\]** Chantrey J, et al. Lip and Perioral Enhancement: A 12-Month Prospective, Randomized, Controlled Study. Journal of Drugs in Dermatology. 2015\. PMID:26659938 **\[27\]** Dreher F. A Novel Matrikine-Like Micro-Protein Complex Technology for Topical Skin Rejuvenation. Journal of Drugs in Dermatology. 2016\. PMID:27050701 **\[28\]** Marten T, Elyassnia D. Facial Fat Grafting: Why, Where, How, and How Much. Aesthetic Surgery Journal. 2017;37(Suppl 3):S16–S32\. doi:10.1093/asj/sjx078 **\[29\]** Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declercq H. Nanofat Grafting: Basic Research and Clinical Applications. Plastic and Reconstructive Surgery. 2013;132(4):1017–1026\. doi:10.1097/PRS.0b013e31829fe1b0 ### Laser Resurfacing: Assessment, Treatment Planning, & Technique URL: https://www.theplasticsfella.com/laser-resurfacing/ Last updated: 2026-07-24T19:14:02.000Z #### Summary Card [****Overview of Laser Fundamentals**](#overview-of-laser-fundamentals) Laser resurfacing works by delivering controlled thermal injury to skin targets such as water, haemoglobin, or melanin. Device selection depends on target depth, thermal effect, healing profile, and pigmentation risk. [****Indications and Suitability**](#indications-and-suitability) Laser resurfacing is considered for photoageing, rhytides, acne scars, selected traumatic or surgical scars, and some disease-related skin problems; defer treatment for active herpetic lesions, recent sunburn or overexposure, and pregnancy or breastfeeding. [****Applied Skin and Laser Anatomy**](#applied-skin-and-laser-anatomy) Resurfacing decisions depend on water-rich epidermal and dermal targets, thermal spread, adnexal re-epithelialisation, regional skin thickness, and danger areas such as eyelids, neck, and scarred skin. [****Assessment and Planning**](#assessment-and-planning) Before resurfacing, assess indications, scar or rhytid pattern, Fitzpatrick phototype, pigmentation risk, HSV and keloid history, medication risks, healing capacity, photographs, and whether laser alone is sufficient. [****Device and Technique Selection**](#device-and-technique-selection) Choose the device by target depth, scar or wrinkle morphology, skin type, downtime tolerance, and risk: CO2 for stronger tightening and remodelling, Er:YAG for precise ablation, fractional approaches for staged healing, and adjuncts for mixed pathology. [****Operative Principles**](#operative-principles) Safe resurfacing requires correct preparation, eye and airway protection, analgesia, conservative parameter selection, endpoint recognition, controlled overlap, plume management, and immediate barrier support. [****Complications**](#complications) Complications include early burns, pain, infection, and HSV reactivation, delayed acneiform eruption and erythema, pigment change, scarring, ectropion, and unsatisfactory or incomplete correction. [****Postoperative Care and Surveillance**](#postoperative-care-and-surveillance) Postoperative care protects the barrier, prevents infection, controls inflammation, enforces sun avoidance, restarts skincare gradually, and reviews early enough to detect HSV, bacterial infection, pigment change, delayed healing, or scarring. [****Outcomes and Counselling**](#outcomes-and-counselling) Laser resurfacing improves texture, rhytides, dyspigmentation, and selected scars, but results vary by indication, skin type, device, and treatment intensity. Most patients improve rather than achieve complete correction. --- ## Overview of Laser Fundamentals ****Key Point** Laser resurfacing works by delivering controlled thermal injury to skin targets such as water, haemoglobin, or melanin. Device selection depends on target depth, thermal effect, healing profile, and pigmentation risk. Laser resurfacing devices differ by wavelength, chromophore target, depth of penetration, and degree of thermal injury. Understanding these differences helps trainees choose the correct device for texture, pigment, vascularity, or scar remodelling. | Laser Type | Main Target | Main Effect | Common Uses | Main Trade-off | | ------------------------------ | ---------------------------- | ----------------------------------------------- | ------------------------------------------ | -------------------------------- | | **CO2** | Water | Ablation + coagulation | Deep rhytides, scars, tightening | More downtime and pigment risk | | **Er:YAG** | Water | Precise ablation with less thermal spread | Superficial rhytides, texture, darker skin | Less contraction/remodelling | | **Fractional lasers** | Water (fractionated columns) | Microscopic treatment zones with faster healing | Acne scars, rejuvenation | Often requires multiple sessions | | **Non-ablative lasers** | Dermal water/chromophores | Dermal remodelling without epidermal removal | Mild texture/pigment change | More gradual improvement | | **Vascular lasers (e.g. PDL)** | Oxyhaemoglobin | Vascular targeting | Erythema, telangiectasia | Does not resurface texture | | **Pigment lasers** | Melanin | Pigment reduction | Lentigines, dyschromia | Higher PIH risk in darker skin | **Think in terms of chromophores and thermal injury** The clinical effect of a laser depends on: - the chromophore absorbing energy, - the depth of penetration, - and the amount of collateral thermal spread. In resurfacing: - **CO2** produces more coagulation and collagen contraction, - **Er:YAG** produces cleaner ablation with less thermal damage, - and **fractional delivery** leaves untreated skin between columns to accelerate healing. --- ## Indications and Suitability ****Key Point** Laser resurfacing is considered for photoageing, rhytides, acne scars, selected traumatic or surgical scars, and some disease-related skin problems; defer treatment for active herpetic lesions, recent sunburn or overexposure, and pregnancy or breastfeeding. Laser resurfacing improves surface texture, dyschromia, fine-to-moderate rhytides, and selected scars by controlled epidermal and dermal injury. It does not correct significant facial descent, deep volume loss, eyelid malposition, or unrealistic expectations. **Match the indication to what resurfacing can actually change** The best indication is a visible skin-quality problem where controlled injury and remodelling can improve contour, texture, or pigment. - **Photoageing:** resurfacing may be used for skin-ageing changes such as rhytides and actinic texture change. [2](#ref-2) - **Acne scarring:** ablative fractional CO2 is a supported option for improving acne scars. - **Postoperative scars:** patients with post-Mohs scars can be counselled for laser as a less invasive scar-revision option with reported safety and satisfaction. [4](#ref-4) - **Damaged skin:** ablative resurfacing may be considered for photodamage, acne scars, hidradenitis-related scarring, and selected posttraumatic or post-excision scars. **Choose suitability before choosing the machine** Suitability depends on skin type, healing capacity, pigmentation risk, downtime tolerance, and the depth of the problem. - **Fractional CO2 candidate:** facial rejuvenation is best suited to Fitzpatrick I–III patients aged 40–60 with moderate-to-advanced wrinkles and mild-to-moderate dyspigmentation. [1](#ref-1) - **Darker skin:** Er:YAG is often preferred for darker-skinned patients undergoing cutaneous resurfacing. [6](#ref-6) - **Milder change:** short-pulsed Er:YAG suits mild rhytides, mildly atrophic scars, and textural changes from fibrosis or dermatochalasis. [6](#ref-6) - **Broader Er:YAG use:** Er:YAG may be considered across skin types and body sites for indications from lentigines to deeper rhytides. **Decline when resurfacing will create risk without benefit** Do not offer resurfacing to solve the wrong problem. Patients with brow ptosis, jowling, lower lid laxity, marked laxity, or deep tethered scars usually need another procedure or combination treatment. - **Active skin disease:** postpone if infection, inflammatory flare, poor barrier function, or recent aggressive treatment is present. - **Healing risk:** review keloid tendency, immunosuppression, smoking, radiation, and previous poor wound healing. - **Expectation mismatch:** decline if the patient expects lifting, scar erasure, or permanent reversal of ageing. - **Timing conflict:** avoid treatment immediately before unavoidable sun exposure or events requiring rapid social recovery. --- ## Applied Skin and Laser Anatomy ****Key Point** Resurfacing decisions depend on water-rich epidermal and dermal targets, thermal spread, adnexal re-epithelialisation, regional skin thickness, and danger areas such as eyelids, neck, and scarred skin. Laser resurfacing is a controlled injury. The trainee must understand where the energy goes, how heat spreads, and which skin units must survive for safe healing. **Treat water as the main ablative target** Ablative resurfacing works because water-containing tissue absorbs energy, vaporises, and leaves a predictable wound with surrounding thermal effect. - **CO2 concept:** ablative fractional lasers are planned as water-targeting devices that create injury to drive re-epithelialisation and remodelling. [4](#ref-4) - **Er:YAG concept:** Er:YAG has a higher affinity for water-containing tissue, supporting finer ablation when precision is prioritised. - **Thermal relaxation:** pulse duration and stacking determine whether heat remains localised or spreads into adjacent dermis. - **Coagulation zone:** more coagulation may improve haemostasis and contraction, but increases erythema, dyspigmentation, and scarring risk. **Plan fractional injury around columns and reservoirs** Fractional treatment leaves untreated skin between treatment zones, which provides epithelial reservoirs for faster closure. - **Microcolumns:** fractional CO2 creates microablative columns through the epidermis into the dermis, relevant for scar remodelling and topical adjuvant delivery. [8](#ref-8) - **Healing reservoir:** hair follicles, sebaceous units, and untreated intervening skin support re-epithelialisation. - **Expected closure:** microablative columns typically re-epithelialise within 2–3 days after fractional CO2 treatment. [8](#ref-8) - **Nonfacial caution:** neck, chest, and extremity skin have fewer adnexal reservoirs and tolerate aggressive resurfacing poorly. **Respect thin skin and functional borders** The same energy is not equally safe across all regions. Thin skin and scarred skin magnify thermal injury. - **Eyelids:** thin skin, globe proximity, and ectropion risk require conservative settings and eye protection. - **Neck:** reduced adnexal density and mobile skin increase scarring and pigment risk. - **Mandibular edge:** visible transition lines occur if resurfacing stops abruptly. - **Scarred fields:** previous surgery, radiation, burns, or undermining reduce vascular reserve. **Use chromophores to avoid the wrong laser** Laser choice should follow the target, not the brand name. - **Water:** CO2 and Er:YAG target water for ablation and resurfacing. - **Oxyhaemoglobin:** pulsed dye laser is anatomically aligned with erythema and telangiectasia treatment. [4](#ref-4) - **Melanin:** pigment-targeting requires caution in darker phototypes because competing epidermal melanin increases dyspigmentation risk. --- ## Assessment and Planning ****Key Point** Before resurfacing, assess indication, scar or rhytid pattern, Fitzpatrick phototype, pigmentation risk, HSV and keloid history, medication risks, healing capacity, photographs, and whether laser alone is sufficient. Assessment prevents the common errors: treating the wrong diagnosis, overtreating high-risk skin, and promising a result that the laser cannot deliver. **Take a history that changes the plan** The history should identify infection risk, pigment risk, photosensitivity, impaired healing, and poor timing. - **HSV history:** ask about cold sores, previous outbreaks after procedures, and current prodromal symptoms. - **Medication risk:** document isotretinoin exposure, photosensitising drugs, anticoagulants, immunosuppression, retinoids, and recent peels. - **Pigment behaviour:** ask about tanning, post-inflammatory hyperpigmentation, melasma, and prior laser response. - **Healing history:** record keloids, hypertrophic scars, radiation, smoking, diabetes, connective tissue disease, and poor wound healing. **Skin type is a planning variable, not a label** Phototype informs risk, settings, staging, and counselling. - **Fitzpatrick classification:** the Fitzpatrick system is the most widely accepted phototyping method, based on sunburn tendency and tanning ability. [9](#ref-9) - **Prediction value:** skin phototyping helps predict outcomes of aesthetic procedures. [9](#ref-9) - **Pigment risk:** higher phototypes, melasma tendency, and recent UV exposure push planning toward staged, conservative treatment. - **Documentation:** record baseline pigment, scars, rhytids, laxity, and asymmetry before treatment. **Examine the deformity before choosing the laser** Not all wrinkles or scars respond to resurfacing alone. Classify the dominant problem before discussing devices. - **Rhytids:** separate fine etched lines from dynamic wrinkles, folds, and laxity. - **Acne scars:** classify ice-pick, boxcar, rolling, hypertrophic, and mixed patterns. - **Ice-pick scars:** assess for adjunctive or combination treatment rather than laser monotherapy alone. - **Atrophic scars:** choose adjuncts according to scar type, severity, and number. [10](#ref-10) **Build the plan around severity, skin type, and downtime** Planning should end with a clear decision: treat now, modify, stage, combine, or defer. - **Acne scar planning:** session number, interval, parameters, phototype, scar severity, and scar type affect fractional CO2 effectiveness. [11](#ref-11) - **Facial ageing:** treatment area, wrinkle depth, phototype, and dyspigmentation tendency should guide fractional ablative CO2 settings. - **Skin preparation:** no universal consensus protocol exists for preprocedural skin preparation before ablative resurfacing, so document the local protocol you are using. A typical regimen is sun avoidance, cessation of retinoids or irritants several days before treatment, antiviral prophylaxis for HSV-risk patients, and pigment suppression such as hydroquinone in selected higher-risk phototypes. [12](#ref-12) - **Consent record:** document target, expected improvement range, downtime, pigment risk, infection risk, scarring risk, and need for staged treatment. **Decide whether to proceed, modify, or defer** Use a simple pre-treatment decision frame. - **Proceed:** stable skin, suitable indication, realistic goals, acceptable pigment risk, and planned prophylaxis. - **Modify:** darker phototype, melasma risk, mixed scars, eyelid or neck treatment, or limited downtime. - **Combine:** tethered scars, ice-pick scars, volume deficit, dynamic wrinkles, or residual vascular redness. - **Defer:** active infection, recent UV injury, pregnancy or breastfeeding, active dermatitis, poor adherence, or unstable expectations. --- ## Device and Technique Selection ****Key Point** Choose the device by target depth, scar or wrinkle morphology, skin type, downtime tolerance, and risk: CO2 for stronger tightening and remodelling, Er:YAG for precise ablation, fractional approaches for staged healing, and adjuncts for mixed pathology. The device is only part of the decision. The trainee must also choose density, energy, number of sessions, intervals, and whether another modality is needed. **Select the device by the dominant clinical problem** The safest selection framework starts with the clinical target, then accepts the trade-off. | Dominant problem | Best-fit option | Main trade-off | | ---------------------------------------------------- | ----------------------------- | ---------------------------------- | | Deep rhytides, photodamage, contraction needed | CO2 resurfacing | More thermal effect and downtime | | Fine rhytides, superficial texture, higher risk skin | Er:YAG | Less dramatic remodelling expected | | Acne scarring with mixed depth | Fractional ablative laser | Multiple sessions often needed | | Mild texture with low downtime priority | Non-ablative fractional laser | More gradual improvement | | Red scar or telangiectasia | Vascular laser adjunct | Does not resurface texture | | Pigment plus texture | Staged combination treatment | More visits and counselling | **Choose CO2 when efficacy matters more than morbidity** CO2 is favoured when collagen contraction, deeper remodelling, and visible rejuvenation are the main goals. - **Wrinkle efficacy:** CO2 may offer greater efficacy for facial wrinkles, while Er:YAG may be favoured when complication profile is prioritised. [13](#ref-13) - **Er:YAG limitation:** Er:YAG should not be expected to produce the same dramatic clinical and histologic improvement as CO2. - **Combined ablation:** combined CO2 and Er:YAG may be selected to maximise targeted collagen contraction while limiting postoperative morbidity. - **High-risk areas:** reduce energy, density, or passes around eyelids, neck, bony prominences, and prior scars. **Stage treatment when pigment risk is higher** Higher pigment risk should push the plan toward lower intensity, staged sessions, and strict sun control. - **Fitzpatrick III–IV:** technique intensity should generally be reduced and staged across sessions compared with single higher-setting treatment in Fitzpatrick I–II skin. [1](#ref-1) - **Dark or sensitive skin:** fractional radiofrequency or needling may be lower-risk alternatives or adjuncts. [10](#ref-10) - **Dark acne scarring:** PRP or fractional radiofrequency microneedling added to fractional laser may improve efficacy and reduce PIH. - **Melasma tendency:** avoid aggressive heat-based treatment unless the indication and counselling are strong. **Combine only when the second treatment solves a defined problem** Combination therapy should not become automatic. Add treatments only for tethering, deep scars, vascularity, pigment, or downtime control. - **Deep acne scars:** fractional laser may need subcision or punch techniques rather than laser alone. - **Vascular redness:** use vascular laser adjuncts such as pulsed dye laser (PDL) when erythema or telangiectasia is the residual target. - **Radiofrequency caution:** adding radiofrequency to CO2 should not be assumed to improve results and may prolong erythema. [2](#ref-2) - **Treatment sequencing:** avoid stacking multiple inflammatory procedures in high-risk skin without a staged plan. --- ## Operative Principles ****Key Point** Safe resurfacing requires correct preparation, eye and airway protection, analgesia, conservative parameter selection, endpoint recognition, controlled overlap, plume management, and immediate barrier support. Operative failure usually comes from excessive energy, unsafe overlap, poor regional adjustment, inadequate protection, or missed infection risk. **Prepare the patient, room, and team before firing** Laser resurfacing is a controlled burn performed in a shared safety environment. - **Consent pause:** confirm indication, target zones, settings, prophylaxis, and expected endpoint. - **Skin preparation:** choose cleansing agents cautiously because efficacy and safety evidence for pre-laser preparation is sparse. [12](#ref-12) - **Eye safety:** use wavelength-specific eyewear and corneal shields for eyelid or periocular treatment. - **Airway safety:** avoid oxygen pooling, use wet towels where appropriate, and coordinate with anaesthesia. **Build analgesia into the workflow** Pain control is a procedural requirement, not an afterthought. - **Pain expectation:** pain is common during dermatological laser procedures, so analgesia should be planned. - **Anaesthesia choice:** active non-invasive anaesthesia is preferable to none; topical anaesthetics and pneumatic flattening appear more effective than cooling. - **Topical protocol:** lidocaine/tetracaine 7%/7% peel cream was applied 45 minutes before fractional resurfacing and removed immediately before treatment in a trial. [15](#ref-15) - **Effect size:** that cream reduced mean pain from 8.6 to 3.0 on a 10-cm VAS in a 30-patient trial. [15](#ref-15) **Choose settings to hit the target, not the maximum** Parameters should be set to the indication, skin thickness, region, and risk profile. - **Target logic:** wavelength and fluence should affect the intended target while limiting collateral injury during scar resurfacing. [4](#ref-4) - **Fractional variables:** energy, density, pulse duration, coverage, and passes determine depth and thermal burden. - **Non-ablative Er:YAG:** settings should account for superficial temperature rise, partial epithelial preservation, and subepithelial matrix coagulation. [16](#ref-16) - **Er:YAG margin:** precise ablation with less thermal injury supports shorter healing times and a greater safety margin. [7](#ref-7) **Execute in a controlled sequence** Order matters because erythema, oedema, smoke, and bleeding obscure endpoints. 1. **Confirm the map:** mark treatment boundaries, transition zones, scars, and regions needing reduced settings. - **Boundary control:** feather edges to avoid visible stop lines. - **Regional adjustment:** reduce intensity over eyelids, neck, thin skin, and scars. 1. **Treat by aesthetic unit:** work systematically so overlapped and skipped zones are visible. - **Overlap control:** avoid pulse stacking unless deliberately planned. - **Endpoint check:** stop when the planned clinical endpoint appears, not after a fixed number of passes. 1. **Control plume and debris:** visibility and staff safety deteriorate quickly without active evacuation. - **Plume control:** use smoke evacuation close to the treatment field. - **Debris removal:** wipe gently according to device protocol without traumatising the wound. 1. **Dress immediately:** the wound should leave theatre protected, cooled, and documented. - **Immediate care:** apply the agreed occlusive or open-care regimen. - **Record:** document device, settings, passes, endpoints, adjuncts, and complications. --- ## Complications ****Key Point** Complications include early burns, pain, infection and HSV reactivation, delayed acneiform eruption and erythema, pigment change, scarring, ectropion, and unsatisfactory or incomplete correction. Complications should be organised by timing and consequence. Escalate severe pain, spreading erythema, purulence, vesicles, visual symptoms, delayed healing, or early contracture. **Recognise early problems before they scar** Early complications are often treatable if identified before deeper injury or infection develops. - **Thermal injury:** excessive pain, blistering, grey tissue, or sharply demarcated burns require senior review. - **Infection:** pustules, honey crusting, malodour, spreading erythema, or systemic symptoms need swab and treatment. - **HSV:** grouped vesicles, disproportionate pain, or known HSV history warrants prompt antiviral treatment. - **Acneiform eruption:** occlusion, ointments, and inflammation may trigger papules or pustules. **Counsel pigment change as common in the right context** Dyspigmentation is central to consent, especially for acne scarring, darker skin, melasma tendency, and UV exposure. - **Acne scars:** pigment changes after facial acne scar resurfacing were reported in up to 44% and usually lasted a few weeks. - **CO2 and Er:YAG:** reported complications include erythema, hyperpigmentation, crusting, and rarely hypopigmentation. [13](#ref-13) - **Expert experience:** hyperpigmentation, contact dermatitis, and local infection were commonly discussed after fractional ablative CO2 resurfacing. - **Late pigment loss:** hypopigmentation can be delayed and difficult to reverse. **Treat scarring and ectropion as high-consequence events** Scarring is uncommon but unacceptable when preventable. Watch functional borders closely. - **Overall adverse events:** a systematic review of 1093 resurfacing patients reported adverse events in 106 patients, or 9.7%. [5](#ref-5) - **Hypertrophic scarring:** hypertrophic scarring was rare in that review, reported in five patients. [5](#ref-5) - **Facelift combination:** in simultaneous facelift and laser resurfacing, ectropion was reported in 0.12% and hypertrophic scarring in 0.51%. [18](#ref-18) - **Escalation triggers:** delayed epithelialisation, lid retraction, contracture, or expanding hypertrophic scar needs early specialist intervention. --- ## Postoperative Care and Surveillance ****Key Point** Postoperative care protects the barrier, prevents infection, controls inflammation, enforces sun avoidance, restarts skincare gradually, and reviews early enough to detect HSV, bacterial infection, pigment change, delayed healing, or scarring. Postoperative instructions must be specific to the device, depth, region, and patient risk. Generic “keep it clean” advice is not enough. **Protect the wound until the barrier recovers** The first priority is cooling, comfort, moisture balance, and avoidance of trauma. - **Immediate care:** cold compresses and topical petrolatum are commonly used after fractional ablative CO2 resurfacing. [1](#ref-1) - **Occlusive care:** petrolatum-based regimens reduce desiccation and friction over ablative wounds. - **Open care:** lighter regimens may be used for less aggressive fractional or non-ablative treatment. - **Analgesia:** prescribe simple analgesia and escalate if pain is worsening rather than settling. **Prevent infection while recognising protocol variation** Prophylaxis should follow local policy and patient risk, with a low threshold to treat suspected infection. - **HSV prophylaxis:** expert consensus supports valacyclovir 500 mg for 5–7 days starting the day before or day of fractional ablative CO2 resurfacing. - **Bacterial prophylaxis:** most expert panelists recommend it for fractional ablative CO2 resurfacing, but antibiotic choice is not standardised. [1](#ref-1) - **Red flags:** vesicles, purulence, spreading erythema, fever, severe pain, or delayed healing require review. - **Swabs:** culture suspicious crusting, pustules, or non-healing areas before changing treatment blindly. **Control inflammation and pigment risk** Sun exposure and premature active skincare can convert an uncomplicated procedure into dyspigmentation. - **Sun avoidance:** strict photoprotection is mandatory while erythema and barrier disruption persist. - **Active skincare:** active ingredients are generally restarted gradually between days 8 and 42 once healing permits. [1](#ref-1) - **Erythema expectation:** reviewed rejuvenation studies reported erythema around 12.8 days with combination treatment versus 15.24 days with monotherapy. [2](#ref-2) - **Pigment surveillance:** review earlier in darker skin, melasma tendency, or any new brown-grey change. **Use follow-up to detect both complications and opportunities** Surveillance is not only complication screening. It also identifies whether further scar or texture treatment is appropriate. - **Early review:** check epithelialisation, pain trajectory, infection signs, and adherence. - **Later review:** assess erythema, pigment, contour, scar softening, and need for staged treatment. - **Mohs scars:** laser scar revision after Mohs has been reported from immediately post-procedure through 4 years later. [4](#ref-4) - **Perioral treatment:** adverse events after perioral rejuvenation should be recognised early so treatment can start without delay. [19](#ref-19) --- ## Outcomes and Counselling ****Key Point** Laser resurfacing improves texture, rhytides, dyspigmentation, and selected scars, but results vary by indication, skin type, device, and treatment intensity. Most patients improve rather than achieve complete correction. Counselling should focus on expected improvement, downtime, pigment risk, need for staged treatment, and the limitations of resurfacing compared with lifting or volume-restoration procedures. **Counsel improvement, not perfection** Patients should understand that: - Laser resurfacing improves rather than completely removes wrinkles, scars, or pigment abnormalities. - Several months may be required for maximal collagen remodelling and final results. - Multiple treatment sessions are often required, particularly for acne scars, non-ablative resurfacing, and darker skin types. - Laser resurfacing improves skin quality but does not replace procedures that address skin laxity, facial descent, or volume loss. - Maintenance treatments and ongoing sun protection help preserve long-term results. **Match expectations to downtime and risk** More aggressive treatment generally increases: - Wrinkle reduction and skin tightening. - Collagen remodelling. - Improvement in deeper scars and photodamage. but also increases: - Recovery time and postoperative erythema. - Risk of post-inflammatory hyperpigmentation, particularly in darker phototypes. - Risk of infection, prolonged healing, and scarring. - Need for meticulous wound care and strict photoprotection. --- ## References **\[1\]** Levy et al.. Expert Consensus on Clinical Recommendations for Fractional Ablative CO 2 Laser, in Facial Skin Rejuvenation Treatment.. Lasers in surgery and medicine. 2025\. doi:10.1002/lsm.23850 **\[2\]** Pour et al.. A systematic review and meta-analysis of efficacy, safety, and satisfaction rates of laser combination treatments vs laser monotherapy in skin rejuvenation resurfacing.. Lasers in medical science. 2023\. doi:10.1007/s10103-023-03856-5 **\[3\]** Xu et al.. Ablative Fractional CO2 Laser for Facial Atrophic Acne Scars.. Facial plastic surgery : FPS. 2018\. doi:10.1055/s-0037-1606096 **\[4\]** Le et al.. Laser Applications in Wound and Scar Management Post-Mohs Micrographic Surgery: A Systematic Review\\.. Journal of cutaneous medicine and surgery. 2024\. doi:10.1177/12034754241227629 **\[5\]** Mirza et al.. Outcomes and adverse effects of ablative vs nonablative lasers for skin resurfacing: A systematic review of 1093 patients.. Dermatologic therapy. 2021\. doi:10.1111/dth.14432 **\[6\]** Alster et al.. Erbium:YAG cutaneous laser resurfacing.. Dermatologic clinics. 2001\. doi:10.1016/s0733-8635(05)70286-2 **\[7\]** Caniglia. Erbium:YAG laser skin resurfacing.. Facial plastic surgery clinics of North America. 2004\. doi:10.1016/j.fsc.2004.03.005 **\[8\]** Kwon et al.. Combination Treatment with Human Adipose Tissue Stem Cell-derived Exosomes and Fractional CO2 Laser for Acne Scars: A 12-week Prospective, Double-blind, Randomized, Split-face Study.. Acta dermato-venereologica. 2020\. doi:10.2340/00015555-3666 **\[9\]** Gupta et al.. Skin typing: Fitzpatrick grading and others.. Clinics in dermatology. 2019\. doi:10.1016/j.clindermatol.2019.07.010 **\[10\]** Bhargava et al.. Acne Scarring Management: Systematic Review and Evaluation of the Evidence.. American journal of clinical dermatology. 2018\. doi:10.1007/s40257-018-0358-5 **\[11\]** Ghazzawi et al.. A systematic review of evaluating the efficacy of acne scar treatment by Fractional Laser with or without using adjunctive treatments.. Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology. 2021\. doi:10.1080/14764172.2022.2033785 **\[12\]** Cox et al.. Skin Preparation for Photodynamic Therapy, Chemexfoliation, and Ablative Laser Resurfacing: a Systematic Literature Review\\.. Dermatologic surgery : official publication for American Society for Dermatologic Surgery \\\[et al.\]. 2021\. doi:10.1097/DSS.0000000000003026 **\[13\]** Chen et al.. A systematic review of comparative studies of CO 2 and erbium:YAG lasers in resurfacing facial rhytides (wrinkles).. Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology. 2017\. doi:10.1080/14764172.2017.1288261 **\[14\]** Greveling et al.. Non-invasive anaesthetic methods for dermatological laser procedures: a systematic review\\.. Journal of the European Academy of Dermatology and Venereology : JEADV. 2017\. doi:10.1111/jdv.14130 **\[15\]** Caprari et al.. Assessment of clinical efficacy of lidocaine/tetracaine 7%/7% peel cream in fractional microablative laser procedure-associated pain for facial skin aging treatment. A randomized, controlled, single-blind trial.. Journal of cosmetic dermatology. 2022\. doi:10.1111/jocd.14296 **\[16\]** Hympanova et al.. Effects of non-ablative Er:YAG laser on the skin and the vaginal wall: systematic review of the clinical and experimental literature.. International urogynecology journal. 2020\. doi:10.1007/s00192-020-04452-9 **\[17\]** Jordan et al.. Laser resurfacing of the skin for the improvement of facial acne scarring: a systematic review of the evidence.. The British journal of dermatology. 2000\. doi:10.1046/j.1365-2133.2000.03350.x **\[18\]** Wen et al.. Laser Resurfacing at the Time of Facelift Surgery: A Systematic Review and Meta-Analysis.. Aesthetic surgery journal. 2026\. doi:10.1093/asj/sjaf203 **\[19\]** Sayan et al.. Adverse reactions associated with perioral rejuvenation using laser, fat and hyaluronic acid: systematic review\\.. The British journal of oral & maxillofacial surgery. 2021\. doi:10.1016/j.bjoms.2021.02.027 ### Brow Ptosis: Anatomy, Assessment, & Management URL: https://www.theplasticsfella.com/brow-ptosis/ Last updated: 2026-07-24T19:01:03.000Z #### Summary Card [****Definition and Pathophysiology**](#definition-and-pathophysiology) Brow ptosis is descent of the eyebrow complex causing aesthetic imbalance or functional visual field obstruction, and its cause may be involutional, neurogenic, traumatic, congenital, hereditary, or iatrogenic. [****Applied Anatomy**](#applied-anatomy) Brow position is determined by the aesthetic brow unit, frontalis-depressor balance, retaining ligaments, lateral fascial support, neurovascular bundles, temporal facial nerve branch, and the safe dissection planes of the forehead and scalp. [****Clinical Assessment**](#clinical-assessment) Assess cause, function, brow position, asymmetry, eyelid pathology, frontalis compensation, facial nerve function, ocular surface risk, and documentation before choosing brow-only, eyelid-only, combined, or non-operative treatment. [****Investigations**](#investigations) Investigations are selective: use visual field testing and standardised photography for functional documentation, ophthalmology for eyelid or ocular uncertainty, and imaging or neurology workup for atypical, progressive, traumatic, or palsy-associated cases. [****Treatment Selection**](#treatment-selection) Choose treatment by the dominant problem: observe mild stable asymmetry, use neuromodulation only for dynamic imbalance, use limited browpexy for mild lateral descent with blepharoplasty, and choose formal brow lift for moderate to severe, functional, paralytic, or structurally low brows. [****Operative Principles**](#operative-principles) Safe brow lift depends on relaxed marking, correct-plane release, protection of supraorbital/supratrochlear and temporal facial nerve branches, stable fixation, symmetry checks, and avoiding overcorrection that destabilises eyelid closure. [****Complications**](#complications) Brow ptosis correction can cause haematoma, infection, nerve injury, sensory change, asymmetry, undercorrection, overcorrection, alopecia, visible scarring, recurrence, ocular surface problems, and revision need. [****Outcomes and Counselling**](#outcomes-and-counselling) Brow ptosis treatment usually improves brow position, visual heaviness, and upper facial balance, but results are technique-dependent, often millimetric, and must be balanced against scar, sensory, recurrence, eyelid, and revision risks. --- ## Definition and Pathophysiology ****Key Point** Brow ptosis is descent of the eyebrow complex causing aesthetic imbalance or functional visual field obstruction, and its cause may be involutional, neurogenic, traumatic, congenital, hereditary, or iatrogenic. Brow ptosis is not simply “too much upper eyelid skin.” It is a positional problem of the brow-soft tissue complex that may load the upper lid and narrow the superior visual field [1](#ref-1). ### Brow Ptosis Define brow ptosis by the brow position, eyelid loading, and patient impact. - **Functional ptosis:** brow descent contributes to superior visual obstruction, heaviness, or compensatory frontalis strain. - **Aesthetic ptosis:** low or asymmetric brow position disrupts upper facial balance. - **Pseudodermatochalasis:** brow descent creates apparent upper eyelid skin excess. - **Severity cue:** lateral brow descent is often the clinically dominant complaint. ### Pathophysiology Treat brow ptosis as a multifactorial imbalance, not isolated skin redundancy. - **Involutional change:** age-related brow ptosis reflects skin, fat, skeletal support, and elevator-depressor imbalance [2](#ref-2). - **Common context:** involutional ageing is the usual setting in older adults, but ageing does not uniformly lower every brow [1](#ref-1) [3](#ref-3). - **Neuromuscular causes:** facial paralysis, myasthenia gravis, trauma, and congenital or hereditary causes change treatment planning [4](#ref-4). - **Iatrogenic causes:** blepharoplasty, ptosis surgery, neuromodulators, or forehead surgery can alter brow position. ### Frontalis Compensation Apparent brow height may be maintained by frontalis overactivity masking true descent. - **Compensated ptosis:** patients may elevate the brow continuously to clear the visual axis. - **Decompensation risk:** removing upper eyelid skin without brow assessment may worsen brow ptosis [4](#ref-4). - **Planning implication:** relax the forehead before marking, photographing, or deciding on blepharoplasty alone. - **Counselling point:** recurrence may reflect early technical failure or later biologic descent [2](#ref-2). --- ## Applied Anatomy ****Key Point** Brow position is determined by the aesthetic brow unit, frontalis-depressor balance, retaining ligaments, lateral fascial support, neurovascular bundles, temporal facial nerve branch, and the safe dissection planes of the forehead and scalp. The anatomy that matters is the anatomy that changes the operation: where to release, where to fix, and what must not be injured. ### Brow Aesthetic Unit Set the target brow according to sex, contour, hairline, asymmetry, and orbital support. - **Female brow:** often lies above the supraorbital rim with a lateral peak [1](#ref-1). - **Male brow:** generally sits at or near the supraorbital rim and should not be over-elevated [1](#ref-1). - **Brow tail:** lateral contour drives perceived rejuvenation and long-term stability in endoscopic planning [2](#ref-2). - **Skeletal support:** orbital rim recession can contribute structurally to brow descent [3](#ref-3). ### Muscle Anatomy Brow position reflects the balance between frontalis elevation and depressor activity. - **Frontalis:** elevates the brow but inserts less directly into the lateral brow. - **Orbicularis oculi:** contributes to brow depression, especially laterally. - **Corrugator-procerus complex:** depresses and medialises the medial brow and glabella. - **Lateral weakness:** lateral brow ptosis is common because lateral frontalis support is weaker [1](#ref-1) [3](#ref-3). ### Retaining Ligaments Stable lift requires release of the structures tethering the brow to the orbital rim and temporal fusion line. - **Orbital retaining ligament:** anchors brow soft tissue near the superior orbital rim. - **Temporal fusion line:** separates forehead region and the temporal fossa. - **Lateral fixation need:** the lateral brow may need specific suspension because fascial support is weaker [5](#ref-5). - **Release-fixation link:** inadequate release forces fixation to fight tethering rather than reposition tissue. ### Neurovascular Anatomy Protect sensory nerves and the temporal facial nerve branch during release, fixation, and scar placement. - **Supraorbital bundle:** exits via notch or foramen and supplies forehead and scalp sensation. - **Supratrochlear bundle:** emerges more medially and is vulnerable during glabellar release. - **Temporal branch:** crosses the zygomatic arch within the temporoparietal fascial system before entering frontalis. - **Danger zone:** keep temporal dissection in the correct plane and avoid blind cautery over the zygomatic arch. ### Forehead Planes Choose the dissection plane by matching exposure, fixation, muscle treatment, nerve risk, and vascular reliability. - **Subcutaneous plane:** simple and direct for limited open access, but raises thin skin flaps and may compromise forehead flap vascularity. - **Subgaleal plane:** commonly used for open brow lift because it is relatively avascular, but the deep division of the supraorbital nerve is at risk during superior dissection. - **Subperiosteal plane:** favoured in endoscopic or limited-incision approaches because it allows broad release and fixation from bone, but requires periosteal release to mobilise the brow. - **Muscle access:** subcutaneous and subgaleal planes can permit direct corrugator or procerus treatment; a purely subperiosteal approach may need deliberate access for glabellar muscle modification. Choose the dissection plane that gives release while respecting nerve depth and hair-bearing scalp. - **Subcutaneous plane:** used in direct and mid-forehead lifts; scar quality becomes central. - **Subgaleal plane:** common in open forehead approaches. - **Subperiosteal plane:** used in many endoscopic lifts to allow broad release from the orbital rim. - **Temporal plane:** respect the relationship between temporoparietal fascia, deep temporal fascia, and facial nerve. --- ## Clinical Assessment ****Key Point** Assess cause, function, brow position, asymmetry, eyelid pathology, frontalis compensation, facial nerve function, ocular surface risk, and documentation before choosing brow-only, eyelid-only, combined, or non-operative treatment. The common planning error is treating upper eyelid skin when the real problem is brow descent, true ptosis, or both. ### History Use the history to separate aesthetic concern, functional obstruction, neurogenic weakness, and iatrogenic change. - **Functional symptoms:** heaviness, brow ache, superior field loss, reading fatigue, or taping the lids. - **Time course:** gradual involutional descent differs from acute, progressive, traumatic, or paralytic onset. - **Previous treatment:** document blepharoplasty, ptosis repair, botulinum toxin, facial trauma, and forehead surgery. - **Neurology trigger:** new upper facial weakness or frontalis dysfunction may require assessment for central causes [6](#ref-6). ### Brow Examination Examine the brow at rest, with frontalis relaxed, and with manual repositioning. - **Resting position:** document brow relative to the supraorbital rim, asymmetry, and frontalis activity [7](#ref-7). - **Aesthetic metrics:** include tarsal platform show and brow fat span, not height alone [8](#ref-8). - **Sex-specific target:** young female brows may sit around 5 mm above the rim, while male brows often sit at the rim [4](#ref-4). - **Severity grading:** lateral brow tail measurement can grade ptosis from degree I to IV using defined centimetre thresholds [9](#ref-9). ### Eyelid Assessment Distinguish brow-related pseudoptosis from dermatochalasis and true blepharoptosis. - **Pseudoptosis:** brow tissue loads the upper lid and skin may contact the lashes [1](#ref-1). - **Manual brow elevation:** if the lid margin remains low, true blepharoptosis is present [1](#ref-1). - **Levator function:** measure excursion before planning eyelid surgery or combined correction. - **Dermatochalasis:** assess skin excess only after brow position is neutralised. ### Facial Nerve Assessment Brow lifting depends on frontalis function and corneal protection, especially in facial palsy. - **Frontalis power:** compare elevation symmetry and fatigability. - **Eye closure:** procedures relying on periocular muscle function require eye-closing power assessment [10](#ref-10). - **Synkinesis:** note paradoxical brow depression or periocular tightness. - **Facial palsy:** assess lagophthalmos, Bell’s phenomenon, exposure symptoms, and lower lid position. ### Documentation Record the findings that justify treatment choice and protect against the wrong operation. - **Photographs:** frontal, oblique, relaxed forehead, raised brow, and eyes closed when relevant. - **Visual function:** document symptoms and objective findings when obstruction is claimed. - **Decision consequence:** decide whether the primary problem is brow descent, lid skin excess, lid ptosis, or combined disease. - **Consent baseline:** record asymmetry before surgery; most patients have some pre-existing asymmetry. --- ## Investigations ****Key Point** Investigations are selective: use visual field testing and standardised photography for functional documentation, ophthalmology for eyelid or ocular uncertainty, and imaging or neurology workup for atypical, progressive, traumatic, or palsy-associated cases. Most brow ptosis is a clinical diagnosis. Investigations should change diagnosis, operative planning, funding justification, or safety. ### Functional Documentation Use testing when the patient reports visual obstruction or funding criteria require objective evidence. - **Perimetry:** formal visual fields can document superior field obstruction and improvement with brow elevation. - **Photography:** clinical photographs and measurements are accepted documentation tools for eyebrow position [11](#ref-11). - **Reference points:** standardised photographs can quantify medial, central, and lateral eyebrow height [12](#ref-12). - **MRD-1:** measure the distance in millimetres from the corneal light reflex to the upper eyelid margin in primary gaze when ptosis is suspected; normal values are cited around 4.0–4.5 mm, but avoid rigid cut-offs [7](#ref-7). ### Selective Workup Escalate investigations when the presentation is not straightforward involutional brow descent. - **Eyelid differential:** distinguish dermatochalasis from blepharoptosis because treatment differs and they may coexist [7](#ref-7). - **Ophthalmology:** involve when levator function, ocular surface disease, diplopia, or ptosis diagnosis is uncertain. - **Neurology:** consider for progressive weakness, fatigability, anisocoria, or central facial weakness. - **Imaging/laboratory tests:** target suspected trauma, mass, myasthenia, Horner syndrome, or facial palsy causes [13](#ref-13). --- ## Treatment Selection ****Key Point** Choose treatment by the dominant problem: observe mild stable asymmetry, use neuromodulation only for dynamic imbalance, use limited browpexy for mild lateral descent with blepharoplasty, and choose formal brow lift for moderate to severe, functional, paralytic, or structurally low brows. Treatment selection is not a list of operations. It is matching the operation to brow severity, hairline, forehead scars, eyelid pathology, facial nerve function, and the patient’s tolerance of scars versus recurrence. ### Non-Operative Management Use non-operative treatment only for mild, dynamic, reversible, or low-risk aesthetic problems. - **Observation:** reasonable for mild asymmetry without field symptoms or progression. - **Botulinum toxin:** useful when depressor overactivity contributes; injection pattern must avoid medial brow ptosis or unwanted lateral elevation [14](#ref-14). - **Device treatment:** micro-focused ultrasound may be considered for selected mild to moderate brow ptosis, but severe ptosis needs surgery [4](#ref-4) [4](#ref-4). - **Boundary:** non-operative options do not reliably correct heavy, functional, paralytic, or structurally descended brows. ### Eyelid-Associated Ptosis Treat the brow, eyelid skin, and levator as separate problems before combining procedures. - **Blepharoplasty alone:** avoid when true lid ptosis or low lid position requires ptosis correction [7](#ref-7). - **Combined correction:** consider brow surgery when dermatochalasis coexists with brow and upper eyelid ptosis [7](#ref-7). - **Ptosis planning:** account for cause, laterality, levator function, severity, age, and neurologic or ophthalmologic abnormalities [13](#ref-13). - **Upper blepharoplasty:** assess forehead and brow contribution so brow ptosis is not left untreated [15](#ref-15). ### Operative Management Select the brow lift approach by severity, scar acceptability, hairline, rhytids, asymmetry, and need for eyelid surgery. | Clinical pattern | Best-fit option | Main trade-off | | --------------------------------------------- | -------------------------- | ---------------------------- | | Mild lateral descent with blepharoplasty | Internal browpexy | Limited elevation | | Severe unilateral or facial palsy brow ptosis | Direct brow lift | Visible suprabrow scar | | Deep forehead rhytids, high scar tolerance | Mid-forehead lift | Forehead scar visibility | | High hairline or long forehead | Pretrichial lift | Hairline scar | | Global descent with acceptable hairline | Endoscopic or coronal lift | Fixation and recurrence risk | | Isolated lateral hooding | Temporal brow lift | Limited medial correction | - **Direct brow lift:** precise, powerful, and useful in men, facial palsy, heavy brows, and marked asymmetry. - **Endoscopic lift:** avoids long visible scars but requires adequate release and reliable fixation. - **Pretrichial/coronal lift:** better for global forehead-brow repositioning; hairline position drives choice. - **Internal browpexy:** adjunct to upper blepharoplasty, not a substitute for formal correction of severe ptosis. ### Patient Selection Modify, defer, or decline treatment when the chosen operation cannot safely meet the patient’s goal. - **Facial palsy:** brow ptosis correction may form part of static periocular reanimation to improve corneal protection [16](#ref-16). - **Degree II-IV:** some grading systems recommend brow elevation surgery for degree II to IV rather than degree I ptosis [9](#ref-9). - **Preference:** individualise treatment by patient goals, anatomy, risk tolerance, and surgeon expertise [1](#ref-1). - **Red flags:** unrealistic symmetry demands, poor ocular surface reserve, active neuromuscular disease, or unstable facial palsy. --- ## Operative Principles ****Key Point** Safe brow lift depends on relaxed marking, correct-plane release, protection of supraorbital/supratrochlear and temporal facial nerve branches, stable fixation, symmetry checks, and avoiding overcorrection that destabilises eyelid closure. The operation fails when the brow is marked under frontalis activation, tethering is not released, fixation is weak, or the eyelid problem is misdiagnosed. ### Marking Mark the patient upright with the brow relaxed and the eyelids assessed separately. - **Relaxed forehead:** neutralise frontalis compensation before deciding the lift vector. - **Existing asymmetry:** mark and photograph asymmetry rather than trying to discover it postoperatively. - **Scar placement:** use brow hair, forehead rhytids, hairline, or scalp access to camouflage scars. - **Eyelid safety:** avoid excessive skin excision if brow elevation will change upper eyelid show. ### Neurovascular Protection Identify sensory exits and respect the temporal facial nerve plane before release or fixation. - **Supraorbital foramen:** identify and mark it during superior orbital rim dissection to reduce nerve injury risk [10](#ref-10). - **Supratrochlear nerve:** protect during medial release and corrugator work. - **Temporal branch:** avoid deep or blind dissection across the zygomatic arch-temporal danger zone. - **Cautery discipline:** use direct vision near neurovascular bundles and hair-bearing scalp. ### Release Adequate release allows the brow to move; fixation should not compensate for tethered tissue. - **Retaining ligaments:** release orbital and forehead attachments sufficiently for tension-free repositioning [2](#ref-2). - **Endoscopic pattern:** medial depressor release, central suspension, and tail suspension may need separate management [2](#ref-2). - **Direct lift:** deep-plane techniques may suspend orbicularis oculi to support brow elevation [17](#ref-17). - **Depressor control:** direct brow planning may target brow elevation, brow fat suspension, and reduced orbicularis depressor action [17](#ref-17). ### Fixation Fix the brow long enough and in the right vector for periosteal adherence and lateral stability. - **Duration principle:** fixation should stabilise the brow for at least 12 weeks to support periosteal adherence [2](#ref-2). - **Vector:** lift the lateral brow obliquely rather than producing surprised vertical elevation. - **Internal browpexy:** useful with blepharoplasty when similar modest elevation and less scarring are acceptable [5](#ref-5). - **Failure point:** recurrent lateral descent often reflects inadequate tail release, vector, or fixation. ### Closure Close for scar quality, hair preservation, and eyelid protection rather than maximal elevation. - **Direct lift:** bevel or design incisions to protect brow hair and avoid conspicuous scar widening. - **Hair-bearing scalp:** avoid follicle injury, excessive tension, and thermal damage. - **Symmetry check:** sit the patient up when feasible before final fixation or closure. - **Ocular check:** confirm no lagophthalmos, excessive upper lid show, or corneal exposure risk. --- ## Complications ****Key Point** Brow ptosis correction can cause haematoma, infection, nerve injury, sensory change, asymmetry, undercorrection, overcorrection, alopecia, visible scarring, recurrence, ocular surface problems, and revision need. Complications are best organised by timing and consequence: urgent threats, nerve-related morbidity, shape failure, scar problems, and ocular protection. ### Early Complications Identify bleeding, infection, exposure symptoms, and acute asymmetry early. - **Haematoma:** urgent swelling, pain, bruising, or visual symptoms require prompt review. - **Infection:** uncommon but consider with erythema, discharge, fever, or wound breakdown. - **Lagophthalmos:** procedures altering frontalis-eyelid mechanics can cause pain, dry eye, blurred vision, and keratopathy [10](#ref-10). - **Follow-up:** after ptosis correction or blepharoplasty, check asymmetry and lagophthalmos at 1–3 months and ideally 9–12 months [7](#ref-7). ### Nerve Complications Separate sensory disturbance from motor weakness and document recovery. - **Sensory change:** supraorbital or supratrochlear neuropraxia causes forehead or scalp paraesthesia. - **Deep-plane direct lift:** transient sensory complications resolved within 3–5 months in one cohort [17](#ref-17). - **Temporal branch injury:** produces brow elevation weakness and may worsen asymmetry. - **Neuromodulators:** brow and eyelid ptosis are recognised complications [18](#ref-18). ### Aesthetic Failure Revision is driven by visible scars, alopecia, contour problems, undercorrection, overcorrection, and recurrence. - **Undercorrection:** residual lateral hooding often follows inadequate release or fixation. - **Overcorrection:** produces surprised appearance, scleral show, or worsened dry eye symptoms. - **Visible scar:** direct brow scars are less conspicuous in thick brow hair or brow tattoos [17](#ref-17). - **Alopecia:** avoid excessive scalp tension, follicle transection, and cautery injury. ### Adjunct-Related Complications Counsel non-surgical and suspension adjuncts according to their own risk profile. - **Upper-face botulinum toxin:** reported brow ptosis and blepharoptosis rates are 3.1% and 2.5% respectively [19](#ref-19). - **Resolution:** botulinum toxin-related brow ptosis and blepharoptosis are generally spontaneously resolving events [19](#ref-19). - **Repeated glabellar treatment:** most reported ptosis episodes lasted less than 3 weeks in one large series [20](#ref-20). - **Synthetic suspension:** reported complications around the brow-eyelid complex include lagophthalmos, graft breakage, granuloma, and infection at 7%–45% [10](#ref-10). --- ## Outcomes and Counselling ****Key Point** Brow ptosis treatment usually improves brow position, visual heaviness, and upper facial balance, but results are technique-dependent, often millimetric, and must be balanced against scar, sensory, recurrence, eyelid, and revision risks. Counsel patients in practical terms: what will lift, what scar they accept, how durable the effect may be, and whether the eyelid also needs treatment. ### Functional Outcomes Functional benefit is greatest when brow elevation relieves true tissue loading or improves ocular protection. - **Visual obstruction:** patients may notice less superior field restriction and forehead strain when brow loading is corrected. - **Facial palsy:** static periocular treatment including brow ptosis correction improved FaCE quality-of-life scores in one facial paralysis cohort [16](#ref-16). - **Corneal protection:** do not promise better closure; brow elevation can help exposure planning but may also reveal ocular surface risk. - **Combined disease:** explain when blepharoplasty or levator repair is also required. ### Aesthetic Outcomes Aim for natural contour and symmetry, not maximal vertical elevation. - **Endoscopic lift:** pooled long-term average elevations were approximately 3.25 mm medial, 3.86 mm central, and 4.35 mm lateral [2](#ref-2). - **Evidence base:** those pooled endoscopic estimates came from 478 measured cases [2](#ref-2). - **Direct deep-plane lift:** one prospective cohort reported symmetrical brow positioning in 97.8% of patients [17](#ref-17). - **Natural appearance:** the same deep-plane direct brow lift cohort reported natural appearance within three months [17](#ref-17). ### Durability Explain that durability depends on release, fixation, tissue quality, technique, and ongoing ageing. - **Endoscopic counselling:** describe durable elevation as measurable but not dramatic. - **Device treatment:** focused ultrasound produced greater brow-lift effect at 90 days than at 180 days in one 40-subject study [4](#ref-4). - **Thread lifting:** expected elevation is modest and time-limited [21](#ref-21). - **Recurrence:** recurrent descent may require revision if it causes renewed functional obstruction or unacceptable asymmetry. ### Patient Counselling Make the trade-off explicit before surgery: scar visibility versus lift power, and brow correction versus eyelid correction. - **Direct lift:** strongest local control but the suprabrow scar must be acceptable. - **Endoscopic/coronal:** hidden scars but wider dissection, fixation reliance, and potential sensory symptoms. - **Blepharoplasty interaction:** aponeurosis advancement for blepharoptosis can be followed by mean eyebrow drooping of about 2.5–2.9 mm [12](#ref-12). - **Revision possibility:** counsel that asymmetry, undercorrection, scar dissatisfaction, recurrence, or ocular symptoms may require further treatment. --- ## References **\[1\]** Rullan et al.. Botulinum Toxin Type A Induced Brow Ptosis Reversal Using Bacteriostatic Saline.. Dermatologic surgery : official publication for American Society for Dermatologic Surgery \\\[et al.\]. 2024\. doi:10.1097/DSS.0000000000004170 **\[2\]** Aesthetic surgery journal. Long-term Stability in Endoscopic Brow Lift: A Systematic Review and Meta-Analysis of the Literature.. Aesthetic surgery journal. 2025\. doi:10.1093/asj/sjae225 **\[3\]** Swift et al.. The Facial Aging Process From the "Inside Out".. Aesthetic surgery journal. 2021\. doi:10.1093/asj/sjaa339 **\[4\]** Chen et al.. Ultrasound rejuvenation for upper facial skin: A randomized blinded prospective study.. Journal of cosmetic dermatology. 2024\. doi:10.1111/jocd.16482 **\[5\]** Sugino et al.. Comparison of two techniques for surgical eyebrow suspension.. Journal francais d'ophtalmologie. 2022\. doi:10.1016/j.jfo.2022.03.011 **\[6\]** Kubota-Hanya et al.. 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Aesthetic surgery journal. 2021\. doi:10.1093/asj/sjaa429 **\[11\]** Custer et al.. Eyebrow Position Before and After Enucleation.. Ophthalmic plastic and reconstructive surgery. 2022\. doi:10.1097/IOP.0000000000002145 **\[12\]** Kokubo et al.. Evaluation of the eyebrow position after aponeurosis advancement.. Journal of plastic surgery and hand surgery. 2019\. doi:10.1080/2000656X.2018.1547735 **\[13\]** Finsterer. Ptosis: causes, presentation, and management.. Aesthetic plastic surgery. 2003\. doi:10.1007/s00266-003-0127-5 **\[14\]** Cotofana et al.. Respecting upper facial anatomy for treating the glabella with neuromodulators to avoid medial brow ptosis-A refined 3-point injection technique.. Journal of cosmetic dermatology. 2021\. doi:10.1111/jocd.14133 **\[15\]** Flowers et al.. The biomechanics of brow and frontalis function and its effect on blepharoplasty.. Clinics in plastic surgery. 1993\. PMID:8485934 **\[16\]** Henstrom et al.. Surgical treatment of the periocular complex and improvement of quality of life in patients with facial paralysis.. Archives of facial plastic surgery. 2011\. doi:10.1001/archfacial.2011.9 **\[17\]** Fakih-Gomez et al.. Deep Plane Direct Brow Lift.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-025-04775-2 **\[18\]** Quach et al.. Complications of Injectables.. Atlas of the oral and maxillofacial surgery clinics of North America. 2024\. doi:10.1016/j.cxom.2023.10.005 **\[19\]** Cavallini et al.. Safety of botulinum toxin A in aesthetic treatments: a systematic review of clinical studies.. Dermatologic surgery : official publication for American Society for Dermatologic Surgery \\\[et al.\]. 2014\. doi:10.1111/dsu.12463 **\[20\]** Moy et al.. Long-term safety and efficacy of a new botulinum toxin type A in treating glabellar lines.. Archives of facial plastic surgery. 2009\. doi:10.1001/archfacial.2009.5 **\[21\]** Park et al.. Anatomical Perspectives of Brow-Lifting Using Threads: Clinical Cases with Techniques. Journal of Cosmetic Dermatology. 2024\. doi:10.1111/jocd.16505 ### Brow Lift: Assessment, Surgical Techniques, & Outcomes URL: https://www.theplasticsfella.com/brow-lift/ Last updated: 2026-09-06T10:50:37.000Z #### Summary Card [****Indications**](#indications) Brow lift is indicated when brow descent, asymmetry, or lateral hooding is the main cause of upper facial heaviness or an adverse resting expression, especially when isolated blepharoplasty would miss the primary deformity. [****Applied Anatomy**](#applied-anatomy) Safe brow lift depends on understanding where the brow is tethered and where the sensory and motor nerves leave the orbit, because release and fixation occur in the same danger zones. [****Preoperative Assessment**](#preoperative-assessment) The main preoperative error is to treat upper lid hooding as dermatochalasis without first neutralising the brow and identifying frontalis compensation. [****Technique Selection**](#technique-selection) Technique selection is driven by lift vector, hairline effect, and scar tolerance, because most modern approaches can elevate the brow but they do not have the same trade-offs. [****Surgical Technique**](#surgical-technique) Durable brow lift depends more on complete release and correct vector fixation than on the size of the incision. [****Complications**](#complications) Most brow lift complications are problems of planning, vector, and nerve irritation rather than flap loss, and they are recognised early by checking brow height, eyelid closure, scalp sensation, and frontalis function. [****Outcomes**](#outcomes) Brow lift gives durable but modest elevation, usually greatest laterally, and the result softens gradually over time. --- ## Indications ****Key Point** Brow lift is indicated when brow descent, asymmetry, or lateral hooding is the main cause of upper facial heaviness or an adverse resting expression, especially when isolated blepharoplasty would miss the primary deformity. Brow lift treats position, not just excess skin. The first decision is whether the patient’s complaint is driven by brow descent, eyelid pathology, or both, because upper lid surgery alone can leave the brow problem behind [1](#ref-1). ### Functional and aesthetic indications Operate when brow position is the dominant abnormality and the patient’s goal is better aperture, softer expression, or reduced hooding. - **Brow ptosis:** descent of the brow below its expected level at rest. - **Lateral hooding:** tail descent crowding the lateral canthus and upper lid [2](#ref-2). - **Asymmetry:** static brow height difference that remains noticeable with the forehead relaxed. - **Field symptoms:** superior or lateral visual obstruction, brow fatigue, or habitual manual brow elevation. - **Expression change:** tired, angry, or sad appearance caused by brow descent rather than lid skin alone. **When a brow lift is preferred over isolated blepharoplasty** Choose brow elevation when manual brow support corrects much of the apparent upper lid excess, because skin excision alone can unmask or worsen the underlying imbalance [1](#ref-1). - **Brow-eyelid mismatch:** apparent dermatochalasis that improves when the brow is returned to neutral. - **Combined treatment:** modest brow elevation can be added through an upper blepharoplasty incision when both problems are being addressed together [3](#ref-3). - **Lateral-only deformity:** a limited lateral lift is reasonable when the medial brow is acceptable and the complaint is temporal hooding [2](#ref-2). **When surgery is more appropriate than nonoperative lifting** Nonsurgical upper-face tightening produces only modest elevation, so it suits mild change or surgery-averse patients rather than established operative brow ptosis [4](#ref-4). - **Best nonoperative candidates:** mild upper facial laxity without marked descent. - **Poor substitutes:** significant brow ptosis, fixed asymmetry, or patients already needing eyelid-brow surgery. --- ## Applied Anatomy ****Key Point** Safe brow lift depends on understanding where the brow is tethered and where the sensory and motor nerves leave the orbit, because release and fixation occur in the same danger zones. Brow shape is set by soft-tissue balance, not by skin alone. The operation works by mobilising tissues fixed at the orbital rim and temporal fusion zones while preserving the supraorbital, supratrochlear, and frontal branch pathways. ### Surface landmarks Surface anatomy determines both the aesthetic target and the lift vector. - **Female brow:** usually arches above the supraorbital rim, with the apex near or just lateral to the lateral limbus. - **Male brow:** flatter and lower, often sitting at the rim. - **Tail position:** lateral descent causes most age-related hooding. - **Medial start:** usually aligns near the medial canthus and alar base line. ### Functional layers and retaining structures Dissection planes matter because the brow moves as a composite soft-tissue unit. - **Frontalis:** the only elevator of the brow. - **Continuity:** frontalis joins the galea superiorly and the brow depressor complex inferiorly. - **Tethers:** periosteal adhesions and temporal retaining structures resist elevation. - **Plane implication:** release can be performed in subgaleal or subperiosteal planes, but the necessary tether release differs between them. ### Neurovascular safety The critical injuries are sensory loss from orbital bundle trauma and motor weakness from temporal branch injury. - **Supraorbital bundle:** exits at the notch or foramen and is vulnerable during superior rim release. - **Supratrochlear bundle:** lies more medially and is at risk in glabellar dissection. - **Frontal branch:** crosses the temporal region toward frontalis and is endangered by fixation passes or aggressive temporal dissection. - **Preservation principle:** periosteal fixation with fewer percutaneous passes may reduce frontal branch entrapment in minimally invasive techniques [5](#ref-5) [6](#ref-6). - **Dynamic distortion:** apparent brow level can be altered by frontalis overactivity or synkinesis, particularly in facial palsy, so true position must be judged with the forehead relaxed [7](#ref-7). --- ## Preoperative Assessment ****Key Point** The main preoperative error is to treat upper lid hooding as dermatochalasis without first neutralising the brow and identifying frontalis compensation. Preoperative assessment decides whether the patient needs brow lift, blepharoplasty, ptosis surgery, or a combination. Brow position, upper eyelid redundancy, and hairline pattern should all be assessed before planning the incision or the vector of lift [5](#ref-5). ### History The history should identify what the patient wants changed and what trade-offs they will accept to achieve it. - **Primary complaint:** heaviness, lateral hooding, asymmetry, tired expression, or visual obstruction. - **Symptom pattern:** brow fatigue, habitual manual brow lifting, or worse hooding late in the day. - **Asymmetry onset:** longstanding imbalance versus new change after palsy, trauma, surgery, or toxin. - **Ocular history:** dry eye, contact lens intolerance, previous blepharoplasty, ptosis repair, or corneal surgery. - **Prior interventions:** toxin, fillers, thread lifts, scars, or prior forehead procedures. - **Scar tolerance:** willingness to accept a visible scar for a stronger or more precise lift. - **Hair concerns:** recession, temporal alopecia, styling habits, and willingness to expose the hairline. ### Brow examination True brow ptosis is assessed with the forehead relaxed, then with animation, because frontalis compensation can hide the deformity. - **Resting level:** document medial, central, and lateral brow relative to the supraorbital rim. - **Compensation check:** gently immobilise the forehead or ask the patient to close the eyes and relax, then reassess brow height. - **Vector:** decide whether the descent is global, predominantly lateral, or unilateral. - **Shape:** assess arch, apex position, and tail flattening. - **Skin quality:** note thick heavy tissues, static rhytids, and brow fat descent. - **Mobility:** palpate how freely the brow moves off the orbital rim and temporal tether points. - **Grading:** mild, moderate, and severe labels are acceptable for description, but planning depends more on vector and hairline than on the grade itself. ### Brow-eyelid relationship Manual brow neutralisation distinguishes brow ptosis from true dermatochalasis and prevents over-resection of upper lid skin. - **Neutralisation test:** support the brow to the planned level, then reassess residual upper lid excess. - **Pretarsal show:** confirm whether lid aperture improves once the brow is corrected. - **Dermatochalasis:** persistent redundancy after brow support justifies blepharoplasty. - **Lid ptosis:** check margin-reflex distance and levator function rather than blaming all hooding on the brow. - **Field effect:** compare the superior and lateral field before and after manual brow elevation when functional impairment is part of the complaint. 💡 ****Tip:** If lateral hooding largely disappears when the brow is manually supported to neutral, isolated upper blepharoplasty will usually under-treat the complaint. ### Asymmetry Baseline asymmetry must be identified before consent, because postoperative asymmetry is often pre-existing rather than created by surgery. - **Prevalence:** baseline brow asymmetry is common, occurring in about 17% of periocular patients in one cohort [8](#ref-8). - **Prognosis:** preoperative asymmetry increased the odds of postoperative asymmetry roughly 17-fold, so it must be documented and discussed explicitly [8](#ref-8). - **Documentation:** photograph both brows at rest and during animation. - **Planning:** decide whether the operation should equalise height, reshape the arch, or both. ### Hairline, scalp, and forehead proportions Hairline pattern often determines the safest approach more than the amount of brow descent alone. - **Forehead length:** a long forehead or high hairline favours approaches that avoid further hairline recession [9](#ref-9) [5](#ref-5). - **Hair density:** thin hair, temporal alopecia, or baldness reduce the value of scalp-hidden incisions [9](#ref-9). - **Rhytids:** deep forehead lines may camouflage a mid-forehead incision. - **Scalp scars:** previous coronal, neurosurgical, or traumatic scars may alter access and vascularity. - **Skin laxity:** heavy redundant forehead skin may favour open excisional approaches. ### Documentation and expectation setting Consent is safer when the patient sees the baseline deformity and understands the likely trade-offs of each strategy. - **Photography:** obtain frontal, oblique, profile, eyes open, eyes gently closed, and forehead-relaxed views. - **Goal definition:** clarify whether the patient wants lateral tail elevation, broader aperture, softer expression, or hairline correction. - **Trade-offs:** discuss scar location, temporary numbness, alopecia risk, asymmetry, recurrence, and the possible need for adjunctive blepharoplasty [5](#ref-5). - **Functional proof:** where visual symptoms drive surgery, record the change with manual brow support. - **Durability:** explain that brow lift repositions tissue but does not stop ongoing ageing. --- ## Technique Selection ****Key Point** Technique selection is driven by lift vector, hairline effect, and scar tolerance, because most modern approaches can elevate the brow but they do not have the same trade-offs. No single brow lift is best for every patient. Endoscopic and open scalp approaches achieve similar average brow elevation, so the choice is usually made on hairline position, exposure needs, visible scar tolerance, and morbidity rather than on lift height alone [10](#ref-10) [11](#ref-11). ### Scalp approaches Use hair-bearing scalp or hairline incisions when a broad forehead release is needed and the patient can hide or accept those scars. **Endoscopic lift:** suited to global brow ptosis, brow asymmetry, and dynamic glabellar ageing when hair density is good and a smaller-incision approach is preferred [5](#ref-5) [12](#ref-12). - **Best candidate:** mild to moderate ptosis, preserved scalp hair, and no need to shorten a long forehead. - **Main advantage:** smaller incisions and less scalp morbidity than traditional wide-scalp exposure [5](#ref-5) [12](#ref-12). - **Main limitation:** less suitable in bald patients, significant scalp scarring, or patients who need forehead skin excision. - **Fixation nuance:** if maximal lateral elevation is the priority, tined fixation can gain more lift than sutures but increases dysesthesia [10](#ref-10). **Coronal lift:** useful when wide exposure is needed and the patient has enough hairline reserve to tolerate posterior shift [5](#ref-5) [12](#ref-12). - **Best candidate:** low hairline, thick hair, broad forehead ageing, and tolerance of a longer scar. - **Main drawback:** the greatest burden of scar, alopecia risk, and postoperative scalp numbness compared with more limited options [10](#ref-10) [11](#ref-11). **Pretrichial lift:** preferred when the forehead is already long or the hairline is high because it lifts without further hairline recession [5](#ref-5) [12](#ref-12). - **Best candidate:** long forehead with diffuse brow descent and willingness to accept a frontal hairline scar. - **Coronal comparison:** pooled analysis does not show a clear long-term difference in lift or complications between pretrichial and post-trichial approaches, so the expected hairline effect becomes the deciding factor [10](#ref-10). ### Visible-scar approaches Choose a visible incision when precision, strength, or unilateral correction matters more than scar concealment. **Direct brow lift:** strongest and most predictable option for focal or unilateral ptosis, facial palsy, severe asymmetry, and patients with high hairlines or baldness [13](#ref-13). - **Main trade-off:** the scar sits immediately above the brow and must be acceptable before surgery [13](#ref-13). - **Best candidate:** older patients, men with heavier brows, or patients prioritising reliable lift over scar concealment. **Deep plane direct lift:** a useful extension of direct lift when a stronger soft-tissue suspension is needed in the same scar pattern [14](#ref-14). - **Use case:** direct-lift candidates with heavier brow soft tissue or greater contour descent [14](#ref-14). **Mid-forehead lift:** best reserved for older patients with deep transverse forehead rhytids that can camouflage the incision [5](#ref-5) [12](#ref-12). - **Main advantage:** effective lift in patients who cannot hide a scalp incision. - **Main drawback:** poor option in smooth foreheads, younger patients, or those with low scar tolerance. ### Limited and adjunctive approaches Use limited approaches when the deformity is mainly lateral or when brow support is being added to planned eyelid surgery. **Temporal or lateral lift:** best for brow-tail descent and lateral orbital hooding, with less effect on the medial brow [2](#ref-2) [12](#ref-12). - **Best candidate:** preserved medial brow height with predominant lateral heaviness. - **Main limitation:** inadequate for global ptosis or strong glabellar descent. **Internal browpexy:** appropriate when upper blepharoplasty is already planned and only modest lateral support is required [15](#ref-15) [5](#ref-5). - **Best use:** mild lateral brow ptosis in a patient already needing upper lid skin excision. - **Comparative point:** in women undergoing upper blepharoplasty, internal browpexy may maintain lateral brow elevation better than temporal brow lift [15](#ref-15). - **Not enough:** usually insufficient for marked ptosis, thick heavy brows, or major asymmetry. In practice, global descent with good hair density tends toward endoscopic or hairline approaches. Focal unilateral descent, baldness, or facial palsy tends toward direct or mid-forehead lifts, while isolated tail ptosis tends toward temporal or transblepharoplasty support. --- ## Surgical Technique ****Key Point** Durable brow lift depends more on complete release and correct vector fixation than on the size of the incision. The named operations differ mainly in access. The shared operative rules are to mark the true deformity before distortion, mobilise the brow fully, fix it in the right vector, and close without compromising follicles, symmetry, or temporal nerve safety [16](#ref-16). 1. **Mark the true brow position:** Markings should be made upright and before infiltration so the lift is based on the resting deformity rather than anaesthetic distortion. - **Upright reference:** mark medial, central, and lateral brow levels and the desired apex. - **Relaxed forehead:** confirm position with frontalis compensation switched off, because frontalis relaxation changes the apparent brow level and forehead shape [17](#ref-17). - **Side-to-side plan:** decide how much each side must move before draping. 1. **Match anaesthesia and incision to the chosen approach:** the incision should solve the brow problem without creating a worse hairline or scar problem. - **Local approaches:** direct, mid-forehead, temporal, and transblepharoplasty lifts are often feasible under local anaesthetic with sedation. - **Scalp approaches:** endoscopic, pretrichial, and coronal lifts more often need general anaesthesia or deeper sedation. - **Incision logic:** scalp-hidden incisions preserve visible forehead skin, while hairline incisions preserve or shorten forehead length. 1. **Enter the intended dissection plane** The plane is chosen for exposure and fixation strategy, not as a matter of dogma. - **Accepted planes:** both subperiosteal and subgaleal elevation are established options [18](#ref-18). - **Subperiosteal use:** helpful when rigid fixation to bone or deep orbital-rim release is planned. - **Subgaleal use:** helpful when broad soft-tissue mobilisation is needed. 1. **Release the retaining structures completely:** the brow should be free enough to sit in the planned position without being forced there by fixation alone. - **Lateral release:** free the temporal and lateral orbital tethering for tail descent. - **Medial release:** address the corrugator and procerus tethering when glabellar descent contributes. - **End point:** if the brow still resists upward movement, the release is incomplete. - **Modern principle:** current endoscopic strategy relies on release rather than large skin excision [19](#ref-19). 💡 ****Tip:** If the brow will not stay in the target position without tension, keep releasing rather than tightening the fixation. 1. **Fix the brow in the required vector:** fixation should maintain the new position until soft-tissue adherence takes over. - **Vector choice:** lateral descent needs superolateral support, while global ptosis needs balanced medial and lateral elevation. - **Fixation trade-off:** tined devices can achieve more lift than sutures but at the cost of more dysesthesia [10](#ref-10). - **Distributed support:** multi-point fixation spreads tension and helps shape the lateral brow more evenly [20](#ref-20). - **Temporal variant:** a temporal subcutaneous lift can add an orbicularis oculi muscle elastic flap when extra lateral support is required [2](#ref-2). 1. **Excise skin only when the approach requires it:** skin resection is the mechanism in direct and mid-forehead lifts, but it is not the main driver of endoscopic success. - **Direct excision:** remove only the amount needed after confirming the new brow position. - **Risk of excess:** over-resection creates overcorrection, lagophthalmos, and poor scar quality. - **Scalp lifts:** rely on mobilisation and fixation rather than aggressive skin removal. 1. **Close gently and dress for oedema control:** closure should preserve follicles, minimise tension, and avoid converting a good lift into a scar problem. - **Follicle care:** handle scalp edges gently and avoid excessive tension to limit alopecia. - **Incision economy:** smaller-incision endoscopic approaches cause less early scalp sensory loss than open techniques, which supports limiting scalp dissection when feasible [21](#ref-21). - **Final check:** confirm brow symmetry, eyelid closure, and absence of focal contour bunching before dressing. - **Dressing:** apply light compression, elevate the head, and protect the cornea if temporary lagophthalmos is present. --- ## Complications ****Key Point** Most brow lift complications are problems of planning, vector, and nerve irritation rather than flap loss, and they are recognised early by checking brow height, eyelid closure, scalp sensation, and frontalis function. Complication risk varies more by incision burden, fixation method, and temporal dissection than by the word attached to the operation. The early review should focus on symmetry, over- or undercorrection, sensory change, scar tension, and frontal branch function. ### Position and contour problems Asymmetry, undercorrection, overcorrection, and early relapse usually reflect incomplete release or poor vector control. - **Asymmetry:** often unmasks pre-existing imbalance rather than creating a new one. - **Undercorrection:** follows limited release or choosing a weak adjunct for a heavy brow. - **Overcorrection:** causes a startled look, brow fatigue, and possible lagophthalmos. - **Contour irregularity:** usually comes from uneven fixation or bunching of mobilised soft tissue. - **Recurrence:** some loss of elevation over time is expected after all techniques, so early relapse should raise concern about release or fixation failure rather than simple ageing [10](#ref-10). ### Scar, sensory, and nerve morbidity The main avoidable morbidity is scalp numbness, dysesthesia, alopecia, visible scar, and frontal branch weakness. - **Scalp sensation:** open brow lifts cause more early postoperative sensory loss than endoscopic lifts, although that difference is not maintained long term [21](#ref-21). - **Fixation dysesthesia:** tined implants increase dysesthesia compared with suture fixation [10](#ref-10). - **Frontal branch:** percutaneous temporal fixation can entrap the nerve; periosteal fixation with fewer passes may reduce that risk [5](#ref-5) [6](#ref-6). - **Scar and alopecia:** risk rises with tension, follicle injury, and poor incision choice; endoscopic approaches reduce visible scar and alopecia compared with broader coronal exposure [19](#ref-19). - **Hematoma:** suspect with escalating pain, tense swelling, or rapid asymmetry and treat early. - **Large-series signal:** major complications were not reported in a large temporal subcutaneous series, supporting the safety of limited lateral approaches in selected hands [2](#ref-2). --- ## Outcomes ****Key Point** Brow lift gives durable but modest elevation, usually greatest laterally, and the result softens gradually over time. Expected improvement is measurable rather than dramatic. Across techniques, long-term elevation is usually in the 2 to 4 mm range and is greatest laterally, which matches the main aesthetic goal in most ageing brows [10](#ref-10). Endoscopic series show a similar lateral-predominant pattern [22](#ref-22). - **Durability:** brow height declines gradually with time, so patients seeking a large permanent correction need realistic revision counselling [10](#ref-10) [19](#ref-19). - **Direct lift:** selected patients report high satisfaction and reliable symmetric correction [23](#ref-23). - **Functional benefit:** in postparalytic facial nerve syndrome, endoscopic brow lift can improve periocular symptoms and quality of life [7](#ref-7). --- ## References **\[1\]** Falcon et al.. Eyelid and Brow Rejuvenation: Technical Pearls and Outcomes of Upper Blepharoplasty with or without Ptosis Correction and Brow Lift.. Plastic and reconstructive surgery. 2024\. doi:10.1097/PRS.0000000000011324 **\[2\]** Pascali et al.. The Temporal Subcutaneous Brow Lift with Orbicularis Oculi Muscle Elastic Flap: Technical Considerations, Systematic Review, and Terminology Standardization.. Facial plastic surgery : FPS. 2023\. doi:10.1055/a-1953-2304 **\[3\]** Silva et al.. Brow Lift Through The Upper Blepharoplasty Incision: Prospective Clinical Study. Aesthetic Surgery Journal. 2023\. doi:10.1007/s00266-023-03548-z **\[4\]** Chen et al.. Ultrasound rejuvenation for upper facial skin: A randomized blinded prospective study.. Journal of cosmetic dermatology. 2024\. doi:10.1111/jocd.16482 **\[5\]** Minehart et al.. The Functional and Cosmetic Brow Lift.. Otolaryngologic clinics of North America. 2025\. doi:10.1016/j.otc.2025.04.003 **\[6\]** Prantl et al.. Anatomical Insights into Frontal Branch Preservation in Minimally Invasive Brow Lift Techniques: A Comparative Analysis of Anatomical Lift Prantl's Suture Suspension (ALPS) Versus Gliding Brow Lift (GBL). Aesthetic Surgery Journal. 2025\. doi:10.1007/s00266-025-05455-x **\[7\]** Bran et al.. Effect of endoscopic brow lift on contractures and synkinesis of the facial muscles in patients with a regenerated postparalytic facial nerve syndrome.. Plastic and reconstructive surgery. 2014\. doi:10.1097/01.prs.0000436834.19066.7c **\[8\]** Karlin et al.. Brow height asymmetry before and after eyelid ptosis surgery.. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2020\. doi:10.1016/j.bjps.2019.07.018 **\[9\]** Dutton et al.. The Hairline Brow Lift.. Clinics in plastic surgery. 2022\. doi:10.1016/j.cps.2022.01.004 **\[10\]** Karanfilian et al.. Long-Term Brow Lift Outcomes: A Systematic Review and Meta-Analysis.. Ophthalmic plastic and reconstructive surgery. 2026\. doi:10.1097/IOP.0000000000002989 **\[11\]** Dayan et al.. The forehead lift: endoscopic versus coronal approaches.. Aesthetic plastic surgery. 2001\. doi:10.1007/s002660010091 **\[12\]** Karimi et al.. Techniques of Eyebrow Lifting: A Narrative Review.. Journal of ophthalmic & vision research. 2022\. doi:10.18502/jovr.v15i2.6740 **\[13\]** PubMed Central. Direct brow lifting: Specific indications for a simplified approach to eyebrow ptosis. PubMed Central. . **\[14\]** Fakih-Gomez et al.. Deep Plane Direct Brow Lift.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-025-04775-2 **\[15\]** Zandi et al.. Temporal brow lift vs internal browpexy in females undergoing upper blepharoplasty: Effects on lateral brow lifting.. Journal of cosmetic dermatology. 2019\. doi:10.1111/jocd.12433 **\[16\]** Atiyeh et al.. Forehead Eyebrow Lift Techniques: Review of the Literature and Critical Appraisal of Long-term Efficacy. Plastic and Reconstructive Surgery Global Open. 2026\. doi:10.1097/GOX.0000000000007578 **\[17\]** Xu et al.. Understanding Perceived Forehead Changes Post-Endoscopic Brow Lift: The Impact of Frontalis Muscle Contraction. Plastic and Reconstructive Surgery. 2026\. doi:10.1097/PRS.0000000000013138 **\[18\]** Archives of otolaryngology--head & neck surgery et al.. Comparison of subperiosteal vs subgaleal elevation techniques used in forehead lifts.. Archives of otolaryngology--head & neck surgery. 1998\. doi:10.1001/archotol.124.11.1209 **\[19\]** Saltz et al.. My Evolution with Endoscopic Brow-Lift Surgery.. Facial plastic surgery clinics of North America. 2021\. doi:10.1016/j.fsc.2021.02.007 **\[20\]** PubMed Central. Lateral Brow Lift: A Multi-Point Suture Fixation Technique. PubMed Central. . **\[21\]** Guillot et al.. Forehead and scalp sensation after brow-lift: a comparison between open and endoscopic techniques.. Archives of facial plastic surgery. 2011\. doi:10.1001/archfacial.2010.97 **\[22\]** Şibar et al.. Long-term Stability in Endoscopic Brow Lift: A Systematic Review and Meta-Analysis of the Literature.. Aesthetic surgery journal. 2025\. doi:10.1093/asj/sjae225 **\[23\]** PubMed Central. The direct brow lift: efficacy, complications, and patient satisfaction. PubMed Central. . ### Non-Surgical Rhinoplasty: Assessment, Anatomy, & Technique URL: https://www.theplasticsfella.com/non-surgical-rhinoplasty/ Last updated: 2026-07-23T11:49:03.000Z #### Summary Card [****Indications and Suitability**](#indications-and-suitability) Non-surgical rhinoplasty is best for selected minor contour problems such as dorsal hump camouflage, concavity, asymmetry, or modest tip projection; severe hump, deviation, or major tip-rotation deformity usually needs surgical discussion. [****Applied Anatomy**](#applied-anatomy) Nasal filler safety depends on respecting the layered soft-tissue envelope, targeting a deep midline supraperichondrial or supraperiosteal plane, and treating the nose as a vascular danger zone because compromise can cause necrosis or vision loss. [****Assessment and Planning**](#assessment-and-planning) Assessment must define the patient’s aesthetic goal, prior nasal interventions, deformity pattern, skin and vascular risk, psychological suitability, baseline documentation, and an emergency plan before deciding to inject. [****Product and Technique Selection**](#product-and-technique-selection) Choose reversible hyaluronic acid filler, a conservative deep midline plane, and a site-specific needle or cannula technique; avoid permanent fillers and high-risk multiplane or critical-site escalation unless clearly justified. [****Procedural Principles**](#procedural-principles) Safe non-surgical rhinoplasty uses consented, marked, aseptic, low-pressure, low-volume midline injection in a deep periosteal or cartilaginous membrane plane, with continuous skin observation and immediate stopping if vascular compromise is suspected. [****Complications**](#complications) The complications to recognise early are vascular occlusion, skin necrosis, and visual symptoms; minor events are commoner, but suspected vascular compromise requires immediate hyaluronidase-based escalation and specialist support. [****Post-Procedural Care and Surveillance**](#post-procedural-care-and-surveillance) After treatment, observe perfusion immediately, give clear vascular red flags, arrange early review, and escalate pain, colour change, visual symptoms, infection, necrosis, or concerning delayed swelling without remote reassurance. [****Outcomes and Counselling**](#outcomes-and-counselling) Counsel that non-surgical rhinoplasty can improve contour and satisfaction for selected patients, usually lasts months rather than years, requires maintenance or dissolution options, and carries rare but severe vascular risks. --- ## Indications and Suitability ****Key Point** Non-surgical rhinoplasty is best for selected minor contour problems such as dorsal hump camouflage, concavity, asymmetry, or modest tip projection; severe hump, deviation, or major tip-rotation deformity usually needs surgical discussion. Non-surgical rhinoplasty uses injectable treatment, usually hyaluronic acid filler, to alter nasal contour by adding volume. It is a camouflage procedure, not a structural rhinoplasty. ### Patient Selection Offer treatment only when the patient’s goal is contour refinement rather than major architectural change. - **Minor contour issues:** consider HA filler for dorsal irregularity, mild asymmetry, concavity, or under-projection [2](#ref-2). - **Tip and dorsum:** selected tip projection and dorsal morphology concerns may be appropriate [1](#ref-1). - **Post-rhinoplasty defects:** filler may help selected imperfections and may avoid revision surgery in some patients [3](#ref-3). - **Post-reconstruction cases:** consider only when oncological surgery is remote, stable, and further surgery is declined or unsuitable [4](#ref-4). ### Treatment Boundaries Decline or redirect treatment when filler cannot safely solve the dominant anatomical problem. - **Severe deformity:** large humps, marked deviation, or significant tip rotation should prompt surgical assessment [2](#ref-2). - **Major structural change:** filler cannot reduce bone, narrow the nose, straighten the septum, or improve airway obstruction. - **Over-augmentation risk:** a bulky nose, thick envelope, or wide dorsum may look worse after additive treatment. - **Unsuitable expectations:** defer when the patient wants a smaller nose, perfect symmetry, or a surgical result without surgery. ### Contraindications Screen actively for medical, anatomical, and psychological factors that make treatment unsafe or inappropriate. - **Medical risks:** assess bleeding risk, antithrombotic therapy, pregnancy or nursing, and lidocaine or HA sensitivity [5](#ref-5). - **Tissue disease:** connective-tissue disease or impaired vascular reserve should lower the threshold to defer [5](#ref-5). - **Prior treatment:** previous filler, threads, surgery, or reconstruction changes anatomy and vascular risk. - **Body image concern:** suspected dysmorphic syndrome should prompt deferral and careful referral rather than injection [5](#ref-5). --- ## Applied Anatomy ****Key Point** Nasal filler safety depends on respecting the layered soft-tissue envelope, targeting a deep midline supraperichondrial or supraperiosteal plane, and treating the nose as a vascular danger zone because compromise can cause necrosis or vision loss. The nose is unforgiving because small filler volumes can alter contour and small vascular events can be catastrophic. Anatomy must guide both aesthetic planning and stopping rules. ### Nasal Layers Choose the injection plane deliberately rather than placing filler wherever the contour deficit appears. - **Layer sequence:** plan from skin through superficial fat, fibromuscular layer, deep fat, perichondrium or periosteum, then cartilage or bone [5](#ref-5). - **Preferred plane:** filler plans commonly target the deep fat layer over perichondrium or periosteum [6](#ref-6). - **Thin skin:** superficial placement risks visibility, Tyndall effect, nodularity, and vascular encounter. - **Thick skin:** contour change may require more volume, increasing over-augmentation and compression risk. ### Blood Supply Assume clinically relevant vessels may be present even in apparently safe midline sites. - **Superficial vessels:** nasal vessels commonly run between superficial fat and fibromuscular layers, making plane selection central to safety [1](#ref-1). - **Tip risk:** Doppler ultrasound found a midline vessel in 18 of 21 nasal tips, with half located deep [7](#ref-7). - **Radix risk:** midline radix vessels were found less often in that sample and were superficial, but this does not make the radix risk-free [7](#ref-7). - **Anastomoses:** dorsal nasal, angular, lateral nasal, and ophthalmic-linked pathways explain skin and visual complications. ### Danger Zones Treat the nasal triangle as a high-consequence filler zone, not a routine facial contour area. - **Nasal triangle:** the nose and adjacent nasal triangle are facial vascular danger zones during filler planning [8](#ref-8). - **Tip and alae:** small-calibre vascular territories are vulnerable to embolic and compressive compromise. - **Dorsum:** midline treatment reduces but does not eliminate vascular risk. - **Glabella-radix link:** retrograde arterial flow can connect filler embolus to ocular circulation. ### Keystone Area Be cautious with post-rhinoplasty dorsal irregularities because thin skin over mixed bone-cartilage support exposes small planning errors. - **Complex overlap:** the keystone area contains bone-cartilage overlap under thin skin, affecting filler camouflage planning [3](#ref-3). - **Defect types:** inverted-V deformity, saddle change, or small asymmetry need careful counselling because correction is challenging [3](#ref-3). - **Camouflage limit:** filler may hide shadowing but cannot rebuild unstable support. - **Scarred envelope:** prior surgery may tether skin and alter vascular pathways. ### Nasal Subunits Match filler placement to the visible subunit deformity while protecting subunit boundaries. - **Radix:** modest augmentation can change the dorsal starting point and nasofrontal angle. - **Dorsum:** linear contour smoothing must avoid widening or dorsal overfill. - **Tip:** projection change needs very small volumes and high vascular caution. - **Alar and sidewall:** avoid casual injection; asymmetry may be structural, scarred, or airway-related. --- ## Assessment and Planning ****Key Point** Assessment must define the patient’s aesthetic goal, prior nasal interventions, deformity pattern, skin and vascular risk, psychological suitability, baseline documentation, and an emergency plan before deciding to inject. Planning prevents two common errors: offering filler for a surgical problem and injecting a nose with unrecognised vascular or scar risk. The decision should be made before the syringe is opened. ### History Use the history to identify altered anatomy, contraindications, and dissatisfaction risk. - **Prior rhinoplasty:** record open or closed surgery, grafts, implants, complications, and revision plans. - **Previous filler:** ask product, date, volume, response, dissolution, nodules, infection, or vascular symptoms. - **Medical risk:** document bleeding tendency, anticoagulants, autoimmune disease, pregnancy, allergy, and wound-healing concerns. - **Satisfaction risk:** pre-procedural ROE assessment may help identify psychological or satisfaction-risk concerns [9](#ref-9). ### Examination Analyse whether the visible concern is correctable by adding small, well-placed volume. - **Frontal view:** assess deviation, asymmetry, dorsal aesthetic lines, tip position, and alar contour. - **Profile view:** assess radix height, dorsal hump, supratip break, tip projection, and nasolabial angle. - **Skin envelope:** thin skin shows filler; thick skin hides correction and encourages overfilling. - **Dynamic features:** depressor septi activity or facial animation may mimic structural tip descent. ### Deformity Mapping Plan target zones and volume conservatively before treatment begins. - **Treatment zones:** planning may include the nasal root, dorsum, tip, wings, and subnasal region [1](#ref-1). - **Volume discipline:** most reviewed protocols used less than 1 mL per procedure, supporting conservative planning [11](#ref-11). - **Staging:** stop early if the nose looks better; further treatment can be staged. - **No reduction:** a hump is camouflaged by filling around it, not removed. ### Imaging and Documentation Photograph and document enough to judge symmetry, consent, and later complications. - **Baseline photography:** obtain frontal, oblique, lateral, basal, and smiling views. - **ROE questionnaire:** ROE can structure subjective assessment before and after NSR [9](#ref-9). - **3D imaging:** 3D surface imaging may support objective outcome assessment, but is not a validated standard for NSR planning [12](#ref-12). - **Ultrasound adjunct:** pre-procedural or procedural ultrasound may improve safety by tailoring placement to vascular pattern [7](#ref-7). --- ## Product and Technique Selection ****Key Point** Choose reversible hyaluronic acid filler, a conservative deep midline plane, and a site-specific needle or cannula technique; avoid permanent fillers and high-risk multiplane or critical-site escalation unless clearly justified. Technique selection is not a matter of injector preference alone. It should follow anatomy, target deformity, product behaviour, and reversibility. ### Filler Choice Prefer hyaluronic acid because nasal treatment needs reversibility, precision, and conservative volume control. - **HA dominance:** after prior rhinoplasty, HA was the most frequently reported filler, used in 1,373 of 2,048 patients [3](#ref-3). - **Product selection:** one review found Juvéderm Ultra commonly used, but product choice should still follow anatomy and technique [14](#ref-14). - **Permanent fillers:** avoid routine permanent filler because complications and later surgery are harder to manage. - **Regulatory consent:** counsel that nasal HA filler use is off-label in the United States [10](#ref-10). ### Injection Instrument Use the instrument that gives the safest controlled placement for the planned site. - **Needle use:** best for precise microbolus placement onto bone or cartilage under direct control. - **Cannula use:** useful for selected linear contouring but still requires vascular caution and a defined plane. - **Access choice:** minimise entry points and avoid repeated traumatic passes through scarred tissue. - **False reassurance:** cannula, aspiration, and midline placement reduce risk but do not abolish it. ### Injection Pattern Match bolus, threading, and sequence to the contour problem rather than filling every nasal subunit. - **Microbolus:** use for focal radix, dorsal, or tip support on a firm deep plane. - **Linear threading:** use sparingly for dorsal smoothing where a continuous contour is required. - **Sequencing:** structured HA protocols may inject tip, then columella, then radix and dorsum [5](#ref-5). - **Site planning:** one described approach plans tip, columellar base, dorsum including the supratip, and radix sites [13](#ref-13). ### Selection Framework Let the dominant deformity decide the product, plane, and endpoint. - **Decision anchor:** choose the minimum intervention that produces a visible, safe improvement. - **Safety anchor:** stop when contour is improved, not when the planned syringe is empty. | Dominant problem | Best-fit approach | Main trade-off | | -------------------------------- | ------------------------------------------ | ------------------------------------------------ | | Low radix or shallow root | Small deep HA bolus | Can lengthen apparent nose | | Mild dorsal hump | Camouflage above and below hump | Adds volume rather than reduces hump | | Dorsal concavity or irregularity | Conservative deep HA smoothing | Thin skin may show product | | Under-projected tip | Tiny deep support only if suitable | High vascular risk | | Dynamic tip descent | Consider botulinum toxin where appropriate | Does not correct structure | | Scarred post-rhinoplasty defect | Staged HA camouflage | Higher uncertainty and lower tolerance for error | ### Adjunct Options Keep threads and toxin secondary to the main filler decision unless they specifically match the problem. - **Threads:** may be considered for selected dorsal or tip support, but extrusion, infection, and revision issues matter. - **Botulinum toxin:** may help a dynamic depressor component but will not correct bony or cartilaginous deformity [6](#ref-6). - **Technique caution:** critical-site and multiplane approaches require caution because higher complication rates were reported in one review [1](#ref-1). --- ## Procedural Principles ****Key Point** Safe non-surgical rhinoplasty uses consented, marked, aseptic, low-pressure, low-volume midline injection in a deep periosteal or cartilaginous membrane plane, with continuous skin observation and immediate stopping if vascular compromise is suspected. The procedure fails when additive treatment is used to chase a reductive goal, or when vascular warning signs are ignored. Set limits before injecting. ### Consent and Time-Out Confirm the plan, product, dose limit, vascular rescue kit, and stopping rules before skin preparation. - **Consent focus:** include asymmetry, overcorrection, nodules, infection, vascular compromise, necrosis, and visual symptoms. - **Additive anatomy:** filler rhinoplasty changes shape by adding volume, so over-augmentation must be planned against [13](#ref-13). - **Emergency readiness:** confirm hyaluronidase availability, contact pathways, and escalation arrangements. - **Photography:** review baseline images and mark target points with the patient upright. ### Asepsis and Marking Mark the aesthetic endpoint and clean the field as for a high-consequence injectable procedure. - **Marking:** identify radix, dorsal irregularity, supratip, tip point, columella, and danger areas. - **Skin preparation:** remove make-up and use antisepsis before injection. - **Anaesthesia:** local anaesthetic with epinephrine may be used in preparation because vasoconstriction may reduce embolism risk [1](#ref-1). - **Minimal trauma:** avoid repeated passes, especially in scarred or previously operated noses. ### Injection Technique Inject slowly, deeply, and centrally, then reassess after every small aliquot. 1. **Set the endpoint:** Decide the smallest correction that will satisfy the planned contour change. - **Volume control:** use micro-aliquots and reassess from frontal and profile views. - **Pitfall:** do not use filler to chase nasal narrowing. 1. **Use the intended plane:** Place product in the midline supraperiosteal or supraperichondrial plane where appropriate. - **Safety principle:** supraperiosteal, above-cartilage, or midline injection is described to limit vascular damage [2](#ref-2). - **Pitfall:** superficial placement increases visibility and vascular risk. 1. **Check perfusion:** Observe pain, blanching, livedo, capillary refill, and patient-reported visual symptoms. - **Capillary refill:** one protocol checked for refill under 2 seconds [5](#ref-5). - **Pitfall:** aspiration is only a checkpoint, not proof of safety, although it is described to reduce intravascular occlusion risk [2](#ref-2). ### Injection Sequence Establish tip position only when indicated, then adjust the dorsum to match the new contour. - **Ascending logic:** in the ascending approach, tip projection and rotation are set first, then the dorsum is adjusted [13](#ref-13). - **Midline discipline:** top-to-bottom and bottom-up midline supraperiosteal approaches are recognised options [1](#ref-1). - **Danger-zone awareness:** technique should prioritise facial vascular danger zones and appropriate filler choice [8](#ref-8). - **Stopping rule:** stop immediately for severe pain, blanching, dusky colour, livedo, or visual symptoms. --- ## Complications ****Key Point** The complications to recognise early are vascular occlusion, skin necrosis, and visual symptoms; minor events are commoner, but suspected vascular compromise requires immediate hyaluronidase-based escalation and specialist support. Nasal filler complications are high-stakes because the treatment is elective and the vascular territory is unforgiving. Minor swelling is common; pain, colour change, or visual symptoms are not minor. ### Vascular Compromise Treat severe pain, blanching, livedo, delayed refill, dusky skin, or visual symptoms as vascular compromise until proven otherwise. - **Prior rhinoplasty:** previous rhinoplasty should be treated as a risk factor for vascular compromise and skin necrosis [3](#ref-3). - **Severe risks:** consent should include blindness, cerebral infarction, skin necrosis, and motor nerve palsy [1](#ref-1). - **Tissue loss:** vascular compromise can cause tissue necrosis and rarely, vision loss [8](#ref-8). - **Action:** stop injection, assess perfusion, initiate hyaluronidase protocol, and escalate urgently. ### Skin Necrosis Early skin change is a rescue opportunity; delayed recognition converts ischaemia into tissue loss. - **Warning pattern:** pain out of proportion, mottling, grey-purple change, pustulation, or ulceration. - **Compression injury:** excessive volume in a tight soft-tissue envelope can compromise perfusion. - **Hyaluronidase access:** clinics performing HA NSR should have hyaluronidase immediately available [15](#ref-15). - **Early treatment:** earlier recognition and treatment are associated with better outcomes and possible complete resolution [15](#ref-15). ### Visual Symptoms Any visual complaint during or after nasal injection is an emergency. - **Symptoms:** blurred vision, field loss, diplopia, ocular pain, headache, ptosis, or ophthalmoplegia. - **Immediate response:** stop injecting, call emergency ophthalmology, and activate local filler-embolus protocol. - **Counselling:** rare major complications include infection, vascular compromise, skin necrosis, and blindness [16](#ref-16). - **Documentation:** record timing, product, volume, site, symptoms, actions, and escalation contacts. ### Infective and Inflammatory Events Distinguish expected swelling from infection, delayed inflammatory oedema, and nodules requiring review. - **Infection:** erythema, warmth, tenderness, pustules, fever, or progressive swelling need review. - **Delayed oedema:** late swelling may reflect inflammatory reaction, product movement, or infection. - **Nodules:** assess timing, tenderness, colour, and relationship to superficial product. ### Aesthetic Problems Most non-vascular failures are due to wrong indication, superficial placement, or excess volume. - **Asymmetry:** reassess against baseline deviation before adding more filler. - **Overcorrection:** dissolve or stage revision rather than layering further product. - **Tyndall effect:** superficial HA may appear blue-grey, especially under thin dorsal skin. --- ## Post-Procedural Care and Surveillance ****Key Point** After treatment, observe perfusion immediately, give clear vascular red flags, arrange early review, and escalate pain, colour change, visual symptoms, infection, necrosis, or concerning delayed swelling without remote reassurance. Aftercare is not generic filler advice. The nose needs explicit vascular surveillance and a low threshold for urgent reassessment. ### Immediate Observation Do not discharge until skin colour, pain, and perfusion have been reassessed. - **Perfusion check:** inspect capillary refill, blanching, livedo, dusky change, and focal tenderness. - **Vision screen:** ask directly about visual blurring, diplopia, field change, or ocular pain. - **Documentation:** record product, batch, total volume, sites, instrument, plane, and immediate findings. - **Rescue readiness:** clinics offering HA NSR should be prepared to administer hyaluronidase for rare vascular compromise [4](#ref-4). ### Patient Instructions Give written instructions that separate expected swelling from red-flag symptoms. - **Expected symptoms:** mild symptoms often subside in about 2 days and may be observed with supportive care when appropriate [1](#ref-1). - **Avoid pressure:** discourage rubbing, tight glasses, or manipulation until early tenderness settles. - **Red flags:** escalating pain, blanching, mottling, ulceration, fever, pustules, or visual symptoms require urgent contact. - **No remote reassurance:** photographic review may help triage, but vascular concerns need in-person assessment. ### Early Review Review early enough to detect vascular, infective, and contour problems before they mature. - **Follow-up timing:** HA-filler NSR follow-up can include review at 21–30 days and at 1 year [5](#ref-5). - **Earlier review:** bring patients back sooner for pain, colour change, swelling, asymmetry, or anxiety. - **Post-rhinoplasty timing:** after surgical rhinoplasty, NSR should be delayed for at least 12 months in one review recommendation [3](#ref-3). - **Touch-up caution:** avoid early additive correction while swelling or vascular uncertainty persists. ### Escalation Pathway Treat concerning nasal changes as time-sensitive until vascular compromise and infection are excluded. - **Necrosis or infection:** suspected infection or skin necrosis warrants urgent antibiotics and steroid treatment with consideration of hyaluronidase [1](#ref-1). - **HA complication:** timely hyaluronidase use may improve outcomes when serious HA-related complications are suspected [1](#ref-1). - **Delayed nodules:** assess for inflammatory nodule, biofilm, superficial product, or delayed hypersensitivity. - **Thread concerns:** persistent clots, visible threads, discomfort, or other concerns after nose-thread NSR should prompt review [17](#ref-17). --- ## Outcomes and Counselling ****Key Point** Counsel that non-surgical rhinoplasty can improve contour and satisfaction for selected patients, usually lasts months rather than years, requires maintenance or dissolution options, and carries rare but severe vascular risks. The counselling standard is high because the procedure is elective, additive, and performed in a danger zone. Patients must understand what filler can improve and what only surgery can change. ### Aesthetic Outcomes Promise contour improvement, not a smaller, straighter, or structurally reconstructed nose. - **Achievable changes:** radix height, dorsal smoothness, concavity camouflage, mild asymmetry, and modest projection. - **Unachievable changes:** reduction, true narrowing, septal straightening, airway improvement, or major tip rotation. - **Satisfaction:** HA NSR studies reviewed reported consistently high satisfaction [14](#ref-14). - **Secondary cases:** one secondary liquid rhinoplasty series reported 92% patient-reported satisfaction [19](#ref-19). ### Durability and Maintenance Frame HA filler as a temporary treatment with planned maintenance rather than a one-off rhinoplasty substitute. - **Longevity:** HA NSR effectiveness has been reported to last 8 to 14 months [11](#ref-11). - **Repeat treatment:** in one 2,130-patient ascending-technique series, 62% repeated NSR after one year [13](#ref-13). - **Reversibility:** HA can be dissolved when contour, vascular, or inflammatory problems require it. - **Maintenance risk:** repeated treatment can accumulate product and complicate later assessment. ### Revision and Dissolution Use revision only after identifying whether the problem is volume, placement, swelling, or wrong indication. - **Overfill:** dissolution is safer than adding more product to a bulky or tense nose. - **Asymmetry:** compare with baseline photographs before treating perceived new deviation. - **Dissatisfaction drivers:** unrealistic goals, poor understanding of additive treatment, and unrecognised baseline asymmetry. - **Surgery later:** prior filler can obscure planes, distort tissues, and affect surgical planning. ### Risk Counselling Severe complications are rare, but consent must treat them as real because consequences can be permanent. - **Severe events:** large cohort data suggest severe complications after HA filler injection are rare, but risk-reduction measures remain necessary [18](#ref-18). - **Patient language:** explain necrosis and blindness plainly, without minimising or catastrophising. - **Evidence limits:** the HA NSR evidence base includes a systematic review of 3,928 patients across 23 articles, but better RCTs were still requested [14](#ref-14). - **Decision standard:** proceed only when the expected contour benefit justifies the vascular risk in that individual nose. --- ## References **\[1\]** Ma et al.. Advances of Hyaluronic Acid Nasal Injection Techniques and Complications: A Systematic Review\\.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-025-05194-z **\[2\]** Al-Taie et al.. Non-surgical Rhinoplasty (NSR): A Systematic Review of Its Techniques, Outcomes, and Patient Satisfaction.. Cureus. 2023\. doi:10.7759/cureus.50728 **\[3\]** Santamaría-Gadea et al.. Non-Surgical Rhinoplasty After Rhinoplasty: A Systematic Review of the Technique, Results, and Complications.. Facial plastic surgery & aesthetic medicine. 2025\. doi:10.1089/fpsam.2024.0116 **\[4\]** Tahan et al.. Non-Surgical Rhinoplasty After Nasal Skin Cancer Reconstruction: Enhancing Esthetic Outcomes.. Journal of clinical medicine. 2025\. doi:10.3390/jcm14155394 **\[5\]** Giammarioli et al.. Non-surgical rhinoplasty technique: An innovative approach for nasal reshaping with hyaluronic acid fillers.. Journal of cosmetic dermatology. 2023\. doi:10.1111/jocd.15669 **\[6\]** Dilber et al.. A narrative-style review of non-surgical rhinoplasty: Indications, outcomes, and limitations.. Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery. 2024\. doi:10.1016/j.jcms.2024.06.014 **\[7\]** Shekarriz et al.. Ultrasound assessment of the nose vasculature: A review of the common method of non-surgical filler-based rhinoplasty.. Journal of cosmetic dermatology. 2024\. doi:10.1111/jocd.16037 **\[8\]** Wollina et al.. Facial vascular danger zones for filler injections.. Dermatologic therapy. 2020\. doi:10.1111/dth.14285 **\[9\]** Di et al.. Psychological Analysis of Non-surgical Rhinoplasty.. Aesthetic plastic surgery. 2020\. doi:10.1007/s00266-019-01538-8 **\[10\]** Saad et al.. Liquid Rhinoplasty.. Clinics in plastic surgery. 2023\. doi:10.1016/j.cps.2022.12.009 **\[11\]** Radulesco et al.. Patient Satisfaction After Non-surgical Rhinoplasty Using Hyaluronic Acid: A Literature Review\\.. Aesthetic plastic surgery. 2021\. doi:10.1007/s00266-021-02182-x **\[12\]** Nguyen et al.. 3D surface imaging technology for objective automated assessment of facial interventions: A systematic review\\.. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2022\. doi:10.1016/j.bjps.2022.06.086 **\[13\]** Kassir et al.. Non-Surgical Rhinoplasty: The Ascending Technique and a 14-Year Retrospective Study of 2130 Cases.. Aesthetic plastic surgery. 2021\. doi:10.1007/s00266-020-02048-8 **\[14\]** Mortada et al.. The Use of Hyaluronic Acid in Non-surgical Rhinoplasty: A Systematic Review of Complications, Clinical, and Patient-Reported Outcomes.. Aesthetic plastic surgery. 2024\. doi:10.1007/s00266-023-03386-z **\[15\]** Babu et al.. A critical review of complications in non-surgical rhinoplasty and their management.. Journal of cosmetic dermatology. 2021\. doi:10.1111/jocd.14489 **\[16\]** Nguyen et al.. Specific complications associated with non-surgical rhinoplasty.. Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology. 2020\. doi:10.1080/14764172.2021.1898643 **\[17\]** Park et al.. Non-surgical rhinoplasty through minimal invasive nose thread procedures: Adverse effects and prevention methods.. Skin research and technology : official journal of International Society for Bioengineering and the Skin (ISBS) \\\[and\] International Society for Digital Imaging of Skin (ISDIS) \\\[and\] International Society for Skin Imaging (ISSI). 2024\. doi:10.1111/srt.13590 **\[18\]** Tamura et al.. Serious Complications of Hyaluronic Acid Fillers-A Retrospective Study of 290,307 Cases.. Annals of plastic surgery. 2025\. doi:10.1097/SAP.0000000000004327 **\[19\]** Valente et al.. Secondary Liquid Rhinoplasty: Challenges, Techniques, and Long-term Outcomes.. Aesthetic surgery journal. 2025\. doi:10.1093/asj/sjaf212 ### How to Assess the Ageing Face: Anatomy, Examination, & Treatment Planning URL: https://www.theplasticsfella.com/how-to-assess-the-ageing-face/ Last updated: 2026-07-23T11:32:58.000Z #### Summary Card [****Assessment Goals**](#assessment-goals) Assessment should identify patient priorities, objective baseline severity, anatomical drivers, safety limits, and the dominant ageing pattern before any treatment is offered. [****Facial Ageing Anatomy**](#facial-ageing-anatomy) Visible facial ageing reflects combined change in skin, fat, retaining ligaments, SMAS, muscle, skeleton, eyelids, brow, midface, lower face, and neck, not skin laxity alone. [****History and Patient Factors**](#history-and-patient-factors) History should define the patient’s goals, prior treatments, ageing exposures, medical risk, psychological suitability, and procedure-specific factors before planning rejuvenation. [****Systematic Facial Examination**](#systematic-facial-examination) Examine the ageing face in a reproducible top-down sequence, combining global facial balance, regional analysis, symmetry, animation, skin quality, and functional findings. [****Documentation and Photography**](#documentation-and-photography) Documentation should create a reproducible baseline using standardised photographs, measurements, validated scales, asymmetry records, and functional findings. [****Assessment-Based Treatment Planning**](#assessment-based-treatment-planning) Treatment planning should target the dominant assessed problem: skin quality, dynamic rhytids, volume loss, ptosis, excess skin, or functional impairment. [****Counselling and Suitability**](#counselling-and-suitability) After assessment, clarify expectations, suitability, risks, maintenance, downtime, staged care, and reasons to defer or decline treatment. --- ## Assessment Goals ****Key Point** Assessment should identify patient priorities, objective baseline severity, anatomical drivers, safety limits, and the dominant ageing pattern before any treatment is offered. The ageing face is not assessed by asking “what procedure does this patient need?”. It is assessed by deciding what is ageing, what is asymmetry, what is functional, and what the patient is actually asking to change. **Define the problem before the treatment** A safe assessment separates ageing mechanisms so treatment is not applied generically. - **Intrinsic ageing:** thinning skin, reduced elasticity, rhytids, and slower tissue recovery. - **Volume loss:** hollowing in temporal, periorbital, malar, perioral, or mandibular regions. - **Soft-tissue descent:** brow, malar fat, jowl, platysma, and neck laxity. - **Skeletal support:** maxillary, mandibular, dental, and chin support affecting apparent soft-tissue ageing. **Measure what will guide the plan** Baseline assessment should document both the patient’s satisfaction goals and objective severity so treatment effects can be judged later [1](#ref-1). - **Quantitative baseline:** use reproducible measurements where they affect operative design or durability assessment [2](#ref-2). - **Skin and soft tissue:** skin elasticity and dermal quality may be relevant outcome measures for ageing interventions [3](#ref-3). - **Anatomic priority:** identify the main drivers of ageing so treatment restores facial balance rather than isolated features [4](#ref-4). - **Safety filter:** choose interventions that prioritise patient safety before maximal rejuvenation or durability [5](#ref-5). **Convert concerns into treatable targets** The assessment should translate vague complaints into anatomical and functional findings. - **Upper-face lines:** distinguish glabellar, lateral canthal, and horizontal forehead lines when botulinum toxin is being considered [6](#ref-6). - **Individual variation:** account for sex, race, ethnicity, and baseline morphology because facial ageing differs between patients [4](#ref-4). - **Asymmetry:** document pre-existing brow, eyelid, midface, mouth, and neck asymmetry before intervention. - **Function:** identify visual field symptoms, exposure, airway, dental, speech, swallowing, or neck mobility concerns. --- ## Facial Ageing Anatomy ****Key Point** Visible facial ageing reflects combined change in skin, fat, retaining ligaments, SMAS, muscle, skeleton, eyelids, brow, midface, lower face, and neck, not skin laxity alone. Ageing anatomy matters because each tissue layer responds to a different treatment. Excision, lifting, filling, resurfacing, neuromodulation, and skeletal correction solve different problems. **Think in layers, not wrinkles** Treatment planning should map ageing changes to the five facial layers: skin, subcutaneous fat and retinacula, SMAS, deep fat, and periosteum or deep fascia [7](#ref-7). - **Skin:** photodamage, pigment, fine rhytids, elastosis, texture change, and scar potential. - **Subcutaneous fat:** compartment deflation, pseudoherniation, descent, and contour irregularity. - **SMAS-platysma:** vector of lift, jowl formation, neck bands, and lower-face support. - **Deep support:** deep fat, periosteum, retaining ligaments, and bony projection guide repositioning. **Separate deflation, descent, and deterioration** Assessment should consider skin, bone or cartilage, fat, and muscle as ageing structures rather than judging skin laxity alone [8](#ref-8). - **Deflation:** temporal hollowing, tear trough, malar flattening, perioral hollowing, and prejowl sulcus. - **Descent:** brow ptosis, malar descent, nasolabial deepening, jowling, and cervical laxity. - **Deterioration:** crepey skin, dyschromia, solar elastosis, and poor recoil. - **Redistribution:** bulging may occur in the submental region, jowls, infraorbital pouches, malar fat, and perioral folds [8](#ref-8). **Use retaining ligaments as both cause and warning** Retaining ligaments create transition zones, tethering, and safety landmarks. Operative planning should choose the dissection plane and ligament release according to the aesthetic goal while using retaining ligaments as nerve-safety landmarks [9](#ref-9). - **Tethering:** ligaments contribute to tear trough, nasolabial fold, mandibular ligament, and neck contour changes. - **Release:** incomplete release limits lift; over-release risks contour and nerve problems. - **Nerve safety:** ligament zones often sit near facial nerve danger areas. - **Vector planning:** lift should oppose descent while preserving natural facial expression. **Read the periorbital unit as one structure** The ageing periorbital region should be assessed as brow, eyelid, orbicularis, lid-cheek junction, and malar area together rather than isolated eyelid skin [10](#ref-10). - **Brow:** ptosis, asymmetry, lateral hooding, and compensatory frontalis overactivity. - **Upper lid:** dermatochalasis, true ptosis, hollowing, fat prolapse, and lash show. - **Lower lid:** laxity, tear trough, fat prolapse, skin excess, and lid-cheek junction depth. - **Malar area:** orbicularis or malar descent, crow’s feet, malar festoons, and cheek support [10](#ref-10). **Match regional anatomy to the complaint** Volume-deficient areas such as periorbital, temporal, malar, mandibular, mental, glabellar, and perioral regions should be assessed for restoration rather than only excision or lifting [8](#ref-8). - **Midface:** assess cheek projection, malar deflation, ogee curve, and submalar hollow. - **Perioral:** evaluate upper-lip length, vermilion show, and maxillary incisor show [2](#ref-2). - **Lower face:** assess prejowl hollow, jowl descent, marionette region, chin support, and mandibular border. - **Neck:** assess submental fat, platysmal bands, skin laxity, hyoid position, and cervicomental angle. --- ## History and Patient Factors ****Key Point** History should define the patient’s goals, prior treatments, ageing exposures, medical risk, psychological suitability, and procedure-specific factors before planning rejuvenation. The consultation should reveal whether the patient is suitable for treatment, not only what bothers them. A technically possible intervention may still be unsafe, poorly timed, or psychologically inappropriate. **Start with goals and treatment history** The patient’s words should be translated into anatomical targets and realistic priorities. - **Main concern:** ask what they want changed, what they want preserved, and what outcome would disappoint them. - **Prior procedures:** record facelifts, blepharoplasty, rhinoplasty, fat grafting, implants, threads, or scars. - **Recent treatments:** document retinoids, fillers, energy-based treatments, botulinum toxin, laser, peels, and dermabrasion because they affect assessment and treatment selection [11](#ref-11). - **Timing:** clarify upcoming events, recovery tolerance, and willingness for staged treatment. **Identify ageing exposures and medical risk** History should include intrinsic factors and extrinsic exposures such as ultraviolet radiation, air pollution, malnutrition, and smoking because these influence ageing and suitability [8](#ref-8). - **Sun exposure:** ultraviolet (UV) radiation may contribute up to 80% of environmental facial ageing effects [8](#ref-8). - **Weight change:** major loss worsens laxity; fluctuation reduces predictability. - **Medication risk:** anticoagulants, immunosuppression, isotretinoin history, steroids, and photosensitising drugs matter. - **Frailty:** older patients should be screened for frailty because it signals reduced stress tolerance and adverse outcome vulnerability [12](#ref-12). **Screen psychological suitability deliberately** Body dysmorphic disorder should be screened for by the surgeon using a validated psychological tool rather than informal questioning alone [13](#ref-13). - **Clinical screen:** cosmetic ageing-face patients should undergo a BDD screen before treatment planning [13](#ref-13). - **Validated tools:** options include BDDQ, BDDQ-DV, BDDQ-AS, COPS, BDSS, and BDD-ST [13](#ref-13). - **Red flags:** fixed dissatisfaction, mirror checking, multiple prior consultations, social avoidance, and disproportionate distress. - **Decision point:** defer treatment if motivation, expectations, or psychological safety is unclear. --- ## Systematic Facial Examination ****Key Point** Examine the ageing face in a reproducible top-down sequence, combining global facial balance, regional analysis, symmetry, animation, skin quality, and functional findings. The examination should be structured enough that another clinician can understand the deformity, reproduce the assessment, and follow the treatment logic. **Begin globally before narrowing regionally** A systematic assessment should examine the face globally as well as by region because adjacent areas, muscle tone, subcutaneous tissue, and skin thickness interact [14](#ref-14). - **Position:** assess in natural head position, centric relation, and relaxed lip posture [15](#ref-15). - **Views:** examine front, oblique, profile, basal, and close-up regional views. - **Balance:** compare upper, middle, and lower facial thirds, projection, width, and facial shape. - **Pattern:** classify the dominant ageing pattern as deflation, tissue deterioration, descent, or combination [4](#ref-4). **Examine the skin as a treatment target** Skin examination should distinguish colour, surface, thickness, elasticity, and tolerance. - **Photoageing:** document fine wrinkles, coarse wrinkles, roughness, hyperpigmentation, and tolerability factors [16](#ref-16). - **Surface:** assess smoothness, scaliness, and wrinkles because these can be measured as treatment-response outcomes [11](#ref-11). - **Quality:** skin colour, elasticity, and radiance may be recorded when evaluating topical response [11](#ref-11). - **Scarring risk:** note keloid tendency, dyspigmentation risk, thin skin, rosacea, and active dermatitis. **Work from the upper face to the neck** Use the same order each time so subtle asymmetry and functional findings are not missed. - **Brow and forehead:** brow height, tail position, frontalis compensation, glabellar strength, and forehead lines. - **Eyelids:** dermatochalasis, ptosis, lid laxity, scleral show, fat prolapse, hollowing, and exposure symptoms. - **Midface:** cheek projection, flattened ogee curve, and submalar concavity should be assessed specifically [4](#ref-4). - **Lower face and neck:** nasolabial fold, perioral rhytids, jowls, platysma bands, submental fullness, and skin excess. **Separate static, dynamic, and functional findings** Animation often reveals the true driver of the patient’s concern. - **Static findings:** ptosis, skin excess, fat prolapse, hollowing, and asymmetry at rest. - **Dynamic findings:** corrugator, orbicularis, mentalis, depressor anguli oris, and platysma activity. - **Functional eyelids:** visual obstruction, brow compensation, lagophthalmos, dry eye, and lid malposition. - **Facial nerve:** document weakness, synkinesis, smile asymmetry, and platysmal imbalance. **Use objective grading when it changes decisions** Facial examination should not rely only on subjective impressions; objective or standardised scoring should be used where available [14](#ref-14). - **Wrinkle grading:** match wrinkles to reference photographs and assign a 0–5 grade when useful [1](#ref-1). - **Infraorbital hollow:** a 5-point photonumeric scale can assess hollowing across sex, age, and skin type [17](#ref-17). - **Brow position:** eyebrow tail position should be measured when periorbital ageing treatment effect is being evaluated [10](#ref-10). - **Patient impact:** record the regions affecting appearance and psychosocial function when volume treatment is being considered [18](#ref-18). --- ## Documentation and Photography ****Key Point** Documentation should create a reproducible baseline using standardised photographs, measurements, validated scales, asymmetry records, and functional findings. Good documentation protects the patient and clinician. It also turns aesthetic assessment into a measurable baseline rather than a memory of the consultation. **Standardise the photographic set** Baseline and follow-up photography should be standardised enough to permit serial measurements at meaningful intervals [14](#ref-14). - **Core views:** frontal, right and left oblique, right and left profile, and close regional views. - **Set-up:** consistent camera distance, lens, lighting, background, head position, and facial expression. - **Hair and make-up:** expose hairline, ears, jawline, eyelids, and neck where relevant. - **Serial comparison:** record baseline and post-treatment assessments to compare outcomes over time [16](#ref-16). **Capture animation and function where relevant** Static photographs are insufficient when the complaint is dynamic or functional. - **Animation views:** frown, smile, brow elevation, eye closure, lip repose, and neck contraction. - **Eyelid function:** document ptosis, brow compensation, scleral show, lagophthalmos, and dry eye symptoms. - **Asymmetry:** record pre-existing brow, eyelid, cheek, mouth, jawline, and neck asymmetry. - **Skeletal traits:** document reproducible facial-skeletal traits so baseline findings inform planning and later care [15](#ref-15). **Record measurements and scales selectively** Objective documentation can use skin microtopography for surface parameters and 3-dimensional imaging for gross lifting effects [11](#ref-11). - **Perioral ageing:** ratios, caliper measurements, or 3-dimensional measurements may be recorded [2](#ref-2). - **Glabellar lines:** maximum frown severity can be graded on a defined 0–3 scale from clinician and patient perspectives [6](#ref-6). - **Validated scales:** use validated assessment scales when tracking clinical change after treatment [16](#ref-16). - **Baseline design:** quantitative baseline measurements can guide operative design and later durability assessment [2](#ref-2). --- ## Assessment-Based Treatment Planning ****Key Point** Treatment planning should target the dominant assessed problem: skin quality, dynamic rhytids, volume loss, ptosis, excess skin, or functional impairment. The plan should follow the diagnosis. Avoid treating every ageing face with the same filler, device, resurfacing treatment, or operation. **Match the treatment category to the dominant finding** Treatment should target the specific ageing elements identified on assessment rather than applying a single standard approach [8](#ref-8). | Dominant assessed problem | Best-fit treatment category | Main limitation | | ------------------------------- | ------------------------------------ | -------------------------------- | | Pigment, texture, fine rhytids | Skincare, resurfacing, peels, lasers | Limited lift | | Dynamic rhytids | Neuromodulator | Temporary effect | | Volume loss | Filler, biostimulator, fat grafting | Overfilling risk | | Soft-tissue descent | Lifting procedure or suspension | Downtime and scars | | Excess skin | Excision-based surgery | Scar and healing risk | | Functional eyelid or neck issue | Specialist surgical assessment | Aesthetic plan becomes secondary | **Use non-surgical options for the right deformity** Non-surgical treatments are strongest when the target is skin quality, dynamic muscle activity, mild laxity, or volume deficit. - **Skin laxity:** mild-to-moderate laxity suits microfocused ultrasound better than advanced laxity [14](#ref-14). - **Severe laxity:** counsel toward surgical options rather than microfocused ultrasound alone [14](#ref-14). - **Modest improvement:** radiofrequency is better suited to patients seeking modest rather than dramatic rejuvenation [19](#ref-19). - **Skin findings:** skin colour, elasticity, and radiance can guide topical or skin-quality treatment choices [11](#ref-11). **Treat volume and laxity as different problems** A full face is not necessarily a lifted face, and a lifted face is not necessarily restored. - **Fat compartments:** minimally invasive planning should identify superficial and deep fat compartments and boundaries for safety and effectiveness [7](#ref-7). - **Volume restoration:** reduced elasticity, wrinkles, or volume loss may make PLLA or CaHA biostimulators relevant options [20](#ref-20). - **HA planning:** patients should understand that 12-week volume maintenance varies by region, with lower maintenance reported in lips than malar or midface regions [18](#ref-18). - **Layered ageing:** skin, bone or cartilage, fat, and muscle should all be considered before selecting a single treatment category [8](#ref-8). **Escalate when surgery solves the actual problem** Surgery becomes more appropriate when the finding is structural descent, skin excess, herniated fat, functional eyelid impairment, or advanced neck laxity. - **Brow and eyelid:** distinguish brow ptosis, dermatochalasis, lid ptosis, and fat prolapse before offering blepharoplasty. - **Midface and lower face:** choose lifting when descent and ligamentous laxity dominate over isolated deflation. - **Upper lip:** balance the longer-lasting lift of surgery against scar inevitability and the more conservative effect of non-surgical methods [2](#ref-2). - **Planning posture:** confirm natural head position, centric relation, and relaxed lip posture before final facial planning [15](#ref-15). --- ## Counselling and Suitability ****Key Point** After assessment, clarify expectations, suitability, risks, maintenance, downtime, staged care, and reasons to defer or decline treatment. Counselling should make the plan safer and more realistic. The patient should understand what the assessment found, what treatment can change, and what it cannot change. **Set realistic expectations before consent** Facial rejuvenation improves selected features; it does not stop ageing or create perfect symmetry. - **Psychosocial motivation:** explore perceived ageing concerns because facial ageing can affect self-perception and social interactions [4](#ref-4). - **Volume treatment:** large-volume HA filler treatment has been associated with improved patient-reported appearance and psychosocial domains [18](#ref-18). - **Regional durability:** midface correction may maintain volume better than mimetic areas through 12 weeks [18](#ref-18). - **Staging:** combine treatments only when sequencing, recovery, and risk remain understandable. **Discuss treatment-specific risk honestly** Consent should be specific to the planned intervention, not a generic aesthetic warning. - **Botulinum toxin:** pooled cosmetic glabellar and forehead botulinum toxin A complication rate was 16% across 4268 sessions [21](#ref-21). - **Upper-face toxin:** headache or migraine, bruising or haematoma, and facial neuromuscular symptoms were reported in 6.3%, 3.8%, and 3.3% of sessions respectively [21](#ref-21). - **Microfocused ultrasound:** bruising, dysaesthesia, burns, striae, and papules were reported in 2% of treated patients [14](#ref-14). - **Biostimulators:** PLLA and CaHA most often caused mild injection-site pain and swelling in reported studies [20](#ref-20). **Explain maintenance and longevity** Patients should know whether they are choosing a temporary, maintenance-based, staged, or surgical strategy. - **Biostimulator duration:** reported durability differs, with PLLA lasting up to 25 months and CaHA 12 to 18 months [20](#ref-20). - **Treatment burden:** periorbital PRP regimens averaged three sessions at mean 23-day intervals in published studies [22](#ref-22). - **Topical care:** topical treatments require adherence and usually suit texture, pigment, and fine-rhytid goals. - **Surgery:** scars, recovery, revision risk, and ongoing ageing should be discussed before listing. **Know when to defer or decline** Suitability is a clinical decision, not a customer preference. - **BDD risk:** patients seeking facial ageing treatment should be screened because BDD is common in cosmetic settings and may be missed [23](#ref-23). - **Prevalence context:** weighted BDD prevalence was 13.2% in general cosmetic surgery and 9.2% in cosmetic dermatology outpatients [23](#ref-23). - **Medical deferral:** uncontrolled disease, smoking risk, unsafe medication status, or frailty may outweigh aesthetic benefit. - **Expectation mismatch:** decline treatment when the requested change is anatomically impossible, unsafe, or unlikely to satisfy. --- ## References **\[1\]** Lemperle et al.. A classification of facial wrinkles.. Plastic and reconstructive surgery. 2001\. doi:10.1097/00006534-200111000-00048 **\[2\]** Zhao et al.. Different Techniques and Quantitative Measurements in Upper lip lift: A Systematic Review\\.. Aesthetic plastic surgery. 2023\. doi:10.1007/s00266-023-03302-5 **\[3\]** Khetpal et al.. Innovations in Skin and Soft Tissue Aging-A Systematic Literature Review and Market Analysis of Therapeutics and Associated Outcomes.. Aesthetic plastic surgery. 2023\. doi:10.1007/s00266-023-03322-1 **\[4\]** Swift et al.. The Facial Aging Process From the "Inside Out".. Aesthetic surgery journal. 2021\. doi:10.1093/asj/sjaa339 **\[5\]** Cotofana et al.. The Anatomy of the Aging Face: A Review\\.. Facial plastic surgery : FPS. 2016\. doi:10.1055/s-0036-1582234 **\[6\]** Shridharani et al.. Efficacy and Safety of RelabotulinumtoxinA, a New Ready-to-Use Liquid Formulation Botulinum Toxin: Results From the READY-1 Double-Blind, Randomized, Placebo-Controlled Phase 3 Trial in Glabellar Lines.. Aesthetic surgery journal. 2024\. doi:10.1093/asj/sjae131 **\[7\]** Cotofana et al.. Anatomy of the Facial Fat Compartments and their Relevance in Aesthetic Surgery.. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG. 2019\. doi:10.1111/ddg.13737 **\[8\]** Zargaran et al.. Facial skin ageing: Key concepts and overview of processes.. International journal of cosmetic science. 2022\. doi:10.1111/ics.12779 **\[9\]** Alghoul et al.. Retaining ligaments of the face: review of anatomy and clinical applications.. Aesthetic surgery journal. 2013\. doi:10.1177/1090820X13495405 **\[10\]** Pascali et al.. The Temporal Subcutaneous Brow Lift with Orbicularis Oculi Muscle Elastic Flap: Technical Considerations, Systematic Review, and Terminology Standardization.. Facial plastic surgery : FPS. 2023\. doi:10.1055/a-1953-2304 **\[11\]** Rattanawiwatpong et al.. Anti-aging and brightening effects of a topical treatment containing vitamin C, vitamin E, and raspberry leaf cell culture extract: A split-face, randomized controlled trial.. Journal of cosmetic dermatology. 2020\. doi:10.1111/jocd.13305 **\[12\]** Abellan et al.. The I.A.N.A Task Force on frailty assessment of older people in clinical practice.. The journal of nutrition, health & aging. 2008\. doi:10.1007/BF02982161 **\[13\]** Thomson et al.. Screening for Body Dysmorphic Disorder in Plastic Surgery Patients.. Aesthetic plastic surgery. 2024\. doi:10.1007/s00266-024-03959-6 **\[14\]** Contini et al.. A Systematic Review of the Efficacy of Microfocused Ultrasound for Facial Skin Tightening.. International journal of environmental research and public health. 2023\. doi:10.3390/ijerph20021522 **\[15\]** Arnett et al.. Facial keys to orthodontic diagnosis and treatment planning. Part I.. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 1993\. doi:10.1016/0889-5406(93)70010-L **\[16\]** Lin et al.. Comparative efficacy of topical interventions for facial photoaging: a network meta-analysis.. Scientific reports. 2025\. doi:10.1038/s41598-025-12597-0 **\[17\]** Biesman et al.. Development and Validation of a Photonumeric Scale for Evaluation of Infraorbital Hollowing.. Journal of drugs in dermatology : JDD. 2023\. doi:10.36849/JDD.7191 **\[18\]** Davis et al.. A Large Prospective Volumetric and Patient-Reported Outcome Analysis of Hyaluronic Acid Facial Fillers.. Plastic and reconstructive surgery. 2025\. doi:10.1097/PRS.0000000000012135 **\[19\]** Austin et al.. Evaluating the effectiveness and safety of radiofrequency for face and neck rejuvenation: A systematic review\\.. Lasers in surgery and medicine. 2022\. doi:10.1002/lsm.23506 **\[20\]** Ferreira et al.. Efficacy, Durability, and Safety of Collagen Biostimulators Based on Poly-L-Lactic Acid (PLLA) and Calcium Hydroxyapatite (CaHA) in the Face: A Systematic Review\\.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-025-05412-8 **\[21\]** Zargaran et al.. Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis.. Aesthetic surgery journal. 2022\. doi:10.1093/asj/sjac036 **\[22\]** Evans et al.. Rejuvenating the periorbital area using platelet-rich plasma: a systematic review and meta-analysis.. Archives of dermatological research. 2021\. doi:10.1007/s00403-020-02173-z **\[23\]** Veale et al.. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence.. Body image. 2016\. doi:10.1016/j.bodyim.2016.07.003 ### Managing Unrealistic Expectations & Patient Dissatisfaction in Plastic Surgery URL: https://www.theplasticsfella.com/managing-unrealistic-expectations-patient-dissatisfaction-in-plastic-surgery/ Last updated: 2026-07-23T11:42:58.000Z #### Summary Card [****Clinical Significance**](#clinical-significance) Unrealistic expectations require active management because patient satisfaction is a clinical outcome in plastic surgery, not an automatic consequence of technical success. [****Risk Factors and Warning Signs**](#risk-factors-and-warning-signs) High-risk situations include disproportionate requests, body-image preoccupation, psychiatric or obsessive traits, surgeon shopping, celebrity-reference goals, poor understanding, prior dissatisfaction, revision context, and communication or marketing that overpromises. [****Preoperative Assessment**](#preoperative-assessment) Before offering treatment, assess the patient’s goal, motivation, understanding, psychosocial risk, information sources, anatomy, alternatives, and capacity to accept an imperfect result. [****Communication and Consent**](#communication-and-consent) Communication should turn a desired outcome into a shared, documented, realistic plan that explains benefits, limitations, alternatives, drawbacks, complications, revision policy, and uncertainty. [****Management Strategy**](#management-strategy) When expectations are unrealistic or dissatisfaction emerges, escalate from reframing and time to deferral, refusal, second opinion, mental health referral, complaint handling, or carefully justified revision. [****The Dissatisfied Postoperative Patient**](#the-dissatisfied-postoperative-patient) Assess postoperative dissatisfaction by first excluding complications, then defining the specific concern, recovery phase, baseline comparison, expectation mismatch, psychosocial distress, and complaint risk. [****Documentation and Medico-Legal Protection**](#documentation-and-medico-legal-protection) Medico-legal protection depends on accurate records, consent-specific photographs, documented expectations, clear correspondence, chaperones when needed, secure data handling, complaint pathways, and professional boundaries. [****Outcomes and Professional Boundaries**](#outcomes-and-professional-boundaries) The realistic endpoint is a safe, documented, proportionate plan with honest follow-up, not guaranteed satisfaction or repeated procedures until the patient feels perfect. --- ## Clinical Significance ****Key Point** Unrealistic expectations require active management because patient satisfaction is a clinical outcome in plastic surgery, not an automatic consequence of technical success. Unrealistic expectations occur when the patient’s desired outcome is disproportionate to the anatomy, procedure, risk, recovery, or likely benefit. Dissatisfaction may relate to the result, the journey, the communication, or a mismatch between what was imagined and what was delivered. **Treat expectation mismatch as a safety problem** Expectation management is part of clinical risk reduction, not customer service. - **Clinical safety:** Dissatisfied patients may miss complications if their concerns are dismissed as “just anxiety.” - **Ethical practice:** Surgery should solve a realistic clinical or aesthetic problem, not reinforce distortion. - **Complaints risk:** Technical success does not protect against conflict if the patient feels unheard. - **Outcome quality:** Plastic surgery patients may have complex goals that influence satisfaction even when appearance or function improves [3](#ref-3). **Separate the result from the patient’s experience** Patients can be pleased overall while still distressed by a specific scar, asymmetry, symptom, or communication failure [4](#ref-4). - **Global satisfaction:** “I am happy overall” may hide a focused unresolved concern. - **Specific dissatisfaction:** pain, numbness, swelling, contour, or asymmetry may drive conflict. - **Consultation duty:** expectations should be explicitly addressed and counselled before operative treatment [5](#ref-5). - **Trainee task:** define what the patient wants, what surgery can deliver, and what it cannot. --- ## Risk Factors and Warning Signs ****Key Point** High-risk situations include disproportionate requests, body-image preoccupation, psychiatric or obsessive traits, surgeon shopping, celebrity-reference goals, poor understanding, prior dissatisfaction, revision context, and communication or marketing that overpromises. Risk factors do not automatically exclude treatment. They tell the trainee to slow down, assess more deeply, document more carefully, and be willing to defer or decline. **Identify body-image and psychological warning signs early** The common error is to assess only the anatomy and ignore the meaning the patient has attached to the defect. - **Disproportionate concern:** a minor or imperceptible finding generates major distress or functional claims. - **Persistent dissatisfaction:** dissatisfaction despite good procedural outcomes should prompt consideration of body dysmorphic disorder [7](#ref-7). - **Social comparison:** social-appearance anxiety and body dissatisfaction are warning signs for heightened cosmetic-surgery desire [8](#ref-8). - **Digital preoccupation:** excessive social media use in known or suspected body dysmorphic disorder may signal increased defect preoccupation and procedure seeking [9](#ref-9). **Treat online behaviour as part of the assessment** Social media can shape what the patient believes is normal, achievable, or deserved. - **Selfie editing:** frequent taking and editing of selfies is linked to greater consideration of cosmetic surgery [8](#ref-8). - **Celebrity photographs:** model or celebrity images may signal a mismatch between the patient’s goal and a natural surgical plan [10](#ref-10). - **Unrealistic ideals:** requests for an extremely narrow Westernised nose in Asian rhinoplasty require direct expectation discussion [10](#ref-10). - **Marketing exposure:** patient-related social-media content must be handled with consent and confidentiality because online material can create ethical and trust risks [8](#ref-8). **Recognise interaction patterns that predict conflict** The consultation style may reveal more risk than the examination. - **Surgeon shopping:** multiple prior opinions, selective quoting, or pressure for a promised result ([24](https://pmc.ncbi.nlm.nih.gov/articles/PMC3552465/?ref=theplasticsfella.com)). - **Entitlement language:** certainty that payment should guarantee perfection or exemption from complications. - **Obsessive traits:** compulsive or obsessive traits, denial, psychiatric disease, and unrealistic goals are warning signs for psychologically challenging patients [11](#ref-11). - **Revision identity:** prior unsatisfactory surgery may be valid, but repeated revision seeking raises the threshold for intervention. **Do not let screening tools replace judgement** A questionnaire can support assessment, but it cannot make the decision for the surgeon. - **Tool limitation:** existing cosmetic-surgery psychological screening tools have limited validity and usefulness when used uncritically [12](#ref-12). - **Health literacy:** poor understanding of risks, recovery, cost, or alternatives increases mismatch risk. - **Procedure sensitivity:** aesthetic, revision, intimate, visible, or device-based procedures tolerate less expectation error. - **System risk:** rushed consultations, inconsistent messages, and sales-driven pathways amplify dissatisfaction. --- ## Preoperative Assessment ****Key Point** Before offering treatment, assess the patient’s goal, motivation, understanding, psychosocial risk, information sources, anatomy, alternatives, and capacity to accept an imperfect result. Preoperative assessment should end with a decision: proceed, modify the plan, delay, seek another opinion, refer, or decline. It is not complete until the patient’s expectation has been stated in their own words. **Ask for the expectation before you teach** If the surgeon explains first, the patient may simply repeat the surgeon’s language. - **Opening question:** ask what the patient expected before the consultation [13](#ref-13). - **Desired change:** record the specific feature, symptom, or functional limitation they want changed. - **Success definition:** ask, “What would make this operation worthwhile for you?” - **Failure definition:** ask, “What outcome would you find unacceptable?” **Test motivation and information sources** The same operation can be reasonable for one patient and unsafe for another because the motivation is different. - **Individual motivation:** assess why the patient wants treatment rather than assuming the reason [14](#ref-14). - **External pressure:** identify partner, family, workplace, social-media, or event-driven urgency. - **Online research:** ask where information came from, because poor-quality internet material can shape expectations [15](#ref-15). - **Social-media fixation:** excessive social media use may indicate increased preoccupation in suspected body dysmorphic disorder [9](#ref-9). **Screen for psychological risk** The trainee’s job is to detect concern, not to provide a psychiatric label unsupported by assessment. - **BDD concern:** disproportionate distress, repetitive checking, camouflage, avoidance, and repeated procedures. - **Psychiatric disease:** untreated depression, severe anxiety, eating disorder, psychosis, addiction, or acute crisis. - **Disproportionate demands:** under-recognised psychiatric disorders may be present in cosmetic patients with disproportionate requests [6](#ref-6). - **Referral threshold:** psychological assessment can identify expectations, motivations, and need for referral [12](#ref-12). **Document the decision consequence** Assessment must change management when it reveals risk. | Assessment finding | Safer decision | Rationale | | ---------------------------------------- | ---------------------------- | ---------------------------- | | Realistic goal and accepts trade-offs | Proceed with documented plan | Consent can be specific | | Unclear goal or poor understanding | Reframe and review again | Avoids premature commitment | | High anxiety but modifiable expectations | Cooling-off period | Allows reflection | | Suspected BDD or acute psychiatric risk | Defer and refer | Surgery may worsen distress | | Nonfunctional or unsuitable request | Decline or second opinion | Protects patient and surgeon | - **Photographic record:** preoperative photographs support counselling and surgical planning in rhinoplasty [16](#ref-16). - **Goal alignment:** review findings, photographs, problem list, and operative plan before rhinoplasty to align surgery with documented goals [10](#ref-10). - **Explicit counselling:** expectation assessment and counselling should be built into the consultation before operative treatment [5](#ref-5). - **Resource stewardship:** screening and evaluation may prevent avoidable resource use in patients with unrealistic expectations [6](#ref-6). --- ## Communication and Consent ****Key Point** Communication should turn a desired outcome into a shared, documented, realistic plan that explains benefits, limitations, alternatives, drawbacks, complications, revision policy, and uncertainty. Consent is not valid because a form is signed. It is valid when the patient understands what is being offered, what is not being promised, and what trade-offs they are accepting. **Align the goal before discussing the operation** Shared decision-making becomes weak if expectations are not discussed [13](#ref-13). - **Patient language:** write the patient’s words for the desired change. - **Surgeon translation:** convert the desire into an anatomical or functional surgical objective. - **Limit statement:** say what surgery cannot change, including skin quality, asymmetry, scarring, ageing, or distress. - **Empathy:** cosmetic-surgery consultations should emphasise patient selection, expectation management, and empathetic communication [1](#ref-1). **Explain uncertainty without sounding dismissive** The aim is realistic hope, not pessimism. - **Balanced tone:** communication should combine hope with realistic information tailored to the individual patient [17](#ref-17). - **Drawbacks:** consent should explicitly explain procedure drawbacks to reduce dissatisfaction from unrealistic expectations [2](#ref-2). - **Complications:** discuss common, serious, and patient-specific risks in plain surgical terms. - **Alternatives:** include no treatment, delay, nonoperative options, and second opinion where appropriate. **Use visual aids as teaching tools** Images can clarify anatomy, but they can also create false certainty. - **Illustrations:** visual tools may help patients form more realistic expectations before surgery [4](#ref-4). - **Simulation:** present morphing as a discussion aid, not a predicted result. - **Photographs:** use standardised views and label asymmetries before the patient forgets baseline features. - **Policies:** preoperative policies on revisions, refunds, complications, and payments should be transparent [18](#ref-18). --- ## Management Strategy ****Key Point** When expectations are unrealistic or dissatisfaction emerges, escalate from reframing and time to deferral, refusal, second opinion, mental health referral, complaint handling, or carefully justified revision. Do not rescue a difficult consultation by offering surgery. The safer response is to slow the pathway and make the next decision explicit. **Reframe expectations before refusing treatment** Some patients become suitable after clearer counselling; others may reveal fixed unrealistic beliefs. - **Clarify likelihood:** changing pre-treatment counselling to explain the chance of success is a practical response to unrealistic expectations [19](#ref-19). - **Restate limits:** define the likely improvement, residual deformity, scars, recovery, and asymmetry. - **Check-back:** ask the patient to repeat the plan and trade-offs in their own words. - **Cooling-off:** use time when urgency is emotional rather than clinical. **Choose the next step by risk** Management should protect the patient, the team, and the therapeutic relationship. | Situation | Best next step | Main purpose | | ----------------------------- | ------------------------- | ----------------------------------- | | Misunderstanding but flexible | Re-educate and review | Restore shared decision | | Anxiety-driven request | Cooling-off period | Reduce impulsive consent | | Disproportionate distress | Psychological referral | Treat the driver, not the defect | | Unsafe requested result | Decline or second opinion | Avoid harmful surgery | | Valid postoperative issue | Objective review | Separate complication from mismatch | | Complaint behaviour | Formal pathway | Maintain boundaries and fairness | - **Specialist referral:** in cleft patients requesting further treatment, realistic expectations support treatment, whereas unrealistic expectations support clinical psychology referral [20](#ref-20). - **Unsuitable result:** if a requested rhinoplasty would be nonfunctional, aesthetically unsuitable, and difficult to achieve, the surgeon should try to dissuade the patient [10](#ref-10). - **Psychiatric contraindication:** anxiety-driven procedures should not proceed when the current psychiatric disorder, cancer phobia, or body dysmorphic syndrome is present in the cited risk-reducing mastectomy pathway [21](#ref-21). **Manage the relationship actively** The difficult patient is not managed by confrontation or avoidance. - **Expectation review:** understanding expectations and psychological needs supports satisfaction in difficult plastic-surgery patients [3](#ref-3). - **Empathy with limits:** acknowledge distress without validating an impossible surgical goal. - **Single communicator:** nominate a senior clinician to avoid mixed messages. - **Written plan:** summarise the decision, review interval, and conditions for reconsideration. **Plan revision only after the problem is stable** Revision should solve a defined technical or functional problem, not anger, regret, or perfectionism. - **Timing:** wait for swelling, scars, implants, or tissues to mature unless there is urgent harm. - **Indication:** define the objective abnormality and how revision would improve it. - **Risk disclosure:** revision usually has less predictability than primary surgery. - **Technique pathway:** cosmetic facial plastic surgery outcomes require patient selection, operative technique, and postoperative care to be addressed together [1](#ref-1). --- ## The Dissatisfied Postoperative Patient ****Key Point** Assess postoperative dissatisfaction by first excluding complications, then defining the specific concern, recovery phase, baseline comparison, expectation mismatch, psychosocial distress, and complaint risk. A dissatisfied patient needs a clinical review, not reassurance alone. Anger may coexist with a wound problem, nerve symptom, haematoma, infection, implant issue, or genuine aesthetic error. **Exclude clinical harm before debating satisfaction** Do not label concern as unrealistic until the operation has been assessed objectively. - **Early threats:** pain out of proportion, haematoma, infection, ischaemia, dehiscence, visual change, or neurological deficit. - **Recovery phase:** swelling, bruising, numbness, firmness, and scar redness may be normal but must be examined. - **Adverse events:** postoperative pathways should record adverse events, injuries, re-surgeries, infections, and deaths [22](#ref-22). - **Comparison:** use preoperative photographs and documented goals before judging asymmetry or contour. **Define the dissatisfaction precisely** A general complaint becomes manageable when reduced to a specific problem. - **Direct question:** absence of a revision request does not prove satisfaction, so ask directly about concerns [20](#ref-20). - **Expectation mismatch:** unmet expectations can lead to dissatisfaction and regret after cosmetic surgery [8](#ref-8). - **Regret:** postoperative regret and requests for further procedures should be addressed before revision surgery [8](#ref-8). - **Broader impact:** requests for further treatment may reflect lower quality of life and require wider assessment [20](#ref-20). **De-escalate anger while maintaining boundaries** The trainee should listen carefully, avoid defensive language, and keep the review structured. - **Acknowledge:** name the distress without admitting fault before assessment is complete. - **Clarify:** ask what the patient believes happened and what they want now. - **Contain:** use chaperones, senior review, and written follow-up for hostile encounters. - **Privacy:** avoid discussing patient-related content on social media without proper consent and confidentiality [8](#ref-8). --- ## Documentation and Medico-Legal Protection ****Key Point** Medico-legal protection depends on accurate records, consent-specific photographs, documented expectations, clear correspondence, chaperones when needed, secure data handling, complaint pathways, and professional boundaries. Good documentation is not defensive medicine. It is how the team proves what was assessed, offered, declined, understood, and agreed. **Record the consultation as a decision trail** The note should let another surgeon understand why treatment was offered, delayed, modified, or refused. - **Expectation record:** document the patient’s stated goal, success definition, and unacceptable outcome. - **Risk discussion:** record material risks, alternatives, limitations, and patient-specific concerns. - **Decision outcome:** write proceed, defer, decline, refer, or seek second opinion. - **Legal protection:** complete and accurate medical records are a priority for plastic surgeons managing dissatisfied or high-risk patients [18](#ref-18). **Use photography with consent and consistency** Photographs are clinical documents, not marketing assets. - **Standard views:** standardised preoperative and postoperative photographs support outcome evaluation and medicolegal documentation in rhinoplasty [16](#ref-16). - **Planning value:** preoperative photographs support counselling and surgical planning in rhinoplasty [16](#ref-16). - **Goal alignment:** reviewing examination, photographs, problem list, and operative plan supports alignment between procedure and goals [10](#ref-10). - **Confidentiality:** patient-related social-media content requires proper consent and confidentiality protection [8](#ref-8). **Control correspondence, complaints, and public messaging** Dissatisfaction often escalates when messages are inconsistent or promotional material appears misleading. - **Follow-up letters:** summarise concerns, examination findings, advice, and agreed next review. - **Chaperones:** use them for intimate examination, distressed patients, or hostile consultations. - **Complaint pathway:** move persistent conflict into the formal process rather than repeated informal negotiation. - **Advertising:** public-facing material should avoid misleading or unrealistic result portrayal because this can contribute to dissatisfaction and harm [8](#ref-8). **Protect data and understand risk** Confidentiality failures can worsen an already difficult relationship. - **Secure storage:** expectation, outcome, and adverse-event data should be stored securely [22](#ref-22). - **Coded data:** coded identifiers with restricted key-code access can protect confidentiality [22](#ref-22). - **Balanced perspective:** many plastic-surgery malpractice cases do not result in payment, but that should not reduce documentation standards [18](#ref-18). - **Shared decisions:** good communication and shared decision-making may reduce lawsuit risk in plastic surgery patients [18](#ref-18). --- ## Outcomes and Professional Boundaries ****Key Point** The realistic endpoint is a safe, documented, proportionate plan with honest follow-up, not guaranteed satisfaction or repeated procedures until the patient feels perfect. Some dissatisfaction cannot be surgically resolved. The surgeon must know when continued intervention becomes reinforcement of harm. **Counsel for improvement, not perfection** Patients may be satisfied overall while remaining dissatisfied with specific symptoms or details [4](#ref-4). - **Residual issues:** scars, asymmetry, numbness, swelling, ageing, and contour limits may persist. - **Revision limits:** revision is justified by a defined correctable problem, not a vague desire to feel whole. - **Evidence limits:** unfulfilled expectations are associated with dissatisfaction after knee arthroplasty, but the evidence base is limited and heterogeneous [23](#ref-23). - **Expectation boundary:** lymphedema patients in one survey often expected significant or complete improvement, illustrating why achievable outcomes must be bounded [5](#ref-5). **End the episode professionally when needed** A therapeutic relationship can rupture despite appropriate care. - **Repeated interventions:** set boundaries against repeated cosmetic procedures driven by pursuit of perfection [8](#ref-8). - **Social-media perfection:** professional limits are needed when online aesthetic ideals drive body-image concerns or unnecessary surgery. - **Follow-up offer:** provide reasonable review, complication care, and referral routes. - **Clinician wellbeing:** involve senior colleagues, document threats, use formal complaints processes, and avoid isolated management. --- ## References **\[1\]** Dilger et al.. Unhappy Patients Can Turn into Angry Patients: How to Deal with Both.. Facial plastic surgery clinics of North America. 2021\. doi:10.1016/j.fsc.2020.06.004 **\[2\]** Rosen et al.. Patient dissatisfaction after functionally successful conjunctivodacryocystorhinostomy with Jones tube.. American journal of ophthalmology. 1994\. doi:10.1016/s0002-9394(14)70070-4 **\[3\]** Sykes et al.. A contemporary review of the management of the difficult patient.. JAMA facial plastic surgery. 2013\. doi:10.1001/jamafacial.2013.932 **\[4\]** Rijpma et al.. Long-term patient satisfaction with their split-thickness skin graft donor site and the need for improved preoperative counselling.. Journal of wound care. 2025\. doi:10.12968/jowc.2023.0037 **\[5\]** Fahradyan et al.. Understanding Patient Expectations of Lymphedema Surgery.. Plastic and reconstructive surgery. 2018\. doi:10.1097/PRS.0000000000004417 **\[6\]** Jafferany et al.. Psychological aspects of aesthetic and cosmetic surgery: Clinical and therapeutic implications.. Dermatologic therapy. 2020\. doi:10.1111/dth.13727 **\[7\]** Castle et al.. Does cosmetic surgery improve psychosocial wellbeing?. The Medical journal of Australia. 2002\. doi:10.5694/j.1326-5377.2002.tb04593.x **\[8\]** Mironica et al.. Social Media Influence on Body Image and Cosmetic Surgery Considerations: A Systematic Review\\.. Cureus. 2024\. doi:10.7759/cureus.65626 **\[9\]** Laughter et al.. Psychology of aesthetics: Beauty, social media, and body dysmorphic disorder.. Clinics in dermatology. 2023\. doi:10.1016/j.clindermatol.2023.03.002 **\[10\]** Facial plastic surgery clinics of North America et al.. Asian rhinoplasty.. Facial plastic surgery clinics of North America. 2010\. doi:10.1016/j.fsc.2009.11.018 **\[11\]** Trost et al.. Managing the difficult penile prosthesis patient.. The journal of sexual medicine. 2013\. doi:10.1111/jsm.12115 **\[12\]** Wildgoose et al.. Psychological screening measures for cosmetic plastic surgery patients: a systematic review\\.. Aesthetic surgery journal. 2013\. doi:10.1177/1090820X12469532 **\[13\]** Kee et al.. What you suggest is not what I expected': How pre-consultation expectations affect shared decision-making in patients with low back pain.. Patient education and counseling. 2023\. doi:10.1016/j.pec.2022.10.001 **\[14\]** Ryan et al.. Impact of dentofacial deformity and motivation for treatment: a qualitative study.. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2012\. doi:10.1016/j.ajodo.2011.12.026 **\[15\]** Fast et al.. Partial nephrectomy online: a preliminary evaluation of the quality of health information on the Internet.. BJU international. 2012\. doi:10.1111/j.1464-410X.2012.11626.x **\[16\]** Kim et al.. Photography and Photodocumentation for the Rhinoplasty Patient.. Clinics in plastic surgery. 2021\. doi:10.1016/j.cps.2021.07.003 **\[17\]** Brown et al.. Patient preferences for the delivery of bad news - the experience of a UK Cancer Centre.. European journal of cancer care. 2011\. doi:10.1111/j.1365-2354.2009.01156.x **\[18\]** Boyd et al.. Plastic Surgery and the Malpractice Industry.. Plastic and reconstructive surgery. 2021\. doi:10.1097/PRS.0000000000007497 **\[19\]** Quatan et al.. Do patients expect too much from extracorporeal shock wave lithotripsy?. Annals of the Royal College of Surgeons of England. 2003\. doi:10.1308/003588403322520735 **\[20\]** Sinko et al.. Evaluation of esthetic, functional, and quality-of-life outcome in adult cleft lip and palate patients.. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association. 2005\. doi:10.1597/03-142.1 **\[21\]** Edlich et al.. Risk-reducing mastectomy.. Journal of long-term effects of medical implants. 2006\. doi:10.1615/jlongtermeffmedimplants.v16.i4.40 **\[22\]** Ljung et al.. Effect of prehabilitation before total knee replacement on postoperative patient-reported joint awareness, enablement and knee function: protocol for the PROTEKT randomised controlled trial.. BMJ open. 2026\. doi:10.1136/bmjopen-2025-113185 **\[23\]** Duivenvoorden et al.. Patient expectations and satisfaction concerning total knee arthroplasty\].. Nederlands tijdschrift voor geneeskunde. 2017\. PMID:28120729 (24) \[https://pmc.ncbi.nlm.nih.gov/articles/PMC3552465/\](https://pmc.ncbi.nlm.nih.gov/articles/PMC3552465/) ### Aesthetic Consultation: Suitability, Consent, & Treatment Planning URL: https://www.theplasticsfella.com/aesthetic-consultation/ Last updated: 2026-07-23T09:09:34.000Z #### Summary Card [****Consultation Goals and Suitability**](#consultation-goals-and-suitability) The consultation exists to decide whether the requested treatment is indicated, proportionate, safe, and autonomously chosen; offer, modify, defer, or decline treatment accordingly. [****Consultation Structure**](#consultation-structure) A safe consultation moves through preparation, patient-led concerns, focused history, examination, photographs, shared priorities, documentation, and a clear closing plan. [****Psychological Assessment and Expectations**](#psychological-assessment-and-expectations) Assess motivation, expectations, body image, psychiatric history, coercion, and BDD risk; defer or refer when distress, distorted beliefs, or unrealistic goals make safe consent doubtful. [****Clinical Assessment and Treatment Planning**](#clinical-assessment-and-treatment-planning) Before proposing treatment, gather the medical risks, medication and allergy history, smoking status, prior procedures, procedure-specific examination, measurements, photographs, and optimisation needs. [****Communication, Consent, and Cooling-Off**](#communication-consent-and-cooling-off) Communicate benefits, material risks, complications, alternatives, no treatment, costs, uncertainty, and cooling-off clearly enough that the patient can decide without pressure. [****Managing Difficult Consultations**](#managing-difficult-consultations) Slow down, set boundaries, decline unsafe requests with clinical reasons, document the discussion, and escalate psychological, safeguarding, or medico-legal concerns early. [****Documentation and Medico-Legal Safety**](#documentation-and-medico-legal-safety) Defensible documentation records the indication, suitability reasoning, baseline appearance, examination, photographs, options, risks, alternatives, questions, written information, consent stage, costs, and follow-up plan. [****Follow-Up and Conversion to Treatment**](#follow-up-and-conversion-to-treatment) End with a written plan and proceed only when the patient is fully informed, physically and psychologically suitable, optimised, and able to access postoperative surveillance. --- ## Consultation Goals and Suitability ****Key Point** The consultation exists to decide whether the requested treatment is indicated, proportionate, safe, and autonomously chosen; offer, modify, defer, or decline treatment accordingly. An aesthetic consultation is a clinical assessment, not a sales encounter. The trainee’s task is to understand the patient’s concern, test whether treatment can safely address it, and recognise when the safest outcome is no procedure. **Define the problem before proposing a treatment** Start with the patient’s own words, then translate the concern into an anatomical or clinical problem. - **Patient concern:** ask what bothers them, when it began, and what change they want. - **Treatable feature:** identify whether the concern maps to skin, soft tissue, volume, shape, proportion, or asymmetry. - **Procedure mismatch:** do not offer an operation for a problem it cannot reliably improve. - **Shared diagnosis:** in rhinoplasty, suitability discussions should reconcile the patient’s perceived concern with the surgeon’s aesthetic assessment [2](#ref-2). **Offer treatment only when suitability survives the challenge** Aesthetic treatment should proceed only after active testing of suitability and expectations, not passive acceptance of the request [3](#ref-3). - **Indication:** the concern is visible, procedure-responsive, and clinically proportionate. - **Expectation:** the patient accepts improvement, trade-offs, scars, asymmetry, and uncertainty. - **Capacity:** the patient can understand options, risks, alternatives, and no treatment. - **Autonomy:** the request is internally motivated rather than coerced by a partner, employer, or event. **Defer or decline when the risk is not procedural** The unsafe patient is not always the medically unfit patient. Psychological risk, coercion, distorted self-image, or fixed unrealistic goals may make technically possible treatment clinically wrong. - **Defer:** active smoking, unstable weight, untreated illness, medication issues, or unresolved decision-making. - **Modify:** choose a smaller, staged, or non-operative plan when risk exceeds benefit. - **Decline:** refuse requests that are unsafe, disproportionate, anatomically impossible, or ethically compromised. - **Document:** record the clinical reason for deferral or refusal in neutral language. --- ## Consultation Structure ****Key Point** A safe consultation moves through preparation, patient-led concerns, focused history, examination, photographs, shared priorities, documentation, and a clear closing plan; structured pathways may combine screening, in-person assessment, and self-report questionnaires [3](#ref-3). Aesthetic consultations fail when they become unstructured conversations. Use a repeatable pathway so that rapport, risk assessment, consent, and documentation are all covered without turning the encounter into a checklist. **Prepare before the patient enters** Preparation reduces missed risks and makes the consultation feel clinical rather than commercial. - **Referral information:** check requested treatment, prior procedures, relevant comorbidities, and red flags. - **Questionnaires:** self-analysis forms can capture the patient’s aesthetic priorities before surgeon-led discussion [2](#ref-2). - **Environment:** ensure privacy, appropriate lighting, mirror access, photography setup, and chaperone availability. - **Mindset:** enter ready to say no if the consultation identifies poor suitability. **Let the patient set the first agenda** The first few minutes should clarify the patient’s own priorities before the clinician reframes them. - **Opening question:** ask what they hope to change and why now. - **Priority ranking:** separate the main concern from secondary dislikes. - **Impact:** explore functional, social, occupational, and emotional consequences. - **Boundary:** explain that the consultation will assess suitability, not guarantee treatment. **Move from story to focused clinical assessment** The surgeon who performs the procedure should conduct the face-to-face aesthetic consultation [4](#ref-4). This preserves accountability and allows the operative plan to reflect the actual clinical findings. - **Focused history:** cover medical risk, prior treatments, medications, allergies, smoking, healing, and expectations. - **Examination consent:** explain exposure, photography, measurements, chaperone use, and patient control. - **Relevant examination:** assess only what changes indication, technique, risk, or counselling. - **Shared mirror review:** identify findings together without exaggerating defects. **Close the consultation safely** Aesthetic consultations should end with a decision pathway, not a pressure point. For cosmetic breast augmentation, patients should generally have at least two face-to-face consultations with the operating surgeon before consent is finalised [4](#ref-4). - **Summary:** repeat the patient’s concern, your clinical findings, and the realistic treatment options. - **Next step:** offer review, further assessment, optimisation, referral, or no treatment. - **Written plan:** provide information that can be considered away from the clinic. - **Safety net:** explain who to contact if concerns, uncertainty, or new medical information arises. --- ## Psychological Assessment and Expectations ****Key Point** Assess motivation, expectations, body image, psychiatric history, coercion, and BDD risk; defer or refer when distress, distorted beliefs, or unrealistic goals make safe consent doubtful. Psychological assessment is not about excluding anyone with anxiety or low confidence. It is about identifying patients whose distress, expectations, or decision-making make aesthetic treatment unlikely to help and potentially harmful. **Separate internal motivation from external pressure** A suitable patient usually wants a specific change for themselves and can describe a realistic benefit. - **Internal motivation:** long-standing personal concern, stable request, and proportionate goals. - **External driver:** partner pressure, social media comparison, workplace demand, bullying, or recent life crisis. - **Timing trigger:** recent breakup, bereavement, litigation, complaint, or major psychological stress. - **Autonomy test:** ask what would happen if treatment were delayed or declined. **Convert expectations into testable outcomes** The trainee should translate “I want to look better” into a specific, achievable, and measurable aim. - **Desired change:** ask what exact feature should change and what should remain unchanged. - **Outcome tolerance:** discuss scars, asymmetry, revision risk, imperfect correction, and ageing. - **Image references:** online aesthetic images may misrepresent outcomes through angle, pose, background, position, or body-part coverage [5](#ref-5). - **Unrealistic endpoint:** perfection, life transformation, relationship repair, or guaranteed symmetry are warning signs. **Screen actively for body dysmorphic disorder** BDD is common enough in cosmetic surgery settings that screening can materially affect patient selection; one cited meta-analysis reported 13% prevalence in this group [6](#ref-6). Where regulatory standards apply, cosmetic consultations should include BDD screening for all potential patients [7](#ref-7). - **Screening tools:** options include BDDQ, BDDQ-DV, BDDQ-AS, COPS, BDSS, and BDD-ST [7](#ref-7). - **Clinical clues:** excessive mirror checking, camouflaging, repeated reassurance seeking, or disproportionate distress. - **Functional impairment:** ask about work, relationships, avoidance, social withdrawal, and time spent preoccupied. - **Previous procedures:** repeated dissatisfaction despite technically adequate treatment increases concern. **Refer or defer when expectations cannot be corrected** Education should improve understanding. If it does not shift unrealistic expectations, non-candidacy is an appropriate outcome [3](#ref-3). - **Psychiatric referral:** suspected BDD should prompt screening and psychiatric assessment before aesthetic treatment [1](#ref-1). - **Deferral language:** explain that treatment is not safe or likely to meet the stated goal at present. - **Shared plan:** offer review after psychological support, stabilisation, or further reflection. - **Do not negotiate:** avoid offering a smaller procedure simply to satisfy an unsafe request. --- ## Clinical Assessment and Treatment Planning ****Key Point** Before proposing treatment, gather the medical risks, medication and allergy history, smoking status, prior procedures, procedure-specific examination, measurements, photographs, and optimisation needs that will change the plan. Clinical assessment turns the patient’s desired change into a safe treatment pathway. The best aesthetic plan is not the most technically impressive option; it is the option that fits the anatomy, risk profile, and patient priorities. **Take a history that can change the plan** Do not collect a generic preoperative history. Ask questions that alter indication, timing, technique, or safety. - **Medical risk:** assess comorbidities and prior aesthetic procedures that may require exclusion, postponement, or specialist clearance [3](#ref-3). - **Medication review:** identify drugs that may need alteration before treatment [3](#ref-3). - **Allergies and reactions:** include dressings, antiseptics, local anaesthetic, antibiotics, fillers, and implants. - **Smoking and nutrition:** modifiable risks may justify deferral while supporting cessation, medication timing changes, or nutritional improvement [1](#ref-1). **Examine the anatomy that determines the treatment** Procedure-specific physical examination should assess skin quality, lesions, tissue characteristics, and relevant anatomical abnormalities [3](#ref-3). Examination should be respectful, explained, and limited to what matters clinically. - **Skin envelope:** quality, laxity, scars, pigmentation, thickness, sun damage, and healing risk. - **Soft tissue:** volume, ptosis, asymmetry, contour, tethering, and tissue mobility. - **Structural support:** skeletal proportion, cartilage, fascial support, muscle tone, or abdominal wall integrity. - **Functional baseline:** document obstruction, dryness, weakness, pain, hernia, or range limitation when relevant. **Use measurements and photographs to plan, not to shame** For facial aesthetic consultations such as blepharoplasty, evaluation should begin with medical work-up, rapport, and preoperative photographic documentation [8](#ref-8). - **Measurements:** record distances, asymmetry, ptosis, skin excess, pinch tests, or circumferences where relevant. - **Photography:** use standard views, consistent lighting, neutral expression, and appropriate exposure. - **Mirror review:** agree which findings are real, which are minor, and which treatment cannot address. - **Baseline limits:** identify pre-existing asymmetry before proposing correction. **Prioritise treatment by risk, sequence, and value** When several procedures are possible, rank them by safety and clinical value rather than by patient enthusiasm alone. | Planning problem | Practical decision | Main trade-off | | ------------------------------- | ------------------------------- | --------------------------- | | Modifiable risk | Optimise before treatment | Delays surgery | | Multiple concerns | Treat dominant concern first | May need staging | | Minor concern, high risk | Observe or decline | Patient may be disappointed | | Prior surgery or complication | Seek records or senior review | Slower planning | | Large body-contouring procedure | Counsel procedure-specific risk | Higher optimisation burden | For abdominoplasty planning, patients should be counselled that major complication rates are 2–4% and increase with combined procedures, higher BMI, and older age [1](#ref-1). --- ## Communication, Consent, and Cooling-Off ****Key Point** Communicate benefits, material risks, complications, alternatives, no treatment, costs, uncertainty, and cooling-off clearly enough that the patient can decide without pressure. Consent in aesthetics is vulnerable because the procedure is elective and the patient is often paying directly. The standard should be slower, clearer, and more documented than a routine transactional discussion. **Make options understandable, not persuasive** Consent discussions should cover risks, complications, benefits, alternatives, and the option of no treatment so the patient can make an informed decision [3](#ref-3). - **Benefits:** describe realistic improvement rather than idealised transformation. - **Risks:** include common, serious, patient-specific, and procedure-specific complications. - **Alternatives:** include non-operative care, staged treatment, different procedures, referral, or observation. - **Uncertainty:** explain limits in symmetry, scarring, longevity, revision, and patient satisfaction. **Use staged consent and cooling-off** Aesthetic treatment decisions may take weeks or months from first evaluation to mutual decision, so consent should not be rushed [3](#ref-3). A minimum cooling-off period before surgery allows reflection rather than same-day commitment [4](#ref-4). - **First consultation:** assess goals, suitability, anatomy, risks, and broad options. - **Information stage:** provide written material, quotation, photographs policy, and questions pathway. - **Second review:** confirm stable decision, understanding, optimisation, and final plan. - **Consent signing:** avoid treating a signature as proof that the patient understood. **Remove sales pressure from the decision** Consultation processes should avoid free-consultation sales tactics, time-limited promotions, nonmedical sales consultations, and should use two-stage written preoperative consent [9](#ref-9). - **Financial transparency:** separate clinical recommendation from price, finance, or package incentives. - **Image caution:** Instagram before-and-after images may be biased; one assessment found 70.8% of image sets favoured the postoperative result [5](#ref-5). - **Language:** avoid guaranteeing results, minimising complications, or framing delay as a lost opportunity. - **Clinician role:** the surgeon advises; the patient decides; the business must not pressure either. --- ## Managing Difficult Consultations ****Key Point** Slow down, set boundaries, decline unsafe requests with clinical reasons, document the discussion, and escalate psychological, safeguarding, or medico-legal concerns early. Difficult consultations are not failures. They are often the point at which clinical judgement matters most. **Name the mismatch appropriately** When concerns arise, safe options include further visits, third-party assessment, or clear communication that the patient is not a candidate [3](#ref-3). - **Expectation mismatch:** explain what treatment can and cannot change. - **Anatomical mismatch:** show the limiting feature using mirror review or photographs. - **Risk mismatch:** state why the risk outweighs the likely benefit. - **Decision pause:** offer time, review, or senior opinion rather than debating in the room. **Say no with clinical reasons** When declining an aesthetic request, give clinical reasons, document them, and offer alternatives rather than relying on moral disapproval [1](#ref-1). - **Unsafe request:** decline procedures that are disproportionate, harmful, or outside competence. - **Unrealistic goal:** explain that surgery is unlikely to meet the stated expectation. - **Alternative plan:** offer observation, optimisation, psychological assessment, or referral where appropriate. - **Tone:** be firm, respectful, and brief; do not overjustify. **Escalate psychological and behavioural risk** Substance misuse, severe distress, coercion, or suspected BDD should change the consultation pathway. - **Drug or alcohol misuse:** mental health evaluation and counselling may be needed before surgery because perioperative risk and postoperative behaviour may be affected [3](#ref-3). - **BDD concern:** suspected BDD is a safety issue, not just a satisfaction issue. - **Suicide risk:** reported suicide-attempt rates in BDD range from 10% to 35%, so self-harm concerns require urgent escalation [6](#ref-6). - **Safeguarding:** pause treatment if coercion, abuse, trafficking, or impaired capacity is suspected. **Manage complications from elsewhere clinically** A patient who is unhappy with another provider’s treatment needs assessment, not reflexive criticism. - **Immediate risk:** identify infection, ischaemia, exposure, wound breakdown, or implant problems. - **Records:** request operative notes, implant details, filler type, product batch, and photographs. - **Boundaries:** clarify whether you are offering emergency care, a second opinion, revision, or referral. - **Complaints:** avoid becoming the patient’s advocate against another clinician without full information. --- ## Documentation and Medico-Legal Safety ****Key Point** Defensible documentation records the indication, suitability reasoning, baseline appearance, examination, photographs, options, risks, alternatives, questions, written information, consent stage, costs, and follow-up plan. Good notes do not make unsafe practice safe, but poor notes can make safe practice indefensible. Document the reasoning behind the decision, not just the fact that a discussion occurred. **Document reasoning** Aesthetic consultations should be documented contemporaneously to support ethical clarity and medico-legal defensibility [1](#ref-1). - **Indication:** record the patient’s concern and the clinical finding it corresponds to. - **Suitability:** note expectations, motivation, capacity, red flags, and reasons for deferral if present. - **Options:** document treatment choices discussed, including no treatment. - **Questions:** record patient questions and the answers given. **Photographs must be accurate and usable** Preoperative photographs should document baseline appearance before aesthetic treatment [3](#ref-3). Consultation photography should aim to present the patient accurately and precisely [10](#ref-10). - **Standardisation:** use consistent lighting, distance, background, views, and posture. - **Consent:** document permission for clinical photography and intended use. - **Chaperone:** record chaperone offer, presence, or patient refusal when intimate examination occurs. - **Storage:** follow local information governance and image-security policy. **Record the consent pathway** Where mandated, the surgeon should personally conduct and document BDD assessment using a validated psychological screening tool [7](#ref-7). Two-stage signed consent is a recognised safety gap in aesthetic practice and should be explicitly recorded when used [9](#ref-9). - **Written information:** note leaflets, web links, implant information, or procedure-specific material provided. - **Material risks:** record patient-specific risks, not just generic complication lists. - **Cooling-off:** document dates of consultations, reflection period, and final decision timing. - **Consent status:** distinguish discussion, provisional plan, and signed consent. **Capture the commercial details separately** Financial clarity protects the patient and the clinician. - **Quotation:** record fees, inclusions, exclusions, revision policy, and expiry date. - **No pressure:** document that treatment was not time-limited or promotion-dependent. - **Follow-up plan:** specify review timing, emergency contact route, and postoperative responsibility. - **Declined treatment:** document the clinical reason and any alternative offered. --- ## Follow-Up and Conversion to Treatment ****Key Point** End with a written plan and proceed only when the patient is fully informed, physically and psychologically suitable, optimised, and able to access postoperative surveillance [3](#ref-3). The end of the consultation should reduce uncertainty. The patient should leave knowing the provisional plan, what remains undecided, and what must happen before treatment. **Close with a clear next step** A safe ending is a clinical checkpoint, not a booking opportunity. - **Summary:** restate the concern, findings, options, risks, and recommendation. - **Patient understanding:** ask the patient to explain the plan back in their own words. - **Written plan:** provide procedure information, optimisation tasks, quotation, and review arrangements. - **Observation:** maintain non-operative review when the concern is mild, unstable, or high risk. **Convert only when prerequisites are complete** When a prerequisite intervention is required, definitive aesthetic surgery should wait until that intervention is complete and healed [3](#ref-3). Surgery should proceed only where postoperative surveillance can be provided, including for patients considering surgical tourism [4](#ref-4). - **Second consultation:** confirm stable goals, consent understanding, photographs, and optimisation. - **Medical readiness:** check smoking, medications, investigations, weight stability, and specialist clearance. - **Escalation trigger:** seek senior, psychological, or multidisciplinary input if new concerns appear. - **Scheduling:** book treatment only after suitability, consent, costs, and follow-up responsibility are clear. --- ## References **\[1\]** Friedman et al.. Saying No in Aesthetic Surgery: Ethical Framework for Declining High-Stakes Requests.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-026-05682-w **\[2\]** Alosfoor et al.. Comparison Between Patient and Plastic Surgeon Aesthetic Analysis in Rhinoplasty Consultation.. Plastic and reconstructive surgery. Global open. 2023\. doi:10.1097/GOX.0000000000004948 **\[3\]** Elist et al.. Patient selection protocol for the Penuma® implant: suggested preoperative evaluation for aesthetic surgery of the penis.. International journal of impotence research. 2020\. doi:10.1038/s41443-020-0237-5 **\[4\]** Cooter et al.. Developing an International Framework for Informed Consent in Plastic Surgery: A Focus on Cosmetic Breast Augmentation.. Plastic and reconstructive surgery. Global open. 2023\. doi:10.1097/GOX.0000000000005371 **\[5\]** ElAbd et al.. Aesthetic Surgery Before-and-After Photography Bias on Instagram.. Aesthetic plastic surgery. 2023\. doi:10.1007/s00266-023-03398-9 **\[6\]** Rück et al.. Body dysmorphic disorder.. Nature reviews. Disease primers. 2024\. doi:10.1038/s41572-024-00577-z **\[7\]** Thomson et al.. Screening for Body Dysmorphic Disorder in Plastic Surgery Patients.. Aesthetic plastic surgery. 2024\. doi:10.1007/s00266-024-03959-6 **\[8\]** Bosniak et al.. Cosmetic blepharoplasty.. Current opinion in ophthalmology. 1992\. doi:10.1097/00055735-199110000-00013 **\[9\]** Rufai et al.. Aesthetic surgery and Google: ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery.. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2014\. doi:10.1016/j.bjps.2014.01.009 **\[10\]** Wang et al.. The art and science of photography in hand surgery.. The Journal of hand surgery. 2014\. doi:10.1016/j.jhsa.2013.03.038 ### Informed Consent in Aesthetic Practice: Assessment, Disclosure, & Documentation URL: https://www.theplasticsfella.com/informed-consent-in-aesthetic-practice/ Last updated: 2026-07-22T20:32:04.000Z #### Summary Card [****Definition and Clinical Significance**](#definition-and-clinical-significance) Valid aesthetic consent is an ongoing shared decision-making process that confirms capacity, voluntariness, material risk understanding, realistic expectations, and authorisation before elective treatment. [****Legal and Ethical Standards**](#legal-and-ethical-standards) Defensible aesthetic consent requires capacity, voluntariness, patient-centred material risk disclosure, reasonable alternatives including no treatment, honest documentation, and protection from commercial pressure. [****Patient Assessment and Suitability**](#patient-assessment-and-suitability) Before aesthetic treatment, assess capacity, psychological readiness, motivation, expectations, body dysmorphic disorder risk, vulnerability, medical safety, communication barriers, and whether treatment should proceed, change, pause, or be declined. [****Risk Disclosure and Alternatives**](#risk-disclosure-and-alternatives) The patient must understand procedure-specific benefits, limits, common and serious risks, catastrophic risks, recovery burden, scars, asymmetry, revision and cost implications, alternatives, different settings, and no treatment. [****Consent Process and Documentation**](#consent-process-and-documentation) Structure consent as staged counselling with clear written information, interpreters when needed, photographs where relevant, documented understanding, adequate reflection time, and final confirmation on the day without introducing new material risks too late. [****Special Scenarios in Aesthetic Practice**](#special-scenarios-in-aesthetic-practice) Adapt consent when vulnerability, age, minor procedures, social media pressure, revision surgery, intimate anatomy, anaesthesia, tourism, training, or remote assessment increases the risk of misunderstanding or regret. [****Complications, Complaints, and Consent Failure**](#complications-complaints-and-consent-failure) A poor outcome is not automatically consent failure, but inadequate disclosure, rushed counselling, poor documentation, or unmanaged expectations can convert a recognised complication into a complaint or claim. [****Outcomes and Counselling**](#outcomes-and-counselling) Patients should understand realistic outcome ranges, uncertainty, durability, ageing, maintenance, repeat treatment, revision thresholds, psychological limits, and the limitations of before-and-after images before treatment. --- ## Definition and Clinical Significance ****Key Point** Valid aesthetic consent is an ongoing shared decision-making process that confirms capacity, voluntariness, material risk understanding, realistic expectations, and authorisation before elective treatment. In aesthetic practice, consent is not a formality. The patient is often healthy, the intervention is elective, and the outcome is judged partly through subjective satisfaction. ### Consent Process Treat consent as a clinical conversation, not a signed transaction. - **Autonomy:** consent protects the patient’s right to choose or refuse elective cosmetic care [1](#ref-1). - **Shared decision-making:** the patient should understand the procedure, relevant information, and especially the risks [2](#ref-2). - **Authorisation:** a signed form records agreement, but it does not replace the discussion; formal documentation may include patient and clinician signatures [3](#ref-3). - **Non-urgency:** confirm the patient understands that most aesthetic treatment is optional and can be deferred. ### Voluntariness Check that the decision belongs to the patient and is not driven by pressure. - **Social pressure:** appearance pressures can impair voluntary aesthetic decision-making and should be actively explored [1](#ref-1). - **Coercion:** pressure may be emotional, financial, social, partner-driven, or commercial. - **Capacity:** the patient must be able to understand, retain, weigh information, and communicate a choice. - **Withdrawal:** consent should remain reversible until treatment starts, subject to practical and safety limits. ### Expectations Aesthetic consent must test the patient’s desired outcome against what the procedure can actually deliver. - **Subjective benefit:** discuss the gap between perceived and actual outcomes before treatment [4](#ref-4). - **Dissatisfaction risk:** unmet expectations may escalate into medico-legal disputes even after technically appropriate elective procedures [4](#ref-4). - **Outcome language:** use ranges, limitations, scars, asymmetry, maintenance, and revision thresholds. - **Red flag:** do not rely on “the patient wants it” when expectations are unrealistic. --- ## Legal and Ethical Standards ****Key Point** Defensible aesthetic consent requires capacity, voluntariness, patient-centred material risk disclosure, reasonable alternatives including no treatment, honest documentation, and protection from commercial pressure. Legal rules vary by jurisdiction. This section teaches safe clinical standards, not legal advice; check local law, regulator guidance, and indemnity requirements. ### Material Risk Disclose what this patient would reasonably want to know, not only what the surgeon routinely mentions. - **Patient-centred test:** include risks that matter to the patient’s values, occupation, lifestyle, appearance goals, and risk tolerance. - **Montgomery principle:** in Montgomery-style jurisdictions, disclosure is anchored to material risks and reasonable alternatives. - **No treatment:** elective aesthetic consent must include doing nothing as a legitimate option. - **Clinician-specific data:** disclose your own outcomes or complication experience when it would materially influence the decision. ### Ethical Principles Balance patient preference against professional duties to avoid harm. - **Autonomy:** respect choice through truthful disclosure and confidentiality [5](#ref-5). - **Non-maleficence:** decline requests that are unsafe, disproportionate, or clinically unwise despite patient demand. - **Voluntariness:** consent is invalid if the patient lacks capacity or is choosing under physical, financial, or emotional coercion [3](#ref-3). - **Justice:** avoid exploiting vulnerable patients, scarcity of access, or unrealistic social ideals. ### Commercial Standards Separate clinical recommendation from advertising, sales pressure, and industry influence. - **Marketing:** aesthetic recommendations and advertising should follow explicit ethical standards, not commercial priorities alone [1](#ref-1). - **Industry influence:** aesthetic practice occurs in an industry-shaped environment, so independent education and ethical counselling are especially important [6](#ref-6). - **Financial conflict:** disclose relevant fees, staged costs, revision policies, deposits, and refund limits. - **Medical tourism:** limited standardisation and regulation can create informed-consent and health-equity concerns [7](#ref-7). ### Documentation Standards Record the decision pathway clearly enough that another clinician can understand what was discussed and why treatment proceeded. - **Core elements:** consent should confirm capacity, voluntariness, information disclosure, recommendation, understanding, decision, and authorisation [2](#ref-2). - **Liability exposure:** unrealistic expectations and undocumented risk discussions increase aesthetic liability risk [4](#ref-4). - **Cooling-off:** follow any mandated reflection period and avoid rushing consent immediately before treatment. - **Record quality:** document alternatives, patient questions, answers, and reasons for deferral or refusal. | Consent standard | Practical test | Common failure | | ---------------- | ----------------------------------------------- | --------------------------------------------- | | Capacity | Can the patient weigh the choice? | Intoxication, crisis, impaired understanding | | Voluntariness | Is the decision freely made? | Partner, finance, influencer, clinic pressure | | Disclosure | Were material risks and alternatives discussed? | Generic form only | | Understanding | Can the patient explain the trade-off? | Passive agreement without comprehension | | Authorisation | Was agreement recorded? | Missing, late, or unclear documentation | --- ## Patient Assessment and Suitability ****Key Point** Before aesthetic treatment, assess capacity, psychological readiness, motivation, expectations, body dysmorphic disorder risk, vulnerability, medical safety, communication barriers, and whether treatment should proceed, change, pause, or be declined. Suitability assessment is part of consent. A patient can request treatment and still be unsuitable for that treatment, that timing, or that provider. ### Capacity Assessment Confirm the patient can make this specific decision at this specific time. - **Understanding:** check comprehension of the procedure, limits, risks, alternatives, and no-treatment option. - **Weighing:** ask how the patient balances benefit against scars, recovery, cost, and revision risk. - **Impairment:** do not accept consent if the patient is unstable or impaired by alcohol or drugs [2](#ref-2). - **Language:** use a professional interpreter when language limits understanding; avoid relying on family for consent translation. ### Psychological Assessment Identify psychological risk before treatment, not after dissatisfaction appears. - **BDD prevalence:** screen for body dysmorphic disorder because estimated weighted prevalence is 13.2% in general cosmetic surgery and 20.1% in rhinoplasty surgery [8](#ref-8). - **Screening method:** combine preliminary BDD questionnaires with direct history about psychiatric history, medication use, and expectations [9](#ref-9). - **Red flags:** unrealistic emotional attribution, multiple prior procedures, near-normal anatomy, childhood trauma, psychiatric comorbidity, and social dysfunction should raise concern [10](#ref-10). - **Action:** defer treatment and seek specialist input when psychological risk appears to dominate the request. ### Motivation And Expectations Test whether the requested change is realistic, internally motivated, and proportionate. - **Expectation mismatch:** identify unrealistic aesthetic expectations before offering elective cosmetic treatment [4](#ref-4). - **Social media:** explore whether the request is driven by social media portrayals rather than personal goals [1](#ref-1). - **Coercion:** assess partner pressure, workplace pressure, influencer culture, and financial inducement. - **Cultural identity:** in ethnic rhinoplasty, discuss preservation of ethnic identity as part of culturally sensitive planning [11](#ref-11). ### Medical Risk Elective treatment should be deferred when modifiable medical risk is unsafe. - **Medication risk:** antiplatelet or anticoagulant therapy needs individual risk-based planning, not a uniform rule [12](#ref-12). - **Bleeding or thrombosis:** defer or avoid treatment if medication-related risk cannot be managed safely [12](#ref-12). - **Pregnancy:** classify requested procedures as urgent, nonurgent, or elective before offering intervention [13](#ref-13). - **Local factors:** active infection, inflammation, scarring tendency, and previous procedures may alter suitability. --- ## Risk Disclosure and Alternatives ****Key Point** The patient must understand procedure-specific benefits, limits, common and serious risks, catastrophic risks, recovery burden, scars, asymmetry, revision and cost implications, alternatives, different settings, and no treatment. Risk disclosure should sound like the proposed procedure, not like a generic consent template. A safe discussion explains what the treatment can do, what it cannot do, and what happens if the patient does nothing. ### Procedure-Specific Risk Describe risks in the language of the actual operation, device, product, and anatomical site. - **Specificity:** risk disclosure should be procedure-specific, with documentation and follow-up plans tailored to the operation [4](#ref-4). - **Filler vascular risk:** HA filler consent should mention rare serious vascular complications including skin necrosis and visual impairment [14](#ref-14). - **Scarring tendency:** hypertrophic or keloid tendency should be screened before facial filler treatment [15](#ref-15). - **Breast implants:** asymptomatic patients with textured implants should be counselled that FDA guidance does not recommend routine prophylactic removal or replacement [16](#ref-16). ### Limits And Burden Explain the treatment burden as clearly as the intended aesthetic gain. - **Limitations:** consent should address realistic expectations, complications, procedure limits, alternatives, and postoperative course before treatment [17](#ref-17). - **Recovery:** discuss pain, swelling, bruising, downtime, activity restriction, garment use, wound care, and follow-up. - **Scars:** state scar position, length, visibility, maturation, hypertrophy risk, and possible asymmetry. - **Revision:** explain thresholds for revision, timing, who pays, and when revision is not advisable. ### Alternatives Present reasonable alternatives neutrally, including less treatment and no treatment. - **Option set:** discuss available options, benefits, and harms of each, and the patient’s values and circumstances [18](#ref-18). - **Non-surgical care:** include observation, skin care, injectables, resurfacing, weight stability, camouflage, or staged treatment where relevant. - **Different setting:** discuss whether the procedure is better done in clinic, theatre, hospital, or by a different specialist. - **No treatment:** document that deferral remains acceptable, especially where the benefit is marginal. ### Consent Content When discussing consent, use a structured framework so that uncommon but important issues are not accidentally overlooked. - **Core sequence:** consent should cover capacity, voluntariness, disclosure, recommendation, understanding, decision, and authorisation [2](#ref-2). - **Financial impact:** include total cost, staged fees, implants or devices, complications, revision, time off work, and insurance exclusions. - **Catastrophic risk:** mention rare but severe events when their consequences are material. - **Pregnancy:** fillers, sclerotherapy, and liposuction should be presented as contraindicated rather than routine aesthetic options in pregnancy [13](#ref-13). --- ## Consent Process and Documentation ****Key Point** Structure consent as staged counselling with clear written information, interpreters when needed, photographs where relevant, documented understanding, adequate reflection time, and final confirmation on the day without introducing new material risks too late. Good documentation does not make poor consent safe. It records a defensible process that has already happened. ### Staged Consent Give the patient enough time to understand, reflect, ask questions, and decline. - **Early discussion:** aesthetic surgical consent should occur early enough for reflection and detailed questions [2](#ref-2). - **No ambush:** consent should not first be presented immediately before a cosmetic procedure [19](#ref-19). - **Cooling-off:** follow local cooling-off requirements, especially for surgery and high-cost interventions. - **Day-of confirmation:** confirm consent on the day, but do not introduce major new risks too late for reflection. ### Written Information Written material supports understanding only after the clinical discussion has occurred. - **Comprehension:** written consent should follow patient understanding of objectives, methods, risks, and benefits [20](#ref-20). - **Language:** forms should be in language the patient can read and understand, using clear wording [3](#ref-3). - **Interpreter:** document interpreter identity, method, and confirmation of patient understanding. - **Device-specific risks:** document distinctive risks rather than relying on generic forms; for early thyroidectomy scar prevention, CO2AFL-IPL had higher adverse-event incidence than silicone or BTX-A in one trial [20](#ref-20). ### Clinical Records Record what was discussed, what the patient asked, and what decision was reached. - **Expectations:** document patient expectations and procedure limitations before treatment [1](#ref-1). - **Discussion record:** the agreed plan and consent discussion should be fully documented in the patient record [2](#ref-2). - **Photographs:** consent for facial photographs should specifically include permission for those photographs [15](#ref-15). - **Roles:** distinguish surgeon, injector, assistant, anaesthetist, trainee, and chaperone involvement. --- ## Special Scenarios in Aesthetic Practice ****Key Point** Adapt consent when vulnerability, age, minor procedures, social media pressure, revision surgery, intimate anatomy, anaesthesia, tourism, training, or remote assessment increases the risk of misunderstanding or regret. Higher-risk scenarios need more safeguards, not more paperwork alone. Slow the process down when capacity, expectations, privacy, or continuity of care is uncertain. ### Minors And Young Adults Apply additional safeguards when maturity, safeguarding, or external pressure may affect consent. - **Guardians:** for minors or patients lacking capacity, involve guardians while including the patient as far as they can understand [3](#ref-3). - **Safeguarding:** assess coercion, bullying, exploitation, gender distress, parental pressure, and social media influence. - **Timing:** defer elective aesthetic treatment when maturation, capacity, or motivation is uncertain. - **Confidentiality:** explain privacy limits when safeguarding concerns arise. ### Office Procedures Minimally invasive treatment still requires procedure-specific consent and emergency planning. - **Injectables:** document product, site, dose or volume, risks, alternatives, aftercare, and emergency contact route. - **Prior treatment:** slowly resorbable or permanent filler below the inferior orbital rim should be identified before nasolabial-fold filler planning [15](#ref-15). - **Pregnancy:** pregnant patients requesting aesthetic treatment should receive written risk explanation and informed consent; video consent may be considered in selected cases [13](#ref-13). - **Images:** when follow-up or clinical images are part of treatment, consent should cover compliance and photograph use [20](#ref-20). ### High-Risk Requests Escalate safeguards when the request predicts regret, dissatisfaction, or complex revision. - **Revision surgery:** consent requires added safeguards for revision cases and refusal or denial of consent situations [17](#ref-17). - **Psychological red flags:** facial aesthetic consultations should treat unrealistic emotional attribution and psychiatric comorbidity as warning signs [10](#ref-10). - **Combined procedures:** disclose additive recovery, cumulative risk, staging alternatives, and when separating procedures is safer. - **Intimate procedures:** assess sexual function goals, privacy, trauma history, coercion, and realistic anatomical limits. ### Remote And External Care Do not let distance, digital media, or travel weaken assessment and follow-up. - **Teleconsultation:** confirm identity, privacy, image quality, limitations of remote examination, and need for in-person assessment. - **Medical tourism:** patients seeking treatment abroad should be warned that limited standardisation and regulation may compromise informed consent [7](#ref-7). - **Training cases:** disclose trainee involvement, supervision, and who performs each critical step. - **Unvalidated treatments:** regenerative aesthetic interventions may lack substantial scientific and regulatory validation [21](#ref-21). --- ## Complications, Complaints, and Consent Failure ****Key Point** A poor outcome is not automatically consent failure, but inadequate disclosure, rushed counselling, poor documentation, or unmanaged expectations can convert a recognised complication into a complaint or claim. When something goes wrong, manage the patient first. Then review whether the complication was disclosed, understood, documented, and managed transparently. ### Complication Recognition Separate the clinical adverse event from the consent question. - **Clinical event:** diagnose and treat bleeding, infection, necrosis, visual symptoms, wound breakdown, scarring, or implant-related problems promptly. - **Filler emergency:** HA filler vascular compromise needs an urgent pathway because hyaluronidase within 6 hours was associated with better outcomes [14](#ref-14). - **Severe filler outcomes:** reported HA filler vascular complication cases included skin necrosis in 60.6% and visual impairment in 52.8% [14](#ref-14). - **Atypical wounds:** after breast surgery, disproportionate pain, nipple-areola sparing, high CRP, and poor antibiotic response should prompt consideration of postsurgical pyoderma gangrenosum [22](#ref-22). ### Consent Failure Look for missing disclosure, misunderstanding, coercion, or expectation mismatch. - **Documentation gap:** absent or inadequate preoperative documentation increases the chance that a claim results in compensation [4](#ref-4). - **Frequency:** incomplete consent was cited in over 50% of reviewed aesthetic medico-legal cases [4](#ref-4). - **Complaint driver:** consent failure appears as a leading allegation in over 50% of reviewed litigation cases [4](#ref-4). - **Revocability:** patients must be allowed to refuse or withdraw consent even after initially agreeing [3](#ref-3). ### Open Disclosure Respond early, honestly, and within local duty-of-candour requirements. - **First response:** acknowledge the concern, assess harm, arrange treatment, and avoid defensive language. - **Record review:** check consent notes, photographs, information leaflets, emails, risk discussions, and follow-up records. - **Escalation:** involve the senior clinician, governance lead, indemnifier, or medico-legal advisor when harm or complaint risk is significant. - **Apology:** express regret for the experience without making unsupported admissions. ### Learning Loop Recurrent complaints usually reveal a system problem, not just a difficult patient. - **Pattern review:** audit repeated issues such as scars, asymmetry, cost, revisions, downtime, and unrealistic outcomes. - **Consent forms:** body-contouring forms may omit procedure-specific complications, so disclosure should be checked against a comprehensive list [2](#ref-2). - **Communication:** rushed or inadequately informative consent is associated with dissatisfaction, complications, or complaints [19](#ref-19). - **Practice change:** update leaflets, templates, cooling-off workflow, photography consent, and escalation triggers. --- ## Outcomes and Counselling ****Key Point** Patients should understand realistic outcome ranges, uncertainty, durability, ageing, maintenance, repeat treatment, revision thresholds, psychological limits, and the limitations of before-and-after images before treatment. Outcome counselling is not reassurance. It is calibration: what improvement is likely, what will remain, what may worsen, and what future care may be needed. ### Outcome Realism Counsel in probabilities, ranges, and trade-offs rather than perfection. - **Shared decision-making:** it can improve communication, expectation accuracy about benefits and harms, involvement, informedness, and satisfaction [18](#ref-18). - **Teach-back:** use teach-back to check that patient and clinician have understood the exchanged information [23](#ref-23). - **Baseline biology:** scarring tendency can affect suitability and expectations before filler treatment [15](#ref-15). - **Images:** before-and-after images demonstrate possibilities, not guarantees; explain lighting, pose, timing, and selection bias. ### Durability And Maintenance Explain that many aesthetic outcomes change with time, ageing, tissue biology, and repeat treatment cycles. - **Fillers:** combined or hybrid HA-CaHA filler improvement and satisfaction may slightly decline after six months [24](#ref-24). - **Ageing:** surgery does not stop laxity, descent, pigment change, volume loss, or weight-related change. - **Maintenance:** injectables, lasers, implants, and skin-quality treatments may need repeat sessions or surveillance. - **Implants:** discuss device lifespan, exchange uncertainty, surveillance, and symptom-driven review where relevant. ### Revision Thresholds Define revision as a risk-management decision, not an automatic response to dissatisfaction. - **Timing:** delay revision until swelling, scar maturation, and psychological adjustment permit reliable assessment. - **Indication:** revise for clear anatomical problems, functional issues, or agreed residual deformity. - **Evidence limits:** revision neck lift can improve contour, but outcomes evidence is limited and largely surgeon-reported [25](#ref-25). - **Financial terms:** document revision fees, exclusions, and responsibility for theatre, anaesthetic, implant, or hospital costs. ### Psychological Outcomes Aesthetic treatment may improve satisfaction, but it cannot reliably treat distress, relationship problems, or identity conflict. - **BDD risk:** do not promise psychological rescue when dysmorphia, crisis, or external pressure is present. - **Breast implant illness:** patients with suspected breast implant illness commonly report arthralgia and fatigue [26](#ref-26). - **Explantation:** symptom improvement after explantation and capsulectomy may be reported, but planning should be individualised [26](#ref-26). - **Intimate surgery:** before labiaplasty, state that evidence about sexual function effects remains limited [27](#ref-27). ### Long-Term Care Align consent with the follow-up relationship the patient will actually need. - **Follow-up:** specify review schedule, emergency access, wound checks, photographs, and late complication surveillance. - **Tourism risk:** medical-tourism literature reports complication rates as high as 56%, including infection, poor aesthetic or functional outcome, and cardiovascular events [7](#ref-7). - **Information quality:** actively correct and contextualise information from the internet and commercial sources. - **Exit plan:** explain who manages complications, revisions, records, implants, and ongoing maintenance if the patient moves the provider. --- ## References **\[1\]** Rostamzadeh et al.. 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Combination Therapy of Intense Pulsed Light and Fractional Carbon Dioxide Laser Versus Botulinum Toxin Type A in Post-thyroidectomy Scar Prevention: A Prospective, Randomized Controlled Trial.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-026-05717-2 **\[21\]** Rahman et al.. Regenerative Aesthetics: A Genuine Frontier or Just a Facet of Regenerative Medicine: A Systematic Review\\.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-024-04287-5 **\[22\]** Caddia et al.. Postsurgical Pyoderma Gangrenosum in Breast Surgery: An Updated Systematic Review, Takeaways, and the 6 Commandments.. Aesthetic surgery journal. 2025\. doi:10.1093/asj/sjaf095 **\[23\]** Montori et al.. Shared decision-making as a method of care.. BMJ evidence-based medicine. 2023\. doi:10.1136/bmjebm-2022-112068 **\[24\]** Amiri et al.. Combined and Hybrid Treatments of Hyaluronic Acid (HA) and Calcium Hydroxylapatite (CaHA): A Systematic Review of Mechanisms of Action, Aesthetic Effectiveness, Satisfaction, and Safety Profile.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-025-04904-x **\[25\]** Aesthetic plastic surgery. Revision Neck Lift Surgery: A Systematic Review of Indications, Techniques, and Outcomes.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-026-05686-6 **\[26\]** Alabdulkarim et al.. Comprehensive Systematic Review of Breast Implant Illness: Symptoms, Management, and Long-Term Outcomes.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-024-04129-4 **\[27\]** Aesthetic plastic surgery et al.. Female Sexual Function After Labiaplasty: A Systematic Review and Meta-analysis.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-025-04946-1 **\[28\]** \\\[Author. A Systemic Review of the “Informed Consent” Process for Aesthetic Cosmetic Surgery Procedures. Aesthetic Surgery Journal (likely; cosmetic surgery ethics/education journal). 2024\. doi:10.1177/07488068241260771 ### Ethical Decision-Making in Cosmetic Surgery: Patient Selection, Consent & Ethics URL: https://www.theplasticsfella.com/ethical-decision-making-in-cosmetic-surgery/ Last updated: 2026-07-22T20:23:56.000Z #### Summary Card [****Indications and Suitability**](#indications-and-suitability) Offer cosmetic surgery only when the request matches a defined treatable problem, the expected benefit is proportionate to risk, and capacity, voluntariness, expectations, and safety are acceptable. [****Assessment and Capacity**](#assessment-and-capacity) Before accepting an autonomous cosmetic request, assess capacity, voluntariness, psychological risk, expectations, maturity, safeguarding concerns, medical risk, and documentation. [****Informed Consent and Shared Decision-Making**](#informed-consent-and-shared-decision-making) Consent is valid only when the patient understands material risks, alternatives including no surgery, realistic limits, uncertainty, and provider-specific factors without coercion or therapeutic misconception. [****Professional Duties and Boundaries**](#professional-duties-and-boundaries) Cosmetic surgeons must act as physicians, not vendors, and should refuse requests that breach competence, honesty, proportionality, or patient welfare. [****Special Patient Groups**](#special-patient-groups) Vulnerable or higher-risk patients need slower decision-making, stronger capacity assessment, safeguarding review, and a lower threshold for deferral or specialist input. [****Complications, Disclosure, and Revision Decisions**](#complications-disclosure-and-revision-decisions) When complications, poor results, or revision requests arise, disclose openly, treat promptly, document carefully, and offer revision only when it is safe, proportionate, and likely to help. [****Outcomes and Counselling**](#outcomes-and-counselling) Counsel patients that cosmetic surgery may improve a defined concern but cannot guarantee happiness, permanence, symmetry, scar invisibility, complication-free recovery, or freedom from revision. --- ## Indications and Suitability ****Key Point** Offer cosmetic surgery only when the request matches a defined treatable problem, the expected benefit is proportionate to risk, and capacity, voluntariness, expectations, and safety are acceptable. Cosmetic surgery starts with a patient's desire, but desire alone is not a surgical indication. The ethical task is to decide whether surgery is a medically responsible way to address that desire. ### Patient Selection Convert the patient’s request into a specific anatomical, functional, or psychosocial problem before offering treatment. - **Patient desire:** clarify what feature, symptom, social burden, or functional problem the patient wants changed. - **Surgical indication:** define what surgery can actually alter, and what it cannot. - **Validated limits:** avoid presenting selection criteria as statistically validated predictors of outcome when they are not [1](#ref-1). - **Financial neutrality:** frame suitability around goals, severity, compliance, and affordability rather than clinician's financial benefit [2](#ref-2). | Ethical decision | Proceed | Modify or defer | Decline | | ----------------- | ------------------------------------- | --------------------------------------- | --------------------------------------- | | Treatable problem | Clear anatomical or functional target | Vague target needing clarification | No surgically correctable concern | | Risk profile | Proportionate and optimised | Modifiable risk factors | Disproportionate risk | | Psychology | Stable expectations | Anxiety, ambivalence, external pressure | Active BDD concern or delusional belief | | Evidence base | Established procedure | Limited evidence or adjunctive role | Uncertain safety or efficacy | ### Benefit-Risk Proportionality The lower the medical necessity, the higher the threshold for safety, evidence, and patient understanding. - **Low-necessity surgery:** cosmetic benefit must justify anaesthetic, scarring, dissatisfaction, and revision risk. - **Benign scars:** suitability should include failed conservative treatment and patient choice after risk discussion [3](#ref-3). - **Patient burden:** for keloid procedures, counselling should include itching, pain, and appearance burden, not only scar dimensions [3](#ref-3). - **Uncertain procedures:** rib resection or remodeling should be treated cautiously because long-term safety and efficacy remain uncertain [4](#ref-4). ### Contraindications Defer or decline when surgery is unlikely to help, likely to harm, or be requested under impaired autonomy. - **Body dysmorphic disorder:** BDD is commonly treated as a contraindication when considering cosmetic surgery suitability [5](#ref-5). - **Unrealistic aim:** perfection, relationship repair, occupational success, or social validation are unsafe indications. - **Coercion:** partner, family, employer, cultural, or online pressure undermines voluntariness. - **Medical instability:** uncontrolled comorbidity, active infection, poor wound-healing risk, or unsafe medication context may make surgery disproportionate. ### Treatment Boundaries Suitability includes choosing the least harmful effective option, including no procedure. - **Anatomy-specific planning:** Asian incisional blepharoplasty should be individualised to eyelid anatomy rather than applying one aesthetic method [6](#ref-6). - **Procedure-area matching:** filler suitability depends on treatment area, and high-elastic-modulus fillers should be avoided in delicate areas such as the tear trough [7](#ref-7). - **Domestic alternatives:** patients considering cosmetic surgery abroad may not have explored local assessment, alternatives, or follow-up options [8](#ref-8). - **Oncologic boundary:** recurrence data for selected nipple-sparing mastectomy patients support oncologic counselling, not conversion of risk-reducing or reconstructive operations into purely cosmetic indications. --- ## Assessment and Capacity ****Key Point** Before accepting an autonomous cosmetic request, assess capacity, voluntariness, psychological risk, expectations, maturity, safeguarding concerns, medical risk, and documentation. Capacity is decision-specific. A patient may understand ordinary medical care yet fail to appreciate cosmetic-surgery risks because of emotional fixation, distorted self-image, or external pressure. ### Capacity Assessment Confirm that the patient can understand, retain, weigh, and communicate a decision about this procedure. - **Understanding:** ask the patient to explain the procedure, scars, recovery, risks, alternatives, and uncertainty. - **Appreciation:** assess whether strong emotional investment is impairing appreciation of surgical or travel-related risks [8](#ref-8). - **Reasoning:** when a patient remains fixed on surgery despite contrary risk information, check understanding and reasoning before consent proceeds [8](#ref-8). In adolescents, assess maturity, psychological vulnerability, and BDD risk specifically in adolescent cosmetic requests [10](#ref-10). ### Voluntariness Treat pressure, dependency, and social threat as clinical findings, not background noise. - **External pressure:** ask whether anyone else wants the operation, is paying, or has made acceptance conditional. - **Social media:** explore edited images, filters, influencer comparisons, and rapidly changing ideals. - **Cultural pressure:** distinguish personal preference from conformity, stigma avoidance, or family expectation. - **Private review:** see the patient alone when coercion, safeguarding, or partner influence is possible. ### Psychological Screening Screen for mental health conditions that may distort motivation, consent, satisfaction, or postoperative coping. - **BDD screening:** ask about preoccupation, checking, camouflaging, reassurance seeking, avoidance, and functional impairment. - **Labiaplasty evidence:** among 55 women seeking labiaplasty, 10 met diagnostic criteria for BDD, supporting routine psychological screening in this group [11](#ref-11). - **Genital procedures:** assess anxiety, depression, and BDD before female genital cosmetic procedures [12](#ref-12). - **Avoidance behaviours:** labiaplasty assessment should explore avoidance and safety-seeking behaviours because these were more frequent among women seeking the procedure [11](#ref-11). ### Documentation and Referral Document the decision process clearly and involve specialists when mental health, maturity, or safeguarding affects judgement. - **Capacity note:** record the information given, the patient’s explanation back, reasoning, voluntariness, and decision. - **Medical review:** for fillers, assess previous complications, allergies, medical conditions, prior procedures, and medication risk [7](#ref-7). - **Psychology referral:** mental health specialist involvement is appropriate when psychological disorders may affect cosmetic treatment decisions or outcomes [13](#ref-13). - **Deferral language:** document deferral as a safety decision, not rejection of the patient. --- ## Informed Consent and Shared Decision-Making ****Key Point** Consent is valid only when the patient understands material risks, alternatives including no surgery, realistic limits, uncertainty, and provider-specific factors without coercion or therapeutic misconception. Cosmetic consent must be more explicit than consent for medically necessary procedures because the benefit is preference-sensitive. The patient must understand both what is possible and what remains uncertain. ### Material Risk Disclosure Discuss the risks that matter to this patient, this procedure, and this surgeon’s plan. - **Procedure-specific risk:** disclose scars, asymmetry, contour change, nerve symptoms, dissatisfaction, revision, and recovery limitations. - **Provider-specific risk:** cosmetic patients report that limited transparency about procedure-specific and provider-specific risks undermines decision quality [8](#ref-8). - **Genital procedures:** consent should include limited evidence for benefit and known procedural risks [12](#ref-12). - **Fillers:** patients should be told that all fillers carry a small risk of complications [7](#ref-7). ### Alternatives Consent must include reasonable alternatives, staged options, non-operative care, delay, and no treatment. - **No surgery:** present observation as a legitimate option, not a failure to decide. - **Travel surgery:** weak regulation and inconsistent standards create informed-consent and health-equity risks before elective cosmetic treatment abroad [14](#ref-14). - **Cultural anatomy:** Asian double-eyelid requests require culturally and anatomically specific assessment rather than extrapolation from non-Asian blepharoplasty norms [6](#ref-6). - **Adjunct limits:** biostimulatory rejuvenation discussions should state that quantifiable product-effect data remain limited [15](#ref-15). ### Comprehension Checks Use decision aids to improve understanding, but never let them replace the surgeon-patient conversation. - **Teach-back:** ask the patient to describe the operation, risks, alternatives, and likely result in their own words. - **Multimedia aids:** adding a short multimedia tool to standard counselling can substantially improve comprehension before implant-based reconstruction [16](#ref-16). - **Decision aids:** structured digital decision aids may improve decision quality compared with usual consultation alone [17](#ref-17). **Important:* multimedia materials should supplement, not replace, individualised surgeon-patient planning* [*16*](#ref-16)*.* ### Shared Decision-Making Share decisions within professional boundaries; do not offer unsafe surgery because the patient requests it. - **Patient factors:** when aesthetic and functional goals overlap, tailor the plan to patient-specific factors through shared decision-making [18](#ref-18). - **Simulation risk:** AI or simulation images must be labelled as illustrative because they may not be surgically achievable [19](#ref-19). - **Nonjudgmental consent:** perceived clinician judgment may stop patients from seeking preoperative advice or postoperative support [8](#ref-8). - **Adolescent autonomy:** adolescent labioplasty consent should address whether BDD undermines autonomy and whether parental consent alone is sufficient [5](#ref-5). --- ## Professional Duties and Boundaries ****Key Point** Cosmetic surgeons must act as physicians, not vendors, and should refuse requests that breach competence, honesty, proportionality, or patient welfare. Autonomy does not oblige a surgeon to operate. Professional integrity requires saying no when the requested intervention is unsafe, misleading, commercially driven, or outside competence. ### Ethical Principles Balance autonomy with beneficence, non-maleficence, justice, and professional integrity. - **Beneficence:** offer interventions likely to help the patient’s defined concern. - **Non-maleficence:** decline disproportionate risk, unsafe repetition, or unstable psychological drivers. - **Autonomy:** respect informed refusal, delay, and alternative choices. - **Justice:** avoid exploiting vulnerability, scarcity, stigma, or social inequality. ### Competence Stay within training, anatomy knowledge, infrastructure, and complication-management capability. - **Physician role:** the cosmetic surgeon’s role should remain that of a physician rather than a vendor of beauty services [20](#ref-20). - **Anatomy:** clinicians performing cosmetic injections should have thorough facial-anatomy knowledge before offering treatment [7](#ref-7). - **Experience:** insufficient experience contributes to filler complications, so practitioners must stay within competence [7](#ref-7). - **Adolescent boundary:** cosmetic surgery in adolescents requires maturity, psychological vulnerability, and BDD risk assessment before treatment is considered [10](#ref-10). ### Commercial Conduct Advertising and financial arrangements must not distort patient selection or consent. - **Marketing:** cosmetic procedure marketing should be accurate and should not mislead prospective patients about benefits or risks [12](#ref-12). - **Incentives:** market incentives must not override assessment of the patient’s real clinical or psychosocial need [20](#ref-20). - **Conflict control:** clinicians offering female genital cosmetic procedures should avoid commercial conflicts influencing care [12](#ref-12). - **Refusal:** decline requests for unsafe exaggeration, serial escalation, or procedures outside your honest competence. --- ## Special Patient Groups ****Key Point** Vulnerable or higher-risk patients need slower decision-making, stronger capacity assessment, safeguarding review, and a lower threshold for deferral or specialist input. Special groups are not automatically excluded from cosmetic care. The ethical threshold changes because autonomy, risk, expectations, or social pressure may be more fragile. ### Minors Defer non-medically indicated cosmetic surgery in minors unless maturity, welfare, and medical justification are clear. - **Adolescent process:** include psychosocial evaluation, caregiver involvement, age-appropriate counselling, and scrutiny of social-media-shaped motivations [10](#ref-10). - **Genital surgery:** for under-18 patients requesting female genital cosmetic procedures, deferral is supported unless there is a medical indication [12](#ref-12). - **Practitioner opinion:** a large majority of surveyed Turkish healthcare practitioners supported avoiding female genital cosmetic procedures in girls under 18 [12](#ref-12). - **Selected exceptions:** adolescent BDD does not automatically exclude cosmetic labioplasty in every circumstance, but it demands careful ethical review [5](#ref-5). ### Psychological Vulnerability Treat distress as a reason to assess more carefully, not as proof that surgery will help. - **Mental health:** depression, anxiety, trauma history, eating disorders, BDD, and personality vulnerability may affect consent and satisfaction. - **Nonjudgmental stance:** perceived judgment may stop patients from seeking preoperative advice or postoperative support [8](#ref-8). - **Gender-diverse patients:** distinguish gender-affirming goals from cosmetic requests, assess dysphoria and support, and avoid pathologising identity. - **Repeat requests:** serial procedures, shifting concerns, and dissatisfaction after technically adequate surgery should trigger psychological review. ### Medical and Social Context Modify counselling when anatomy, comorbidity, culture, or care continuity changes risk. - **Cultural anatomy:** Asian patients seeking double-eyelid surgery need culturally and anatomically specific assessment [6](#ref-6). - **Bariatric tourists:** waiting-time pressure may drive decisions, so counselling should address urgency and continuity of postoperative care [8](#ref-8). - **Complex rhinoplasty:** thick-skinned rhinoplasty patients may discuss adjunct isotretinoin for short-term benefit, not as a durable one-year advantage [21](#ref-21). - **Medical complexity:** optimise smoking, diabetes, anticoagulation, wound risk, nutrition, and postoperative support before elective surgery. --- ## Complications, Disclosure, and Revision Decisions ****Key Point** When complications, poor results, or revision requests arise, disclose openly, treat promptly, document carefully, and offer revision only when it is safe, proportionate, and likely to help. The ethical test does not end at the operation. Dissatisfaction and complications require candour, clinical responsibility, and boundaries around corrective surgery. ### Duty of Candour Tell the patient what happened, what it means, what you will do next, and what uncertainty remains. - **Disclosure:** acknowledge complications early, avoid blame-shifting, and explain the clinical plan. - **Apology:** apologise for the patient’s experience without making unsupported admissions. - **Medical tourism:** counsel travel patients that reported complication rates have been as high as 56%, including infection, poor aesthetic or functional outcomes, and cardiovascular events [14](#ref-14). - **Documentation:** record findings, photographs, advice, escalation, prescriptions, and follow-up arrangements. ### Complication Management Manage urgent harm first, then address aesthetics, blame, cost, and revision. - **Filler preparedness:** clinicians offering hyaluronic acid fillers should have hyaluronidase readily available where legally permitted [7](#ref-7). - **Vascular event:** suspected intravascular infarction after hyaluronic acid filler should be treated with at least 200 to 300 U hyaluronidase across the threatened area, repeated daily for at least 2 days until necrosis or reperfusion is evident [7](#ref-7). - **Infection:** acute bacterial infection signs after filler injection should prompt antibiotic therapy [7](#ref-7). - **Foreign body:** filler granuloma may require excision when repeated non-surgical therapies fail [7](#ref-7). ### Revision Surgery Revision is an indication, not an entitlement, and must meet the same ethical threshold as primary surgery. - **Reassessment:** before revising filler-related problems, reassess prior complications, allergies, medical conditions, previous procedures, and medication risks [7](#ref-7). - **Psychology:** poor communication and inadequate psychological screening are modifiable contributors to aesthetic disputes [13](#ref-13). - **Conflict risk:** patients with psychological disorders should be counselled about higher dissatisfaction and increased conflict risk after aesthetic procedures [13](#ref-13). - **Minor boundary:** avoid allowing revision pressure to justify non-medically indicated genital cosmetic surgery in under-18s [12](#ref-12). --- ## Outcomes and Counselling ****Key Point** Counsel patients that cosmetic surgery may improve a defined concern but cannot guarantee happiness, permanence, symmetry, scar invisibility, complication-free recovery, or freedom from revision. Outcome counselling should be concrete and modest. Patients need a realistic picture of benefit, limits, uncertainty, maintenance, and what disappointment may look like. ### Realistic Benefit Frame the expected result around achievable change rather than transformation. - **Functional claims:** female genital cosmetic procedures should not promise improved quality of life or sexual function because practitioner studies showed little agreement on these benefits [12](#ref-12). - **Keloid burden:** benign keloid counselling should include patient-reported itching, pain, and aesthetic concern [3](#ref-3). - **Filler benefit:** most hyaluronic acid filler adverse reactions are mild and transient, while serious adverse events are rare [7](#ref-7). - **Residual risk:** careful planning and technique can reduce many avoidable filler adverse events but cannot eliminate all risk [7](#ref-7). ### Durability and Revision Explain that ageing, tissue biology, implants, scars, and patient preference may change the result over time. - **Biostimulators:** stronger controlled evidence is still needed to define treatment effects in biostimulatory facial rejuvenation [15](#ref-15). - **Thick skin:** postoperative isotretinoin after thick-skinned rhinoplasty may improve satisfaction at three and six months, but this often declines by 12 months [21](#ref-21). - **Implants:** patients with suspected breast implant illness should be told that BII lacks diagnostic criteria and has multiple treatment options [22](#ref-22). - **Travel care:** weak regulation and inconsistent standards in cosmetic tourism create informed-consent and health-equity risks that can affect postoperative outcomes [14](#ref-14). ### Psychosocial Counselling Surgery can change anatomy, but it cannot reliably resolve identity, relationships, social status, or psychological distress. - **Expectation mismatch:** ask what outcome would disappoint the patient despite technical success. - **BII symptoms:** arthralgia and fatigue are commonly reported in breast implant illness literature [22](#ref-22). - **Explant counselling:** symptoms are frequently alleviated after en bloc explantation or capsulectomy, but planning must remain individualised [22](#ref-22). - **Minors:** counselling should test whether the intervention supports long-term well-being rather than a transient response to digital pressure [10](#ref-10). --- ## References **\[1\]** Wengle. The psychology of cosmetic surgery: old problems in patient selection seen in a new way--Part II.. Annals of plastic surgery. 1986\. doi:10.1097/00000637-198606000-00006 **\[2\]** Nestor et al.. Treatment options for androgenetic alopecia: Efficacy, side effects, compliance, financial considerations, and ethics.. Journal of cosmetic dermatology. 2021\. doi:10.1111/jocd.14537 **\[3\]** Bijlard et al.. Intralesional cryotherapy versus excision and corticosteroids or brachytherapy for keloid treatment: study protocol for a randomised controlled trial.. Trials. 2013\. doi:10.1186/1745-6215-14-439 **\[4\]** Ferreira et al.. Is There Scientific Evidence on the Practice of Rib Resection or Remodeling for Body Contouring Purposes?-A Systematic Review\\.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-025-04685-3 **\[5\]** Spriggs et al.. Body Dysmorphic Disorder: Contraindication or Ethical Justification for Female Genital Cosmetic Surgery in Adolescents.. Bioethics. 2018\. doi:10.1111/bioe.12278 **\[6\]** Jin et al.. Surgical Decision Making in Incisional Blepharoplasty in Asians.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-025-05427-1 **\[7\]** Signorini et al.. Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence- and Opinion-Based Review and Consensus Recommendations.. Plastic and reconstructive surgery. 2016\. doi:10.1097/PRS.0000000000002184 **\[8\]** Nichol et al.. Decision-making about bariatric and cosmetic medical tourism from countries with universal healthcare: a rapid systematic review\\.. Globalization and health. 2026\. doi:10.1186/s12992-026-01207-x **\[9\]** Galimberti et al.. Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications.. Breast (Edinburgh, Scotland). 2017\. doi:10.1016/j.breast.2017.06.034 **\[10\]** M. et al.. Social Media, Adolescent Aesthetic Pressures, and Ethical Decision-Making in Pediatric Plastic Surgery. Journal of Craniofacial Surgery. 2026\. doi:10.1097/SCS.0000000000013090 **\[11\]** Veale et al.. Psychological characteristics and motivation of women seeking labiaplasty.. Psychological medicine. 2014\. doi:10.1017/S0033291713001025 **\[12\]** Azmoude et al.. Female genital cosmetic procedures from the perspective of health practitioners: a systematic review of knowledge, attitude and practice studies.. BMC women's health. 2024\. doi:10.1186/s12905-024-03439-8 **\[13\]** Yan et al.. Psychological Disorders Are a Non-negligible Factor in Medical Aesthetic Disputes.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-025-04940-7 **\[14\]** Foley et al.. Patient care without borders: a systematic review of medical and surgical tourism.. Journal of travel medicine. 2019\. doi:10.1093/jtm/taz049 **\[15\]** Fisher et al.. The emerging role of biostimulators as an adjunct in facial rejuvenation: A systematic review\\.. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2024\. doi:10.1016/j.bjps.2024.02.069 **\[16\]** De et al.. Effect of a Multimedia-Assisted Informed Consent Procedure on the Information Gain of Patients Undergoing Mastectomy and Implant-Based Reconstruction.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-025-05493-5 **\[17\]** Deckert et al.. Facilitators and barriers to the use of a personalised digital decision aid in total knee replacement consultations: insights from patients and orthopaedic surgeons - an interview study.. BMC health services research. 2025\. doi:10.1186/s12913-025-13351-y **\[18\]** Bracale et al.. The Italian national consensus conference on the diagnosis and treatment of Rectus Abdominis diastasis in Post-gravidic Women.. Hernia : the journal of hernias and abdominal wall surgery. 2025\. doi:10.1007/s10029-025-03403-x **\[19\]** Nogueira et al.. Machine Learning, Deep Learning, Artificial Intelligence and Aesthetic Plastic Surgery: A Qualitative Systematic Review\\.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-024-04421-3 **\[20\]** Atiyeh et al.. Aesthetic/Cosmetic Surgery and Ethical Challenges.. Aesthetic plastic surgery. 2020\. doi:10.1007/s00266-020-01821-z **\[21\]** Rammal et al.. Benefits and Safety of Isotretinoin in Rhinoplasty for Thick-Skinned Patients: A Systematic Review\\.. Aesthetic plastic surgery. 2026\. doi:10.1007/s00266-025-05324-7 **\[22\]** Alabdulkarim et al.. Comprehensive Systematic Review of Breast Implant Illness: Symptoms, Management, and Long-Term Outcomes.. Aesthetic plastic surgery. 2025\. doi:10.1007/s00266-024-04129-4 ### After You Submit, 3 Research Concerns, & Can Your Study Be Reproduced? URL: https://www.theplasticsfella.com/july-19th/ Last updated: 2026-07-19T02:36:05.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/july-19th/#a-letter-from-pfella) What actually happens after you press submit? 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-19th/#image-of-the-week) The 1984 description of the ALT Flap 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/july-19th/#technique-tip) Guide: Research methods in plastic surgery 4. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/july-19th/#how-i-operate) Not all muscle flaps behave the same 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-19th/#what-does-the-evidence-say) Could someone reproduce your study? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-19th/#articles-of-the-week) Research in plastic surgery 7. 💕 [****Feedback**](https://www.theplasticsfella.com/july-19th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **What Actually Happens After You Press Submit?* 👋 Research is one of those things medicine seems to expect you to learn by osmosis. You find a question, choose a method, collect the data, write it up, and then press submit. From that point onwards, most of the process is happening somewhere you can’t see. From the outside, the editorial process can feel like a black box. One paper is rejected before it reaches peer review, while another gets sent out. Reviewer comments can point in completely different directions. A project you’ve spent months on can come back with a two-line decision, and you have no way of knowing whether the problem was the research, the writing, or simply that it wasn’t the right fit for the journal. The strange thing is that we spend years learning how to *write* papers, but very little time understanding how they're actually *read*. We learn study design, statistics, and reporting guidelines, but almost nobody explains what an editor is looking for when a manuscript lands on their desk. What makes them keep reading? What makes them decide, within a few minutes, that a paper isn't the right fit? At what point does a reviewer become involved, and how much influence do they really have on the final decision? Those are the parts of research that most people only learn through trial and error. Most of us spend our time trying to become better authors, but I've come to realize that understanding the perspective of an editor is probably just as valuable. It might not guarantee publication, but it might help you write a stronger paper before you even press submit. **That's why we’re planning a podcast recording with journal editors (we will soon reveal who they are!) to open that process up a little.** I wouldn't want it to become a polite conversation about just impact factors and publication numbers. The goal is to ask the practical questions that need to be brought to light. We want to understand the decisions that happen before reviewer comments arrive, the common mistakes authors make, and the things that journals wish more researchers knew. So, I’d like you to use this opportunity to ask the questions you actually care about when it comes to research. What would you ask the person on the other side of the process? P’Fella ❤️ ## Image of the Week **The 1984 Description of the Anterolateral Thigh (ALT) Flap* 🖼️ ****Image of the Week** This week's image is from Song et al.’s original 1984 description of the anterolateral thigh (ALT) flap. At the time, this was a hypothesis that reliable skin flaps could be based on these perforators without sacrificing muscle. What’s striking is how this single anatomical observation evolved into one of the most versatile flaps in modern microsurgery. Today, the ALT flap is used routinely for soft tissue reconstruction across the body. Most impactful papers don’t begin with complex trials. They start with an observation, a clear anatomical insight, and the willingness to question existing dogma. This is what publishing in plastic surgery often looks like at its best: 👉 See something others haven’t 👉 Define it clearly 👉 Show how it changes practice ![The original ALT flap paper](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/Screenshot-2026-07-17-at-01.26.01.png) [The original ALT flap paper](https://www.jprasurg.com/article/0007-1226%2884%2990002-X/pdf?ref=theplasticsfella.com) ## Technique Tip **Research Methods in Plastic Surgery* 🚑 ****Technique Tip of the Week** Great research starts long before data collection. Choosing the right study design, understanding bias, selecting appropriate outcome measures, and critically appraising the literature are all essential skills for producing meaningful, publishable work. This week's technique tip highlights our ****Research Methods in Plastic Surgery** guide. This is a practical resource covering study designs, systematic reviews, patient-reported outcome measures (PROMs), qualitative research, and evidence appraisal. [Research Methods in Plastic Surgery: Study Designs, PROMs, & Evidence AppraisalThis article summarises observational and experimental study designs, RCTs, systematic reviews/meta-analyses, PROMs, qualitative methods, and bias-appraisal tools; highlights registries, collaborative networks, and priority-setting to boost evidence quality in plastic surgery.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/Logo-Small-2-10fe7c9e-9a10-43e5-bd84-551c10ca6b69.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/Untitled-design--20--87214034-cca3-45bb-b0eb-e4f758299637.png)](https://www.theplasticsfella.com/research-methods-in-plastic-surgery/) ## How I Operate **Not All Muscle Flaps Behave the Same* In this clip from ****How I Operate**, Professor Foad Nahai walks through the logic behind the ****Mathes & Nahai classification**. From Type I muscles with a single dominant pedicle, to Type IV muscles with segmental blood supply, and finally Type V. Type V is where things get especially interesting: a major pedicle with secondary segmental pedicles, allowing the muscle to be turned over or rotated in different ways. Rather than just memorising types, the classification was built to understand vascular anatomy well enough to make muscle flaps safer, more reliable, and more useful. 0:00 /0:55 1× Prof. Foad Nahai on How I Operate [Listen Now](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## What Does the Evidence Say? **Could Someone Reproduce Your Study?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. A paper is not fully useful if another researcher cannot understand exactly how it was conducted. Yet reproducibility remains uncommon in plastic surgery literature. In an analysis of empirical studies published across 12 plastic surgery journals, ****97% had no data-availability statement**, only ****3.4%** linked to an accessible protocol, ****2%** were preregistered, and none provided their analysis scripts. Only ****8.4%** included a statement explaining whether study materials were available. More recent evidence suggests that the problem persists. Among 727 original articles published in seven leading plastic surgery journals, only ****1.5% included a data-sharing statement**, and stated availability did not necessarily translate into data being provided when requested. Patient confidentiality and consent can limit what clinical researchers are able to share, but reproducibility does not always require publishing an identifiable dataset. A clear protocol, precise eligibility criteria, detailed outcome definitions, a complete statistical plan, and transparent reporting of any deviations can still allow readers to scrutinise and build on the work. The practical lesson begins before submission. Authors should select the relevant reporting guideline, such as ****CONSORT, STROBE, PRISMA, or CARE** while planning the study, rather than treating it as a final checklist. Where appropriate, protocols and analyses should be preregistered, and deidentified data, materials, and code should be shared when ethical and feasible. The goal is not simply to get the paper accepted. It is to leave enough of a research trail that someone else could understand, test, and extend its findings. ([Ascha](https://journals.lww.com/plasreconsurg/abstract/10.1097/prs.0000000000005784~the-importance-of-reproducibility-in-plastic-surgery?ref=theplasticsfella.com), 2019); ([Ascha](https://europepmc.org/article/MED/35196293?ref=theplasticsfella.com), 2022); ([Keefer](https://pmc.ncbi.nlm.nih.gov/articles/PMC12061464/?ref=theplasticsfella.com), 2025); ([Douglas](https://www.equator-network.org/wp-content/uploads/2016/12/AltmanSimera-Chapter-4-Guidelines-for-Reporting-Health-Research-A-Users-Manual.pdf?ref=theplasticsfella.com), 2014); ([Becker](https://journals.lww.com/plasreconsurg/abstract/10.1097/prs.0b013e31829fe0f7~evidence-based-plastic-and-reconstructive-surgery?ref=theplasticsfella.com), 2013) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Patient-Reported Outcomes in Plastic Surgery Are Underreported, Not Underused**](https://www.jprasurg.com/article/S1748-6815%2824%2900576-X/abstract?ref=theplasticsfella.com) Plastic surgery RCTs frequently include patient-reported outcomes, but report less than 40% of CONSORT-PRO criteria, meaning patient perspectives are often captured but not clearly or reliably communicated for clinical use. ✅ [****Journal Access Is a Hidden Barrier to Global Plastic Surgery Research**](https://www.jprasurg.com/article/S1748-6815%2825%2900632-1/fulltext?ref=theplasticsfella.com) Half of surgeons in LMICs struggle to access journals, with paywalls, poor institutional access, and cost limiting both research output and the ability to stay clinically up to date. ✅ [****Plastic Surgery Research Priorities May Miss Key Voices**](https://www.jprasurg.com/article/S1748-6815%2822%2900582-4/fulltext?ref=theplasticsfella.com) Most research priorities are set in high-income settings with limited patient and multidisciplinary input, raising concerns that funded research may not reflect real clinical needs or global disease burden. ## Feedback ### I hope you enjoyed it 😄 --- ### Foad Nahai on How I Operate, 5 Flap Concepts, & Ideas That Changed Our Specialty URL: https://www.theplasticsfella.com/july-12th/ Last updated: 2026-07-12T10:21:45.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/july-12th/#a-letter-from-pfella) The ideas that change how we work 2. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/july-12th/#how-i-operate) Episode 2 releasing tomorrow! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-12th/#image-of-the-week) Latissimus Dorsi: Type V in action 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/july-12th/#technique-tip) Gracilis myocutaneous free flap harvest 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-12th/#what-does-the-evidence-say) Reverse-flow flaps: Why the vein matters most 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-12th/#articles-of-the-week) Perforator flaps & the lower trapezius musculocutaneous flap. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/july-12th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Ideas That Change How We Work* 👋 Most papers have a shelf life. They get read, cited a few times, maybe shape a bit of practice, and then drift into the background with time. A few do something else entirely. They stop being just papers and become part of the way a specialty thinks. That’s what happened with Mathes and Nahai. At some point, it just became the language people use when they talk about muscle flaps. Type I. Type II. Type V. Dominant pedicle. Secondary segmental supply. Once an idea starts doing that, it’s no longer just living on the page. What’s interesting is that this usually doesn’t happen because the underlying subject is simple. Muscle vascular anatomy isn’t simple. Flap behaviour isn’t simple. What lasts is when someone manages to take something complicated and present it in a way that's simple enough for most to grasp. A lot of clever ideas get dismissed because a majority can't carry them. They’re too messy, too buried in detail, too badly explained, or too difficult to teach. The ideas that survive are the ones that break down the complexity, instead of making it even more complex. The Mathes and Nahai publication gave surgeons a framework they could actually use. You could teach it, test it against real anatomy, and apply it in theatre. You could explain why the latissimus behaves one way and the gracilis another. You could predict what changes when the pedicle changes. The contribution wasn't simply discovering something, it was figuring out the way to break it down in a way for everyone to understand When it comes to lasting concepts in surgery, it’s not only about whether the idea was right, although that obviously is the key thing. An idea needs to be communicated clearly enough, taught well enough, and built simply enough that those who come after you could pick it up and actually use it. Otherwise, good ideas might stay trapped with the people who first discovered them. We’re releasing my conversation with **Professor Foad Nahai** tomorrow, and it’s really about where one of those rare ideas came from. Not just the anatomy, but the thinking, the presentation, and why it managed to last. If you haven’t already subscribed, [keep an eye out for it tomorrow](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com)! P’Fella ❤️ ## How I Operate **Episode 2 Releasing Tomorrow!* Our next episode of ****How I Operate** comes out this Monday, featuring ****Professor Foad Nahai**, co-creator of the ****Mathes & Nahai classification**. More than 40 years after its publication, the classification remains one of the core frameworks in plastic surgery training. In this conversation, Professor Nahai reflects on the ****anatomy lab work**, ****clinical problems**, and ****collaboration with Dr Stephen Mathes** that led to a system still used to understand muscle flap vascular anatomy today. Stay tuned for Monday’s release! 0:00 /0:59 1× How I Operate - Episode 2 [Subscribe & Stay Tuned](https://howioperatie.transistor.fm/subscribe?ref=theplasticsfella.com) ## Image of the Week **Latissimus Dorsi: Type V in Action* 🖼️ ****Image of the Week** This week's image is from the original Mathes and Nahai publication, illustrating the principle that ****blood supply** determines what a flap can do. The ****latissimus dorsi** is a ****Type V** muscle with one dominant pedicle (thoracodorsal) and additional segmental perforators. The diagrams highlight the key idea: ****change the pedicle, and you change the arc of rotation**. This is what makes the reverse latissimus possible. The operative image reinforces that preserving segmental vessels creates options when the main pedicle isn’t usable. This is the core of the classification: ****predicting how far a flap can safely reach, and under what conditions**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/Screenshot-2026-01-23-at-17.15.51.png) Latissimus Dorsi Flap - Source: Mathes and Nahai, 1981 ## Technique Tip **Gracilis Myocutaneous Free Flap Harvest* 🚑 ****Technique Tip of the Week** The ****gracilis** is a classic ****Mathes & Nahai Type II** muscle flap, supplied by a single dominant vascular pedicle with additional minor pedicles. Its reliable anatomy, long pedicle, and minimal donor-site morbidity make it a versatile option for free tissue transfer in head and neck, perineal, and extremity reconstruction. This operative video demonstrates the key steps of ****gracilis flap harvest**, including muscle identification, pedicle dissection, preservation of the skin paddle, and flap elevation. ## What Does the Evidence Say? **Reverse-Flow Flaps: Why the Vein Matters Most* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Reverse-flow flaps are a useful reminder that flap reliability is not always dictated by the “dominant” pedicle alone. We usually think in terms of named vascular territories and major pedicles, but reverse-flow flaps show that ****distal communications and secondary inflow can be clinically usable**, provided venous outflow is respected. Classic anatomic and clinical work on reverse-flow island flaps showed that retrograde arterial perfusion is possible, but that the real challenge is ****how venous blood escapes against venous valves**. Cadaveric studies of the deep venous system suggested that simple macrovenous bypass channels are often insufficient on their own, helping explain why venous congestion has always been the issue in reverse-flow designs. Reverse-flow flaps opened up reconstructive options without microsurgical transfer or sacrifice of a major axial vessel. Studies have shown that the reverse-flow posterior tibial artery island flap can be a reliable option for foot defects, supporting the idea that reverse perfusion can be dependable in carefully selected cases. The ****distally based superficial sural flap** then became a major workhorse for the distal third of the leg, ankle, and heel, precisely because it exploits this same reverse-flow principle through peroneal perforators and the sural vascular axis. While reverse-flow flaps do not “break” vascular rules, they depend on understanding them more deeply, especially the balance between ****retrograde inflow and precarious venous return**. ([Torii](https://journals.lww.com/plasreconsurg/abstract/00006534-198704000-00015~reverse-flow-island-flap-clinical-report-and-venous-drainage?ref=theplasticsfella.com), 1987); ([del Pinal](https://www.jprasurg.com/article/0007-1226%2893%2990195-H/fulltext?ref=theplasticsfella.com), 1993); ([Liu](https://pubmed.ncbi.nlm.nih.gov/2367580/?ref=theplasticsfella.com), 1990); ([Hasegawa](https://europepmc.org/article/MED/8134458?ref=theplasticsfella.com), 1994); ([Almeida](https://europepmc.org/article/MED/11818840?ref=theplasticsfella.com), 2002) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Perforator Flaps: Classification and Applications**](https://www.ovid.com/jnls/annalsplasticsurgery/abstract/00000637-200301000-00016~perforator-flaps-evolution-classification-and-applications?ref=theplasticsfella.com) Perforator flaps achieve reliable reconstruction while minimising donor site morbidity by preserving muscle, but require precise anatomical understanding and careful perforator selection to maximise their versatility and outcomes. ✅ [****Direct vs Indirect Perforators: A Simpler Way to Think About Flaps**](https://journals.lww.com/plasreconsurg/abstract/10.1097/01.prs.0000040462.38363.c7~direct-and-indirect-perforator-flaps-the-history-and-the?ref=theplasticsfella.com) All perforator flaps can be reduced to a simple principle of vascular anatomy, with reliability determined by whether the perforator reaches the skin directly or indirectly, guiding flap design and predicting outcomes. ✅ [****Lower Trapezius Flap: Long Pedicle with Reliable Supply**](https://journals.lww.com/plasreconsurg/abstract/10.1097/01.prs.0000117188.03152.10~the-lower-trapezius-musculocutaneous-flap-from-pedicled-to?redirectionsource=fulltextview&ref=theplasticsfella.com) The lower trapezius musculocutaneous flap offers a long, consistent pedicle via the dorsal scapular artery with low donor morbidity, but requires precise anatomical understanding to safely extend its arc of rotation or use it as a free flap. ## Feedback ### I hope you enjoyed it 😄 --- ### Pushing the Limits of Microsurgery, 5 Reconstructive Strategies, & How I Operate Is Live URL: https://www.theplasticsfella.com/july-5th/ Last updated: 2026-07-05T08:25:55.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/july-5th/#a-letter-from-pfella) Pushing the limits of microsurgery 2. 🎓 [****Building in Public**](https://www.theplasticsfella.com/july-5th/#building-in-public) Weekly updates and behind-the-scenes on Instagram 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-5th/#image-of-the-week) AV loops in limb reconstruction 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/july-5th/#technique-tip) Chimeric ALT musculocutaneous free flap 5. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/july-5th/#how-i-operate) Episode 1 is out now! 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-5th/#what-does-the-evidence-say) Double venous anastomosis in free flaps 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-5th/#articles-of-the-week) MSAP flap, one-stage limb reconstruction, & AV loops 8. 💕 [****Feedback**](https://www.theplasticsfella.com/july-5th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Pushing The Limits of Microsurgery* 👋 Lately, I've been thinking a lot about the mindset of a very small group of microsurgeons in the world. Not just people who can do difficult cases, because there are plenty of technically excellent surgeons. I mean the ones who seem to keep moving the boundary of what microsurgery can actually do. The ones who look at a case most people would file under “too difficult”, “too damaged”, or “not sensible”, and instead of reacting emotionally, they just start breaking the problem down properly. Tissue. Vessels. Timing. Sequence. Function. What is the real limitation here? And which part of it can actually be changed? I find this super interesting. It doesn’t feel like bravado when you hear them speak. In fact, it’s usually the opposite. They sound calmer than everyone else. Less dramatic. More stripped back. The deeper you go into their thinking, the more it comes back to the same things: anatomy, planning, repetition, respect for blood supply, and a willingness to stay with a problem longer than most people would. A lot of the time, what looks extreme from the outside is actually just first-principles thinking taken very seriously. The conversations I have during our podcast recordings have been eye-opening for me. We recently released our episode with **JP Hong**, and what stayed with me afterwards was not just the SCIP flap itself, but the mindset of experts who shaped these techniques. The refinement and the discipline. The way a good idea gets made dependable. I'm also halfway through recording with another microsurgery expert, Pedro Cadavas, and it’s been fascinating. Once you get past the surface in these conversations, what’s underneath is a very clear internal logic about what is possible, what is sensible, and what should be left alone. That is the part worth studying. Not just the operation, but the way of thinking that follows it. Because if microsurgery is going to keep moving forward, it probably won’t happen through noise or theatrics. It’ll come from a small number of people who understand the fundamentals so well that they know exactly when they can be stretched. If you haven’t listened to our podcast episode with **JP Hong** yet, [check it out on your preferred platform](https://pod.link/1746377600?ref=theplasticsfella.com)! And if there’s something specific you’d like us to ask **Pedro Cavadas** while we’re still recording, send it over. We’d love to hear it. P’Fella ❤️ ## Building in Public **Weekly Updates and Behind-the-Scenes on Instagram* This has been a long time coming, mostly because I refused to get on Instagram for years. But I’ve finally given in. To see the more informal side of things like bits from the podcast, weekly updates, and some behind-the-scenes stuff from what we’re building at the P'Fella, you can [find me here](https://www.instagram.com/sugrue%5F?utm%5Fsource=ig%5Fweb%5Fbutton%5Fshare%5Fsheet&igsh=ZDNlZDc0MzIxNw==). ## Image of the Week **AV Loops in Limb Reconstruction* 🖼️ ****Image of the Week** This week's image features the use of an arteriovenous (AV) loop; A strategy used when local recipient vessels are unavailable or unsuitable. In complex limb trauma, vessel injury, scarring, or prior surgery can leave no reliable targets for microsurgical anastomosis. Here, a vein graft is used to create a temporary ****artery-to-vein loop**, establishing a new vascular conduit outside the zone of injury. This loop can then be divided and used as recipient vessels for free tissue transfer, either immediately or in a staged approach. 👉 When recipient vessels don’t exist, ****create them**. ![AV Loops in Limb Recon](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/07/medicina-56-00632-g011-1.png) AV Loops in Limb Recon - [Source](https://www.mdpi.com/1648-9144/56/11/632?ref=theplasticsfella.com) ## Technique Tip **Chimeric ALT Musculocutaneous Free Flap* 🚑 ****Technique Tip of the Week** Complex defects often require more than skin alone. The ****chimeric anterolateral thigh (ALT) flap** combines separate skin and muscle components supplied by branches of the same vascular pedicle, allowing each tissue element to be positioned independently. This makes it particularly valuable for three-dimensional reconstruction of composite head and neck, lower limb, and traumatic defects. This video demonstrates harvest of a chimeric ALT musculocutaneous flap, highlighting perforator identification, intramuscular dissection, preservation of independent tissue components, and flap elevation. ## How I Operate **Episode 1 Is Out Now!* The first episode of ****How I Operate** is now live. In this episode, we are joined by ****Professor JP Hong** for a deep dive into the ****SCIP flap**: from its evolution as a modification of the groin flap to the anatomical principles, technical refinements, and decision-making that helped make it a reconstructive workhorse. We discuss perforator anatomy, flap reliability, ultrasound planning, when to use the SCIP flap, when not to use it, and how small, deliberate refinements can change the way an operation is taught and performed. [Available Now!](https://pod.link/1746377600?ref=theplasticsfella.com) ## What Does the Evidence Say? **Double Venous Anastomosis in Free Flaps* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. One of the practical ways microsurgery has pushed its own limits is by trying to make free flaps more reliable at the level that most often fails: ****venous outflow**. Across the literature, the balance of evidence suggests that performing ****two venous anastomoses instead of one** can reduce flap failure, venous thrombosis, and unplanned re-exploration overall. That said, the benefit is not universal in every setting. Systematic reviews support dual venous drainage as a general protective strategy, particularly in head and neck reconstruction, but lower-extremity evidence is more mixed and does not show the same clear reduction in complications across all studies. A second vein is best understood as a way to improve reliability ****when it is technically feasible and meaningfully adds drainage**, rather than as a rule for every flap. The takeaway is not that simply “two is always better.” It is that venous compromise remains one of the main reasons free flaps fail, and building robust outflow at the first operation is often easier than trying to salvage congestion later. ([Sánchez-Moreno](https://pubmed.ncbi.nlm.nih.gov/42203589/?ref=theplasticsfella.com), 2026); ([Christianto](https://pubmed.ncbi.nlm.nih.gov/29395670/?ref=theplasticsfella.com), 2018); ([Kim](https://www.jwmr.org/journal/view.php?doi=10.22467%2Fjwmr.2020.01410&ref=theplasticsfella.com), 2021); ([Matthews](https://pmc.ncbi.nlm.nih.gov/articles/PMC5967168/?ref=theplasticsfella.com), 2017); ([Riot](https://pubmed.ncbi.nlm.nih.gov/26595023/?ref=theplasticsfella.com), 2015) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****The MSAP Flap: Thin, Long Pedicle, Low Morbidity**](https://www.ovid.com/jnls/plasreconsurg/abstract/00006534-200111000-00027~the-medial-sural-artery-perforator-free-flap?ref=theplasticsfella.com) The medial sural artery perforator flap provides a thin, pliable tissue option with a long, reliable pedicle and minimal donor site morbidity, but requires meticulous intramuscular dissection and precise perforator selection to succeed consistently. ✅ [****One-Stage Limb Reconstruction: Bone and Soft Tissue in a Single Move**](https://journals.lww.com/plasreconsurg/abstract/2004/11000/one%5Fstage%5Freconstruction%5Fof%5Fcomposite%5Fbone%5Fand.13.aspx?ref=theplasticsfella.com) One-stage vascularised bone and soft tissue reconstruction can achieve high union rates and reliable limb salvage in complex lower extremity trauma, reducing the need for staged procedures when meticulous debridement and appropriate flap selection are performed. ✅ [****AV Loops in Reconstruction: Creating Vessels Where None Exist**](https://journals.lww.com/plasreconsurg/abstract/2008/02000/arteriovenous%5Fvascular%5Floops%5Fin%5Ffree%5Fflap.20.aspx?ref=theplasticsfella.com) Arteriovenous loops enable free flap reconstruction in vessel-depleted extremities with high success rates, with one-stage loops showing lower thrombosis risk than delayed two-stage approaches. ## Feedback ### I hope you enjoyed it 😄 --- ### How I Operate: Releasing Tomorrow, 3 SCIP Decisions, & Flap Failure URL: https://www.theplasticsfella.com/june-28th/ Last updated: 2026-06-28T06:52:51.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/june-28th/#a-letter-from-pfella) What consistently shows up in skilled surgeons 2. ****🎧** [****How I Operate**](https://www.theplasticsfella.com/june-28th/#how-i-operate) Episode one: Releasing tomorrow! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-28th/#image-of-the-week) Reconstruction determined by the defect 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/june-28th/#technique-tip) SCIP flap harvest 5. 🎓 [****Building in Public**](https://www.theplasticsfella.com/june-28th/#building-in-public) Catching up with the team 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/june-28th/#what-does-the-evidence-say) Venous congestion in free flaps 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-28th/#articles-of-the-week) Supermicrosurgery in lower limb, predict free flap failure, & MSAP flap 8. 💕 [****Feedback**](https://www.theplasticsfella.com/june-28th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **What Consistently Shows Up in Skilled Surgeons* 👋 One thing I’ve noticed from doing the podcast recordings is that, when you speak to people who are genuinely very good, the same patterns keep coming up. **They reply to emails quickly. And at some point in their training, they’ve usually had proper cadaver exposure. That's it.** The first one sounds small, but it tells you a lot. People who are organised, switched on, and serious about their work tend to move quickly. It’s not about trying to impress anyone. It usually comes from simple habits around being reliable. The second one feels even more important. Again and again, when I speak to surgeons whose understanding feels really deep, not just technically good but properly three-dimensional, cadaver work is somewhere in the background. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/Screenshot-2026-06-28-at-12.22.18.png) [Subscribe Today](https://pod.link/1746377600?ref=theplasticsfella.com) That makes sense, really. There are some things you can’t learn properly from slides, or diagrams, or even theatre alone. Cadaver labs give you time. Time to slow down. Time to see where things actually sit. Time to make mistakes without consequence. Time to understand anatomy with your hands, not just your eyes. And the more I think about it, the more I feel this is one of the areas we’re starting to lose. Access to cadaver labs feels harder now than it should be. Costs, rules, legislation, and logistics all play a part, and what should be a core part of surgical training can end up feeling rare or out of reach. That’s a shame, and it’s something we shouldn’t just accept. If we’re serious about training people well, then we should be trying to bring that access back, not letting it slowly disappear. We talk about this a bit in some of the upcoming [podcast](https://pod.link/1746377600?ref=theplasticsfella.com) episodes as well. A few of the people I’ve spoken to make this point in their own way, and it’s interesting how often it comes back to the same thing: the best surgeons usually didn’t just read anatomy. They spent time with it. And on that note, the podcast drops tomorrow. We’ve spoken to some really interesting and influential people in plastics, and we’re super excited for you to check it out. [Check it out on your preferred platform](https://pod.link/1746377600?ref=theplasticsfella.com)! P’Fella ❤️ ## How I Operate **Episode One: Releasing Tomorrow!* Loved recording our first episode and it will be released tomorrow. We cover the SCIP flap, microsurgery, and why SCIP has become a modern reconstructive workhorse, replacing the ALT flap in up to 85% of cases in some practices. 0:00 /2:31 1× Episode One Trailer: Releasing Tomorrow! 🎙️ ****When to use the SCIP Flap:** \- Lymph node transfer: Especially for upper limb lymphoedema \- Ultra-thin reconstruction: Ideal for the dorsum of the hand or foot \- Facial contouring: Useful when submental or supraclavicular options are unavailable [Listen Tomorrow!](https://pod.link/1746377600?ref=theplasticsfella.com) ## Image of the Week **Reconstruction Determined by the Defect* 🖼️ ****Image of the Week** **The reconstruction is determined by the defect, not the other way around.* We see a traumatic thumb defect with exposed structures, followed by ****preoperative flap design on the forearm**, elevation of a fasciocutaneous flap, inset, and final functional outcome. The key step isn’t the anastomosis, it’s the ****planning**: selecting tissue with the right thickness, vascularity, and arc of rotation to restore both contour and function. This reflects a shift in modern microsurgery, moving beyond “can we do a free flap?” to “what is the best reconstructive option for this specific defect?” The end result demonstrates what good planning achieves: in addition to survival of the flap, durable coverage, preserved length, and functional recovery. ![post traumatic arthritis to the dorsum of the non-dominant left little finger](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/medicina-58-01065-g004b.png) Post traumatic arthritis to the dorsum of the non-dominant left little finger - [Source](https://www.mdpi.com/1648-9144/58/8/1065?ref=theplasticsfella.com) ## Technique Tip **SCIP Flap Harvest* 🚑 ****Technique Tip of the Week** The SCIP (Superficial Circumflex Iliac Artery Perforator) flap is a versatile, thin perforator flap with minimal donor-site morbidity. This cadaveric demonstration highlights the key anatomical landmarks, identification of the medial and lateral perforators, and elevation of the flap in the superficial fascial plane. A valuable insight from the video is to ****identify the perforators before committing to pedicle dissection**. Assessing perforator size, course, and venous drainage early allows the surgeon to select the most suitable pedicle and tailor the flap to the reconstructive requirements. 🎙️ ****Releasing Tomorrow: How I Operate** Professor JP Hong will be the first guest on our new "How I Operate" podcast series. Join us as we discuss the evolution of the SCIP flap, including flap design, perforator selection, harvest techniques, and the principles. [Subscribe and stay tuned](https://pod.link/1746377600?ref=theplasticsfella.com)! ## Building in Public **Catching Up with the Team* Each month, we catch up as a team to reflect, challenge ideas, and think out loud about where The Plastics Fella is heading next. This month’s conversation focused on building the systems and infrastructure that will allow the platform to grow into more specialised departments, without losing the values that got us here. Different countries, different training systems, different perspectives, but the same shared goal: to build the best possible educational product for plastic surgery. ![On-Call Team - Cosmetics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/Screenshot-2026-06-27-at-19.56.32-1.png) On-Call Team - Cosmetics ## What Does the Evidence Say? **Venous Congestion in Free Flaps* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. In microsurgery, the problem to anticipate is often venous outflow, not arterial inflow. Across the flap literature, venous compromise is repeatedly identified as a common cause of re-exploration and failure, and the key practical message is that flap loss is not always an immediate all-or-none event. Some flaps deteriorate progressively, which is why early recognition and rapid return to theatre matter. The evidence also suggests that prevention is more reliable than rescue. In pooled analyses, ****double venous anastomosis** has been associated with ****lower flap failure and fewer venous complications overall**, although this benefit is not uniform across every setting and appears less clear in lower-limb reconstruction specifically. Once venous congestion occurs, the best-supported first step remains ****surgical revision** to restore mechanical outflow. Beyond that, the evidence for adjuncts is much weaker: systematic review data suggest that, of the nonsurgical options, ****medicinal leeches** have the strongest clinical support, whereas other measures remain supported mainly by low-level evidence. The practical takeaway is simple. ****Build reliable venous drainage at the index operation, and treat postoperative congestion as a time-critical surgical problem.** Sources: ([Riot](https://journals.lww.com/plasreconsurg/abstract/2015/12000/a%5Fsystematic%5Freview%5Fand%5Fmeta%5Fanalysis%5Fof%5Fdouble.26.aspx?ref=theplasticsfella.com), 2015); ([Boissiere](https://journals.lww.com/prsgo/fulltext/2021/01000/Flap%5FVenous%5FCongestion%5Fand%5FSalvage%5FTechniques%5F%5FA.37.aspx?ref=theplasticsfella.com), 2021); ([Weinzweig](https://pubmed.ncbi.nlm.nih.gov/7638289/?ref=theplasticsfella.com), 1995); ([Matthews](https://pmc.ncbi.nlm.nih.gov/articles/PMC5967168/?ref=theplasticsfella.com), 2017); ([Kubo](https://europepmc.org/article/MED/12497578?ref=theplasticsfella.com), 2002) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Supermicrosurgery in Lower Limb Reconstruction**](https://journals.lww.com/plasreconsurg/abstract/2009/01000/the%5Fuse%5Fof%5Fsupermicrosurgery%5Fin%5Flower%5Fextremity.30.aspx?ref=theplasticsfella.com) Perforator-to-perforator supermicrosurgery is a safe and efficient option for lower extremity reconstruction, offering high flap survival with less vessel morbidity but requiring advanced technical skill. ✅ [****Can We Predict Free Flap Failure Before It Happens?**](https://www.sciencedirect.com/science/article/pii/S1748681520304782?ref=theplasticsfella.com) Developing a practical risk index showing that comorbidities and defect etiology strongly predict vascular compromise and flap failure, to help surgeons stratify risk & guide reconstructive decision-making. ✅ [****Is the MSAP Flap the Ideal Thin Flap or a Venous Trap?**](https://link.springer.com/content/pdf/10.1007/s00238-015-1110-5.pdf?ref=theplasticsfella.com) The MSAP flap offers a thin, low-morbidity alternative to RFFF but carries a higher risk of late venous thrombosis, making vigilant monitoring and dual venous anastomoses critical for flap survival. ## Feedback ### I hope you enjoyed it 😄 --- ### Breast Reduction Planning, 3 Pedicle Decisions, & Podcast Sneak Peek URL: https://www.theplasticsfella.com/june-21st/ Last updated: 2026-06-21T12:13:31.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/june-21st/#a-letter-from-pfella) Why knowing something and teaching it are different skills 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-21st/#image-of-the-week) Blood supply to the nipple (intra-op pic) 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/june-21st/#technique-tip) How Elizabeth Hall-Findlay does breast reduction 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/june-21st/#building-in-public) Sneak peek: How I Operate 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/june-21st/#what-does-the-evidence-say) Superomedial vs inferior pedicle 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-21st/#articles-of-the-week) Wise pattern origin, vertical mammoplasty, & breast reduction by Elizabeth Hall-Findlay 7. 💕 [****Feedback**](https://www.theplasticsfella.com/june-21st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Why Knowing Something and Teaching It Are Different Skills* 👋 Often, we assume that if someone knows a subject well, they’ll automatically be good at teaching it. That's not always the case. You can spend years doing something, understanding it deeply, and still struggle to explain it in a way that makes sense to someone earlier on. That doesn’t mean you don’t know enough, but the things that feel obvious to you now aren't always obvious to everyone, especially if they're just getting started. Once you’ve lived with a subject for long enough, it’s very easy to forget where people actually struggle. That’s become much clearer while we’ve been working through articles and building our pilot Aesthetics Department. Quite a lot of good surgical knowledge starts off in a form that makes perfect sense to the person writing it, but not always to the person reading it. The steps are there, the facts are there, the logic is there somewhere too, but it still doesn’t quite teach. It doesn’t always show you where decisions have to be made in real life. It doesn’t always explain when and why something might be important. It also doesn’t help when you’re tired, or reading quickly, or trying to make sense of something you’ve only half understood before. This is why we care so much about reviewing and editing the articles, not just approving and publishing them. A piece can have all the accurate facts and technique breakdowns, and still not be very helpful. It can be technically correct and still leave the reader doing too much of the work. The difference usually comes down to a few things: Does the flow make sense? Is the explanation doing more than listing facts? Are the diagrams and images actually supporting the text? Is the key takeaway clear enough to stay with you after you close the page? Over the years of creating educational content, our team has come to understand teaching as its own skill. It takes thought, patience, honesty, and usually a few rounds of editing and refining before something really starts to land. That’s what we’re trying to build towards. Not just articles that are right, but articles that genuinely help people learn in a way that stays with them. **P’Fella ❤️** **P.S.** Two days ago, I had the privilege of speaking with one of the most influential plastic surgeons in breast surgery. We recorded the conversation and will be releasing it soon. In the meantime, here’s another technique-focused episode: [**SCIP Flaps**.](https://www.theplasticsfella.com/june-21st/#building-in-public) ## Image of the Week **Blood Supply the Nipple (Intra-Op Pic)* 🖼️ ****Image of the Week** The superomedial pedicle works because its key blood supply is superficial, not full thickness. A bulky dermoglandular pedicle may actually compress the vessels during inset. Thinning the pedicle allows safer positioning while preserving the dominant superficial vascular supply and improving breast shape. Ian Taylor’s anatomical insight helped define the superficial vascular basis of the true superomedial pedicle, supporting safe thinning and reliable nipple-areola perfusion. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/image.png) [Source](https://ajops.com/article/123942-breast-reduction-what-i-have-changed-over-the-years?attachment%5Fid=252106&ref=theplasticsfella.com) ## Technique Tip **How Elizabeth Hall-Findlay Does her Breast Reduction* 🚑 ****Technique Tip of the Week** Some techniques shape how an entire generation of surgeons operates. Dr Elizabeth Hall-Findlay walks through her superomedial pedicle vertical breast reduction technique, covering markings, pedicle design, breast shaping, and closure. Whether you're learning the operation for the first time or refining your current approach, there are practical pearls throughout. Source AJOPS/Elizabeth Hall-Findlay ## Building in Public **Sneak Peek: How I Operate* The diagrams below are from our upcoming podcast season: How I Operate. In this episode, we’ll be diving into the SCIP flap: how it became a workhorse option, where it fits best, and when it is not the right choice. In the upcoming season, we’ll have discussions with experts in plastic surgery about decision-making on the spot, technical details that matter, and the practical lessons that come from using certain techniques in real cases. Watch out on [Spotify](https://open.spotify.com/episode/76EpMfATZyXGqXvsfLgIIW?si=Tq%5FoZJHWTU-FH0rEiB1BaA&ref=theplasticsfella.com) for more snippets dropping soon! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/SOMETHING-EXCITING-IS-COMING-YOUR-WAY---1--1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/SOMETHING-EXCITING-IS-COMING-YOUR-WAY---2-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/SOMETHING-EXCITING-IS-COMING-YOUR-WAY---3-.png) Sneak Peek from How I Operate - New Podcast Season ## What Does the Evidence Say? **Superomedial vs Inferior Pedicle* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The most useful evidence question in breast reduction is not whether one pedicle is always “best,” but whether the superomedial pedicle’s ****anatomical logic translates into better clinical outcomes**. Imaging studies suggest that nipple-areola complex **(NAC) blood supply is commonly superomedial**, often from internal thoracic perforators, but they also show ****meaningful variation**, including asymmetry in hypertrophic breasts. That supports why superomedial techniques are attractive, while also explaining why pedicle choice still needs to be individualized in larger or higher-risk reductions. Clinically, the current evidence does ****not** show a universal winner. A recent meta-analysis found that ****superomedial pedicles** were associated with ****shorter operative time, lower infection rates, and higher BREAST-Q satisfaction**, but also with more **seroma** and more **decreased NAC sensation**, with ****no significant difference in NAC loss, fat necrosis, asymmetry, or hematoma** compared with inferior pedicles. A matched cohort study similarly found ****no significant difference in overall complication rates** between superomedial vertical-scar reduction and inferior-pedicle Wise-pattern reduction. In moderate-sized reductions, randomized evidence also suggests that ****vertical/medial-pedicle** techniques may produce **more acceptable scars**, but at the cost of ****more revisions** than Wise-pattern/inferior-pedicle reductions. Sources: ([Tanas](https://link.springer.com/article/10.1007/s00266-024-04389-0?ref=theplasticsfella.com), 2025); ([Antony](https://pmc.ncbi.nlm.nih.gov/articles/PMC3923626/pdf/nihms549765.pdf?ref=theplasticsfella.com), 2013); ([Cruz-Korchin](https://pubmed.ncbi.nlm.nih.gov/14578787/?ref=theplasticsfella.com), 2003); ([Seitz](https://bobresource.com/wp-content/uploads/2023/04/NAC-blood-supply-MRI.pdf?ref=theplasticsfella.com), 2015); ([Zheng](https://link.springer.com/article/10.1007/s00266-017-0791-5?ref=theplasticsfella.com), 2017) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****The Origin of the Wise Pattern Was a Bra**](https://annas-archive.pk/scidb/10.1097/00006534-195605000-00004/?ref=theplasticsfella.com) Wise’s technique shows that using brassiere measurements to guide markings improves symmetry, nipple positioning, and safe resection limits, while reducing flap necrosis and aesthetic unpredictability compared to freehand planning. ✅ [****Why Vertical Mammoplasty Replaced the Wise Pattern**](https://annas-archive.pk/scidb/10.1097/00006534-199407000-00010/?ref=theplasticsfella.com) Vertical mammoplasty with liposuction reshapes the breast through glandular suturing rather than skin, reducing scars, preserving vascularity and sensation, and improving long term shape stability. ✅ [****The Evolution of Breast Reduction Over 40 Years**](https://ajops.com/article/123942-breast-reduction-what-i-have-changed-over-the-years?ref=theplasticsfella.com) Elizabeth Hall-Findlay refines vertical reduction by prioritising a superomedial pedicle, parenchymal reshaping over skin tension, and removing inferior lateral excess to improve shape, safety, and long-term outcomes. ## Feedback ### I hope you enjoyed it 😄 --- ### LVA Technique, 3 Lymphatic Decisions, & Building the Next Department URL: https://www.theplasticsfella.com/june-14th/ Last updated: 2026-06-12T19:37:09.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/june-14th/#a-letter-from-pfella) Working on the next department 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-14th/#image-of-the-week) ICG lymphography patterns in early lymphatic dysfunction 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/june-14th/#technique-tip) Guide to Lymphaticovenous Anastomosis (LVA) 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/june-14th/#building-in-public) How I Operate: Releasing soon! 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/june-14th/#what-does-the-evidence-say) Reverse lymphatic mapping in VLNT 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-14th/#articles-of-the-week) ICG velocity, lymphedema pathophysiology, & dermal backflow patterns 7. 💕 [****Feedback**](https://www.theplasticsfella.com/june-14th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Working on the Next Department* 👋 A lot of our energy lately has been going into refining the Cosmetics Department, which means we’re now getting ready to launch our second: the Lymphovascular Department. The Cosmetics team has been a really eye-opening pilot for us because it’s shown us how building a department works in real life. Not just on a planning doc, but in the day-to-day process of taking an article and trying to make it educational, clear, and useful for trainees. That’s probably been the most helpful part so far. It’s shown us where the process already works, where it needs improvement, and what good collaboration actually looks like when everyone is working with the same goal in mind. A lot of that has come down to feedback. The On-Call Team has been keen from the start. Thoughtful, sharp, and willing to get past the surface. Good article review is not just about spotting what’s technically wrong. It’s about knowing how to make the teaching better. Benedetta Agnelli, our clinical lead, has played a big part in helping us put a proper system around that, so the feedback is honest, guided, and actually useful rather than generic and vague. At the same time, the Core Team has been working closely with the On-Call Team on how to improve the feedback itself, so the review process gets stronger and more consistent each round. That’s what gives us the best chance at publishing articles that don’t just say the right things, but teach them well. We’ve also been spending more time on the visual side of these articles, including clinical images, diagrams, guides, and other teaching aids. Those are often the bits that make something click more quickly. That part is still evolving, but it’s already changing how we think about these articles. Not just what they should contain, but what they should actually do for the person reading them. The team is getting along well, the process is sharper than it was when we first launched, and there’s a lot more confidence in how to do this properly. So now, we’re getting ready to do the same with the **Lymphovascular Department**. We’ve reattached the form below for anyone who missed it the first time and wants to be part of the next department. Let’s build this together 👇 **P’Fella ❤️** ## Image of the Week **ICG Lymphography Patterns in Early Lymphatic Dysfunction* 🖼️ ****Image of the Week** This image demonstrates the complementary roles of ****lymphoscintigraphy and indocyanine green (ICG) lymphography** in assessing lymphatic function. Despite ****normal lymphoscintigraphy (a)** and no clinical asymmetry, ICG lymphography reveals early pathology: a ****stardust (SD) pattern** in the proximal thighs and lower abdomen, alongside preserved ****linear patterns (LP)** distally. This reflects ****early dermal backflow**, where lymphatic overload leads to leakage into the dermis before overt vessel failure. ICG lymphography is ****more sensitive** than conventional imaging, detecting ****subclinical lymphatic dysfunction** before measurable limb swelling develops. The transition from ****linear - splash - stardust - diffuse** patterns represents progressive disease. ![ICG Lymphography Patterns in Early Lymphatic Dysfunction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/Screenshot-2026-06-12-at-02.00.04.png) ICG Lymphography Patterns in Early Lymphatic Dysfunction - [Source](https://www.jvsvenous.org/article/S2213-333X%2812%2900013-3/pdf?ref=theplasticsfella.com) ## Technique Tip **Lymphaticovenous Anastomosis (LVA)* 🚑 ****Technique Tip of the Week** Lymphaticovenous anastomosis (LVA) is a supermicrosurgical procedure that diverts lymphatic fluid directly into the venous system by connecting functioning lymphatic channels to nearby venules. The operation is performed through small incisions using vessels that are often less than ****0.8 mm** in diameter, making it one of the most technically demanding procedures in reconstructive microsurgery. This video follows patients from assessment through surgery, highlighting the importance of ****patient selection**, ****lymphatic mapping**, and ****meticulous supermicrosurgical technique**. It provides an overview of how physiologic lymphatic reconstruction is performed and why LVA has become a key treatment option for lymphedema. ## Building in Public **How I Operate: Releasing Soon!* ![How I Operate: Podcast Releasing Soon!](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/SOMETHING-EXCITING-IS-COMING-YOUR-WAY--1.png) How I Operate: Releasing Soon! This season explores the depths of plastic surgery innovation: Real cases, constraints, turning points, failures, refinements, and decisions that shape how expert surgeons operate today. Each episode follows the journey behind an idea. Starting from the problem, to the moment something had to change, to the trial and error that turned a technique into something teachable, repeatable, and useful. Moving beyond what happens in theatre, we discuss judgment, progress, and the stories behind surgical innovation. Watch out on [Spotify](https://open.spotify.com/episode/76EpMfATZyXGqXvsfLgIIW?si=Tq%5FoZJHWTU-FH0rEiB1BaA&ref=theplasticsfella.com) for more snippets dropping soon! ## What Does the Evidence Say? **Reverse Lymphatic Mapping in VLNT* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Reverse lymphatic mapping has become one of the most important safety refinements in ****vascularized lymph node transfer (VLNT)**. The core idea is simple: the lymph nodes that drain the ****trunk** are not always the same nodes that drain the ****limb**, so harvesting “by anatomy alone” risks taking the wrong nodes and causing ****donor-site lymphedema**. Reverse mapping uses dual tracers to identify and ****preserve extremity-draining nodes** while selecting safer nodes for transfer. Early prospective work introduced this as a physiology-based way to reduce iatrogenic lymphedema, and later technical studies showed that ****indocyanine green (ICG) plus blue dye** can localize the same limb-draining nodes as technetium-based mapping, without the complexity of radioisotopes. The most useful takeaway is that this is ****not just anatomy.** It matters clinically. In a prospective groin-VLNT series using reverse lymphatic mapping, ****no patient developed donor-site lymphedema**, and lower-limb drainage was preserved in all cases. More recent prospective data also support donor-site safety: after groin VLNT with reverse mapping, ****no patient had a >10% lower-extremity volume difference** at 12 months, and most donor-site adverse events were minor. Broader review-level evidence suggests that donor-site complication rates are generally low across VLNT donor sites. However, reporting remains inconsistent, so reverse mapping is best understood as a ****risk-reduction strategy**, not an absolute guarantee. Sources: ([Pons](https://pubmed.ncbi.nlm.nih.gov/33565822/?ref=theplasticsfella.com), 2021); ([Pajula](https://pubmed.ncbi.nlm.nih.gov/39226714/?ref=theplasticsfella.com), 2024); ([Dayan](https://pubmed.ncbi.nlm.nih.gov/25285683/?ref=theplasticsfella.com), 2015); ([Raman](https://www.oaepublish.com/articles/2347-9264.2022.62?ref=theplasticsfella.com), 2023) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****ICG Velocity: A 5-Minute Metric That Tracks Lymphedema Progression**](https://journals.lww.com/annalsplasticsurgery/abstract/2013/11000/indocyanine%5Fgreen%5Fvelocity%5F%5Flymph%5Ftransportation.34.aspx?ref=theplasticsfella.com) Indocyanine green (ICG) velocity offers a rapid, clinical way to assess lymphatic pump function, dropping predictably as lymphedema worsens, and unlike transit time (which can take over an hour in severe disease), ICG velocity can be measured in just 5 minutes. ✅ [****Pathophysiology of Lymphedema**](https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/%28SICI%291097-0142%2819981215%2983%3A12B%2B%3C2798%3A%3AAID-CNCR28%3E3.0.CO%3B2-E?ref=theplasticsfella.com) Lymphedema after breast surgery is driven not just by lymphatic failure but also by increased capillary filtration and limb blood flow, creating a persistent fluid overload that surgeons must account for in management. ✅ [****Dermal Backflow Patterns Map Lymphedema Severity**](https://journals.lww.com/plasreconsurg/abstract/2011/10000/indocyanine%5Fgreen%5Fenhanced%5Flymphography%5Ffor%5Fupper.26.aspx?ref=theplasticsfella.com) ICG lymphography shows a predictable progression from linear flow to splash, stardust, and diffuse dermal backflow, closely mirroring clinical stage and offering a quick, visual method to stage disease and guide timing and targeting of lymphatic surgery. ## Feedback ### I hope you enjoyed it 😄 --- ### The Basics Still Matter, 5 Suture Choices, & Upcoming Podcast Release URL: https://www.theplasticsfella.com/june-7th/ Last updated: 2026-06-07T09:36:51.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/june-7th/#a-letter-from-pfella) The basics are still the job 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-7th/#image-of-the-week) Donati vs Allgöwer-Donati sutures 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/june-7th/#technique-tip) Simple interrupted suturing 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/june-7th/#building-in-public) What should a great thumbnail look like? 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/june-7th/#what-does-the-evidence-say) Square knot vs Granny knot 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-7th/#articles-of-the-week) Suture choices, tectonic “sutures”, & staples vs sutures. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/june-7th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Basics Are Still The Job* 👋 This week’s issue is really about basic principles. Plastic surgery has a habit of making the interesting part look like the advanced bit: the flap, the plan, the reconstruction, the clever solution. But most of the time, the thing that decides whether a case goes well is much simpler than that. It’s tension, tissue handling, blood supply, knowing when to take a smaller bite, when to leave well alone, when a closure is helping, and when it’s making things worse. Those are the bits people like to file under “early training,” but they don’t stay there. They follow you into every bigger case you ever do. That’s also why we care about the basics so much at P’Fella. The basics are where people build their instincts. If someone really understands the principle, they can adapt when the tissue is friable, swollen, under tension, or just not behaving the way the textbook said it would. If they only know the rule, they’re in trouble the second the case stops looking tidy. Good teaching should help people understand what their hands are actually doing and why it matters. ![Journal on knot tying](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/Screenshot-2026-06-05-at-18.41.07.png) Journal on knot tying I recently came across this [journal on knot tying](https://www.instagram.com/p/DRhsfDpgDQ-/?igsh=MXg5aXo1dW1hMWNxag%3D%3D&ref=theplasticsfella.com) on a slipknot-based “sliputure” that helped standardise closing force and improved knot-force precision in less experienced surgeons. Interesting in itself, but the reason it stood out is because it points back to the same thing: even something as ordinary as knot tension can change perfusion and healing. So, the takeaway this week is a straightforward one. You do not outgrow the basics. You either keep sharpening them, or they become the weak point in everything else you do. Suturing and knot-tying are a good example of that. People talk about them as if they’re just the final step, the tidy-up at the end. But that's a critical point where judgment shows up, and they matter a lot more than most of us care to admit. **P’Fella ❤️** ## Image of the Week **Donati vs Allgöwer-Donati Sutures* 🖼️ ****Image of the Week** This schematic compares the ****classic Donati (vertical mattress)** with the ****Allgöwer-Donati modification**. The Donati vertical mattress provides excellent ****wound edge eversion and tension distribution**, making it useful in high-tension closures. However, the superficial return bite passes through the epidermis, which can lead to ****skin edge strangulation and track marks** if tied tightly. The Allgöwer-Donati modification addresses this by placing the superficial component ****intradermally rather than transcutaneously**, preserving dermal perfusion while maintaining eversion. The result is ****reduced risk of skin necrosis and improved cosmetic outcomes**, particularly in areas where soft tissue is already compromised. In trauma, subtle changes in suture technique can significantly influence healing and complication rates. ![Donati vs Allgöwer-Donati Sutures](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/Schematic-drawings-of-Donati-vertical-mattress-suture-a-and-Allgoewer-Donati-suture-b.png) Donati vs Allgöwer-Donati Sutures - [Source](https://www.researchgate.net/figure/Schematic-drawings-of-Donati-vertical-mattress-suture-a-and-Allgoewer-Donati-suture-b%5Ffig4%5F333117213?ref=theplasticsfella.com) ## Technique Tip **Simple Interrupted Suturing* 🚑 ****Technique Tip of the Week** Good suturing is built on fundamentals. This week's video demonstrates the principles of instrument handling, needle control, and consistent tissue approximation that underpin every surgical closure. A practical tip is to let the ****needle do the work**. Follow the curve of the needle through the tissue rather than forcing it in a straight line, minimising tissue trauma and producing more accurate wound edge approximation. ## Building in Public **What Should a Great Thumbnail Look Like?* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/ChatGPT-Image-Jun-6--2026--08_50_00-PM.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/ChatGPT-Image-Jun-6--2026--08_55_10-PM.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/06/ChatGPT-Image-Jun-6--2026--09_04_59-PM.png) You have 3 seconds. Which thumbnail would you click on? As we’re getting ready to release our upcoming podcast season, we want to hear your opinion on something super important: ****the thumbnail**. A thumbnail is the first thing people see before they ever hear the episode. It has to do a lot of work in a very small space. It should feel intriguing, easy to read, and true to the tone of the show. We’ve been testing a few visual directions for our upcoming release and we’d love your take 👇 You can now subscribe on [Spotify](https://open.spotify.com/episode/76EpMfATZyXGqXvsfLgIIW?si=Tq%5FoZJHWTU-FH0rEiB1BaA&ref=theplasticsfella.com) to be notified when we go live! ## What Does the Evidence Say? **Square Knot vs Granny Knot* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. For basic wound closure, a majority of surgical evidence supports the ****square knot as the safer default**. Comparative mechanical studies consistently show that ****granny knots are more prone to slippage and premature failure**, whereas square knots are more reliable under load. In experimental testing across multiple suture materials, granny and sliding half-hitch knot****s reduced tensile performance** because of premature loop failure, while square and surgeon’s knots performed better. More recent nylon-based testing also found that square knots outperformed granny knots, although ****surgeon’s knots were strongest overall**, and with very fine ****7-0 nylon**, the difference between knot types became less important. Additionally, ****knot security is not just about the knot type**. It also depends on ****suture material** and ****throw count**. Studies in commonly used surgical sutures show that knot security varies with ****technique, material, and number of throws**, and is ****not simply fixed by suture size**. In practical terms, ****monofilaments** are less forgiving and usually **need more throws** than braided sutures. Older comparative work also supports why the square knot remains the core teaching knot: it remains the benchmark against which modified knots are judged, even when a surgeon’s knot is chosen to improve initial friction in higher-tension situations. Sources: ([Lim](https://europepmc.org/article/MED/38595155?ref=theplasticsfella.com), 2024); ([Silver](https://www.joms.org/article/S0278-2391%2816%2900167-1/fulltext?ref=theplasticsfella.com), 2016); ([Muffly](https://pmc.ncbi.nlm.nih.gov/articles/PMC4167833/?ref=theplasticsfella.com), 2014); ([Avoine](https://pmc.ncbi.nlm.nih.gov/articles/PMC4836043/?ref=theplasticsfella.com), 2016) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Suture Choice and Other Methods of Skin Closure**](https://www.surgical.theclinics.com/article/S0039-6109%2809%2900035-8/abstract?ref=theplasticsfella.com) The appropriate suture (monofilament vs braided, absorbable vs non-absorbable, barbed vs smooth) directly impacts tensile strength, infection risk, tissue reactivity, and scar quality, making it a key determinant of both healing and long-term aesthetic outcome. ✅ [****Why Tectonic “Sutures” Are Rarely Straight Lines**](https://www.sciencedirect.com/science/article/abs/pii/0040195177900294?ref=theplasticsfella.com) Rather than a single plate boundary, Tectonic “Sutures” are often a complex, multi-layered zone of deformation with multiple “mini-sutures,” reactivated crust, and distributed strain, making reconstruction of past continental positions far less straightforward than textbook descriptions. ✅ [****Staples vs Sutures: The Infection Risk You Might Be Overlooking**](https://www.bmj.com/content/340/bmj.c1199.abstract?ref=theplasticsfella.com) This meta-analysis suggests staple closure in orthopaedic surgery may carry a 3-4× higher risk of superficial wound infection compared to sutures (particularly in hip procedures), challenging the assumption that faster closure equals equivalent outcomes. ## Feedback ### I hope you enjoyed it 😄 --- ### Why Are Doctors Leaving Their Jobs? 3 Pedicle Decisions, & Aesthetics Breast Assessment URL: https://www.theplasticsfella.com/may-31st/ Last updated: 2026-05-31T09:39:38.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/may-31st/#a-letter-from-pfella) Why are doctors leaving their careers so early? 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-31st/#image-of-the-week) Fascial architecture of the inframammary fold 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-31st/#technique-tip) Superior pedicle breast reduction 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/may-31st/#building-in-public) Updates from the On-Call Team 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/may-31st/#what-does-the-evidence-say) Blood supply to the nipple 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-31st/#articles-of-the-week) Aesthetic breast dimensions, patient-reported outcome measure for breast surgery, & 5 Decisions in breast augmentation. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/may-31st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Why Are Doctors Leaving Their Careers So Early?* 👋 A paper I came across this week made me stop for a second. Doctors are leaving medicine, indeed, and it's concerning ****how early** some of them are leaving. [In a national survey](https://www.thepermanentejournal.org/doi/10.7812/TPP/25.219?ref=theplasticsfella.com) of 971 clinically inactive physicians, the mean age of doctors who had left clinical practice was ****48.1**. That’s ****nine years younger** than a similar cohort in 2008\. And ****11%** said they never practiced at all after graduate medical education. Late 40s is not the **end** of a medical career. Not after that much training, that much sunk time, and that much personal cost. So what were the reasons? **Hassle factor, stress, unrealistic patient demands, and lack of professional satisfaction** were the biggest ones. Overwork and frustration with health-system structures kept coming up too. None of that reads like a motivation problem. It reads like people getting worn down by the shape of the job itself. ![Why Are Doctors Leaving Their Careers So Early?](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/ChatGPT-Image-May-30--2026--11_44_23-AM.png) Why Are Doctors Leaving Their Careers So Early? - [Source](https://www.thepermanentejournal.org/doi/10.7812/TPP/25.219?ref=theplasticsfella.com) The gender side of it is hard to ignore as well. Women made up **63.9%** of respondents, were more likely than men to say they left to care for children or other family members, and among doctors no longer practicing, the median clinical career was **9 years for women versus 12 for men**. We talk about workforce shortages as if the answer is mostly at the front end: train more people, open more posts, widen the pipeline. But if fully trained doctors are leaving in their 40s, and some never enter practice at all, then the problem sits much further downstream too. You can’t keep talking about recruitment while ignoring what clinical work has become for the people already inside it. If we want doctors to stay, the job has to feel worth staying in. That means less pointless friction, less admin disguised as care, better support for family life, and a lot more of looking into why good people are walking away, so we can fix the issues from within. Otherwise, we’ll keep calling it a workforce problem when really it’s a retention problem we’ve been watching in plain sight. **P’Fella ❤️** ## Image of the Week **Fascial Architecture of the Inframammary Fold* 🖼️ ****Image of the Week** This schematic highlights the inframammary fold (IMF): a key structure defining the ****lower pole contour and breast footprint**. The IMF is not a single ligament, but a ****fascial system** formed by: \- ****(1)** Breast parenchyma \- ****(2)** Skin envelope \- ****(4-5)** Superficial and deep fascial layers \- ****(6)** Chest wall \- **(9-13)** Fibrous septa extending from the dermis to deep fascia These septa create a ****zone of adherence**, anchoring the breast and defining the fold. Clinically: \- It is critical for ****implant positioning and symmetry** \- Disruption leads to ****double-bubble deformity** or ****bottoming out** \- Breast aesthetics depend on restoring this ****fascial architecture**, not just skin or volume. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/gr1_lrg.jpg) Fascial Architecture of the Inframammary Fold ## Technique Tip **Superior Pedicle Breast Reduction* 🚑 ****Technique Tip of the Week** The superior pedicle technique preserves vascularity to the nipple-areola complex through a superiorly based dermoglandular pedicle while allowing resection of excess inferior and lateral breast tissue. It is particularly useful for mild to moderate reductions where significant nipple transposition is not required. A key technical point is maintaining adequate pedicle thickness to preserve blood supply while achieving sufficient parenchymal resection for breast shaping. The technique also facilitates upper pole fullness and reliable nipple positioning, making it a versatile option for both functional and aesthetic breast reduction surgery. ## Building in Public **Updates from The On-Call Team* We recently had our first monthly catch-up with the On-Call Team. During the discussion, the team focused on how we can continue improving the quality and educational value of our articles. A major theme of the discussion was strengthening quality control, with the team agreeing on refining the current structured approach to article development, with clearer learning objectives, stronger reviewer feedback, and a continued emphasis on accuracy and usability 🚀 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/Screenshot-2026-05-30-at-15.48.12.png) On-Call Team - Monthly Catch-Up ## What Does the Evidence Say? **Blood Supply to the Nipple* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The nipple-areola complex is not simply supplied by one dominant vessel. The best anatomical descriptions support a redundant vascular network, with medial contribution from ****internal mammary/internal thoracic perforators**, lateral contribution from ****lateral thoracic and thoracoacromial/external mammary branches**, and input from ****intercostal perforators**. These vessels communicate through ****dermal**, ****subdermal**, and ****subareolar plexuses**, which is why different pedicles can safely support the nipple in reduction or mastopexy when enough vascular tissue is preserved. The clinical evidence from nipple-sparing mastectomy reinforces the same principle. Once breast tissue is undermined or retroareolar tissue is separated, nipple viability depends less on a single named artery and more on preservation of the ****dermal-subdermal plexus, flap thickness, incision choice, and patient factors**. Thin flaps, circumareolar scars, smoking, previous radiotherapy, large or ptotic breasts, and aggressive undermining all increase concern for ischaemia. Delay procedures work for the same reason: they precondition collateral flow before definitive surgery. The most evidence-based takeaway is therefore that the nipple has a rich but vulnerable collateral blood supply. In practice, preserving the dermal/subdermal plexus and an adequately thick, well-perfused pedicle is most important. Sources: ([Nimboriboonporn](https://pubmed.ncbi.nlm.nih.gov/25083492/?ref=theplasticsfella.com), 2014); ([Del Riego](https://pubmed.ncbi.nlm.nih.gov/32757082/?ref=theplasticsfella.com), 2020); ([Lohsiriwat](https://pubmed.ncbi.nlm.nih.gov/25083428/?ref=theplasticsfella.com), 2012); ([Jensen](https://pubmed.ncbi.nlm.nih.gov/22829005/?ref=theplasticsfella.com), 2012); ([Chirappapha](https://pubmed.ncbi.nlm.nih.gov/25289296/?ref=theplasticsfella.com), 2014); ([Lee](https://pubmed.ncbi.nlm.nih.gov/36699239/?ref=theplasticsfella.com), 2023) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Concepts in Aesthetic Breast Dimensions: Analysis of the Ideal Breast**](https://patrickmallucci.com/wp-content/uploads/2014/01/the-perfect-breast.pdf?ref=theplasticsfella.com) Defining four objective parameters of the “ideal” breast - 45:55 upper-to-lower pole ratio, upward nipple angulation, straight/concave upper pole, and convex lower pole, to guide aesthetic surgical planning. ✅ [****Patient-Reported Outcome Measure for Breast Surgery: The BREAST-Q**](https://journals.lww.com/plasreconsurg/abstract/2009/08000/development%5Fof%5Fa%5Fnew%5Fpatient%5Freported%5Foutcome.1.aspx?ref=theplasticsfella.com) A multicentre study developing and validating the BREAST-Q, a reliable patient-reported outcome tool assessing satisfaction and quality of life across six domains in breast surgery patients. ✅ [****Five Critical Decisions in Breast Augmentation Using Five Measurements in 5 Minutes**](https://journals.lww.com/plasreconsurg/abstract/2006/12001/five%5Fcritical%5Fdecisions%5Fin%5Fbreast%5Faugmentation.9.aspx?ref=theplasticsfella.com) A structured, measurement-based “High Five” planning system can streamline breast augmentation decision-making while achieving very low reoperation rates (\~3%). ## Feedback ### I hope you enjoyed it 😄 --- ### 1.2 Million Minutes of Teaching, Now Build with Us, & Podcast Teaser with JP Hong URL: https://www.theplasticsfella.com/may-24th/ Last updated: 2026-05-24T09:43:33.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/may-24th/#a-letter-from-pfella) What 1.2 million minutes of learning means 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-24th/#image-of-the-week) Building the new plastics visual library 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-24th/#technique-tip) Upcoming podcast teaser: SCIP flap 4. 📖 [****Build with Us**](https://www.theplasticsfella.com/may-24th/#build-with-us) Help choose the next version of thePlasticsFella 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-24th/#articles-of-the-week) Digital education and visual tools: 3 recommended articles 6. 💕 [****Feedback**](https://www.theplasticsfella.com/may-24th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **What 1.2 Million Minutes of Learning Means* 👋 Over the last little while, we’ve hit a couple of milestones that made me stop for a second. We recently passed ****5,000 members** in the community, and over the last 12 months we’ve also crossed ****1 million minutes of learning** on the platform. **Those numbers are exciting,** but more than that, they show the platform has become part of people’s actual training. It’s not something they find once and forget. They’re coming back, reading properly, revising, checking things before cases, and using it during real working weeks. That means a lot to us. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/ChatGPT-Image-May-22--2026--05_13_41-PM-1.png) ### It also sharpens the responsibility. The original version of The Plastics Fella was, in many ways, about getting good information in one place. That still matters. But what we’re trying to do more and more now is move beyond simply stating facts. The goal is to help people **understand**. - **Why** something is done a certain way. - **Where** decision points are. - **What** actually matters when you’re trying to apply something, not just remember it. That shift is important to us, because there’s plenty of information out there already. What people need is something that makes the information make sense. I heard a great quote in the post-AI era: 💬 ****"You can now outsource your knowledge, but you can't outsource your understanding"** **Someone on X/Twitter* ### That’s why we’ve started building out the team more thoroughly. **We’ve recently onboarded a new on-call team**, who are already reviewing articles with that exact focus: improving educational quality, not just technical accuracy. ![On-Call Team for the Cosmetic Department](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/image-1.png) On-Call Team for the Cosmetic Department **There’s a difference between an article that contains information and one that genuinely teaches.** That’s the standard we want to hold ourselves to, and we’re committed to maintaining and refining that level of care behind the work. So this week’s letter is really just that: a small pause to celebrate the milestones and share what we’re building. **The numbers are nice, but what we care about most is whether The Plastics Fella keeps becoming more useful, more thoughtful, and more educational for the people who trust it.** We’ve got a lot more coming. **P’Fella ❤️** ## Image of the Week **Building the New Plastics Visual Library* 🖼️ ****Image of the Week** This week is a little different. We’re working on updating the visuals across our textbook and articles and moving away from static, textbook-heavy diagrams toward ****cleaner and clinically intuitive visuals** that actually reflect how you learn in theatre, clinic, and exams. The images you’re seeing below are very beginner-level prototypes of that shift. The goal is simple: Make images do the teaching, instead of simply supporting the text. These visuals are guaranteed to improve over time as this is just where we're starting. Reply below and let us know — this is your platform more than it is ours. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/04-test-brow-lift-response.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/01-heed-temporal-motor-risk.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/01-match-lift-to-pattern.png) ## Technique Tip **Upcoming Podcast Teaser: SCIP Flap* 🚑 ****Technique Tip of the Week** We’re excited to announce the upcoming release of our new podcast series, ****“How I Operate”**, featuring discussions with leading experts in plastic and reconstructive surgery. Here’s a teaser from an upcoming episode where ****Professor JP Hong** explores the ****SCIP flap** and the evolution of modern reconstructive microsurgery. This upcoming podcast series is designed to go beyond textbook learning and give insight into how world experts approach operative planning, technique, and decision-making. 🎙️ Stay tuned for more details on the release! 0:00 /1:38 1× ## Build with Us **Help Choose the Next Version of thePlasticsFella* ****We’re testing a new way of presenting clinical content on thePlasticsFella.** The current version is concise and direct: it tells the reader what to assess. The new version tries to go one step further. It explains why those assessment points matter, how they connect to patient concerns, and how they help build a deformity-specific treatment plan. Please compare the two versions below and think about which format is more useful for understanding, revision, and applying the information in clinical practice. You’ll then be asked to complete a short form indicating which version you prefer. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/32dca0a0-3d68-4143-b8e0-d186c2a1edc4-1.png) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Seeing Is Understanding: Visual Tools Improve Health Literacy**](https://link.springer.com/article/10.1186/s12913-024-11138-1?utm%5Fsource=chatgpt.com) Visual-based interventions, particularly videos, significantly improve patient comprehension of health information compared to written or traditional methods, though they offer no clear advantage over direct clinician-patient discussion. ✅ [****VR Training Boosts Skills More Than Knowledge in Healthcare Education**](https://www.jmir.org/2019/1/E12959/?ref=theplasticsfella.com) Virtual reality modestly improves knowledge but produces larger gains in clinical skills among health professionals, outperforming traditional and digital learning, though evidence on attitudes, satisfaction, and real-world impact remains limited. ✅ [****Virtual Patient Simulations in Health Professions Education**](https://www.jmir.org/2019/7/e14676?ref=theplasticsfella.com) Virtual patients match traditional teaching for knowledge but produce larger gains in clinical skills, particularly reasoning and procedural ability, though evidence on attitudes, satisfaction, and optimal design remains limited and heterogeneous. ## Feedback ### I hope you enjoyed it 😄 --- ### Before You Submit, 3 Tips for Dog Bite Management, & Irrigation Technique URL: https://www.theplasticsfella.com/may-17th/ Last updated: 2026-05-15T08:23:16.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/may-17th/#a-letter-from-pfella) Before you submit 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-17th/#image-of-the-week) Facial dog bite reconstruction 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-17th/#technique-tip) Dog bite wounds: Irrigation procedure 4. 🎓 [****Building in Public**](https://www.theplasticsfella.com/may-17th/#building-in-public) Meet the pilot On-Call Team - Aesthetics 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/may-17th/#what-does-the-evidence-say) Dog bites: Primary closure and hand antibiotics 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-17th/#articles-of-the-week) Bite injuries and risks of infection 7. 💕 [****Feedback**](https://www.theplasticsfella.com/may-17th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Before You Submit* 👋 A couple of weeks ago, I wrote about something that doesn’t sit right with me. People charging for research “courses” while also sitting close to the journals, the review process, and the people deciding what gets through. A lot of you replied to that letter, which tells me the issue landed where I thought it would. Because underneath all of that is a simpler problem: a lot of people want to do research properly, but the way in still feels hidden. You’re told to publish, told it matters, and somehow still left to figure out the basics on your own. And when something feels confusing enough, someone will always find a way to package that confusion and sell it back to you. That got me thinking about what would actually be useful here. Not another polished course with a promise that you’ll “get published.” Just something open, practical, and properly explained. The sort of thing that helps with the real questions people get stuck on. - How do you come up with a sensible project? - What does good methodology actually look like? - How do you know if a study is strong enough to submit? - How do you choose the right journal? - What should you check before you send it off? - What usually goes wrong after submission, and what can you do about it? So we want to start working on something that tackles exactly that. The working idea at the moment is **Before You Submit**. The aim is simple. Make research feel less opaque. Give people a clearer path into it. Research should feel like something you can learn with proper guidance, honest feedback, and a bit of structure. It shouldn’t feel like a closed world where access belongs only to the people already inside it. So, I wanted to ask you first. If we build this, what do you actually want in it? What part of research still feels unclear? What do you wish someone had explained before your first project or your first submission? Let us know below, and we’ll use that to build it properly. With love, **P’Fella ❤️** ## Image of the Week **Facial Dog Bite Reconstruction* 🖼️ ****Image of the Week** This week's image demonstrates the management of a ****severe perioral dog bite injury (Lackmann type III)**, progressing from initial soft tissue loss to reconstruction and early outcome. The initial defect (A) shows ****full-thickness soft tissue loss** with irregular wound edges, typical of high-energy bite injuries. Following meticulous irrigation and debridement, the wound is primarily closed with careful layered approximation and placement of a drain (B) to reduce dead space and infection risk. At follow-up (C, D), there is ****good restoration of oral competence** and acceptable aesthetic outcome, highlighting the capacity of facial tissues for recovery when managed early and appropriately. ****Key learning points:** \- Facial dog bites often involve complex, contaminated soft tissue defects \- ****Early thorough washout + debridement** is critical \- ****Primary closure** is frequently achievable due to robust facial vascularity \- Functional goals (oral competence) are as important as cosmesis ![Facial Dog Bite Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/jcm-12-06942-g003.png) Facial Dog Bite Reconstruction - [Source](https://www.mdpi.com/2077-0383/12/21/6942?ref=theplasticsfella.com) ## Technique Tip **Dog Bite Wounds: Irrigation Procedure* 🚑 ****Technique Tip of the Week** This video highlights one of the most important steps in dog bite management: ****copious irrigation**. Dog bites are crush-contamination injuries with a high bacterial burden, so the priority is not immediate closure, but reducing inoculum and removing debris. High-pressure saline washout, gentle exploration, and removal of devitalised tissue are the key principles before any decision about closure is made. Even “simple” bite wounds deserve a systematic assessment. Always examine tendon function, neurovascular status, joint involvement, and occult puncture tracts, especially in the hand. Most uncomplicated wounds can be dressed loosely and reviewed within 48 hours, while high-risk injuries (hand bites, puncture wounds, crush injury, delayed presentation, immunocompromised patients) often warrant prophylactic co-amoxiclav and closer follow-up. ## Building in Public **Pilot On-Call Team - Aesthetics* We’ve officially onboarded our ****10-member On-Call Reviewer Team** for our new aesthetic pilot and kicked things off with our first intro call this week. This is a global group of students and junior trainees, led by Benedetta Agnelli (Clinical Lead) with expert input from Prof. Foad Nahai. We also introduced our new backend platform, where reviewers can claim articles and provide structured feedback as part of the workflow. This is an important step toward building a ****scalable and high-quality platform** powered by both automation and real clinical judgement. We're super excited to see where this goes 🚀 ![Pilot On-Call Team - Aesthetics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/Screenshot-2026-05-10-at-17.25.59.png) Pilot On-Call Team - Aesthetics ## What Does the Evidence Say? **Dog Bites: Primary Closure and Hand Antibiotics* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Dog-bite wounds do not all need to be left open. In the available randomized evidence, wounds that were ****thoroughly irrigated and debrided** before treatment did ****not show a clear increase in infection** with ****primary closure** compared with no closure or delayed closure. The important caveat is that the certainty of this evidence is ****low**, so the most accurate conclusion is that selected dog bites can be **closed primarily**, rather than that primary closure is always equivalent or always preferable. A clear cosmetic advantage has also ****not been firmly established**. Antibiotic prophylaxis is also better understood as ****selective rather than routine**. Systematic-review evidence does ****not show a clear overall benefit** for all dog bites, but it does show a meaningful reduction in infection for bites to the hand. That makes the most evidence-based approach meticulous washout, selective primary closure of appropriate wounds, and targeted antibiotics for higher-risk injuries, especially hand bites rather than blanket antibiotics for every uncomplicated dog bite. Sources: ([Maimaris](https://pmc.ncbi.nlm.nih.gov/articles/PMC1285519/?ref=theplasticsfella.com), 1988); ([Paschos](https://europepmc.org/article/MED/23916901?ref=theplasticsfella.com), 2013); ([Cheng](https://www.jprasurg.com/article/S1748-6815%2814%2900293-9/abstract?ref=theplasticsfella.com), 2014); ([Medeiros](https://www.cochrane.org/evidence/CD001738%5Fantibiotics-reducing-rate-infection-after-bites-mammals-such-humans?ref=theplasticsfella.com), 2001); ([Quinn](https://pmc.ncbi.nlm.nih.gov/articles/PMC3027435/?ref=theplasticsfella.com), 2010) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Bite Injuries of the Hand Are High Risk**](https://journals.lww.com/jaaos/abstract/2015/01000/human%5Fand%5Fother%5Fmammalian%5Fbite%5Finjuries%5Fof%5Fthe.6.aspx?ref=theplasticsfella.com) Even seemingly minor human or animal bite wounds to the hand carry a high risk of polymicrobial infection due to unique anatomy and oral flora, requiring prompt irrigation, prophylactic antibiotics, and often delayed closure to prevent significant morbidity. ✅ [****Atypical Infection After a “Simple” Bite**](https://www.sciencedirect.com/science/article/abs/pii/S0002962915340763?ref=theplasticsfella.com) Seemingly trivial dog bite injuries can lead to delayed, atypical infections such as **Mycobacterium kansasii* tenosynovitis, requiring prolonged antimicrobial therapy and multiple surgeries for functional recovery. ✅ [****Not Just a Bite: Polymicrobial and Systemic Risk**](https://www.thelancet.com/journals/laninf/article/PIIS1473309909701100/abstract?ref=theplasticsfella.com) Cat and dog bites introduce polymicrobial flora that can progress from local infection to severe systemic disease, including sepsis, meningitis, and endocarditis, highlighting the need for early, targeted antimicrobial management and vigilance for atypical pathogens. ## Feedback ### I hope you enjoyed it 😄 --- ### Surgical Dogma, 5 Evidence-Based Shifts, & WALANT Technique URL: https://www.theplasticsfella.com/may-10th/ Last updated: 2026-05-10T08:49:53.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/may-10th/#a-letter-from-pfella) Dogma has a long shelf life 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-10th/#image-of-the-week) WALANT - Wide Awake Local Anaesthesia No Tourniquet 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-10th/#technique-tip) Microsurgery dogma: Do free flaps need prolonged bed rest? 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/may-10th/#what-does-the-evidence-say) Pressure sore recon: Does every sore need muscle underneath? 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-10th/#articles-of-the-week) Moist vs dry wound healing and suitable dressings. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/may-10th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Dogma Has a Long Shelf Life* 👋 One thing plastic surgery is very good at is passing down rules with a lot of confidence. Most of the time they don’t arrive as “dogma.” They arrive as common sense. Someone senior says it, enough people repeat it, a few good outcomes sit in the memory, and before long it becomes part of the furniture. That is usually how dogma works in real life. Not as something obviously wrong, but as something nobody feels the need to question anymore. A recent paper I read looked specifically at dogmas in plastic surgery and found challenged assumptions across flap surgery, hand surgery, wound healing, and craniofacial work, which tells you this is not a one-off problem in one tiny corner of the specialty. The paper looked at commonly repeated perioperative practices in microsurgery and found that quite a few of the “standard” rules don’t hold up particularly well once you actually look at the evidence. Judicious vasopressor use appears safe. NSAIDs do not seem to raise hematoma or thrombosis risk. Routine therapeutic anticoagulation and dextran do not improve flap survival and add bleeding risk. Antibiotics beyond 24 hours do not seem to lower surgical site infection. Most vascular events happen in the first 48 to 72 hours, which makes some longer monitoring habits worth revisiting. Even older age, diabetes, and obesity on their own were not good reasons to rule patients out of microsurgical reconstruction. ![Dogma in plastic surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/Screenshot-2026-05-09-at-00.22.13.png) Dogma in plastic surgery - [Source](https://pmc.ncbi.nlm.nih.gov/articles/PMC13105801/?ref=theplasticsfella.com) This table shows how much of practice can keep going long after the evidence has moved on. ![Dogma in plastic surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/Screenshot-2026-05-09-at-00.22.42.png) Dogma in plastic surgery - [Source](https://pmc.ncbi.nlm.nih.gov/articles/PMC13105801/?ref=theplasticsfella.com) What I find interesting is that this is not really a microsurgery problem. It is a surgery problem. Broader surgical work has shown that evidence can take years to change practice, and the barriers are usually very human ones: habit, selective memory, concern about complications, and the feeling that the old way is safer simply because it is familiar. In another recent study on surgical dogma, surgeons openly described reluctance to move away from long-standing practice, concerns about losing training opportunities, and the fact that personal experience often carries more weight than the paper in front of them. That is why I like this topic. It isn’t about catching people out, and it isn’t about pretending every tradition is foolish. Some of the rules we were taught deserve to survive. Some probably don’t. The harder part is being perceptive enough to tell the difference. In plastic surgery, certainty travels very quickly, while evidence may take the longer route. With love, **P’Fella ❤️** ## Image of the Week **WALANT - Wide Awake Local Anaesthesia No Tourniquet* 🖼️ ****Image of the Week** This week's image demonstrates a ****carpal tunnel release** performed under ****WALANT** (Wide Awake Local Anaesthesia No Tourniquet) using lidocaine with adrenaline. The operative field remains remarkably bloodless despite the absence of a tourniquet, illustrating one of the most important paradigm shifts in modern hand surgery. For decades, surgeons were taught the dogma: **“Never use adrenaline in the fingers or hand.”* Modern evidence has largely overturned this belief. In appropriately selected patients, epinephrine-containing local anaesthetic provides reliable vasoconstriction, improved visibility, reduced operative pain, and avoidance of general anaesthesia or tourniquet discomfort. WALANT has since transformed hand surgery by enabling: \- Awake tendon assessment \- Outpatient procedures \- Reduced anaesthetic burden \- Greater operative efficiency ![Carpal tunnel release performed under WALANT](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/Screenshot-2026-05-09-at-01.09.47.png) Carpal tunnel release performed under WALANT - [Source](https://pmc.ncbi.nlm.nih.gov/articles/PMC5582825/?ref=theplasticsfella.com) ## Technique Tip **Microsurgery Dogma: Do Free Flaps Really Need Prolonged Bed Rest?* 🚑 ****Technique Tip of the Week** Traditional lower-limb free flap care often involved strict bed rest, delayed dangling, no caffeine, and cautious mobilisation, largely from concern that dependency, vasospasm, or increased flow demand might compromise the anastomosis. Increasingly, this is being challenged: modern evidence suggests ****early, monitored dangling** and **mobilisation** can be **safe**, with some studies showing reduced length of stay when protocols begin as early as POD1-5. The key technical point is not “mobilise everyone early,” but replace ritual with **monitored physiology**. Assess flap colour, capillary refill, turgor, Doppler signal, and adjuncts such as tissue oximetry where available; stop dangling if perfusion parameters deteriorate. Similarly, blanket caffeine bans are increasingly difficult to justify, as recent reviews note limited evidence linking caffeine to flap loss. ## What Does the Evidence Say? **Pressure Sore Reconstruction: “Every Sore Needs Muscle Underneath”* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Although musculocutaneous flaps were traditionally favoured for pressure sores because they bring bulk and help obliterate dead space, comparative evidence has not shown that **muscle is universally superior**. A systematic review found no statistically significant difference in complication or recurrence rates between ****musculocutaneous, fasciocutaneous**, and **perforator-based flaps**, and a newer systematic review of local flap options reached a similar conclusion: the literature does ****not** support one flap category as clearly best for all pressure sores. In other words, the key issue is ****durable coverage** and **pressure redistribution**, not simply “putting muscle underneath.” Clinical series support the same message. Retrospective pressure-sore cohorts show that ****recurrence and complication** rates remain high **regardless of flap type**, and outcomes are heavily influenced by factors such as ****ulcer location, patient comorbidity, wound contamination,** and the **quality of off-loading** and **long-term care**. Smaller comparative studies in ****sacral sores** show that both ****fasciocutaneous** and **myocutaneous flaps** can work, with no consistent universal winner. ****Takeaway:** Muscle is ****not mandatory** beneath every pressure sore reconstruction; flap choice should be ****defect- and patient-specific**, with enough tissue to fill dead space where needed, while preserving future reconstructive options whenever possible. Sources: ([Sameem](https://pubmed.ncbi.nlm.nih.gov/22743956/?ref=theplasticsfella.com), 2012); ([Vathulya](https://pubmed.ncbi.nlm.nih.gov/34225313/?ref=theplasticsfella.com), 2022); ([Chiu](https://pubmed.ncbi.nlm.nih.gov/28552279/?ref=theplasticsfella.com), 2017); ([Oksman](https://pmc.ncbi.nlm.nih.gov/articles/PMC7061668/?ref=theplasticsfella.com), 2018) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Moist Wound Healing with Common Dressings**](https://europepmc.org/article/PMC/PMC8568799?ref=theplasticsfella.com) Maintaining a moist wound environment (via appropriate dressings) accelerates healing by promoting keratinocyte migration, collagen synthesis, and autolytic debridement, while reducing pain and scarring compared to dry wound care. ✅ [****Moist vs Dry Wound Healing**](https://journals.sagepub.com/doi/abs/10.1089/wound.2012.0412?ref=theplasticsfella.com) Wounds treated in a moist or wet environment demonstrate faster re-epithelialisation, reduced inflammation, and improved scar quality compared to dry healing, while also enabling delivery of growth factors and cells to enhance regenerative outcomes. ✅ [****Wet-to-Dry Dressings Are Outdated**](https://pmc.ncbi.nlm.nih.gov/articles/PMC4511549/?ref=theplasticsfella.com) Evidence consistently shows that wet-to-dry dressings delay healing, increase pain and infection risk, and are now considered substandard compared to modern moisture-retentive dressings that significantly improve wound outcomes and cost-effectiveness. ## Feedback ### I hope you enjoyed it 😄 --- ### The Pay-to-Publish Funnel, 3 Lipofilling Tips, & Submental Lipo URL: https://www.theplasticsfella.com/may-3rd/ Last updated: 2026-05-03T11:38:45.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/may-3rd/#a-letter-from-pfella) The pay-to-publish funnel 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-3rd/#image-of-the-week) Fat grafting: Strategic lipofilling 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-3rd/#technique-tip) Submental liposuction 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/may-3rd/#what-does-the-evidence-say) Coleman fat grafting: Quick evidence-based review 5. ****🎈** [****Events**](https://www.theplasticsfella.com/may-3rd/#events) Recap of the pilot Grassroots event in Malaysia! 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-3rd/#articles-of-the-week) Lipofilling for breast & oncologic safety, burn scars, & PAL as an alternative to flap recon. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/may-3rd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Pay-to-Publish Funnel* 👋 There’s something I keep seeing online that doesn’t sit right with me. It's when the people selling a "course" also control the gate. Here's what i mean 👇 **Someone early in training wants to get into research. They don’t know where to start, they’ve been told they need publications, and they’re already feeling behind. Then along comes a course. Pay this fee, learn how to do research, get your paper ready, understand the submission process, improve your chances.** On paper, that sounds helpful. In reality, a lot of it feels like people have found a way to turn insecurity into a business model. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/ChatGPT-Image-May-3--2026--12_37_11-PM.png) The part that really bothers me is what happens next. The people running these courses are often not just “teaching research.” They’re already living inside the publication ecosystem. They review papers, they work with the journals, and they sit close to the editorial processes. Sometimes it’s the same person. Sometimes it’s the same small circle. Either way, the line starts to blur. If you’re making money from people who feel lost and then you’re also anywhere near the system judging what gets through, that’s a problem. Because at that point, it stops feeling like mentorship and starts feeling like access is being sold. You’re no longer just teaching someone how to think, question, write well, and do honest work. You’re selling them the sense that you know the route in. That if they pay you, they’ll be a bit closer to the gate. And that is exactly what makes it feel so grubby. The whole thing feeds off the same pressure juniors have been dealing with for years: publish something, get something on your CV, don’t fall behind. People know how anxious that makes trainees and students. To be clear, this isn’t a swipe at trainees doing peer review, and it’s not a swipe at people who teach research properly. Plenty of them are brilliant. The issue is much simpler than that.... > **If you are charging people to teach how to get published, you should not also be anywhere near deciding what gets published.** That shouldn’t be a controversial standard. Research already has enough problems without turning it into a pay-to-enter loop dressed up as education. What younger researchers need is proper supervision, honest feedback, and a clearer way into research that doesn’t depend on paying to get in. What they do not need is another polished course promising confidence, access, and a paper at the end of it. We should be much more honest about that. With love, **P’Fella ❤️** ## Image of the Week **Fat Grafting: Strategic Lipofilling* 🖼️ ****Image of the Week** This week's image focuses on ****lipofilling strategy**, highlighting how fat grafting is planned and delivered in a structured, multi-zone approach. Fat is placed in ****small, layered aliquots** across different planes, maximising surface area for revascularisation and graft survival. This staged, distributed technique is key to achieving predictable **volume retention** and **smooth contour**. In practice, fat grafting outcomes are often built over multiple sessions, with each stage refining contour and volume. ![Fat Grafting: Strategic Lipofilling](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/04/lipofilling-strategy-for-the-first-session-in-a-patient-6-months-after-the-end-of.png) [Fat Grafting: Strategic Lipofilling](https://www.researchgate.net/figure/lipofilling-strategy-for-the-first-session-in-a-patient-6-months-after-the-end-of%5Ffig1%5F341644870?ref=theplasticsfella.com) ## Technique Tip **Submental Liposuction* 🚑 ****Technique Tip of the Week** This video demonstrates ****submental liposuction**, a targeted body contouring procedure to improve jawline definition by removing excess submental fat. The key principle is ****controlled, even** fat removal rather than aggressive suction, as over-resection leads to contour irregularities and poor aesthetic outcomes. The technical takeaway is ****strategic cannula movement** through small access points, maintaining a uniform plane while preserving dermal support. Smooth, fan-shaped passes and constant reassessment are essential to achieve a balanced contour and natural cervicomental angle, rather than simply volume reduction. ## What Does the Evidence Say? **Coleman Fat Grafting* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Across the classic Coleman literature, the most consistently supported parts of structural fat grafting are ****atraumatic harvest, removal of oil/blood/infiltrate,** and **reinjection** as multiple tiny aliquots into well-vascularised tissue planes. That logic is biologically plausible and still widely used: small parcels increase surface area for revascularisation, and the technique’s modern evolution continues to centre on the same three steps: harvesting, refinement, and placement. In the best-known comparative laboratory study of the technique, fat processed with the Coleman method showed ****higher viable adipocyte counts** and ****higher glycerol-3-phosphate dehydrogenase activity** than fat obtained with conventional liposuction processing. The more controversial question is whether ****centrifugation itself** is the reason Coleman grafting works so well. Modern evidence reviews are more cautious here. The clinical literature is limited and heterogeneous, and a systematic review concluded that there is still **no universal best processing method** across all indications. In breast fat grafting specifically, it did ****not** find a consistent long-term retention advantage for one processing method over another, while ****washing and filtration** performed as well as or better than centrifugation in some settings. The Coleman framework remains highly influential, but the strongest evidence supports ****gentle handling** and **layered micro-droplet placement** more than rigid adherence to one exact spin protocol. Sources: ([Coleman](https://europepmc.org/article/MED/16936550?ref=theplasticsfella.com), 2006); ([Lee](https://physicians.ucdavis.edu/Custom/PhysicianFileUploads/CVUploads/ViabilityofFatGraftsColeman-07292013180422-1375.pdf?ref=theplasticsfella.com), 2008); ([Gir](https://europepmc.org/article/MED/22743888?ref=theplasticsfella.com), 2012); ([Egro](https://journals.lww.com/plasreconsurg/fulltext/2022/08000/evolution%5Fof%5Fthe%5Fcoleman%5Ftechnique.17.aspx?ref=theplasticsfella.com), 2022), ([Langridge](https://www.sciencedirect.com/science/article/abs/pii/S1748681523000141?ref=theplasticsfella.com), 2023) ## Events **Pilot Grassroots Event in Malaysia!* 🚨 ****Grassroots pilot event on Burns happened yesterday!** Our first-ever Grassroots session on burns brought together a small group of medical students for a focused, case-based introduction to early plastic surgical thinking. Led by Dr Mohd Shahrul (Plastic, Burn & Reconstructive Surgeon; MSBI President), the session explored how to approach burn assessment, resuscitation, and decision-making in real clinical contexts. From working through acute scenarios to discussing longer-term considerations, the emphasis was to localise universal surgical principles and make core knowledge more relevant to real clinical contexts on the ground. A strong start to the Grassroots series, with more sessions to come! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/WhatsApp-Image-2026-05-02-at-09.50.18.jpeg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/WhatsApp-Image-2026-05-02-at-09.50.19--2-.jpeg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/WhatsApp-Image-2026-05-02-at-09.50.20.jpeg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/WhatsApp-Image-2026-05-02-at-09.50.19--1-.jpeg) Pilot Grassroots Event in Malaysia Thank you to the amazing Grassroots Malaysia team for making this possible! ![Grassroots Malaysia team](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/05/Grassroots-intro-post--2--1.png) Grassroots Malaysia team ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Percutaneous Aponeurotomy & Lipofilling (PAL): Alternative to Flap Reconstruction**](https://dupuytrens.org/wp-content/uploads/2023/05/2013%5FKhouri.pdf?ref=theplasticsfella.com) PAL is a minimally invasive technique that converts restrictive scar/aponeurotic tissue into a vascularised “regenerative scaffold” via percutaneous mesh release (Rigottomy), then seeds it with micro-fat grafts, enabling in-situ tissue regeneration rather than tissue transfer. ✅ [****Lipofilling of the Breast: Oncological Safety**](https://www.banffplasticsurgery.ca/wp-content/uploads/2017/07/Krnowitz%5FLipofilling%5FBreast%5FCancer%5FPRS%5F2016.pdf?ref=theplasticsfella.com) Autologous fat grafting in breast reconstruction does not increase local or systemic recurrence rates compared to matched controls, with comparable long-term outcomes, even across different tumour types and treatments, supporting its oncologic safety in clinical practice. ✅ [****Lipofilling for Burn Scars**](https://www.researchgate.net/profile/Giancarlo-Delli-Santi-2/publication/256611426%5FBurn%5FScar%5FLipofilling/links/5af93b9aaca2720af9eeca67/Burn-Scar-Lipofilling.pdf?ref=theplasticsfella.com) Fat grafting into burn scars induces progressive histological remodelling: normalising collagen architecture, reducing inflammation, and enhancing vascularity, resulting in significant functional and aesthetic improvement. ## Feedback ### I hope you enjoyed it 😄 --- ### Local Flaps of the Hand, 5 Flap Decisions, & Our First Grassroots Event URL: https://www.theplasticsfella.com/april-26th/ Last updated: 2026-04-24T22:01:15.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/april-26th/#a-letter-from-pfella) Your chance to request new platform features 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/april-26th/#image-of-the-week) FDMA flap: Sensate thumb reconstruction 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/april-26th/#technique-tip) Fingertip replantation: Single artery + vein graft strategy 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/april-26th/#what-does-the-evidence-say) Choose the local flap by defect geometry, not by habit 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-26th/#upcoming-events) Launching Grassroots in Malaysia! 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/april-26th/#articles-of-the-week) Dorsal metacarpal artery flap, V-Y rotation advancement flap, & an overview of local hand flaps 7. 💕 [****Feedback**](https://www.theplasticsfella.com/april-26th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Your Chance to Request New Platform Features* 👋 Outside building the team, the rest of our time at the moment is going into the new website. So we've been carefully considering what actually needs building next. What would genuinely make the site more useful for the people who come back to it every week? When something is still small, you can keep adding pages and resources and hope it all sorts itself out. But once you start building something thousands of people are going to use daily, again and again, you have to make very informed decisions. What should be easier to find? What should work faster? What would actually help someone when they’re revising, teaching, on call, or trying to think through a case the night before theatre? That’s the bit we’ve been paying extra attention to. It includes everything: how it should look, how it should feel, what it should actually *do*. There are loads of things we could try and build next. Operative walkthroughs, more revision tools, decision-making aids, the list goes on. While none of those are bad ideas, we just don’t want to sit in a room and decide for everyone else what matters most. **So this week, we wanted to ask you something simple. What tool would actually help you most right now? What would make your life easier in an instance?** This’ll help us decide what gets prioritised as we shape the next version of the site. If there’s something you keep wishing The Plastics Fella could do better, or something you’ve wanted us to build for a while, this is the best time to tell us. With love, **P’Fella ❤️** ps - completely rebuilt platform is coming soon 🔥 ## Image of the Week **FDMA Flap: Sensate Thumb Reconstruction* 🖼️ ****Image of the Week** This image demonstrates an innervated first dorsal metacarpal artery (****FDMA**) **island flap** for reconstruction of a ****thumb pulp defect** with **exposed bone**. The flap is raised from the ****dorsum** of the index finger, based on the FDMA, and transferred as an island flap to the thumb. Incorporation of a ****sensory branch** of the ****superficial radial nerve** (arrow) allows restoration of ****protective sensation**, a key requirement for thumb function. Postoperative images show good contour, coverage, and functional recovery, with the donor site managed using a ****full-thickness skin graft**. The FDMA flap remains a reliable local option for thumb defects, combining ****vascular reliability** with **sensory restoration**. ![FDMA Flap: Sensate Thumb Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/04/An-innervated-first-dorsal-metacarpal-artery-FDMA-island-flap-reconstruction-A-B.webp) [FDMA Flap: Sensate Thumb Reconstruction](https://www.researchgate.net/figure/An-innervated-first-dorsal-metacarpal-artery-FDMA-island-flap-reconstruction-A-B%5Ffig5%5F281084793?ref=theplasticsfella.com) ## Technique Tip **Fingertip Replantation: Single Artery + Vein Graft Strategy* 🚑 ****Technique Tip of the Week** This video shows ****Tamai Zone I** fingertip replantation, highlighting a key principle: ****arterial inflow** is prioritised, even when venous outflow is limited. In distal amputations, suitable veins are often absent, making ****artery-only** or **artery + vein graft** techniques essential salvage strategies. The technique shows meticulous identification of ****proximal and distal vessels**, followed by ****interposition vein grafting** (from the thenar) to bridge arterial gaps. Critical steps include atraumatic handling, precise supermicrosurgical anastomosis, and intraoperative **patency checks** (bleeding/refill). ## What Does the Evidence Say? **Choose the Local Flap by Defect Geometry, Not by Habit* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. For fingertip soft-tissue loss, the evidence most consistently supports a ****defect-specific** approach. Reviews of local hand flaps emphasise that local flaps are valuable because they replace ****like with like**, preserve sensibility, and avoid the morbidity of distant options; within that framework, ****V-Y advancement flaps** remain one of the best-supported workhorse options for ****transverse and dorsal-oblique fingertip amputations**, with literature reviews reporting generally good ****sensory, functional, and aesthetic outcomes** in appropriately selected injuries. It goes without saying that one flap does not fit every fingertip. For ****oblique lateral or volar losses**, the literature repeatedly points to the ****oblique triangular (Venkataswami) flap** as a better geometry-matched option because it can preserve ****digit length** and provide ****sensate coverage** when simple straight advancement may not reach; on the ****thumb**, the same principle underpins the continued role of the ****Moberg flap** for palmar thumb-tip defects. Sources: ([Rehim](https://pubmed.ncbi.nlm.nih.gov/24731606/?ref=theplasticsfella.com), 2014); ([Chakraborty](https://pubmed.ncbi.nlm.nih.gov/34912662/?ref=theplasticsfella.com), 2021); ([Venkataswami](https://pubmed.ncbi.nlm.nih.gov/7403318/?ref=theplasticsfella.com), 1980); ([Elsewify](https://pubmed.ncbi.nlm.nih.gov/37120304/?ref=theplasticsfella.com), 2023) ## Upcoming Events **Launching Grassroots in Malaysia!* 🚨 Announcing our first-ever Grassroots event: BURNS 📍 Malaysia | 📅 2 May 2026 | ⏰ 8:30 AM - 1:00 PM Led by Dr Mohd Shahrul (Plastic, Burn & Reconstructive Surgeon; MSBI President), this session explores practical burn assessment, resuscitation, and early surgical decision-making, using real clinical scenarios to move beyond generalised formulas. What to expect: \- Pre-reading to guide learning \- Small-group, case-based teaching \- Early exposure to surgical thinking in burns \- Grassroots merch 🎟️ Limited spots available, register below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/04/Grassroots-Speaker-Reveal.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/04/Grassroots-Speaker-Reveal--1--1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/04/Grassroots-Speaker-Reveal--3--1.png) [Register Now!](https://forms.gle/5LKxJ3p9JvA42jxu9?ref=theplasticsfella.com) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****First Dorsal Metacarpal Artery Flap Has Consistent Anatomy for Thumb Recon**](https://www.sciencedirect.com/science/article/abs/pii/0363502394902208?ref=theplasticsfella.com) The FDMA is consistently present with predictable radial, ulnar, and intermediate branches, plus a cutaneous branch accompanying the radial nerve, providing a dependable vascular basis for sensate flaps covering thumb and dorsal hand defects up to the PIP joint. ✅ [****Bilateral V-Y Rotation Advancement Flap: A Simple, One-Stage Solution for Fingertip Recon**](https://pmc.ncbi.nlm.nih.gov/articles/PMC3280365/pdf/11552%5F2011%5FArticle%5F9389.pdf?ref=theplasticsfella.com) A bilateral V-Y rotation advancement flap enables reliable, sensate fingertip reconstruction without donor morbidity, achieving 100% flap survival, preserved sensation, and early return to work by combining advancement with rotation to increase tissue reach while maintaining the neurovascular bundle. ✅ [****Local Hand Flaps: Versatile, Anatomically-Based Options for Soft Tissue Reconstruction**](https://d1wqtxts1xzle7.cloudfront.net/50521345/local%5Fflaps-libre.pdf?1479998417=&response-content-disposition=inline%3B+filename%3DLOCAL%5FHAND%5FFLAPS.pdf&Expires=1776981903&Signature=c5n2GaKEm1Ss3fER7z2s58XUc7cJ2XkS1nKfSH8vsJomERtVK8ZwreFUf7ZqXoJdjQKds-FqdcnYbH8q7evyGk9tQNo9v82xc-xYc4Xhxhh3U2joY8CzKf40zd7NdHOjtaJch-oakRSSQ86voQK~l1KzwxXhp7UDg5syuXYTio1NdoKXVbgFHeFWmczWc5I9aQTYzsd1XwhYhQD8mnPpUBALR8lhSuHEMyaASEB1E~qQ4aZHX7L-0cgOpsaNsKizXV3RUtV1t3oMVgCvW3QcrRvVe759U6i320pABTW7-oUA3WyzSp3qrjYnACuJqSF1xxOstF83xjeBUaiA4mpe7g%5F%5F&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA&ref=theplasticsfella.com) Local hand flaps provide reliable, well-vascularised soft tissue coverage using adjacent tissue, allowing preservation of sensation, contour, and function while avoiding the morbidity of distant or free flaps; selection is guided primarily by defect characteristics and regional vascular anatomy. ## Feedback ### I hope you enjoyed it 😄 --- ### Breast Reduction Principles, 3 Pedicle Decisions, & Building a Team URL: https://www.theplasticsfella.com/april-19th/ Last updated: 2026-04-17T19:53:31.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/april-19th/#a-letter-from-pfella) Building a team together 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/april-19th/#image-of-the-week) Managing lift and skin excess in superior pedicle reduction 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/april-19th/#technique-tip) Wise pattern & pedicle principles 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/april-19th/#what-does-the-evidence-say) Pedicle choice is really an NAC perfusion question 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/april-19th/#articles-of-the-week) No vertical scar breast reduction, vertical reduction mammaplasty, & breast reduction complications. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/april-19th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Building A Team Together* 👋 I've written about this before, but I wanted to re-emphasise that one of the nicest things about the last few weeks has been getting to speak to so many of you properly. Real conversations about where you work, what you care about, what parts of plastic surgery you consistently revise, and where you’d love to contribute. There’s something very special about realising that this isn’t just a platform people read from a distance. It’s something people genuinely want to be involved in. And that’s made us even more excited about where this is heading. As The Plastics Fella grows, one of the things we’ve been building out more deliberately is a *department* structure across different areas of plastic surgery. Each specialty has its own sub-areas, questions, specific surgical scenarios and people who really live and breathe it every day. It feels right that the teaching grows in the same way. So instead of having everything in one big pile, we’re starting to build dedicated units around each specialty, with the right people leading them. The first of those is now in place: our **Aesthetics Unit**, with **Foad Nahai** as the expert and **Benedetta Agnelli** as clinical lead. We’re incredibly excited about this. For our second stage, we're already working on the **Lymphovascular Department**, and there are more to come after that. We're planning for this to be the start of something much bigger, and much more collaborative, than what we could build with one small team. What’s probably been most encouraging is how many people have reached out wanting to be involved in some way. Some of you want to review, some want to teach, some want to help shape how surgical education is done, and some simply want to be part of building something worthwhile. We’re truly grateful for that. And as we start opening up the next departments, we’ll open applications again so more of you can join us when the right fit comes up. There’s a lot more ahead, and we’re very excited about it. With love, **P’Fella ❤️** ## Image of the Week **Managing Lift and Skin Excess in Superior Pedicle Reduction* 🖼️ ****Image of the Week** This image demonstrates a ****superior pedicle breast reduction** performed with an ****inverted-T** (****Wise** pattern) skin resection. You can see preoperative ptosis, markings, intraoperative pedicle elevation, and final result. The nipple-areola complex (NAC) is maintained on a superiorly based pedicle, preserving its vascular and neural supply while allowing controlled repositioning. In this case, a ****5 cm lift** is achieved, but the key decision is not just the pedicle. Significant skin excess and poor skin quality necessitate an ****inverted-T pattern**, which allows reliable reshaping and removal of redundant tissue. This pattern remains widely used due to its ****predictability and versatility**, especially in larger or more ptotic breasts. ![Managing Lift and Skin Excess in Superior Pedicle Reduction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/04/10.1177_30499240251344018-fig6.jpg) Managing Lift and Skin Excess in Superior Pedicle Reduction - [Source](https://journals.sagepub.com/doi/10.1177/30499240251344018?ref=theplasticsfella.com) ## Technique Tip **Wise Pattern & Pedicle Principles* 🚑 ****Technique Tip of the Week** This video demonstrates a ****Wise pattern (inverted-T) reduction**, providing reliable skin excision and three-dimensional control of breast shape. A key principle is that skin pattern determines the **envelope**, while the pedicle determines **NAC viability**, and these must be planned independently. The operative focus is ****controlled parenchymal resection** with preservation of a **well-vascularised pedicle**, followed by ****pillar-based shaping** to recreate projection. Final contour should come from internal architecture, not skin closure alone as poor pillar support leads to flattening or bottoming out over time. ## What Does the Evidence Say? **Pedicle Choice Is Really an NAC Perfusion Question* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The strongest anatomical message across cadaveric, CTA, and MRI studies is that nipple-areola complex (NAC) blood supply is most often **medial/superomedial**, usually from ****internal thoracic perforators**, with ****lateral/superolateral contributions** also common. In the Hall-Findlay superomedial pedicle, both the key vessels and the sensory branches run ****very superficially**, so aggressive superficial thinning or de-epithelialisation risks ****vascular compromise or denervation**; when larger resections are needed, the safer principle is to take tissue from the ****deep surface/base of the pedicle**. The imaging studies also show that vascular dominance is not identical in every patient, which is why ****individualised pedicle design** makes sense in very large or higher-risk reductions. Clinically, that anatomy helps explain why ****superomedial/vertical techniques** have become so popular, but the outcomes literature does ****not** show a universal winner. In a matched cohort study, ****superomedial vertical-scar reduction** had ****no significant difference** in major or minor complications compared with the traditional ****inferior-pedicle Wise-pattern** approach. In the classic randomized comparison of ****moderate-sized reductions**, patients having a vertical/medial pedicle reduction were less disappointed by the scar, but they also underwent ****more revisions** than patients treated with the Wise pattern. Sources: ([le Roux](https://www.sciencedirect.com/science/article/abs/pii/S1748681509000680?ref=theplasticsfella.com), 2010); ([Seitz](https://pubmed.ncbi.nlm.nih.gov/25733199/?ref=theplasticsfella.com), 2015); ([Stirling](https://pubmed.ncbi.nlm.nih.gov/28432407/?ref=theplasticsfella.com), 2017); ([Antony](https://pubmed.ncbi.nlm.nih.gov/24165588/?ref=theplasticsfella.com), 2013); ([Cruz-Korchin](https://pubmed.ncbi.nlm.nih.gov/14578787/?ref=theplasticsfella.com), 2003) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****No Vertical Scar Breast Reduction Requires Careful Patient Selection**](https://d1wqtxts1xzle7.cloudfront.net/106583876/s00266-003-3006-120231014-1-jowmmu-libre.pdf?1697262603=&response-content-disposition=inline%3B+filename%3DThe%5FNo%5FVertical%5FScar%5FBreast%5FReduction%5FA.pdf&Expires=1776374897&Signature=H2t7yvDLiqB9pEz7Q7Jd~7OxTnp3lyM5jVVBRp2cf-7kVXPyoaah0ijwiQHpih54o-OkDf52I-1H3-bGachjLj8RCViUrPfrCDAmIGMb8ODF398zASA4yZ6ZvWZ1UysXvCf7aVWtKWtjXIKXlU5tHh7Xn77vvVHJfw2D~fb7P~Y4v-lMqI3fXF~5TJovc5prfGREA8tcOqHnTvMhFhEyfJPFkNjtrOa87OYkd3NDxWamqP93zKAc4OQCYvrv~cXaqtzyB5lxyVc~9dM1oPUWSOLHNEU~rszA7JwEwy7jGoJ74PJYT6D7rO8OBlipw0mvv2i017QbI2YSV88zEVGhmA%5F%5F&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA&ref=theplasticsfella.com) This technique removes the visible vertical scar by limiting incisions to the periareolar region and inframammary fold, ideal for patients with significant ptosis (>5-7 cm nipple elevation needed), but it can risk boxy contour or dog-ear deformities if not carefully executed. ✅ [****Simplified Vertical Reduction Mammaplasty for Reliability + Minimised Scarring**](https://journals.lww.com/plasreconsurg/abstract/1999/09010/A%5FSimplified%5FVertical%5FReduction%5FMammaplasty%5F.20.aspx?ref=theplasticsfella.com) This technique refines the classic vertical (lollipop) reduction by using a dermoglandular pedicle and minimal tissue undermining, making it easier to learn, applicable to both small and large reductions, and associated with reduced scarring while maintaining safe nipple-areolar vascularity. ✅ [****Breast Reduction Complications Are Common, but Often Predictable**](https://www.researchgate.net/profile/Richard-Lewin-3/publication/236579377%5FRisk%5Ffactors%5Ffor%5Fcomplications%5Fafter%5Fbreast%5Freduction%5Fsurgery/links/55787df008aeb6d8c01f16d7/Risk-factors-for-complications-after-breast-reduction-surgery.pdf?ref=theplasticsfella.com) About 1 in 3 patients develop early postoperative complications, with key risk factors including smoking, diabetes, high BMI, large resection weight, and long sternal notch-to-nipple distance, showing the importance of thorough preoperative optimisation. ## Feedback ### I hope you enjoyed it 😄 --- ### Facial BCC Management, 3 Reconstruction Tips, & Excision Strategy URL: https://www.theplasticsfella.com/april-12th/ Last updated: 2026-04-10T11:15:22.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/april-12th/#a-letter-from-pfella) We probably don’t teach delayed reconstruction properly enough 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/april-12th/#image-of-the-week) Basal cell carcinoma: The facial “H-zone” 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/april-12th/#technique-tip) Excision of basal cell carcinoma 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/april-12th/#what-does-the-evidence-say) Defect-driven nasal reconstruction after BCC excision 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/april-12th/#articles-of-the-week) Facial BCC: Recurrence risk, Mohs vs standard excision, & non-Mohs eyelid BCC excision. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/april-12th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **We Probably Don’t Teach Delayed Reconstruction Properly Enough* 👋 One thing I felt the need to address is how little we actually talk about delayed reconstruction in skin cancer. It’s not rare, and it’s not controversial, but it often sits in the background of how we teach. Most of the focus goes on margins, pathology, flap choice, and closure. The timing of reconstruction (when to close and when to wait) is usually picked up along the way rather than taught directly. If you look at how patients experience this, it’s very different. The common questions are always about what happens next. - *Will it be closed on the same day?* - *Why am I coming back?* - *Who’s doing the reconstruction?* Because from their side, that gap between excision and reconstruction feels huge, even when it makes perfect clinical sense. And I think that’s the bit we probably don’t teach properly enough. We spend a lot of time on margins, pathology, flap choices, grafts, and subunits. All important. But the decision of **when** to reconstruct is often treated like an afterthought, when in reality it can shape everything: the quality of the planning, the confidence of the surgeon, the availability of the right reconstructive input, and the conversation the patient has with the whole experience. Many clinical resources explicitly note that reconstruction after Mohs may be scheduled several days later, and recent conference discussion in dermatologic surgery has focused not just on how to close defects, but when to close them and when to refer. That matters for trainees especially, because delayed reconstruction can look, on the surface, like hesitation. As if something has been left unfinished. But often it’s the opposite. Sometimes, delay is what allows you to do the reconstruction properly: once margins are certain, once the defect is fully understood, once the right surgeon is involved, once you’ve had time to choose the option that serves function and appearance rather than just ending the case quickly. That’s proper judgment. So maybe this is one of the lessons that need more attention in skin cancer surgery: not every good reconstruction happens immediately, and not every immediate reconstruction is the best one. We probably need to talk about that more openly, teach it more deliberately, and explain it better to patients too. Delayed reconstruction isn’t a compromise. It’s part of doing the job properly. With love, **P’Fella ❤️** ## Image of the Week **Basal Cell Carcinoma: The Facial “H-Zone”* 🖼️ ****Image of the Week** This image demonstrates the ****distribution of basal cell carcinoma** (BCC) across facial aesthetic units, highlighting the high-risk ****“H-zone”** of the face. The central face, including the ****nose, periorbital region, perinasal area, lips,** and **ears,** represents a zone of ****increased** tumour density, embryological fusion planes, and deeper tissue invasion. BCCs in this region are more likely to be aggressive, recurrent****,** and require tissue-sparing techniques such as **Mohs surgery**. This has two key implications: **Location determines both oncological risk and reconstructive strategy.* ![Distribution of basal cell carcinoma on the face](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/04/Distribution-of-basal-cell-carcinoma-on-facial-esthetic-units-A-The-predilection-sites.png) Distribution of basal cell carcinoma on the face - [Source](https://www.researchgate.net/figure/Distribution-of-basal-cell-carcinoma-on-facial-esthetic-units-A-The-predilection-sites%5Ffig2%5F253330870?ref=theplasticsfella.com) ## Technique Tip **Excision of Basal Cell Carcinoma* 🚑 ****Technique Tip of the Week** This video demonstrates ****simple excision of a BCC**, the cornerstone of treatment for low-risk lesions. The key principle is ****complete tumour removal** with **appropriate margins**, balancing oncological clearance with tissue preservation. The technical takeaway is ****planning your excision** before you cut: mark ****elliptical margins** along **relaxed** skin tension lines, ensure adequate peripheral clearance, and perform layered closure to optimise healing. Early excision of small lesions is critical as delayed treatment leads to larger defects, more complex reconstruction, and worse cosmetic outcomes. ## What Does the Evidence Say? **Defect-Driven Nasal Reconstruction After BCC Excision* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. For ****nasal defects after BCC excision**, the evidence from large reconstructive series supports a simple principle: reconstruction should be guided by ****defect size, depth, involved subunit, and the need to preserve airway support**. Across high-volume Mohs and tumour-resection cohorts, ****local flaps and grafts** remain appropriate for many smaller defects, while larger or deeper ****tip, ala, and multi-subunit defects** more often require more complex staged reconstruction and structural support. Just as importantly, the classic ****aesthetic subunit principle** is useful, but not absolute. Large case series show good results with ****individualised reconstruction** beyond rigid subunit replacement when that better matches the actual defect. When defects are ****larger, distal, or full-thickness**, the ****forehead flap** remains the most consistently supported workhorse option. In major Mohs-based nasal reconstruction series, it is repeatedly used for sizeable defects after BCC excision, while broader reviews of outer-nose BCC emphasise that convex nasal areas, especially the ****tip and ala,** are reconstructively unforgiving and often need flap-based rather than simple secondary healing strategies. The practical takeaway is that after oncologically sound BCC clearance, the best reconstruction is usually the one that ****restores contour and patency with the fewest stages necessary**. Sources: ([Rohrich](https://journals.lww.com/plasreconsurg/abstract/2004/11000/nasal%5Freconstruction%5Fbeyond%5Faesthetic%5Fsubunits%5F%5Fa.6.aspx?ref=theplasticsfella.com), 2004); ([Moolenburgh](https://journals.lww.com/plasreconsurg/abstract/2010/07000/nasal%5Freconstruction%5Fafter%5Fmalignant%5Ftumor.12.aspx?ref=theplasticsfella.com), 2010); ([Halani](https://journals.lww.com/plasreconsurg/abstract/2021/07000/nasal%5Freconstruction%5Fafter%5Fmohs%5Fcancer%5Fresection%5F.28.aspx?ref=theplasticsfella.com), 2021); ([Boyd](https://jamanetwork.com/journals/jamadermatology/fullarticle/190754?ref=theplasticsfella.com), 2000); ([Wollina](https://pmc.ncbi.nlm.nih.gov/articles/PMC4271293/?ref=theplasticsfella.com), 2014) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Eyelid BCC: Recurrence Risk Depends on Location and Histology**](https://bjo.bmj.com/content/83/1/85?ref=theplasticsfella.com) After excision of eyelid basal cell carcinoma, recurrence risk is highest at the medial canthus and in sclerosing subtypes, and increases with each subsequent surgery, highlighting the importance of complete initial excision and consideration of adjuvant therapy in high-risk cases. ✅ [****Mohs vs Standard Excision: It Depends on Primary vs Recurrent BCC**](https://www.thelancet.com/journals/lanonc/article/PIIS1470204508702602/abstract?ref=theplasticsfella.com) For facial basal cell carcinoma, Mohs micrographic surgery significantly reduces recurrence in recurrent tumours (≈2.4% vs 12.1%), but offers no significant advantage over standard excision for primary lesions, making case selection key. ✅ [****Non-Mohs Eyelid BCC Excision Can Still Achieve Excellent Outcomes**](https://bjo.bmj.com/content/89/8/992.short?ref=theplasticsfella.com) Standard excision with \~4 mm margins can achieve very low recurrence rates (\~4.3%) and even 0% in non-infiltrative BCC, but infiltrative histology and prior recurrence remain key predictors requiring long-term follow-up. ## Feedback ### I hope you enjoyed it 😄 --- ### Can You Trust AI in Surgery? 3 Rhinoplasty Decisions, & Osteotomy Strategy URL: https://www.theplasticsfella.com/april-5th/ Last updated: 2026-04-02T23:52:59.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/april-5th/#a-letter-from-pfella) AI in surgery: Where do we draw the line? 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/april-5th/#image-of-the-week) The tripod theory for nasal tip support. 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/april-5th/#technique-tip) Open rhinoplasty - structural approach. 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/april-5th/#what-does-the-evidence-say) Lateral osteotomy in rhinoplasty 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/april-5th/#articles-of-the-week) Rhinoplasty: Preservation vs structure, septal cartilage availability, & osteotomy selection. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/april-5th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **AI in Surgery: Where Do We Draw the Line?* 👋 Whether AI is coming to medicine is not a question anymore. It’s already here, sitting in inboxes, in search bars, in clinic summaries, and in places where doctors go when they want a quick answer. The question I have now is: **if a surgeon asks, “Which one of these tools should I trust?” who can actually answer that properly?** [This article](https://www.futurehealth.live/thoughts/no-medical-llm-league-tables?ref=theplasticsfella.com) I recently came across put it well. Medicine now has a crowded market of clinician-facing AI tools, but no real independent scoreboard telling us which ones are safest or most reliable. And that’s not just a philosophical problem. A 2025 [JAMA systematic review](https://jamanetwork.com/journals/jama/fullarticle/2825147?ref=theplasticsfella.com) looked at over 500 studies on medical AI and found that only a tiny proportion actually used real patient care data. Most were still testing performance on exam-style questions rather than real-world clinical scenarios. So while accuracy claims are everywhere, evidence that reflects how these tools behave in actual practice is still limited. In other words, we are producing lots of accuracy claims, but not nearly enough evidence that reflects how these tools would behave in the messy, real-world workflow of clinical care. Plastic surgery is no different. Reviews in hand surgery and broader plastics literature describe real potential in imaging, prediction, planning, and education, but most studies remain small, retrospective, and single-centre, with limited external validation. Even when models perform well, they often drop off when tested outside the environment they were built in. Where AI does seem genuinely helpful is in very specific parts of the workflow. Pre-operative planning, for example, where better imaging or anatomical mapping can improve efficiency and precision. Or risk prediction, where models can support counselling and expectation-setting. Burns literature suggests similar roles in assessment and monitoring. But these are all assistive roles, not replacements for judgment. So to me, the real question is not whether AI is useful. It clearly can be. The real question is **where it should sit in the surgical workflow** and what level of evidence should be required before we let it sit there comfortably. In plastics, that means AI *helps* with pattern recognition, imaging, planning, literature retrieval, risk estimation, and repetitive admin. It probably means being much more cautious when the task starts to look like judgment, prioritization, or decision-making under uncertainty. Medicine doesn’t just need more AI tools. It independent head-to-head benchmarking with validation and prospective testing. In a specialty like ours, “pretty good” is not a standard. If a tool is going to shape how surgeons think, plan, or counsel patients, then it should be judged like a medical intervention. Until then, the most sensible position is probably this: stay curious, use the parts that genuinely help, and don’t confuse fluency with trustworthiness. How are you actually using AI right now? Where do you trust it and where do you hesitate? With love, **P’Fella ❤️** ## Image of the Week **The Tripod Theory for Nasal Tip Support* 🖼️ ****Image of the Week** This image illustrates the ****tripod theory of nasal tip support**, a concept in rhinoplasty. The nasal tip is supported by three components: the paired ****lateral crura** and the central ****medial crura**. Together, they function as a tripod, altering the length or position of any limb changes ****tip projection** and **rotation**. Shortening the lateral crura increases rotation, while modifying the medial crura affects projection and columellar support. 👉 **Tip position is engineered through the tripod.* ![Tripod theory for nasal tip support](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/04/Nasal-tripod-a-clinical-photograph-b-line-diagram-showing-medial-crus-yellow.webp) Tripod theory for nasal tip support - [Source](https://www.researchgate.net/figure/Nasal-tripod-a-clinical-photograph-b-line-diagram-showing-medial-crus-yellow%5Ffig3%5F349401113?ref=theplasticsfella.com) ## Technique Tip **Open Rhinoplasty - Structural Approach* 🚑 ****Technique Tip of the Week** This video demonstrates an ****open rhinoplasty** approach, where the nasal skin, soft tissue envelope is elevated to expose the underlying osseocartilaginous framework. The key principle in modern rhinoplasty is that this is ****not a reductive** procedure, but a structural one focused on reshaping and supporting the nasal framework using controlled modification and grafting. The critical technical takeaway is ****precise framework control**: careful elevation, preservation of key support structures, and targeted cartilage modification (tip work, dorsal adjustment, graft placement). Successful rhinoplasty depends on maintaining or reconstructing structural support while achieving aesthetic goals, as imbalance can lead to functional compromise or long-term deformity. ## What Does the Evidence Say? **Lateral Osteotomy in Rhinoplasty* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Across the classic lateral-osteotomy papers, it is shown that as much as narrowing the bony vault, it is important to ****protect the airway** and **minimise intranasal trauma**. Webster’s classic description of the ****curved lateral osteotomy** showed that leaving a small triangular segment of bone at the pyriform aperture can prevent medialised bone from impinging on the nasal airway. Later anatomical and radiographic work reinforced the same principle: along a standard high-low-high track, the lateral nasal wall is usually thin enough that a ****small osteotome** (about ****233 mm**) is sufficient, which helps limit unnecessary soft-tissue and mucosal injury. When the papers directly compare technique, the signal generally favours a ****controlled external/perforated osteotomy** over a continuous internal approach. In the Rohrich cadaver study, summarized in their later update, ****mucosal tearing** was far less common with the external perforated technique than with the internal continuous technique (11% vs 74%). A larger clinical/cadaver series likewise reported that ****edema** and **ecchymosis** were less severe, fracture-line control was excellent, mucosal injury was lower, and visible cutaneous scarring was essentially absent by 1 month with the external approach. Most of the supporting literature is ****anatomic, cadaveric,** and **retrospective** rather than high-level randomized evidence. But taken together, it supports an osteotomy strategy that is function-preserving, small-osteotome based. Sources: ([Webster](https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/606874?ref=theplasticsfella.com), 1977); ([Becker](https://doi.org/10.1097/00006534-200004050-00032?ref=theplasticsfella.com), 2000); ([Giacomarra](https://ricerca.unityfvg.it/entities/publication/a07f4486-1a2d-4a0a-9339-41b4213d384b?ref=theplasticsfella.com), 2001); ([Rohrich](https://drjeffreyjanis.com/wp-content/uploads/2014/04/An-update-on-the-lateral-nasal-osteotomy-in-rhinoplasty-PMID-12794496.pdf?ref=theplasticsfella.com), 2003); ([Rohrich](https://journals.lww.com/plasreconsurg/abstract/1997/05000/the%5Flateral%5Fnasal%5Fosteotomy%5Fin%5Frhinoplasty%5F%5Fan.15.aspx?ref=theplasticsfella.com), 1997) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Preservation vs Structural Rhinoplasty: It’s Not Either/Or**](https://journals.lww.com/plasreconsurg/abstract/2026/04000/aspects%5Fand%5Fconcepts%5Fof%5Fwhat%5Fi%5Fpreserve%5Fin.10.aspx?context=featuredarticles&collectionid=2&ref=theplasticsfella.com) Modern rhinoplasty is increasingly about selective preservation as top surgeons advocate blending preservation and structural techniques to maintain function, optimise 3D nasal anatomy, and improve teachability. ✅ [****Septal Cartilage Availability Is Often Overestimated**](https://journals.lww.com/annalsplasticsurgery/abstract/2010/12000/intraoperative%5Fmeasurements%5Fof%5Fharvestable%5Fseptal.3.aspx?ref=theplasticsfella.com) In rhinoplasty, harvestable septal cartilage is frequently insufficient with only \~9% of patients having adequate length for a full dorsal onlay graft, and external nasal dimensions do not reliably predict septal cartilage volume. ✅ [****Osteotomy Selection Is Key to Effective Dorsal Narrowing**](https://journals.lww.com/plasreconsurg/abstract/2007/03000/broad%5Fnasal%5Fbone%5Freduction%5F%5Fan%5Falgorithm%5Ffor.39.aspx?ref=theplasticsfella.com) In rhinoplasty, medial oblique osteotomies positioned at the lateral aspect of the open roof apex achieve greater dorsal width reduction and may obviate the need for lateral osteotomies in cases of isolated dorsal widening. ## Feedback ### I hope you enjoyed it 😄 --- ### Building a Plastics Community, 5 Flaps for Lower Limb Trauma, & ALT Reconstruction URL: https://www.theplasticsfella.com/march-29th/ Last updated: 2026-03-29T10:30:47.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/march-29th/#a-letter-from-pfella) Feeling more and more like a community 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/march-29th/#image-of-the-week) Adipofascial flap for salvaging exposed tibia 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-29th/#technique-tip) ALT flap harvest for lower limb trauma 4. ****🎙️** [****New Podcast Season Coming Soon!** ](https://www.theplasticsfella.com/march-29th/#new-podcast-season-coming-soon) Quick call out for medical illustrators/animators 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/march-29th/#what-does-the-evidence-say) Muscle vs fasciocutaneous free flaps in lower-limb open fractures 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-29th/#articles-of-the-week) Lower limb recon: ALT perforator flaps for sole recon, pedicled perforator flaps, & antibiotics in open fractures. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/march-29th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Feeling More and More Like a Community* 👋 Over the past couple of weeks, we’ve had the chance to speak to a lot of you. And it has been great! Mostly on calls. Some continued interactions over email. I truly don’t think we expected just how much we’d take away from having conversations with you face-to-face. There’s something quite different about hearing how people are actually navigating training. The specifics are rarely what you’d predict from the outside. And more than anything, it’s been genuinely inspiring. In a very real sense, seeing how much people care about getting better, about doing things properly, about helping the next person coming through. You can feel it in the way people talk about cases, teaching, mistakes, and connecting with others who experience similar things. It’s made something very clear to us. This isn’t just a platform anymore. It’s starting to feel more and more like the community we've been striving to build. What’s super interesting is that the value isn’t just coming from what we put out, it’s coming from all of you by interacting with us. And the way your ideas, perspectives, and experiences shape what we do next. That’s the part we want to lean into more. Because these meaningful ideas come from conversations. The kind where someone explains how they actually approach something, or why they do it a certain way, or what caught them out the first time. So we’ve been thinking about how to create more space for that. Last week, we asked you about building a monthly specialised newsletter, similar to this Plastics Paper, but something that allows us to go deeper and bring more of you into the conversation. Instead of just us writing and publishing, we want it to be more like, - Sharing thoughts and perspectives from different people - Highlighting how others approach problems - Opening up space for discussion - Helping you build connections with each other along the way Something that feels like a **shared space for learning**. We’re still shaping what this looks like, but the intention is simple: To make this something you’re part of instead of something you just read. We’ll share more on this soon. We're so excited to speak to more of you in the upcoming weeks and hear your thoughts and ideas. With love, **P’Fella ❤️** ## Image of the Week **Adipofascial Flap for Salvaging Exposed Tibia* 🖼️ ****Image of the Week** This image demonstrates a ****local adipofascial flap** used to cover exposed tibia following debridement in lower limb trauma. The flap is raised from the ****subcutaneous tissue and fascia**, based on perforators (here from the ****posterior tibial system**), then flipped onto the **exposed bone**. The overlying skin is preserved and can be repositioned or grafted, creating a thin, well-vascularised coverage layer. In open fractures, exposed bone will not heal without soft tissue coverage. This technique highlights a key reconstructive principle: 👉 **Well-vascularised tissue is essential for bone healing and infection control.* Adipofascial flaps offer a ****local, reliable** option for selected defects, avoiding the need for free tissue transfer while still achieving durable coverage. ![Adipofascial Flap for Salvaging Exposed Tibia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/03/1-s2.0-S1877056820301754-gr5_lrg.jpg) Adipofascial Flap for Salvaging Exposed Tibia - [Source](https://www.sciencedirect.com/science/article/pii/S1877056820301754?ref=theplasticsfella.com) ## Technique Tip **ALT Flap Harvest for Lower Limb Trauma* 🚑 ****Technique Tip of the Week** This video demonstrates ****anterolateral thigh (ALT) flap** harvest, a workhorse technique for reconstruction of complex lower limb defects. The flap is based on perforators from the ****descending branch** of the ****lateral circumflex femoral artery**, which are often musculocutaneous and require careful intramuscular dissection through vastus lateralis to isolate the pedicle. The key technical principle is meticulous **perforator dissection** and preservation. Identifying a reliable perforator early and dissecting it safely through muscle is critical to avoid injury and ensure flap viability. With a long pedicle, large skin paddle, and ability to include muscle if needed, the ALT flap provides ****versatile, reliable** coverage for open fractures and exposed structures in lower limb trauma. ## New Podcast Season Coming Soon **Quick Call Out for Medical Illustrators/Animators* 🎧 We’ve been busy behind the scenes recording episodes for our upcoming podcast season (name reveal soon 👀). As we prepare for the launch, we’re looking for a ****medical illustrator/animator** to help bring the visuals to life. We’ve worked with general editors before, but what’s been missing is someone who truly understands medical and surgical concepts to translate complex ideas into simple, engaging visuals. If you’re someone (or know someone) who: \- Has experience in medical illustration or animation \- Understands clinical/surgical language and concepts \- Can create clean, high-quality graphics/animation We’d love to hear from you! ## What Does the Evidence Say? **Muscle vs Fasciocutaneous Free Flaps in Lower-Limb Open Fractures* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Historically, severe lower-limb open fractures were often reconstructed with ****muscle flaps**, because they bring well-vascularised bulk into contaminated wounds and dead space, and classic free-flap series established microvascular reconstruction as a major limb-salvage tool. But modern comparative data do ****not** show a universal overall winner. In a large multicentre trauma series, muscle and fasciocutaneous free flaps achieved **similar limb-salvage** and **functional outcomes**, with no meaningful difference in flap thrombosis, flap loss, or tibial nonunion requiring bone grafting; fasciocutaneous flaps did, however, require ****fewer secondary skin-grafting** procedures, although they were more often re-elevated for later orthopaedic work. A trauma-specific systematic review/meta-analysis reached a very similar conclusion: ****total flap failure, reoperation,** and **limb salvage** were **not significantly different**, while ****partial flap failure** was **lower** with **fasciocutaneous flaps**. The main nuance is ****bone healing**. In acute ****Gustilo IIIB tibial fractures**, retrospective radiographic data suggest ****muscle flaps** may **accelerate early healing**, with faster radiographic progression in the first 6 months and more fractures united by 6 months. So the current evidence supports a ****defect-driven approach** rather than dogma: muscle flaps remain attractive when you need ****bulk** and **dead-space obliteration**, while fasciocutaneous flaps are very competitive overall and appear to offer lower **donor-site morbidity** and lower ****partial-failure risk**. The bottom line is that the comparative literature is still ****retrospective**, so flap choice should be tailored to the wound, the bone problem, and the reconstructive plan. Sources: ([Khouri](https://journals.lww.com/jtrauma/abstract/1989/08000/reconstruction%5Fof%5Fthe%5Flower%5Fextremity%5Fwith.5.aspx?ref=theplasticsfella.com), 1989); ([Cho](https://doi.org/10.1097/PRS.0000000000003927?ref=theplasticsfella.com), 2018); ([Mehta](https://journals.lww.com/jorthotrauma/Abstract/2018/08000/Comparing%5FRadiographic%5FProgression%5Fof%5FBone%5FHealing.2.aspx?ref=theplasticsfella.com), 2018); ([Dow](https://www.thieme-connect.com/products/ejournals/abstract/10.1055/a-2003-8789?ref=theplasticsfella.com), 2023); ([Mégevand](https://www.mdpi.com/2077-0383/11/6/1557?ref=theplasticsfella.com), 2022) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****ALT Perforator Flaps in Sole Reconstruction: Coverage for Weight-Bearing Defects**](https://pubmed.ncbi.nlm.nih.gov/17255672/?ref=theplasticsfella.com) The ideal plantar reconstruction needs to balance durability, contour, and sensation, and ALT perforator flaps can be thinned to 4-6 mm while still supporting long-term weight bearing and sensory recovery. ✅ [****Pedicled Perforator Flaps in Lower Limb Reconstruction**](https://www.jprasurg.com/article/S1748-6815%2816%2930336-9/abstract?ref=theplasticsfella.com) Pedicled perforator flaps can cover up to 75% of the lower leg surface area, offering a powerful alternative to free flaps with good reliability and versatility. ✅ [****Antibiotics in Open Fractures: Proven Interventions**](https://pmc.ncbi.nlm.nih.gov/articles/PMC8728739/pdf/CD003764.pdf?ref=theplasticsfella.com) Early antibiotics (typically gram-positive cover like first-gen cephalosporins) given at initial management reduce infection risk by \~57% (RR 0.43; ARR \~7%). ## Feedback ### I hope you enjoyed it 😄 --- ### A New Monthly Edition (for Specialists), 5 LVA Tips, & Supermicro URL: https://www.theplasticsfella.com/march-22nd/ Last updated: 2026-03-26T20:31:17.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/march-22nd/#a-letter-from-pfella) A new monthly edition... for the Specialists. 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/march-22nd/#image-of-the-week) Supermicrosurgical exposure in lymphaticovenular anastomosis 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-22nd/#technique-tip) Supermicrosurgical lymphovenous anastomosis (LVA) 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/march-22nd/#what-does-the-evidence-say) Supermicrosurgery for lymphedema: When is LVA enough? 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-22nd/#articles-of-the-week) LVA for lymphedema, SEATTLE technique, & supermicrosurgery in lower limb recon: 3 articles with 1-sentence summaries. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/march-22nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **A New Specialist Edition... Every Month.* 👋 There’s something we’ve been circling back to again recently. A while ago, we spoke about building a monthly newsletter. Similar to this Plastics Paper that comes to your inbox, but more in-depth, more structured, and more like a journal than a newsletter. Most of you don’t have a knowledge problem. You’ve read the topic. You recognise it. You can explain it. But when you’re in theatre... or on call... and someone asks what you want to do… **That’s where you might feel a little exposed.** Most resources stop at recognition. Very few take you to the point where you can actually use it. So we’re building something different. ### The Specialists (name can change if you have a better one!) Each release focuses on one area of plastic surgery. Not broader. Just clearer. A single subspecialty, broken down by people who actually do the work... so you understand how it fits together, not just what it is. The first will be **Hand Surgery**. Inside, we’re not trying to cover everything. We’re trying to make it make sense. - How to approach the subspecialty - How the key concepts connect - Where people get lost - What isn’t usually explained, but expected The aim is simple: Something you read once to understand it— and come back to when you need it. Over time, we’ll build this across other subspecialties. If this is something you’d use, we’ll keep going With love, **P’Fella ❤️** ## Image of the Week **Supermicrosurgical Exposure in Lymphaticovenular Anastomosis* 🖼️ ****Image of the Week** This week's image demonstrates lymphaticovenular anastomosis (LVA) using ****hook-type retractors** to stabilise a small operative field. In supermicrosurgery, vessels are often ****<0.8 mm**, and even minimal movement can compromise precise suturing. The incision is typically just ****1-2.5 cm**, requiring fine retraction to maintain exposure without obstructing the field. Here, multiple micro-hooks create a ****stable, tension-free** window, allowing accurate dissection and ****intima-to-intima anastomosis** under the microscope. This image highlights a key principle: control of the operative field is critical when working at the limits of vascular repair. ![Supermicrosurgical Exposure in Lymphaticovenular Anastomosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/03/Fixation-of-the-LVA-incision-using-four-hook-type-retractors-Fixation-of-the-surgical.png) Supermicrosurgical Exposure in Lymphaticovenular Anastomosis - [Source](https://www.researchgate.net/figure/Fixation-of-the-LVA-incision-using-four-hook-type-retractors-Fixation-of-the-surgical%5Ffig4%5F354505459?ref=theplasticsfella.com) ## Technique Tip **Supermicrosurgical Lymphovenous Anastomosis (LVA)* 🚑 ****Technique Tip of the Week** This video demonstrates lymphovenous anastomosis (LVA) performed at the supermicrosurgical level, connecting ****submillimetre lymphatic channels to venules** to bypass lymphatic obstruction. The key challenge is the ****fragility** and **collapse-prone** nature of lymphatics, requiring meticulous handling and precise lumen identification under high magnification. The core technical principle is ****atraumatic manipulation** and **exact intima-to-intima alignment**. Gentle dilation of the lymphatic, minimal handling, and precise suture placement are essential to avoid tearing or thrombosis. Successful anastomosis is confirmed intraoperatively by visualisation of **flow across the junction**, often seen as movement at the lymph-blood interface, a critical indicator of patency in supermicrosurgery. ## What Does the Evidence Say? **Supermicrosurgery for Lymphedema: When Is LVA Enough?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Supermicrosurgery is generally defined as anastomosis on vessels around ****0.3-0.8 mm**, and one of its most established clinical applications is ****physiologic lymphedema** surgery. Across the major reviews, lymphaticovenular anastomosis (LVA/LVB****)** is most consistently supported for ****earlier-stage** disease, when functional lymphatics can still be identified, whereas more advanced disease is less reliably treated with bypass alone. The same reviews are also clear that the evidence base is still dominated by cohort studies rather than high-level trials. That pattern is reflected in clinical outcomes. In prospective breast cancer-related lymphedema series, supermicrosurgical LVA **reduced limb-volume difference** and **improved quality of life** at 6-12 months, with over half of patients in one study able to stop compression garments. Comparative cohort data also suggest that microsurgical treatment outperforms **decongestive therapy**, but that ****vascularized lymph node transfer** (VLNT) may produce greater improvement in circumference, reduction rate, and cellulitis burden than ****LVA alone**; adding microvascular breast reconstruction did ****not** further improve lymphedema outcomes. ****Practical Takeaway:** LVA is most convincing in early disease with functional lymphatics, while VLNT becomes more attractive when disease is more advanced or bypass alone is unlikely to be enough. Sources: ([Koshima](https://pubmed.ncbi.nlm.nih.gov/23641262/?ref=theplasticsfella.com), 2013); ([Hong](https://doi.org/10.1002/jso.25243?ref=theplasticsfella.com), 2018); ([Badash](https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2018.00023/full?ref=theplasticsfella.com), 2018); ([Winters](https://link.springer.com/article/10.1007/s10549-017-4335-0?ref=theplasticsfella.com), 2017); ([Engel](https://pubmed.ncbi.nlm.nih.gov/28594742/?ref=theplasticsfella.com), 2017) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Supermicrosurgical LVA for Upper Limb Lymphedema: Bypassing Obstruction at the Lymphatic Level**](https://pubmed.ncbi.nlm.nih.gov/10993089/?ref=theplasticsfella.com) Supermicrosurgical lymphaticovenular anastomosis produced far greater limb reduction than bandaging alone, establishing the key principle that lymphedema can be treated by restoring lymphatic outflow rather than relying on compression alone. ✅ [****SEATTLE Technique in Supermicrosurgery: Expanding Lymphatics to Enable Side-to-End LVA**](https://pmc.ncbi.nlm.nih.gov/articles/PMC3607574/?ref=theplasticsfella.com) Temporary lymphatic expansion increases vessel diameter and significantly improves success rates of side-to-end lymphaticovenular anastomosis, reinforcing that in supermicrosurgery, small technical modifications can determine whether submillimetre anastomoses succeed or fail. ✅ [****Supermicrosurgery in Lower Limb Reconstruction: Perforator-to-Perforator as a New Paradigm**](https://journals.lww.com/plasreconsurg/abstract/2009/01000/the%5Fuse%5Fof%5Fsupermicrosurgery%5Fin%5Flower%5Fextremity.30.aspx?ref=theplasticsfella.com) Perforator-to-perforator anastomosis expands recipient vessel options while reducing dissection and major vessel sacrifice, demonstrating that supermicrosurgery shifts reconstruction toward smaller vessels with equivalent reliability and less morbidity. ## Feedback ### I hope you enjoyed it 😄 --- ### The Community Has Spoken, 5 Metacarpal Decisions, & Thumb Fixation URL: https://www.theplasticsfella.com/march-15th/ Last updated: 2026-03-15T04:13:13.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/march-15th/#a-letter-from-pfella) The community has spoken. Now we build. 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/march-15th/#image-of-the-week) Rotation deformities in metacarpal fractures 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-15th/#technique-tip) Intra-articular base of thumb metacarpal fracture fixation 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/march-15th/#what-does-the-evidence-say) Metacarpal fractures: When is surgery actually worth it? 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-15th/#articles-of-the-week) Thumb base trauma & metacarpal fixes: 3 articles with 1-sentence summaries. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/march-15th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Community Has Spoken. Now We Build.* 👋 Over the last few months, I’ve realised something. I keep ending these letters with a question… and you lot keep replying. Properly replying. And I’m really grateful for that, because it makes this feel like a community rather than a broadcast. Across the last few questionnaires, we’ve had 100s of responses from 100s of people. I wouldn't want to label that as “engagement,” because I consider it a conversation. So instead of another letter where I just ask a question, I thought I’d share what came back and what we’re doing with it. **You Don’t Want “More Content”. You Want *Usable* Content.** This was probably the clearest pattern across all the responses. When we asked what should be in an international curriculum, the top ask (by far) was step-by-step operative walkthroughs. Videos were close behind. After that came anatomy explained for operating, complication playbooks, acute algorithms, and checklists. In other words, the things you actually reach for when you’re tired and the case is moving. We also asked a follow-up: if you were building a core international plastics curriculum, what topics should sit at its centre? The responses were fairly consistent. Most clustered around the areas trainees repeatedly rotate through and rely on. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/03/Green-Dynamic-Inventory-and-Supply-Chain-Planning-Presentation--4-.gif) Answers to the question: What should an international plastics curriculum include? The theme is practical guidance. Essentially, "Don’t just tell me what it is. Show me how to do it, and what can go wrong." **You Want Quick Refreshers And The “What Catches You Out” Bits.** Most of you said the same thing: you want more insight into plastic surgery education, not more noise. And when we asked what you’d actually like more insight on, three things came up again and again. - **Most visited topics** - **Super quick refreshers** - **Most revisited complications & pitfalls** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/03/Green-Dynamic-Inventory-and-Supply-Chain-Planning-Presentation--1-.gif) Answers to the question: What insights do you like to see on your plastic surgery education? That’s a really honest reflection of how surgical learning actually works. It’s not always “sit down and study for two hours”. It’s “I’ve got five minutes, so remind me of the key decisions, and warn me what I’m about to miss.” **“International” Shouldn't Mean Generic.** The international curriculum responses came from **22 different locations**. And the message wasn’t “add every topic under the sun.” Instead, it was something more thoughtful: Make it **portable, but real.** Give the principles that travel across systems, but explain the differences that don’t. **So What Are We Doing With That?** We’re building an **international curriculum** that’s more than a library of articles. It’ll be structured around the things you keep asking for: step-by-step technique, decision-making, complications, and the “what to do next” parts that matter when you’re under time pressure. The goal isn’t to make something generic. It’s to build a shared foundation that travels across training systems while still respecting that practice looks different depending on where you train and work. Over the next few weeks, we’ll start showing you what this curriculum looks like as it takes shape: what’s in, what’s missing, and what we’re prioritising. And we’ll continue doing this the same way we started: asking, listening, and feeding back what we build from what you tell us. Genuinely, **thank you** for replying, for sharing what you actually need, and for being here each week. With love, **P’Fella ❤️** ## Image of the Week **Rotation Deformities in Metacarpal Fractures* 🖼️ ****Image of the Week** This image demonstrates an early malunion of a **second metacarpal fracture** (A) and the resulting ****rotational deformity** seen clinically when the patient makes a fist (B-C). Unlike angulation, even small degrees of rotation are **poorly tolerated** in the hand. When a metacarpal heals with rotational malalignment, the affected finger deviates from its normal trajectory, producing ****“scissoring”** or overlap of the digits during **flexion**. The key lesson is simple 👉 **Rotation is a clinical diagnosis.* X-rays may underestimate the deformity, so the ****finger cascade during fist formation** must always be assessed. Persistent malrotation is a common indication for reduction or fixation, as untreated rotational deformity leads to significant functional impairment. ![Metacarpal Fracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/03/A-C-A-An-xray-shows-an-early-malunion-of-a-second-metacarpal-fracture-of-a.png) Metacarpal Fracture - [Source](https://www.researchgate.net/figure/A-C-A-An-xray-shows-an-early-malunion-of-a-second-metacarpal-fracture-of-a%5Ffig1%5F7271475?ref=theplasticsfella.com) ## Technique Tip **Intra-Articular Base of Thumb Metacarpal Fracture Fixation* 🚑 ****Technique Tip of the Week** This week's technique guide demonstrates operative fixation of an ****intra-articular fracture** at the **base of the thumb metacarpal**, where the key principle is ****anatomic reduction of the joint surface** to restore stability and reduce the risk of post-traumatic arthritis. These fractures are unstable because deforming forces from the thumb musculature tend to displace the metacarpal shaft, so surgery focuses on accurately reducing the articular fragment and maintaining that reduction with stable fixation. The technical takeaway is that this is not just a “thumb fracture,” it is a ****joint reconstruction problem**. Careful exposure, precise reduction of the articular surface, and appropriately contoured fixation are essential to preserve thumb CMC congruity and allow early motion while minimising long-term stiffness and degenerative change. ## What Does the Evidence Say? **Metacarpal Fractures: When Is Surgery Actually Worth It?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Most ****isolated, stable metacarpal fractures** still do well without surgery. The evidence-based reviews are fairly consistent on this: the goal is to restore hand function with the least morbidity, and operative treatment is driven less by the fracture label and more by ****rotation, instability, open or intra-articular injury,** and **unacceptable shortening or angulation**. The same reviews also make an important point: although metacarpal fractures are common, high-level comparative evidence remains limited, which is why management still varies between surgeons. When fixation is needed, the **construct** matters. In displaced fifth metacarpal neck fractures, ****antegrade intramedullary splinting** produced better MCP joint motion, less shortening, less pain, and a better overall clinical score than ****retrograde crossed pinning**, although grip strength and DASH scores were similar. In metacarpal shaft fractures **requiring surgery**, ****locking plates** produced better range of motion, grip strength, rotational control, and DASH scores than ****intramedullary pinning**, but at the cost of longer operative time and longer radiographic healing time. ****Practical Takeaway:** Treat uncomplicated fractures conservatively, but when you operate, prioritise fixation that controls rotation and permits early mobilisation for that specific fracture pattern. Sources: ([Wong](https://journals.lww.com/plasreconsurg/abstract/2017/07000/evidence%5Fbased%5Fmedicine%5F%5Fmanagement%5Fof%5Fmetacarpal.43.aspx?ref=theplasticsfella.com), 2017); ([Kollitz](https://link.springer.com/article/10.1007/s11552-013-9562-1?ref=theplasticsfella.com), 2014); ([Schädel-Höpfner](https://link.springer.com/article/10.1007/s00402-006-0254-y?ref=theplasticsfella.com), 2007); ([Dreyfuss](https://journals.sagepub.com/doi/abs/10.1177/1558944718798854?ref=theplasticsfella.com), 2019) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Thumb Base Trauma: Key Principles for Bennett, Rolando, and UCL Injuries**](https://www.sciencedirect.com/science/article/abs/pii/S0363502309002810?ref=theplasticsfella.com) Stability of the thumb CMC joint hinges on the volar ulnar fragment anchored by the anterior oblique (beak) ligament, meaning Bennett fractures displace predictably and usually require fixation to restore joint congruity and preserve pinch strength. ✅ [****Metacarpal Fixation Strategy: When ORIF Buys Earlier Motion Over CRPP**](https://journals.lww.com/prsgo/FullText/2019/05000/Extra%5Farticular%5FMetacarpal%5FFractures%5F%5FClosed.25.aspx?ref=theplasticsfella.com) For closed extra-articular metacarpal fractures, ORIF enables earlier mobilization without sacrificing overall outcomes, with a particular range-of-motion advantage in transverse shaft fractures, making fixation choice less about union and more about matching stability to rehabilitation demands. ✅ [****Fasciculated Intramedullary Pinning: Stable Metacarpal Fixation with Early Motion**](https://www.sciencedirect.com/science/article/abs/pii/S0266768196801045?ref=theplasticsfella.com) Fasciculated intramedullary pinning provides enough stability to permit early mobilization while preserving motion and grip strength, making it a technically simple fixation strategy for displaced metacarpal neck fractures when conservative treatment is inadequate. ## Feedback ### I hope you enjoyed it 😄 --- ### Burns Training Gap, 2 Burn Care Tips, & STSG Basics URL: https://www.theplasticsfella.com/march-8th/ Last updated: 2026-03-07T18:14:52.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/march-8th/#a-letter-from-pfella) Why burns education matters more than it gets credit for 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/march-8th/#the-sunday-quiz) Still renovating! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/march-8th/#image-of-the-week) Hand escharotomy: Restoring perfusion 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-8th/#technique-tip) Split-thickness skin grafting for burn coverage 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/march-8th/#what-does-the-evidence-say) Can we reduce “procedural burden” without compromising care? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-8th/#articles-of-the-week) Dermal substitution in burn management: 3 articles with 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/march-8th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Why Burns Education Matters More Than It Gets Credit For* 👋 Burns don’t show up often for most people. And that’s exactly why they’re dangerous. Because the moments that matter are high-stakes, and the exposure is patchy. You can do months of training without seeing the right case at the right time, with someone who explains why they’re doing what they’re doing. So you end up with a weird gap in surgical education: We all agree burns are important ... but many surgeons feel under-trained in them. **The Part of Burns People Underestimate** Most people think “burns education” is about the acute phase: TBSA, fluids, escharotomy, dressings, infection, and when to transfer. That stuff is important. But it’s not the bit that quietly causes the most long-term harm. The harder part is what comes after. Late reconstruction. Contractures. Scar patterns that tighten over months. Hands that lose web spaces. Necks that won’t extend. Eyelids that drift. Joints that stiffen. Kids who grow into their scars. **What Good Burns Education Should Look Like** Burns education needs a different rhythm compared with higher-volume conditions. It has to be **structured and revisitable**, because you won’t see enough cases for repetition to do the work for you. Burns needs a *system*, not just content. **Why We’re Investing in This Now** This week’s issue is burns-focused for a reason. We’re putting real energy into building burns education that’s **practical**, **clear**, and **usable**. Because if we can make burns feel more teachable, it raises the baseline for everyone: trainees, generalists, and specialists. Behind the scenes, we’re building an internal **Burns Department:** a small team whose job is to keep this area sharp, current, and clinically honest. We’ve got expert input lined up (more on that soon), and we’re now looking for a few people with a genuine burns interest to help us pressure-test and strengthen what we build. If burns is something you care about... whether you’re early in training or you’ve been doing this for years....applications are open to join our team! Because good burns education shouldn’t depend on luck. It should depend on good systems. If you haven't already, let us know you're interested below. We'll reach out soon! With love, **P’Fella ❤️** ## The Sunday Quiz **Still Renovating!* Still building - will be here next week (promise!) ## Image of the Week **Hand Escharotomy: Restoring Perfusion* 🖼️ ****Image of the Week** This image shows a ****dorsal hand escharotomy** performed for a ****circumferential full-thickness burn**. In deep burns, the rigid eschar acts as a constricting band, raising tissue pressure and compromising ****digital perfusion**. Incisions are taken through the **eschar to the subcutaneous tissue**, with extensions through the ****interdigital spaces** to decompress the interosseous compartments and restore blood flow. 👉 **Escharotomy relieves the constricting burn and restores perfusion before irreversible tissue damage occurs.* ![Escharotomy of the dorsum of the hand ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/03/Escharotomy-performed-on-the-back-of-the-hand-with-total-thickness-burn-The-incision--1-.png) Escharotomy of the dorsum of the hand - [Source](https://www.researchgate.net/figure/Escharotomy-performed-on-the-back-of-the-hand-with-total-thickness-burn-The-incision%5Ffig1%5F318581369?ref=theplasticsfella.com) ## Technique Tip **Split-Thickness Skin Grafting for Burn Coverage* 🚑 ****Technique Tip of the Week** Deep partial- and full-thickness burns often require ****tangential excision** followed by split-thickness skin grafting (STSG) to achieve early wound closure. In this procedure, the ****epidermis** and a **portion of the dermis** are harvested from a donor site using a dermatome and transferred to the prepared wound bed, allowing coverage of large defects while the donor site re-epithelialises. Key technical principles include preparing a ****well-vascularised wound bed** after excision of ****non-viable tissue**, harvesting a thin, uniform graft, and securing it carefully to avoid shearing or haematoma formation. When successful, STSG enables rapid coverage of burn wounds, reduces infection risk, and accelerates healing compared with delayed closure. ## What Does the Evidence Say? **Can We Reduce “Procedural Burden” Without Compromising Care?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. During burn dressing changes and debridement, procedural pain can be extreme even with opioids. Controlled clinical studies show ****immersive virtual reality** (VR) used alongside **standard analgesia** reduces reported **procedural pain** during wound debridement, with the biggest effect seen in patients who feel strongly “present” in the VR environment (e.g., worst-pain ratings dropping from severe to mild in responders). For the **procedure itself*, enzymatic debridement with bromelain-based agents (e.g., ****NexoBrid**) has randomized trial evidence showing ****faster** time to complete debridement and ****reduced** need for **surgical excision and grafting**, while reporting similar **scar quality** and **quality-of-life** outcomes compared with standard care and similar adverse-event rates. A broader evidence-mapping review of burn debridement literature supports enzymatic debridement as one of the better-supported “newer” debridement strategies, while also highlighting that the overall field still contains major evidence gaps and heterogeneity. ****Bottom line:** If your goal is to make burn care **more tolerable* and potentially **less surgically intensive*, the evidence supports two complementary moves: VR as a **non-pharmacologic analgesic** adjunct for painful wound care, and ****enzymatic debridement** as a selective eschar-removal strategy that can reduce operative excision/grafting in appropriate deep burns — both best used within a protocolised burn-service pathway rather than ad hoc. Sources: ([Hoffman](https://journals.lww.com/clinicalpain/Abstract/2008/05000/Virtual%5FReality%5FPain%5FControl%5FDuring%5FBurn%5FWound.4.aspx?ref=theplasticsfella.com), 2008); ([Maani](https://journals.lww.com/jtrauma/Abstract/2011/07001/Virtual%5FReality%5FPain%5FControl%5FDuring%5FBurn%5FWound.22.aspx?ref=theplasticsfella.com), 2011); ([Rosenberg](https://www.sciencedirect.com/science/article/pii/S0305417913002519?ref=theplasticsfella.com), 2014); ([Ziegler](https://europepmc.org/article/MED/33215038?ref=theplasticsfella.com), 2020) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****One-Stage Dermal Substitution: Improving Elasticity Without Compromising Graft Survival**](https://journals.lww.com/plasreconsurg/abstract/2000/09010/Graft%5FSurvival%5Fand%5FEffectiveness%5Fof%5FDermal.14.aspx?ref=theplasticsfella.com) A collagen-elastin dermal substitute placed beneath a split-thickness graft preserves graft take while significantly improving long-term skin elasticity and pliability in reconstructive wounds, reinforcing the principle that dermal restoration is key to functional scar quality. ✅ [****Dermal Substitutes in Acute Burn Surgery: Rebuilding the Dermis to Improve Long-Term Outcomes**](https://onlinelibrary.wiley.com/doi/abs/10.1111/wrr.12119?ref=theplasticsfella.com) Dermal substitutes in acute burn care provide a scaffold that restores dermal architecture, improving long-term functional and cosmetic outcomes while laying the foundation for regenerative strategies such as tissue engineering and stem cell–based skin replacement. ✅ [****NovoSorb BTM in Major Burns: A Synthetic Dermal Matrix That Integrates Before You Graft**](https://www.sciencedirect.com/science/article/pii/S0305417921001996?ref=theplasticsfella.com) NovoSorb BTM typically requires about 4 weeks to integrate, then supports high split-thickness graft take with improving scar quality over 12 months, reinforcing temporisation plus neodermis formation when early autografting is not possible. ## Feedback ### I hope you enjoyed it 😄 --- ### A Curriculum That Travels, 3 Axillary Decisions, & Thoracodorsal Nerve Transfer URL: https://www.theplasticsfella.com/march-1st/ Last updated: 2026-03-01T11:38:17.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/march-1st/#a-letter-from-pfella) Building a curriculum that actually travels 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/march-1st/#the-sunday-quiz) Making some renovations! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/march-1st/#image-of-the-week) The intercostobrachial nerve during axillary dissection 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-1st/#technique-tip) Thoracodorsal to long thoracic nerve transfer 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/march-1st/#what-does-the-evidence-say) Axillary dissection in melanoma & cutaneous SCC: survival vs regional control 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-1st/#articles-of-the-week) High-risk cutaneous SCC, SLNB selection in cSCC, & cSCC and precursor lesion guidelines 7. 💕 [****Feedback**](https://www.theplasticsfella.com/march-1st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Building a Curriculum That Actually Travels* 👋 “International curriculum” sounds tidy on a slide. In real life, it’s complicated. Because plastic surgery isn’t practised in a vacuum. It’s practised inside systems with different referral pathways, different theatre times, different kits, different caseloads, different training structures, different cultural expectations, and different “normal”. A registrar in London and a trainee in Kuala Lumpur might both be learning burns… but the *system around burns* can look completely different. And yet, the patient still turns up with the same problem: a hand injury at 2am, a lower limb defect after trauma, a skin cancer that needs a plan, a burn that can spiral if the first decisions are wrong. That’s the tension we’re trying to solve. Not “one curriculum to replace everyone else’s”. More like a **shared map**. Something that’s useful wherever you work, and flexible enough to adapt to the reality you’re in. **What we mean by “international curriculum”** This isn’t about chasing a perfect syllabus. It’s about building a foundation that holds up across borders: - **Principles that don’t change:** Anatomy, planning, reconstruction logic, wound healing, complications - **Decision-making that’s portable:** “What’s the next safest step?” - **Technique with context:** Why this flap, why this plane, what goes wrong, what to watch for - **Clear pathways for learners:** So you’re not drowning in tabs And yes, it includes articles. We already have a lot of those. But if we’re honest: **a curriculum isn’t just a bunch of articles.** A curriculum is the stuff that actually helps you move from: “I’ve heard of this” – “I can plan it” – “I can do it” – “I can teach it” – “I can fix things when it goes sideways.” That requires more than text. **What we think we might be missing** If we’re going to do this properly, an international curriculum probably needs things like: - Core “must-know” modules - Step-by-step operative walkthroughs - Decision trees/algorithms - Complication playbooks - Case-based learning - Anatomy layers explained in surgical language - Post-op protocols and common pitfalls - Exam frameworks (where relevant), without making everything exam-brained And I’m sure there are blind spots we can’t see from our side. So rather than guessing, I’d rather ask. **Help us build it** If we were to build a **proper international curriculum**, something you’d actually want to follow, what should be in it? What do you wish existed when you started? What do you still find yourself looking up? What formats genuinely help you learn (or teach)? We’ll read every response. And we’ll use it to shape what we build next. With love, **P’Fella ❤️** ## The Sunday Quiz **Making Some Renovations!* We are making some renovations based on your suggestions. Check back next week :) ## Image of the Week **The Intercostobrachial Nerve During Axillary Dissection* 🖼️ ****Image of the Week** This image highlights the ****intercostobrachial nerve** (ICBN) during axillary dissection, shown here bifurcating near the axillary vein. A schematic alongside demonstrates its common branching pattern, including anterior and posterior divisions. The ICBN (T2) provides sensory innervation to the **medial upper arm** and frequently crosses the operative field during nodal clearance. Its proximity to the ****axillary vein and lymphatic tissue** makes it particularly vulnerable during Level I and II dissections for melanoma and SCC. Preservation, when oncologically safe, reduces the risk of ****chronic paraesthesia, dysaesthesia,** and **neuropathic pain** — a significant contributor to long-term morbidity after axillary surgery. 👉 **Oncological clearance and functional preservation must coexist in the axilla.* ![The Intercostobrachial Nerve During Axillary Dissection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/image.png) The Intercostobrachial Nerve During Axillary Dissection - [Source](https://www.researchgate.net/figure/Cadaver-displaying-a-bifurcating-intercostobrachial-nerve%5Ffig3%5F315292157?ref=theplasticsfella.com) ## Technique Tip **Thoracodorsal to Long Thoracic Nerve Transfer* 🚑 ****Technique Tip of the Week** Long thoracic nerve palsy leads to ****scapular winging** and **loss of forward elevation** beyond **90°** due to serratus anterior paralysis. This technique uses a ****distal posterior branch of the thoracodorsal nerve** to reinnervate the distal long thoracic nerve via a lateral thoracic approach, targeting the portion of serratus anterior responsible for inferior angle stabilisation and scapular upward rotation. Key principles are ****distal coaptation** to shorten **reinnervation time**, preservation of adequate thoracodorsal input to maintain latissimus function, and tension-free microsurgical repair. In selected cases, this is combined with a proximal transfer (“double-level transfer”) to optimise serratus recovery and shoulder biomechanics. ## What Does the Evidence Say? **Axillary Dissection in Melanoma & Cutaneous SCC: Survival vs Regional Control* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. In melanoma with a **positive sentinel node**, immediate completion lymph node dissection (including axillary CLND when that’s the draining basin) does not improve ****melanoma-specific** survival compared with ultrasound-based observation (3-year melanoma-specific survival 86% vs 86%). It does improve ****regional nodal control** (92% vs 77% at 3 years) and provides added ****prognostic information** (e.g., nonsentinel-node metastases predict recurrence), but at the cost of substantially higher ****lymphedema** (24.1% vs 6.3%). For cutaneous SCC of the trunk/extremities, outcomes appear to track strongly with ****nodal status**: presenting with ****regional nodal disease** is a dominant adverse prognostic factor (remaining significant on multivariable analysis for recurrence/death risk). Histology matters too. Metastases **cluster** in thicker and poorly differentiated tumors, and certain subtypes are more aggressive. ****Perineural invasion** is not “all equal”: larger-caliber PNI and the presence of additional high-risk features markedly increase the risk of ****nodal metastasis**. Clinically extensive perineural spread also signals aggressive biology with poor outcomes despite intensive local therapy. Sources: ([Faries](https://pmc.ncbi.nlm.nih.gov/articles/PMC5548388/?ref=theplasticsfella.com), 2017); ([Mullen](https://link.springer.com/article/10.1245/ASO.2006.07.022?ref=theplasticsfella.com), 2006); ([Petter & Haustein](https://pubmed.ncbi.nlm.nih.gov/10848931/?ref=theplasticsfella.com), 2000); ([Carter](https://jamanetwork.com/journals/jamadermatology/fullarticle/1557780?ref=theplasticsfella.com), 2013); ([McNab](https://www.sciencedirect.com/science/article/abs/pii/S016164209730116X?ref=theplasticsfella.com), 1997) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Negative Sentinel Nodes, Positive Metastases: Why Thickness Trumps SLNB in High-Risk cSCC**](https://academic.oup.com/bjd/article-abstract/172/4/1029/6616041?ref=theplasticsfella.com) In high-risk cutaneous SCC, tumour thickness >4 mm and recurrence predict early metastasis more reliably than sentinel lymph node biopsy, shifting the surgical priority from nodal sampling to vigilant 2-year surveillance. ✅ [****Refining SLNB Selection in cSCC: The Prognostic Significance of T2b Staging**](https://jamanetwork.com/journals/jamadermatology/fullarticle/1774052?ref=theplasticsfella.com) Sentinel node positivity concentrates in AJCC T2 tumours >2 cm and, more precisely, in the alternative system’s T2b category, positioning tumour stage as the operative criterion for considering SLNB. ✅ [****Guidelines for the Diagnosis and Treatment of cSCC and Precursor Lesions**](https://www.sfdermato.org/upload/recommandations/guidelines-scc-ared-f47380ad9d255491edd2ed5edc8f64a5.pdf?ref=theplasticsfella.com) These guidelines reposition cutaneous SCC management around formal risk stratification, defining surgical margins, indications for Mohs, adjuvant therapy, and follow-up intensity according to tumour biology rather than size alone. ## Feedback ### I hope you enjoyed it 😄 --- ### Predictable by Design, 3 SCIP Decisions, & Cadaver Proof URL: https://www.theplasticsfella.com/february-22nd/ Last updated: 2026-02-21T11:18:52.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/february-22nd/#a-letter-from-pfella) The groin was always there. The system wasn’t. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-22nd/#the-sunday-quiz) Making some renovations! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/february-22nd/#image-of-the-week) The superficial circumflex iliac artery in detail. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-22nd/#technique-tip) Modified SCIP flap (superficial circumflex iliac artery perforator). 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/february-22nd/#what-does-the-evidence-say) SCIA perforator cadaver injection. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-22nd/#articles-of-the-week) SCIP flap for recon, groin flap for hand recon, & perforasomes. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/february-22nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Groin Was Always There. The System Wasn’t.* 👋 The groin has always been tempting territory in reconstruction. Good vessels. Familiar anatomy. Scars you can hide. A donor site most patients won’t hate you for. But for years, it came with a trade-off: you could have reliability, or you could have refinement. Not both. The “classic” groin flap worked, but it often meant bulk, awkward inset, and a flap that didn’t always feel like it belonged in modern microsurgery. Then the **SCIP flap** turned up in the 2000s and changed the mood completely. Perforator-based. Anatomically precise. Thin on purpose. And at some point, SCIP stopped being “an alternative” and became something people reached for without doubts. A lot of surgeons trace that shift to one person: **Professor JP Hong**. We recorded an episode of our podcast, *How I Operate* with him recently, and I came away thinking the same thing I’ve thought after meeting the best technical surgeons: It’s not that they have better hands. It’s that they’ve built a **system** that makes good outcomes more likely, even when the day is busy and the case is moving fast. **What makes SCIP feel “predictable”** When people talk about JP Hong’s SCIP, they usually say one word: **Predictable.** And the more we dug into the history, the more you realise how much of that predictability is earned. Koshima’s original description was elegant, but anyone who has tried it early on knows the friction points show up quickly: - Short pedicle. - Bulk where you don’t want it. - Vessel mismatch. - Seroma at the donor. - And the reputational killer: venous congestion. What JP has done over the last two decades is take those weak points seriously, then refine the flap until it behaves with a sequence of small, deliberate decisions. The SCIP flap doesn’t become reliable because you *know* the anatomy. It becomes reliable because you **confirm** the anatomy. **Quick teaser from the podcast** Midway through the recording, I asked JP to do something that sounds simple and is actually brutal: Describe a SCIP flap clearly enough that someone can **mentally rehearse it** on the way to theatre. With no slides, no diagrams. Just words. And he did it. And it’s exactly why this episode will be worth your time. It’s the closest thing to a practical operating manual you’ll get from the person who helped make this flap mainstream. We’ll be releasing the episode soon as part of the new season. **The point of all this** A lot of good ideas never spread. SCIP spread because it became **teachable**. With love, **P’Fella ❤️** ## The Sunday Quiz **Making Some Renovations!* We are making some renovations based on your suggestions. Check back next week :) ## Image of the Week **The Superficial Circumflex Iliac Artery in Detail* 🖼️ ****Image of the Week** This image illustrates the ****superficial branch of the superficial circumflex iliac artery (SCIA)** — the vascular foundation of the SCIP flap. The 3D overview (A) shows the main vessel coursing laterally, while the 2D section (B) demonstrates multiple ****small-calibre perforators** branching before one dominant perforator penetrates the superficial fascia to become the primary supply. Note the ****tortuous course** of these vessels, which is a feature that likely contributes to the flap’s ability to tolerate rotation and inset tension. After fascial penetration, the main perforator travels within the ****superficial fat**, arborising into the subdermal plexus, enabling harvest of a ****thin, pliable perforator flap**. ![The Superficial Circumflex Iliac Artery in Detail](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/mCT-overview-illustrating-the-typical-course-of-the-superficial-branch-of-the-SCIA-A-3D.png) The Superficial Circumflex Iliac Artery in Detail - [Source](https://www.researchgate.net/figure/mCT-overview-illustrating-the-typical-course-of-the-superficial-branch-of-the-SCIA-A-3D%5Ffig5%5F345309216?ref=theplasticsfella.com) ## Technique Tip **Modified SCIP Flap (Superficial Circumflex Iliac Artery Perforator)* 🚑 ****Technique Tip of the Week** The SCIP flap is a thin, pliable perforator flap ideal for ****extremity and small soft tissue defects**, with minimal donor morbidity. In the video below, J.P. Hong demonstrates elevation on the ****superficial fascia plane** for rapid, safe harvest. ****🖊️ Flap Design** \- Mark along the inguinal ligament, centred over the SCIA perforators. \- Identify perforators (Doppler helpful). \- Design flap according to defect size; can be harvested thin. \- Preserve the pedicle length for microsurgical reach. ****🔪 Surgical Technique** \- Incise and elevate in the superficial fascia plane (relatively avascular). \- Preserve the perforator while maintaining flap thinness. \- Skeletonize the SCIA pedicle as required. \- Rapid elevation possible due to minimal bleeding in this plane. \- Donor site typically closed primarily. ## What Does the Evidence Say? **SCIA Perforator Cadaver Injection* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Selective cadaveric injection evidence supports a practical point: when a ****dominant deep-branch SCIA musculocutaneous perforator** is present, it can perfuse a clinically meaningful skin territory (mean injected area \~****162 cm²**) via perforators through sartorius, supporting the deep branch as more than a “small groin” pedicle in the right anatomy. Injection + CT/micro‑CT work shows both **superficial and deep branches** typically provide **multiple** perforators, but the ****deep-branch pattern** has greater anatomic **“headroom”** (larger potential flap territory and longer pedicle), and superficial-plane elevation reliably reduces bulk. Perforasome mapping similarly finds ****large territories f**or both patterns **(\~156-179 cm²)** despite variation, with major perforators consistently present and occasional links toward the lateral circumflex femoral system. Because thin/supra-fascial SCIP issues often come down to outflow, venous dye injection with clinical correlation identifies the SCIV as an **independent, sizeable** drainage network (≈2× the venae comitantes diameter) with communicating links and reports ****no higher flap loss** or **venous congestion** when using ****SCIV-only** drainage compared with venae comitantes or dual drainage. Practical takeaway: cadaver injection evidence supports choosing the ****deep branch** when size/pedicle length matter, elevating superficially for thinness, and planning robust **venous outflow**, often prioritising the **SCIV**. Sources: ([Sinna](https://pmc.ncbi.nlm.nih.gov/articles/PMC2808053/?ref=theplasticsfella.com), 2010); ([Zubler](https://www.sciencedirect.com/science/article/pii/S0940960220301680?ref=theplasticsfella.com), 2021); ([Gandolfi](https://link.springer.com/article/10.1007/s00276-019-02402-9?ref=theplasticsfella.com), 2020); ([Sun](https://pubmed.ncbi.nlm.nih.gov/37948880/?ref=theplasticsfella.com), 2024) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****SCIP Flap for Limb Reconstruction: Small Pedicle, Big Advantages**](https://pubmed.ncbi.nlm.nih.gov/14707641/?ref=theplasticsfella.com) The SCIP flap reimagines the traditional groin flap by relying on a single perforator with just a 3-4 cm pedicle, allowing quicker elevation, primary thinning, minimal donor-site morbidity, and a concealed scar, all while preserving major vessels. ✅ [****The Groin Flap: A Game-Changer in Hand Reconstruction**](https://www.jprasurg.com/article/S0007-1226%2872%2980003-1/fulltext?ref=theplasticsfella.com) The original groin flap harnessed the superficial circumflex iliac vessels to create a reliable single-stage pedicled flap for hand and forearm resurfacing, offering a simpler, more versatile alternative to the traditional tube pedicle. ✅ [****The Perforasome Theory: Redefining Perforator Flap Anatomy**](https://pubmed.ncbi.nlm.nih.gov/20009839/?ref=theplasticsfella.com) Every perforator supplies its own distinct vascular territory (perforasome) and adjacent perforasomes are connected through direct and indirect linking vessels, which reshaped the design and extending of perforator flaps in both pedicled and free tissue transfer. ## Feedback ### I hope you enjoyed it 😄 --- ### Technique Without Context, 4 PIA Flap Principles, & Quiz Winner Announced! URL: https://www.theplasticsfella.com/february-15th/ Last updated: 2026-02-15T10:20:15.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/february-15th/#a-letter-from-pfella) Technique without context. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-15th/#the-sunday-quiz) \*Drumroll🥁\* Winner announced! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/february-15th/#image-of-the-week) Cadaveric injection of the posterior interosseous artery. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-15th/#technique-tip) PIA flap for dorsal hand & first web space reconstruction. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/february-15th/#what-does-the-evidence-say) Reverse PIA flap: When is it the right choice? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-15th/#articles-of-the-week) Original PIA flap study, PIA flap for fingers, & Extending the Posterior Interosseous Artery Flap. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/february-15th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Technique Without Context* 👋 I wanted to bring attention to one of the most interesting moments from our recent podcast recording with ****Claudio Agrigiani** (more on this later!) It was about reading. Specifically: reading the work that came before you. When we were preparing for the episode, we went back to the original publications. Not summaries. Not textbook adaptations. The actual papers. And it’s striking. When Claudio published in the 1980s, reconstructing the first web space wasn’t just another case on the list. Microsurgery wasn’t routine. Options were limited. Paying an “artery price” with a radial forearm flap was a real trade-off. Free tissue transfer was significant. How does one understand the elegance of a local dorsal hand flap unless they understand the problem it was built to solve? That context disappears if you only read modern summaries. Because techniques don’t appear fully formed. They evolve because something wasn’t working. Flap congestion. Unreliable perforators. Tension across the web space. Poor arc of rotation. Every modification, every refinement, every step in the technique came from someone struggling with a specific limitation. If you skip the original work, you miss that reasoning. And if you miss the reasoning, you don’t really understand the flap. Instead, you just memorise the steps. There’s a temptation in academic surgery to add another publication. Another small variation. Another case series. But sometimes the better use of your time isn’t writing something new. It’s reading something old. - Go back to the original paper. - Read what they were worried about. - Read what failed. - Read what they were trying to avoid. Your patients will benefit far more from that than from you adding one more PDF to the pile. If you’re revisiting muscle flaps, dorsal hand flaps, or web space reconstruction, don’t just learn the steps. Learn the why. The era. The constraint. Technique without context is just choreography. And your surgical skills deserve better than that. With love, **P’Fella ❤️** ## The Sunday Quiz **\*Drumroll🥁\* Winner Announced!* ****Congratulations to the Winner** of The Weekly Quiz 🥁 We're thrilled to announce the winner of this edition's quiz. After seven rounds of questions on plastic surgery, our top scorer is ****Paul**! A huge thank you to everyone who joined us throughout the series. If you missed it, don't worry. New quizzes and challenges are already in the works! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/Leaderboard-Team-Post-Template--1-.png) Winner Announced! ## Image of the Week **Cadaveric Injection of the Posterior Interosseous Artery* 🖼️ ****Image of the Week** This week's image demonstrates cadaveric injection of the posterior interosseous artery (PIA), outlining the vascular territory that underpins the ****reverse-flow PIA flap**. The left panel shows the injected vascular network along the dorsal forearm, highlighting the consistent septocutaneous perforators. The right panel demonstrates clinical planning over the distal forearm: a common indication zone for dorsal hand defects. The PIA flap is a ****distally based fasciocutaneous flap**, relying on retrograde flow through the interosseous system and preserved distal anastomoses. Its key advantage is: 👉 **Coverage of dorsal hand and wrist defects without sacrificing a major forearm artery.* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/Cadavar-Injections.png) Cadaveric Injection of the Posterior Interosseous Artery ## Technique Tip **PIA Flap for Dorsal Hand & First Web Space Reconstruction* 🚑 ****Technique Tip of the Week** The PIA flap is a reliable reverse-flow fasciocutaneous flap ideal for coverage of dorsal hand, wrist, and first web space defects without sacrificing a major forearm vessel. ****Flap Design** The flap is designed along the line between the lateral epicondyle and the distal radioulnar joint, corresponding to the course of the posterior interosseous artery within the septum between ****EDC and ECU**. \- Mark the line from the lateral epicondyle to the distal radioulnar joint (PIA course between EDC and ECU). \- Pivot point: \~2-3 cm proximal to the DRUJ (distal AIA–PIA anastomosis). \- Design the flap proximally in the mid-forearm. \- Size according to defect and avoid overextending beyond the reliable distal pivot. ****Surgical Technique** \- Elevate in a subfascial plane, preserving septal perforators. \- Identify the intermuscular septum between EDC and ECU. \- Dissect and island the pedicle proximally, maintaining distal retrograde inflow. \- Transfer without kinking; avoid tight tunnels (venous congestion risk). \- Donor site usually requires skin graft. Thin, reliable dorsal coverage while preserving major forearm vessels is ideal for traumatic or post-tumour dorsal hand defects. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/Flap-Design.png) Source: Claudio Agrigiani ## What Does the Evidence Say? **Reverse PIA Flap: When Is It the Right Choice?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. For distal upper-limb soft-tissue defects, the reverse PIA flap is a reliable regional option that can provide thin, like-for-like coverage without sacrificing the radial or ulnar artery. Across large clinical experience and reviews, the most supported “sweet spots” for indication are: ****dorsal hand defects up to the metacarpal/MCP region**, ****first web space reconstruction** (often up to the thumb IP level), and ****ulnar border hand defects**, with additional reported utility for ****thumb and selected volar/dorsal traumatic defects** when local options are limited. The key decision-driver (and the reason it still gets picked over forearm options based on major axial vessels) is ****arterial preservation**: multiple sources highlight it as particularly attractive when you want coverage but can’t justify sacrificing a main hand artery (or when the vascular situation is uncertain after injury). Outcomes are generally strong, with contemporary reporting showing ****\~90%+** overall success, but the trade-off is a recognizable complication profile: most notably ****venous congestion** and ****partial/rare total flap loss**, plus a not-infrequent need for **donor-site grafting** depending on flap width/closure. One consistent technical constraint behind “indication creep” is ****territory**: classic anatomical/clinical work supports the concept that the reliably perfused skin territory is not unlimited (with ****proximal overreach increasing risk**), which matters when deciding whether a defect is “in reach” for a reverse PIA versus requiring an alternative flap. Sources: ([Angrigiani](https://pubmed.ncbi.nlm.nih.gov/8337279/?ref=theplasticsfella.com), 1993), ([Costa](https://pubmed.ncbi.nlm.nih.gov/11121314/?ref=theplasticsfella.com), 2001), ([Cheema](https://link.springer.com/article/10.1007/s11552-007-9031-9?ref=theplasticsfella.com), 2007), ([Kelada](https://link.springer.com/article/10.1186/s12891-022-05630-0?ref=theplasticsfella.com), 2022), ([Cho](https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0045-1812467.pdf?ref=theplasticsfella.com), 2025) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****The Original Posterior Interosseous Reverse Forearm Flap Publication**](https://pubmed.ncbi.nlm.nih.gov/8337279/?ref=theplasticsfella.com) The posterior interosseous “reverse” forearm flap is a reliable distal forearm flap that is actually perfused by direct flow through the recurrent dorsal branch of the anterior interosseous artery rather than true reversed flow, making it dependable when raised within its defined vascular territory. ✅ [****Posterior Interosseous Free Flap for Fingers**](https://www.sciencedirect.com/science/article/abs/pii/S1748681509002010?ref=theplasticsfella.com) The posterior interosseous free flap can resurface complex finger defects without sacrificing a major hand artery, achieving 100% flap survival, direct donor-site closure, improved total active motion, and even allowing dual-paddle designs to reconstruct separate finger regions in one go. ✅ [****Extended Posterior Interosseous Artery Flap Reaches the Fingertips**](https://www.researchgate.net/profile/Ezequiel-Zaidenberg/publication/313430496%5FExtended%5FPosterior%5FInterosseous%5FArtery%5FFlap%5FAnatomical%5Fand%5FClinical%5FStudy/links/5a05d880aca272ed279bf06c/Extended-Posterior-Interosseous-Artery-Flap-Anatomical-and-Clinical-Study.pdf?ref=theplasticsfella.com) Moving the pivot point of the classic reverse PIA flap from the anterior interosseous artery to the dorsal intercarpal arch helps gain roughly 8.5 cm of additional pedicle length, enough to extend coverage all the way to the fingertips without sacrificing a major forearm artery. ## Feedback ### I hope you enjoyed it 😄 --- ### Local Grassroots Education, 5 Melanoma Decisions, & Staged Excision Guide URL: https://www.theplasticsfella.com/february-8th/ Last updated: 2026-02-08T11:52:42.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/february-8th/#a-letter-from-pfella) Where good education actually starts. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-8th/#the-sunday-quiz) How well do you know *melanoma*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/february-8th/#image-of-the-week) Inguinal lymph node dissection - key anatomy. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-8th/#technique-tip) Staged excision for skin cancer in tissue-critical areas 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/february-8th/#what-does-the-evidence-say) Post melanoma excision adjuvant therapy: Does it reduce recurrence? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-8th/#articles-of-the-week) Adjuvant therapy in stage III melanoma, imaging vs clinical follow-up for high-risk melanoma, & malignant melanoma in the hand. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/february-8th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Where Good Education Actually Starts* 👋 Most surgical education is built top-down. Big centres. Big names. Big conferences. Then, eventually, it trickles down to the people who actually need it on a Tuesday afternoon. But if you think about how most of us really learned and the stuff that stuck, it usually didn’t come from a stage. It came from small groups, local teaching, someone deciding, “This would actually be useful for our lot.” That’s the kind of education that lasts. Over the past few weeks, we’ve been piloting something new that leans into exactly that idea. **The Grassroots Project: Malaysia Pilot** We’ve started a Grassroots initiative in Malaysia:a local team working with us to organise teaching that’s designed for their system, their patients, and their reality, instead of a carbon copy of someone else’s curriculum. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/WhatsApp-Image-2026-02-08-at-06.24.06-1.jpeg) Team for The Grassroots Project: Malaysia Pilot The premise is simple: Good surgical knowledge should travel, and it has to make sense when it gets there. We’re not trying to build a new national dataset or over-engineer the “perfect” programme. And we’re not pretending one country’s way of working should automatically apply everywhere else. The first session is currently in the works. Short teaching, case-based discussion, and hands-on elements where possible: The kind of session you’d want to attend yourself. If it works, we build on it, and if something doesn’t work, we change it. What I find most encouraging isn’t the content, it’s the model. When teaching is owned locally, it travels deeper. And when it fits the system people are working in, it actually gets used. That’s where the real impact is. And if we help local teams teach locally, the impact compounds. **A Quick Ask** If you’re part of a teaching group, society, student organisation, or departmental programme anywhere in the world, and you’d like to do something similar, tell us. This doesn’t need to be complicated. It starts with a small team (even one person) and a good teaching session. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Melanoma?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the final round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ## Image of the Week **Inguinal Lymph Node Dissection - Key Anatomy* 🖼️ ****Image of the Week** This image demonstrates the anatomy encountered during inguinal lymph node dissection, a procedure most commonly performed for ****melanoma with regional nodal disease**. The ****femoral vessels and nerve** form the deep boundary of dissection, with the ****great saphenous vein stump**, ****sartorius**, and ****adductor longus** acting as critical landmarks. The ****femoral canal** is shown as the site of the ****node of Cloquet**, marking the proximal extent of superficial nodal clearance and its interface with the pelvis. For melanoma surgeons, this anatomy underpins two competing priorities 👉 Adequate oncological clearance while minimising morbidity, particularly vascular injury, lymphoedema, and wound complications. ****Source:** Lupinacci RM et al. **Inguinal lymph node dissection*. Surgical Technique. ![Inguinal Lymph Node Dissection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/02/Screenshot-2026-02-07-at-13.37.10.png) Inguinal Lymph Node Dissection ## Technique Tip **Staged Excision for Skin Cancer in Tissue-Critical Areas* 🚑 ****Technique Tip of the Week** This video outlines the principles of ****staged excision** for skin cancer, a technique used when lesions arise on the face or other anatomically and **cosmetically sensitive sites** where tissue preservation is important. Unlike standard wide local excision where margins are excised and reconstruction proceeds in a single sitting, staged excision involves ****stepwise removal** of peripheral margins with delayed reconstruction, allowing full histological assessment before closure. This approach is particularly valuable for ****lentigo maligna and melanoma in situ**, where subclinical lateral spread is common and predefined margins may either be inadequate or excessively morbid. The key technical decision is ****timing**. Margins are cleared first, often over multiple procedures, and definitive reconstruction is only undertaken once oncologic clearance is confirmed. This technique emphasises that melanoma surgery is not just about excision margins, but about planning reconstruction around **oncologic certainty**, optimising both tumour control and aesthetic outcome. ## What Does the Evidence Say? **Post Melanoma Excision Adjuvant Therapy: Does It Reduce Recurrence?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. High-risk resected melanoma is one of the clearest areas where systemic adjuvant therapy **does* move the needle, primarily by lowering recurrence risk, at the cost of treatment-related toxicity. Across large adjuvant trials in ****resected stage III/IV melanoma**, PD-1 blockade consistently improves recurrence-free survival versus older standards or placebo. For example, nivolumab improved 12-month recurrence-free survival (70.5% vs 60.8%; HR 0.65) with markedly fewer grade 3-4 toxicities than ipilimumab (14.4% vs 45.9%). ([Weber](https://pubmed.ncbi.nlm.nih.gov/28891423/?ref=theplasticsfella.com) et al., 2017). Pembrolizumab versus placebo similarly improved 1-year recurrence-free survival (75.4% vs 61.0%; HR 0.57), with grade 3-5 treatment-related events reported in 14.7% (vs 3.4% with placebo). ([Eggermont](https://pubmed.ncbi.nlm.nih.gov/29658430/?ref=theplasticsfella.com) et al., 2018). For ****BRAF V600-mutated stage III melanoma**, targeted therapy is another high-quality option. Dabrafenib + trametinib improved 3-year relapse-free survival (58% vs 39%; HR 0.47). Overall survival was numerically higher at 3 years (86% vs 77%; HR 0.57), though that interim analysis didn’t meet the prespecified boundary for statistical significance. ([Long](https://pubmed.ncbi.nlm.nih.gov/28891408/?ref=theplasticsfella.com) et al., 2017). Even in ****resected stage IIB/IIC melanoma**, adjuvant PD-1 therapy reduces recurrence risk. In KEYNOTE-716, pembrolizumab lowered recurrence/death versus placebo at interim analyses (HR 0.61 at the second interim), with grade 3–4 treatment-related adverse events reported in 16% (vs 4% with placebo). ([Luke](https://pubmed.ncbi.nlm.nih.gov/35367007/?ref=theplasticsfella.com) et al., 2022). ****Bottom line:** Adjuvant systemic therapy meaningfully reduces recurrence risk in resected high-risk melanoma. The practical decision is less “does it work?” and more which pathway (PD-1 vs BRAF/MEK), and is the recurrence-risk reduction worth the toxicity trade-off for this patient? ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Changing Role of Adjuvant Therapy in Stage III Melanoma**](https://www.nejm.org/doi/abs/10.1056/NEJMe2514054?ref=theplasticsfella.com) Effective immunotherapy has shifted stage III melanoma management away from traditional “clean-up” adjuvant treatment toward earlier, more biologically powerful systemic therapy that alters long-term outcomes. ✅ [****TRIM Trial: Imaging vs Clinical Follow-Up After Surgery for High-Risk Melanoma**](https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2825%2900487-5/abstract?ref=theplasticsfella.com) This interim phase 3 trial suggests that routine whole-body imaging during follow-up after surgery for stage IIB-III melanoma does not improve survival compared with careful physical examination alone. ✅ [****Malignant Melanoma in the Hand: Current Evidence and Recommendations**](https://pubmed.ncbi.nlm.nih.gov/38663875/?ref=theplasticsfella.com) Melanoma of the hand often presents later and carries a worse prognosis than elsewhere, so any pigmented lesion of the hand or nail unit should be treated as malignant until proven otherwise. ## Feedback ### I hope you enjoyed it 😄 --- ### Medicine vs the Knife, 5 Compartment Syndrome Lessons, & Last Call for Foundations URL: https://www.theplasticsfella.com/february-1st/ Last updated: 2026-01-31T13:44:09.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/february-1st/#a-letter-from-pfella) Medicine is slowly replacing the knife. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-1st/#the-sunday-quiz) How well do you know *hand compartment syndrome*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/february-1st/#image-of-the-week) Key compartments of the hand. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-1st/#technique-tip) Volar forearm fasciotomy for compartment syndrome. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/february-1st/#foundations-textbook) Last call to grab foundations! 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-1st/#articles-of-the-week) Acute compartment syndrome, diagnosis and management of compartment syndrome, & Volkmann’s ischaemic contracture. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/february-1st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Medicine Is Slowly Replacing the Knife* 👋 Something’s changing an it’s becoming more noticeable. A lot of conditions that were once clearly surgical are slowly becoming medical. Not because surgeons are worse, but because the biology is finally being understood. **Melanoma** is the obvious example. Wide excisions and nodes used to be the main event. Now, for many patients, immunotherapy does the heavy lifting. Surgery still matters, but more for diagnosis, staging, or local control. Completion clearance? Much less common. The centre of gravity has shifted. **Arthritis feels similar**. For years, it’s been treated as a mechanical failure: injections, symptom control, then replacement. Papers like the Stanford cartilage study hint at a different future.... arthritis as something biologically modifiable earlier, rather than something we wait to collapse before operating. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/image.png) The knee joint of a young mouse (left), an aged mouse (middle), and a treated aged mouse (right). The red indicates cartilage. ([Source](https://news.stanford.edu/stories/2025/11/joint-cartilage-aging-osteoarthritis-therapy-research?utm%5Fsource=twitter&utm%5Fmedium=social&utm%5Fcontent=ap%5Fz6a3o3yymj)) This isn’t surgery losing ground. It’s medicine moving upstream. Plastic surgery sits in an interesting place here. We often step in when nothing else works — wounds, scars, tissue loss. But as mechanisms get clearer, medicine tends to arrive earlier, and surgery moves later. The pattern’s familiar: - Poor understanding → we operate - Better biology → medicine leads - Surgery becomes more selective Not good or bad. Just reality. The real question isn’t *“are we being replaced?”* It’s *“are we paying attention early enough?”* Because the work doesn’t disappear...it just changes shape. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Hand Compartment Syndrome?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the sixth round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ## Image of the Week **Key Compartments of the Hand* 🖼️ ****Image of the Week** This cross-sectional diagram illustrates the key compartments of the hand: the ****thenar**, ****hypothenar**, ****midpalmar**, ****adductor**, and ****interosseous compartments**. In hand sepsis, infection spreads ****within these closed anatomical spaces**, not randomly through soft tissue. This explains why dorsal swelling often originates from a palmar space, and why inadequate drainage leads to persistent infection. 👉 Successful drainage depends on identifying and decompressing the correct compartment. ![Key Compartments of the Hand](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/The-eleven-compartments-of-the-hand-12.png) Key Compartments of the Hand - [Source](https://www.researchgate.net/figure/The-eleven-compartments-of-the-hand-12%5Ffig1%5F303029021?ref=theplasticsfella.com) ## Technique Tip **Volar Forearm Fasciotomy for Compartment Syndrome* 🚑 ****Technique Tip of the Week** 1\. ****Plan an extensile volar S-incision** (prox forearm → wrist), positioned to preserve viable skin bridges and allow easy proximal/distal extension. 2\. ****Raise full-thickness flaps** (skin + subcut), then perform a ****long, continuous volar fasciotomy**. 3\. ****Release both volar compartments explicitly:** superficial then deep volar (common miss); extend proximally if tethered. 4\. ****Distal add-on:** carpal tunnel release when distal swelling/reperfusion risk or median symptoms/concern. 5. **If any doubt about completeness:** add dorsal decompression and release mobile wad when lateral/dorsal tension persists or mechanism is crush/reperfusion/delay. ****6\. Dress + plan:** VAC/loose dressings, second look 24-48h, document compartments + extent. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/image-1.png) Volar Forearm Fasciotomy for Compartment Syndrome (Hand & Forearm) - [Source](https://www.nejm.org/doi/pdf/10.1056/NEJMicm1701729?ref=theplasticsfella.com) ## Foundations Textbook **Last Call to Grab Foundations* Just a quick reminder that [****Foundations**](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) sales close on **February 3rd**. Foundations was designed for the reality that most learning happens in short gaps: between cases, on call, late at night, or the morning before a list. We've built it with concise lessons, anatomy that connects directly to the OR, and material you can pick up in spare moments instead of slogging through endless pages. It’s become part of the daily routine for thousands of trainees, and we’re genuinely thankful for that. If you’ve been considering it, this is the final window before it’s taken offline for a while again. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/250521--1--4.png) Foundations Textbook [Grab Your Copy!](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Acute Compartment Syndrome of the Upper Extremity** ](https://www.jhandsurg.org/article/S0363-5023%2825%2900384-3/abstract?ref=theplasticsfella.com) Although rare, upper-extremity compartment syndrome demands rapid diagnosis and fasciotomy, as delays quickly lead to irreversible muscle necrosis and permanent limb dysfunction. ✅ [****Contemporary Diagnosis and Management of Compartment Syndrome**](https://journals.lww.com/prsgo/fulltext/2024/03000/practical%5Freview%5Fon%5Fthe%5Fcontemporary%5Fdiagnosis%5Fand.19.aspx?ref=theplasticsfella.com) Despite modern pressure monitors and imaging adjuncts, compartment syndrome is still fundamentally a clinical diagnosis — and outcomes hinge on maintaining a low threshold for early fasciotomy rather than waiting for perfect measurements. ✅ [****Management of Volkmann’s Ischaemic Contracture of the Upper Limb** ](https://pubmed.ncbi.nlm.nih.gov/4078477/?ref=theplasticsfella.com) Management of Volkmann’s contracture is severity-dependent: mild, moderate, and severe patterns require different surgical and rehabilitative strategies rather than a single uniform approach. ## Feedback ### I hope you enjoyed it 😄 --- ### The Information Age Paradox, 3 Pedicle-Saving Moves, & Mathes-Nahai in Action URL: https://www.theplasticsfella.com/january-25th/ Last updated: 2026-01-25T09:55:53.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/january-25th/#a-letter-from-pfella) The information age (that hides information). 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-25th/#the-sunday-quiz) How well do you know *muscle flaps*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/january-25th/#image-of-the-week) Latissimus Dorsi: Mathes & Nahai in action. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/january-25th/#technique-tip) Medial gastrocnemius muscle flap for proximal tibial coverage. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/january-25th/#what-does-the-evidence-say) When the “dominant” pedicle isn’t dominant: Using secondary inflow to rescue muscle flaps. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/january-25th/#articles-of-the-week) Fracture healing under muscle flaps, free flap salvage, & muscle flaps in lower limb recon. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/january-25th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Information Age (That Hides Information)* 👋 There’s a strange thing happening in surgical education right now. We have more information than ever… and somehow it feels **harder* to get to the right bit, at the right time, when you actually need it. This past month week made that painfully obvious. We had our podcast researcher trying to track down the original Mathes paper. Not a niche study; a foundational piece of work. And it still took days of back-and-forth, access issues, dead links, journal gates, the whole obstacle course. Then you finally read it and there’s Mathes and Nahai referencing an article from **1919** like it was sitting on the desk beside them. Let that sink in. Before PDFs, before databases, before “institutional access”, someone could cite half a century old paper with less friction than it sometimes takes us to access a landmark classification today. So yes, the world is digital now. But the barrier hasn’t disappeared. In some ways, it’s just changed shape. The point isn’t that people don’t want to learn. It’s that most of us are already operating at full capacity. You’re in clinic. You’re prepping a list. You’re teaching. You’re on-call. You don’t have the time (or patience) to fight your way through five layers of “request access” just to confirm one detail. And that’s exactly why the way surgical knowledge is organised matters. All of this came up during a podcast recording with Foad Nahai we did this week. One of those conversations that starts about “muscle flaps” and showed way to tackle a bigger problem: how we access knowledge, how we teach it, and what gets lost when it’s too hard to find. We’re kicking off the new season of our podcast in **February**, and we’ve got a very exciting **guest** **appearance** for episode one. More soon! But for now, here’s the takeaway: We don’t have a knowledge problem in surgery. We have an **access problem**. And every time it takes days to retrieve a paper that should be easy to find, it reinforces why we need better systems for learning, revising, and decision-making. That’s the track we’re on. And we’re staying on it. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Muscle Flaps?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the fifth round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ## Image of the Week **Latissimus Dorsi: Mathes & Nahai in Action* 🖼️ ****Image of the Week** This classic image from the original Mathes & Nahai work demonstrates how ****vascular anatomy dictates flap reliability and reach**. The latissimus dorsi is a ****Type V** muscle flap: it has a ****dominant pedicle** (thoracodorsal artery) with additional secondary segmental perforators. The top diagrams illustrate how the ****arc of rotation** changes depending on whether the flap is based on the dominant pedicle versus the secondary segmental supply (the concept behind the ****reverse latissimus dorsi**). The operative photo reinforces the practical point: preserving these segmental vessels can expand reconstructive options when the dominant pedicle isn’t usable. ![Latissimus Dorsi Flap - Source: Mathes and Nahai, 1981](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/Screenshot-2026-01-23-at-17.15.51.png) Latissimus Dorsi Flap - Source: Mathes and Nahai, 1981 ## Technique Tip **Medial Gastrocnemius Muscle Flap for Proximal Tibial Coverage* 🚑 ****Technique Tip of the Week** This week's technique tip focuses on harvesting the ****medial gastrocnemius flap**, a dependable local muscle flap for covering ****medial proximal third tibial defects**, particularly after trauma (exposed tibia) or following tumour resection with a bone/soft tissue gap. The key operative principle is preserving the ****dominant vascular pedicle**, which typically enters the muscle approximately ****3 cm proximal to the knee joint**, making careful proximal dissection essential. Once elevated, the flap can be mobilised and transposed to provide well-vascularised coverage over the upper tibial bone, improving protection of exposed structures and creating a robust bed for reconstruction. Safe harvesting depends on systematic elevation in the correct plane while maintaining pedicle integrity, allowing reliable rotation into proximal leg defects without the morbidity of free tissue transfer in many cases. ## What Does the Evidence Say? **When the “Dominant” Pedicle Isn’t Dominant: Using Secondary Inflow to Rescue Muscle Flaps* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The Mathes-Nahai system is still the quickest way to predict how forgiving a muscle flap will be when you rotate it, thin it, or (accidentally) compromise inflow. But real-world cases keep reminding us that “minor” pedicles can matter more than the label suggests. In the sternocleidomastoid (traditionally Type II), angiographic work suggests the ****superior thyroid artery branch** can perfuse most of the muscle, raising the possibility that SCM behaves more like a ****two-dominant-pedicle (Type III)** pattern in many patients, supporting why STA-preserving techniques can improve reliability in practice. The same “don’t over-trust the map” lesson shows up in the rectus femoris (Type II): viability has been reported even after **proximal inflow ligation**, consistent with clinically meaningful collateralisation, particularly in vascular-disease territory where you’d expect the opposite. And for classic Type V territory, latissimus dorsi reconstruction has been reported using a ****posterior intercostal artery perforator-based pedicle** when the **thoracodorsal artery** is compromised, demonstrating how secondary segmental supply can be leveraged deliberately (not just hoped for). ****Takeaway:** Use Mathes-Nahai to plan the flap, but confirm **perfusion** in the patient you’re actually operating on (CTA/Doppler/ICG where appropriate), and preserve/identify alternative inflow early when operating in scarred fields or after prior dissection. Sources: ([Mathes & Nahai](https://pubmed.ncbi.nlm.nih.gov/7465666/?ref=theplasticsfella.com), 1981), ([Srivastava](https://pmc.ncbi.nlm.nih.gov/articles/PMC8690521/?ref=theplasticsfella.com), 2021), ([Julian](https://pmc.ncbi.nlm.nih.gov/articles/PMC10795896/?ref=theplasticsfella.com), 2024), ([Spiegel](https://pmc.ncbi.nlm.nih.gov/articles/PMC11902951/?ref=theplasticsfella.com), 2025). ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ [****Why Fractures Heal Better Under Muscle Flaps**](https://www.sciencedirect.com/science/article/abs/pii/S1748681525003808?ref=theplasticsfella.com) Muscle flaps outperform fasciocutaneous flaps in fracture healing by improving angiogenesis, reducing infection, enhancing bone strength, and promoting a more biologically active healing environment despite inconclusive clinical data. ✅ [****The Failing Flap Playbook: Salvage Fast, or Switch Plans**](https://pmc.ncbi.nlm.nih.gov/articles/PMC9911216/?ref=theplasticsfella.com) Free flap salvage depends on rapid recognition and early re-exploration, with success falling steeply after repeat compromise or delayed presentation, often necessitating early secondary reconstruction. ✅ [****Historical Paper: Muscle Matters: What Early Flap Data Got Right**](https://pubmed.ncbi.nlm.nih.gov/3273073/?ref=theplasticsfella.com) In lower limb reconstruction, muscle flaps (free or pedicled) promote better fracture and osteomyelitis healing, with free flaps showing fewer overall complications despite slightly higher major complication risk. ## Feedback ### I hope you enjoyed it 😄 --- ### Join the Foundations Review Team, 5 Chemical Burn Lessons, & Burn Wound Debridement URL: https://www.theplasticsfella.com/january-18th/ Last updated: 2026-01-17T19:09:09.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/january-18th/#a-letter-from-pfella) Join the Foundations review team. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-18th/#the-sunday-quiz) How well do you know *chemical burns*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/january-18th/#image-of-the-week) Ocular chemical burns: Severe grades. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/january-18th/#technique-tip) Burn wound debridement & surgical preparation. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/january-18th/#foundations-textbook) Your reminder to grab Foundations while it's available. 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/january-18th/#what-does-the-evidence-say) Hydrofluoric acid burns: Calcium Gluconate and pain-driven treatment. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/january-18th/#articles-of-the-week) First aid, irrigation with water, & clinical and forensic signs for chemical burns. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/january-18th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Join the Foundations Review Team* 👋 One of the best parts of building The Plastics Fella is that the work doesn’t stop when something gets published. That’s also the hard part. Surgery moves. Guidance changes. Techniques evolve. The “standard approach” from a few years ago becomes outdated quietly… and then one day it matters, because someone reads an article right before theatre and trusts what’s written. So we’ve always taken being up-to-date seriously. This year, we’re running our first annual refresh of [**Foundations**](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com), our plastic surgery textbook. This **3-6 month** project is focused on maintaining content accuracy, clinical relevance, and consistency with contemporary practice. And we want to build a team for this. **The Role: Clinical Reviewer** We’re looking for a small group of clinical reviewers to help us keep our textbook content up to date. - Fact-checking and clinical accuracy. - Making sure content reflects current practice. - Spotting gaps and outdated content. - Join in on other projects such as live events, teaching, etc. We’re looking for both junior and senior reviewers. So whether you’re a student, in training (trainee/resident), or a consultant, we’d love to hear from you — as long as you’re practical, detail-oriented, and give honest feedback. If you’re interested, drop your details in the form below. We’ll follow up with more information and next steps. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Chemical Burns?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the fourth round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ## Image of the Week **Ocular Chemical Burns: Severe Grades* 🖼️ ****Image of the Week** This figure shows ****severe ocular surface burns** and how grading is driven by ****limbal ischaemia** (clock hours) and ****corneal haze**. In this series, ****Roper-Hall Grade IV** is subdivided by ****Dua** into: \- ****Dua 4:** ****6-9** clock hours limbal ischaemia (A-D) \- ****Dua 5:** ****9-11** clock hours (E-H) \- ****Dua 6:** ****12** clock hours (I-L) The top row shows presentation; the bottom row shows final follow-up. Panels also contrast ****standard medical therapy** (A, B, E, F, I, J) versus cases that underwent ****amniotic membrane transplantatio**n (C, D, G, H, K, L). ****Takeaway:** More limbal ischaemia = higher grade, worse prognosis, and earlier need for specialist escalation. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/Representative-photographs-of-patients-with-severe-ocular-surface-burns-Grade-4-Roper.png) Ocular Chemical Burns - [Source](https://www.researchgate.net/figure/Representative-photographs-of-patients-with-severe-ocular-surface-burns-Grade-4-Roper%5Ffig2%5F45440597?ref=theplasticsfella.com) ## Technique Tip **Burn Wound Debridement & Surgical Preparation* 🚑 ****Technique Tip of the Week** This video demonstrates a key principle in operative burn care: ****convert an unstable burn wound into a clean, viable wound bed** before definitive dressings or grafting. The creator debrides the burn by removing devitalised epidermis and slough, including lifting away loose blistered tissue, to expose the underlying dermis and clearly define the true burn depth. The technique is deliberately systematic and controlled, working in tissue planes, trimming only what is non-viable, and aiming for a healthy, stable surface rather than aggressive “over-excision.” This step is essential because retained necrotic tissue increases infection risk and impairs healing, whereas proper debridement improves topical agent penetration and prepares the wound for either reassessment, biologic coverage, or later split-thickness skin grafting if the burn proves deep. The key takeaway is that good burn surgery starts with **meticulous wound bed preparation**: remove what must go, preserve what can heal, and leave behind tissue you’d be confident to graft onto if needed. ## Foundations Textbook **Your Reminder to Grab Foundations While it's Available* 📘 Here's your reminder to grab [Foundations](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) while it's available! We created a plastic surgery textbook that fits the reality of training: fragmented, time-pressured, and clinical, this is it. 150+ curriculum-mapped topics: Short chapters, theatre-first explanations, curriculum mapping, and live updates via QR code. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/-SSS-Posts--49-.png) [Grab Your Copy!](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) ## What Does the Evidence Say? **Hydrofluoric Acid Burns: Calcium Gluconate and Pain-Driven Treatment* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Hydrofluoric acid burns are not “just” acid burns. The fluoride ion can penetrate deeply and drive ****progressive local injury** and ****systemic toxicity**, and the surface area can be misleading (i.e., burn size isn’t reliably predictive of severity). Symptoms can also be ****delayed**, particularly with more dilute solutions, and systemic effects relate to disrupted calcium, magnesium, and potassium balance (with potential for dysrhythmias). Across guidance and published strategies, the most consistent message is ****speed + calcium**: rapid decontamination/irrigation followed by ****topical calcium gluconate** (commonly a 2.5% gel or calcium-containing slurry) with ****pain used as a practical bedside endpoint**. Continue treatment until pain is relieved. If meaningful pain relief is not achieved within roughly 30-60 minutes, escalation to calcium gluconate injection-based approaches is recommended, and ****calcium chloride is specifically discouraged for skin burns** due to severe pain and potential tissue injury. While high-quality human comparative trials are limited, ****experimental burn models** support topical calcium gluconate as a biologically plausible and effective early intervention: repeated application of ****2.5% calcium gluconate gel** reduced burn severity and improved healing versus no treatment in controlled settings. Taken together with clinical protocols, the implication is straightforward: ****earlier, sustained topical calcium appears better than delayed or minimal treatment**, especially for hand exposures where deeper penetration is common. For ****digit/hand burns** that remain painful despite topical therapy (including challenging ****subungual** injuries), the clinical literature supports “getting calcium to the fluoride” via targeted delivery: local infiltration, ****regional IV calcium (Bier-block-type)**, or ****selective intra-arterial calcium infusion** in severe cases. Case-series style evidence for intra-arterial infusion reports ****excellent symptom relief** with improvement of lesions, and regional IV calcium reports ****effective analgesia** with a goal of limiting ongoing tissue injury, typically requiring expert input and careful monitoring. Sources: ([Wang](https://www.sciencedirect.com/science/article/abs/pii/S0305417914001508?ref=theplasticsfella.com), 2014), ([Roblin](https://academic.oup.com/jbcr/article-abstract/27/6/889/4605472?redirectedFrom=fulltext&ref=theplasticsfella.com), 2006), ([Vance](https://www.sciencedirect.com/science/article/abs/pii/S0196064486806709?ref=theplasticsfella.com), 1986), ([Ryan](https://emj.bmj.com/content/14/6/401?ref=theplasticsfella.com), 1997) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Chemical Burn to the Skin: First Aid Impacts on Clinical Outcomes** ([Chai](https://www.sciencedirect.com/science/article/abs/pii/S0305417922001139?ref=theplasticsfella.com), 2022) Immediate, prolonged cool-water irrigation after cutaneous chemical burns is associated with improved clinical outcomes such as reduced hospital length of stay and less scarring, reinforcing the importance of early decontamination (with Diphoterine as a potential alternative when instantly available). ✅ ****Cum Grano Salis: Irrigation of Chemical Burns?** ([Crane](https://www.sciencedirect.com/science/article/abs/pii/S0305417924003802?ref=theplasticsfella.com), 2025) While “irrigate with water” is the classic first-aid advice for chemical burns, it isn’t a one-size-fits-all rule because different chemicals behave differently on skin, so the best first aid depends on what the agent actually is. ✅ ****Clinical and Forensic Signs Related to Chemical Burns** ([Dinis-Oliveira](https://www.sciencedirect.com/science/article/abs/pii/S0305417914002897?ref=theplasticsfella.com), 2015) Different chemicals leave surprisingly recognisable “signature” burn patterns because acids, alkalis, and specific agents damage tissue through different mechanisms, so the appearance + progression of the injury can sometimes hint at the exact chemical involved (e.g., sulphuric acid dehydration/heat injury vs alkali liquefactive necrosis vs hydrofluoric acid with deep toxicity). ## Feedback ### I hope you enjoyed it 😄 --- ### Foundations Returns, 3 HA Filler Safety Rules, & the Cost of Surgical Work URL: https://www.theplasticsfella.com/january-11th/ Last updated: 2026-01-19T10:06:47.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/january-11th/#a-letter-from-pfella) What causes a surgeon to die? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-11th/#the-sunday-quiz) How well do you know **HA fillers*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/january-11th/#image-of-the-week) Facial danger zones for injectables. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/january-11th/#technique-tip) Precision botox for upper facial dynamic lines. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/january-11th/#foundations-textbook) Back on the shelf! 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/january-11th/#what-does-the-evidence-say) Needle vs cannula: Does a cannula actually reduce vascular occlusion risk? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/january-11th/#articles-of-the-week) Injectability of HA dermal fillers, filler myomodulation, & hybrid filler efficacy. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/january-11th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **What Causes a Surgeon to Die?* 👋 Surgeons aren’t dying because we don’t know how health works. We’re dying because we keep pretending the way we work doesn’t count. This [**JAMA Surgery**](https://jamanetwork.com/journals/jamasurgery/fullarticle/2837077?guestAccessKey=017bc2f5-4c69-4da2-8e56-22ed194e084e&utm%5Fsource=twitter&utm%5Fmedium=social%5Fjamasurg&utm%5Fterm=19075003875&utm%5Fcampaign=video%5Fshorts&linkId=891076499) paper landed quietly, but it shouldn’t have. Using US mortality data from 2023, it showed that **surgeons die at higher rates than nonsurgeon physicians**. Same intelligence. Same medical access. Same awareness of risk. Yet surgeons come out worse. That’s not random — it’s structural. **We Don’t Lack Insight. We Lack Margin.** If you want to argue this is about “poor self-care,” then you’re saying surgeons are uniquely bad at applying basic medical knowledge to themselves. I don’t buy that for a second. The real difference is margin. Surgeons work in systems that run permanently close to failure: long hours, constant cognitive load, no real recovery, and zero tolerance for being “off.” That’s not a lifestyle problem. That’s job design. > Higher mortality rates among surgeons may be associated with work environment, professional demands, & lifestyle. A cross-sectional study analyzes mortality rates & leading causes of death among US surgeons compared with other occupation groups. > > 🔗 [https://t.co/jr1QdE4LD1](https://t.co/jr1QdE4LD1?ref=theplasticsfella.com) [pic.twitter.com/whxffqGCZ6](https://t.co/whxffqGCZ6?ref=theplasticsfella.com) > > — JAMA Surgery (@JAMASurgery) [December 26, 2025](https://twitter.com/JAMASurgery/status/2004537681234051568?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) **Fatigue Is the Quiet Killer We Joke About** One finding should stop everyone cold: **motor vehicle collisions are a leading cause of death among surgeons**. That’s not bad driving. That’s exhaustion. The post-call commute isn’t a badge of honour — it’s a risk exposure we’ve collectively normalised because “that’s how it’s always been.” If airline pilots did this, flights would be grounded (yes, I know, the airplane analogy). In surgery, we just laugh about the coffee stops and keep going. **Cancer Isn’t Just Bad Luck** The most uncomfortable signal? **Surgeons had higher cancer mortality than any other group studied — even other doctors.** The study can’t explain why, but we don’t need to be geniuses to suspect cumulative exposure: radiation, theatre chemicals, disrupted circadian rhythms, decades of stress physiology simmering in the background. We’re meticulous about shielding the patient. We’re far less thoughtful about shielding ourselves. **The Real Takeaway** If we actually want surgeons to live longer, the fix won’t come from mindfulness apps or wellness emails. It comes from redesigning work so recovery is real, fatigue is treated like the risk factor it is, and self-destruction stops being confused with commitment. Because here’s the uncomfortable truth: we’ve engineered one of the most technically advanced professions in medicine — and paired it with one of the most biologically stupid ways to live. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know HA Filler?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the third round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ## Image of the Week **Facial Danger Zones for Injectables* 🖼️ ****Image of the Week** This image highlights ****Danger Zone 1: the brow and glabella**, where filler and toxin injections carry the ****highest vascular risk**. The supratrochlear and supraorbital arteries ascend from the ophthalmic circulation and lie in close proximity to common injection planes. Inadvertent intra-arterial injection or retrograde embolisation can result in skin necrosis or irreversible visual loss. For injectors, this region reinforces a core safety principle: In high-risk zones, anatomy matters more than technique. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/download.jpeg) Facial danger zones 1 - brow and glabella - [Source](https://journals.lww.com/plasreconsurg/pages/video.aspx?v=1092&autoPlay=true&ref=theplasticsfella.com) ## Technique Tip **Precision Botox for Upper Facial Dynamic Lines* 🚑 ****Technique Tip of the Week** This video demonstrates injection of the ****glabellar “11” complex (corrugators and procerus), frontalis (forehead), and orbicularis oculi (crow’s feet)**, targeting dynamic lines while preserving harmonious muscle function. Effective treatment hinges on **anatomical understanding and judicious placement*: weakening the corrugators softens frown lines, careful frontalis dosing reduces horizontal forehead creases without inducing brow ptosis, and lateral orbicularis oculi injections smooth crow’s feet without affecting eyelid function. ## Foundations Textbook **Back on the Shelf!* 📘 [Foundations](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) is back on the shelf for January 2026! We wanted to create a plastic surgery textbook that works the way training actually feels: fragmented, time-pressured, and clinical. Foundations exists to make the fundamentals reliable under pressure. 150+ curriculum-mapped topics with: 👉 Short chapters 👉 Theatre-first explanations 👉 Curriculum-mapped structure 👉 AI-enhanced visuals 👉 QR-linked to the website that keep the content up-to-date [Grab Your Copy!](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) ## What Does the Evidence Say? **Needle vs Cannula: Does a Cannula Actually Reduce Vascular Occlusion Risk?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Vascular occlusion from dermal fillers is uncommon but can cause ****skin ischemia/necrosis** and, rarely, ****visual loss**, so prevention and immediate recognition matter. Across published clinical evidence, ****microcannulas** are associated with a lower reported ****occlusion rate** than needles (roughly 1 per 40,882 vs 1 per 6,410 syringe injections), but risk is not zero and both needles and cannulas can perforate vessels. Severe events cluster in higher-risk zones with arterial connections to the ophthalmic circulation, particularly the glabella/medial brow, nose, forehead, and superior nasolabial fold. No management strategy has been shown to consistently reverse established filler-related vision loss. When ****cutaneous ischemia** is suspected after ****hyaluronic acid (HA)** filler, the most consistently recommended intervention is to stop injecting and promptly infiltrate high-dose hyaluronidase into the ischemic area and immediate periphery, repeating treatment guided by capillary refill/colour/pain; delayed treatment (beyond \~1-2 days) may be too late to prevent necrosis. Sources: \- [Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection](https://pubmed.ncbi.nlm.nih.gov/33377939/?ref=theplasticsfella.com) \- [Preventing and Treating Adverse Events of Injectable Fillers](https://pubmed.ncbi.nlm.nih.gov/33543879/?ref=theplasticsfella.com) \- [Update on Avoiding and Treating Blindness From Fillers](https://pubmed.ncbi.nlm.nih.gov/30805636/?ref=theplasticsfella.com) \- [New High Dose Pulsed Hyaluronidase Protocol for Hyaluronic Acid Filler Vascular Adverse Events](https://pubmed.ncbi.nlm.nih.gov/28333326/?ref=theplasticsfella.com) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Injectability of Cross-Linked Hyaluronic Acid Dermal Fillers** ([Micheels](https://pmc.ncbi.nlm.nih.gov/articles/PMC10888303/?ref=theplasticsfella.com), 2024) The injectability of cross-linked hyaluronic acid dermal fillers varies significantly between and within brands, is strongly influenced by formulation factors such as lidocaine incorporation and manufacturing technology, and depends on injector-specific technique. ✅ ****Myomodulation With Injectable Fillers: Addressing Facial Muscle Movement** ([de Maio](https://pmc.ncbi.nlm.nih.gov/articles/PMC5945756/?ref=theplasticsfella.com), 2018) Injectable fillers can be strategically used to alter facial muscle dynamics by restoring structural support or mechanically limiting overactivity, thereby rebalancing synergistic and antagonistic muscle groups to improve facial aesthetics and functional asymmetries. ✅ ****Combining Calcium Hydroxylapatite and Hyaluronic Acid Fillers for Aesthetic Indications** ([Fakih-Gomez](https://pmc.ncbi.nlm.nih.gov/articles/PMC8831259/?ref=theplasticsfella.com), 2021) Premixed CaHA:CPM-HA injections to the midface and lower face were associated with clinically meaningful improvements in jawline contour (CR-MASJ) at 3 months with partial attenuation by 12 months, supporting the volumizing and lifting potential of this hybrid filler with no reported adverse events. ## Feedback ### I hope you enjoyed it 😄 --- ### Your 2025 Wrapped: How You & 349,000 Others Used thePlasticsFella URL: https://www.theplasticsfella.com/january-4th/ Last updated: 2026-01-03T20:10:31.000Z It’s that time of year — ****thePlasticsFella Wrapped**. We’ve been going through the 2025 data, and the more we look at it, the less this feels like a story about traffic. It’s a story about behaviour. In 2025, people didn’t use thePlasticsFella like a website. Instead, they used it like a ****clinical tool**: something you reach for under pressure, when you need clarity quickly. The headline numbers are strong for a niche specialty: ****349,000 unique visitors**, ****373,000 visits**, and ****553,000 pageviews**. But the number that matters most to me is this: ****users stayed longer**. Average visit duration increased ****36% to 1:27...**not a vanity metric, but a sign of ****trust**. So here’s the 2025 wrap: the moments, the patterns, and what this community reached for most. ❤️ P'Fella ## How You Found thePlasticsFella in 2025 **Being discovered and remembered* The entry points tell their own story. In 2025, you most often arrived through **organic search (259k visitors)**, followed by **direct traffic (66.8k)** and **email (21.8k)**. Each route reflects a different relationship with the platform. Search is need-based... you’re looking for an answer in the moment. Direct traffic is habit, which means you know exactly where to go without asking Google. Email is the strongest signal of all: an owned connection that doesn’t depend on algorithms or rankings. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/3.png) Taken together, it shows thePlasticsFella isn’t just being discovered. It’s increasingly being **remembered**. ## The Biggest Insight from 2025 **You used the platform in two modes* The most important thing the data revealed this year is that your behaviour falls into two clear patterns. You arrived either **task first** or **topic first**, and almost everything else followed from that. **Task first is the dominant mode.** This is when you come with one urgent question and very little patience because your context is clinical, not academic. You typically arrive via Google, spend about **53 seconds** on a page, and leave. Only around **16%** click into a second article, yet this group makes up roughly **80%** of all users. At first glance, that looks like shallow engagement, but it is not. It is the digital equivalent of grabbing a senior colleague in the corridor to ask one question before going back to a patient. You are not there to browse. You are there to do the right thing and avoid making a mistake. **Topic-first is different.** In this mode, you are more likely to arrive directly and stay longer, reading multiple articles and moving through related topics. The content does not change between the two groups. The difference is intent. When you arrive topic first, thePlasticsFella stops functioning like an answer engine and starts functioning more like a mentor. That distinction explains why certain metrics look the way they do, and more importantly, it should shape how the platform evolves next. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/2.png) ## Global Reach, but Universal Needs **Which country ranked first?* In 2025, thePlasticsFella’s reach was unmistakably global. The largest audiences came from the **United States**, **United Kingdom**, **India**, and **Australia**, followed by **Turkey**, **Canada**, **Mexico**, **Brazil**, and **Malaysia**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/7.png) But the real insight is not just geography. It is that the same learning gaps show up again and again across very different training systems. Different exams, different hospitals, different cultures, but strikingly similar questions and anxieties. That is why scalable education is possible. The need is not local. It is universal. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/5.png) ## The €25,000 Experiment [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com)**.. and what actually makes you learn* The most decisive work of 2025 was stopping the guesswork and properly testing how people learn on the platform. We invested **€25,000** in an experiment that delivered the same plastic surgery curriculum in three formats: a traditional [**textbook**](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) with a digital version, the website as the control, and a chat interface combined with a textbook. The early results looked predictable. The [textbook](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com), despite its authority, had the highest friction and produced the shallowest engagement, with shorter sessions and weaker depth. The website reduced friction and produced moderate depth. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/Your-Year-in-Plastics--9-.png) [Get it Today](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) But the real insight came when formats were combined. The **chat plus** [**textbook**](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) experience consistently produced the deepest reading, the longest sessions, and the strongest signals of genuine learning. This reframes what we assume about modern trainees. You are not incapable of depth, and you are not unwilling to learn. You are time-poor, cognitively overloaded, and constantly context-switching. You need low friction and a strong structure. Chat reduces the barrier to entry and helps you maintain momentum. Structured content provides the framework that turns momentum into understanding. ## What You Proved in 2025... **and what it means for 2026* When we distil 2025 down, you proved a few key truths about how surgeons actually learn. Most learning begins as retrieval because that is how clinical work operates. Retrieval is not laziness, it is necessity. Trust is earned by delivering reliable answers quickly under pressure. The fundamentals dominate demand globally. And deep learning is achievable when the pathway is clear and friction is low. Most importantly, hybrid delivery, especially chat paired with structured content, seems to be the strongest bridge between “I need this now” and “I want to understand this.” ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2026/01/4.png) That is the focus for 2026\. In 2025, I built pages. In 2026, I need to build pathways that adapt to your intent. The platform must stay exceptional for task first use, because that is the reality of surgery and the reason you trust it. But it also needs to convert urgency into progression by guiding you toward what to read next, building structured learning sequences, and using AI as the bridge between retrieval and real understanding. The goal is not just answers, but competence, confidence, and performance at scale. The most remarkable part of 2025 is not the growth. It is that **349,000 people showed up and used the platform seriously**. You did not come for entertainment. You came for clarity, structure, and confidence in a specialty that is hard. That is a responsibility, and the clearest signal that this is worth building properly. ## What do you want to see in 2026? ### **We love all ideas!* --- ### Upcoming Year-End Review, 3 Melanoma Decisions, & ALND Guide URL: https://www.theplasticsfella.com/december-21st/ Last updated: 2025-12-21T08:18:27.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/december-21st/#a-letter-from-pfella) Help us shape: A wrapped year in Plastics. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/december-21st/#the-sunday-quiz) How well do you know **ALND*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/december-21st/#image-of-the-week) Nerve preservation in axillary dissection. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/december-21st/#technique-tip) Axillary lymph node removal in recurrent melanoma. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/december-21st/#what-does-the-evidence-say) Completion ALND in positive SLN melanoma. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/december-21st/#articles-of-the-week) Lymph node metastases, elective dissection, & sentinel node biopsy. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/december-21st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Help Us Shape: A Wrapped Year in Plastics* 👋 For the final ****Plastics Paper** of the year, we’re planning a Christmas special: a proper ****Year in Review** that reflects how people actually use this platform. It's less of an annual report, more of a **Spotify Wrapped* for plastics! For most people in surgery, December isn’t just “reflection season”. It’s just… a bit fried. Handovers. End-of-year loose ends. Clinics that somehow get busier, a list of cases you promise to write up over the holidays, and a brain that’s been running hot since August. So next week, for the final Plastics Paper of the year, we’re gathering up some useful insights for you. We don't want to just focus on what we published. We want to bring light to what you actually went back to. - What shaped your year in training? - What genuinely changed how you think or practise? - And what do you want more help with going into 2026? Because here’s what I love about looking at the patterns: you get a much truer picture of modern practice than any curriculum ever captures. That’s the story I want next week’s issue to tell. A handful of topics get hammered all year. The same questions keep coming up. Certain pages get opened late at night, or early in the morning, or five minutes before a list. So next week, we’ll pull together the big themes, the repeat offenders, the reliable favourites, and the few surprises. This'll also shape what we build and write next year. Rather than guessing what would be most useful, I’d much rather ask. On our *Plastics Wrapped*, what would you actually want to see? With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know ALND?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the fourth round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ps - a bit of over-enthusiasm on our side resetting the leaderboard, so a couple of weeks vanished. Everyone’s been reset equally. ## Image of the Week **Nerve Preservation in Axillary Dissection* 🖼️ ****Image of the Week** This intraoperative image highlights the ****intercostobrachial nerves** (ICBNs) encountered during axillary lymph node dissection. The second and third ICBNs traverse the axilla in close proximity to the ****axillary vein and nodal tissue**, making them particularly vulnerable during melanoma clearance. These nerves provide sensory innervation to the upper medial arm and axilla. When oncologically safe, identification and preservation of the ICBN reduces the risk of chronic paraesthesia, dysaesthesia, and neuropathic pain — a major source of long-term morbidity after axillary surgery. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/12/axillary-dissection.jpg) [****Source**](https://www.sciencedirect.com/science/article/pii/S1015958413000377?ref=theplasticsfella.com) ## Technique Tip **Axillary Lymph Node Removal in Recurrent Melanoma* 🚑 ****Technique Tip of the Week** This week's technique tip demonstrates axillary lymph node removal using standard axillary dissection principles across two clinical scenarios. The first case shows ****removal of a superficial axillary lymph node**, illustrating careful layer-by-layer dissection through skin and subcutaneous tissue to expose the nodal basin. The second case involves ****excision of a significantly larger node from recurrent melanoma**; although the mass is more bulky, the surgical approach remains the same. Key steps include adequate exposure, controlled dissection around the lymph node, and systematic mobilisation of surrounding tissue while maintaining respect for axillary anatomy. Meticulous dissection, clear identification of tissue planes, and adherence to oncological principles are essential in both routine and complex axillary node surgery. ## What Does the Evidence Say? **Completion ALND in Positive SLN Melanoma* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Completion axillary lymph node dissection** (CLND) for positive sentinel lymph node melanoma shows modest benefits with significant surgical considerations. A large meta-analysis of 7,966 patients (Macedo et al., 2019) found CLND improved 3-year and 5-year ****disease-free survival** (71.0% vs 66.2%, p=0.02), but did not significantly improve melanoma-specific or overall survival. Surgical complications are notable: (Vries et al., 2005) reported increased short-term complications and ****functional shoulder limitations** with CLND. (Hieken et al., 2018) recommends a selective, individualized approach, considering patient factors like comorbidities, life expectancy, and likelihood of additional positive nodes. The current evidence suggests CLND may be beneficial for carefully selected patients, but cannot be universally recommended. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Do Lymph Node Metastases Change Survival or Just Refine Risk in Melanoma?** ([Faries](https://pmc.ncbi.nlm.nih.gov/articles/PMC6202130/?ref=theplasticsfella.com), 2018) While sentinel lymph node metastasis remains one of the strongest prognostic factors in melanoma, early completion lymph node dissection (MSLT-II, DeCOG-SLT) improves regional control and staging accuracy but does not improve melanoma-specific survival. ✅ ****Historical Publication: Elective Lymph Node Dissection Improves Survival In Intermediate-Thickness Melanoma** ([Balch](https://pubmed.ncbi.nlm.nih.gov/8813254/?ref=theplasticsfella.com), 1996) In stage I-II melanoma (1-4 mm), elective (immediate) regional lymph node dissection did not improve overall 5-year survival for the full cohort, but it did confer a survival advantage in key subgroups such as ****≤**60 years-old patients, non-ulcerated primaries, and tumors 1-2 mm. ✅ ****Why Is Sentinel Node Biopsy The Standard For Early-Stage Melanoma?** ([Morton](https://pubmed.ncbi.nlm.nih.gov/16135917/?ref=theplasticsfella.com), MSLT-I, 2005) Sentinel lymph node biopsy provides accurate regional nodal staging with low morbidity, avoiding the significantly higher complication rates of routine completion lymph node dissection, establishing SLNB as the standard of care for staging clinically node-negative melanoma. ## Feedback ### I hope you enjoyed it 😄 --- ### 2 Types of Trainees, Facial Nerve Anatomy, Reanimation Tips URL: https://www.theplasticsfella.com/december-14th/ Last updated: 2025-12-13T20:22:07.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/december-14th/#a-letter-from-pfella) Two types of trainees and the gap between education & training. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/december-14th/#the-sunday-quiz) How well do you know **facial nerve palsy*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/december-14th/#image-of-the-week) Superficial nerves of the head & neck. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/december-14th/#technique-tip) Masseteric-innervated free gracilis for facial reanimation. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/december-14th/#what-does-the-evidence-say) Is faster always better in facial reanimation? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/december-14th/#articles-of-the-week) Bell’s palsy, muscle transfer for facial reanimation, & House-Brackmann system for grading facial nerve function. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/december-14th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Two Types of Trainees and The Gap Between Education & Training* 👋 Most surgical education is built for a version of the trainee that barely exists. On a slide deck, it looks beautiful. Chapters. Guidelines. Textbooks. PDFs. Long-form courses. Everything assumes a calm, well-rested learner with time, silence, and linear attention. But real training doesn’t happen in lecture halls. It happens between bleeps, before ward rounds, and minutes before decisions. We built education for readers, while trainees live in a world of retrieval. **Two Ways Trainees Show Up** When you strip everything back, every trainee arrives in one of two modes: Task-first or topic-first. That single difference dictates everything about how they behave. **Task-first learners** arrive with one question and zero patience. They’re not “learning” in the traditional sense. Instead they’re trying to survive a clinical decision. The data is blunt: - They arrive via Google - They read one article for \~53 seconds - Only 16% ever open a second page This isn’t laziness. It’s reality. It’s the digital equivalent of grabbing a senior in the corridor: *urgent question → fast answer → back to the patient.* Here’s the uncomfortable part: this is **80%** oftrainees. Task-first learning isn’t a niche. It’s the default operating mode of modern surgery. Then there’s the other group. **Topic-first learners** come intentionally. They arrive directly. And their behaviour flips. They stay longer. They read more. They explore. The content hasn’t changed — their intent has. This is where education platforms like The Plastics Fella must stop acting like a search engine and start acting like a mentor. **The Mistake We Nearly Made** When I first saw that 80% figure, the conclusion felt obvious. “The world has become retrievers. Reading is dead.” But assumptions are dangerous, especially in education. So instead of reacting, we tested it. Properly. What we found wasn’t that deep learning had disappeared. It was that **timing matters**. Trainees don’t want long-form education instead of retrieval. They want it after. First, help me right now. Then teach me properly. Most education systems only serve the second moment and completely ignore the first. **The Real Lesson** If surgical education wants to stay relevant, it has to stop pretending trainees live in lecture halls and start designing for the moments that actually define training. The quiet evening of reading still matters. But so does the chaotic minute before a decision. Build for both, or you build for no one. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Facial Nerve Palsy?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the third round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ## Image of the Week **Superficial Nerves of the Head & Neck* 🖼️ ****Image of the Week** This week's image shows the superficial nerve anatomy of the face, scalp, and lateral neck, highlighting the facial nerve branches in relation to key ****cutaneous sensory nerves**. While facial nerve palsy is a motor deficit, understanding this layered anatomy is essential: \- to avoid iatrogenic nerve injury during facial surgery, \- to differentiate motor weakness from sensory disturbance, and \- to safely plan incisions, dissections, and nerve blocks. Key landmarks include the ****extratemporal facial nerve branches** as they traverse the face, alongside sensory nerves such as the supratrochlear, infratrochlear, nasociliary, and auriculotemporal nerves. The close relationship between motor nerves, sensory nerves, and vascular structures explains why facial procedures carry both functional and sensory risk. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/12/Gray790.jpg) Superficial Nerves of the Head & Neck - [Source](https://www.ncbi.nlm.nih.gov/books/NBK554569/figure/article-49275.image.f3/?report=objectonly&ref=theplasticsfella.com) ## Technique Tip **Masseteric-Innervated Free Gracilis for Facial Reanimation* 🚑 ****Technique Tip of the Week** In long-standing facial nerve palsy with irreversible muscle denervation, a free gracilis muscle flap innervated by the masseteric nerve provides reliable, powerful dynamic smile restoration. The masseteric nerve offers: \- High axonal load \- Short reinnervation distance \- Predictable and early muscle activation Early post-operative movement is volitional (smile triggered by jaw clenching). Masseteric innervation prioritises ****strength and reliability**, making it ideal in: ****\-** Long-standing palsy ****\-** Failed nerve grafts ****\-** Older patients or those unsuitable for cross-facial nerve grafting This video demonstrates free gracilis transfer with masseteric nerve coaptation. ## What Does the Evidence Say? **Is Faster Always Better in Facial Reanimation?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. In long-standing facial paralysis, the choice between ****cross-facial nerve grafting** (CFNG) and ****masseteric nerve transfer** reflects a balance between speed of recovery and smile spontaneity. Masseteric nerve transfer provides rapid and reliable reinnervation, typically within ****3-6 months**, with greater oral commissure excursion due to the strength of the masseteric nerve input. However, smiles are predominantly volitional, with low rates of true spontaneity, as cortical activation is linked to mastication rather than emotional expression. CFNG reinnervates more slowly, often taking up to ****18-24 months**, but achieves significantly higher rates of spontaneous, emotion-driven smiling by recruiting neural input from the contralateral facial nerve. Commissure excursion is generally lower than with masseteric transfer, but smile quality is more natural, particularly in younger patients and when nerve graft lengths are short. ****Dual innervation strategies** combining CFNG and masseteric nerve transfer aim to balance early power with long-term spontaneity. Comparative studies demonstrate similar overall facial outcome scores, including eFACE assessments, compared with single-nerve approaches, with gradual improvement in resting tone and facial symmetry over time, at the cost of increased surgical complexity. Overall, no single technique is superior. Reinnervation strategy should be individualised based on patient age, duration of paralysis, comorbidities, and whether speed or spontaneity is the primary goal, with shared decision-making central to management. Sources: ([Fattah](https://journals.lww.com/plasreconsurg/abstract/2012/02000/facial%5Fpalsy%5Fand%5Freconstruction.42.aspx?ref=theplasticsfella.com), 2012) ([Hontanilla](https://pubmed.ncbi.nlm.nih.gov/26143295/?ref=theplasticsfella.com), 2015) ([Terzis](https://www.researchgate.net/publication/40028601%5FBabysitter%5FProcedure%5Fwith%5FConcomitant%5FMuscle%5FTransfer%5Fin%5FFacial%5FParalysis?ref=theplasticsfella.com), 2009) ([Terzis](https://pubmed.ncbi.nlm.nih.gov/18470829/?ref=theplasticsfella.com), 2008) ([Biglioli](https://www.sciencedirect.com/science/article/abs/pii/S101051821830057X?ref=theplasticsfella.com), 2018) ([Banks](https://journals.sagepub.com/doi/full/10.1001/jamafacial.2015.2095?ref=theplasticsfella.com), 2015) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****When Should Corticosteroids Be Used in Bell’s Palsy?** ([Chung](https://pmc.ncbi.nlm.nih.gov/articles/PMC12298506/?ref=theplasticsfella.com), 2025) Early oral corticosteroids started within 72 hours of symptom onset significantly improve recovery in Bell’s palsy, achieving higher complete facial nerve recovery rates and faster functional return, establishing steroids as the standard of care for acute facial paralysis. ✅ ****Is Single-Stage Gracilis Free Muscle Transfer Sufficient for Facial Reanimation?** ([Fukumoto-Inukai](https://pubmed.ncbi.nlm.nih.gov/40100160/?ref=theplasticsfella.com), 2025) Single-stage gracilis free muscle transfer achieves comparable flap survival and long-term functional and aesthetic outcomes to two-stage facial reanimation, while reducing operative time, hospital stay, and overall morbidity, supporting its use as an efficient and cost-effective approach for long-standing facial paralysis. ✅ ****The Standard System for Grading Facial Nerve Function** ([House-Brackmann](https://www.researchgate.net/profile/John-House-2/publication/16322036%5FFacial%5FNerve%5FGrading%5FSystem/links/5ac28e65a6fdcccda65f7f4e/Facial-Nerve-Grading-System.pdf?ref=theplasticsfella.com), 1985) The House-Brackmann scale provides a simple, validated 6-grade classification of facial nerve dysfunction from Grade I (normal) to Grade VI (total paralysis), enabling consistent clinical assessment, outcome reporting, and communication across providers managing facial paralysis. ## Feedback ### I hope you enjoyed it 😄 --- ### The Time Index, 3 Keys in Melanoma Care, & Evidence on SLNB URL: https://www.theplasticsfella.com/december-7th/ Last updated: 2025-12-07T10:14:00.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/december-7th/#a-letter-from-pfella) Introducing the time index. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/december-7th/#the-sunday-quiz) How well do you know **melanomas*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/december-7th/#image-of-the-week) The ABCDEs of melanoma detection. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/december-7th/#technique-tip) Glabellar flap for melanoma reconstruction. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/december-7th/#what-does-the-evidence-say) Does SLNB improve survival? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/december-7th/#articles-of-the-week) NCCN guidelines: cutaneous melanoma, neoadjuvant immunotherapy for stage III melanoma, & sentinel node-positive melanoma management. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/december-7th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Introducing the Time Index* 👋 The metrics publishers celebrate in medical education are mostly useless. Submission counts, acceptance rates, pageviews — they make for nice annual reports, but they tell us nothing about whether anyone actually learns. If we really cared about education, our scoreboard would look completely different. **The Metric We *Should* Care About** The ideal metric is *Retrieval-to-Bedside Time*: **How long does it take for someone to learn something and then use it safely, in real clinical practice, more than once?** That’s the real proof of understanding. And right now, we can’t measure it — not accurately. Realistically, not until 2027. So until then, we can work with the next best proxy: time. Retention measures comprehension. Recurrence measures adoption. **Introducing the Time Index** This is why surgical education needs a new cultural metric: the **Time Index**. **How long does a trainee stay with a single idea?** Not how many visited. Not how many clicked. But how long they stayed — voluntarily, repeatedly, because the concept mattered. A crucial caveat: more time doesn’t automatically mean more learning. Ten hours trapped in an ISCP portfolio is a design failure, not a victory. But consistent, repeated time spent with a concept? That’s behaviour change. Commitment changes behaviour — and behaviour is the closest proxy we have to genuine learning. And that’s the beginning of a real metric. We are currently rebuilding thePlasticsFella to enable us to personalise these metrics to you. Stay tuned! With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Melanomas?* ****Ready to climb the leaderboard?** Join this round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the second round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ## Image of the Week **The ABCDEs of Melanoma Detection* 🖼️ ****Image of the Week** This week’s image highlights the ABCDE criteria: a simple and effective tool for distinguishing benign moles from suspicious lesions. A - ****Asymmetry**: Melanomas often lack symmetry. B - ****Border**: Irregular, notched, or uneven edges raise concern. C - ****Color**: Multiple or uneven colors can indicate malignancy. D - ****Diameter**: Lesions larger than 6 mm warrant closer assessment. E - ****Evolving**: Any change in size, shape, or colour is a key red flag. ![The ABCDEs of Melanoma Detection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/12/Illustration-of-ABCDE-criteria-for-skin-cancer-detection.png) The ABCDEs of Melanoma Detection - [Source](https://www.researchgate.net/figure/Illustration-of-ABCDE-criteria-for-skin-cancer-detection%5Ffig2%5F359338536?ref=theplasticsfella.com) ## Technique Tip **Glabellar Flap for Melanoma Reconstruction* 🚑 ****Technique Tip of the Week** This week’s technique tip focuses on reconstruction after wide excision of a melanoma on the nasal dorsum — an area where tissue match is important but ****oncologic safety must guide every decision**. ****Image sequence:** (a) Melanoma marked for wide local excision (b) Defect after excision with a glabellar flap elevated (c) Flap inset restoring nasal contour (d) Three-week healing with good colour match ⚠️ Caution: While the ****glabellar flap** offers excellent tissue match, ****flaps in melanoma are risky** because they can bury residual disease and make re-excision difficult. For melanoma and MIS, ****skin grafts are generally preferred** until margins are confirmed, and flaps should only be used when oncologic safety is certain. ![Glabellar Flap for Melanoma Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/12/fig5.png) Glabellar Flap for Melanoma Reconstruction - [Source](https://www.intechopen.com/chapters/47760?ref=theplasticsfella.com) ## What Does the Evidence Say? **Does SLNB Improve Survival?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Major Trials** ****MSLT-I** showed that SLNB improves staging accuracy and disease-free survival, and provides therapeutic benefit mainly in patients with intermediate-thickness melanoma and positive nodes compared with observation and delayed lymphadenectomy. ****MSLT-II** and ****DeCOG-SLT** then showed that ****completion lymph node dissection (CLND) after positive SLNB does not improve melanoma-specific survival**, but increases morbidity (especially lymphedema). ****Take-Home** SLNB is a ****prognostic and staging tool** that identifies patients for adjuvant systemic therapy and guides the intensity of follow-up. CLND is now rarely indicated; nodal basins with metastatic disease are managed with ****systemic therapy + ultrasound surveillance** in many centres. ****Key Trials and Summaries** \- Morton DL, et al. [Sentinel-node biopsy or nodal observation in melanoma (MSLT-I)](https://pubmed.ncbi.nlm.nih.gov/24521106/?ref=theplasticsfella.com). **N Engl J Med*. 2014;370:599–609\. \- Faries MB, et al. [Completion dissection or observation for sentinel-node metastasis in melanoma (MSLT-II)](https://pubmed.ncbi.nlm.nih.gov/28591523/?ref=theplasticsfella.com). **N Engl J Med*. 2017;376:2211–22\. \- Leiter U, et al. [DeCOG-SLT trial – CLND vs observation](https://pubmed.ncbi.nlm.nih.gov/27161539/?ref=theplasticsfella.com). **Lancet Oncol*. 2016;17(6):757–67\. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Neoadjuvant Immunotherapy Outperforms Adjuvant-Only Approach in Resectable Stage III Melanoma** ([Chen](https://pubmed.ncbi.nlm.nih.gov/40305630/?ref=theplasticsfella.com), 2025) The NADINA trial established neoadjuvant immunotherapy as superior to surgery-first followed by adjuvant therapy for resectable stage III melanoma, demonstrating improved long-term outcomes and changing the standard treatment paradigm. ✅ ****Do Patients with a Positive Sentinel Node Still Need Completion Lymph-Node Dissection?** ([Faries](https://pubmed.ncbi.nlm.nih.gov/28591523/?ref=theplasticsfella.com), 2017) MSLT-II showed that in sentinel node-positive melanoma, routine completion lymph-node dissection improves regional nodal control and prognostic information but does not improve melanoma-specific survival, so ultrasound nodal surveillance is now preferred and dissection is reserved for therapeutic indications. ✅ ****NCCN Guidelines: Cutaneous Melanoma - Key Clinical Principles** ([NCCN Guidelines: Cutaneous Melanoma - Key Clinical Principles](https://www.nccn.org/professionals/physician%5Fgls/pdf/cutaneous%5Fmelanoma.pdf?ref=theplasticsfella.com), 2025) These guidelines recommend complete excisional biopsy for accurate staging, stratify wide excision and sentinel-node biopsy by Breslow depth, endorse neoadjuvant immunotherapy for resectable stage III disease, prioritize modern systemic therapy for advanced melanoma, and outline risk-based follow-up to detect recurrence early. ## Feedback ### I hope you enjoyed it 😄 --- ### Skill School Manifesto, 3 Oncoplastic Lessons, & Foundations Referral System URL: https://www.theplasticsfella.com/november-30th/ Last updated: 2025-11-29T22:02:21.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/november-30th/#a-letter-from-pfella) Shifting from mere courses to competence: The Skill School manifesto. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-30th/#the-sunday-quiz) How well do you know **breast recon*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/november-30th/#image-of-the-week) Classic implant capsular contracture 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-30th/#technique-tip) Meticulous DIEP Perforator Dissection 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/november-30th/#foundations-textbook) Foundations referral system - coming soon! 6. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/november-30th/#upcoming-events) New breast surgery events added. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-30th/#articles-of-the-week) Oncoplastic recon, PRS CME, and DIEP Original Case Series. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/november-30th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Shifting From Mere Courses to Competence: The Skill School Manifesto* 👋 On a [previous Plastics Paper](https://www.theplasticsfella.com/november-9th/#a-letter-from-pfella), we asked a simple question. ****Are we ready to move beyond the course circuit?** The response wasn’t only positive, it was loud too. Surgeons from every stage of training and from every corner of the world share the same idea: *“I’m not done learning, but I’m done pretending weekend courses make me better.”* And that’s exactly the gap we’re trying to fill. **So, we’re building something. Together.** Not a weekend high. Not another certificate. Not a course you forget a month later. From your survey responses, a few themes were crystal clear: - You want accountability: Because real learning requires someone holding the mirror. - You want repetition: Not once. Not twice. Enough times that it becomes automatic. - You want mentorship that lasts: The kind that evolves as your skill evolves. - You want real measures of progress: Not “you’ll be fine,” but “here’s what improved and here’s what still needs work.” - You want a motivated community: A place where everyone is trying to get better. Not to just perform, impress, or collect certificates. We’re exploring what a **Skill School** could look like. Something designed from the ground up to help surgeons actually improve, retain, and refine their skills over time. Think of it as the opposite of a crash course. A Skill School is slow, deliberate, and honest. It asks more of you, but it gives more back. We’re imagining a system where: - You don’t just learn a technique, you revisit it until it sticks. - Feedback isn’t generic and vague. It’s built in to track your performance. - Mentorship is ongoing with support where you need it. - Your progress is visible to you and your faculty. - You become part of a motivated, accountable community. If we’re going to build a Skill School that actually works, it needs to solve your problems, not our assumptions. So, let us know how a Skill School can serve you 👇 With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Breast Recon?* ****Ready to climb the leaderboard?** Join this fresh round of our *Weekly Quiz* in each edition of thePlasticsPaper. This is the first round of seven rounds! The ****top** scorer wins our [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) textbook at a discount! ## Image of the Week **Wise‑Pattern Oncoplastic Reduction for Lower Pole Tumour* 🖼️ ****Image of the Week** Clinical example of ****severe capsular contracture** — note the high-riding, distorted breast mound and visible firmness from pathologic capsule tightening. In panel B, the highlighted area marks the ****inferior pole deficit**, where the contracted capsule pulls the implant upward and restricts natural contour. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/image-4.png) [Source](https://pubmed.ncbi.nlm.nih.gov/38983947/?ref=theplasticsfella.com) ## Technique Tip **How to Dissect the DIEP Perforator* 🚑 ****Technique Tip of the Week** A clear walkthrough of DIEP perforator dissection — identifying reliable perforators, protecting motor nerves, and separating vessels from the rectus muscle to preserve strength. ****Watch how meticulous perforator dissection ensures a well-perfused flap with minimal donor-site morbidity.** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/ChatGPT-Image-Nov-29--2025--09_59_27-PM.png) [Watch Full Video](https://www.youtube.com/watch?v=Xm69DMwq9Eg&ref=theplasticsfella.com) ## Foundations Textbook **Foundations Referral System - Coming Soon!* 📘 For those who purchased **Foundations* and loved it: We're opening a ****referral system** for you! We’re about to open a referral system for people who use Foundations for their daily practice and want to share it with colleagues in a trackable way. The plan: \- You’ll get a ****unique referral link** as an existing user. \- Colleagues who use it will get a small discount. \- For each purchase via your link, you’ll get a small reward. This referral system is simply us formalising what the community is already doing and giving you some credit for it. You'll receive the full details (and your link) in the next couple days, so keep an eye out on your ****inbox**. As always, thanks for being with the P'fella and growing with us! ## Upcoming Events **New Breast Surgery Events Added* 📣 We’ve just updated the Events page with newly added breast-related courses and webinars. If you’re interested in breast reconstruction, aesthetics, or oncoplastic updates, you’ll find a few fresh additions worth checking out. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Timing the Breast Recon? Too Long** ([JPRAS](https://www.jprasurg.com/article/S1748-6815%2825%2900337-7/fulltext?ref=theplasticsfella.com)) Longer delays to final breast reconstruction are linked to lower quality-of-life scores, but the drop only becomes clinically meaningful with very long waits. ****Fact:** Patients with BMI ≥35 kg/m² waited the longest median 936 days. ✅ ****4 Things to Know about Pre-Pectoral Breast Recon** ([PRS](https://pubmed.ncbi.nlm.nih.gov/39700251/?ref=theplasticsfella.com)) Prepectoral breast reconstruction avoids muscle dissection, and this review outlines who benefits, how implant/mesh choices affect outcomes, and how to revise complications. It provides a practical, controversy-focused framework with current evidence rather than just a standard overview. ✅ ****DIEPs Original Case Series** (Bob Allen, [1994](https://pubmed.ncbi.nlm.nih.gov/8141534/?ref=theplasticsfella.com)) The original DIEP flap paper shows you can reconstruct a breast using lower-abdominal skin and fat ****without sacrificing muscle**, reducing hernia and weakness risks. ****Fact:** In this early series, ****15 breasts were successfully reconstructed** using perforators alone. ## Feedback ### I hope you enjoyed it 😄 --- ### Apert's Hand: Clinical Features, Investigations, & Management URL: https://www.theplasticsfella.com/aperts-hand/ Last updated: 2025-11-29T18:55:22.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/aperts-hand/#overview-of-aperts-hand) Apert syndrome (acrocephalosyndactyly) is a rare genetic condition marked by characteristic differences in the skull, face, hands, and feet. It has a distinctive presentation affecting the upper limbs. [****Clinical Features**](https://www.theplasticsfella.com/aperts-hand/#clinical-features-of-aperts-hand) Key features are craniosynostosis, midface hypoplasia, and complex syndactyly affecting both the hands and feet. Upper limb anomalies significantly impact function. [****Management**](https://www.theplasticsfella.com/aperts-hand/#management-of-aperts-hand) The Upton classification guides the surgical management of Apert's hand. The primary goal is to optimize function and create a five-digit structure while preserving neurovascular integrity. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## Overview of Apert's Hand ****Key Point** Apert syndrome (acrocephalosyndactyly) is a rare genetic condition marked by characteristic differences in the skull, face, hands, and feet. It involves severe syndactyly and craniosynostosis, with a distinctive presentation affecting the upper limbs. Apert syndrome is characterized by: - **Bicoronal craniosynostosis:** Premature fusion of the coronal sutures in the skull. - **Midface hypoplasia:** Underdevelopment of the middle facial structures. - **Severe, complex syndactyly** of the hands and feet: Fusion of the digits leading to mitten-like hands and feet, often requiring staged surgical corrections. The image below illustrates an Apert's hand. ![Definition and presentation of Apert's hand](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-22T181131.839-1.png) Definition and presentation of Apert's hand ### Epidemiology The estimated prevalence is 15.5 per 1,000,000, making it a relatively rare condition. Apert syndrome accounts for about 4.2% of all craniosynostosis cases ([Cohen Jr.](https://pubmed.ncbi.nlm.nih.gov/1303629/?ref=theplasticsfella.com), 1992). ### Aetiology Apert syndrome results from a mutation in the fibroblast growth factor receptor 2 (FGFR2) gene, located on chromosome 10\. The condition follows an autosomal dominant inheritance pattern, although most cases are de novo mutations. FGFR2 mutations cause altered signaling during early embryonic development, leading to characteristic physical anomalies. **Related Syndromes** - **Crouzon syndrome:** Craniosynostosis without hand anomalies. - **Jackson-Weiss syndrome:** Craniosynostosis, 2nd and 3rd digit syndactyly, broad proximal phalanx, fused metatarsals and tarsals. - **Pfeiffer syndrome:** Craniosynostosis, broad and deviated great toes and thumbs. - **Antley-Bixler syndrome:** Craniosynostosis, slender hands, PIPJ contractures. 😎 ****Fun Fact:** The eponymous name is derived from the French paediatrician Eugene Apert, who described the condition in 1906. --- ## Clinical Features of Apert's Hand ****Key Point** Key features are craniosynostosis, midface hypoplasia, and complex syndactyly affecting both the hands and feet. Upper limb anomalies significantly impact function, particularly in the shoulder, elbow, and hand. **Key Features** - **Craniosynostosis** - **Midface hypoplasia** - **Complex syndactyly** of the hands and feet **Upper Limb Manifestations** - **Shoulder:** Asymmetrical development of the glenohumeral joint, with a hypoplastic glenoid fossa leading to restricted shoulder movement, which worsens with growth. - **Elbow:** Radiocapitellar articulation anomalies that limit elbow function. **Hand Anomalies** The hand deformities in Apert syndrome can be classified based on the extent and type of syndactyly: - **Complete vs. Incomplete Syndactyly:** Syndactyly that either extends to the tips of the digits (complete) or does not (incomplete). - **Simple vs. Complex Syndactyly:** Syndactyly involving only soft tissue (simple) or both soft tissue and bones (complex). **Specific Finger Involvement** - The **index, long, and ring fingers** typically present with complex syndactyly. - **Simple syndactyly** is often observed between the ring and little fingers. **Functional Impact** - The degree of **first webspace syndactyly**, along with **radial clinodactyly of the thumb** (a curvature of the thumb), is critical in determining hand function. The severity of these deformities has the most significant impact on fine motor skills and grasping ability. Upton classification of Apert's hand is illustrated in the table below. ![Upton classification of Apert's hand](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-22T143711.445.png) Upton classification of Apert's hand The image below illustrates clinical features of Apert's hand according to its types. ![Clinical features of Apert's hand according to its types](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-22T143004.061-1.png) Clinical features of Apert's hand according to its types --- ## Management of Apert's Hand ****Key Point** The Upton classification guides the surgical management of Apert's hand. The primary goal is to optimize function and create a hand that resembles a five-digit structure while preserving neurovascular integrity. ### Investigations - **X-rays of the hands** to assess bony abnormalities. - **Anaesthetic workup** to ensure surgical safety, usually around 4 months of age. - **Genetic testing** if the diagnosis is not established, to confirm a unifying diagnosis. ### Management Goals - Optimize hand function while preserving **neurovascular bundles**. - Achieve an aesthetic outcome as close as possible to a **five-digit hand**. - Surgery is **staged**, with the first procedures starting at around 4 months to ensure anaesthetic safety, usually performed before craniofacial surgery. ### Surgical Staging This is based on Upton classification. **Upton Type 1 Hand** - **At 4 months:** Release of the 2nd and 4th webspaces with skin grafting. - **Craniofacial surgery** may follow. - **6 years:** Further surgery includes deepening of the webspace and thumb lengthening using an opening wedge osteotomy of the delta phalanx, potentially with K-wire fixation. - Incisions are made in straight lines, with advancement of v-shaped dorsal and volar flaps that interdigitate at the webspace. - A **dorsal approach** is used to protect neurovascular bundles, with internal neurolysis to facilitate digital separation. - **Bony connections** are divided using a 15 blade or osteotome. - Skin grafts are harvested considering future **hair growth patterns**. **Upton Type 2 Hand** - **First stage (4 months):** Release of the 2nd and 4th webspaces. - **Second stage:** Release of the 1st and 3rd webspaces with release of the tight **adductor pollicis fascia**. - Thumb lengthening is achieved with an opening wedge osteotomy for the radially deviated thumb. **Upton Type 3 Hand** - **First stage:** Release of the 1st and 4th webspaces to free the border digits. - **Second stage:** Release the 2nd or 3rd webspaces, depending on the phalangeal fusion pattern. A **five-digit hand** may not always be the surgical goal. - Release of the tight **adductor pollicis fascia**, thumb lengthening, and opening wedge osteotomy for thumb deviation. Bone grafts may be necessary for thumb lengthening. 😎 ****Fun Fact:** Children with Apert syndrome often have ****hyperhidrosis**, so avoiding surgery during warmer seasons may reduce maceration and improve graft success. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Apert Syndrome Overview:** Apert syndrome is a rare genetic disorder caused by mutations in the FGFR2 gene, leading to craniosynostosis, midface hypoplasia, and severe syndactyly of the hands and feet. It occurs in about 15.5 per million and follows an autosomal dominant inheritance. ****2\. Clinical Features:** Key characteristics include craniosynostosis, midface hypoplasia, and complex syndactyly. Upper limb deformities impact shoulder, elbow, and hand function, with syndactyly affecting fine motor skills and grasp. ****3\. Investigations:** X-rays assess bony deformities, and genetic testing confirms the diagnosis. An anaesthetic workup is done before surgery, typically starting around 4 months of age. ****4\. Surgical Management:** The Upton classification guides staged surgeries to separate webspaces and correct thumb deformities. Early procedures focus on releasing the 2nd and 4th webspaces, with later surgeries addressing thumb length and webspace deepening. --- ## Further Reading 1. Cohen MM Jr, Kreiborg S, Lammer EJ, Cordero JF, Mastroiacovo P, Erickson JD, Roeper P, Martínez-Frías ML. [Birth prevalence study of the Apert syndrome](https://pubmed.ncbi.nlm.nih.gov/1303629/?ref=theplasticsfella.com). Am J Med Genet. 1992 Mar 1;42(5):655-9\. doi: 10.1002/ajmg.1320420505\. PMID: 1303629. 2. Kracoff SL. [Radiographic Characteristics of the Hand in Apert Syndrome](https://pubmed.ncbi.nlm.nih.gov/32000596/?ref=theplasticsfella.com). J Hand Surg Asian Pac Vol. 2020 Mar;25(1):82-86\. doi: 10.1142/S2424835520500113\. PMID: 32000596. 3. Al-Qattan MM. [A Review of the Genetics and Pathogenesis of Syndactyly in Humans and Experimental Animals: A 3-Step Pathway of Pathogenesis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766129/?ref=theplasticsfella.com). Biomed Res Int. 2019 Sep 15;2019:9652649\. doi: 10.1155/2019/9652649\. PMID: 31637260; PMCID: PMC6766129. 4. Upton J. Apert syndrome. [Classification and pathologic anatomy of limb anomalies](https://pubmed.ncbi.nlm.nih.gov/2065493/?ref=theplasticsfella.com). Clin Plast Surg. 1991 Apr;18(2):321-55\. PMID: 2065493. 5. Zucker RM, Cleland HJ, Haswell T. [Syndactyly correction of the hand in Apert syndrome](https://pubmed.ncbi.nlm.nih.gov/1648464/?ref=theplasticsfella.com). Clin Plast Surg. 1991 Apr;18(2):357-64\. PMID: 1648464. 6. Stauffer A, Farr S. [Is the Apert foot an overlooked aspect of this rare genetic disease? Clinical findings and treatment options for foot deformities in Apert syndrome](https://pubmed.ncbi.nlm.nih.gov/33248465/?ref=theplasticsfella.com). BMC Musculoskelet Disord. 2020 Nov 28;21(1):788\. doi: 10.1186/s12891-020-03812-2\. PMID: 33248465; PMCID: PMC7700708. 7. Harvey I, Brown S, Ayres O, Proudman T. [The Apert hand--angiographic planning of a single-stage, 5-digit release for all classes of deformity](https://pubmed.ncbi.nlm.nih.gov/22196295/?ref=theplasticsfella.com). J Hand Surg Am. 2012 Jan;37(1):152-8\. doi: 10.1016/j.jhsa.2011.10.017\. PMID: 22196295. 8. Raposo-Amaral CE, Denadai R, Furlan P, Raposo-Amaral CA. [Treatment of Apert Hand Syndrome: Strategies for Achieving a Five-Digit Hand](https://ern-ithaca.eu/wp-content/uploads/2020/12/Raposo%5FApert%5FHand%5FPlastReconstrSurg2018.pdf?ref=theplasticsfella.com). Plast Reconstr Surg. 2018 Oct;142(4):972-982\. doi: 10.1097/PRS.0000000000004815\. PMID: 29994846. ### ASPS Age Trends, 4 Craniofacial Lessons, & New Quiz Winners URL: https://www.theplasticsfella.com/november-23rd/ Last updated: 2025-11-23T09:23:09.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/november-23rd/#a-letter-from-pfella) Are we treating birthdays or bodies? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-23rd/#the-sunday-quiz) \*Drumroll🥁\* announcing the winners! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/november-23rd/#image-of-the-week) Sagittal craniosynostosis - preoperative 3D CT. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-23rd/#technique-tip) Recreating the levator sling in cleft palate repair. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/november-23rd/#upcoming-events) Newly added craniofacial & cleft conferences. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-23rd/#articles-of-the-week) Cleft lip/palate evaluation parameters, Pittsburgh fistula classification, & pharyngeal flap outcomes: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/november-23rd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Are We Treating Birthdays or Bodies?* 👋 When you look at the [ASPS](https://www.plasticsurgery.org/news/articles/the-most-popular-plastic-surgery-procedures-by-age?utm%5Fsource=Instagram&utm%5Fmedium=Social&utm%5Fcampaign=PSEC) stats by age, it reads like a tidy little biography of the human body. Teens reduce. Twenty- and thirty-somethings augment. Forties and fifties sculpt. And over-55s freshen the eyes. Not dramatic, not controversial — just honest, predictable human physiology meeting modern aesthetics. **Teens: Breast Reduction Rules the Roost** If you’ve ever treated a teenager with symptomatic macromastia, none of this is surprising. Back pain, shoulder grooves, embarrassment in school, PE avoidance — it’s heavy stuff for a young person. So yes, this is the decade where reduction surgery sits comfortably at the top. And honestly? It’s one of the most instantly gratifying procedures in the whole specialty. **20s & 30s: The Breast Augmentation Years** This group is classic: - In your 20s, you finally have independence and can act on an insecurity you might have carried for years. - In your 30s, pregnancy and breastfeeding have done their thing, and patients want a return to their pre-baby shape. The overall vibe? *Natural, proportionate, athletic.* Even in Texas, apparently. And with new implants like Motiva pushing surgeons to rethink submuscular vs subglandular placement, this space is evolving fast. **40-55: Liposuction Steps Into the Spotlight** This is the decade where metabolism slows, hormones shift, and weight redistributes… often in the most inconvenient places. So liposuction becomes the go-to move, especially for people who genuinely take care of themselves but still have the stubborn flank/saddlebag/bra-roll areas that literally laugh at diet and exercise. Add in how common it is to pair lipo with tummy tucks and lifts, and it’s no surprise this age group accounts for nearly half of all lipo procedures. **55+: Eyelids Take Centre Stage** Blepharoplasty becomes the star attraction here, and for good reason. Patients hit the point where hooding, puffiness and the “I slept eight hours but still look tired” look finally pushes them toward something more durable than Botox and filler. Fast recovery, discreet scars and a huge payoff? No wonder it’s popular. **The Real Takeaway** Zoom out and the pattern is crystal clear: - **Teens:** Remove the burden - **20s-30s:** Add volume - **40-55:** Shape the contour - **55+:** Brighten the eyes It’s not dramatic. It’s not philosophical. It’s simply how our bodies change and how people choose to keep up. With love, **P’Fella ❤️** ## The Sunday Quiz **\*Drumroll🥁\* Announcing the Winners!* ****Congratulations to the Winners** of The Weekly Quiz! We're thrilled to announce the winners of this edition's quiz. After seven rounds of questions on plastic surgery, we have our top scorers! The winners will receive a copy of our textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com), at a discount. We truly appreciate everyone who took part, and we wish you the best of luck for the next round! ![Sunday Quiz Leaderboard](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/Leaderboard-Team-Post-Template.png) Sunday Quiz Leaderboard ## Image of the Week **Sagittal Craniosynostosis - Preoperative 3D CT* 🖼️ ****Image of the Week** This week’s image is a preoperative 3D CT of sagittal craniosynostosis, showing a classic scaphocephalic skull and a fused sagittal suture. Early diagnosis on imaging opens the door to endoscopic strip craniectomy with postoperative helmet therapy when the child presents before 3-4 months. ****Takeaway:** Don’t just recognise the scaphocephalic shape. Use the 3D CT to decide if your patient still qualifies for a less invasive, growth‑friendly endoscopic option. ![Sagittal Craniosynostosis - Preoperative 3D CT](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/image.png) Sagittal Craniosynostosis - Preoperative 3D CT - [Source](https://commons.wikimedia.org/wiki/File:Original.01720096-201812000-00008.F2.jpg?ref=theplasticsfella.com) ## Technique Tip **Recreating the Levator Sling in Cleft Palate Repair* 🚑 ****Technique Tip of the Week** In a Furlow double-opposing Z-plasty, the levator repair ****is the operation**, not an add-on. Treat the levator as a mislocated muscle: dissect it off the posterior hard palate, retroposition the bellies onto the posteriorly based soft palate, and re-approximate them in a transverse sling within the opposing oral and nasal Z-flaps. The Z-plasty both lengthens the palate and hides your intravelar veloplasty inside well-vascularised, interdigitating flaps, improving velopharyngeal closure while keeping tension off the midline. Don’t start closing until you can see the full levator bellies and the reconstructed sling sitting at the hard-soft palate junction where it actually belongs. ![Levator Sling in Cleft Palate Repair](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/image-2.png) Levator Sling in Cleft Palate Repair - [Source](https://link.springer.com/chapter/10.1007/978-3-031-84663-2%5F17?ref=theplasticsfella.com) ## Upcoming Events **Newly Added Craniofacial & Cleft Conferences* 📣 We’ve just added a few craniofacial and cleft meetings to the Events page. If you’re deepening VPI/fistula skills or planning study leave with your team SLP and ortho colleagues, go check these out! ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Parameters for Evaluation and Treatment of Patients with Cleft Lip/Palate** ([American Cleft Palate - Craniofacial Association](https://pubmed.ncbi.nlm.nih.gov/34162066/?ref=theplasticsfella.com), 2018) US multidisciplinary guidance emphasizing SLP-led perceptual evaluation, nasopharyngoscopy for suspected VPI, and coordinated timing of secondary procedures with orthodontics and alveolar bone grafting. ✅ ****The Pittsburgh Fistula Classification System** ([Smith](https://pubmed.ncbi.nlm.nih.gov/18177198/?ref=theplasticsfella.com), 2007) A standardized, location-based system that improves reporting, communication, and selection of repair strategy from local two-layer closure to buccal/tongue flaps for wide anterior defects. ✅ ****Pharyngeal Flap Outcomes for Velopharyngeal Insufficiency and Postoperative Rates of Obstructive Sleep Apnoea** ([Boynuyoğun](https://www.jprasurg.com/article/S1748-6815%2823%2900750-7/abstract??ref=theplasticsfella.com), 2024) Matched to closure pattern, pharyngeal flap and sphincter pharyngoplasty yield comparable resonance outcomes, with measurable OSA risk for both, reinforcing endoscopy-led selection and careful port sizing especially in syndromic or obese children. ## Feedback ### I hope you enjoyed it 😄 --- ### Surgeon Stress, 3 Lower Limb Lessons, & Platform Updates Ahead URL: https://www.theplasticsfella.com/november-16th/ Last updated: 2025-11-16T11:53:51.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/november-16th/#a-letter-from-pfella) Calm surgeons make more complications? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-16th/#the-sunday-quiz) How well do you know *tibial fractures?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/november-16th/#image-of-the-week) Medial gastrocnemius flap. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-16th/#technique-tip) How to mark a gracilis flap. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/november-16th/#upcoming-events) Newly added lower limb trauma-related conferences. 6. ****🆕** [****New Feature**](https://www.theplasticsfella.com/november-16th/#new-feature) Platform update in 2026 - What do you want to see? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-16th/#articles-of-the-week) Standards in lower limb management, muscle vs FC flap, & when to flap a leg: With 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/november-16th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Calm Surgeons Make More Complications?* 👋 A new JAMA Surgery study shows that surgeons with **higher* stress in the first 5 minutes of a case had **fewer* major complications. Yes, you read that right. More sympathetic activation → *better* outcomes. It’s the exact opposite of everything the “wellness era” keeps preaching. **The Real Message** Here’s the uncomfortable truth: **Experienced surgeons operate best when they’re switched on,** not when sedated into calmness. This isn’t about burnout or chronic stress. It’s about the acute “I’m responsible for this patient” surge we all feel at knife-to-skin. Kill that feeling, and you kill performance. **Why This Matters for Training** We’ve already talked about [*Gen Shaky Hands*](https://www.theplasticsfella.com/february-2nd/#a-letter-from-pfella) — residents watching more than doing, graduating with big CVs and tiny case logs. And now this study basically tells us: **Peak performance requires arousal + ownership.** Most trainees get neither. We’ve built a system where: - Attendings jump in too early. - Trainees rarely get true responsibility. - Everyone pretends calm = competence. But if stress actually *helps* experienced surgeons, what happens when a trainee finally faces a high-stakes case… having never been allowed to feel anything except boredom? > I’ve learned that for long and difficult cases, if you openly verbalize your struggles too much, the staff picks up on this and you tend to get a reputation for being slow. > > The surgeons who act like the case is \*supposed\* to be taking that long, usually don’t have this problem. > > — Ron Barbosa MD FACS (@rbarbosa91) [November 5, 2025](https://twitter.com/rbarbosa91/status/1986111759334449362?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) Ron Barbosa on X **The Takeaway: Stress isn’t the enemy. Unpreparedness is.** A little physiological “edge” at the start of a case seems to sharpen performance, not sabotage it. For attendings, it’s protective. For trainees, it’s missing. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Tibial Fractures?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the final round of seven rounds! The ****top** scorer wins one our **Foundations* textbook at a discount! ## Image of the Week **Medial Gastrocnemius Flap* 🖼️ ****Image of the Week** This week’s image shows a medial gastrocnemius flap elevated for coverage around the knee and proximal tibia. The flap’s reliability, easy dissection, and generous arc of rotation make it a true workhorse for exposed bone, hardware, or prostheses. This operative view highlights the muscle belly lifted and ready for rotation: a reminder that even with modern microsurgical options, the gastroc flap remains one of the simplest and most dependable solutions in lower-limb reconstruction. ![The medial gastrocnemius flap - lower limb reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/pmfaam17-gastrocnemius_part7.jpg) The medial gastrocnemius flap - [Source](https://www.thepmfajournal.com/features/post/the-medial-gastrocnemius-flap?ref=theplasticsfella.com) ## Technique Tip **Marking a Gracilis Flap* 🚑 ****Technique Tip of the Week** This week, we’re highlighting the key surface markings for harvesting a gracilis flap: a reliable option for lower-limb coverage, perineal reconstruction, and functional muscle transfer. The image shows the gracilis traced from the pubic tubercle to the medial femoral condyle, with adductor longus, adductor magnus, sartorius, and semitendinosus clearly outlined. Accurate marking like this makes the dissection faster, safer, and helps you stay oriented when anatomy gets distorted by trauma or scarring. A simple tip: always palpate the adductor longus first. Once you anchor that landmark, the gracilis is almost impossible to miss. ![Surface markings for harvesting a gracilis flap - lower limb reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/f049-005-9780323243223.webp) Surface markings for harvesting a gracilis flap - [Source](https://i0.wp.com/plasticsurgerykey.com/wp-content/uploads/2019/03/f049-005-9780323243223.jpg?w=960&ref=theplasticsfella.com) ## Upcoming Events **Newly Added Lower Limb Trauma-Related Conferences* 📣 We’ve just added a fresh set of ****lower-limb trauma conferences** to the Events page. Have a look if you are looking to sharpen your reconstruction skills or planning your study leave. ## New Feature **Platform Update in 2026 - What Do You Want to See?* We’re rebuilding thePlasticsFella platform from the ground up for 2026\. Smarter tools, cleaner design, better learning. Shaped by you, for you. Tell us what would actually make your training easier, faster, or less frustrating. More videos? Personalised study plans? Step-by-step surgical guides? Better note-taking? Something wild we haven’t thought of yet? Your ideas will directly shape what gets built next. Share your thoughts below: ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Standards for the Management of Open Fractures of the Lower Limb** ([British Association of Plastic, Reconstructive & Aesthetic Surgeons/British Orthopaedic Association](https://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf?ref=theplasticsfella.com), 2009) These evidence-based multidisciplinary standards emphasise early orthoplastic specialist care, prompt wound excision and skeletal stabilisation, and referral to dedicated centres. ✅ ****Muscle Flaps Outperform Fasciocutaneous in Fracture Healing** ([Arshad](https://www.jprasurg.com/article/S1748-6815%2825%2900380-8/abstract?ref=theplasticsfella.com), 2025) Evidence shows muscle flaps enhance angiogenesis, reduce infection, and strengthen bone repair more effectively than fasciocutaneous flaps, supporting their superiority for traumatic lower limb reconstruction. ✅ ****When Should You Use NovoSorb BTM in Trauma Reconstruction?** ([Hendrickson](https://pmc.ncbi.nlm.nih.gov/articles/PMC11519400/?ref=theplasticsfella.com), 2024) NovoSorb BTM reliably integrates as a primary or salvage option in complex lower-limb trauma including bridging exposed bone or failed flaps, providing a durable neodermis for grafting when autologous options are limited, inappropriate, or exhausted. ## Feedback ### I hope you enjoyed it 😄 --- ### Project "Skill School", 3D Printed Bones, & 2 Important Microsurgery Drills. URL: https://www.theplasticsfella.com/november-9th/ Last updated: 2025-11-07T10:03:46.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/november-9th/#a-letter-from-pfella) Building a skill school: Not another weekend course. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-9th/#the-sunday-quiz) How well do you know **the bone.* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/november-9th/#image-of-the-week) 3D printed bone. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-9th/#technique-tip) Microsurgical arena exercise. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/november-9th/#upcoming-events) Reminder: BAPRAS Congress 2025 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-9th/#articles-of-the-week) Synehtic micro simulators, 3D printing, & VR in surgical training: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/november-9th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Building a Skill School: Not Another Weekend Course* 👋 Most surgical courses make you feel amazing for about 48 hours. You scrub in, get your hands on a cadaver or a simulator, nod along to a few big names, take the group photo… and then it’s gone. The muscle memory fades, the notes sit in your inbox, and the next time that rare case rolls around, you’ve already forgotten half of it. That’s not learning, that’s a dopamine hit disguised as education. **The Problem with Courses** Here’s the dirty little secret: the course industry thrives on that forget-relearn-forget cycle. It’s the surgical version of a gym membership. You keep coming back, not because it works, but because it doesn’t stick. And let’s not pretend the faculty are always stellar. Too often, they’re there because of reputation, not relevance. You can feel it when the teaching turns into a performance, more ego than education. **The Idea: A “Skill School”** Leo Gundle from [Claribone](https://claribone.com/?ref=theplasticsfella.com) dropped a simple but radical idea: **what if we built a Skill School instead of a course?** Not a weekend high. Not a one-off lecture. But a place where **skills are built, tracked, and reinforced** over time. Imagine a system that: - Identifies your weak points with brutal honesty. - Reinforces techniques through spaced repetition and simulation. - Matches you with real surgical cases once your competence is proven. - Keeps faculty accountable, not just for showing up, but for teaching effectively. This isn’t about certificates or selfies or "feeling honoured & blessed" on Instagram It’s about **measurable skill acquisition.** Something no PowerPoint or panel discussion can deliver. **The Real Takeaway** Plastic surgery is too complex to be learned in bursts of inspiration. If we’re serious about developing surgeons, we need to stop selling them weekend confidence and start giving them durable competence. A Skill School doesn’t make you feel good for two days. It makes you **better for your career** What do you think? Are we ready to move beyond the course circuit? Would you join a Skill School that tracks real improvement, not attendance? Drop your thoughts. This one could change how we train, teach, and stay sharp. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know* The Bone ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the sixth round of seven rounds! The ****top** scorer wins one our **Foundations* textbook at a discount! ## Image of the Week **3D Printed Bone* 🖼️ ****Image of the Week** This week’s image illustrates a ****3D-printed phalangeal bone** fitted with a fixation plate, a practical model used for surgical planning, simulation, and teaching. 3D printing continues to transform surgical education, allowing trainees to visualize fracture patterns, test implant placement, and rehearse complex reconstructions — all without compromising patient safety. Models like this one make anatomical learning and procedural precision far more accessible. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/specimenHold.jpg) 3D Printed Bone - Image from [Claribone](https://claribone.com/?ref=theplasticsfella.com) ## Technique Tip **Microsurgical Arena* 🚑 ****Technique Tip of the Week** This week, we’re featuring a video walkthrough of a microsurgical arena exercise, ideal for sharpening your fine-motor skills and instrument handling. It walks through instrument handling, suturing angles, and positioning to help trainees replicate realistic operative conditions outside the OR. ## Upcoming Events **Reminder: BAPRAS Congress 2025* 📅 A quick reminder that I will be speaking at ****BAPRAS Congress 2025** in ****Belfast** on ****Friday, December 5th**. This year’s theme, **“Forward,”* focuses on innovation, collaboration, and the future of plastic surgery. If you’re attending, come say hi! I'd love to connect in person. Learn more about [BAPRAS Congress 2025](https://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2025?ref=theplasticsfella.com). ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Are Synthetic Simulators the Future of Microsurgical Training?** ([Sapino](https://pmc.ncbi.nlm.nih.gov/articles/PMC11281774/?ref=theplasticsfella.com), 2024) Synthetic microsurgery simulators offer a low-cost, ethical, and effective way to build and assess microsurgical skills, helping trainees master basic to advanced procedures before progressing to live or cadaveric models. ✅ ****3D Printed Models Boost Surgical Training Success** ([Zhu](https://www.nature.com/articles/s41598-024-84887-y?ref=theplasticsfella.com), 2025) Using realistic 3D-printed intestinal models significantly improved medical students’ suturing performance, speed, and engagement compared to standard pads. ✅ ****VR Simulation Accelerates Plastic Surgery Training** ([Fuertes Bielsa](https://pubmed.ncbi.nlm.nih.gov/33972199/?ref=theplasticsfella.com), 2021) Virtual reality is transforming plastic surgery education with technical safety and decision-making skills through immersive simulation, and holds strong promise for integration into standardized surgical training curricula. ## Feedback ### I hope you enjoyed it 😄 --- ### Lower Limb Examination: 5-Step Approach & Documentation URL: https://www.theplasticsfella.com/lower-limb-examination/ Last updated: 2025-11-02T19:47:22.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/lower-limb-examination/#overview-of-lower-limb-examination) A thorough lower‐limb examination follows the sequence look, feel, move, and neurovascular condition. Always compare both limbs and remember that airway, breathing, and circulation take priority over limb injuries. [****How to Examine the Lower Limb**](https://www.theplasticsfella.com/lower-limb-examination/#how-to-examine-the-lower-limb) Use a consistent sequence: inspect, palpate, assess movement and power, test nerves, examine vascular status, then scan for limb-threatening conditions. Always compare sides and recheck after any intervention. [****Suggested Documentation Template**](https://www.theplasticsfella.com/lower-limb-examination/#suggested-documentation-template) A structured note ensures consistency, clarity, and early recognition of evolving neurovascular compromise. Document findings systematically under standard headings to create a clear baseline for comparison. ****Verified by thePlasticsFella ✅** --- ## Overview of Lower Limb Examination ****Key Point** A thorough lower‐limb examination follows the sequence look, feel, move, and neurovascular condition. Always compare both limbs and remember that airway, breathing, and circulation take priority over limb injuries. The lower limb is a complex structure of bones, muscles, nerves, and vessels. A systematic assessment can reveal subtle signs of compartment syndrome, nerve damage, or vascular injury that require urgent intervention. Examination begins with inspection for deformity, skin changes, and wounds, followed by palpation for compartment tension and bony tenderness. Movement testing assesses joint range and muscle power, while focused neurological and vascular examinations evaluate nerve function, sensation, and distal pulses. Document findings carefully and repeat assessments after any intervention. **Key Principles** - **Life Over Limb:** Even dramatic injuries should not distract from resuscitation and the primary trauma survey. Control bleeding manually and delay definitive limb management until the patient is stable. - **Assessment is Dynamic:** Compartment pressures can rise over hours. Reassess neurovascular status frequently and document serial examinations. - **Subtle Signs are Critical:** Pain with passive stretch of the compartment muscles is the earliest and most sensitive sign of compartment syndrome. Tense compartments and altered pulses mandate urgent evaluation. --- ## How to Examine the Lower Limb ****Key Point** Use a consistent sequence: inspect, palpate, assess movement and power, test nerves, examine vascular status, then scan for limb-threatening conditions. Always compare sides and recheck after any intervention. A structured lower-limb examination combines observation, palpation, and targeted functional testing to identify injuries or disease affecting bones, joints, muscles, nerves, and vessels. The goal is to localise pathology while assessing perfusion, stability, and motor integrity. ### Inspection Begin with full exposure from pelvis to toes. Note posture, symmetry, wounds, and skin changes. Observe the gait if the patient can walk. Early pattern recognition can reveal fractures, nerve injuries, vascular insufficiency, or infection. **What to Look for and What it May Mean** - **Posture and Symmetry:** Limb shortening, external rotation, or abnormal angulation suggest fracture, dislocation, or pelvic injury. - **Gait:** Antalgic gait indicates pain. A high-stepping gait suggests foot drop from deep peroneal nerve palsy; a Trendelenburg gait (contralateral pelvic drop) reflects weak hip abductors or superior gluteal nerve injury. - **Skin:** Shiny, hairless skin, mottling or pallor point to peripheral arterial disease; erythema, swelling, and blisters raise concern for infection, including necrotising fasciitis. - **Wounds:** Document location, depth, and contamination. Exposed bone or tendon suggests an open fracture and possible neurovascular compromise. - **Muscle and Tendon:** Wasting, fasciculations, or loss of contour indicate denervation or rupture. Use straight-leg raise and the Thompson test when relevant. - **Bones and Joints:** Swelling, malalignment, warmth, or redness can reflect septic arthritis, crystal arthropathy, or dislocation. 💡 ****Tip:** When assessing gait, always watch the patient’s pelvis: A Trendelenburg gait (pelvic drop on the opposite side) signals weakness of the hip abductors supplied by the superior gluteal nerve. ### Palpation Palpate compartments, bones, and joints. The combination of a tense compartment and pain on passive stretch is the hallmark of acute compartment syndrome. **Compartment Assessment** - Palpate for tension, swelling, and tenderness. - Passive stretch tests (pain is an early, specific sign). - **Anterior Compartment:** Plantarflex the ankle. - **Lateral Compartment:** Invert the ankle. - **Superficial Posterior Compartment:** Dorsiflex the ankle. - **Deep Posterior Compartment:** Dorsiflex the hallux. **Skeletal and Joint Assessment** - **Bones:** Tibia, fibula, femur, and pelvis for point tenderness or crepitus, which localise fractures. - **Joints:** Hips, knees, ankles, and toes for effusion or instability, suggesting septic arthritis, synovitis, or ligamentous injury. 😎 ****Fun Fact:** Pain on passive stretch is the earliest and most reliable sign of compartment syndrome. It appears long before loss of pulse or paralysis. ### Move Assess active range of motion at each joint, then test strength against resistance. Compare with the contralateral limb. Evaluate tone by passively moving the relaxed limb. - **Tone:** Hypertonia suggests an upper motor neuron lesion. Hypotonia suggests a lower motor neuron or acute root lesion. - **Hip:** Test flexion, extension, abduction, and rotation. Weak abduction may produce a Trendelenburg sign. - **Knee:** Test flexion and extension. If the range is limited, evaluate for instability. - **Ankle:** Test dorsiflexion, plantarflexion, inversion, and eversion. Loss of dorsiflexion suggests a deep peroneal nerve lesion. - **Toes:** Great-toe dorsiflexion assesses deep peroneal function. - **Power (MRC 0-5)** - 0 - no contraction - 1 - flicker - 2 - active movement with gravity eliminated - 3 - active movement against gravity - 4 - movement against gravity and resistance - 5 - normal power ### Nerve Assessment Test motor function, key sensory areas, and reflexes. Correlate deficits with root levels and specific peripheral nerves. **Motor and Mixed Nerves** - **Femoral:** Hip flexion (L2-L3), knee extension (L3-L4). Test resisted hip flexion and resisted knee extension. - **Sciatic:** Knee flexion (L5-S1). Test resisted knee flexion. - **Deep Peroneal (deep fibular):** Ankle dorsiflexion and great-toe extension (L4-L5/L5). Test resisted dorsiflexion and EHL extension. Sensory check in the first web space. - **Superficial Peroneal:** Foot eversion. Sensory over most of the dorsum of the foot except the first web space. Test resisted eversion and light touch on the dorsum. - **Tibial:** Plantarflexion and toe flexion (S1-S2). Test calf raise and toe flexion. Check plantar sensation. - **Superior gluteal:** Hip abduction (L4-S1). Test single-leg stance or resisted abduction. - **Inferior gluteal:** Hip extension (L5-S2). Test resisted extension. **Pure Sensory Nerves** - **Saphenous:** Medial leg and foot. - **Sural:** Lower lateral leg, lateral heel, ankle, and lateral dorsum of foot. **Sensory Modalities and Reflexes** - Use cotton wool or a neurotip for light touch and pinprick, a tuning fork for vibration, and move the toes up and down for proprioception. - **Reflexes:** Patellar (L3-L4) and Achilles (S1-S2). A positive Babinski (upgoing plantar) indicates an upper motor neuron lesion. 😎 ****Fun Fact:** The deep peroneal nerve supplies only a small patch of skin: the first dorsal web space, yet testing this area is crucial, as loss of sensation here is one of the earliest indicators of anterior compartment syndrome. ### Vascular Examination Palpate distal pulses and document strength on a 0 to 4+ scale. Compare sides and reassess after splinting, manipulation, or surgery. Pulses can still be palpable even when compartment pressures are high. **Pulse Landmarks and Practical Tips** - **Femoral:** Just distal to the inguinal ligament, a little medial to the midpoint between the pubic symphysis and ASIS. Often the most informative pulse during resuscitation. - **Popliteal:** In the popliteal fossa, slightly lateral to midline. Flex the knee slightly and use both hands. - **Posterior Tibial:** Immediately posterior to the medial malleolus; can be difficult for novices. - **Dorsalis Pedis:** Dorsum of the foot, lateral to the EHL tendon and within about a centimetre of the navicular. It may be absent in a minority of healthy people; asking the patient to extend the great toe helps locate the tendon. Also assess capillary refill time (aim for under two seconds) and skin temperature. In trauma or suspected vascular injury, bedside Doppler and calculation of the ankle-brachial index can aid diagnosis. 💡 ****Tip:** A palpable pulse does not rule out compartment syndrome. Arterial flow may persist even when microvascular perfusion is compromised by high compartment pressures. ### Limb-Threatening Conditions Recognise early features and act without delay. Rapid decisions prevent limb loss and reduce mortality. - **Acute Compartment Syndrome:** Early pain on passive stretch with or without a tense compartment. Aim for decompression within six hours. Perform a two-incision, four-compartment fasciotomy of the leg when indicated. - **Major Arterial Injury:** Pale, cold, pulseless limb. Proceed to immediate temporary shunting or definitive revascularisation, with consideration of systemic heparinisation if appropriate. - **Open Fracture or Open Joint:** Visible communication between the bone or joint and skin. Give intravenous antibiotics within one hour, perform early debridement, and achieve soft-tissue coverage within about 72 hours. - **Necrotising Fasciitis:** Rapid progression with erythema, swelling, and haemorrhagic or yellow fluid–filled blisters. Treat as a surgical emergency with broad-spectrum antibiotics and urgent debridement. - **Crush Syndrome:** Rising creatine kinase, dark urine, and hyperkalaemia after extrication. Begin aggressive intravenous fluids, consider urine alkalinisation, treat hyperkalaemia, and monitor renal function closely. Dermatomes and dorsalis pedis pulse are illustrated below. ![Dermatomes and dorsalis pedis pulse](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/Main-Article-Images--24-.png) Dermatomes and dorsalis pedis pulse 💡 ****Tip:** Compartment syndrome becomes limb-threatening when compartment pressure approaches diastolic pressure. A delta pressure (diastolic minus compartment) < 30 mmHg is considered diagnostic and mandates fasciotomy. --- ## Suggested Documentation Template ****Key Point** A structured note ensures consistency, clarity, and early recognition of evolving neurovascular compromise. Document findings systematically under standard headings to create a clear baseline for comparison. When examining the lower limb, documentation should capture both what is normal and what requires ongoing review. Recording a thorough baseline helps detect subtle changes, especially in trauma, vascular, or postoperative settings. The following template demonstrates concise, clinically useful phrasing for a normal neurovascular examination. - **Inspection:** No deformity, wounds, or erythema. Skin warm and pink with normal hair distribution. - **Palpation:** Compartments soft and non-tender with no pain on passive stretch. Bones non-tender. - **Sensation:** Intact across dermatomes L2-S2\. Saphenous and sural territories are normal. - **Motor (MRC):** Power 5/5 in hip, knee, ankle, and toe movements with normal tone. - **Pulses:** Femoral, popliteal, dorsalis pedis, and posterior tibial pulses are palpable and symmetrical. Capillary refill <2 seconds. - **Reflexes:** Patellar and Achilles reflexes present and symmetrical. Plantar responses down-going. - **Plan:** Repeat neurovascular assessment one hour after splint application and monitor for swelling or increasing pain. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Use a structured lower limb assessment - look, feel, move, neurovascular while prioritising airway, breathing, and circulation in trauma. ****2\. Examination Sequence:** Begin with inspection, then palpate compartments and bones, test movement and tone, assess nerves and reflexes, and check vascular status. ****3\. Notice Red Flags:** Early pain on passive stretch, tense compartments, or altered pulses may signal compartment syndrome or vascular injury. ****4\. Pulse ≠ Perfusion:** Palpable pulses do not rule out ischaemia. Compartment pressure can still compromise microvascular flow. Repeat neurovascular checks. ****5\. Suggested Documentation:** Record inspection, palpation, sensation, motor strength, pulses, and reflexes. Reassess and document neurovascular status serially. --- ## Further Reading 1. American College of Surgeons (2018) ATLS. Advanced Trauma Life Support Manual. 10th edn. Chicago, IL: American College of Surgeons. 2. Sharma, S. and Hashmi, M.F. (2024). [Peripheral pulse](https://www.ncbi.nlm.nih.gov/books/NBK538497/?ref=theplasticsfella.com). StatPearls. Treasure Island (FL): StatPearls Publishing. 3. Physiopedia (n.d.) [Myotomes](https://www.physio-pedia.com/Myotomes?ref=theplasticsfella.com). 4. Physiopedia (n.d.) [Sural nerve & saphenous nerve](https://www.physio-pedia.com/Sural%5FNerve?ref=theplasticsfella.com). 5. Cleveland Clinic (2024). Necrotizing fasciitis: causes, symptoms & treatment. ### Microsurgical Principles - Angiosomes: Vascular Territories, Choke Vessels, & Delay Phenomenon URL: https://www.theplasticsfella.com/microsurgical-principles-angiosomes/ Last updated: 2025-11-02T19:03:19.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/microsurgical-principles-angiosomes/#overview-of-angiosomes) An angiosome is a three‑dimensional unit of tissue nourished by one artery and vein. Knowing where these territories begin and end allows surgeons to choose flaps with reliable perfusion and to avoid necrosis and donor‑site morbidity. [****Vascular Territories and Regional Anatomy**](https://www.theplasticsfella.com/microsurgical-principles-angiosomes/#vascular-territories-and-regional-anatomy) Angiosomes are subdivided into anatomical, dynamic, and potential territories, representing progressively wider zones of perfusion as choke vessels open and collateral flow develops. [****Choke Vessels and Delay Phenomenon**](https://www.theplasticsfella.com/microsurgical-principles-angiosomes/#choke-vessels-and-the-delay-phenomenon) Choke vessels are narrow arteries and veins linking adjacent angiosomes. Over several days, they enlarge and transform into true anastomoses, thereby enlarging the functional territory. Harnessing their biology through delay procedures reduces necrosis and expands reconstructive options. [****Clinical Applications**](https://www.theplasticsfella.com/microsurgical-principles-angiosomes/#clinical-applications-of-angiosomes) Angiosome mapping informs every stage of flap surgery from design through perforator selection to intra‑operative decision‑making. Thereby improving outcomes and guiding targeted revascularisation. [****Benefits and Limitations**](https://www.theplasticsfella.com/microsurgical-principles-angiosomes/#benefits-and-limitations-of-the-angiosome-concept) Angiosome‑based planning reduces necrosis, improves aesthetics, and guides targeted revascularisation, yet its predictive value is limited by individual vascular variability, comorbidities, and the need for time‑dependent dilation. ****Verified by thePlasticsFella ✅** --- ## Overview of Angiosomes ****Key Point** An angiosome is a three‑dimensional unit of tissue nourished by one artery and vein. Knowing where these territories begin and end allows surgeons to choose flaps with reliable perfusion and to avoid necrosis and donor‑site morbidity. Modern reconstructive microsurgery relies on transferring vascularised tissue rather than avascular grafts. Because angiosome-based flaps bring their own arterial and venous supply, they remain viable even in compromised wound beds. The concept, first mapped by **Taylor and Palmer (1987)** and built on the anatomical studies of Manchot and Salmon, provides a vascular “atlas” for flap design. By defining the limits of reliable perfusion, surgeons can plan reconstructions with predictable survival and contour. ### Core Principles Angiosomes give a predictable map of the body’s vascular territories, each supplied by one source artery-vein pair. Their interconnections through choke vessels and true anastomoses explain flap reliability and the potential for perfusion beyond strict anatomical borders. Every angiosome is composed of smaller perforasomes, each supplied by an individual perforator. Recognising these subdivisions is central to perforator-flap surgery, guiding both pre-operative imaging and intra-operative dissection. ### Perforator Types - A perforator is a block of skin, fat, fascia, muscle, or bone supplied by a single source artery and vein. Boundaries are defined by **choke vessels** or **true anastomoses**. - **Perforator Types** - **Direct Cutaneous:** Arise straight to the skin. - **Septocutaneous:** Travel through intermuscular septa. - **Musculocutaneous:** Passes through muscle before reaching the skin. - **Functional Angiosome:** The tissue volume that can be safely perfused by a source vessel. It expands where true anastomoses link adjacent territories, but is smaller where only choke vessels connect them. ### Angiosome Principles (Taylor & Palmer, 1987) - **Territorial Definition:** Angiosomes define flap boundaries; adjacent zones meet at choke vessels or anastomoses. - **Connective-Tissue Pathways:** Source vessels follow intermuscular septa and fascial planes, forming predictable harvest routes. - **Law of Equilibrium:** When one artery is small, its neighbour enlarges to compensate. - **Continuity and Neurovascular Relationships:** Arteries, veins, and nerves travel together from fixed to mobile points, maintaining continuity despite variable origins. ### Flap Design Principles Effective angiosome-based reconstruction requires precise geometry and meticulous technique. - **Length-to-Width Ratio:** Keep random-pattern flaps ≤3:1 to reduce distal necrosis. - **Orientation & Tension:** Align along the source vessel. Avoid twisting or kinking to prevent venous congestion. - **Respect Natural Boundaries:** Plan incisions along angiosome or aesthetic unit borders for optimal contour. - **Tissue Handling:** Elevate suprafascially where possible; preserve perforasomes and avoid over-skeletonising vessels to maintain perfusion. --- ## Vascular Territories and Regional Anatomy ****Key Point** Angiosomes are subdivided into anatomical, dynamic, and potential territories, representing progressively wider zones of perfusion as choke vessels open and collateral flow develops. For practical planning, surgeons distinguish the reliably perfused core tissue from adjacent zones that might be recruited after delay. Awareness of these layers and of perfusion gradients across different body regions allows safe harvest and minimises complications. ### Territories of an Angiosome For surgical planning, it is crucial to distinguish the core perfused zone from areas that can be recruited over time. - **Anatomical Territory:** Directly supplied by the source artery’s perforators and reliably perfused without delay. - **Dynamic Territory:** Perfused after choke vessels dilate during flap elevation or surgical delay, represents a time-dependent expansion of the core. - **Potential Territory:** Becomes viable only after deliberate delay procedures, when choke vessels remodel into true anastomoses, useful in large composite or extended flaps. Pre-operative imaging (e.g. indocyanine green angiography) and patient factors such as vascular disease, prior surgery, or smoking history help determine how much of the dynamic or potential territories can safely be included. ### Foot and Ankle Angiosomes The foot and ankle receive blood from three main arteries: The anterior tibial (ATA), posterior tibial (PTA), and peroneal arteries, which together form six angiosomes. - **Dorsalis Pedis (ATA):** dorsum of the foot and extensor tendons. - **Medial Plantar (PTA):** instep and medial forefoot. - **Lateral Plantar (PTA):** lateral midfoot and forefoot. - **Calcaneal Branch (PTA):** heel pad. - **Anterior Perforating and Calcaneal Branches (peroneal):** lateral ankle, heel, and Achilles region. Adjacent angiosomes are connected by arterial collaterals that can redirect flow when one territory is compromised. However, choke vessels open slowly, particularly in ischaemic limbs, underscoring the value of delay techniques or staged reconstructions in compromised vascular beds. ### Abdominal Perfusion Zones (Hartrampf Classification) In breast reconstruction, the Hartrampf zones describe perfusion across the lower abdominal flap based on the deep inferior epigastric artery (DIEA). - **Zone I:** Ipsilateral and central - best perfused, forming the flap’s core. - **Zone II:** Contralateral medial - less consistent, often dependent on crossover flow. - **Zone III:** Ipsilateral lateral - may be better perfused than Zone II when lateral perforators dominate. - **Zone IV:** Contralateral lateral - least perfused, often discarded or deepithelialised. Subsequent refinements by Holm et al. and Saint-Cyr demonstrated that perfusion depends more on **individual perforator dominance** than on static zone boundaries. This evolving understanding aligns with modern interpretations discussed in [Zones of Perfusion](https://www.theplasticsfella.com/hartrampfs-zones-of-perfusion/) by The Plastics Fella, which highlights how imaging and anatomical variation redefine flap design principles. --- ## Choke Vessels and the Delay Phenomenon ****Key Point** Choke vessels are narrow arteries and veins linking adjacent angiosomes. Over several days, they enlarge and transform into true anastomoses, thereby enlarging the functional territory. Harnessing their biology through delay procedures reduces necrosis and expands reconstructive options. Besides the main source vessels, flap survival depends on these interconnections. Initially small and low‑flow, choke vessels can be coaxed to dilate. Surgeons must know how long this takes, when to perform staged delay and where to place incisions. ### Characteristics & Delay - **Morphology:** Choke vessels are small arteries and veins connecting adjacent angiosomes. They have reduced calibre and minimal flow compared with true anastomoses. - **Growth Patterns:** Their orientation and diameter reflect developmental growth patterns; arteries have fixed destinations but variable origins, while avalvular veins accompany them and allow bidirectional flow. - **Delay Phenomenon:** When vascular supply is temporarily reduced (e.g., partial flap elevation), choke vessels dilate over **3-10 days**, converting into true anastomoses. Delayed flaps exploit this process to increase viability. ### Practical Guidance - **Plan for Dynamic and Potential Territories:** Tissue beyond the anatomical zone may be included if enough time is allowed for choke vessels to open. - **Delay When Needed:** If a flap design crosses into neighbouring angiosomes, perform a staged delay to enlarge the vascular network. - **Respect Vascular Borders:** Place incisions along angiosome boundaries when both sides have good perfusion; include adjacent territories when one side is compromised. Choke vessels and the delay phenomenon are illustrated below. ![Choke vessels and the delay phenomenon, microsurgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/Main-Article-Images--23-.png) Choke vessels and the delay phenomenon --- ## Clinical Applications of Angiosomes ****Key Point** Angiosome mapping informs every stage of flap surgery from design through perforator selection to intra‑operative decision‑making. Thereby improving outcomes and guiding targeted revascularisation. In practice, surgeons pair defect analysis with donor‑site angiosome maps, choose the best perforators and decide whether delay, supermicrosurgery or other strategies are required. Imaging tools such as Doppler and ICG angiography provide dynamic confirmation that complements anatomical planning. **Flap Design & Selection** - **Design Within Reliable Zones:** Pedicled and perforator flaps should stay within well‑perfused zones; for example, discard or deepithelialise Zone IV of the [DIEP flap](https://www.theplasticsfella.com/diep-flap-reconstruction/) and avoid overharvesting beyond radial forearm, scapular or facial artery angiosomes without delay. **Perforator Planning** - **Identify Dominant Perforators:** In the DIEP flap, medial‑row perforators perfuse central and contralateral tissue (Zones I-II) while lateral‑row perforators perfuse ipsilateral lateral tissue (Zones I-III). - **Tailor Flap Choice:** For ALT, SGAP and similar flaps, use Doppler or CTA/ICG to locate perforators that supply the needed tissue and minimise donor morbidity. **Intra‑operative Strategy** - **Place Incisions Wisely:** Incisions should follow angiosome borders to maximise perfusion; when one angiosome is ischaemic, include adjacent territories to preserve blood supply. - **Use Delay When Needed:** Stage flap elevation when crossing into a neighbouring angiosome; allow time for choke vessels to dilate. - **Consider Supermicrosurgery:** When major recipient vessels are absent (e.g., diabetic foot), anastomose to small perforators from adjacent angiosomes. **Perfusion Assessment & Imaging** - **Doppler Ultrasound:** Locates perforators and arterial boundaries pre‑ and intra‑operatively. - **Indocyanine Green (ICG) Angiography:** Provides real‑time perfusion maps and confirms viability of extended zones. - **Skin Perfusion Pressure (SPP):** Helps identify dominant arteries in critical limb ischaemia. - **CT/MR Angiography:** Offers detailed maps of perforators and reveals individual vascular variations. --- ## Benefits and Limitations of the Angiosome Concept ****Key Point** Angiosome‑based planning reduces necrosis, improves aesthetics, and guides targeted revascularisation, yet its predictive value is limited by individual vascular variability, comorbidities, and the need for time‑dependent dilation. The angiosome model has transformed reconstruction, but surgeons must apply it judiciously. Benefits include predictable perfusion and tailored interventions, while limitations relate to anatomical variation, patient factors and the dynamic behaviour of choke vessels. Supplemental imaging and clinical judgement remain essential. **Benefits** - **Predictable Perfusion:** Mapping angiosomes provides a framework for flap design, reducing distal necrosis (e.g., discarding Zone IV in abdominal flaps). - **Optimised Aesthetics and Function:** Using tissue from the same angiosome achieves better colour, contour and reduced contraction compared with skin grafts. - **Targeted Revascularisation:** Directing bypass or angioplasty to the artery feeding the affected angiosome improves wound healing in critical limb ischaemia. - **Perforator Planning:** Matching perforators to zones ensures minimal donor morbidity and facilitates thin, pliable flaps. **Limitations** - **Anatomical Variation:** Individuals deviate from standard zone maps. Perfusion may differ based on perforator row. - **Time Dependence:** Choke vessel dilation requires 4-10 days. Urgent reconstructions may not allow delay. - **Comorbidities:** Diabetes, vascular disease and smoking impair perfusion and choke vessel maturation. Patient optimisation is vital. - **Need for Imaging:** CT/CTA and ICG are often required to confirm perforator anatomy and perfusion patterns. Access and cost may limit use. **Common Complications & Mitigation** - **Partial Flap or Fat Necrosis:** Occurs when tissue beyond the perfused zone is included; prevent by adhering to zone maps and performing delay if needed. - **Venous Congestion:** Results from pedicle kinking or tight closure. Prevent by positioning pedicles gently and ensuring tension‑free inset. - **Trapdoor Deformity:** Caused by circular scars contracting. Avoid by designing flaps with angular shapes and placing incisions along relaxed skin tension lines. - **Poor Healing:** Associated with comorbidities or compromised perfusion; optimise patient health, revascularise when necessary and monitor post‑operative perfusion. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Importance of Angiosomes:** An angiosome is a three‑dimensional territory supplied by one artery and vein; using these maps reduces necrosis and guides revascularisation. ****2\. Principles & Mapping:** Fundamental laws (equilibrium, continuity, and neurovascular relationships) and knowledge of perforator types underpin perforator‑flap surgery ****3\. Territory Stratification:** Distinguish anatomical, dynamic, and potential territories; functional angiosomes may extend beyond anatomical boundaries when true anastomoses exist ****4\. Choke Vessels & Delay:** Recognise that choke vessels take days to dilate; delay procedures expand functional territories and inform incision placement ****5\. Clinical Applications:** Apply angiosome maps to design flaps, select perforators, plan incisions, use delay, and assess perfusion with Doppler or ICG. ****6\. Balanced Perspective:** Leverage the benefits of angiosomes while acknowledging limitations related to vascular variability, comorbidities, and the need for imaging. --- ## Further Reading 1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. British Journal of Plastic Surgery (1987). The seminal paper outlining the angiosome concept. 2. Scheflan M, Hartrampf CR**.** Breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap. Annals of Plastic Surgery (1983). Describes the original four‑zone perfusion model for abdominal flaps. 3. Holm C et al. Perfusion zones of the DIEP flap revisited. Plastic and Reconstructive Surgery (2006). Provides data demonstrating that lateral zones may out‑perfuse contralateral zones. 4. Saint‑Cyr M et al. The perforasome theory: vascular anatomy and clinical implications. Clinical Plastic Surgery (2011). Introduces the perforasome concept and emphasises perforator‑row–dependent perfusion. 5. Fujii M, Terashi H. [Angiosome and Tissue Healing](https://pmc.ncbi.nlm.nih.gov/articles/PMC6600089/?ref=theplasticsfella.com). Annals of Vascular Diseases (2019). Describes clinical applications of the angiosome concept in critical limb ischaemia and foot surgery. 6. Attinger CE et al. Angiosome theory and foot surgery. Plastic and Reconstructive Surgery (1999). Applies the concept to safe incisions, flap planning and revascularisation in the diabetic foot. ### Paronychia & Felon: Causes, Clinical Features, & Management URL: https://www.theplasticsfella.com/paronychia-felon/ Last updated: 2025-11-02T18:25:27.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/paronychia-felon/#overview-of-paronychia-felon) Paronychia and felon are distal finger infections differing by depth: paronychia affects the nail fold, while a felon is a deep pulp abscess. Early treatment prevents spread to the bone, joint, or tendon. [****Paronychia**](https://www.theplasticsfella.com/paronychia-felon/#paronychia) Paronychia is an infection or inflammation of the lateral or proximal nail folds. Acute cases are usually caused by Staphylococcus aureus after minor trauma or manicures, whereas chronic cases often involve Candida and dermatitis. [****Felon**](https://www.theplasticsfella.com/paronychia-felon/#felon) A felon is a pus-filled abscess within the septated compartments of the fingertip pulp, typically following a penetrating injury or untreated paronychia, and it causes intense throbbing pain. [****Complications**](https://www.theplasticsfella.com/paronychia-felon/#complications-of-paronychia-and-felon) Delayed or inadequate management of paronychia or felon can cause significant morbidity: Nail deformity, osteomyelitis, septic arthritis, or loss of fingertip sensibility. ****Verified by thePlasticsFella ✅** --- ## Overview of Paronychia & Felon ****Key Point** Paronychia and felon are distal finger infections differing by depth: paronychia affects the nail fold, while a felon is a deep pulp abscess. Early treatment prevents spread to the bone, joint, or tendon. The distal finger has distinct fascial spaces that determine how infections spread. Paronychia is inflammation or infection of the lateral or proximal nail fold. Acute cases usually result from bacterial entry through minor trauma, nail biting, or manicuring, while chronic cases are linked to irritant exposure and Candida colonisation A felon is a localized abscess within the fibrous septae of the fingertip pulp, producing severe throbbing pain and swelling. It often follows a penetrating injury or evolves from an untreated paronychia. Both may respond initially to conservative management, but **fluctuance or escalating pain requires surgical drainage** to prevent complications such as osteomyelitis or sensory loss. Paronychia and felon are illustrated below. ![Paronychia and felon](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/Main-Article-Images--20-.png) Paronychia and felon 😎 ****Fun Fact:** The fingertip pulp contains 15-20 fibrous septa, dividing it into closed compartments. A design that enhances grip but predisposes to intense pressure and ischemia when infection develops. --- ## Paronychia ****Key Point** Paronychia is an infection or inflammation of the lateral or proximal nail folds. Acute cases are usually caused by **Staphylococcus aureus* after minor trauma or manicures, whereas chronic cases often involve Candida and dermatitis. If left unchecked, infection can extend beneath the nail plate or seed a felon. ### Causes & Pathophysiology Paronychia refers to infection or inflammation of the nail folds. **Acute paronychia** develops rapidly after a cuticle break or nail-fold injury and is bacterial. **Chronic paronychia** persists for more than 6 weeks and reflects mixed bacterial-fungal infection with recurrent inflammation. **Typical Organisms** - **Acute:** *Staphylococcus aureus* (most common), *Streptococcus pyogenes*, *Pseudomonas*, or *Herpes simplex*. - **Chronic:** *Candida albicans* and Gram-negative bacilli. **Risk Factors** Nail biting, manicuring, artificial nails, ingrown nails, or minor trauma provide bacterial entry. Recurrent water or chemical exposure (e.g., cleaners, bartenders, healthcare workers) and dermatitis predispose to chronic cases. **Pathophysiology** Infection begins at the nail fold and may extend under the nail plate. Trapped pus increases pressure and pain; without drainage, the infection may track into the fingertip pulp and form a felon. ### Clinical Presentation & Diagnosis **History** Acute cases present with rapid-onset pain, erythema, and swelling. Chronic cases cause recurrent tenderness and thickened nail folds. Ask about trauma, nail habits, or recent manicures. **Examination** Localised erythema, swelling, and tenderness around the lateral or proximal nail fold are typical. Fluctuance suggests abscess formation. Chronic paronychia shows retracted nail folds and persistent discharge. **Differential Diagnoses** - **Herpetic Whitlow:** *G*rouped vesicles, HSV exposure. - **Glomus Tumour:** Chronic fingertip pain, cold sensitivity. - **Subungual Melanoma:** Pigmented nail streak. - **Pyogenic Granuloma:** Vascular, bleeding nodule. **Investigations** Usually clinical. Obtain swab cultures for recurrent or atypical infections. Ultrasound can detect subungual abscess; radiographs exclude foreign bodies or osteomyelitis in chronic cases. ### Management **Conservative** Early infections respond to warm water or antiseptic soaks (3-4 × daily for 5-7 days). Apply topical mupirocin or fusidic acid; use oral flucloxacillin, cephalexin, or clindamycin if cellulitis spreads beyond the nail fold. Adjust based on cultures. **Surgical Drainage** If an abscess is present, perform digital block anaesthesia and make a small incision parallel to the eponychial fold to release pus. Avoid crossing the nail matrix to prevent deformity. If pus tracks beneath the nail plate, **partially lift or remove** it for drainage. Irrigate with saline, insert a wick if needed, and advise warm soaks and elevation. Cover *S. aureus* (including MRSA where indicated). **Chronic Paronychia** Eliminate irritants and manage underlying dermatitis. Use topical antifungals for *Candida* and short steroid courses for inflammation. Surgical excision of chronically inflamed tissue is rarely required. 💡 ****Tip:** Drain only when there’s a fluctuant collection or worsening pain despite conservative care; early cases often resolve with warm soaks and antibiotics. --- ## Felon ****Key Point** A felon is a pus-filled abscess within the septated compartments of the fingertip pulp, typically following a penetrating injury or untreated paronychia and it causes intense throbbing pain. Early drainage via a longitudinal incision is essential to prevent ischemic necrosis or osteomyelitis. ### Causes & Pathophysiology **Definition & Anatomy** A felon is an infection of the **distal pulp space** of the finger or thumb. The pulp is divided by fibrous septa into closed compartments; when infected, pressure builds rapidly, causing severe pain and vascular compromise. **Typical Causes** Usually follows penetrating trauma (splinter, needle, bite, sharp object), though up to half have no obvious injury. It may also arise from extension of an untreated paronychia. **Pathogens** Most are caused by *Staphylococcus aureus* (including MRSA) and *Streptococcus* species. Human bites may introduce Eikenella or oral anaerobes. **Pathophysiology** Infection within rigid septa raises intracompartmental pressure, compromising perfusion and venous outflow. Without decompression, infection can extend to bone, tendon, or joint, leading to osteomyelitis, septic arthritis, or flexor tenosynovitis. ### Clinical Presentation & Diagnosis **History** Rapid-onset, throbbing fingertip pain often follows minor trauma or paronychia. Ask about splinters, bites, or systemic symptoms. **Examination** The fingertip distal to the DIP joint is swollen, tense, shiny, and exquisitely tender. Pain worsens with dependency or pressure. Paresthesia suggests ischemia. Check for lymphangitis and adjacent joint involvement. **Differential Diagnoses** - **Herpetic Whitlow:** Grouped vesicles. - **Subungual Haematoma:** Post-trauma discoloration. - **Glomus Tumour:** Chronic fingertip pain, cold sensitivity. - **Gouty Tophus or Calcinosis:** Firm deposits mimicking abscess. **Investigations** Diagnosis is clinical. Use X-ray for suspected foreign body or osteomyelitis. Ultrasound can localise the abscess for incision planning. ### Management **Early Conservative Management** If no fluctuance is present, manage with elevation, warm soaks, and oral antibiotics covering *S. aureus* (e.g., flucloxacillin or cephalexin). Use trimethoprim-sulfamethoxazole or doxycycline if MRSA is suspected. **Surgical Drainage** Tense, fluctuant felons require prompt incision and drainage under digital block. - **Lateral longitudinal incision:** Along the radial or ulnar midline, avoiding the pad. Preferred for access and minimal sensory loss. - **High midline incision:** Over the midline proximal to the DIP crease, avoiding neurovascular bundles. Do not extend past the crease. - **Avoid transverse or fish-mouth incisions:** Risk injury to digital arteries and nerves, reserve for complex cases only. After incision, break the septa bluntly, irrigate, and place a wick for continued drainage. Elevate the hand post-operatively and begin gentle motion once drainage subsides. **Adjunctive Care** Continue appropriate antibiotics. Admit patients with diabetes, immunosuppression, or systemic symptoms for IV therapy and close monitoring. 💡 ****Tip:** Always use a longitudinal incision (midline or paramedian) to protect digital nerves and arteries. Transverse cuts risk permanent sensory loss. --- ## Complications of Paronychia and Felon ****Key Point** Delayed or inadequate management of paronychia or felon can cause significant morbidity: Nail deformity, osteomyelitis, septic arthritis, or loss of fingertip sensibility. Prompt recognition, targeted antibiotics, and timely drainage are essential to preserve function. ### Potential Complications - **Paronychia:** Chronic infection may lead to thickened, retracted nail folds, nail dystrophy, or granulation tissue formation. Subungual extension can cause persistent pain and may progress to a felon. - **Felon:** Untreated cases risk skin necrosis, osteomyelitis of the distal phalanx, septic arthritis of the DIP joint, or flexor tenosynovitis, threatening fingertip viability and occasionally requiring reconstructive surgery. - **Nerve or Vascular Injury:** Poor incision technique, especially transverse or cross-pad incisions, may damage digital nerves or arteries, leading to sensory loss or ischemia. Use gentle, longitudinal incisions to minimise these risks. 😎 ****Fun Fact:** A neglected felon can destroy the distal phalanx in under a week. The fingertip pulp pressure can exceed 100 mmHg, cutting off arterial inflow and leading to necrosis. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Differentiate Paronychia from Felon:** Recognise that paronychia involves the nail folds (acute vs chronic), whereas felon is a deep abscess of the fingertip pulp. ****2\. Identify Typical Causes and Pathogens:** Understand that Staphylococcus aureus predominates in acute paronychia and felon, while chronic paronychia often involves Candida and mixed flora. ****3\. Assess Clinical Presentation:** Elicit risk factors, inspect for erythema and fluctuance, differentiate from herpetic whitlow or glomus tumour, and recognise signs of pressure‑induced ischemia in felon. ****4\. Manage Appropriately:** Apply warm soaks and antibiotics for simple cases; perform timely incision and drainage when an abscess is present, choosing appropriate incision techniques and postoperative care. ****5\. Prevent Complications:** Recognise that delays can lead to osteomyelitis, septic arthritis, tenosynovitis, and permanent sensory loss. Emphasise early recognition and proper technique to preserve function --- ## Further Reading 1. DermNet New Zealand (n.d.) [Paronychia](https://dermnetnz.org/topics/paronychia?ref=theplasticsfella.com). 2. LacerationRepair.com (n.d.) [Felons & paronychia](https://lacerationrepair.com/felons-paronychias/?ref=theplasticsfella.com)s. 3. Melbourne Hand Surgery (n.d.) [Felon](https://www.melbournehandsurgery.com/hand-infections/31-hands/infections/209-felon?ref=theplasticsfella.com). ### Compartments of the Lower Limb: Muscles, Innervation, & Blood Supply URL: https://www.theplasticsfella.com/compartments-of-the-lower-limb/ Last updated: 2025-11-02T14:46:43.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/compartments-of-the-lower-limb/#overview-of-compartments-of-the-lower-limb) Lower-limb compartments group muscles, nerves, and vessels by function within rigid fascial boundaries. This organisation aids coordination but limits expansion, predisposing to compartment syndrome when swelling or bleeding occurs. [****Compartments of the Thigh**](https://www.theplasticsfella.com/compartments-of-the-lower-limb/#compartments-of-the-thigh) The thigh is divided by intermuscular septa into anterior, medial, and posterior compartments. Muscles within each compartment share a primary action and are supplied by predictable nerves and blood vessels. [****Compartments of the Leg**](https://www.theplasticsfella.com/compartments-of-the-lower-limb/#compartments-of-the-leg) The leg is divided into four compartments: Anterior, lateral, superficial posterior, and deep posterior by septa and the interosseous membrane. The anterior contains dorsiflexors, the lateral evertors, and the posterior compartments plantarflexors and toe flexors. [****Compartment Syndrome**](https://www.theplasticsfella.com/compartments-of-the-lower-limb/#compartment-syndrome-and-clinical-considerations) The rigid fascia of the lower limb limits expansion; when pressure exceeds perfusion (>30 mmHg or ΔP < 30 mmHg), acute compartment syndrome develops, often following fractures, crush injury, burns, or reperfusion. ****Verified by thePlasticsFella ✅** --- ## Overview of Compartments of the Lower Limb ****Key Point** Lower-limb compartments group muscles, nerves, and vessels by function within rigid fascial boundaries. This organisation aids coordination but limits expansion, predisposing to compartment syndrome when swelling or bleeding occurs. The lower limb is optimised for weight bearing and locomotion. To achieve stability and efficient force transmission, muscles are grouped into compartments bound by fascial septa. These compartments anchor the muscles for leverage, channel neurovascular structures along predictable routes and permit subtle movements such as knee extension, hip adduction or ankle dorsiflexion to be executed with precision. Understanding the organisation of lower limb compartments helps when interpreting trauma, planning incisions, and recognising compartment syndrome. 😎 ****Fun Fact:** Each lower-limb compartment acts like a sealed unit. This precise organisation allows efficient movement control but also explains why swelling or bleeding can rapidly cause compartment syndrome. --- ## Compartments of the Thigh ****Key Point** The thigh is divided by intermuscular septa into anterior, medial, and posterior compartments. Muscles within each compartment share a primary action (knee extension, hip adduction, or knee flexion/hip extension) and are supplied by predictable nerves and blood vessels. The deep fascia and intermuscular septa divide the femoral shaft into three muscular compartments. - **Anterior Compartment:** Between medial and lateral septa. - **Medial Compartment:** Bounded by the medial septum. - **Posterior Compartment:** Posterior to the lateral septum. Compartments are separated by tough fascia, limiting expansion. Swelling, bleeding, or reperfusion injury can elevate pressure within a compartment, leading to compartment syndrome. Vascular and neural separation helps localise pathology and guide incision placement during surgery. #### Anterior (Extensor) Compartment of the Thigh - **Muscles:** Iliopsoas (iliacus and psoas major), quadriceps femoris (vastus lateralis, vastus medialis, vastus intermedius, rectus femoris), sartorius, and part of pectineus. - **Function:** Hip flexion (iliopsoas, sartorius), knee extension (quadriceps), and assistance in hip abduction/external rotation (sartorius). - **Nerve Supply:** Femoral nerve innervates all muscles in this compartment. Pectineus may receive a dual supply from the femoral and obturator nerves. - **Arterial Supply:** Primarily the femoral artery and its branches, including the profunda femoris and lateral circumflex femoral arteries. - **Clinical Notes:** Quadriceps are the chief knee extensors. The patellar tendon reflex tests L3-L4 integrity. Injury to the femoral nerve impairs knee extension and patellar reflexes. Deep haemorrhage or swelling here may compress the femoral nerve or artery. #### Medial (Adductor) Compartment of the Thigh - **Muscles:** Adductor longus, adductor brevis, adductor magnus, obturator externus, and gracilis. The adductor canal also contains part of the pectineus. - **Function:** Primarily hip adduction; adductor magnus also assists in hip extension via its hamstring portion, and obturator externus laterally rotates the thigh. - **Nerve Supply:** Obturator nerve supplies most adductors; the hamstring part of the adductor magnus is supplied by the tibial division of the sciatic nerve. The femoral nerve may supply the pectineus. - **Arterial Supply:** Obturator artery, medial circumflex femoral artery, and perforating branches of the profunda femoris. - **Clinical Notes:** The obturator nerve passes through the obturator canal and can be injured during pelvic surgery, leading to weakened thigh adduction. Chronic groin pain from adductor tendinopathy is common in athletes. #### Posterior (Flexor) Compartment of the Thigh - **Muscles:** Hamstrings – biceps femoris (long and short heads), semitendinosus, semimembranosus. Part of the adductor magnus is often included here due to the common hamstring origin. - **Function:** Hip extension and knee flexion; biceps femoris also laterally rotates the leg when the knee is flexed; semitendinosus and semimembranosus medially rotate the leg. - **Nerve Supply:** Tibial division of the sciatic nerve supplies most hamstrings; the short head of the biceps femoris is supplied by the common fibular division. - **Arterial Supply:** Perforating branches of the profunda femoris and contributions from the inferior gluteal artery. - **Clinical Notes:** Hamstring strains occur at the musculotendinous junction; sciatic nerve pathology can present with weakness in knee flexion. Swelling in this compartment is less common but can compress the sciatic nerve or perforating arteries. 💡 ****Tip:** Remember muscle actions by compartment. Anterior extends the knee, posterior flexes the knee, and medial adducts the hip. This simple pattern helps orient you in anatomy exams and surgery. --- ## Compartments of the Leg ****Key Point** The leg is divided into four compartments: Anterior, lateral, superficial posterior, and deep posterior by septa and the interosseous membrane. The anterior contains dorsiflexors (deep peroneal nerve), the lateral evertors (superficial peroneal nerve), and the posterior compartments plantarflexors and toe flexors (tibial nerve). The crural fascia and interosseous membrane subdivide the segment between the knee and ankle into narrow muscular canals. Each compartment hosts muscles performing related movements at the ankle and toes, with an accompanying artery and nerve. Understanding this arrangement helps diagnose nerve palsies and vascular compromise, choose incision placement, and recognise the patterns of compartment syndrome. The leg compartments are separated by strong fascial walls which limit swelling. For example, the anterior compartment’s stiff boundaries make it the most frequent site of acute compartment syndrome. ### Anterior (Dorsiflexor) Compartment - **Muscles:** Tibialis anterior, extensor hallucis longus (EHL) and extensor digitorum longus (EDL). Fibularis tertius (often considered part of EDL) contributes to dorsiflexion. - **Function:** Dorsiflexion of the ankle; tibialis anterior inverts the foot while EDL and EHL assist in extending the lateral four toes and the great toe respectively. - **Nerve Supply:** Deep peroneal (fibular) nerve. - **Arterial Supply:** Anterior tibial artery. - **Clinical Notes:** Foot drop results from deep peroneal nerve injury, causing loss of dorsiflexion and toe extension. Anterior compartment syndrome may present with pain on passive plantarflexion and paresthesia in the first web space. ### Lateral (Evertor) Compartment - **Muscles:** Fibularis (peroneus) longus and fibularis brevis. - **Function:** Eversion of the foot and weak plantarflexion. - **Nerve Supply:** Superficial peroneal nerve. - **Arterial Supply:** No major artery traverses this compartment; it receives branches from the peroneal (fibular) artery and perforating branches of the anterior tibial artery. - **Clinical Notes:** Injury to the superficial peroneal nerve leads to loss of foot eversion and sensory loss over the dorsum of the foot. The lateral compartment is seldom involved in compartment syndrome but can be affected by fibular fractures or crush injuries. ### Superficial Posterior (Plantarflexor) Compartment - **Muscles:** Gastrocnemius, soleus, and plantaris. - **Function:** Plantarflexion of the ankle, gastrocnemius also flexes the knee. These muscles form the Achilles tendon, which transmits force to the calcaneus. - **Nerve Supply:** Tibial nerve. - **Arterial Supply:** Branches of the posterior tibial artery and sural arteries; the gastrocnemius is also supplied by sural branches from the popliteal artery. - **Clinical Notes:** Rupture of the Achilles tendon weakens push‑off during walking. Calf pain and swelling after exertion may indicate deep posterior compartment pathology or deep vein thrombosis. ### Deep Posterior (Plantarflexor/Toe Flexor) Compartment - **Muscles:** Tibialis posterior, flexor hallucis longus (FHL), flexor digitorum longus (FDL) and popliteus. - **Function:** Plantarflexion of the ankle, flexion of the toes (FHL and FDL), and medial rotation of the femur on the tibia (popliteus). The tibialis posterior also inverts the foot and supports the medial longitudinal arch. - **Nerve Supply:** Tibial nerve. - **Arterial Supply:** Posterior tibial artery and fibular (peroneal) artery. - **Clinical Notes:** Tibialis posterior dysfunction causes adult‑acquired flat foot. FHL tendinopathy affects ballet dancers due to repetitive plantarflexion. Deep posterior compartment syndrome may manifest with severe pain on passive dorsiflexion of the toes and decreased sensation in the sole. These leg compartments are illustrated below. ![Compartments of the leg](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/Main-Article-Images--19-.png) Compartments of the leg 😎 ****Fun Fact:** The anterior leg compartment is the most common site of acute compartment syndrome because its tough fascia and rigid interosseous boundaries leave little room for swelling. --- ## Compartment Syndrome and Clinical Considerations ****Key Point** The rigid fascia of the lower limb limits expansion; when pressure exceeds perfusion (>30 mmHg or ΔP < 30 mmHg), acute compartment syndrome develops, often following fractures, crush injury, burns, or reperfusion. Acute compartment syndrome arises when increased fluid volume (oedema, haemorrhage) or constrictive dressings raise intracompartmental pressure above capillary perfusion pressure, leading to ischaemia and muscle necrosis. The compartments of the leg, especially the anterior, are most often affected. Normal intracompartmental pressures are less than 10 mmHg. Pressures above 30 mmHg or a delta pressure (diastolic blood pressure minus compartment pressure) less than 30 mmHg indicate the need for fasciotomy. Presentation includes, - Severe pain out of proportion to injury - Pain on passive stretch - Tense swollen compartments, paraesthesia - Later, **paresis** and **pulselessness**. Early diagnosis is clinical. Pressure measurement helps with uncertain cases. A **two‑incision fasciotomy** of the leg releases all four compartments and must not be delayed. In the thigh, a single **lateral or medial incision** can release the compartments. **Risk Factors and Precipitating Events** - Long‑bone fractures, particularly tibial shaft fractures. - Crush injuries, burns, vascular injuries, drug overdoses, and prolonged limb compression. - Reperfusion after ischaemia or thrombosis. - Tight casts, dressings, or external compression devices. - Vigorous exercise or prolonged surgery in fixed positions. Early recognition and prompt fasciotomy within six hours preserve muscle and nerve function. Delayed treatment risks permanent neurological deficit, muscle necrosis, contractures, rhabdomyolysis, and amputation. After any reduction, splint, or dressing change, repeat neurovascular assessment and document findings. A dynamic assessment is key. 💡 ****Tip:** Classic warning signs: pain on passive stretch, tense swelling, and pain out of proportion. Don’t wait for pulselessness. Early fasciotomy is limb-saving. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Compartment Contents and Functions:** Understand how the thigh’s anterior, medial, and posterior compartments and the leg’s anterior, lateral, superficial posterior, and deep posterior compartments organise muscles with related actions and innervation. ****2\. Neurovascular Organisation:** Recognise that each compartment carries a distinct nerve and artery, guiding incision planning and diagnosis of nerve lesions. ****3\. Compartment Syndrome:** Detect that normal pressures are <10 mmHg, and a threshold of >30 mmHg suggests the need for fasciotomy; recall risk factors such as fractures, crush injuries, and reperfusion ****4\. Clinical Principles:** Perform systematic examination of the lower limb, repeat assessments, document findings, and be prepared to decompress the limb urgently when signs of compartment syndrome appear. --- ## Further Reading 1. Yang, M. (2023). [Acute compartment syndrome: why do we miss it and how do we improve?](https://www.emdocs.net/acute-compartment-syndrome-why-do-we-miss-it-and-how-do-we-improve/?ref=theplasticsfella.com#:~:text=TL%3BDR) emDocs. 2. Taljanovic, M.S., Jones, M.D. and Hunter, T.B. (2024). [Acute Compartment Syndrome](https://www.ncbi.nlm.nih.gov/books/NBK448124/?ref=theplasticsfella.com#:~:text=Fascia%C2%A0is%20a%C2%A0thin%2C%C2%A0inelastic%20sheet%20of%20connective,nerve%2C%20and%20the%20tibial%20artery). StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing. 3. Bhimji, S.S. and Sinha, U.K. (2024) [Anatomy, bony pelvis and lower limb, thigh muscles](https://www.ncbi.nlm.nih.gov/books/NBK482445/?ref=theplasticsfella.com#:~:text=The%20thigh%20muscles%20are%20divided,see%20Image). StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing. ### Describing a Fracture: Pattern, Location, & Investigations URL: https://www.theplasticsfella.com/describing-a-fracture/ Last updated: 2025-11-02T08:59:53.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/describing-a-fracture/#overview-of-describing-a-fracture) Fractures are three‑dimensional injuries. Accurate diagnosis and description require at least two orthogonal radiographic views. PLACES framework identifies key elements: fracture pattern, location, alignment, open/closed status, examination findings, and special investigations. [****Pattern of Fracture**](https://www.theplasticsfella.com/describing-a-fracture/#pattern-of-fracture-p) Fracture pattern describes the configuration of the fracture line and reflects the mechanism of injury. Recognising pattern (e.g., transverse, oblique, spiral, comminuted, avulsion, buckle, or greenstick) helps infer forces involved and anticipate stability. [****Location of Fracture**](https://www.theplasticsfella.com/describing-a-fracture/#location-of-fracture-l) Always identify the bone and precisely locate the fracture: diaphysis, metaphysis, epiphysis, or physeal region, and state whether the fracture extends into a joint. [****Alignment of Fracture Fragments**](https://www.theplasticsfella.com/describing-a-fracture/#alignment-of-fracture-fragments-a) Alignment describes the relative position of fracture fragments. Specify displacement, angulation, rotation, and length change, referencing the distal fragment. [****Closed vs Open injury**](https://www.theplasticsfella.com/describing-a-fracture/#closed-vs-open-injury-c) A closed fracture does not communicate with the external environment. An open fracture penetrates the skin and has a higher risk of infection, soft‑tissue damage, and non‑union. Grading open fractures by the Gustilo-Anderson system helps guide management. [****Examination Findings**](https://www.theplasticsfella.com/describing-a-fracture/#examination-findings-e) After radiographs, clinical assessment addresses the soft‑tissue envelope and neurovascular status. Document stability, contamination, exposed bone or tendon, and any associated nerve or vessel injury. Unstable fractures typically require fixation. [****Special Investigations**](https://www.theplasticsfella.com/describing-a-fracture/#special-investigations-s) Radiographs remain the cornerstone of fracture diagnosis, but CT and MRI are important for complex injuries. Always obtain at least two orthogonal X‑ray views and image adjacent joints to fully assess injury extent. ****Verified by thePlasticsFella ✅** --- ## Overview of Describing a Fracture ****Key Point** Fractures are three‑dimensional injuries. Accurate diagnosis and description require at least two orthogonal radiographic views. ****PLACES** framework identifies key elements: fracture pattern, location, alignment, open/closed status, examination findings, and special investigations. A **fracture** is a complete or incomplete break in the continuity of bone that results in mechanical instability. Clinically, fractures present with pain, swelling, deformity, and functional impairment. Plastic surgeons frequently manage hand and facial fractures, where precise description guides operative planning and highlights associated soft‑tissue injuries. Radiological evaluation should include at least two orthogonal views (e.g., AP and lateral) to assess the three‑dimensional relationship of fragments and joint involvement. A structured template for describing fractures and facilitating comprehensive documentation is the systematic **PLACES** mnemonic: **Pattern**, **Location**, **Alignment**, **Closed vs open**, **Examination findings,** and **Special investigations**. --- ## Pattern of Fracture (P) ****Key Point** Fracture pattern describes the configuration of the fracture line and reflects the mechanism of injury. Recognising pattern (e.g., transverse, oblique, spiral, comminuted, avulsion, buckle, or greenstick) helps infer forces involved and anticipate stability. Patterns are defined by the orientation of the fracture line and the number of fragments. In **complete fractures**, the fracture line traverses the entire cortex. **Incomplete fractures** occur when one cortex remains intact, usually in paediatric patients. The image below illustrates the key fracture patterns: Transverse, oblique, spiral, comminuted, avulsion, buckle, or greenstick. ![Key fracture patterns: Transverse, oblique, spiral, communited](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/Main-Article-Images--15-.png) Key fracture patterns: Transverse, oblique, spiral, communited The table below summarises common bone fracture patterns. ![Common bone fracture patterns, their type, mechanism, and clinical insight](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/Main-Article-Images--17-.png) Common bone fracture patterns, their type, mechanism, and clinical insight Using consistent terminology for fracture patterns allows clinicians to convey injury severity and anticipate stability. Paediatric fractures often involve unique patterns such as **buckle** and **greenstick** due to pliable cortices. 💡 ****Tip:** The mechanism of injury often predicts the fracture pattern. For example, torsion produces a spiral fracture, while a direct blow causes a transverse one. --- ## Location of Fracture (L) ****Key Point** Always identify the bone and precisely locate the fracture: diaphysis, metaphysis, epiphysis, or physeal region, and state whether the fracture extends into a joint. Fractures are described first by bone (e.g., radius, metacarpal) and then by the affected segment. Accurate localisation influences prognosis and surgical strategy. Long bones have distinct regions. - **Epiphysis:** The end portion participating in the joint. Fractures here are termed epiphyseal. - **Metaphysis:** The flared region between epiphysis and diaphysis. Metaphyseal fractures may extend to growth plates in children. - **Diaphysis:** The shaft is further divided into proximal, middle, and distal thirds. Diaphyseal fractures may be transverse, oblique, spiral, comminuted, or segmental. State whether the fracture is **intra‑articular** or **extra‑articular**. Intra‑articular fractures involve the articular surface and often require anatomical reduction to prevent post‑traumatic arthritis. Extra‑articular fractures spare the joint but may still affect stability or soft tissue attachments. Note any involvement of tubercles, condyles, or other bony landmarks when relevant. For paediatric fractures, mention the Salter–Harris classification if the growth plate is involved. 💡 ****Tip:** Always describe a fracture by bone first, then segment (e.g. “proximal humeral metaphysis”) and specify whether it’s intra- or extra-articular. This defines both prognosis and surgical approach. --- ## Alignment of Fracture Fragments (A) ****Key Point** Alignment describes the relative position of fracture fragments. Specify displacement, angulation, rotation, and length change, referencing the distal fragment. After naming the bone and pattern, describe how the fragments are aligned. These details influence reduction methods and stability. - **Displacement:** The amount of offset of the distal fragment relative to the proximal fragment, described as a percentage of the bone diameter or in millimetres. For example: “50 % dorsal displacement.” *Translation* refers to side‑to‑side displacement, while *distraction* indicates separation by a gap. - **Angulation:** The angle between fragments, described by the direction of the apex of the angle relative to the bone’s long axis (e.g., volar/dorsal, valgus/varus). Valgus indicates the distal fragment points laterally, while varus indicates it points medially. - **Rotation:** Rotation of the distal fragment relative to the proximal fragment. Clinically assessed by observing finger cascade or limb alignment and best visualised on oblique views. Rotational malalignment is common in spiral fractures of the hand and forearm. - **Length Changes:** Shortening due to impaction or overriding of fragments or lengthening due to distraction. Note the degree (e.g., “shortened by 1 cm”). Always describe displacement and angulation relative to the distal fragment. Recognising significant malalignment aids in decision‑making. Unstable alignment usually requires reduction and fixation. 💡 ****Tip:** Always describe displacement and angulation relative to the distal fragment, not the proximal one. This is the universal orthopaedic convention. --- ## Closed vs Open Injury (C) ****Key Point** A closed fracture does not communicate with the external environment. An open fracture penetrates the skin and has a higher risk of infection, soft‑tissue damage, and non‑union. Grading open fractures by the Gustilo-Anderson system helps guide management. Fractures are broadly classified based on whether the fracture site communicates with the external environment. This distinction is crucial, as open fractures carry a substantially higher risk of infection and soft-tissue complications. The Gustilo-Anderson grading system for fractures guides both the urgency and approach to management. - **Closed Fracture:** The skin and soft tissues overlying the fracture are intact. There is no communication between the fracture site and the environment. Closed fractures may still have significant soft‑tissue contusion or crushing. - **Open (compound) Fracture:** The fracture site communicates with the outside environment via a wound in the skin or mucosa. The wound may vary from a small puncture to extensive soft‑tissue loss. Open fractures are graded by the **Gustilo-Anderson classification**, which considers wound size, soft‑tissue damage, contamination, and fracture severity. For example, - Type I is a puncture wound < 1 cm - Type II has lacerations 1-10 cm - Type III involves extensive soft‑tissue damage or high‑energy mechanisms and is subdivided into IIIA, IIIB, and IIIC based on periosteal coverage and vascular injury. Early intravenous antibiotics, tetanus prophylaxis, surgical debridement, and stabilisation are essential. 😎 ****Fun Fact:** The Gustilo-Anderson system was first published in 1976 after analysing 1,025 open fractures. It remains the foundation for classifying soft-tissue injury severity and guiding antibiotic and surgical timing. --- ## Examination Findings (E) ****Key Point** After radiographs, clinical assessment addresses the soft‑tissue envelope and neurovascular status. Document stability, contamination, exposed bone or tendon, and any associated nerve or vessel injury. Unstable fractures typically require fixation. A thorough clinical examination complements radiographic assessment by evaluating the soft-tissue envelope and neurovascular integrity. Early recognition of instability, contamination, or compromised circulation is vital, as these findings determine both urgency and the need for surgical intervention. Detailed examination supplements radiographic findings. - **Soft‑Tissue Assessment:** Inspect for wounds, degloving, contamination, or foreign bodies. Palpate for crepitus or instability. Check whether the bone or tendon is exposed. Assess skin colour, temperature, and capillary refill. - **Stability:** Determine if the fracture is stable (non‑displaced or minimally displaced) or unstable (displaced, comminuted, intra‑articular, segmental). Unstable fractures often require surgical fixation to restore anatomy and function. - **Neurovascular Examination:** Document sensation in the distal nerves (e.g., median, ulnar, radial distributions in the upper limb) and motor function. Evaluate distal pulses and capillary refill. Doppler or arterial imaging may be needed when pulses are diminished. Assess tendon function (e.g., mallet finger or rupture of extensor/flexor tendons) and check for compartment syndrome in high‑energy injuries. Red flag features include open fractures, neurovascular compromise, impending compartment syndrome, intra‑articular extension, and pathological fractures. 💡 ****Tip:** Always document neurovascular status early and repeatedly. Diminished perfusion or sensory changes may indicate compartment syndrome or evolving vascular compromise. --- ## Special Investigations (S) ****Key Point** Radiographs remain the cornerstone of fracture diagnosis, but CT and MRI are important for complex injuries. Always obtain at least two orthogonal X‑ray views and image adjacent joints to fully assess injury extent. Accurate imaging is essential for diagnosing fractures and planning management. While plain radiographs remain the first-line tool, advanced modalities like CT and MRI provide valuable detail for complex or occult injuries. Always obtain at least two orthogonal views and include adjacent joints to avoid missing associated injuries. Recommended imaging include, - **Plain Radiographs:** Obtain **anteroposterior** (AP) and **lateral** views for all suspected fractures. Oblique views or dedicated views (e.g., scaphoid, radial head) may be needed to assess rotation or specific anatomy. For hand fractures, the oblique view helps identify rotational deformity by evaluating the finger cascade and overlapping of metacarpal heads. - **Computed Tomography (CT):** Provides a detailed three‑dimensional assessment of complex fractures, comminution, and articular involvement. CT is invaluable for pre‑operative planning of intra‑articular fractures and in high‑energy injuries with multiple fragments. - **Magnetic Resonance Imaging (MRI):** Useful for detecting occult fractures not visible on X‑ray (e.g., scaphoid, femoral neck) and for assessing associated soft‑tissue injuries (ligament, tendon, cartilage). MRI is also employed to evaluate growth plate injuries or stress fractures. - **Additional Tests:** Ultrasound may help detect occult wrist fractures and tendon injuries. Arteriography or CT angiography is indicated when arterial injury is suspected. Always image the joint above and below the fracture to identify associated injuries (e.g., elbow for forearm fractures). 💡 ****Tip:** Two orthogonal X-ray views are mandatory because fractures are three-dimensional. A single view may completely miss displacement or joint involvement. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Fractures are breaks in bone continuity identified on X-rays. Use the PLACES framework: Pattern, Location, Alignment, Closed/open, Examination, and Special investigations. ****2\. Pattern:** Fracture configuration reflects mechanism: transverse (tension), oblique (compression), spiral (torsion), comminuted (high-energy), and paediatric types like buckle or greenstick. ****3\. Location & Alignment:** Describe the bone, its segment (epiphysis, metaphysis, diaphysis), and joint involvement. Alignment is assessed by displacement, angulation, rotation, and length changes using the distal fragment as reference. ****4\. Closed vs Open & Examination:** Open fractures penetrate skin and risk infection; classify using Gustilo-Anderson. Clinical assessment includes soft tissue, neurovascular status, and tendon function. ****5\. Investigations:** At minimum, obtain orthogonal X-rays and include adjacent joints. CT aids with articular or comminuted injuries; MRI helps detect occult fractures and soft tissue damage. --- ## Further Reading 1. OrthoPaedia. [Describe a Fracture Pattern Over the Phone](https://www.orthopaedia.com/describe-a-fracture-pattern-over-the-phone/?ref=theplasticsfella.com). 2. Physiopedia. [Fracture](https://www.physio-pedia.com/Fracture?ref=theplasticsfella.com). 3. Gustilo RB, Anderson JT. [Prevention of infection in the treatment of one thousand and twenty five open fractures of long bones](https://pubmed.ncbi.nlm.nih.gov/773941/?ref=theplasticsfella.com). *J Bone Joint Surg Am.* 1976;58(4):453–458. 4. American College of Surgeons. ATLS: Advanced Trauma Life Support - 11th edition. Chapter on orthopaedic trauma evaluation. ### Halloween Edition: 4 Firework + Pumpkin Injuries, & AI vs Real Surgeons URL: https://www.theplasticsfella.com/november-2nd/ Last updated: 2025-11-01T21:04:57.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/november-2nd/#a-letter-from-pfella) Will AI replace doctors, or just bill for them? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-2nd/#the-sunday-quiz) How well do you know *chemical burns?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/november-2nd/#image-of-the-week) Firework hand injury. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-2nd/#technique-tip) Tips for a finger replant - video guide. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/november-2nd/#upcoming-events) Speaking at BAPRAS Congress 2025! 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-2nd/#articles-of-the-week) Pumpkin carving injuries, firework facial injuries, & firework injuries over a decade: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/november-2nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Will AI Replace Doctors, or Just Bill for Them?* 👋 Let’s stop pretending this isn’t coming. I recently came across something [interesting…](https://x.com/jbcarmody/status/1983610497816785378?ref=theplasticsfella.com) **OpenEvidence has $50 million in revenue but a $6.1 billion valuation.* That’s not a typo, it’s a warning. Because investors don’t pour billions into a company that plans to politely “assist” doctors. They invest in companies that plan to **replace* them. And if you think plastic surgery is immune, think again. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/data-src-image-518bb1d8-31c9-413e-8a9d-dbcf53af9121.png) [Source](https://x.com/jbcarmody/status/1983610497816785378?ref=theplasticsfella.com) **The $430 Billion Opportunity** Here’s the cold math: physician compensation represents roughly 8.6% of total healthcare spending, about **$430 billion** a year. Whoever cracks the code to automate that revenue stream won’t just be rich; they’ll own the most profitable slice of medicine. AI doesn’t need to replace every surgeon. It just needs to replace enough decision-making to claim the professional fee. And for much of modern medicine, that’s already technically possible. Diagnosis, triage, post-op management: LLMs can do all of it today. The only thing stopping them is regulation. And regulation always bends to money. **Plastic Surgery’s Blind Spot** Plastic surgery prides itself on artistry and human nuance, which are qualities we love to think are irreplaceable. But here’s the uncomfortable truth: - Most post-op wound checks could be automated with image recognition. - Flap viability could be tracked with AI-assisted perfusion monitoring. - Even consultation scripts can now be generated, personalized, and delivered better than most rushed clinics. The only domain left purely human? **Touch.** For now. **Our Choice: Build With It, or Be Billed By It** This isn’t a fight against technology, it’s a fight for ownership. We can either build systems that keep clinicians at the core, or watch as venture-backed platforms turn our skills into prompts. Plastic surgery has an opportunity to lead here: - Integrate AI to enhance — not replace — our decision-making. - Push for ethical frameworks that preserve clinical accountability. - Teach trainees to use AI tools fluently, so they’re not sidelined by them. Because if we don’t define how AI fits into our profession, someone else will, and they’ll send us the invoice. With love (and mild existential dread), **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Chemical Burns?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the fifth round of seven rounds! The ****top** scorer wins one our **Foundations* textbook at a discount! ## Image of the Week **Firework Hand Injury* 🖼️ ****Image of the Week** This week’s image highlights the devastating impact of firework-related hand trauma: a severe blast injury with multi-level soft tissue, bone, and neurovascular disruption. These injuries often require complex reconstructive approaches, combining debridement, skeletal stabilization, and staged flap coverage. It’s a stark reminder of how prevention and safety education remain as important as surgical reconstruction. ![Firework Hand Injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/11/bmjcr-2019-October-12-10--F2.large.jpg) Firework Hand Injury - [Source](https://casereports.bmj.com/content/bmjcr/12/10/e231804/F2.large.jpg?ref=theplasticsfella.com) ## Technique Tip **Tips for a Finger Replant* 🚑 ****Technique Tip of the Week** This week’s technique tip features a detailed video on finger replantation covering key steps from tissue preservation to microsurgical repair. Use this as a refresh on how to approach digit loss scenarios, focusing on structure-by-structure repair and maximizing functional outcomes. 🎥 Watch the video below. [Fingertip Replantation TechniqueThis video shows a demonstration of the fingertip replantation technique.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/favicon.png)LWW![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/627)](https://journals.lww.com/plasreconsurg/pages/video.aspx?v=2697&ref=theplasticsfella.com) ## Upcoming Events **Speaking at BAPRAS Congress 2025* 📅 I’m delighted to share that I’ll be speaking at ****BAPRAS Congress 2025** in Belfast on ****Friday, December 5th**. The event, themed **“Forward,”* brings together plastic surgeons from across the UK and beyond for three days of discussion, innovation, and collaboration. If you’re attending, come say hello! It’s always great to connect in person. Learn more about [BAPRAS Congress 2025](https://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2025?ref=theplasticsfella.com). ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Beware the Halloween Hand Injury Spike** ([Johnson](https://pubmed.ncbi.nlm.nih.gov/35930995/?ref=theplasticsfella.com), 2022) From 2012-2021, over 20,000 pumpkin-related knife injuries occurred in the U.S. 88% to the hand, most often the thumb or index finger, peaking on October 30th, highlighting a clear need for targeted safety education. ✅ ****When Fireworks Hit the Face: Who’s Most at Risk?**([Heilenman](https://journals.sagepub.com/doi/abs/10.1177/27325016251362421?ref=theplasticsfella.com), 2025) Firework-related facial trauma mainly affects young males; children suffer soft tissue wounds while adults sustain complex fractures, highlighting the need for age-specific management and stricter safety measures. ✅ ****Firework Injuries: Lessons from a Decade of Data** ([Puri](https://pubmed.ncbi.nlm.nih.gov/18603491/?ref=theplasticsfella.com), 2009) Over 10 years at KEM Hospital, 157 patients, mostly unsupervised children aged 5-14, presented with firework injuries, mainly from misuse or device failure; flares and rockets caused the most severe burns and blast injuries, while sustained awareness campaigns led to a marked decline in cases. ## Feedback ### I hope you enjoyed it 😄 --- ### Compartments of the Upper Limb: Neurovascular Anatomy & Clinical Relevance URL: https://www.theplasticsfella.com/compartments-of-the-upper-limb/ Last updated: 2025-10-30T20:25:21.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/compartments-of-the-upper-limb/#overview-of-upper-limb-compartments) Compartments are fascial “rooms” in the upper limb that house specific muscles, nerves, and vessels. Knowing their arrangement helps predict function, guide surgical exposure, and diagnose compartment syndrome. [****Upper Arm Compartments**](https://www.theplasticsfella.com/compartments-of-the-upper-limb/#upper-arm-compartments) The brachium contains two large compartments encased by the brachial fascia. Fascial septa extend from the humerus to partition the arm into anterior and posterior spaces and provide surfaces for muscle attachment. [****Forearm Compartments**](https://www.theplasticsfella.com/compartments-of-the-upper-limb/#forearm-compartments) The forearm spans from the elbow to the wrist and contains three main compartments created by the interosseous membrane between the radius and ulna and the lateral intermuscular septum. [****Compartment Syndrome**](https://www.theplasticsfella.com/compartments-of-the-upper-limb/#compartment-syndrome-clinical-considerations) Rigid fascial boundaries mean that swelling or bleeding within a compartment raises pressure, impairing venous return and arterial inflow. Recognizing compartment syndrome early prevents irreversible ischemia. ****Verified by thePlasticsFella ✅** --- ## Overview of Upper Limb Compartments ****Key Point** Compartments are fascial “rooms” in the upper limb that house specific muscles, nerves, and vessels. Knowing their arrangement helps predict function, guide surgical exposure, and diagnose limb‑threatening compartment syndrome. The upper limb extends from the shoulder to fingertips and is organized into mechanical compartments by strong layers of **deep fascia** and i**nterosseous membranes**. These compartments compartmentalize muscles performing similar actions and restrict swelling or infection to a defined space. Surgeons must know which muscles, nerves, and vessels lie within each compartment to choose appropriate incisions and to recognize when elevated pressure threatens perfusion. The compartments of the arm and forearm are key to understanding surgical approaches and safe operative technique. - The armdivides into, - **Anterior** compartment - **Posterior** compartment - The forearm contains three compartments separated by the **interosseous membrane** and the **lateral intermuscular septum**. - **Volar (flexor-pronator)** compartment - **Dorsal (extensor-supinator)** compartment - **Mobile wad of Henry** (lateral forearm group) This knowledge is essential for fracture fixation, tendon transfer planning, and compartment release. 😎 ****Fun Fact:** Deep fascia doesn’t just wrap muscles. It mechanically separates them into compartments, limiting swelling and infection spread. --- ## Upper Arm Compartments ****Key Point** The brachium contains two large compartments encased by the brachial fascia. Fascial septa extend from the humerus to partition the arm into anterior and posterior spaces and provide surfaces for muscle attachment. Upper arm compartments also guide major neurovascular bundles. ### Anterior Compartment (Arm) The anterior compartment contains the elbow flexors and key neurovascular structures essential for upper limb function. **Muscles** - **Biceps brachii** - **Origin:** Supraglenoid tubercle (long head) and coracoid process (short head) of the scapula. - **Insertion:** Radial tuberosity and bicipital aponeurosis. - **Action:** Flexes the elbow and powerfully supinates the forearm, also assists in shoulder flexion. - **Nerve Supply:** Musculocutaneous nerve. - **Brachialis** - Lies deep to the biceps. - **Action:** Primary elbow flexor, acting regardless of forearm position. - **Nerve supply:** Musculocutaneous nerve. - **Coracobrachialis** - **Origin:** Coracoid process. - **Insertion:** Medial surface of the humeral shaft. - **Action:** Weak flexor and adductor of the arm. - **Nerve Supply:** Musculocutaneous nerve. **Neurovascular Structures** - **Brachial artery** travels through this compartment, giving muscular branches before dividing into the **radial** and **ulnar arteries** near the **cubital fossa**. - The **musculocutaneous nerve** innervates all muscles in this compartment before continuing as the **lateral cutaneous nerve of the forearm**. ### Posterior Compartment (Arm) The posterior compartment contains the **extensors of the elbow** and key neurovascular structures that must be protected during surgery. **Muscle** - **Triceps Brachii** - **Heads:** Long (from the scapula), lateral, and medial (from the humerus). - **Insertion:** Common tendon on the olecranon. - **Action:** Sole extensor of the elbow. - **Nerve Supply:** Radial nerve. **Neurovascular Structures** - **Radial Nerve:** Travels through the **radial groove** of the humerus with the profunda brachii artery. Supplies the triceps and skin of the posterior arm. - **Profunda Brachii Artery:** Branch of the brachial artery accompanying the radial nerve. 💡 ****Tip:** Two compartments, two nerves: musculocutaneous for flexors, radial for extensors. --- ## Forearm Compartments ****Key Point** The forearm spans from the elbow to the wrist and contains three main compartments created by the interosseous membrane between radius and ulna and the lateral intermuscular septum. Each forearm compartment groups muscles of similar function and determines the path of nerves and vessels. ### Volar (Anterior/Flexor-Pronator) Compartment This compartment houses the muscles that flex the wrist and fingers and pronate the forearm. Most muscles originate from the medial epicondyle and are supplied primarily by the **median nerve** with the ulnar nerve innervating the flexor carpi ulnaris and the medial half of the flexor digitorum profundus. The volar compartment is organized into superficial, intermediate, and deep layers. **Superficial Layer** - **Pronator Teres:** Pronates the forearm and assists in elbow flexion. - **Flexor Carpi Radialis (FCR):** Flexes and abducts the wrist. - **Palmaris Longus (PL):** Weak wrist flexor; absent in \~15 % of people. - **Flexor Carpi Ulnaris (FCU):** Flexes and adducts the wrist; innervated by the ulnar nerve. These muscles share a common flexor origin at the medial epicondyle. They are supplied by branches of the ulnar and radial arteries, with the FCU receiving branches from the ulnar artery. **Intermediate Layer** - **Flexor digitorum superficialis (FDS):** Splits into four tendons to flex the proximal interphalangeal (PIP) joints of digits 2-5\. It is innervated by the median nerve. The FDS forms a bridge over the median nerve and ulnar artery as they enter the forearm. **Deep Layer** - **Flexor digitorum profundus (FDP):** Flexes the distal interphalangeal (DIP) joints. Lateral half is innervated by the anterior interosseous branch of the median nerve, while the medial half receives ulnar nerve branches. - **Flexor pollicis longus (FPL):** Flexes the thumb’s interphalangeal joint and is supplied by the anterior interosseous nerve. - **Pronator quadratus (PQ):** Pronates the forearm; forms a square muscle between the distal radius and ulna. Supplied by the anterior interosseous nerve. The anterior interosseous artery, a branch of the ulnar artery, runs along the interosseous membrane and supplies the deep flexors. The **median nerve** travels between the FDS and FDP, entering the carpal tunnel to supply the hand. ### Dorsal (Posterior/Extensor-Supinator) Compartment Contains muscles that extend the wrist and fingers and supinate the forearm. Innervation is via the radial nerve and its posterior interosseous branch. This compartment is also arranged into superficial and deep layers. **Superficial Layer** - **Extensor digitorum (ED):** Extends the fingers (metacarpophalangeal and interphalangeal joints). Its tendon divides into four slips forming the extensor hoods. - **Extensor digiti minimi (EDM):** Extends the little finger; its tendon runs ulnar to the extensor digitorum tendon. - **Extensor carpi ulnaris (ECU):** Extends and adducts the wrist. - **Anconeus:** Assists triceps in elbow extension and stabilizes the elbow joint. These muscles are innervated by the posterior interosseous nerve (PIN), a branch of the radial nerve. Blood supply derives from the posterior interosseous artery, a branch of the ulnar artery, which travels with the PIN along the extensor compartment. **Deep Layer** - **Supinator:** Unwinds the radius around the ulna to supinate the forearm. - **Abductor pollicis longus (APL):** Abducts and extends the thumb. - **Extensor pollicis brevis (EPB):** Extends the thumb’s metacarpophalangeal joint. - **Extensor pollicis longus (EPL):** Extends the thumb’s interphalangeal joint. - **Extensor indicis (EI):** Extends the index finger and assists the extensor digitorum. All of these deep extensors share innervation from the posterior interosseous nerve. Their arterial supply is mainly via the posterior interosseous artery. ### Mobile Wad of Henry (Lateral Compartment) This compartment houses three muscles (brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis) that flex the elbow during rapid or resisted movement and assist in radial deviation of the wrist. These muscles bridge functions between flexors and extensors and are supplied by the radial nerve before its bifurcation. The **mobile wad** sits on the lateral aspect of the forearm. - **Brachioradialis:** Originates from the proximal lateral supracondylar ridge of the humerus and inserts near the radial styloid. It is the strongest forearm flexor, especially when the forearm is in mid‑pronation. - **Extensor carpi radialis longus (ECRL):** Extends and abducts the wrist. Originates from the distal lateral supracondylar ridge and inserts on the base of the second metacarpal. - **Extensor carpi radialis brevis (ECRB):** Extends the wrist and assists in radial deviation, inserts on the base of the third metacarpal. The **radial nerve** innervates all three muscles before dividing into its superficial sensory branch and deep motor branch (posterior interosseous nerve). The **radial artery**, running along the lateral forearm, supplies the mobile wad. 💡 ****Tip:** ‘F-PRAM’: Flexor-Pronator, Anterior, Median nerve — a quick way to recall volar compartment anatomy. --- ## Compartment Syndrome & Clinical Considerations ****Key Point** Rigid fascial boundaries mean that swelling or bleeding within a compartment raises pressure, impairing venous return and arterial inflow. Recognizing compartment syndrome early prevents irreversible ischemia. Each muscle compartment is bound by inelastic fascia. When fluid volume rises due to fractures, vascular injury, reperfusion, burns, or tight casts, the pressure within the compartment increases. Fascia cannot stretch, so elevated pressure first collapses thin-walled veins, reducing venous outflow. As pressure climbs, arterial inflow also falls, leading to ischemia and eventual necrosis. Symptoms include severe pain (often out of proportion to the injury), tense swelling, paresthesia, and pain with passive stretch, while pulses may remain palpable. In the upper limb, compartment syndrome most commonly affects the forearm, but it can occur anywhere there is a closed fascial space. Pressure measurements > 30 mmHg help confirm the diagnosis, but serial clinical examinations are paramount. Treatment is emergent fasciotomy to release the fascia and restore perfusion. For more details, read our article on [compartment syndrome of the hand](https://www.theplasticsfella.com/hand-compartment-syndrome/). 💡 ****Tip:** Compartment syndrome pain is often out of proportion. Don’t wait for pulse loss as that’s a late sign. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. The Role of Deep Fascia:** Understand how fascial septa compartmentalize muscles and why swelling within a closed osteofascial space can lead to compartment syndrome. ****2\. Upper Limb Compartments:** Recognize that the arm has two compartments (anterior and posterior) and the forearm three (volar, dorsal, mobile wad) and list the muscles contained in each. ****3\. Nerve and Vascular Supply:** Match the major nerves (musculocutaneous, median, radial, ulnar, posterior interosseous) and arteries (brachial, ulnar, radial, interosseous) to their respective compartments. ****4\. Clinical Signs of Compartment Syndrome:** Describe the pathophysiology of acute compartment syndrome and appreciate the urgency of fasciotomy when intracompartmental pressure rises. --- ## Further Reading - Chaudhry MA, Hafeez AM, Sinkler MA, Arain A. [Forearm Compartments](https://www.ncbi.nlm.nih.gov/books/NBK539784/?ref=theplasticsfella.com#:~:text=The%20forearm%20is%20the%20region,to%20a%20lateral%20intermuscular%20septum). In: *StatPearls*. Treasure Island (FL). - Alshammari SM, Bordoni B. [Arm Muscles](https://www.ncbi.nlm.nih.gov/books/NBK554420/?ref=theplasticsfella.com#:~:text=The%20upper%20limb%20can%20be,1). In: *StatPearls*. Treasure Island (FL). - Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. In: *StatPearls*. Treasure Island (FL). ### 5 Levels of Plastic Surgery Work, Body Contouring Tips, & Last Call for Lifetime Patrons URL: https://www.theplasticsfella.com/october-26th/ Last updated: 2025-11-01T19:47:20.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/october-26th/#a-letter-from-pfella) The 5 levels of work in Plastic Surgery. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-26th/#the-sunday-quiz) How well do you know *abdominoplasty?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/october-26th/#image-of-the-week) Huger's vascular zones of the abdomen. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/october-26th/#technique-tip) Marking for a fleur-de-lis abdominoplasty. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/october-26th/#foundations-textbook) On sale again late November! 6. ****🆕** [****New Feature**](https://www.theplasticsfella.com/october-26th/#new-feature) Last call: Lifetime Patrons - closes today! 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-26th/#articles-of-the-week) Algorithm for body contouring, how to tighten the skin, & the effect of massive weight loss on body contouring: With 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/october-26th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The 5 Levels of Work in Plastic Surgery* 👋 Healthcare loves hierarchy more than it loves initiative. We celebrate “teamwork,” but the moment someone acts without permission, they’re labeled “disruptive.” It’s no wonder so many brilliant people in medicine stop thinking like problem-solvers and start thinking like checklist-followers. ### That’s why I love the “5 Levels of Work” framework. It nails what separates high-agency professionals from everyone else. But here’s the twist: it also exposes why so few hospitals, departments, and training programs can actually handle high-agency people. **The Framework Everyone’s Sharing** If you missed it, here’s the short version: - **Level 1:** “There’s a problem.” - **Level 2:** “There’s a problem and I’ve found some causes.” - **Level 3:** “Here’s the problem, causes, and possible solutions.” - **Level 4:** “Here’s the problem, the cause, possible solutions, and my recommended fix.” - **Level 5:** “There was a problem. I fixed it. Just keeping you in the loop.” Simple, right? But in medicine, *dangerous.* Because the system isn’t designed for Level 4 or 5 thinkers, it’s built to protect Level 1s from making mistakes.Plastic surgery attracts high-agency people — creative, impatient, allergic to bureaucracy. Yet, our institutions often grind that initiative out of us. - **Trainees** learn to escalate everything “up the chain” instead of owning outcomes. - **Consultants** are rewarded for compliance, not creativity. - **Administrators** want initiative until it challenges their policy. We end up with brilliant people who notice problems daily but stop trying to fix them. Because every “Level 5” act becomes a “Level 0” reprimand. **Leadership Failure, Not Employee Failure** Critics of the framework argue it promotes an individualistic culture where everyone fixes their own problems. They’re right; if leadership abdicates responsibility. A *good* leader doesn’t punish Level 5 behavior; they build safety nets around it. They teach when to escalate, when to act, and how to share responsibility. They don’t just tolerate initiative, they multiply it. If every person in your department hesitates before saying, “I took care of it,” that’s not a competence problem. That’s a culture problem. **The Plastic Surgery Version of “Level 5”** Here’s what Level 5 looks like in our world: - The registrar who builds a shared flap logbook instead of complaining about missing data. - The consultant who reworks the MDT workflow so cases don’t pile up. - The trainee who spots a teaching gap, makes a resource, and shares it with peers without asking permission. High-agency surgeons change systems quietly and make everyone look better in the process. **The Real Takeaway** High agency doesn’t mean rebellion, it means responsibility. It’s the courage to act when something’s broken, even when nobody asked you to. If we want a culture that produces world-class surgeons, not bureaucratic survivors, we need more Level 4s, and leaders who don’t fear Level 5s. With love (and agency), **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Abdominoplasty?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the fourth round of seven rounds! The ****top** scorer wins one our **Foundations* textbook at a discount! ## Image of the Week **Huger's Zones of the Abdomen* 🖼️ ****Image of the Week** This week’s image illustrates Huger’s vascular zones, which describe the dominant ****blood supply** to different regions of the ****abdominal wall**: a foundational concept for safe and reliable ****flap elevation**. ****\- Zone I:** Centrally located, supplied by the deep superior epigastric arteries. ****\- Zone II:** Lateral zones supplied by the deep inferior epigastric, superficial inferior epigastric, and circumflex femoral arteries. ****\- Zone III:** Lateral and posterior areas with variable perfusion, often requiring careful consideration during flap design. Understanding these zones helps reduce the risk of flap necrosis during abdominal flap harvests such as TRAM and DIEP. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/A-drawing-demonstrating-the-Huger-zones-of-vascularity-for-the-abdominal-wall-Reproduced.png) Huger's Zones of the Abdomen - [Source](https://www.researchgate.net/publication/344421309/figure/fig3/AS:955483275927552@1604816373513/A-drawing-demonstrating-the-Huger-zones-of-vascularity-for-the-abdominal-wall-Reproduced.png?ref=theplasticsfella.com) ## Technique Tip **Marking for a Fleur-de-Lis Abdominoplasty* 🚑 ****Technique Tip of the Week** This week’s technique tip examines ****patient marking** for a fleur-de-lis abdominoplasty, focusing on how to achieve both ****horizontal** and ****vertical** ****skin excision** in major weight-loss cases. The video clearly shows operative markings and highlights how proper planning supports optimal contouring. ## Foundations Textbook **On Sale Late November!* 📘 We’re preparing for the next **Foundations* release - sales open at the end of November. If you missed the first round, this is your chance to secure **Foundations*. Join the waitlist below and you'll get access as the sale goes live. For everyone who’s already supported Foundations — thank you! This project has grown because of you. We’ve invited early readers to join our referral circle. You’ve already received an email from us, including details on how you can share the book with others who might find it helpful. ## New Feature **Last Call: Lifetime Patrons - Closes Today* ****Reminder: Lifetime Patrons sign-up form closes end of today** We’re rebuilding The Plastics Fella the right way: A faster, cleaner, and more optimized educational platform. To fund this next chapter with our community, we're opening a tiny window for ****Lifetime Patrons**: a handful of people (****10 spots**) who’ll get lifetime access to everything we build and a yearly roundtable with our team to help steer the platform. If this speaks to you, tell us ****why you want in** and what you’re willing to invest. We’ll read every note and reply personally. Talk to via the form below! ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Choosing the Right Abdominoplasty Approach: Body Contouring Algorithm** ([Rosenfield](https://www.ovid.com/journals/aesj/abstract/10.1093/asj/sjz013~evidence-based-abdominoplasty-review-with-body-contouring?ref=theplasticsfella.com), 2019) A patient-specific algorithm for abdominoplasty grounded in anatomy, comorbidities, and aesthetic goals outperforms the “one-size-fits-all” model, optimizing both safety and long-term aesthetic outcomes. ✅ ****Which Nonsurgical Device Works Best for Skin Tightening?** ([Shridharani](https://journals.lww.com/plasreconsurg/abstract/2025/05000/skin%5Ftightening%5Ftechnologies%5Fin%5Fbody%5Fcontouring.30.aspx?ref=theplasticsfella.com), 2025) Energy-based skin tightening devices, ranging from lasers to radiofrequency offer effective, low-downtime alternatives to surgical lifts, with higher energy systems giving stronger results but at the cost of more pain and recovery. ✅ ****Body Contouring After Massive Weight Loss** ([Rhodes](https://www.jprasurg.com/article/S1748-6815%2807%2900025-3/abstract?ref=theplasticsfella.com), 2007) With rising obesity and bariatric surgery rates, post-massive weight loss patients are rapidly increasing, creating a growing need for body contouring surgery to address redundant skin and restore body shape. ## Feedback ### I hope you enjoyed it 😄 --- ### Special Edition: A One-Time Invitation to Shape The Plastics Fella’s Future — Limited Seats URL: https://www.theplasticsfella.com/october-19th/ Last updated: 2025-10-19T12:10:55.000Z ## The Origin. Every surgeon has a few places they return to again and again — the ones that make complex ideas click. ****For many,** ***The Plastics Fella** **has become one of them.** ## *The Plastics Fella* began not as a company, but as an **idea** — that world-class plastic surgery education should be clear, independent, and reachable for anyone serious about learning. Since then, **tens of thousands of surgeons** have used this platform every month to study, teach, and stay sharp. It’s become a living classroom — shaped by the people who use it, not owned by those who don’t. Now we’re stepping into the next chapter. Not to add noise, but to deepen what already works — clarity, independence, and belonging. And as we rebuild for the decade ahead, I want to make sure the people who’ve been part of this journey can keep it — permanently. ### And as always, we’re doing it the only way that’s ever worked here — *with you, in the open.* ## The Next 10 Years. We’re building something quieter, deeper, and more lasting — a space where where information flows cleanly. Where independence stays intact. ****Where great teaching belongs to everyone who seeks it.** ## Everywhere you go, thePlasticsFella will be there. The next decade isn’t about expansion — it’s about refinement. We’re creating a platform where every part of learning connects — what you read, what you practise, and what you teach. Articles that lead to viva cases. Viva cases that link to surgical videos. Videos that loop back to the textbooks that ground your understanding. One seamless ecosystem — faster, smarter, and built to grow with you from trainee to consultant, across countries, exams, and specialties. ### This isn’t about adding more. It’s about making everything work together — a space where independence stays intact and great teaching belongs to everyone who seeks it. ### ## Your Personal Invite Get a seat at the table. I’m opening something that’s never existed before: ****Lifetime Access to thePlasticsFella. An option for those who want to invest in their education.** ### Now you can always have a place in the conversation — to see what’s coming, what’s evolving, and how this platform continues to grow with you in mind. Only **a handful of places at the table** will be offered. Those willing or have the ability to financially invest in their education. Not to create hype — but because I want to personally know the people who hold them. When the last place is taken, this closes. A lifetime inside the idea that knowledge should stay open. You’re investment will give you lifetime access to everything we build — articles, viva cases, digital textbooks, flashcards, and videos (and some secret stuff). You’ll get early access to new tools and invitations to pilot projects and events. Even a direct line to our team. ### And every year, you’ll be at the table — to hear the next chapter first, long before it’s shared with the world. It’s a moment to discuss ideas, share your thoughts, and hear our vision for the future directly from the core team — the same people building it every day. Not as an insider or investor, but as someone whose belief keeps this platform independent, focused, and true to its purpose. Someone who currently has the ability to finance their education. You’ll always move with it — every update, every idea, every evolution. As it grows, you grow with it. ## If this speaks to you. If **The Plastics Fella* has ever given you clarity when you needed it, or made teaching feel simple again — this is your chance to make that connection permanent. ### ## If you’ve ever thought, “I wish TPF did *X*,” this is your chance to help us make *X* happen. ## --- Warm regards, **Ryan** Founder, *The Plastics Fella* ### 3 Suture Studies, A Microsurgery Guide, & Foundations Waitlist Is Back! URL: https://www.theplasticsfella.com/october-12th/ Last updated: 2025-10-12T12:00:55.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/october-12th/#a-letter-from-pfella) Microsurgery Without Microsurgeons 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-12th/#the-sunday-quiz) How well do you know *sutures?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/october-12th/#image-of-the-week) Suture sizes at a glance. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/october-12th/#technique-tip) Microsurgical technique: Arterial anastomosis. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/october-12th/#foundations-textbook) Opening a second waitlist! 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-12th/#articles-of-the-week) Absorbable vs nonabsorbable sutures in hand surgery and facial wounds, & long-term suture strength: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/october-12th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella ****Microsurgery Without Microsurgeons?** 👋 Robots are coming for our microscopes. A recent [post](https://x.com/AlanLumsdenMD/status/1976685588612088075?ref=theplasticsfella.com) about the ****Symani robot** hit a nerve: magnify a 1–2 mm vessel to look like an aorta, use AI to erase tremor, and suddenly **everyone* can perform microsurgery. Democratization, they call it. Disruption, I’d say. ### If a robot can outsteady your hand and AI can outplan your anastomosis, what exactly defines a microsurgeon anymore? > Magnify a 1-2mm vessel to look like an Aorta, use aI to remove your tremor, create a new "surgical like" interface - democratizing the ability to do microsurgery with the Symani robot [@DeBakeyCVedu](https://twitter.com/DeBakeyCVedu?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@Bookout](https://twitter.com/Bookout?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/Y9npDw9JmB](https://t.co/Y9npDw9JmB?ref=theplasticsfella.com) > > — Alan Lumsden, MD, CV Chairman/Director (@AlanLumsdenMD) [October 10, 2025](https://twitter.com/AlanLumsdenMD/status/1976685588612088075?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ### **The Allure of Precision** We get it. Tremor-free suturing. Scaled motion. Better ergonomics. The Symani robot can make a novice’s movements look like a veteran’s, turning a 2-hour anastomosis into a near-perfect digital ballet. And that’s exciting—no denying it. For complex lymphatic surgery or supermicrosurgery, where skill gaps are huge, this tech could flatten the learning curve overnight. But flattening the curve also flattens the hierarchy. The gap between expert and average starts to vanish. When finesse is automated, expertise becomes software. ### **The Soul of Surgery** Here’s the thing: microsurgery isn’t just about precision. It’s about judgment, patience, the *feel* of tissue under tension. Those moments when you improvise because nothing looks like the textbook. A robot can’t feel panic when the vein tears—or relief when the flap pinks up. ### **The Real Future** The smart move isn’t to resist—it’s to redefine. The future microsurgeon will be less a technician and more a strategist: designing, planning, and directing systems that *do* the work while we make the calls. Maybe the next “supermicrosurgeon” isn’t the one with the steadiest hand—it’s the one who knows when *not* to touch the console. --- ### **What Do You Think?** Would you trust a robot to perform your next anastomosis? Would you train differently if AI could stabilize your tremor and magnify your precision? Reply with your thoughts. With love, **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know Sutures?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the third round of seven rounds! The ****top** scorer wins one our **Foundations* textbook at a discount! ## Image of the Week **Suture Sizes at a Glance* 🖼️ ****Image of the Week** This week’s image is a simple reference guide to commonly used suture sizes in plastic surgery, ranging from #0 to 9-0\. It includes USP size, diameter in millimetres, and typical clinical uses: from closing fascia and muscle to microsurgery and nerve repair. ![Suture Sizing (USP Scale)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/image.png) Suture Sizing (USP Scale) ## Technique Tip **Microsurgical Technique: Arterial Anastomosis* 🚑 ****Technique Tip of the Week** This week’s featured technique is a practical video on arterial anastomosis, shared by [**Suturing & Surgery by MedSync*](https://www.youtube.com/watch?v=vdQSq1ZIw84&ref=theplasticsfella.com). The step-by-step demonstration highlights precision handling and needle control, which are fundamental skills for microsurgery trainees. ## Foundations Textbook **Opening a Second Waitlist!* 📘 We’re opening a second waitlist to gauge interest in the next round of textbook sales, and we want to better understand demand for ****digital** vs **physical** copies. If you missed the first round or are deciding which format suits you best, this is your chance to get on the list. We’ll keep you updated until the sale goes live. Join the waitlist below! ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Absorbable vs Nonabsorbable Sutures After A1 Pulley Release** ([Kim](https://pubmed.ncbi.nlm.nih.gov/37997760/?ref=theplasticsfella.com), 2025) At 12 weeks post-op, scar quality, pain, and functional outcomes were equivalent between absorbable and nonabsorbable sutures, suggesting that choice of material can be guided by surgeon preference, cost, or convenience. ✅ ****Absorbable vs Nonabsorbable Sutures for Facial Wounds** ([Gillanders](https://pubmed.ncbi.nlm.nih.gov/30268743/?ref=theplasticsfella.com), 2018) Cosmetic outcomes, infection rates, and scar quality showed no significant difference between absorbable and nonabsorbable sutures for primary facial closure, supporting absorbable sutures as an equally effective, patient-convenient alternative. ✅ ****Which Sutures Hold Strongest Over Time?** ([Erten Taysi](https://pubmed.ncbi.nlm.nih.gov/33851242/?ref=theplasticsfella.com), 2021) Polydioxanone showed the highest tensile strength and elongation across all immersion periods, while polytetrafluoroethylene remained the most stable, making both ideal for durable, reliable wound closure. ## Feedback ### I hope you enjoyed it 😄 --- ### Suturing & Knot Tying: Suture Type Evaluation & Techniques URL: https://www.theplasticsfella.com/suturing-knot-tying/ Last updated: 2025-10-07T11:01:56.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/suturing-knot-tying/#overview-of-suturing-knot-tying) Suturing techniques are tailored to wound characteristics. Understanding when to choose each method and how to execute it safely ensures secure closures and minimizes complications. [****Simple Interrupted Sutures**](https://www.theplasticsfella.com/suturing-knot-tying/#simple-interrupted-sutures) Simple interrupted sutures are the work‑horse of wound closure. Each stitch provides strong closure and can be individually removed, making this technique versatile and safe for many wounds. [****Horizontal Mattress Sutures**](https://www.theplasticsfella.com/suturing-knot-tying/#horizontal-mattress-sutures) The horizontal mattress suture distributes tension across a wound and provides efficient edge eversion, making it useful for fragile skin. However, mismatched bites can lead to edge misalignment, and exposed sutures increase infection risk. [****Deep Dermal Interrupted Sutures**](https://www.theplasticsfella.com/suturing-knot-tying/#deep-dermal-interrupted-sutures) Deep dermal sutures relieve tension on the skin edges by approximating the dermis and hypodermis. They bury the knot within the wound, providing structural support. [****Subcuticular Continuous Sutures**](https://www.theplasticsfella.com/suturing-knot-tying/#subcuticular-continuous-sutures) Subcuticular continuous sutures run within the dermis to create an almost invisible closure with excellent cosmetic results. They provide minimal tensile strength on their own and must be supported by deep sutures in high‑tension wounds. [****Vertical Mattress Sutures**](https://www.theplasticsfella.com/suturing-knot-tying/#vertical-mattress-sutures) Vertical mattress sutures combine a far‑far bite with a near‑near bite to achieve robust closure and edge eversion. They are particularly useful in high‑tension areas but require meticulous technique and may cause tissue necrosis or scarring if tied too tightly. [****How to Tie a Surgeon’s (Triple) Knot**](https://www.theplasticsfella.com/suturing-knot-tying/#how-to-tie-a-surgeons-triple-knot) The surgeon’s knot is a variation of the square knot with a double first throw for added friction and security. It is used when wound tension is high or tissues are prone to separation; secure knots prevent dehiscence. ****Verified by thePlasticsFella ✅** --- ## Overview of Suturing & Knot Tying ****Key Point** Suturing techniques are tailored to wound characteristics. Understanding when to choose each method and how to execute it safely ensures secure closures and minimizes complications. Proper wound closure is fundamental in surgical practice. In plastic surgery and trauma care, the surgeon selects a technique based on **wound tension**, **skin thickness**, **cosmesis**, and **location**. **Interrupted sutures** are versatile and allow individual removal if infection occurs. **Mattress sutures** (horizontal or vertical) distribute tension across wider bites and help evert edges, but they can cause tissue strangulation if overtightened or if bites are unequal. **Deep dermal sutures** provide internal support and reduce dead space; they must be combined with superficial closure for optimal skin alignment. **Subcuticular continuous sutures** hide the suture line to provide a superior cosmetic result. Finally, the knot tying technique, particularly the surgeon’s knot with its double first throw, ensures knot security when tension is high. 💡 ****Tip:** ****Match Suture Size and Material:** Select appropriate suture (monofilament or braided, absorbable or non‑absorbable) based on tissue type and required support duration; absorbable monofilaments generate less inflammation but may provide shorter support. --- ## Simple Interrupted Sutures ****Key Point** Simple interrupted sutures are the work‑horse of wound closure. Each stitch provides strong closure and can be individually removed, making this technique versatile and safe for many wounds. The simple interrupted technique is suitable for wounds with well‑approximated edges under little tension. Each suture is placed separately, allowing removal of one or more stitches without compromising the rest of the closure if there is infection or dehiscence. This independence improves safety but increases the number of knots and time needed. Proper placement with equal distance from the edge and equal depth ensures wound eversion and minimizes step‑off. **Technique (out‑to‑in and in‑to‑out)** - **Insertion:** Gently lift the skin edge with forceps; insert the needle perpendicular (90°) to the skin about **4 mm** from the wound edge and drive it through the dermis. - **Pass:** Follow the curvature of the needle through the tissue until it emerges in the middle of the wound. Use the forceps to re‑grasp the needle for precision. - **Re‑entry:** On the opposite side, lift the skin and insert the needle from inside to outside at an equal distance (\~4 mm) and depth. - **Tie:** Pull the suture through, leaving approximately 3 cm of tail. Tie a secure square or surgeon’s knot, then trim the ends to about 5–6 mm to avoid unravelling. - **Advantages** - Allows individual removal of stitches; useful if part of the wound becomes infected. - Provides strong closure with good control of edge approximation. - Versatile for many body sites and wound shapes. - **Limitations** - Time‑consuming due to multiple knots. - Numerous external knots may harbor bacteria and increase infection risk. - Less effective in high‑tension areas without additional deep sutures. 💡 ****Tip:** Avoid overtightening; excessive tension can strangulate tissue, leading to necrosis and widened scars. --- ## Horizontal Mattress Sutures ****Key Point** The horizontal mattress suture distributes tension across a wound and provides efficient edge eversion, making it useful for fragile skin. However, mismatched bites can lead to edge misalignment, and exposed sutures increase infection risk. Horizontal mattress sutures are placed in two bites on each side of the wound in a transverse orientation. They spread tension along the wound edges, making them ideal for friable or thin tissue that might tear with standard interrupted sutures. Because the loop of suture sits outside the skin, removal is straightforward, but prolonged exposure may cause cross‑hatching scars or infection; early removal is recommended in cosmetic areas. **Technique** - **Insert:** Enter the skin **4-8 mm** from the wound edge and exit on the opposite side. - **Mirror:** Move laterally **3-5 mm** along the wound; re‑enter the far side and bring the needle back to the original side at the same distance and depth. - **Secure:** Tie the knot lateral to the wound so the external loop lies flat across the incision. Avoid overtightening to prevent strangulation and tissue necrosis. - **Advantages** - Provides excellent edge eversion and distributes tension across a larger area. - Useful in fragile or thin skin and for controlling hemostasis. - **Limitations** - External loops may leave cross‑hatched scars; should be removed within a few days in cosmetic areas. - If bites are unequal, edges may misalign, causing a stepped scar. - Increased risk of infection due to more suture material exposed externally. --- ## Deep Dermal Interrupted Sutures ****Key Point** Deep dermal sutures relieve tension on the skin edges by approximating the dermis and hypodermis. They bury the knot within the wound, providing structural support. These buried stitches begin and end at the wound base, inverting the knot under the dermal plane. Their primary role is to close dead space and reduce tension on superficial sutures. Deep dermal sutures are indicated for deep wounds under tension, areas prone to keloids, and wounds with dead space. They are contraindicated in severely contaminated wounds or when the dermis is too thin to support the knot. **Technique** - **Prepare:** After cleansing and draping, insert the needle into the dermis at the bottom of the wound and direct it upward, exiting near the dermal‑epidermal junction on the same side. - **Cross:** Insert the needle on the opposite side near the dermal‑epidermal junction, directly across from the exit point; take small bites to avoid puckering. - **Tie and bury:** Exit at the same dermal plane and tie the knot using a few throws; bury the knot under the dermis, leaving a 3‑mm tail to prevent knot unraveling. - **Finish:** If needed for accurate skin approximation, add a superficial running or interrupted closure after the deep sutures. - **Advantages** - Reduces tension on the skin surface, decreasing the risk of widened scars or dehiscence. - Buried knot avoids external suture marks and reduces infection risk. - Helps obliterate dead space in deep wounds. - **Limitations** - Technically more challenging, particularly in areas with thin dermis. - Requires additional superficial closure for proper epidermal alignment. - Should be avoided in contaminated wounds; may increase infection risk in dirty fields. 💡 ****Tip:** Layered closure involves using deep dermal sutures before superficial closure to relieve tension in thick skin or high‑stress areas; finish with a subcuticular stitch for optimal cosmesis when appropriate. --- ## Subcuticular Continuous Sutures ****Key Point** Subcuticular continuous sutures run within the dermis to create an almost invisible closure with excellent cosmetic results. They provide minimal tensile strength on their own and must be supported by deep sutures in high‑tension wounds. This technique involves a continuous intradermal suture that lies beneath the epidermis. It is ideal for straight, low‑tension wounds, particularly on the face or areas where cosmetic outcome is paramount. Because the suture is hidden, there are no external stitches to remove. The method relies on proper tension, equal spacing, and avoiding full‑thickness bites, which could lead to “railroad track” scars or dehiscence. **Technique** - **Anchor:** Start with a buried knot at the apex of the wound by taking a deep‑dermal bite and tying the suture. This anchors the continuous stitch. - **Insert:** Bring the needle out at the dermo‑epidermal junction; this ensures the suture lies within the dermis. - **Pass:** Progress with small, alternating intradermal bites (2-3 mm) in an S‑shaped pattern along the wound, keeping bites parallel to the skin surface. - **Finish:** At the end of the wound, secure the suture with an Aberdeen knot or loop knot; bury the tail beneath the skin and cut flush. - **Advantages** - Provides excellent cosmetic results with no external suture marks. - Avoids the need for suture removal; well‑tolerated by patients. - Minimal inflammatory response when absorbable monofilament is used. **Limitations** - Offers limited tensile strength; must be combined with deep sutures to prevent dehiscence. - Technique‑sensitive; inconsistent spacing or excessive tension can cause poor cosmetic outcomes or tissue ischemia. - Less suitable for curved or irregular wounds. 💡 ****Tip:** Reload the needle after each pass to maintain accurate bite spacing; consistent spacing and depth are key for a neat closure. --- ## Vertical Mattress Sutures ****Key Point** Vertical mattress sutures combine a far‑far bite with a near‑near bite to achieve robust closure and edge eversion. They are particularly useful in high‑tension areas but require meticulous technique and may cause tissue necrosis or scarring if tied too tightly. The vertical mattress suture incorporates two pairs of bites at different distances from the wound edge. The first (far‑far) bite takes a deep, wide pass that secures underlying tissues. The second (near‑near) bite takes a shallower pass close to the wound edge for eversion. This technique is valuable in deep wounds under tension but is more time‑consuming and may create cross‑hatched scars; it is less commonly used in cosmetic areas. **Technique** - **Far‑far (first bite):** Insert the needle **8 mm** from the wound edge, pass it deep across the wound, and exit on the opposite side also 8 mm from the edge. - **Far‑far mirror:** Reinsert on the far side and exit back to the original side at the same depth and distance. - **Near‑near (second bite):** Reverse the needle; insert it **2 mm** from the wound edge on the original side at half the depth, then exit on the opposite side at an equal distance. - **Tie:** Gently tighten the suture to evert edges; tie a knot, ensuring not to constrict tissue. - **Advantages** - Provides strong closure and excellent edge eversion in high‑tension areas. - Distributes tension across deeper tissues, reducing superficial scarring. - **Limitations** - Time‑consuming and technically demanding; not routinely used in plastic surgery. - If tied too tightly, can cause tissue necrosis or noticeable cross‑hatched scars. - External loops must be removed promptly to avoid marks. 💡 ****Tip:** ****Edge Eversion:** Maintain slight eversion of wound edges; flat or inverted closure can result in depressed scars. Mattress sutures are useful for eversion but may need early removal to avoid scar marks. --- ## How to Tie a Surgeon’s (Triple) Knot ****Key Point** The surgeon’s knot is a variation of the square knot with a double first throw for added friction and security. It is used when wound tension is high or tissues are prone to separation; secure knots prevent dehiscence. A surgeon’s (triple) knot provides increased friction in the first throw by looping the long end twice around the needle holder. This helps maintain tension during subsequent throws. While the term “triple knot” sometimes implies three throws in the first hitch, most surgical practice uses two loops for the first throw followed by two single throws to secure the knot. Excessive throws can bulk up the knot and may compromise closure. **Steps of Tying a Surgeon's Knot** ![Steps of tying a surgeon's knot](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--14-.png) Steps of tying a surgeon's knot A surgeon's knot-tying technique is illustrated below. ![A surgeon's knot-tying technique, Suturing and knot tying](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--13-.png) A surgeon's knot-tying technique 💡 ****Tip:** Always maintain tension along the line of the wound; avoid twisting the knot, which can create a slip knot. Practice with rope or larger sutures before progressing to fine materials. --- ## Conclusion Upon completing this article, you will have accomplished the following: 1\. ****Technique Selection:** Each suture method has specific indications, advantages, and pitfalls. Matching the technique to the wound type ensures optimal closure and cosmetic outcome. ****2\. Key Steps:** Proper needle placement (perpendicular entry at appropriate distance), equal bites, and secure knot tying (double loop for surgeon’s knot) are fundamental for strong closures. ****3\. Layered Approach:** Combining deep dermal sutures for tension relief with subcuticular continuous sutures for cosmesis results in durable and aesthetic wound repair. ****4\. Risk Management:** Avoid overtightening and misaligned bites to prevent tissue necrosis, scarring, or dehiscence. ****5\. Continual Practice:** Practicing knot tying and suturing on models enhances precision and speed, reducing operative time and improving patient outcomes. --- ## Further Reading - Zuber, T.J. (2002) [The mattress sutures: vertical, horizontal, and corner stitch](https://www.aafp.org/pubs/afp/issues/2002/1215/p2231.html?ref=theplasticsfella.com#:~:text=The%20horizontal%20mattress%20suture%20is,patient%20receiving%20chronic%20steroid%20therapy). *American Family Physician*, 66(12), pp. 2231–2236. - Streitz, M.J. (2023) [How to do plastic surgical repair with buried deep dermal sutures](https://www.merckmanuals.com/professional/injuries-poisoning/how-to-care-for-wounds-and-lacerations/how-to-do-plastic-surgical-repair-with-buried-deep-dermal-sutures?ref=theplasticsfella.com). *MSD Manual - Professional Version*. Reviewed by Birnbaumer, D.M. - Medico (n.d.) [Continuous subcuticular suture technique.](https://medicogrp.com/continuous-subcuticular-suture-technique/?ref=theplasticsfella.com#:~:text=Follow%20these%20steps%20to%20ensure,an%20effective%20continuous%20subcuticular%20closure) - Brewster, C. and Anderson, I. (2017) [Simple interrupted suture - OSCE guide](https://geekymedics.com/simple-interrupted-suture-osce-guide/?ref=theplasticsfella.com). Geeky Medics, 29 July. - University of Washington (2025) [Knot tying: two-handed tie](https://sites.uw.edu/uwgensurgtechskills/knot-tying-two-handed-tie/?ref=theplasticsfella.com). UW General Surgery Technical and Professional Skills. ### Transposition Flap: Design Principles, Clinical Use, & Complications URL: https://www.theplasticsfella.com/transposition-flap/ Last updated: 2025-10-07T09:53:53.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/transposition-flap/#overview-of-transposition-flaps) Transposition flaps are pivotal flaps that are rotated laterally across adjacent intact skin, redirecting lines of tension and effectively closing nearby defects with minimal distortion. [****Indications & Contraindications**](https://www.theplasticsfella.com/transposition-flap/#indications-contraindications-of-transposition-flaps) Transposition flaps are indicated for cheek, nose, periorbital, forehead, and hand web space reconstruction. Contraindications include poor vascularity, excessive local tension, or inadequate tissue laxity in the donor site. [****Design & Execution**](https://www.theplasticsfella.com/transposition-flap/#design-execution-of-transposition-flaps) The success of a transposition flap relies on accurate flap length (typically 1.5–2× the defect), precise pivot point placement, and ensuring that flap movement avoids vascular compromise or excessive tension at the arc of rotation. [****Design Variations**](https://www.theplasticsfella.com/transposition-flap/#design-variations-of-transposition-flaps) Limberg, Dufourmentel, bilobed, Z-plasty, and banner flaps offer modifications for different anatomical regions, defect shapes, and tension distributions. These designs allow tailored flap planning with respect to nearby aesthetic or functional units. [****Complications**](https://www.theplasticsfella.com/transposition-flap/#complications-of-transposition-flaps) Postoperative complications include tip necrosis, trapdoor deformity, and pincushioning. Prevention involves appropriate flap thinning, tension offloading, and consideration of secondary procedures such as Burow’s triangle excision or Z-plasty. ****Primary Contributor:** Dr Mustafa Al-Khafaji, Plastics SHO ****Verified by thePlasticsFella ✅** --- ## Overview of Transposition Flaps ****Key Point** Transposition flaps are important local flaps rotated across adjacent intact skin to resurface defects. They redistribute lines of tension, minimize distortion, and are effective in cosmetically and functionally sensitive areas. These flaps belong to local cutaneous flaps and are classified by geometry and transfer mechanics. Their reliability stems from simple design, versatility, and effective redistribution of closure vectors, though they carry limitations related to donor-site management. **Principles of Transposition Flap Design** - Angled flap pivoting across intact skin to reach the defect. - Best suited for defects adjacent to areas with skin laxity where direct advancement is limited. - Reduces closure tension by redirecting vectors away from the primary axis. - Preserves contour in regions requiring precision (e.g., nose, cheek, periorbital area). **Vascular Basis** Flaps are classified into two main vascular categories. According to the McGregor and Morgan classification of cutaneous flaps, **random pattern flaps** depend on the **subdermal vascular plexus** for their blood supply and are generally limited to a length-to-width ratio of up to **3:1**. These flaps are categorized based on their geometry and method of tissue transfer. - **Random Pattern Flaps** - Rely on the dermal-subdermal plexus. - Limited by length-to-width ratio (1:1 up to 3:1). - **Examples:** Rhomboid (Limberg), bilobed, Z-plasty, hatchet flap. - **Advantages:** Simple design, easy to raise. - **Limitations:** Less reliable for long flaps or compromised vascular beds. - **Axial Pattern Flaps** - Supplied by a named artery running along the flap. - Allows longer, thinner designs with predictable perfusion. - **Examples:** **Dorsal metacarpal artery flap** (first dorsal metacarpal artery)**, Nasolabial flap** (facial artery)**, Groin flap** (superficial circumflex iliac artery). - **Advantages:** Robust vascularity, greater reach. - **Limitations:** Technically more demanding dissection, higher skill required. **Advantages** - Local flap with reliable vascularity. - Straightforward technique. - Redirects and redistributes tension. - Often smaller than advancement or rotation flaps. **Disadvantages** - Donor site may require grafting (especially in classic designs). - Risk of dog-ear deformity if one flap edge is shorter than the other. A transposition flap design is illustrated below. ![Transposition flap design](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--9-.png) Transposition flap design --- ## Indications & Contraindications of Transposition Flaps ****Key Point** Transposition flaps are versatile local flaps used when direct closure risks distortion or tension. Indications vary by anatomical region, while contraindications primarily relate to tissue availability, vascularity, and prior damage. These flaps are widely applied in facial and extremity reconstruction, particularly where precision and contour preservation are paramount. Their design allows redirection of tension vectors, making them especially useful in cosmetically sensitive regions. Contraindications generally reflect situations where local tissue is insufficient, poorly vascularized, or compromised by prior treatments. ### Indications by Region & Clinical Use - **Face & Scalp** - **Rhomboid (Limberg) Flap:** Small-to-medium rhomboid-shaped defects after oncologic excisions (e.g., face, scalp, trunk). - **Dufourmentel Flap:** Larger or tension-prone rhomboid defects; allows broader angles (up to 90°). - **Bilobed Flap:** Excellent for small nasal ala and cheek defects, distributing tension across two lobes (Zitelli modification). - **Z-Plasty/Double Z-Plasty:** Scar revision, contracture release, and reorientation of scars in the face, neck, and axilla. - **Banner (Flag) Flap:** Useful for circular/oval defects of the cheek and trunk. - **Periorbital & Perinasal** - **Nasolabial Flap**: Alar, columellar, and lateral nasal wall reconstruction (axial, facial artery-based). - **Fricke Flap (temporal forehead):** Upper eyelid and periocular reconstruction. - **V-Y Transposition Flap:** Common for periorbital defects where advancement plus slight transposition is required. - **Lip & Perioral** - **Webster Flap:** Used in cleft lip revision, lengthening short lip segments. - **Karapandzic Flap (variant):** For full-thickness lip defects, maintaining neurovascular bundles and competence. - **Hand & Extremities** - **Dorsal Metacarpal Artery Flap:** Proximally based, ideal for first web space reconstruction (trauma or contracture). - **Keystone Flap:** Fasciocutaneous, perforator-based; behaves like a transposition flap for trunk/limb oncologic or trauma defects. - **Hatchet Flap:** Simple closure of circular cutaneous defects, often dermatologic. ### Contraindications - **Local Limitations** - Insufficient tissue laxity at the donor site to allow tension-free closure. - Excessive tension vectors that risk distortion of free margins (eyelids, nasal ala, lips). - **Vascular Concerns** - Poor vascularity of donor site (e.g., irradiated skin, previous surgery, infection, or scarring). - In random flaps, exceeding the length-to-width ratio risks necrosis. - **Defect Characteristics** - Very large or deep defects exceeding the capacity of local transposition. - Situations requiring more robust coverage (consider regional or free flaps). 💡 ****Tip:** Whenever possible, align donor site scars with relaxed skin tension lines (RSTLs) to maximize functional outcome and minimize aesthetic compromise. --- ## Design & Execution of Transposition Flaps ****Key Point** The success of a transposition flap depends on careful design: accurate flap length (typically 1.5-2× the defect), precise pivot point placement, preservation of vascular supply, and tension management at the arc of rotation. Designing and executing a transposition flap requires balancing geometry with biology. The flap must be long enough to rotate freely into the defect while preserving its vascular pedicle. Planning the pivot point, respecting skin laxity, and aligning scars with relaxed skin tension lines (RSTLs) are critical to both functional and aesthetic outcomes. **Step 1: Assess Defect and Donor Site** - Define defect **size, shape,** and **depth**. - Assess **adjacent skin laxity** to determine flap donor site suitability. - Select an appropriate flap type (rhomboid, bilobed, banner, Z-plasty, or keystone) depending on defect geometry and region. **Step 2: Establish the Pivot Point** - The pivot lies adjacent to the defect at the **flap base**. - Must be in a region with reliable **vascularity**. - Controls the **arc of rotation** (ideally ≤90° to prevent torsion). - Avoid excessive stretching or twisting at this point. 💡 ****Tip:** Doppler ultrasound can confirm perforator position for axial flaps before committing to the design. **Step 3: Outline Flap Geometry & Dimensions** - **Length:** Plan flap at least **1.5-2×** the defect diameter to allow free movement. - **Angles** - **Rhomboid:** 60°/120° geometry. - **Bilobed:** Lobes angled at \~45° to evenly distribute tension. - **Orientation:** Align scars with **RSTLs** or natural creases. - Oversize slightly to minimize tip necrosis and donor site tension. **Step 4: Flap Elevation** - Incise along marked lines with precision. - Elevate in the **subcutaneous or subfascial plane**, depending on region. - Preserve vascular pedicle and perforators at the base. - Undermine adjacent tissue as needed to facilitate flap mobility. **Step 5: Flap Transposition & Inset** - Gently **rotate the flap** across intact skin into the defect. - Avoid kinking or twisting vessels at the pivot. - Inset with a **layered closure** to distribute tension evenly. - Close the donor site primarily where possible; grafting if closure is not feasible. 💡 ****Tip:** Tension vectors should be planned ****away from free margins** (e.g., eyelid, lip, nasal ala) to avoid distortion. **Step 6: Optimize Tension & Contour** - Excise **Burow’s triangles** or perform **small back-cuts** to relieve tension. - Consider **flap thinning** to prevent trapdoor deformity or pincushioning. - For large or complex flaps, combine with **secondary techniques** (e.g., Z-plasty, V-Y advancement) to refine contour and redistribute tension. --- ## Design Variations of Transposition Flaps ****Key Point** Different transposition flap designs including rhomboid, Dufourmentel, bilobed, Z-plasty, and banner flaps, are tailored to specific anatomical regions, defect geometries, and tension requirements, allowing surgeons to balance function, contour, and scar placement. Transposition flaps are highly adaptable, and numerous geometric modifications have been developed to optimize tissue recruitment, tension distribution, and aesthetic outcomes. Each design is suited to particular regions or clinical challenges, making it essential to understand the strengths and limitations of each variant. **1\. Banner (Flag) Flap** - Simplest transposition flap, rotated across a single arc. - **Use:** Circular/oval defects. Commonly used on the **cheek and trunk**. - Straightforward design and execution. - **Limitations:** The donor site may occasionally require grafting. **2\. Rhomboid (Limberg) Flap** - Converts the defect into a rhomboid (angles 60° and 120°). - The flap rotates across a **60°** angle. - Commonly used for the **face, scalp,** and **back**. - **Advantages:** Predictable closure, donor site usually closed primarily. - **Important:** Orient donor site scars along relaxed skin tension lines (RSTLs) for best cosmesis. **3\. Dufourmentel Flap** - A modified rhomboid flap with **broader angles (up to 90°)**. - Better suited for **larger defects** or areas requiring wider tension distribution. - **Regions:** Face, trunk, extremities. - Provides a **broader vascular base** than the Limberg flap, enhancing perfusion. **4\. Bilobed Flap** - Two lobes, - First lobe fills the primary defect. - Second lobe fills the donor site of the first. - Zitelli's modification uses **45° arcs** between lobes to reduce dog-ears and tension. - **Use:** Small circular defects (esp. nasal ala). Excellent for **nasal and cheek reconstruction**, particularly in tight skin. **5\. Z-Plasty** - Classic **triangular transposition** flap. - **Purposes:** Lengthen contracted scars, reorient linear scars, or improve contour. - **Regions:** Face, neck, limbs. - Optimal angle **60°**, giving \~75% increase in central limb length. - Serial/double Z-plasties are used for **long scar contractures** (e.g., burns) in regions like the neck, axilla, and groin. **6\. Dorsal Metacarpal Artery (DMA) Flap** - Axial flap based on the **first dorsal metacarpal artery**. - Proximally based, ideal for **first web space reconstruction**. - The donor site sometimes requires a second flap or graft. **7\. Nasolabial Flap** - Designed along the **nasolabial fold**, can be superiorly or inferiorly based. - **Indications:** Alar, columellar, or nasal sidewall reconstruction. - May be combined with cartilage grafting for support. - Can also line full-thickness eyelid reconstructions with mucosal grafts. - **Notes:** Axial flap; supplied by first dorsal metacarpal artery (Doppler advised). **8\. Hatchet Flap** - Named for its **broad base and narrow tip** resembling a hatchet. - Commonly used for **dermatologic defects** of the face or eyelids. - Allows closure of circular lesions while minimizing distortion. **9\. V-Y Transposition Flap** - Combines **advancement with transposition**. - Central V is advanced; limbs transpose laterally to fill the defect. - Commonly used for **perioral, perianal,** and **fingertip** reconstructions. - **Notes:** Random or axial, depending on site. **10\. Keystone Flap** *(debated classification)* - A **perforator-based island flap**, but functionally behaves like a transposition flap. - **Use:** Large cutaneous oncologic or traumatic defects. Widely used in **oncologic trunk and extremity** reconstructions. - Four design subtypes exist depending on depth and incorporation of fascia. **11\. Webster & Fricke Flaps** - **Webster Flap:** Used in cleft lip revision, transposes mucosa/skin to lengthen the lip. Based on local blood supply. - **Fricke (temporal forehead) Flap:** Used for **upper eyelid and nasal reconstruction**, based superiorly on the forehead. 💡 ****Tip:** Always match the flap design to the region’s functional needs and aesthetic units. For example, bilobed flaps are best for the nose, rhomboids for flat facial or trunk surfaces, and Z-plasties for scar contracture release. --- ## Complications of Transposition Flaps ****Key Point** Complications include tip necrosis, trapdoor deformity, pincushioning, dog-ears, and malposition. Prevention hinges on meticulous flap design, appropriate tension management, and preserving vascularity. Although transposition flaps are reliable, their success depends on respecting geometric principles and vascular supply. Even well-designed flaps may develop complications, often related to excessive tension, poor perfusion, or contour mismatch. Recognizing the underlying causes enables both prevention and effective management. **1\. Tip Necrosis** - **Cause:** Excessive tension at the arc of rotation, poor vascular supply, or over-thinning of the flap tip. - **Signs:** Dusky or pale discoloration, delayed capillary refill. - **Management:** Conservative wound care in minor cases; revision or re-advancement for extensive necrosis. **2\. Trapdoor Deformity** - **Cause:** Inadequate flap thinning or scar contracture at the periphery. - **Signs:** Raised central portion of the flap with depressed edges. - **Management:** Intralesional triamcinolone injections, flap thinning, or secondary revision. **3\. Pincushioning** - **Cause:** Excess bulk or inadequate tissue leveling at inset. - **Signs:** Dome-shaped elevation of flap compared to surrounding tissue. - **Management:** Flap debulking, secondary revision, or compression dressings. **4\. Dog-Ear Formation** - **Cause:** Tissue redundancy at the donor site, especially when flap sides are mismatched. - **Signs:** Protruding puckers at incision ends. - **Management:** Excision of Burow’s triangles or secondary scar revision. **5\. Malposition** - **Cause:** Poor vector planning, excessive flap rotation, or closure distortion. - **Signs:** Misalignment of free margins (eyelid, lip, nasal ala). - **Management:** Revision flap design, redistribution of tension, or staged correction. 💡 ****Tip:** Always align the flap’s vector parallel to free margins (eyelids, lips) to prevent distortion, and slightly oversize the flap to reduce tip tension. --- ## Conclusion Upon completing this article, you will have accomplished the following: 1\. ****Overview:** Transposition flaps are cutaneous flaps that rotate over intact skin to resurface nearby defects. They are useful when direct advancement or rotation flaps would lead to excessive tension or poor aesthetic outcomes. ****2\. Indications & Contraindications:** Commonly indicated for reconstructing small to medium-sized facial defects, webspace contractures, and dorsal hand defects. Contraindications include insufficient local tissue laxity, poor vascularity, or prior radiation compromising the flap base. ****3\. Flap Design & Execution:** Precise design includes selecting a flap length approximately 1.5-2× the defect diameter, choosing an optimal pivot point, and maintaining a 45-60° angle of transposition. ****4\. Tension Management & Modifications:** Tension is distributed by adjusting the flap angle, using Burow’s triangles, performing controlled back-cuts, or adding adjacent tissue recruitment techniques like V-Y advancement or Z-plasty. ****5\. Postoperative Care & Complications:** Key aspects include hematoma prevention, vascular monitoring in the first 24-48 hours, activity restriction, and scar care (including sun protection). Complications such as pincushioning, ectropion, or trapdoor deformity are uncommon and manageable with minor revisions or steroid injections. --- ## Further Reading 1. Janis, Jeffrey E. Essentials of Plastic Surgery. 3rd ed. Thieme, 2023. 2. Bednarek RS, Sequeira Campos MB, Hohman MH, et al. [Transposition Flaps](https://www.ncbi.nlm.nih.gov/books/NBK500028/?ref=theplasticsfella.com). \[Updated 2025 May 4\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. 3. Starkman SJ, Williams CT, Sherris DA. Flap Basics I: Rotation and Transposition Flaps. Facial Plast Surg Clin North Am. 2017 Aug;25(3):313-321\. doi: 10.1016/j.fsc.2017.03.004\. Epub 2017 May 30\. PMID: 28676159. 4. Bednarek, R. S., Sequeira Campos, M. B., Hohman, M. H., & Ramsey, M. L. (2025). Transposition Flaps. In StatPearls. StatPearls Publishing. 5. Blake BP, Simonetta CJ, Maher IA. Transposition Flaps: Principles and Locations. Dermatol Surg. 2015 Oct;41 Suppl 10:S255-64\. doi: 10.1097/DSS.0000000000000479\. PMID: 26418691. 6. Joshi, S., Jaiswal, D., Chougle, Q., Wadasadawala, T., & Badwe, R. A. (2021). Transposition flap for the oncoplastic reconstruction of outer quadrant breast defects. *Journal of plastic, reconstructive & aesthetic surgery: JPRAS*, *74*(9), 2176–2183\. https://doi.org/10.1016/j.bjps.2020.12.037 ### Surgical Instruments: Function, Selection, & Specialty Use URL: https://www.theplasticsfella.com/surgical-instruments/ Last updated: 2025-10-06T20:51:32.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/surgical-instruments/#overview-of-surgical-instruments) Surgical instruments act as precise extensions of the surgeon’s hands. Mastery of instrument names, functions, and safe handling improves operative flow and patient outcomes while minimizing tissue trauma. [****Scalpels & Handles**](https://www.theplasticsfella.com/surgical-instruments/#scalpels-handles) Blades vary in shape and application: No. 10 is suited for broad skin incisions; No. 11 for sharp punctures; and No. 15 for fine, precise skin work. Matching the blade to the task ensures clean cuts and protects tissue. [****Forceps**](https://www.theplasticsfella.com/surgical-instruments/#forceps) Choose toothed forceps for sturdy tissues and atraumatic forceps for delicate structures; when unsure, err on the side of non‑toothed to reduce crush injury. [****Retractors**](https://www.theplasticsfella.com/surgical-instruments/#retractors) Retractors provide exposure by gently holding tissues aside; choose the smallest retractor that affords a clear field to minimize tissue ischemia and pressure injury. [****Scissors**](https://www.theplasticsfella.com/surgical-instruments/#scissors) Use the right scissors for the right task: fine scissors for delicate dissection and heavier scissors for cutting sutures. Never use dissecting scissors to cut sutures, as this dulls their blades. [****Electrosurgery**](https://www.theplasticsfella.com/surgical-instruments/#electrosurgery) Electrosurgery uses high‑frequency current to cut and coagulate tissue; monopolar circuits return current through a dispersive pad, whereas bipolar circuits confine current between two tips, limiting collateral damage. [****Instrument Safety, Sterility, & Sharps Handling**](https://www.theplasticsfella.com/surgical-instruments/#instrument-safety-sterility-sharps-handling) Maintaining sterility and preventing sharps injuries depends on proper handling, instrument counts, and clear communication. Use hands‑free techniques and checklists to protect both patients and staff. [****Specialized Instruments**](https://www.theplasticsfella.com/surgical-instruments/#specialized-instruments-in-plastic-surgery) Plastic surgery employs specialized tools, such as dermatomes for skin grafts and microsurgical instruments for vessel and nerve repair to achieve precise and aesthetic outcomes. [****Instrument Sets by Phase**](https://www.theplasticsfella.com/surgical-instruments/#instrument-sets-by-phase) Preassembling instrument sets for each phase of surgery improves efficiency and ensures critical tools are available when needed. ****Verified by thePlasticsFella ✅** --- ## Overview of Surgical Instruments ****Key Point** Surgical instruments act as precise extensions of the surgeon’s hands. Mastery of instrument names, functions, and safe handling improves operative flow and patient outcomes while minimizing tissue trauma. An operation proceeds in phases: preparation, incision, exploration, dissection, and closure. Each phase calls for specific tools. Good communication with the scrub team and adherence to safety protocols, such as the WHO Surgical Safety Checklist, prevent errors and protect both patient and staff. Surgical instruments by operative step are summarised below. ![Surgical instruments for each operative step](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--8-.png) Surgical instruments for each operative step 💡 ****Tip:** Before making the first incision, pause for a time‑out to review the surgical plan, check instrument counts and confirm that all necessary tools are available. --- ## Scalpels & Handles ****Key Point** Blades vary in shape and application: No. 10 is suited for broad skin incisions; No. 11 for sharp punctures; and No. 15 for fine, precise skin work. Matching the blade to the task ensures clean cuts and protects tissue. Scalpels are composed of a reusable handle and a disposable blade. In plastic surgery, the No. 3 Bard‑Parker handle accommodates blades No. 10, 11, and 15\. The **No. 10 blade** has a wide, curved cutting edge and is used to make long skin incisions or raise full‑thickness skin grafts. The **No. 11 blade** is triangular with a sharp point, suitable for stab incisions such as drain insertion or creating liposuction ports. The **No. 15 blade** has a small, curved cutting edge; it is the work‑horse for precise skin incisions in facial and hand surgery. **Common Pairings** - **No. 3 handle + No. 15 blade:** Used for delicate skin incisions on the face and hands. - **No. 3 handle + No. 10 blade:** Used to harvest full‑thickness skin grafts or make long incisions. - **No. 3 handle + No. 11 blade:** Used for small puncture wounds and drain or port insertion. Always mount and remove blades with an artery forceps (never with fingers) to avoid sharps injury and maintain sterility. Dispose of used blades immediately in a sharps container. Establish a neutral zone on the mayo stand or a magnetic pad to pass scalpel handles without hand‑to‑hand contact. Scalpels are illustrated below. ![Scalpels, Surgical instruments guide](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--5-.png) Scalpels 💡 ****Tip:** Use a neutral zone for passing scalpels and other sharps; place the instrument in the zone and verbally announce its placement to keep the entire team aware. --- ## Forceps ****Key Point** Choose toothed forceps for sturdy tissues and atraumatic forceps for delicate structures; when unsure, err on the side of non‑toothed to reduce crush injury. Forceps are used to grip, hold, or manipulate tissues. **Toothed forceps**, such as Adson forceps, have interdigitating teeth that provide secure purchase on skin, fascia, or muscle. They are invaluable when approximating dermal edges during closure or lifting thick fascia. **Atraumatic forceps**, such as DeBakey forceps, feature fine longitudinal serrations and are designed for delicate tissues like vessels, nerves, and skin grafts. A variation for microsurgery is the jeweler’s forceps, which has extremely fine tips for nerve and vessel work. **Adson (toothed) Forceps** - **Features:** Interdigitating 1×2 teeth, providing a strong grip. - **Typical Use:** Handling skin, fascia, and muscle edges. **DeBakey (atraumatic) Forceps** - **Features:** Fine serrations and a narrow profile for gentle handling. - **Typical Use:** Manipulation of blood vessels, nerves, and grafts. **Jeweler’s Forceps** - **Features:** Very fine tips for precision work. - **Typical Use:** Microsurgical handling of vessels and nerves. Forceps are illustrated below. ![Forceps, Surgical instruments guide](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--6-.png) Forceps 💡 ****Tip:** When handling delicate tissue (e.g., perforator flap pedicles), select atraumatic forceps and apply only minimal pressure. --- ## Retractors ****Key Point** Retractors provide exposure by gently holding tissues aside; choose the smallest retractor that affords a clear field to minimize tissue ischemia and pressure injury. Retractors allow the surgeon to visualize deeper structures while leaving both hands free. **Skin hooks** are delicate single‑prong retractors used to elevate thin skin flaps without damaging dermis. **Langenbeck retractors** are flat‑ended, right‑angled instruments for retracting deeper soft tissue; they are commonly used in head and neck operations. **Cat’s paw** or **Weitlaner** retractors are double‑ended instruments with several prongs; they self‑retain to hold skin and subcutaneous tissue apart during longer procedures. The placement of self‑retaining retractors should be periodically adjusted to relieve pressure and avoid compressive injury. Retractors are illustrated below. ![Retractors, Surgical instruments guide](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--7-.png) Retractors 💡 ****Tip:** Release self‑retaining retractors intermittently during long cases to restore perfusion and prevent tissue necrosis. --- ## Scissors ****Key Point** Use the right scissor for the right task: fine scissors for delicate dissection and heavier scissors for cutting sutures. Never use dissecting scissors to cut sutures, as this dulls their blades. Scissors are classified by their blade length, tip shape and intended use. **Tenotomy scissors** and **Metzenbaum scissors** have long, narrow blades with blunt or gently curved tips; they are used for fine dissection and undermining of tissues. **Iris scissors** are smaller and used for very fine, precise cuts, such as trimming the edges of skin grafts. **Mayo scissors** are heavier and typically used to cut thick tissues or dressings; there are straight and curved versions. A dedicated suture scissor should be used for cutting sutures; never compromise the sharpness of dissecting scissors by cutting suture material. To handle scissors, insert the thumb and ring finger into the rings and stabilize the instrument with the index finger on the shaft. This grip allows control during cutting and helps achieve straight, accurate lines. --- ## Electrosurgery ****Key Point** Electrosurgery (Diathermy) uses high‑frequency current to cut and coagulate tissue; monopolar circuits return current through a dispersive pad, whereas bipolar circuits confine current between two tips, limiting collateral damage. Electrosurgical units (ESUs) generate alternating current at 100 kHz-5 MHz to cut, coagulate, dissect, or fulgurate tissue. In **bipolar electrosurgery**, both the active and return electrodes are located on the forceps tips; only tissue grasped between the tips completes the circuit, so no dispersive pad is needed. This makes bipolar electrosurgery ideal for precise work near nerves or vessels and for use in a fluid environment, such as wet field cautery. In **monopolar electrosurgery**, the active electrode is placed at the surgical site and current flows through the patient to a return (dispersive) pad elsewhere on the body. The dispersive pad dissipates the current to prevent burns; poor contact can cause thermal injury. Monopolar diathermy is versatile and can both cut and coagulate tissue, making it the most commonly used modality. It requires careful pad placement and is avoided in patients with implanted electronic devices when possible. **Pacemakers and implantable cardioverter defibrillators (ICDs)** may malfunction in the presence of electromagnetic interference from monopolar electrocautery. Electromagnetic interference can inhibit pacing or trigger inappropriate therapy. Guidelines recommend using bipolar cautery when possible or limiting monopolar bursts to a few seconds and placing the dispersive pad so that the current path does not cross the device. Magnets may be used to reprogram devices, but their effects are variable; device‑specific consultation is advised. 💡 ****Tip:** Announce “energy on” when activating diathermy. Confirm pad placement and check for pacemakers or ICDs before using monopolar electrosurgery. --- ## Instrument Safety, Sterility, & Sharps Handling ****Key Point** Maintaining sterility and preventing sharps injuries depends on proper handling, instrument counts, and clear communication. Use hands‑free techniques and checklists to protect both patients and staff. A sterile instrument remains sterile only if handled correctly. The **WHO Surgical Safety Checklist** prompts the surgical team to confirm critical tasks before incision and at closure, including verification that instruments, sponges, and sharps counts are correct. Adherence to the checklist reduces surgical complications and adverse events, such as retained instruments or site infections. Sharps injuries are common when scalpels or needles are passed directly between team members. Establish a **neutral zone**, a designated area on the mayo stand or a magnetic pad, where sharps are placed and retrieved without hand‑to‑hand passing. Instruments or blades are placed in the neutral zone and verbalized so the receiving person is aware. This “no‑touch” technique significantly reduces suture needle and scalpel injuries. **Instrument counts** are performed before incision, at closure of a body cavity, and before skin closure. Counting ensures that all instruments, sponges, and needles are accounted for and prevents retained foreign bodies. Team members should speak up if there is uncertainty about counts or instrument placement. Any contaminated instrument should be isolated to prevent cross-contamination. 💡 ****Tip:** Use sterile technique when opening instrument packs; handle only gloved or clamped surfaces; and never place used sharps back on the sterile field without passing through the neutral zone. --- ## Specialized Instruments in Plastic Surgery ****Key Point** Plastic surgery employs specialized tools, such as dermatomes for skin grafts and microsurgical instruments for vessel and nerve repair to achieve precise and aesthetic outcomes. While a detailed survey of all specialized instruments is beyond the scope of this overview, here's a list of the most important instruments. - **Dermatome and Mesher:** A dermatome is a powered or manual instrument that harvests thin slices of skin for grafting. Electric and air dermatomes produce long, uniform grafts with consistent thickness, while drum or knife dermatomes provide manual control for smaller grafts. A mesher is used to expand a harvested split‑thickness skin graft, allowing it to cover a larger surface area. - **Hand Surgery Aids:** A lead hand is a malleable metal frame used to stabilize the hand and fingers during delicate procedures; tendon retrievers help retrieve retracted tendons through small incisions. Microsurgical sets include fine jeweler’s forceps, micro‑scissors, micro‑needle holders, and micro clamps to handle tiny vessels and nerves. - **Venous Couplers:** These devices mechanically join small veins without sutures; they simplify microvenous anastomoses and reduce operative time. In supermicrosurgery, sutures as small as 11‑0 or 12‑0 may be used to join vessels or nerves. 💡 ****Tip:** Organize specialty instrument sets before the case; check that dermatome depth settings, mesher ratio plates and microsurgery sets are complete before sterile draping begins. --- ## Instrument Sets by Phase ****Key Point** Preassembling instrument sets for each phase of surgery improves efficiency and ensures critical tools are available when needed. Organizing instruments by operative step allows the scrub and surgeon to anticipate what comes next and reduces delays. A typical instrument sequence for a minor plastic surgery procedure might include, - **Preparation:** Sponge holders, gallipots or bowls for antiseptic solutions, towel clips, and marking pens. Verify counts and confirm equipment readiness. - **Incision:** Scalpel with selected blade (No. 10/11/15) mounted on a No. 3 handle, Adson or DeBakey forceps, and small retractors (skin hook or Langenbeck) for exposure. - **Exploration and Exposure:** Deeper retractors (Langenbeck or Cat’s paw) and atraumatic forceps to gently separate tissues. Use of suction or irrigation may be necessary to keep the field clear. - **Dissection:** Tenotomy or Metzenbaum scissors for sharp or blunt dissection; electrosurgery (preferably bipolar near critical structures) for coagulation. For pedicle dissection, micro‑instrumentation may be required. - **Closure:** Needle holders matched to the chosen suture size, fine forceps for dermal approximation, suture cutters or Mayo scissors for trimming ends, and skin adhesives or strips. Confirm final counts before dressing the wound. 💡 ****Tip:** Think one step ahead; while closing the wound, ensure suture removal instruments or dressings are available for the next case. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. The Ability to Identify:** The main categories of surgical instruments (scalpels, forceps, retractors, scissors, electrosurgical devices) and match them to each operative phase. ****2\. Differentiating:** Between monopolar and bipolar electrosurgery, understand their current pathways and safety implications, and apply precautions for patients with pacemakers or ICDs. ****3\. Maintaining:** Sterility and sharps safety by adhering to the WHO Surgical Safety Checklist, establishing a neutral zone, and performing complete instrument and sponge counts. ****4\. The Ability to Select:** Appropriate instruments for specialized plastic surgery tasks, such as skin graft harvest with dermatomes and microsurgical repair with fine forceps and micro‑scissors. ****5\. Effectively Communicating:** With the operative team to anticipate instrument needs, ensure patient safety, and respond confidently to questions encountered on the ward, in clinic and in theatre. --- ## Further Reading - World Health Organization (2009) [Surgical safety checklist](https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery/tool-and-resources?ref=theplasticsfella.com). Geneva: World Health Organization. - King, J. (2023) [Neutral zones: the bordered region](https://www.aorn.org/article/neutral-zones?ref=theplasticsfella.com#:~:text=Defining%20the%20Neutral%20Zone). AORN Journal \[online\], 14 November. Association of perioperative Registered Nurses. - Cordero, I. (2015) [Electrosurgical units - how they work and how to use them safely](https://pmc.ncbi.nlm.nih.gov/articles/PMC4579996/?ref=theplasticsfella.com#:~:text=In%20bipolar%20electrosurgery%20,to%20as%20%E2%80%98wet%20field%E2%80%99%20cautery). Community Eye Health, 28(89), pp. 15–16. - Neelankavil, J.P., Thompson, A. & Mahajan, A. (2013) [Managing cardiovascular implantable electronic devices (CIEDs) during perioperative care](https://www.apsf.org/article/managing-cardiovascular-implantable-electronic-devices-cieds-during-perioperative-care/?ref=theplasticsfella.com#:~:text=Electromagnetic%20interference%20,it%20is%20more%20commonly%20used). Anesthesia Patient Safety Foundation Newsletter, 28(2), Fall. - Buckner, B. (2023). [Scalpels](https://jomi.com/article/300.1/scalpels?ref=theplasticsfella.com). Journal of Medical Insight (JOMI), 2023(300.1). doi:10.24296/jomi/300.1. ### Suture Types & Sizes: USP System, Needle designs, & Use URL: https://www.theplasticsfella.com/suture-types-sizes/ Last updated: 2025-10-06T20:51:45.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/suture-types-sizes/#overview-of-suture-types-sizes) Sutures are medical threads and needles used to approximate tissues and facilitate healing. Their properties: material, structure, absorbability, and diameter, determine how they behave in tissue and influence scar quality and infection risk. [****Material**](https://www.theplasticsfella.com/suture-types-sizes/#material-of-sutures-natural-vs-synthetic) Sutures are classified by material and filament structure. Monofilament sutures glide smoothly through tissue but have more “memory,” while multifilament sutures handle better but harbour bacteria. [****Structure & Coating of Sutures**](https://www.theplasticsfella.com/suture-types-sizes/#structure-coating-of-sutures) Monofilament sutures are single strands with low tissue drag and lower infection risk but have high memory and require secure knots. Multifilament sutures are braided or twisted, offering superior handling and knot security but increased tissue drag and bacterial colonisation. [****Absorbability**](https://www.theplasticsfella.com/suture-types-sizes/#absorbability-of-sutures) Absorbable sutures lose most of their tensile strength over weeks to months and are used for deep or temporary closure. Non‑absorbable sutures maintain strength for months or years. [****Common Suture Types & Their Uses**](https://www.theplasticsfella.com/suture-types-sizes/#common-suture-types-their-uses) Vicryl is a braided absorbable for deep and subcuticular closures; Monocryl is a smooth absorbable for skin; PDS provides long‑term support; Nylon and Prolene are inert monofilaments for skin; Silk offers excellent handling but high tissue reactivity. [****Sizing System**](https://www.theplasticsfella.com/suture-types-sizes/#suture-sizing-usp-scale) The USP scale labels sutures by diameter; more zeroes indicate a smaller suture (e.g., 6‑0 is finer than 3‑0). Larger sizes (#0–10) are used for fascia or strong tissues, while small sizes (4‑0 to 7‑0) are used for skin and delicate structures. [****Suture Needles**](https://www.theplasticsfella.com/suture-types-sizes/#suture-needles) A suture needle comprises a swage, body, and point, and is selected according to tissue type and access. Cutting needles are used for skin, taper needles for soft tissue, and curved needles. [****Clinical Selection & Removal**](https://www.theplasticsfella.com/suture-types-sizes/#clinical-selection-removal-of-sutures) Choose sutures based on tissue biology, healing timeline. and contamination risk. Use absorbable monofilaments for deep closures, non‑absorbable monofilaments for skin, and avoid multifilaments in contaminated wounds. ****Verified by thePlasticsFella ✅** --- ## Overview of Suture Types & Sizes ****Key Point** Sutures are medical threads and needles used to approximate tissues and facilitate healing. Their properties: material, structure, absorbability, and diameter, determine how they behave in tissue and influence scar quality and infection risk. Suturing remains the mainstay of wound closure in plastic and reconstructive surgery. Although alternatives such as staples and tissue adhesives exist, sutures provide versatility, control, and strength across a wide range of tissues. No single suture is perfect and the surgeon’s challenge is to understand the available options and match them to the biological and mechanical requirements of each wound. This article summarises the classification of sutures, common materials used in plastic surgery, the USP sizing system, needle designs, and practical guidelines for choosing and removing sutures. --- ## Material of Sutures: Natural vs Synthetic ****Key Point** Natural sutures such as catgut and silk degrade by proteolysis and provoke more inflammation, whereas modern synthetic sutures (e.g., Vicryl, Monocryl, PDS) degrade by hydrolysis and elicit less tissue reaction Suture material influences tensile strength, absorption and immune response. Historically, surgeons relied on natural fibres like gut and silk, but these incite significant inflammation and unpredictable absorption. Synthetic polymers now dominate because they offer predictable degradation and minimal immunogenicity. - **Catgut:** Twisted collagen from sheep or bovine intestine; absorbs rapidly via proteolysis; significant tissue reaction; used for mucosal closures and rapidly healing tissues. - **Silk:** Natural braided fibre; technically non‑absorbable but loses strength over about one year; superb handling and knot security; high tissue reactivity; mainly used to secure drains or retract tissues. - **Synthetic Absorbable:** Vicryl (braided polyglactin 910) retains strength for 2-3 weeks and is fully absorbed within 8-10 weeks. Monocryl (monofilament poliglecaprone 25) loses 50 % strength within a week and disappears by 120 days. PDS (monofilament polydioxanone) provides long‑term support for 4-6 months. - **Synthetic Non‑Absorbable:** Nylon (monofilament polyamide) retains strength for years and has very low tissue reactivity but high memory. Polypropylene (Prolene/ProNova) is inert, non‑degradable, and widely used for skin and vascular sutures. Polyester (Ethibond) is strong and pliable but braided, so infection risk is higher. The suture types based on material are illustrated below. ![Suture types based on material](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--3-.png) Suture types based on material --- ## Structure & Coating of Sutures ****Key Point** Monofilament sutures are single strands with low tissue drag and lower infection risk but have high memory and require more secure knots. Multifilament sutures are braided or twisted, offering superior handling and knot security but increased tissue drag and bacterial colonisation. Filament structure affects how a suture handles and how tissues respond. Coating can reduce friction or deliver antibacterial agents. - **Monofilament:** Smooth passage through tissues; minimal capillarity; high memory; examples include PDS, Monocryl, Prolene, and Nylon. - **Multifilament:** Braided or twisted strands; better flexibility and knot security; higher friction and capillarity; examples include Vicryl, Silk, and Polyester. - **Coated & Barbed:** Braided sutures such as Vicryl may be coated with polymer or wax to reduce drag. Antibacterial coatings (e.g., triclosan in Vicryl Plus) lower infection rates. Barbed sutures (e.g., Stratafix) have small hooks that anchor tissue and obviate the need for knots. - **Alternatives & Adhesives:** Tissue adhesives (cyanoacrylate glues) and surgical strips can serve as adjuncts or alternatives to sutures for superficial wounds. Adhesives provide rapid closure, eliminate knot tying, and yield excellent cosmetic outcomes, but they lack tensile strength and are reserved for small, low‑tension incisions. Surgical strips (steri‑strips) are often applied after suture removal to support skin edges during maturation. --- ## Absorbability of Sutures ****Key Point** Absorbable sutures lose tensile strength over weeks to months, making them suitable for internal tissues that heal quickly. Non‑absorbable sutures retain strength long term and are removed when used on skin or left in place when buried. Absorbable sutures are degraded by the body and obviate the need for removal. Natural absorbables like catgut degrade by proteolysis and provoke more inflammation, while synthetic absorbables degrade by hydrolysis and are less reactive. Non‑absorbable sutures may remain permanently or be removed after healing. - **Absorbable (Natural):** Catgut and chromic gut absorb within weeks; high variability and inflammation; limited use today. - **Absorbable (Synthetic):** Vicryl, Monocryl, and PDS. Vicryl provides moderate support and is widely used for muscle and skin closure. Monocryl is smooth with rapid absorption and minimal tissue reaction. PDS retains strength for 4–6 months and is used for fascial closures. - **Non‑Absorbable:** Nylon and Polypropylene are inert monofilaments used for skin closure, vascular, and nerve repair. Silk and Polyester are braided and used for ligatures, tendon repairs, and sternal closures. --- ## Common Suture Types & Their Uses ****Key Point** Familiarity with common suture brands helps match properties to clinical needs. Vicryl is a braided absorbable for deep and subcuticular closures; Monocryl is a smooth absorbable for skin; PDS provides long‑term support; Nylon and Prolene are inert monofilaments for skin; Silk offers excellent handling but high tissue reactivity. The typical properties and uses of frequently employed sutures are summarised below. - **Vicryl (Polyglactin 910):** Braided, absorbable; retains strength for 2-3 weeks; fully absorbed by 8-10 weeks; moderate tissue reaction; used for muscle, subcuticular, and pediatric skin closure. - **Monocryl (Poliglecaprone 25):** Absorbable monofilament; loses 50 % strength by 1 week and disappears by 120 days; very smooth with minimal reactivity; ideal for intradermal and facial sutures. - **PDS (Polydioxanone):** Absorbable monofilament; retains strength for 4-6 months; high memory; used for fascia, tendons, and gastrointestinal anastomoses. - **Nylon (Ethilon):** Non‑absorbable monofilament; strong with minimal reactivity but high memory; used for interrupted skin sutures, nerve, and microvascular repairs. - **Polypropylene (Prolene/ProNova):** Non‑absorbable monofilament; inert and permanently strong; used for skin closure, vascular anastomoses, and abdominal wall reinforcement. - **Silk:** Braided natural fibre; excellent handling but high tissue reaction; loses strength over one year; used to secure drains or as stay sutures. - **Polyester (Ethibond):** Braided synthetic; very strong and durable; minimal tissue reaction; used in tendon repairs, sternotomy closure, and orthopaedic fixation. --- ## Suture Sizing (USP Scale) ****Key Point** The United States Pharmacopeia's (USP) system ranks sutures by diameter: larger numbers (#1-10) are thicker, whereas more zeros denote finer sutures (2‑0 to 12‑0). Adjacent sizes differ by about 0.01-0.05 mm. Suture size impacts tensile strength and scar visibility. Thicker sutures are stronger but leave larger needle holes; finer sutures are less visible but break more easily. The table below summarises typical sizes and uses. Choose a size that balances strength and cosmesis. For example, 3‑0 for muscle and 6‑0 for facial skin. The USP scale is summarised below. ![USP size of sutures, their diameter, and typical use](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--4-.png) USP size of sutures, their diameter, and typical use --- ## Suture Needles ****Key Point** A suture needle comprises a swage, body and point, and is selected according to tissue type and access. Cutting needles (conventional or reverse) are used for skin, taper needles for soft tissue, and curved needles — most commonly 3/8 circles to provide optimal control. Needles are manufactured with the suture swaged to the end, eliminating the bulk of an eye and reducing tissue trauma. The body dictates curvature; the point dictates penetration. Selecting the right combination ensures efficient passage through tissue and minimal damage. **Components** - **Swage:** Connection between needle and suture; modern needles are swaged rather than eyed, creating a smooth transition. - **Body & Curvature:** Curved needles are specified by the fraction of a circle — 1/4, 3/8, 1/2, and 5/8\. A 3/8‑circle needle is versatile for most skin closures; a 1/2‑circle needle is useful in confined spaces such as the oral cavity. - **Point:** Cutting needles have a triangular tip; conventional cutting needles slice toward the wound edge, while reverse cutting needles protect the wound edge and are preferred for skin. Taper needles have a round tip that spreads tissue and are used for muscle, bowel, and vessels. Blunt and spatula needles are used for friable tissues and ophthalmic surgery respectively. --- ## Clinical Selection & Removal of Sutures ****Key Point** Suture choice depends on tissue type, healing time, and infection risk. Use absorbable sutures for internal tissues, monofilaments in contaminated wounds, and select appropriate sizes for strength and cosmesis. Remove skin sutures at 3-14 days, depending on location. Matching suture properties to clinical circumstances optimises healing and minimises complications. In contaminated or high‑risk wounds, avoid braided sutures because bacteria harbour in interstices. Absorbable monofilaments are ideal for deep layers or when patients may not return for removal, while non‑absorbable monofilaments are used for skin where removal is planned. Removal timing hinges on location: remove facial sutures after 3-5 days; scalp, arms, and hands after 7-10 days; trunk and legs after 10-14 days. **Guidelines for Suture Selection** - **Tissue & Healing:** Use absorbable sutures (Vicryl, Monocryl) for mucosa and subcutaneous layers; use durable sutures (PDS) for fascia and tendons; use non‑absorbable monofilaments (Prolene, Nylon) for skin and vascular repairs. - **Contamination:** Choose monofilament sutures in contaminated or infection-prone sites; avoid braided sutures like Silk or Vicryl in these settings. - **Cosmetic Sites:** Use fine monofilament sutures (5‑0 to 7‑0) or subcuticular absorbable sutures for the face and hand to minimise scarring. - **High‑Tension Areas:** Use stronger sutures (2‑0 to 3‑0) for knees, elbows, and abdomen where tension is high; consider buried absorbable sutures with a second layer of non‑absorbables for added support. - **Removal Timing:** Follow region‑specific removal guidelines: face 3-5 days; scalp and arms 7-10 days; trunk, back, and legs 10-14 days. --- ## Conclusion Upon completing this article, you will have accomplished the following: 1\. ****Understand Material Differences:** Recognise that natural sutures (catgut, silk) degrade by proteolysis and incite more inflammation, whereas synthetic sutures (Vicryl, Monocryl, PDS, Nylon, Prolene) degrade by hydrolysis or do not degrade and are now preferred. ****2\. Distinguish Filament Structures:** Differentiate between monofilament sutures, which reduce infection risk but have high memory and braided multifilaments, which handle better but harbour bacteria. ****3\. Select by Absorbability:** Match absorbable sutures to tissues that heal quickly and non‑absorbable sutures to tissues requiring prolonged support or planned removal. ****4\. Choose Appropriate Sizes & Needles:** Use the USP scale to select suture diameter based on tissue strength and cosmesis, and select needle curvature and point type to suit tissue characteristics. ****5\. Apply Clinical Guidelines:** Choose sutures based on tissue, infection risk, and cosmetic needs, and remove them according to body region (3-14 days). --- ## Further Reading - Rose, J. & Tuma, F. (2023) [Sutures and Needles](https://www.ncbi.nlm.nih.gov/books/NBK539891/?ref=theplasticsfella.com#:~:text=The%20main%20factors%20used%20to,classify%20sutures%20types%20are). In: StatPearls. Treasure Island (FL): StatPearls Publishing - Khan, A.Z., Tønseth, K.A., Koidl, A. & Utheim, T.P. (2023) ‘[Suture materials](https://tidsskriftet.no/en/2023/06/clinical-review/suture-materials?ref=theplasticsfella.com#:~:text=Key%20properties%20of%20suture%20materials,they%20are%20monofilament%20or%20multifilament)’, Tidsskrift for Den norske legeforening, 143\. doi: 10.4045/tidsskr.22.0708. - Lippincott Procedures (2024) [Skin suture removal, ambulatory care](https://intermountainhealthcare.org/-/media/files/intermountain-health/contingent-workforce/assessments/medical-assistant-skills-assessment/skin-suture-removal-ambulatory-care-lippincott-solutions.ashx?ref=theplasticsfella.com#:~:text=TIMING%20OF%20SKIN%20SUTURE%20REMOVAL,Trunk%2010%20to%2014%20days). Revised 19 February 2024\. Philadelphia: Wolters Kluwer. - Watson, L.J. (2015). [Types of suture material](https://geekymedics.com/suture-material/?ref=theplasticsfella.com#:~:text=PDS%20is%20absorbed%20slowly%20by,absorbed%20within%20about%20180%20days). Geeky Medics, 5 February. - Mathes, S.J. & Nahai, F. (1997). Reconstructive surgery: principles, anatomy, and technique. New York: Churchill Livingstone. ### Classification of Flaps: Design Principles, Applications, & Complications URL: https://www.theplasticsfella.com/classification-of-flaps/ Last updated: 2025-10-07T10:08:12.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/classification-of-flaps/#overview-of-the-classification-of-flaps) Local flaps are tissue transfers with their own blood supply from adjacent areas, classified by blood supply, tissue composition, movement patterns, and anatomical location. [****Blood Supply Classification**](https://www.theplasticsfella.com/classification-of-flaps/#blood-supply-classification-of-flaps) Random pattern flaps rely on subdermal plexus, axial pattern flaps have named vessels, and perforator-based flaps receive blood through deeper structures. [****Tissue Composition Categories**](https://www.theplasticsfella.com/classification-of-flaps/#tissue-composition-categories-of-flaps) Flaps range from simple cutaneous to complex osseomyocutaneous, with each type including progressively more tissue layers for specific reconstructive needs. [****Movement Pattern Types**](https://www.theplasticsfella.com/classification-of-flaps/#movement-pattern-types-of-flaps) Four primary movement patterns exist: advancement (direct forward), rotation (curved arc), transposition (lateral crossing), and interpolation (staged crossing over intact skin). [****Clinical Applications & Selection**](https://www.theplasticsfella.com/classification-of-flaps/#clinical-applications-selection-of-flaps) Flap selection depends on defect characteristics, tissue requirements, and anatomical constraints, with specific indications for each movement type and blood supply pattern. [****Design Principles & Complications**](https://www.theplasticsfella.com/classification-of-flaps/#design-principles-complications-of-flaps) Successful flap design requires understanding tension vectors, aesthetic subunits, and blood supply patterns to prevent necrosis, trapdoor deformities, and functional impairment. ****Verified by thePlasticsFella ✅** --- ## Overview of the Classification of Flaps ****Key Point** Local flaps are tissue transfers with their own blood supply from adjacent areas, offering superior outcomes to skin grafts through better color match, contour, and reduced contracture. Local flaps represent one of the most versatile and reliable techniques in reconstructive surgery, providing surgeons with the ability to transfer well-vascularized tissue from adjacent areas to reconstruct defects while maintaining excellent aesthetic and functional outcomes. The fundamental advantage of local flaps lies in their inherent **blood supply**, which ensures **tissue viability** and promotes **optimal healing**. Unlike skin grafts, which depend on the recipient bed for survival, local flaps bring their own vascular network, making them suitable for challenging reconstructive scenarios including contaminated wounds, irradiated tissue, and areas with poor vascularity. Local flaps also provide superior aesthetic outcomes due to their excellent color and texture match with surrounding tissue. This is particularly important in visible areas such as the face, where achieving natural-appearing reconstruction is important for patient satisfaction and psychological well-being. An overview of flap classification is illustrated below. ![Overview of flap classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--10-.png) Overview of flap classification 😎 ****Fun Fact:** The rhomboid flap, designed by Limberg in 1928, remains one of the most mathematically precise flap designs in plastic surgery, with its 60-degree angles ensuring optimal tension distribution and reliable healing! thePlasticsFella created the **"FLAPS MOVE" mnemonic** to describe and classify a type of flap: **f**orm/composition, **l**ocation, **a**ttachments, **p**erfusion, **s**pecial features, and **move**ment of the flap. This memory hook is illustrated below. ![How to classify/describe a flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--11-.png) How to classify/describe a flap --- ## Blood Supply Classification of Flaps ****Key Point** Local flaps are classified by blood supply into random pattern (subdermal plexus), axial pattern (named vessels), and perforator-based (indirect axial) types. Understanding flap blood supply classification is fundamental to successful flap design and execution. The vascular basis of a flap determines its reliability, size limitations, and potential complications. The evolution of flap blood supply understanding has revolutionized reconstructive surgery, progressing from simple random pattern flaps to sophisticated perforator-based designs that maximize tissue transfer while minimizing donor site morbidity. ![Flap classification by blood supply](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images.png) Flap classification by blood supply ### Random Pattern Flaps **Characteristics** Random pattern flaps lack a specific named blood vessel and depend entirely on the subdermal vascular plexus for perfusion. Blood flow enters the flap base and travels through the network of small vessels within the subcutaneous tissue. **Vascular Anatomy** - Blood supply from the subdermal plexus. - No dominant vessel along the flap axis. - Perfusion decreases with distance from the base. - Length-to-width ratio is typically limited to 2:1 or 3:1. **Clinical Examples** - Rhomboid flaps for trunk and extremity reconstruction. - Bilobed flaps for nasal tip defects. - Simple advancement flaps for small defects. - Local rotation flaps for scalp reconstruction. **Advantages** - Simple design and execution. - No need to identify specific vessels. - Reliable for small to moderate defects. - Minimal preoperative planning required. **Limitations** - Size restrictions due to perfusion constraints. - Higher risk of distal necrosis. - Length-to-width ratio limitations. - Not suitable for large defects. ### Axial Pattern Flaps **Characteristics** Axial pattern flaps are based on a named artery that runs along the long axis of the flap, providing direct blood supply and allowing for larger, more reliable tissue transfers. **Vascular Anatomy** - Named artery along the flap's long axis. - Direct arterial perfusion. - Venous drainage through accompanying veins. - Allows for greater length-to-width ratios. **Clinical Examples** - Groin flap based on the superficial circumflex iliac artery. - Deltopectoral flap based on perforating branches of internal mammary artery. - Forehead flap based on supratrochlear or supraorbital arteries. - Nasolabial flap based on facial artery branches. **Advantages** - Larger flap dimensions are possible. - More reliable blood supply. - Lower complication rates. - Suitable for complex reconstructions. **Limitations** - Requires knowledge of vascular anatomy. - More complex surgical planning. - Potential for vascular injury. - Limited by anatomical vessel distribution. ### Perforator-Based Flaps **Characteristics** Perforator-based flaps represent indirect axial flaps that receive their blood supply from vessels that perforate through deeper structures, such as muscle or fascia to reach the skin and subcutaneous tissue. **Vascular Anatomy** - Blood supply from perforating vessels. - Vessels traverse muscle or fascial planes. - Allows tissue harvest without sacrificing underlying structures. - Complex three-dimensional vascular anatomy. **Clinical Examples** - Anterolateral thigh (ALT) flap based on the lateral circumflex femoral artery perforators. - Deep inferior epigastric perforator (DIEP) flap. - Superior gluteal artery perforator (SGAP) flap. - Thoracodorsal artery perforator (TDAP) flap. **Advantages** - Preserves underlying muscle function. - Large tissue volumes available. - Excellent blood supply reliability. - Minimal donor site morbidity. **Limitations** - Complex vascular anatomy. - Requires microsurgical skills. - Longer operative times. - Steep learning curve. 💡 ****Tip:** Remember the 3:1 rule for random pattern flaps - length should not exceed three times the width to ensure adequate perfusion and prevent distal necrosis. --- ## Tissue Composition Categories of Flaps ****Key Point** Flaps are categorized by tissue composition from simple cutaneous to complex osseomyocutaneous, with each type including progressively more tissue layers. The tissue composition of local flaps determines their reconstructive capabilities, functional potential, and complexity of harvest. Understanding these categories allows surgeons to select the appropriate flap type based on the specific requirements of each defect. Modern reconstructive surgery has evolved to utilize increasingly sophisticated flap designs that incorporate multiple tissue types, allowing for complex reconstructions that restore both form and function in a single procedure. These tissue composition categories are summarised below. ![Tissue composition categories of flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--12-.png) Tissue composition categories of flaps ### Cutaneous Flaps **Composition** - Skin (epidermis and dermis). - Subcutaneous fat. - Superficial fascia. **Applications** - Simple skin defects. - Aesthetic reconstruction. - Areas requiring thin, pliable coverage. - Facial reconstruction where bulk is undesirable. **Examples** - Bilobed flaps for nasal reconstruction. - Rhomboid flaps for trunk defects. - V-Y advancement flaps for small defects. ### Fasciocutaneous Flaps **Composition** - All layers of cutaneous flaps. - Deep fascia layer. - Enhanced vascular network. **Applications** - Moderate-sized defects requiring durable coverage. - Areas needing structural support. - Reconstruction over exposed bone or tendon. - Defects in high-tension areas. **Examples** - Radial forearm flaps. - Lateral arm flaps. - Scapular and parascapular flaps. ### Myocutaneous Flaps **Composition** - Skin and subcutaneous tissue. - Underlying muscle. - Associated fascia. - Robust blood supply. **Applications** - Large defects requiring bulk. - Dead space obliteration. - Functional muscle reconstruction. - Coverage of complex three-dimensional defects. **Examples** - Latissimus dorsi myocutaneous flaps. - Pectoralis major myocutaneous flaps. - Rectus abdominis myocutaneous flaps. ### Osseomyocutaneous Flaps **Composition** - All soft tissue components. - Bone segment. - Periosteum. - Complex vascular supply. **Applications** - Composite defects involving bone and soft tissue. - Mandibular reconstruction. - Complex extremity reconstruction. - Structural and aesthetic restoration. **Examples** - Fibula osseomyocutaneous flaps. - Iliac crest osseomyocutaneous flaps. - Scapular osseomyocutaneous flaps. 😎 ****Fun Fact:** The deep fascia in fasciocutaneous flaps acts like a "highway" for blood vessels, significantly improving flap reliability compared to simple cutaneous flaps! --- ## Movement Pattern Types of Flaps ****Key Point** Four primary movement patterns exist: advancement, rotation, transposition, and interpolation, each with specific geometric requirements and clinical applications. Understanding flap movement patterns is crucial for successful flap design and execution. Each movement type has distinct geometric principles, tension vectors, and optimal applications that must be considered during surgical planning. The selection of movement pattern depends on defect characteristics, surrounding tissue availability, and aesthetic considerations. Proper pattern selection ensures optimal outcomes while minimizing complications and donor site morbidity. ![Classification by the movement of flaps, Flap classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--1-.png) Classification by the movement of flaps ### Advancement Flaps **Movement Characteristics** - Direct linear movement into the defect. - No rotation or lateral displacement. - Tissue advances straight forward. - Maintains original tissue orientation. **Design Principles** - Requires adequate tissue laxity. - Length determined by tissue elasticity. - Width should accommodate closure without tension. - May require back-cuts or Burow's triangles. **Clinical Applications** - Linear defects. - Areas with good tissue mobility. - Situations requiring simple, reliable closure. - Defects where tissue orientation is important. **Common Examples** - V-Y advancement flaps. - A-T advancement flaps. - Bilateral advancement flaps. - Single advancement flaps with back-cuts. **Advantages** - Simple design and execution. - Maintains tissue characteristics. - Minimal distortion of surrounding structures. - Reliable blood supply. **Limitations** - Limited by tissue elasticity. - May create standing cones. - Not suitable for large defects. - Requires adequate surrounding tissue. ### Rotation Flaps **Movement Characteristics** - Curved movement around a pivot point. - Arc-like motion into the defect. - Maintains connection to original blood supply. - Creates curved closure lines. **Design Principles** - Arc length is typically 2-4 times of defect diameter. - Pivot point determines the rotation radius. - May require back-cuts to reduce tension. - Consider aesthetic unit boundaries. **Clinical Applications** - Curved or circular defects. - Scalp reconstruction. - Areas where curved scars are acceptable. - Situations with abundant adjacent tissue. **Common Examples** - Scalp rotation flaps. - Cheek rotation flaps. - Trunk rotation flaps. - Modified rotation flaps with advancement. **Advantages** - Can cover large defects. - Utilizes abundant tissue reservoir. - Good blood supply maintenance. - Versatile design options. **Limitations** - May create dog-ears. - Curved scars may be noticeable. - Requires careful planning. - Potential for trapdoor deformity. ### Transposition Flaps **Movement Characteristics** - Lateral movement over intact skin. - Crosses intervening tissue bridge. - Changes tissue orientation. - Creates angular closure patterns. **Design Principles** - The flap must be larger than the defect. - Consider tissue thickness matching. - Plan for secondary defect closure. - Geometric precision is important. **Clinical Applications** - Defects where direct closure is impossible. - Areas requiring tissue from different orientation. - Complex geometric defects. - Situations with limited local tissue. **Common Examples** - Rhomboid (Limberg) flaps. - Bilobed flaps. - Z-plasty flaps. - Dufourmentel flaps. **Advantages** - Precise geometric design. - Predictable outcomes. - Can utilize distant tissue. - Excellent for facial reconstruction. **Limitations** - Complex planning required. - May create multiple scars. - Risk of flap necrosis. - Requires geometric precision. ### Interpolation Flaps **Movement Characteristics** - Crosses over intact skin bridge. - Requires staged division. - Maintains connection during healing. - Two-stage procedure. **Design Principles** - Robust blood supply is essential. - Plan for pedicle division timing. - Consider patient compliance. - Aesthetic planning is crucial. **Clinical Applications** - Defects distant from the tissue source. - Complex facial reconstruction. - Areas requiring specialized tissue. - Situations where other options are inadequate. **Common Examples** - Forehead flaps for nasal reconstruction. - Nasolabial flaps. - Cross-finger flaps. - Temporal flaps. **Advantages** - Access to distant tissue. - Excellent tissue match possible. - Can provide specialized tissue. - Reliable blood supply. **Limitations** - Two-stage procedure. - Patient compliance required. - Temporary aesthetic concerns. - Risk of pedicle injury. 💡 ****Tip:** Use the mnemonic "FLAPS MOVE" - Form (tissue composition), Location (local/regional/distant), Attachments (pedicled/free), Perfusion (random/axial), Special features, MOVEment type - to systematically describe any flap! --- ## Clinical Applications & Selection of Flaps ****Key Point** Flap selection depends on defect characteristics, tissue requirements, and anatomical constraints, with specific decision-making algorithms guiding optimal choice. Successful local flap reconstruction requires systematic evaluation of multiple factors to select the most appropriate technique for each clinical scenario. This decision-making process integrates defect analysis, patient factors, and technical considerations to optimize outcomes. The evolution of flap selection has moved from simple algorithmic approaches to sophisticated decision-making frameworks that consider long-term functional and aesthetic outcomes alongside immediate reconstructive needs. ### Defect Analysis Framework **Size Considerations** - **Small Defects (<2cm):** Simple advancement or small rotation flaps. - **Medium Defects (2-5cm):** Transposition flaps, larger rotation flaps. - **Large Defects (>5cm):** Complex flaps, multiple flaps, or alternative techniques. **Location Factors** - **Facial Defects:** Aesthetic subunit principles, tissue match priority. - **Trunk Defects:** Functional considerations, scar placement. - **Extremity Defects:** Joint function preservation, durability requirements. - **Scalp Defects:** Hair-bearing tissue considerations, large tissue availability. **Depth Requirements** - **Superficial Defects:** Cutaneous flaps are adequate. - **Deep Defects:** Fasciocutaneous or myocutaneous flaps required. - **Bone Exposure:** Muscle flaps or complex reconstructions needed. - **Composite Defects:** Multi-tissue flaps or staged procedures. ### Patient Factor Considerations **Medical Factors** - Age affecting healing capacity and tissue elasticity. - Comorbidities impacting wound healing and surgical risk. - Smoking status as a major risk factor for flap complications. - Previous surgery or radiation affecting tissue quality. - Medications affecting healing or bleeding risk. **Functional Requirements** - Occupational demands and activity levels. - Aesthetic expectations and psychological factors. - Compliance with postoperative restrictions. - Long-term maintenance requirements. ### Technical Selection Criteria **Blood Supply Matching** - Random pattern for small, simple defects. - Axial pattern for larger, more complex reconstructions. - Perforator-based for specialized tissue requirements. **Movement Pattern Selection** - Advancement for linear defects with good tissue laxity. - Rotation for curved defects with abundant adjacent tissue. - Transposition for complex geometry or limited local options. - Interpolation for distant tissue requirements. **Tissue Composition Matching** - Cutaneous for simple skin replacement. - Fasciocutaneous for structural support requirements. - Myocutaneous for bulk and dead space obliteration. - Complex flaps for composite tissue replacement. ### Decision-Making Algorithm **Step 1: Defect Assessment** Evaluate size, depth, location, and surrounding tissue quality to determine reconstructive requirements. **Step 2: Patient Evaluation** Assess medical status, functional needs, aesthetic goals, and compliance potential. **Step 3: Option Analysis** Consider all viable flap options, evaluating the advantages and limitations of each approach. **Step 4: Risk-Benefit Assessment** Compare complication rates, functional outcomes, and aesthetic results for each option. **Step 5: Final Selection** Choose the optimal technique based on a comprehensive analysis and patient preferences. 😎 ****Fun Fact:** The "aesthetic subunit principle" revolutionized facial reconstruction by showing that replacing entire aesthetic units often provides better results than patching small areas! --- ## Design Principles & Complications of Flaps ****Key Point** Successful flap design requires understanding tension vectors, aesthetic subunits, and blood supply patterns to prevent necrosis, trapdoor deformities, and functional impairment. Flap design represents the intersection of surgical artistry and scientific precision, where understanding of anatomy, geometry, and healing biology converge to create optimal reconstructive outcomes. Poor design decisions can lead to significant complications and suboptimal results. Modern flap design incorporates evidence-based principles derived from decades of clinical experience and research, providing surgeons with reliable guidelines for achieving consistent, excellent outcomes. ### Fundamental Design Principles **Geometric Precision** - Mathematical relationships ensure optimal tension distribution. - Specific angles and proportions minimize complications. - Precise measurements prevent size mismatches. - Geometric planning reduces revision requirements. **Vascular Considerations** - Blood supply orientation determines flap viability. - Pedicle width affects perfusion reliability. - Vessel location influences design modifications. - Perfusion assessment guides size limitations. **Tension Vector Analysis** - Force distribution affects healing outcomes. - Closure tension determines complication risk. - Vector planning prevents distortion. - Tension reduction techniques improve results. **Aesthetic Integration** - Subunit boundaries guide incision placement. - Natural contours influence flap orientation. - Scar camouflage techniques improve appearance. - Symmetry considerations affect design choices. ### Common Design Errors **Inadequate Blood Supply** - Narrow pedicles leading to venous congestion. - Excessive flap length, causing distal necrosis. - Poor vessel orientation resulting in kinking. - Insufficient perfusion assessment. **Geometric Mistakes** - Incorrect angle calculations in transposition flaps. - Inadequate size planning leading to tension. - Poor proportion relationships, causing distortion. - Measurement errors affecting closure. **Aesthetic Oversights** - Crossing aesthetic subunit boundaries unnecessarily - Creating unnatural contours or asymmetries. - Poor scar placement in visible areas. - Ignoring hair growth patterns. ### Complication Prevention Strategies **Vascular Complications** - Adequate pedicle width (minimum 1:1 ratio). - Gentle tissue handling to prevent vessel injury. - Proper flap positioning to avoid kinking. - Postoperative monitoring for perfusion. **Geometric Complications** - Precise template creation and measurement. - Mathematical verification of angles and proportions. - Adequate tissue mobilization before closure. - Tension assessment throughout the procedure. **Aesthetic Complications** - Respect for aesthetic subunit boundaries. - Symmetric design planning. - Natural contour preservation. - Appropriate scar placement. ### Specific Complication Management **Flap Necrosis** - Early recognition through monitoring. - Conservative debridement when appropriate. - Secondary reconstruction planning. - Prevention through proper design. **Trapdoor Deformity** - Caused by circular scar contracture. - Prevention through geometric modification. - Treatment with scar revision techniques. - Long-term monitoring and management. **Functional Impairment** - Assessment of movement restrictions. - Physical therapy interventions. - Surgical revision when necessary. - Prevention through careful planning. **Aesthetic Dissatisfaction** - Realistic expectation setting. - Revision surgery planning. - Non-surgical improvement options. - Psychological support when needed. 💡 ****Tip:** Always create a paper template of your flap design before making any incisions - this simple step prevents many geometric errors and improves surgical precision! --- ## Conclusion Upon completing this article, you will have accomplished the following: 1\. ****Overview**: Understand that local flaps are tissue transfers with their own blood supply from adjacent areas, offering superior outcomes to skin grafts through better color match, contour, and reduced contracture. 2\. ****Blood Supply Classification**: Master the three main blood supply types - random pattern (subdermal plexus), axial pattern (named vessels), and perforator-based (indirect axial) - each with specific reliability and size limitations. 3\. ****Tissue Composition Categories**: Learn the progression from simple cutaneous to complex osseomyocutaneous flaps, with each type including progressively more tissue layers for specific reconstructive needs. 4\. ****Movement Pattern Types**: Understand the four primary movement patterns - advancement, rotation, transposition, and interpolation - each with specific geometric requirements and clinical applications. 5\. ****Clinical Applications & Selection**: Develop systematic approaches to flap selection based on defect characteristics, tissue requirements, and anatomical constraints using evidence-based decision-making algorithms. 6\. ****Design Principles & Complications**: Master the fundamental principles of flap design including tension vectors, aesthetic subunits, and blood supply patterns to prevent common complications and achieve optimal outcomes. --- ## Further Reading 1. Limberg AA. The Planning of Local Plastic Operations on the Body Surface: Theory and Practice. Leningrad: Medgiz; 1928. 2. Esser JFS. Gestielte lokale Nasenplastik mit zweizipfligem Lappen, Deckung des sekundären Defektes vom ersten Zipfel durch den zweiten. Deutsche Zeitschrift für Chirurgie. 1918;143:385-390. 3. Zitelli JA. The bilobed flap for nasal reconstruction. Archives of Dermatology. 1989;125(7):957-959. 4. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plastic and Reconstructive Surgery. 1985;76(2):239-247. 5. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. New York: Churchill Livingstone; 1997. 6. Wei FC, Mardini S. Flaps and Reconstructive Surgery. 2nd ed. Philadelphia: Elsevier; 2017. ### The Reconstructive Ladder: Core Principles, the Six Rungs, & Applications URL: https://www.theplasticsfella.com/the-reconstructive-ladder/ Last updated: 2025-10-06T20:52:09.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/the-reconstructive-ladder/#overview-of-the-reconstructive-ladder) The reconstructive ladder is a systematic framework for selecting optimal reconstruction methods, progressing from simple to complex techniques while considering patient factors and long-term outcomes. [****Core Principles**](https://www.theplasticsfella.com/the-reconstructive-ladder/#core-principles-of-the-reconstructive-ladder) The ladder was formalized by Mathes and Nahai in 1982, establishing systematic evaluation principles that balance simplicity with optimal outcomes through evidence-based decision making. [****The Six Rungs: Secondary to Free Tissue Transfer**](https://www.theplasticsfella.com/the-reconstructive-ladder/#the-six-rungs-secondary-to-free-tissue-transfer-of-the-reconstructive-ladder) Each rung represents increasing complexity: secondary intention, primary closure, skin grafting, local flaps, pedicled flaps, and free tissue transfer, each with specific indications and limitations. [****Clinical Decision-Making**](https://www.theplasticsfella.com/the-reconstructive-ladder/#clinical-decision-making-framework-of-the-reconstructive-ladder) Success requires systematic patient assessment, wound evaluation, risk-benefit analysis, and shared decision making to select the most appropriate reconstructive option. [****Applications**](https://www.theplasticsfella.com/the-reconstructive-ladder/#applications-of-the-reconstructive-ladder) Contemporary modifications include the reconstructive elevator concept, hybrid approaches, and specialty-specific applications with documented success rates and outcomes data. [****Complications**](https://www.theplasticsfella.com/the-reconstructive-ladder/#complications-of-the-reconstructive-ladder) Complications vary by rung complexity, from infection and scarring in simple techniques to flap failure in complex procedures, requiring prevention strategies and early intervention protocols. ****Verified by thePlasticsFella ✅** --- ## Overview of the Reconstructive Ladder ****Key Point** The reconstructive ladder provides a systematic framework for wound reconstruction, progressing from simple to complex techniques while prioritizing optimal outcomes over simplicity. The reconstructive ladder represents one of the most fundamental decision-making tools in plastic surgery, providing surgeons with a logical framework for approaching wound reconstruction. This systematic approach ensures that all viable options are considered before selecting the most appropriate technique for each individual patient. Originally conceived as a stepwise progression from simple to complex methods, the modern understanding of the reconstructive ladder emphasizes that the "best" option isn't always the simplest one. Instead, it's the technique that provides optimal **long-term functional and aesthetic outcomes** while minimizing patient morbidity and resource utilization. The ladder promotes evidence-based decision-making while maintaining flexibility to address individual patient needs and circumstances. ![Overview of the reconstructive ladder](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Main-Article-Images--2-.png) Overview of the reconstructive ladder 😎 ****Fun Fact:** The reconstructive ladder concept revolutionized plastic surgery by being the first systematic approach to reconstruction. Before this, surgical decisions were often based purely on individual surgeon preference rather than evidence-based principles! --- ## Core Principles of the Reconstructive Ladder ****Key Point** Formalized by Mathes and Nahai in 1982, the ladder transformed reconstruction from individual experience to evidence-based science. The reconstructive ladder emerged from decades of surgical experience and the need for a standardized approach to complex reconstructive decisions. The formal description by Mathes and Nahai in their 1982 work "Clinical Applications for Muscle and Musculocutaneous Flaps" represented a paradigm shift in reconstructive surgery. ### Core Principles The reconstructive ladder is built on four fundamental principles that guide surgical decision-making. **Systematic Evaluation** Every rung must be considered methodically to ensure no viable options are overlooked. This prevents tunnel vision and promotes comprehensive patient care. **Risk-Benefit Analysis** Each technique carries different risks, benefits, and resource requirements. The ladder provides a framework for weighing these factors systematically. **Patient-Centered Care** The optimal choice considers not just the wound characteristics, but also patient factors, functional requirements, and personal goals. **Evidence-Based Selection** Modern application of the ladder incorporates outcome data and success rates to guide decision-making rather than relying solely on tradition or preference. 💡 ****Tip:** Remember that the ladder is a guide, not a rigid protocol. Sometimes jumping to a higher rung initially provides better outcomes than multiple failed attempts at lower rungs. --- ## The Six Rungs: Secondary to Free Tissue Transfer of the Reconstructive Ladder ****Key Point** The six rungs progress from secondary intention through free tissue transfer, each with increasing complexity and specific applications. Understanding each rung of the reconstructive ladder requires knowledge of the techniques involved, their optimal applications, and their inherent limitations. This systematic approach ensures appropriate technique selection for each clinical scenario. Each rung represents not just increasing technical complexity, but also different risk profiles, resource requirements, and outcome expectations. ### Rung 1: Secondary Intention **Mechanism** Secondary intention healing allows wounds to heal naturally through the body's repair mechanisms, progressing through hemostasis, inflammation, proliferation, and remodeling phases over weeks to months. **Optimal Applications** - Small, superficial wounds (<2cm diameter). - Contaminated or infected wounds requiring drainage. - Wounds in well-vascularized areas. - Certain facial wounds where natural contours are preserved. - Pressure sores in appropriate candidates. **Advantages** - Natural tissue regeneration with preserved sensation. - No surgical risks or anesthesia requirements. - Cost-effective with minimal resource needs. - Allows infection management and wound cleaning. **Limitations** - Extended healing time (weeks to months). - Often results in depressed, irregular scars. - Open wound vulnerable to contamination. - Impractical for large defects. - May limit mobility during healing. ### Rung 2: Primary Intention (Direct Closure) **Types:** Direct approximation of wound edges using sutures, staples, adhesives, or specialized dressings. Can be immediate (at time of injury) or delayed (3-5 days later for observation). **Technical Considerations** - Tension assessment critical for success. - Tissue viability must be ensured. - Clean wounds have the highest success rates. - Patient factors affect healing potential. **Advantages** - Fastest healing method (7-14 days). - Minimal scarring with good cosmetic results. - Reduced infection risk in a closed environment. - Single procedure with immediate function. **Limitations** - Size restrictions based on tissue elasticity. - Risk of trapping infection in contaminated wounds. - Cannot address significant tissue deficits. - Tension-related complications possible. 💡 ****Tip:** Use the "pinch test" - if you can't easily pinch wound edges together with your fingers, primary closure will likely fail or result in poor outcomes. ### Rung 3: Skin Grafting **Split-Thickness Skin Grafts (STSG)** - **Composition:** Epidermis + partial dermis (0.2-0.3mm thick). - High take rate (90-95%) in optimal conditions. - Can cover extensive defects, donor site regenerates. - Poor cosmetic result with contracture tendency. **Full-Thickness Skin Grafts (FTSG)** - **Composition:** Epidermis + entire dermis. - Superior cosmetics with less contracture. - Lower take rate (80-90%) with size limitations. - Better durability and sensation recovery. **Graft Take Process** - **Imbibition (0-48 hours):** Passive nutrient absorption. - **Inosculation (48-72 hours):** Vascular connections begin. - **Revascularization (4-7 days):** New blood vessel ingrowth. - **Maturation (weeks-months):** Integration and remodeling. **Applications** - Burns covering >20% body surface area. - Traumatic wounds with healthy granulation tissue. - Tumor resection defects. - Chronic wounds after debridement. ### Rung 4: Local Flaps **Classification** Transfer of tissue from immediately adjacent areas while maintaining the original blood supply through a pedicle. Classified by blood supply (random vs axial pattern) and movement (advancement, rotation, transposition). **Common Types** - **Advancement Flaps:** V-Y advancement, bilateral advancement. - **Rotational Flaps:** Simple rotation, bilobed, rhomboid. - **Transposition Flaps:** Z-plasty, Limberg, Dufourmentel. **Advantages** - Excellent color and texture match. - Preserved sensation and blood supply. - Single-stage procedure. - Maintains local tissue characteristics. **Limitations** - Size restrictions based on local tissue availability. - May create secondary defects. - Geometric constraints for flap design. - Requires adequate tissue laxity. ### Rung 5: Distant/Regional/Pedicled Flaps **Definition** Transfer of tissue from distant sites while maintaining connection to the original blood supply. These techniques have centuries of documented use, including the Italian forehead flap for nasal reconstruction from the 15th century. **Classification by Tissue Type** - **Fasciocutaneous:** Skin and fascia. - **Musculocutaneous:** Muscle with overlying skin. - **Muscle only:** Dead space filling or functional reconstruction. - **Osteocutaneous:** Bone with soft tissue components. **Common Examples** - **Upper Extremity:** Latissimus dorsi, pectoralis major, trapezius. - **Lower Extremity:** Gastrocnemius, soleus, rectus abdominis. - **Head and Neck:** Forehead flap, deltopectoral, temporalis. **Advantages** - Reliable, well-defined vascular anatomy. - Large tissue volume available. - Can restore muscle function. - Multiple tissue types in a single flap. **Limitations** - Donor site functional loss. - Limited reach from origin. - May require multiple stages. - Bulk issues in some applications. ### Rung 6: Free Tissue Transfer/Free Flaps **Definition** Complete tissue transfer with microsurgical vascular anastomosis. The first successful free flap in 1973 by Daniel and Taylor marked the beginning of the microsurgical era. **Microsurgical Principles** - Arterial and venous anastomosis required. - Often needs two veins for drainage. - Requires specialized monitoring protocols. - Immediate re-exploration capability is essential. **Common Free Flaps** - **Fasciocutaneous:** Radial forearm, anterolateral thigh, scapular. - **Muscle/Musculocutaneous:** Latissimus dorsi, rectus abdominis, gracilis. - **Bone-Containing:** Fibula, iliac crest, scapula. - **Specialized:** Jejunum, omentum, toe transfer. **Advantages** - Unlimited reach to any body area. - Multiple tissue types available. - Functional and sensory reconstruction are possible. - Optimal tissue selection for each defect. **Limitations** - Technical complexity requiring expertise. - 5-10% complete flap loss rate. - 6-12 hour operative times. - Resource intensive with specialized requirements. 😎 ****Fun Fact:** Free flap success is often determined in the first 72 hours - establish robust monitoring protocols and maintain a low threshold for re-exploration if there's any concern about flap viability. --- ## Clinical Decision-Making Framework of the Reconstructive Ladder ****Key Point** Effective ladder application requires systematic evaluation integrating patient factors, wound characteristics, and functional requirements. Effective use of the reconstructive ladder requires a structured approach to clinical decision making that considers multiple factors beyond just wound characteristics. The decision-making process must integrate medical factors, wound characteristics, functional requirements, and patient preferences into a comprehensive treatment plan. ### Patient Assessment Components **Medical Factors** - Age and comorbidities affecting healing and surgical risk. - Nutritional status is critical for wound healing success. - Smoking history as a major risk factor for complications. - Medications including anticoagulants, steroids, and chemotherapy. - Previous surgery or radiation affecting tissue quality. **Wound Characteristics** - Size and depth determining reconstructive requirements. - Location affecting functional and aesthetic considerations. - Tissue quality and viability of surrounding structures. - Contamination level (clean vs contaminated vs infected). - Timing factors (acute vs chronic wounds). **Functional Requirements** - Mobility needs and joint function preservation. - Sensory requirements in critical areas. - Aesthetic goals for visible vs hidden locations. - Occupational demands and return to work needs. - Recreational activities and lifestyle considerations. ### Decision-Making Algorithm **Step 1: Comprehensive Assessment** Document wound characteristics, assess contamination status, evaluate surrounding tissue availability, and consider timing factors. **Step 2: Patient Evaluation** Review medical history, assess surgical risk, discuss patient goals and expectations, and evaluate compliance potential. **Step 3: Systematic Ladder Review** Methodically consider each rung from secondary intention through free tissue transfer, evaluating feasibility and appropriateness. **Step 4: Risk-Benefit Analysis** Compare success rates, evaluate potential complications, consider long-term outcomes, and assess cost-effectiveness. **Step 5: Shared Decision Making** Present viable options, discuss risks and benefits, consider patient preferences, and develop a comprehensive treatment plan. 💡 ****Tip:** Always document your decision-making rationale - this protects you medicolegally and helps with quality improvement initiatives. --- ## Applications of the Reconstructive Ladder ****Key Point** Contemporary practice embraces the "reconstructive elevator" concept, moving beyond rigid stepwise progression to optimize outcomes. Modern reconstructive surgery has evolved beyond the traditional stepwise ladder approach to embrace more nuanced decision-making frameworks. These contemporary modifications reflect advances in surgical techniques, materials science, and outcome measurement. The integration of evidence-based medicine with reconstructive surgery has provided objective data to guide technique selection. ### The Reconstructive Elevator This modern concept challenges traditional stepwise progression, suggesting that sometimes jumping directly to a higher rung provides better outcomes than multiple failed attempts at lower rungs. **Key Principles** - Outcome optimization over simplicity. - Resource efficiency through definitive treatment. - Patient-centered care considering lifestyle factors. - Evidence-based selection using outcome data. **Hybrid Approaches** Modern reconstruction often combines multiple techniques. - Negative pressure therapy, enhancing healing at all levels. - Tissue engineering for complex reconstruction. - Staged procedures with planned sequential treatments. - Adjuvant therapies including hyperbaric oxygen and growth factors. **Specialty-Specific Applications** - **Trauma Surgery** - Damage control with initial stabilization. - Time-sensitive decision making. - Staged approach for contaminated wounds. - Priority on functional preservation. - **Oncologic Reconstruction** - Timing considerations with adjuvant therapy. - Margin requirements vs reconstructive complexity. - Quality of life maintenance. - Psychological impact of appearance changes. ### Evidence-Based Outcomes **Success Rates by Rung** - **Secondary Intention:** 95% healing rate, variable timeline. - **Primary Closure:** 90-95% success in appropriate cases. - **Skin Grafts:** STSG 90-95%, FTSG 80-90%. - **Local Flaps:** 95-98% success rate. - **Pedicled Flaps:** 90-95% success rate. - **Free Flaps:** 90-95% success in experienced hands. **Factors Affecting Outcomes** - Surgeon experience significantly impacts complex procedures. - Patient selection is crucial for success. - Institutional resources and support systems. - Postoperative monitoring and early intervention. **Cost-Effectiveness Analysis** - Higher rungs are more expensive initially. - Failed simple procedures may cost more long-term. - Functional outcomes affect overall value. - Societal impact through productivity and return to work. 😎 ****Fun Fact:** Modern outcome studies show that jumping to higher ladder rungs initially often provides better long-term results and lower total costs than multiple failed attempts at simpler techniques. --- ## Complications of the Reconstructive Ladder ****Key Point** Complication patterns vary by technique complexity, requiring prevention through patient optimization and early intervention protocols. Understanding complications associated with each rung of the reconstructive ladder is essential for informed consent, prevention strategies, and early management. Complication rates and types vary significantly based on technique complexity and patient factors. Successful complication management requires early recognition, understanding of underlying mechanisms, and prompt intervention. Prevention through proper patient selection, meticulous technique, and appropriate postoperative care remains the most effective strategy. ### Complications by Rung **Secondary Intention** - Infection (10-15% incidence). - Delayed healing with a variable timeline. - Hypertrophic scarring (20-30% in susceptible patients). - Contracture formation depending on location and size. **Primary Closure** - Dehiscence (5-10% overall incidence). - Infection (2-5% in clean wounds). - Hypertrophic scarring (10-15% incidence). - Tension-related necrosis (1-3% with proper technique). **Skin Grafts** - Graft failure (5-20% depending on conditions). - Infection (10-15% incidence). - Contracture (30-50% with STSG). - Donor site problems (5-10% incidence). **Local Flaps** - Partial necrosis (5-10% incidence). - Total flap loss (1-3% incidence). - Donor site morbidity is variable by flap type. - Aesthetic concerns (20-30% may desire revision). **Pedicled Flaps** - Partial necrosis (10-15% incidence). - Total flap loss (3-5% incidence). - Significant donor site functional impact. - Pedicle complications from compression or kinking. **Free Flaps** - Total flap loss (5-10% incidence). - Partial necrosis (10-20% incidence). - Vascular complications with thrombosis most common. - Permanent donor site functional changes. ### Prevention Strategies **Preoperative Optimization** - Address medical comorbidities. - Ensure adequate nutritional support. - Smoking cessation minimum of 4-6 weeks preoperatively. - Prophylactic antibiotics when indicated. **Intraoperative Techniques** - Gentle tissue handling to minimize trauma. - Meticulous hemostasis without excessive cautery. - Tension-free closure techniques. - Strict sterile technique throughout. **Postoperative Care** - Vigilant wound monitoring for early problem detection. - Activity modification to protect reconstruction. - Infection surveillance with prompt treatment. - Patient education ensuring compliance with restrictions. 💡 ****Tip:** Prevention is always better than treatment - invest time in proper planning, patient optimization, and meticulous technique rather than managing complications later. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Understand that the reconstructive ladder provides a systematic framework for wound reconstruction, progressing from simple to complex techniques while prioritizing optimal outcomes over simplicity. ****2\. Historical Development & Core Principles:** Learn how Mathes and Nahai formalized the ladder concept in 1982, transforming reconstruction from individual experience to evidence-based science. ****3\. The Six Rungs:** Master the six rungs that progress from secondary intention through free tissue transfer, each with increasing complexity and specific applications. ****4\. Clinical Decision-Making Framework:** Develop systematic approaches through structured algorithms that integrate patient factors, wound characteristics, and functional requirements. ****5\. Modern Applications & Evidence-Based Practice:** Appreciate how contemporary practice embraces the "reconstructive elevator" concept, moving beyond rigid stepwise progression to optimize outcomes. ****6\. Complications & Management:** Recognize that complication patterns vary by technique complexity, requiring prevention through patient optimization and early intervention protocols. --- ## Further Reading 1. Mathes SJ, Nahai F. Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis: CV Mosby; 1982. 2. Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93(7):1503-1504. 3. Janis JE, Kwon RK, Lalonde DH. A practical guide to wound healing. Plast Reconstr Surg. 2010;125(6):230e-244e. 4. Neligan PC, Gurtner GC. Plastic Surgery: Principles. 4th ed. Philadelphia: Elsevier; 2017. 5. Wei FC, Mardini S. Flaps and Reconstructive Surgery. 2nd ed. Philadelphia: Elsevier; 2017. 6. Siemionow M, Eisenmann-Klein M. Plastic and Reconstructive Surgery. London: Springer; 2010. ### Research Methods in Plastic Surgery: Study Designs, PROMs, & Evidence Appraisal URL: https://www.theplasticsfella.com/research-methods-in-plastic-surgery/ Last updated: 2025-10-06T20:42:36.000Z #### Research Methods in Plastic Surgery This chapter offers a comprehensive overview of the most relevant research methods, structured to help trainees and clinicians critically appraise evidence, select appropriate designs, and contribute meaningfully to the evolving plastic surgery literature. 1. [****Study Design Overview**](https://www.theplasticsfella.com/research-methods-in-plastic-surgery/#study-design-overview) 2. [****Observational Studies**](https://www.theplasticsfella.com/research-methods-in-plastic-surgery/#observational-studies) 3. [****Experimental Studies**](https://www.theplasticsfella.com/research-methods-in-plastic-surgery/#experimental-studies) 4. [****Systematic Reviews and Meta-Analyses**](https://www.theplasticsfella.com/research-methods-in-plastic-surgery/#systematic-reviews-and-meta-analyses) 5. [****Patient-Centred Research Methods**](https://www.theplasticsfella.com/research-methods-in-plastic-surgery/#patient-centred-research-methods) 6. [****Improving the Quality of Research**](https://www.theplasticsfella.com/research-methods-in-plastic-surgery/#improving-the-quality-of-research) ****Primary Contributors:** Suraya Yusuf & Justin Conrad Rosen Wormald ****Verified by thePlasticsFella ✅** --- ## Study Design Overview Study design determines what question can be asked, how it is answered, and how robust and generalisable the results will be. At the highest level, research design divides into two core types. - **Observational Studies:** Examine existing data or naturally occurring exposures without intervention. - **Experimental Studies:** Involve deliberate intervention and prospective outcome measurement. - **Other:** These include qualitative, PROMS, and a combination/mixed-methods. Study types, their characteristics, and examples are detailed in the table below. ![Study types and their characteristics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Journal-Club-Images--21-.png) Study types and their characteristics --- ## Observational Studies Observational studies are the foundation of most plastic surgery research. Unlike experimental studies, they do not involve interventions but instead examine existing data to explore patient characteristics, outcomes, and associations. They are generally classified into two categories. - **Descriptive studies,** such as case reports and case series. - **Analytical studies,** including cross-sectional, case-control, and cohort designs. The table below summarises the key types of observational studies. ![Key types of observational studies](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Journal-Club-Images--22-.png) Key types of observational studies ### Observational Descriptive Studies These describe clinical features or outcomes without comparing groups. **Case report** - **Purpose:** Describes a single patient’s unique or rare presentation, management, or outcome. - **When to Use:** Highlight novel or high-risk conditions; stimulate further research. - **Example:** Yusuf et al. (2025) reported a rare case of necrotising myositis, underscoring diagnostic challenges and surgical urgency. - **Limitations:** Anecdotal; prone to bias. - **Guideline:** CARE Guidelines. **Case series** - **Purpose:** Describes outcomes in a group with similar features or interventions. - **Common Use:** Reporting early results of novel techniques before formal evaluation. - **Example:** Euwen et al (2025) demonstrated Botulinum Toxin A for ischaemic feet in Raynaud’s syndrome. - **Pros/Cons:** Offers early safety and feasibility data, lacks a control group; prone to selection bias. - **Guideline:** NHLBI Case Series Tool. 💡 ****Tip:** Consecutive case series are more robust than selective ones. ### Observational Analytical Studies These compare groups to identify relationships between exposures and outcomes. **Cross-Sectional Studies** A snapshot of outcome and exposure at a single time point; useful for prevalence estimates. - **Purpose:** Examine a population at a single time point to assess disease prevalence or patient characteristics. - **Examples:** Patient satisfaction after implant or autologous tissue breast reconstruction (Pirro et al, 2017). - **Pros/Cons:** Fast and efficient; useful for generating hypotheses, no causality inference as there is no longitudinal follow-up; may suffer from sampling bias if the samples are not representative of the wider population. - **Guideline:** NHLBI Cohort & Cross-Sectional Tool, STROBE Statement. ### Cohort Studies Follows exposed and unexposed groups over time; can establish a temporal relationship, but may be time-consuming and costly. - **Purpose:** Follow patients over time to assess how exposure(risk factor or intervention) affects outcomes (prospective or retrospective). - **Example:** Davis et al (2020): Prospective multicentre study on infection risk with delayed hand surgery. - **Pros/Cons:** Strong for studying incidence and temporal relationships, prone to confounding; expensive; high attrition risk; can study multiple outcomes within one cohort to maximise efficiency. - **Guidelines:** NHLBI Appraisal Tool, STROBE Statement, Consider ROBINS-I Tool for non-randomised bias assessment. 💡 ****Tip:** Use standardised protocol templates and reporting guidelines when developing studies. ### Case-Control Studies Retrospective comparison of subjects with and without outcome; efficient for rare outcomes but at risk of recall and selection bias. - **Purpose:** Case-control studies compare individuals with a specific outcome (cases) to those without (controls), assessing past exposures to identify potential risk factors. This outcome-to-exposure approach makes case-control studies ideal for rare outcomes or long latency periods, avoiding the time and cost of tracking large cohorts over time. - **Example:** Hsiung et al. (2024) - Compared patients with and without flap failure post-free tissue transfer to identify risk factors. - **Pros/Cons:** Case-control studies are efficient for exploring potential associations but cannot establish causality. They rely on historical data, making them prone to recall and measurement bias — especially with self-reported exposures. Accurate control selection is crucial, as poor matching can distort results. - **Guideline:** [NHLBI Case-Control Tool, ](https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools?ref=theplasticsfella.com) always align with[ STROBE Statement](https://www.strobe-statement.org/?ref=theplasticsfella.com). 💡 ****Tip:** These studies are best suited for hypothesis generation and should ideally be followed by prospective research. --- ## Experimental Studies Unlike observational designs, experimental studies involve active intervention by the researcher. They are typically prospective and aim to evaluate the efficacy, safety, cost-effectiveness, or impact of a treatment or surgical approach. Experimental studies can be either randomised or non-randomised. ### Non-Randomised Studies of Interventions (NRSIs) Also known as quasi-experimental studies, these deliver an intervention but lack random allocation. - **Purpose:** To assess treatment effects in real-world settings where randomisation is not feasible. It offers causal insights. - **Example:** Comparing surgical site infection rates before and after introducing a new antibiotic protocol. - **Pros/Cons:** More pragmatic and often used in quality improvement. Prone to confounding and bias; can offer causal inferences, though less robust than RCTs and highly dependent on design quality and confounding control. - **Risk of Bias Tool:** Use ROBINS-I for appraisal. 💡 ****Tip:** Consider ethical approval requirements and patient involvement from the planning stage. ### Randomised Control Trials (RCTS) Randomised controlled trials (RCTs) provide the highest level of clinical evidence by using random allocation to reduce bias and allow causal inference. Randomisation helps equalise confounding variables across groups, but small sample sizes can still lead to imbalances by chance. **Key Features** - **Randomisation:** Reduces selection bias and balances known/unknown confounders. Small sample sizes can still lead to chance imbalances. - **Blinding:** Minimises performance and detection bias. Challenging in surgical trials due to visible differences between procedures. Sham surgeries may be used, but raise ethical concerns. Bias can be further reduced through blinding, where participants, investigators, or both (‘double-blinding’) are unaware of group allocation. - **Equipoise:** Ethical justification requires genuine uncertainty about which treatment is superior. For example, the BRAVE study highlighted surgeon resistance to randomisation due to personal preferences and misunderstanding of trial design. A central ethical and methodological requirement for running a randomised controlled trial is the presence of clinical equipoise. When equipoise exists, randomisation is ethically justified because no patient is knowingly given inferior treatment. - **Practical Challenges:** Surgical RCTs are complex and costly due to small patient pools, blinding difficulties, technique variability, & equipoise concerns. - **Pragmatic Trials:** Focus on real-world effectiveness, broad eligibility, and patient-centred outcomes like function or quality of life. Often preferred in surgery to increase generalisability and recruitment. In contrast to explanatory trials, which assess whether an intervention *can* work under idealised circumstances, a pragmatic trial asks whether an intervention *does* work when applied to the real world. - **Reporting Guidelines:** Use the CONSORT statement to ensure trial reports are transparent, complete, and reproducible. Appraise trial quality with the Cochrane [RoB 2 tool](https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool?authuser=0&ref=theplasticsfella.com) for assessing risk of bias in randomised trials. **Examples** Despite the inherent challenges of conducting surgical RCTs, several high-quality trials have been successfully delivered in plastic surgery, demonstrating that rigorous evidence is both achievable and essential for guiding clinical practice. - **NINJA Trial (Jain et al., 2023): Paediatric Hand Surgery** - **Design:** Pragmatic, multicentre (NHS hospitals). - **Focus:** Replace vs. discard nail plate after nailbed repair. - **Findings:** No difference in infection or cosmesis; discarding nails may save £720,000 annually. - **Impact:** Informed widespread practice change for a common paediatric injury. - **MSLT Trials (Morton, Faries, Leiter) - Melanoma Surgery** - **MSLT-I:** Validated sentinel lymph node biopsy (SLNB) as a staging tool. - **MSLT-II & DeCOG-SLT:** Showed no survival benefit from completion lymphadenectomy in positive SLNB cases. - **Impact:** Transformed global melanoma guidelines — SLNB became standard; routine completion lymphadenectomy was de-emphasised. - **WOLLF Trial (Costa et al., 2018) - Open Lower Limb Fractures** - **Design:** 24-centre UK trauma RCT. - **Focus:** Negative pressure wound therapy (NPWT) vs. standard dressings. - **Findings:** No significant difference in disability, infection, or quality of life. - **Impact:** Shaped NICE guidance and NHS funding decisions for cost-effective wound care. - **SWIFFT Trial (Dias et al., 2020) - Scaphoid Fractures** - **Design:** 31-centre UK RCT. - **Focus:** Early surgical fixation vs. cast for minimally displaced fractures. - **Findings:** No functional difference; surgery had a higher complication rate (14% vs. 1%). - **Impact:** Supports cast immobilisation as first-line, saving \~£1,295 per patient. --- ## Systematic Reviews and Meta-Analyses As plastic surgery literature expands, synthesising evidence through systematic reviews (SRs) and meta-analyses (MAs) has become essential for guiding practice and research. These methods inform clinical guidelines and help identify research gaps for future studies. **Types** - **Systematic Reviews (SRs):** Identify, appraise, and summarise all relevant studies using transparent, reproducible methods. - **Meta-Analysis (MA):** Statistically combines results to improve power and precision when studies are sufficiently similar. - **Network Meta-Analysis (NMA):** Allows comparison of multiple interventions, even without direct head-to-head trials. **Examples** - A meta-analysis directly informed national hand surgery guidelines and led to the HAWAII RCT on antimicrobial use. - NMA has been used in areas like antibiotic prophylaxis and skin grafting techniques, where multiple treatment permutations limit direct comparisons. **Advantages and Limitations** - Plastic surgery often involves small, heterogeneous studies; MAs can overcome underpowered data and yield stronger conclusions. - However, the strength of SRs and MAs depends on the quality of included studies. Researchers must assess: Risk of bias using validated tools, Statistical heterogeneity (e.g., I²), and publication bias. - NMAs additionally require careful evaluation of transitivity and consistency assumptions. **Reporting and Quality Tools** - Use PRISMA guidelines for transparent reporting. - **Assess quality with AMSTAR 2:** [amstar.ca](http://amstar.ca/?ref=theplasticsfella.com). - **Evaluate evidence certainty with GRADE:** [gradeworkinggroup.org](https://www.gradeworkinggroup.org/?ref=theplasticsfella.com) or via Cochrane resources. - **For NMAs, use CINeMA:** [cinema.ispm.unibe.ch](http://cinema.ispm.unibe.ch/?ref=theplasticsfella.com). - Pre-register protocols on PROSPERO to enhance transparency and reduce duplication. 💡 ****Tip:** A minimum of 3 relevant studies are required to complete a meta-analysis. However, you should aim to include at least 5 high-quality studies to ensure sufficient power and validity of pooled results. --- ## Patient-Centred Research Methods In plastic surgery, clinical success alone is not enough. Factors like identity, satisfaction, and quality of life often define the true impact of a procedure. Two complementary approaches help capture these dimensions: **qualitative research** and **patient-reported outcome measures (PROMs).** ### Qualitative Research Although still underused, qualitative research is gaining traction as plastic surgery shifts toward more patient-centred care. Understanding the *why* behind patient decisions is increasingly valued alongside measuring *what* was done. - **Purpose:** Explores patient motivations, experiences, and perceptions, particularly relevant in cosmetic surgery, body image, and congenital conditions. - **Methods:** Involves collecting non-numerical data through interviews, focus groups, or narratives, analysed using structured approaches like thematic analysis or grounded theory. - **Rigour:** High-quality studies ensure transparency in sampling, data saturation, and reflexivity. - **Application:** Often integrated into mixed-methods designs, providing crucial context to numerical outcomes. While these insights are rich and deeply informative, they may lack generalisability and require nuanced interpretation. 💡 ****Tip:** As the field evolves, qualitative research is essential for designing interventions that reflect what patients truly value — not just what can be measured. **Patient Reported Outcomes Measures (PROMS)** PROMs are now central to plastic surgery research and care, reflecting a shift toward measuring success from the patient’s perspective. They capture important outcomes that traditional clinical endpoints often miss. - **Purpose:** Assess aspects of health that only patients can report, such as pain, function, satisfaction, and emotional well-being, especially relevant in reconstructive and aesthetic surgery. - **Tools:** PROMs like the BREAST-Q, FACE-Q, CLEFT-Q, and BODY-Q are designed specifically for plastic surgery. They’re validated using psychometric methods such as Rasch analysis to ensure consistency and relevance. - **Innovation:** AI-driven platforms like Computerised Adaptive Testing (CAT) and Ecological Momentary CAT (EMCAT) tailor question sets in real-time, reducing the burden while maintaining precision. - **Application:** PROMs are widely used in trials, audits, and service evaluations. In the UK, programmes like NHS England’s GIRFT use PROM data to benchmark outcomes, identify variation, and support value-based care. - **Interpretation:** PROM studies must distinguish between statistical and clinical significance. Reporting Minimal Important Difference (MID) and Minimal Detectable Change (MDC) helps determine whether observed changes are truly meaningful to patients. As plastic surgery evolves, PROMs ensure we measure not just what was done, but how it improved patients’ lives. --- ## Improving the Quality of Research While research in plastic surgery has advanced, much of it remains fragmented, underpowered, or misaligned with real-world needs. Improving quality requires better infrastructure, collaboration, and alignment with patient and clinical priorities. Three key strategies are driving this shift. **Collaborative Research in Plastic Surgery** Collaborative research networks are transforming surgical research, particularly in plastic surgery, where single-centre studies often lack scale or generalisability. - **Purpose:** By pooling data, expertise, and infrastructure, these networks enable large, multicentre projects that are otherwise unfeasible. - **Examples:** The **Reconstructive Surgery Trials Network (RSTN)** and **Plastic Surgery Trainee Collaborative (PSTC)** in the UK have led high-quality prospective studies, RCTs, and audits. Their distributed leadership models promote trainee engagement, faster recruitment, and more inclusive authorship. 💡 ****Tip:** Collaboration improves study power, speeds up delivery, and fosters a culture of shared research across career stages. **Registries and Big Data** Registries provide a foundation for large-scale outcome tracking in plastic surgery. Combined with AI and machine learning, big data is being used to predict outcomes, guide decision-making, and personalise care. - **Purpose:** Track long-term safety, performance, and efficacy, especially for implants and low-volume procedures. - **Examples:** The **UK National Flap Registry** and **ICOBRA** support benchmarking, audit, and international quality improvement. - **Strengths and Limitations:** Linking registries with PROMs and electronic records allows for deep, real-time analysis. Key challenges include data quality, completeness, and governance, solvable through good design and clinician engagement. 💡 ****Tip:** Collaborate with research methodologists early to refine study design and data collection strategies. **Research Priority Setting Partnerships** PSPs reduce research waste by aligning funding and effort with genuine clinical uncertainty. They increase transparency, inclusivity, and relevance, strengthening the evidence base where it matters most. Many studies still focus on questions with limited relevance or impact. **Priority-setting partnerships (PSPs)** aim to correct this by identifying questions that matter most to patients and clinicians. - How it works: The **James Lind Alliance (JLA)** brings together stakeholders to reach consensus on research priorities through structured, inclusive processes. - **Examples** - **Global Burns PSP:** Identified top priorities like infection, scarring, skin regeneration, and first aid in low-resource settings. - **Hand & Wrist PSP (BSSH):** Highlighted uncertainties around peripheral nerve compression, arthritis, scar management, and PROM use. --- ### Fake Educational Metrics, 3 Perforator Tips, & Feedback on Foundations URL: https://www.theplasticsfella.com/october-5th/ Last updated: 2025-10-04T11:54:39.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/october-5th/#a-letter-from-pfella) The fake metrics of plastic surgery. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-5th/#the-sunday-quiz) How well do you know *perforators?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/october-5th/#image-of-the-week) Original publication of angiosomes. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/october-5th/#technique-tip) How to dissect a perforator. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/october-5th/#foundations-textbook) We're collecting your feedback for improvements. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-5th/#articles-of-the-week) Original angiosomes publication, technical tips for perforators, & the term “perforator”: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/october-5th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Fake Metrics of Plastic Surgery* 👋 Most educational organizations love to talk about “impact,” but when they can’t measure it, they default to measuring performativeness. They count attendance at webinars, not whether anyone actually learned something. Trainees boast about the number of abstracts accepted at a meeting, the number of publications that nobody reads, not whether any of those findings changed clinical practice. They measure hours of “teaching delivered” or “courses run,” rather than whether trainees are more competent, confident, or safe afterwards. It’s the classic trap: *if you can’t measure what matters, you make what’s measurable matter.* So, we end up rewarding noise over nuance. Committees pat themselves on the back for glossy reports or “successful” events that generate LinkedIn posts, but the actual educational return is near zero. Online personalities in plastic surgery, podcasts, and platforms do the same, focusing on clicks, follows, and engagement graphs, rather than long-term retention, skill transfer, or exam performance. Plastic surgery is especially vulnerable here. A trainee who binge-watches 20 conference recordings looks “engaged” in the metrics, but that says nothing about their ability to dissect a flap or counsel a patient. Societies pump out guidelines and webinars, but when the dust settles, has anything changed in the OR? The uncomfortable truth is this: **when organizations can’t measure learning, they measure loyalty and optics instead.** And that creates an ecosystem where what “looks good” (numbers, logos, noise) gets rewarded over what *is* good (competence, clarity, patient outcomes). 👉 Maybe that’s the real challenge for us: should educational bodies start investing in real metrics like skill assessment, knowledge retention, patient outcomes, rather than vanity ones? With love, P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Perforators?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the second round of seven rounds! The ****top** scorer wins one our **Foundations* textbook at a discount! ## Image of the Week **Original Publication of Angiosomes* 🖼️ ****Image of the Week** This figure comes from the original publication on angiosomes, illustrating the continuous network of cutaneous arteries and arterioles across the body. It highlights key anatomical insights for flap planning in reconstructive surgery, from the large perforators in the head, torso, and limbs to the fine, densely packed vessels in the forearms and legs. These vascular territories guide many modern reconstructive techniques. ![Original Publication of Angiosomes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Angiosomes.png) Original Publication of Angiosomes ## Technique Tip **How to Dissect a Perforator* 🚑 ****Technique Tip of the Week** This week's technique tip highlights the step-by-step dissection of a perforator, demonstrating careful elevation from surrounding tissues while preserving its course and calibre. 🔍 ****What to Note:** \- Begin by gently identifying the perforator as it emerges from deep fascia. \- Carefully skeletonise along its length, avoiding trauma or undue traction. \- Secure control before flap elevation to prevent avulsion. These images illustrate the anatomy, tissue planes, and technique involved, ideal for flap planning or perforator-based reconstructions. ![How to Dissect Perforator - Source](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/10/Screenshot-2025-10-04-at-16.04.49.png) How to Dissect Perforator - [Source](https://www.plasticsurgery.theclinics.com/article/S0094-1298%2810%2900056-8/abstract?ref=theplasticsfella.com) ## Foundations Textbook **Feedback Form* 📘 It's been around six weeks since we shipped the Foundations textbook, and we’d love to hear your thoughts! Your feedback helps us improve future editions, and we’ll also be reaching out personally to a few readers for deeper insight. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Original Publication: The Angiosome Concept** ([Taylor](https://pubmed.ncbi.nlm.nih.gov/12916590/?ref=theplasticsfella.com), 2003) Angiosomes are three-dimensional tissue territories supplied by a single source artery and its perforators, forming the anatomical basis for designing reliable perforator flaps and predicting their vascular territories. ✅ ****Technical Tips for Perforator Flap Dissection** ([Dancey](https://pubmed.ncbi.nlm.nih.gov/20816515/?ref=theplasticsfella.com), 2010) Mastery of regional anatomy and meticulous dissection technique allows safe elevation of virtually any perforator flap, minimizing donor site morbidity and avoiding common intraoperative pitfalls. ✅ ****What Does a Perforator Really Perforate?** ([Yamamoto](https://pubmed.ncbi.nlm.nih.gov/33330765/?ref=theplasticsfella.com), 2019) Redefining the term “perforator” as a vessel that pierces the envelope of a target tissue (e.g., superficial fascia for skin, periosteum for bone) allows more precise flap classification and reflects modern supermicrosurgical approaches. ## Feedback ### I hope you enjoyed it 😄 --- ### Scrub Caps, Best Zone 1 FDP Techniques, & Fresh Quiz Round URL: https://www.theplasticsfella.com/september-28th/ Last updated: 2025-09-27T20:58:21.000Z #### In this week's edition 1. ****✍️** [****Letter from** ****P'Fella**](https://www.theplasticsfella.com/september-28th/#a-letter-from-pfella) The scrub cap saga. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-28th/#the-sunday-quiz) A fresh round starts today! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/september-28th/#image-of-the-week) FDP avulsion injury classification. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/september-28th/#technique-tip) How to fix a zone 1 FDP. 5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/september-28th/#what-does-the-evidence-say) What is the best way to repair a zone 1 FDP? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/september-28th/#articles-of-the-week) Overview of techniques, anatomical repair, & button vs anchor: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/september-28th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Scrub Cap Saga: Sterility or Symbolism?* 👋 Every so often, scrub caps resurface on Twitter. Bouffant vs. skullcap. Cloth vs. disposable. Studies get posted, jokes are made, and the conclusion is always the same: there’s no difference in infection rates. The point isn’t whether scrub caps have a role — they do. The point is how quickly a simple, practical measure turns into dogma. Instead of “keep hair out of the sterile field,” it becomes a war of fabrics and policies, written and enforced as if one type of cap is the savior of patient safety. ### A Familiar Pattern We’ve seen this before. Disposable jackets? Millions spent, zero effect. The real issues, like hand hygiene, teamwork, and trainee exposure, remain untouched, while caps and coats get policed like the frontlines of infection control. It’s a comfortable kind of distraction. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/Screenshot-2025-09-27-at-18.46.14-1.png) ### The Metaphor We Wear Scrub caps remind us that surgery often runs on inherited rules. Policies get handed down, enforced, and rarely questioned. A small practical truth (“hair sheds”) becomes inflated into ritual, tradition, and paperwork. It’s not about the hat. It’s about how we make decisions. With love, P’Fella ❤️ ## The Sunday Quiz **A Fresh Round Starts Today!* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the first round of seven rounds! The ****top** scorer wins one our **Foundations* textbook at a discount! ## Image of the Week **FDP Injury Classification* 🖼️ ****Image of the Week** This week's image outlines the Leddy and Packer classification of ****flexor digitorum profundus (FDP) avulsion injuries**, originally divided into three types. These injury types describe the ****level of tendon retraction**, ****presence of bony fragments**, and ****status of the vincula**, which are key for planning surgical repair. ****I:** Tendinous avulsion, vinculum disrupted, retraction into the palm. ****II:** Tendinous avulsion, intact vinculum, retraction to PIPJ. ****III:** Bony avulsion, retraction to A4 pulley. Later additions include, ****IV:** Combined bony and tendinous avulsion with distal phalanx fracture at A4 pulley. ****V:** Intra-articular bony avulsion with extra-articular fracture. [****Type VI**](https://pmc.ncbi.nlm.nih.gov/articles/PMC11127527/?ref=theplasticsfella.com)****:** FDP avulsion with concurrent FDS rupture, likely from FDP entrapment at Camper’s chiasm, causing secondary FDS avulsion. ![FDP Avulsion Injury Classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/1-s2.0-S1748681513002295-gr1.jpg) FDP Avulsion Injury Classification ## Technique Tip **How to Fix a Zone 1 FDP* 🚑 ****Technique Tip of the Week** A lateral oblique transosseous technique using Kirschner wires offers an anatomical and reliable method for zone I FDP tendon reinsertion. In a study of 18 patients, this approach showed 14 good-to-excellent outcomes, with no reported ruptures and minimal morbidity, making it a simple, low-profile alternative to suture anchors or pull-out buttons. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/Screenshot-2025-09-27-at-18.53.32.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/Screenshot-2025-09-27-at-18.53.48.png) How to Fix a Zone 1 FDP - [Source](https://pubmed.ncbi.nlm.nih.gov/19182621/?ref=theplasticsfella.com) ## What Does the Evidence Say? **The Best Way to Repair a Zone 1 FDP* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Zone 1 flexor digitorum profundus (FDP) repair techniques have evolved to address the challenges of achieving ****strong tendon-bone attachment** while minimizing complications. Chu et al. (2013) demonstrated that an all-inside suture technique, where the FDP tendon is attached to bone with two 3-0 Ethibond sutures tied over the dorsal distal phalanx, showed no significant biomechanical differences compared to traditional pull-out suture and suture anchor repairs in terms of ****tensile stiffness**, ****ultimate load**, and ****work to failure**. This technique avoids external buttons and anchor costs. Cogswell (2014) described a simplified adaptation where sutures are passed through the FDP tendon and tied over the ****distal phalanx tip**, supplemented with volar epitendinous repair. The ****Mantero technique**, as reported by Guinard et al. (1999), achieved 23 excellent to good results in 24 cases with active mobilization protocols. For complex cases involving ****bony avulsion fractures**, Nho et al. (2018) introduced a combined approach using both suture anchors and miniscrews to enhance repair strength. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Which Zone 1 Repair Technique Works Best?** ([Boyce](https://pubmed.ncbi.nlm.nih.gov/23672773/?ref=theplasticsfella.com), 2013) No single repair method for Zone 1 FDP avulsions (button pullout, internal sutures, or bone anchors) shows clear superiority, with outcomes and complication rates remaining similar across techniques. ✅ ****How Effective Is Anatomical Zone 1 FDP Repair?** ([Teo](https://pubmed.ncbi.nlm.nih.gov/19182621/?ref=theplasticsfella.com), 2009) Transosseous modified Kessler repairs for Zone 1 FDP injuries achieved excellent/good outcomes in 78% of patients with zero tendon ruptures over 8 months, demonstrating strong functional results and low morbidity. ✅ ****Button vs. Anchor in Zone 1 FDP Repair** ([Payne](https://pubmed.ncbi.nlm.nih.gov/35135429/?ref=theplasticsfella.com), 2022) Bone anchor repair achieved good function in 95% of patients versus 41% with button-over-nail, with roughly half the complication rate, showing superior motion, safety, and early outcomes at 12 weeks. ## Feedback ### I hope you enjoyed it 😄 --- ### Who Deserves Cadavers?, 4 SCIP Flap Tricks, & Quiz Winner! URL: https://www.theplasticsfella.com/september-21st/ Last updated: 2025-09-19T12:30:00.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/september-21st/#a-letter-from-pfella) Who has cadavers? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-21st/#the-sunday-quiz) \*Drumroll🥁\* We've got a new winner! 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/september-21st/#technique-tip) Marking and dissecting the SCIP flap. 4. ****🆕** [****New Feature**](https://www.theplasticsfella.com/september-21st/#new-feature) Build the team with us! 5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/september-21st/#what-does-the-evidence-say) SCIP vs. the "workhorse flaps". 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/september-21st/#articles-of-the-week) Original SCIP flap study, modified SCIP flap, & SCIP tricks: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/september-21st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Should Plastic Surgery Get Serious About Cadavers?* 👋 I just spent three days in Spain with J.P. Hong and some of the best in the game, and it reminded me of something we don’t talk about enough: nothing replaces cadaver work. You can read, watch, or simulate all you like, but until you’ve held a scalpel and worked through real tissue, it’s theory, not surgery. And yet, most of us don’t get access. Not because cadavers don’t exist, but because of patchwork ethics, laws, and logistics. Some countries ban them outright, others make them so tied up in red tape they may as well not exist. The result? We’re raising surgeons with immaculate exam scores but shaky hands. So maybe the real question isn’t *where’s the best cadaver course;* it’s bigger than that. Should we, as a specialty, be pushing harder to make cadaver training a global standard? Should every trainee, no matter where they live, have the chance to learn this way? Because right now, cadaver training is a privilege, not a baseline. And if we don’t change that, we risk producing a generation of plastic surgeons who can consult beautifully but can’t operate with confidence. 👉 So what do you think: do we double down and make cadaver access a priority for plastic surgery training worldwide? And if so, who’s willing to lead the charge? With love, P’Fella ❤️ ## The Sunday Quiz **\*Drumroll🥁\* We've Got a New Winner!* ****Congratulations to the Winner** of The Weekly Quiz! We're thrilled to announce the winner of this edition's quiz. After seven rounds of questions on plastic surgery, our top scorer is ****AL**! A huge thank you to everyone who joined us throughout the series. If you missed it, don't worry. New quizzes and challenges are already in the works! ![Sunday Quiz Leaderboard](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/Leaderboard-Team-Post-Template--7-.png) Sunday Quiz Leaderboard ## Technique Tip **Marking and Dissecting the SCIP Flap* 🚑 ****Technique Tip of the Week** This week’s technique tip features a visual walkthrough by JP Hong on marking and dissecting the SCIP flap. In this short video, you'll see: \- Preoperative surface marking \- Use of Doppler for perforator localisation \- Tips on safe dissection and preserving perforators Watch the video below 🎥 ## New Feature **Build the Team With Us* We’re building a team of experts and we want your input. Know someone brilliant in their field? Fill out the short form below to recommend them. We’ll reach out to potential collaborators directly! ## What Does the Evidence Say? **SCIP vs the "Workhorse Flaps"* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The superficial circumflex iliac artery perforator (SCIP) flap has emerged as an increasingly popular alternative to traditional flaps in ****head and neck reconstruction**. Comparative studies demonstrate that SCIP flaps offer several advantages over radial forearm free flaps (RFFF), including shorter operative times, longer vascular pedicles, and reduced thickness, making them particularly suitable for ****facial reconstruction** (Hurrell et al., 2022; Shpitser et al., 2023). The SCIP flap has evolved from the groin flap with improved characteristics and is now considered a "****workhorse**" flap for ****oral cavity** and ****throat reconstruction** (Shpitser et al., 2023). A systematic review of 174 oncologic patients showed excellent outcomes with SCIP flaps, with only two cases of total flap loss and primary donor site closure achieved in all patients (Rosti et al., 2023). Recent clinical experience confirms the reliability of SCIP flaps across various body regions, with a ****4.7% flap loss rate** and high patient satisfaction when given donor site choice (Franchi et al., 2025). ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Original SCIP Flap: Why Use It for Limb Defects?** ([Koshima](https://pubmed.ncbi.nlm.nih.gov/14707641/?ref=theplasticsfella.com), 2004) The superficial circumflex iliac artery perforator (SCIP) flap offers a thin, customizable flap with concealed donor site and minimal morbidity, though its small-caliber perforators demand delicate microsurgical technique. ✅ ****How Thin Can You Make a Perforator Flap?** ([Hong](https://pubmed.ncbi.nlm.nih.gov/24554571/?ref=theplasticsfella.com), 2014) Elevating perforator flaps in the superficial fascial plane yields consistently thin, viable flaps (\~5–8 mm) with good survival and fewer secondary debulking procedures, improving both function and aesthetics. ✅ ****What Makes the SCIP Flap Reliable?** ([Ishibashi](https://pubmed.ncbi.nlm.nih.gov/40612916/?ref=theplasticsfella.com), 2025) With thorough preoperative Doppler mapping, the SCIP flap accommodates major SCIA variations and can incorporate skin, fat, lymphatics, fascia, nerve, and bone, offering a versatile low-morbidity reconstructive option. ## Feedback ### I hope you enjoyed it 😄 --- ### Pulvertaft Debate, 6 Flexor Fixes, & Going Live with PLASTA URL: https://www.theplasticsfella.com/september-14th/ Last updated: 2025-09-13T17:45:14.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/september-14th/#a-letter-from-pfella) 3 Lessons from London 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-14th/#the-sunday-quiz) How well do you know f**lexor tendon injuries?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/september-14th/#image-of-the-week) Cadaveric example of a vascularised tendon graft. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/september-14th/#technique-tip) EIP vascularised tendon graft. 5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/september-14th/#what-does-the-evidence-say) Is Pulvertaft weave the best option? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/september-14th/#articles-of-the-week) Tendon defects, transfers, & hamstring tendons: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/september-14th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **3 Lessons from London* 👋 I was lucky enough to be invited over to London for a hackathon—thanks to ****Fawz** and ****PLASTA** for the warm welcome. The energy was incredible. Ideas everywhere, teams sprinting to build something real, and some genuinely impressive projects (shout out to **Claribone**). But what stuck with me most weren’t the projects—it was the lessons. A hackathon compresses months of work into hours, and you see people’s instincts play out in real time. Here are three things I took away: **1\. Keep it focused:** A lot of teams went broad, trying to solve everything at once. The best ideas were the simplest—tackling one problem, for one clear customer. **2\. Stop overthinking:** Plenty of groups got stuck planning. The winning teams just started building. They tested, failed, fixed, and by the end of the weekend had something real in their hands. **3\. Show, don’t tell:** A working prototype always beats a polished pitch. Even a rough demo carries more weight than slides or words. It made me wonder: what if we applied this to education in plastic surgery? Instead of endless debates about curriculum, imagine focused sprints where we just *build* the tools trainees actually need. Sometimes progress isn’t about having the smartest idea—it’s about starting small, keeping it sharp, and just doing the work. **It got me thinking....** With love, P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Flexor Tendon Injuries?* ### ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the final round of seven rounds! The ****top** scorer wins one of the first print [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) at a discount! ## Image of the Week **Cadaveric Example of a Vascularised Tendon Graft* 🖼️ ****Image of the Week** This week’s image shows a cadaveric demonstration of a vascularised tendon graft, highlighting both ****arterial** and ****venous** ****anastomoses**. These grafts are valuable in complex tendon reconstruction, particularly when both structural and biological support is needed to optimise healing. The image shows the completed vascular connections and the preparation of the tendon within the ****fibrous canal**. Vascularised tendon grafts are increasingly relevant in ****secondary reconstruction** where the tendon bed is scarred or poorly vascularised, such as in chronic injuries or post-infection settings. Keep an eye out for the inset detail showing <1 mm anastomoses; a reminder of the precision and microsurgical finesse required. ![Vascularised Tendon Graft ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/10-1055-s-0044-1792128-i2452856-3.jpg) Vascularised Tendon Graft - [Source](https://pmc.ncbi.nlm.nih.gov/articles/PMC12213023/figure/FI2452856-3/?ref=theplasticsfella.com) ## Technique Tip **EIP Vascularised Tendon Graft* 🚑 ****Technique Tip of the Week** This week’s tip focuses on a fundamental but critical move during dorsal hand approaches: safe and strategic extensor tendon retraction. In both the diagram and intra-op image shown, you’ll notice the use of ****Senn retractors** and ****mosquito clips** to protect and mobilize the extensor tendons. Careful retraction improves access to the underlying structures (e.g., metacarpals, joints, plates) while preserving tendon integrity. ****Tip:** Retract ****longitudinally**, not laterally, while avoiding excessive tension to reduce the risk of tendon fraying or delayed repair issues. This technique is especially relevant when working around dorsal plates, midshaft fractures, or when exposing intrinsic muscles for reconstruction. ![Extensor Retraction in Dorsal Hand Surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/Screenshot-2025-09-13-at-01.02.57.png) Extensor Retraction in Dorsal Hand Surgery ## What Does the Evidence Say? **Is Pulvertaft Weave the Best Option?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The ****Pulvertaft weave** remains a standard technique for ****tendon grafts** and ****transfers** in hand surgery, though several modifications and alternatives have been developed to improve biomechanical performance. Van Royen et al. (2021) demonstrated that a ****modified core sutur**e Pulvertaft weave using ****FiberLoop 4.0** showed significantly superior biomechanical properties compared to the traditional technique, with 5 times greater strength in stiffness, first failure load, and ultimate failure load. Crook et al. (2013) introduced ****a novel loop weave** that demonstrated significantly higher initial failure and ultimate strengths compared to the Pulvertaft weave, with failures occurring through tendon splitting rather than suture failure. Duprat et al. (2017) found no significant difference in failure load between Pulvertaft weave and ****step-cut suture** ****techniques** (116N vs 103N), though step-cut repairs had smaller cross-sectional areas. Bidic et al. (2009) showed that ****lasso repairs** achieved equivalent maximum load to Pulvertaft weaves (155.8N vs 159.7N) while requiring less weave time and tendon length. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Can Flexor Tendon Defects Be Reconstructed in a Single Stage?** ([Cavadas](https://journals.sagepub.com/doi/abs/10.1177/1753193413520277?ref=theplasticsfella.com), 2014) Single-stage vascularized FDS tendon transfers based on the ulnar vessels achieved \~178° total active motion with fewer complications than staged grafting, offering a viable alternative in select cases. ✅ ****When Should You Combine Tendon and Nerve Transfers in the Upper Extremity?** ([Giuffre](https://www.bssh.ac.uk/%5Fuserfiles/pages/files/professionals/Resources/The%5FBest%5Fof%5FTendon%5Fand%5FNerve%5FTransfers%5Fin%5Fthe%5F49.pdf?ref=theplasticsfella.com), 2014) For Sunderland IV-V injuries, tendon and nerve transfers are often used together, nerve transfers being increasingly popular for excellent outcomes, and tendon transfers being a reliable backup if nerve recovery fails. ✅ ****Are Hamstring Tendons Viable Grafts for Flexor Tendon Reconstruction?** ([Lynch](https://www.jhandsurg.org/article/S0363-5023%2822%2900211-8/abstract?ref=theplasticsfella.com), 2023) Cadaveric analysis shows the gracilis tendon matches flexor tendon dimensions for staged reconstruction (except in the little finger), while the semitendinosus is too thick for use in intact pulley systems. ## Feedback ### I hope you enjoyed it 😄 --- ### Sherpa Surgeons, 5 Finger Fracture Rules, & Upcoming Study Club URL: https://www.theplasticsfella.com/september-7th/ Last updated: 2025-09-07T09:48:11.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/september-7th/#a-letter-from-pfella) **Be a Sherpa -* plan the route before incision. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-7th/#the-sunday-quiz) How well do you know **Bennett's fractures?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/september-7th/#image-of-the-week) Plating a finger fracture. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/september-7th/#technique-tip) Lag screw fixation at 90°. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/september-7th/#upcoming-events) Study Club: Join the interest list! 6. 📚 [****Book Review**](https://www.theplasticsfella.com/september-7th/#book-review) A guide to finger plating. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/september-7th/#articles-of-the-week) Conservative management of proximal phalanx fractures, finger fracture evidence, & treatment strategies: With 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/september-7th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Be a Sherpa - Plan the Route Before Incision* 👋 The “watch me, copy me” era is over. Plastic surgery needs mentors who guide up the mountain, not sages on a hill. [Graham et al](https://journals.lww.com/plasreconsurg/fulltext/2025/09000/the%5Fsherpa%5Fmodel%5Fof%5Ftraining%5Fand%5Fthe%5Ffuture%5Fof.1.aspx?ref=theplasticsfella.com) nailed the metaphor: be a Sherpa—set the route, coach on the slope, and bring everyone back safe. The Sherpa model is a great metaphor: agree on the route, climb together, adjust to the weather, and get everyone home safe. The old script rewards compliance over judgment. Trainees swallow tasks without context, mentors gatekeep autonomy by vibe, and everyone pretends progression is linear. It isn’t. Today’s trainees want transparency, tailored growth, and mentors who recognise that technical skill is necessary but not sufficient — communication, leadership, and strategy matter too. ### What “Sherpa” Actually Looks Like 1. **Base camp before the climb.** Shared goals, strengths, limits, and communication preferences — set explicitly. That’s not soft; it’s safety engineering. 2. **Clear, frequent, behavioral feedback.** In theatre: precise coaching on the next move. Outside: short debriefs that target *actions*, not identity 3. **Graded, reversible autonomy.** The rope lengthens or shortens based on performance you can point to, not seniority you can’t defend. 4. **Many guides, one summit.** No single mentor can be your operative coach, research sponsor, and career architect. Build a small board with clear lanes. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/image.png) [**Source*](https://journals.lww.com/plasreconsurg/fulltext/2025/09000/the%5Fsherpa%5Fmodel%5Fof%5Ftraining%5Fand%5Fthe%5Ffuture%5Fof.1.aspx?ref=theplasticsfella.com) **My personal take:** Observe → Coach-through → Do-with-rescue → Do-alone (mentor scrubbed) → Do-alone (mentor unscrubbed/in-room). Pick the rung before incision. Move in **both directions** in real time. Full credit to Graham, Huang & Chung for the Sherpa framing. Will you try it this week? With love, P’Fella ❤️ ps - i'll be in London next Saturday, giving a talk [here](https://www.instagram.com/p/DNaWYZ1IoCw/?utm%5Fsource=ig%5Fweb%5Fcopy%5Flink&igsh=MzRlODBiNWFlZA==) ## The Sunday Quiz **How Well Do You Know Bennett's Fractures?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the sixth round of seven rounds! The ****top** scorer wins one of the first print [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) at a discount! ## Image of the Week **Plating a Finger Fracture* 🖼️ ****Image of the Week** This week’s image captures the internal fixation of a phalangeal fracture using a low-profile plate. The exposure is meticulous, soft tissue handling is deliberate, and drilling is underway with the use of a drill guide to ensure precision. Fracture plating like this is often used when lag screws alone won’t provide sufficient stability, especially in multi-fragmentary or oblique fractures. Image-guided planning, anatomical contouring of the plate, and maintaining extensor mechanism integrity are all essential. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/image-1.png) Plating a Finger Fracture - [Source](https://ortho.luanmd.com/upper-limb/internal-fixation-of-proximal-phalanx-with-synthes-15-mm-compact-hand-plate/?ref=theplasticsfella.com) ## Technique Tip **Lag Screw Fixation at 90°* 🚑 ****Technique Tip of the Week** This week’s technique tip highlights a key principle in fracture fixation: the importance of screw trajectory. Lag screws should ideally be placed ****perpendicular (90°)** to the fracture line to achieve optimal interfragmentary compression. This orientation maximises the compressive force across the fracture and reduces the risk of displacement. The image demonstrates this concept. Note the screw’s trajectory relative to the fracture line, and how proper positioning contributes to construct stability. ![Lag Screw Fixation at 90°](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/41_X010_i150.png) Lag Screw Fixation at 90° - [Source](https://media.aofoundation.org/-/jssmedia/surgery/41/41%5Fx010%5Fi150.png?w=665&ref=theplasticsfella.com) ## Upcoming Events **Study Club: Join the Interest List!* 📅 Our ****Live Study Club** is currently set to launch this October! This is a study session designed to help you sharpen core surgical knowledge in a collaborative, case-based environment. We're planning a monthly virtual session that will be led by our educational fellows. ****What to expect:** Small group format, interactive discussions, and focused takeaways within a virtual session. Spots will be limited, so join our ****interest list** below to stay in the loop! ## Book Review **A Brilliant Finger Plating Guide (Not a Book)* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/09/Screenshot-2025-09-06-at-01.19.05.png) #### ****Phalangeal Product Guide** This week’s pick isn’t a textbook, but it’s just as helpful. The [****Medartis TriLock 1.5 Phalangeal Product Guide**](https://medartis.com/fileadmin/Downloadcenter%5Fglobal/Documents/Product%5FInformation/Aptus%5FHand/01%5Fhand%5Fsystem/EN/HAND-01000001%5Fhand%5Ftrilock%5F1.5%5Fphalanges%5Fproduct%5Finformation.pdf?ref=theplasticsfella.com) offers a concise and comprehensive overview of finger fracture plating. With clear diagrams, implant specs, screw details, and intraoperative visuals, it’s a go-to resource if you’re learning (or teaching) the principles of phalangeal fracture fixation. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****When Can You Skip Surgery for Proximal Phalanx Fractures?** ([Zhang](https://www.jprasopen.com/article/S2352-5878%2824%2900065-2/fulltext?ref=theplasticsfella.com), 2024) Conservative management of isolated extra-articular proximal phalanx fractures (orthosis with MCP flexion 70-90° and early free IPJ motion) yields \~99.5% union and \~249° total active motion, making it a credible surgical alternative. ✅ ****When Can You Skip Surgery for Phalangeal Fractures?** ([Kumar](https://journals.lww.com/plasreconsurg/abstract/2021/05000/an%5Fevidence%5Fbased%5Fguide%5Ffor%5Fmanaging%5Fphalangeal.32.aspx?ref=theplasticsfella.com), 2021) Most phalangeal fractures can be treated with splinting, but unstable or intra-articular patterns often require fixation; evidence-based selection of cases is key to preserving motion and avoiding stiffness. ✅ ****When Should You Operate on Hand Fractures?** ([Meals](https://www.jhandsurg.org/article/S0363-5023%2813%2900243-8/abstract?ref=theplasticsfella.com), 2013) Most hand fractures can be managed non-operatively with early mobilization, but surgery offers clear advantages for unstable patterns and selected cases to prevent stiffness and functional loss. ## Feedback ### I hope you enjoyed it 😄 --- ### 6 Steps to Build Better Books, AI-Generated Medical Illustrations, & Blended Surgical Education URL: https://www.theplasticsfella.com/august-31st/ Last updated: 2025-08-31T08:33:38.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-31st/#a-letter-from-pfella) The Big Mac Burger = Cost of a Textbook 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-31st/#the-sunday-quiz) How well do you know Radial Nerve Palsy**?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-31st/#image-of-the-week) Foundations cover and AI-generated visuals. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-31st/#technique-tip) How to build a textbook in 6 steps. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/august-31st/#upcoming-events) New events by P'Fella: What to look forward to. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-31st/#articles-of-the-week) Online, physical, and blended learning in plastic surgery: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/august-31st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella The Big Mac Burger = Cost of a Textbook 👋 It sounds absurd, but it’s true: the price of a burger can tell you what a surgeon will pay for a textbook. When knowledge travels the same way as sneakers and iPhones—through global shipping lanes and customs checks—economics, not education, set the rules. ### When Knowledge Becomes Cargo Shipping exposed the madness of global inequality. Sending a book to the US costs about **$5**. To Saudi Arabia? **$40**. South Africa? **$60**. At those prices, almost no one would buy. So we set a flat global fee of **$9**. The true average came to $11\. We lost $2 per book, but access became possible everywhere. --- ### The Big Mac Index of Education But fairness isn’t just about postage—it’s about purchasing power. Economists use the [**Big Mac Index**](https://www.economist.com/interactive/big-mac-index?ref=theplasticsfella.com) to compare how much people can afford across countries. Strangely enough, it mapped perfectly onto textbooks. Americans paid more. Southeast Asia paid less. Not because the knowledge was worth less, but because a burger in Bangkok doesn’t cost what it does in Boston. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/image.png) ### Outsmarting Import Taxes The next hurdle? Import fees that often cost more than the book itself. The fix was simple but unglamorous: print locally. By producing books in multiple countries, they were never technically “imports.” Customs couldn’t inflate the cost, and surgeons could get their copy like any other domestic delivery Here’s the uncomfortable truth: the hardest part of global education isn’t writing or teaching—it’s shipping. With love, P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Radial Nerve Palsy?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the fifth round of seven rounds! The ****top** scorer wins one of the first print [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) at a discount! ## Image of the Week **Foundations Cover and Other AI-Generated Visuals* 🖼️ ****Image of the Week** This week’s image is the cover of **Foundations*, our newly released textbook. Beyond its bold visual design, this cover reflects a key principle that runs throughout the book: The integration of modern, inclusive visuals into plastic surgery education. These AI-generated visuals have allowed us to: 👉 ****Represent a broader spectrum of skin tones and anatomy**, going beyond the limitations of traditional surgical photography. 👉 ****Maintain consistency and clarity** in anatomical illustrations, eliminating visual noise and variability often present in clinical photos. 👉 ****Update and adapt visuals quickly**, ensuring our educational content remains current with evolving techniques and guidelines. 👉 ****Avoid patient confidentiality concerns**, making it easier to share educational content safely and widely. Teaching plastic surgery shouldn’t rely solely on limited datasets or generic images. Every diagram in **Foundations* is part of our commitment to accuracy, accessibility, and representation in surgical education. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Screenshot-2025-08-31-at-09.31.44.png) ## Technique Tip **6 Steps to Building a Textbook* 🚑 ****Technique Tip of the Week** This week’s technique tip is a little different. We’re breaking down the process of creating a textbook because just like surgery, it takes planning, precision, and teamwork. ****Here’s how we built** ***Foundations** **in 6 (very simplified) steps.** ****1\. Define the Vision:** What problem are we solving? Who are we teaching? Before a single word was written, we set our learning objectives and tone. ****2\. Build the Team:** Fellows, trainees, advisors, designers, surgeons — each brought a unique lens to the table. Diversity was key. ****3\. Structure the Content:** We broke down topics into digestible, logical formats. Every section had to teach clearly, not just be an info-dump. ****4\. Create Visuals:** AI-generated. Confidentiality-safe. Diverse. We reimagined what educational anatomy could look like. ****5\. Review Ruthlessly:** Internal edits, student reviewers, peer feedback. Every single page went through multiple rounds before approval. ****6\. Print, Package, Publish:** From writing rooms to print runs, it all came together in one hardcover book: **Foundations*. ## Upcoming Events **New Events by P'Fella: What to Look Forward to* 📅 ****Live Sessions & Recordings Coming Soon** We’ve got a busy event schedule coming up, including live teaching, journal reviews, and live podcasts. These sessions are designed to dive deeper into plastic surgery education while building a collaborative community around Foundations and beyond. We're currently planning Study Club, Journal Club, Roundtable Discussions, and Residency Q&A events. Stay tuned for more info! ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Don't Rely on Online Education Alone** ([Zhang](https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-023-04746-8?ref=theplasticsfella.com), 2023) Blended learning outperforms both online-only and traditional offline methods, with students achieving higher exam scores and showing stronger motivation, comprehension, and satisfaction. ✅ ****How to Balance Physical and Digital Study Resources?** ([Shmanee](https://pmc.ncbi.nlm.nih.gov/articles/PMC11016158/?ref=theplasticsfella.com), 2024) Most students prefer using a mix of textbooks, lecture handouts, and online tools, choosing resources based mainly on quality of information and time efficiency rather than format alone. ✅ ****Textbook or Simulation: Which Teaches Better?** ([Kantar](https://pmc.ncbi.nlm.nih.gov/articles/PMC6211963/?ref=theplasticsfella.com), 2018) Digital simulation training led to significantly greater accuracy and learner satisfaction in cleft lip repair markings than traditional textbook study. ## Feedback ### I hope you enjoyed it 😄 --- ### 7 Deadly Sins of Research Grifters, Useful Research Tools & Sunday Quiz. URL: https://www.theplasticsfella.com/august-24th/ Last updated: 2025-08-23T19:45:09.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-24th/#a-letter-from-pfella) 7 Deadly Sins of Research Grifters ( + ultimate sin) 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-24th/#the-sunday-quiz) How well do you know **research design?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-24th/#image-of-the-week) Spot the Difference in these Abstracts. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-24th/#technique-tip) Spotlight tool: Elicit. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/august-24th/#foundations-textbook) General release happening soon! 6. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/august-24th/#the-fellows-corner) Experience as a textbook reviewer: Adebusola Olabiran. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-24th/#articles-of-the-week) Future of research, analysis of RCT quality, & NEJM protocols: With 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/august-24th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella 7 Deadly Sins of Research Grifters ( + ultimate sin) 👋 Let’s be honest — plastic surgery research is crawling with grifters: CV-padding, PubMed gaming, and posters paraded like Nobel prizes. Every week we read a mountain of papers on this platform. And after a while, the patterns start to show. Here’s a list of the ones to watch out for. 1. **Lust – Bragging on Social Media** Every poster, preprint, or case report instantly screenshotted and blasted on Instagram with hashtags like #blessed #teamwork. Forget peer review — the real validation comes from likes and LinkedIn applause. 2. **Gluttony – CV Obesity** Stuffing résumés with 40+ open-access papers and conference abstracts. Nobody reads them, nobody cites them — but in the pass/fail era, the CV arms race is the only game in town. 3. **Greed – Career Development Only** Research as cold, hard currency. Not for patients. Not for progress. Just for fellowship points and consultant interviews. A loyalty card for academia — publish 10, get one free. 4. **Sloth – Ctrl+C Ctrl+V Science** Why design something new when you can recycle the same dataset? Copy-paste introductions, swap the hospital name, slap on a new DOI. Laziness dressed as “productivity,” while clinical skills quietly rot. 5. **Wrath – Reviewer #2** The eternal tormentor. Rejects your paper for “lack of novelty,” then miraculously publishes the same idea six months later. 6. **Envy – Of Prestige, Not Proof** It’s not the good papers that spark envy — it’s the big names. Watching the same “celebrity academics” rack up citations for mediocre work, while solid studies from others sink without trace. 7. **Pride – The Spin Doctors** Six patients? That’s a “landmark.” A dodgy retrospective? “Paradigm shifting.” Old errors from the 1970s? Still gospel in the textbooks. Pride turns weak evidence into holy scripture. --- ****SIN NUMBER 8 - the ultimate sin** ****Selling Research as a Service** The endgame of the shadow economy: research sold as “academies,” “bootcamps,” and “PubMed hacks” to trainees chasing résumé lines. The sellers rarely have high-impact work. Some even sit on editorial boards, reviewing the very papers they’ve already charged trainees for advice on. A conflict of interest disguised as mentorship. ### With love (and Gluttony for good research), P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Research Design?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the fourth round of seven rounds! The ****top** scorer wins one of the first print [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) at a discount! ## Image of the Week **Spot the Difference in These Abstracts* 🖼️ ****Image of the Week** This week’s image features two recently published bibliometric reviews in plastic surgery: one on aesthetic breast surgery and the other on gluteal augmentation. Both appear strikingly similar, with only ten words differentiating their conclusions. Both were authored by overlapping research teams and accepted ****by the same journal just eight days apart. Submitting so close together, it would usually bypass the journal's plagarism detectors.** This highlights a broader issue in academic publishing: where does thoughtful replication end, and copy-paste convenience begin? ![Redundancy in Academic Research](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Gy5C90OXYAA1KJH.jpeg) Spot the Difference. ## Technique Tip **Spotlight Tool: Elicit* 🚑 ****Technique Tip of the Week** This week’s tip is regarding your research workflow. [**Elicit*](https://elicit.com/?ref=theplasticsfella.com) is an AI-powered tool designed to help you find, summarise, and organise academic papers with ease. While it's not a medical-specific platform, it’s been surprisingly helpful for quick literature reviews and hypothesis exploration. Just a heads-up: This is not sponsored; we just think it’s useful. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Screenshot-2025-08-23-at-20.07.41.png) ## Foundations Textbook **General Release Happening Soon!* 📘 ****Foundations Textbook: General Release** We’ve had a lot of questions about the general release of Foundations — thank you for the enthusiasm! 📆 We're currently planning to open public sales on September 1st. 📩 Everything will be announced right here in The Plastics Paper, so you won’t miss a thing. Stay tuned — more updates coming soon. ![Foundations Textbook: General Release](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/-SSS-Posts--30-.png) Foundations Textbook: General Release ## the Fellows' Corner **Experience as a Textbook Reviewer: Adebusola Olabiran* 🎓 ****the Fellows' Corner** Adebusola was one of our very first textbook reviewers and one of the reasons this book exists. From the beginning, we designed Foundations with surgeons like her in mind. All our contributors', including Adebusola's, insights pushed us to go beyond default models and build a truly global resource for the next generation of plastic surgeons. ![Experience as a Textbook Reviewer: Adebusola Olabiran](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/our-Fellows--7-.png) Experience as a Textbook Reviewer: Adebusola Olabiran ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****What Can AI Do with Synthetic Data in Surgery?** ([Ozmen](https://www.jprasurg.com/article/S1748-6815%2824%2900280-8/fulltext?ref=theplasticsfella.com), 2024) Generative adversarial networks (GANs) can create synthetic surgical datasets to train predictive AI models, improving accuracy, personalization, and outcomes research in plastic surgery despite limited real-world data. ✅ ****What Shapes the Quality of RCTs in Plastic Surgery?** ([Wong](https://journals.lww.com/plasreconsurg/abstract/2025/07000/a%5Fcritical%5Fanalysis%5Fof%5Frandomized%5Fcontrolled%5Ftrial.38.aspx?ref=theplasticsfella.com), 2025) Randomized controlled trials in plastic surgery show only moderate methodological rigor, with device and surgical technique studies scoring lower than drug interventions and reporting standards often falling short. ✅ ****How Do Master Protocols Improve Clinical Trials?** ([Woodcock](https://www.nejm.org/doi/full/10.1056/NEJMra1510062?ref=theplasticsfella.com), 2017) Master protocols allow multiple therapies and diseases to be studied under one trial structure, making research faster, more efficient, and better suited for precision medicine. ## Feedback ### I hope you enjoyed it 😄 --- ### We’re Going Live, Otoplasty Classics, & Foundations Out! URL: https://www.theplasticsfella.com/august-17th/ Last updated: 2025-08-22T17:30:15.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-17th/#a-letter-from-pfella) We’re taking the PlasticsFella live. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-17th/#the-sunday-quiz) How well do you know **otoplasty?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-17th/#image-of-the-week) Trapdoor flap for auricular recon. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-17th/#technique-tip) Antia-buch flap: Step-by-step. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/august-17th/#foundations-textbook) Now available on the website! 6. 🎓 [****The Fellows' Corner**](https://www.theplasticsfella.com/august-17th/#the-fellows-corner) Experience as an educational fellow: Benedetta Agnelli. 7. 📖 [****JPRAS Journal Club**](https://www.theplasticsfella.com/august-17th/#jpras-journal-club) Early oral feeding after head & neck free flaps. 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-17th/#articles-of-the-week) Creating a cartilage frame, simplifying ear lobe recon, & antia buch original publication: With 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/august-17th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **We’re Taking The Plastics Fella Live* 👋 Hey Team, After months of experimenting, tweaking, and — let’s be honest — a bit of trial and error — we think we’ve found something special. The Plastics Fella is about to step into a new chapter… and we want you right there with us. We’re going **live**. Not just once in a while — **a few times every month** — with sessions designed to make you sharper, more confident, and better connected to the specialty you love. **What’s in the Works** - **Study Clubs** where we tackle tricky, high-yield topics together. - **Roundtables** with the kind of surgeons you’d want to scrub in with. - **Journal Clubs (without the fluff)** — short, clear, and actually worth your time. We’ve tested different ways to do it, and this feels like the format that will really bring our community closer. **Help Shape This New Chapter** We’ve got the bones of the plan, but the details? That’s where you come in. You’ve never been shy about telling me what works (and what doesn’t), and that honesty is why this platform works at all. Right now, we’re deciding between formats — small-group discussions, case-based deep dives, rapid-fire teaching — and we want your vote. We’re also lining up our first sessions, and we can go in a few directions. We don't want this to be just another webinar; we want to improve on what is already out there. Tell us what would get you to block out time in your calendar — and we’ll build this new face of The Plastics Fella around it. The truth is, The Plastics Fella has always been more than a platform — it’s a group of people who show up for each other, share what they know, and push the specialty forward. These live sessions are our way of making that connection even more real. So let’s do it. Let’s make something we all look forward to — like catching up with friends, except the friends are world-class surgeons and the conversations might just change how you operate. With love, P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Otoplasty?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the third round of seven rounds! The ****top** scorer wins one of the first print [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) at a discount once it's released! ## Image of the Week **Trapdoor Flap for Auricular Recon* 🖼️ ****Image of the Week** This week’s image features a step-by-step demonstration of a posterior auricular (trapdoor) flap. \- The flap is marked on the ****posterior ear surface**, then elevated and rotated 180° anteriorly to reconstruct a ****conchal defect**. \- This versatile flap technique includes an extension into the ****external auditory meatus**, allowing for resurfacing with excellent tissue match. A useful flap for auricular defects involving both skin and conchal cartilage with aesthetic and functional relevance. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Screenshot-2025-08-15-at-09-47-49.png) Trapdoor Flap for Auricular Recon - [Source](https://www.jprasurg.com/article/S0007-1226%2803%2900307-2/pdf?ref=theplasticsfella.com) ## Technique Tip **Antia-Buch Flap: Step-by-Step* 🚑 ****Technique Tip of the Week** This week’s technique tip breaks down the Antia-Buch flap, a reliable option for helical rim reconstruction. In this video, you'll see: \- How to design and elevate the chondrocutaneous advancement flap. \- Key steps in mobilising the helical root for tension-free closure. \- How to optimise cosmetic contour and preserve vascularity. ## Foundations Textbook **Now Available on the Website!* 📘 ****Foundations Textbook: eBook Release** After months of collaboration, editing, and student input, **Foundations*: The Textbook is now officially available as an eBook. Watch the short intro below for a glimpse — built by students, fellows, and surgeons from around the world. The printed version has also started shipping, watch out for any deliveries! 0:00 /0:08 1× ## the Fellows' Corner **Experience as an Educational Fellow: Benedetta Agnelli* 🎓 ****the Fellows' Corner** While working on the Foundations Textbook, Benedetta Agnelli played a key role as one of our Educational Fellows — helping turn complex surgical topics into engaging, structured content. Here’s what she had to say about her time as an educational fellow at the P'fella👇 ![ Benedetta Agnelli - Educational Fellow](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/our-Fellows--6-.png) Benedetta Agnelli - Educational Fellow ## JPRAS Journal Club **Early Oral Feeding After Head & Neck Free Flaps* 👄 A systematic review of 13 studies (1,657 patients) challenges the old "**nil-by-mouth*" dogma after mucosal free flap recon. Patients who started oral feeding within 5 days had: ✅ Lower fistula rates (3.7% vs 11.4%) ✅ Fewer pneumonias (6.3% vs 12.4%) ✅ Shorter hospital stays (9.8 vs 13.1 days) 🚫 No increased flap failure or dehiscence Read the full breakdown below. [Read the Article](https://www.theplasticsfella.com/journal-free-flap-reconstruction/) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****3D Rib Cartilage Frames in Microtia Surgery** ([Nagata](https://journals.lww.com/plasreconsurg/pages/video.aspx?v=535&autoPlay=true&ref=theplasticsfella.com), 2014) Satoru Nagata’s video demonstrates how three-dimensional frameworks sculpted from autologous costal cartilage form the structural basis for auricular reconstruction in microtia. ✅ ****Earlobe Reconstruction Simplified** ([Jain](https://www.jprasurg.com/article/S1748-6815%2814%2900411-2/abstract?ref=theplasticsfella.com), 2014) Recreating the earlobe’s smooth, rounded contour — long considered a challenging aesthetic detail — can be achieved with a simplified surgical technique that restores natural appearance more reliably. ✅ ****A Classic Flap for Ear Margin Repair** ([Antia](https://pubmed.ncbi.nlm.nih.gov/5336914/?ref=theplasticsfella.com), 1967) The Antia-Buch chondrocutaneous advancement flap, first described in 1967, remains a foundational and effective technique for reconstructing marginal ear defects with preserved contour. ## Feedback ### I hope you enjoyed it 😄 --- ### PRS Awards, 5 Step Blepharoplasty, & Foundations Hits Print! URL: https://www.theplasticsfella.com/august-10th/ Last updated: 2025-08-22T17:29:57.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-10th/#a-letter-from-pfella) Who won Best PRS Articles 2025? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-10th/#the-sunday-quiz) How well do you know **blepahroplasty?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-10th/#image-of-the-week) Intra-op lower eyelid bleph. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-10th/#technique-tip) How to mark for upper lid blepharoplasty. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/august-10th/#foundations-textbook) In the printer! 6. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/august-10th/#the-fellows-corner) Meet the team behind foundations. 7. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/august-10th/#jpras-journal-club) Early oral feeding following head and neck mucosal free flap recon. 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-10th/#articles-of-the-week) Blepharoplasty outcomes, why the Asian bleph is different, & 5-step bleph: With 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/august-10th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Who won best PRS awards in 2025?* 👋 Let’s be honest — most journal awards are a bit part merit, part politics, and occasionally a surprise hit. But the ****PRS Best Paper Awards 2025** just dropped, and there’s a lot we can learn from what topped the charts this year. ### What Got the Nod Across [14 categories](https://journals.lww.com/plasreconsurg/pages/collectiondetails.aspx?TopicalCollectionId=586&ref=theplasticsfella.com), the big winners leaned heavily on **systematic reviews, anatomical deep-dives, and patient-safety angles**. A few standouts: - **Best Breast Paper:** Prepectoral vs. Subpectoral Reconstruction for complication prevention. Yet another meta-analysis proving that sometimes, the simplest surgical question still needs answering. - **Best Cosmetic Surgery Paper:** *The Superficial Musculoaponeurotic System: Does It Really Exist?* — [**my personal pick of the year**](https://journals.lww.com/plasreconsurg/fulltext/2024/05000/the%5Fsuperficial%5Fmusculoaponeurotic%5Fsystem%5F%5Fdoes%5Fit.9.aspx?ref=theplasticsfella.com). Mendelson & co. tackle the SMAS controversy head-on, dissecting (literally) decades of dogma. - **Best Experimental Paper:** Vascularized adipose tissue engineering with sustained-release adipokines — the kind of lab magic that sounds like science fiction until it’s in your OR. - **Best Hand/Peripheral Nerve Paper:** Targeted muscle reinnervation reducing symptomatic neuromas — a practical win for amputees and anyone managing nerve pain. - **Best Special Topic:** The global macroeconomic burden of burns — a sobering reminder that reconstructive surgery is as much public health as it is operative craft. ### My Take If you strip the PR gloss, these awards tell us two things: 1. **Evidence still sells** — systematic reviews and meta-analyses dominated. 2. **Anatomy isn’t dead** — when done well, foundational anatomical work can still make waves. It’s refreshing to see a mix of high-tech experimental work and gritty, clinically relevant topics Hit reply — let’s compile our own “real” best paper list for 2025. With love, P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Blepharoplasty?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the second round of seven rounds! The ****top** scorer wins one of the first print [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) at a discount once it's released! ## Image of the Week **Intra-op Lower Eyelid Bleph* 🖼️ ****Image of the Week** This week’s image captures an intraoperative view of a transconjunctival lower eyelid blepharoplasty, highlighting fat pad exposure beneath the orbicularis and lower lid retractor. This is important for recognising key anatomy and the surgical approach from the conjunctival side. ![Intraoperative view of a transconjunctival lower eyelid blepharoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Transconjunctival-Lower-Blepharoplasty-intraop-Dr-Barry-Eppley-Indianapolis.jpg) Intraoperative view of a transconjunctival lower eyelid blepharoplasty ## Technique Tip **How to Mark for Upper Lid Blepharoplasty* 🚑 ****Technique Tip of the Week** This week’s tip features a clear, step-by-step demonstration of how to mark the skin before performing an upper eyelid blepharoplasty, shared by Mr Richard Caesar. Watch the visual guide below👇 ## Foundations Textbook **In the Printer!* 📘 It’s official — Foundations is now with the printer! We expect the earliest deliveries to begin within 10 days, although this may vary slightly depending on your location. Keep an eye on your inbox for any shipping updates! ## the Fellows' Corner **Meet the Team Behind Foundations* 🎓 ****the Fellows' Corner** A huge thank you to the incredible team that brought Foundations to life. This textbook was built by a truly international crew of fellows, advisors, trainees, creatives, and students — each contributing greatly to bring Foundations to your hands. ****Core Team** Ryan Sugrue Tara Wickramasinghe Michael Edgar Waruguru Wanjau Kurt Lee Chircop Benedetta Agnelli Hatan Mortada ****External Authors** Carissa J. Jacobs Robert Browne Justin Wormald Suraya Yusuf Mustafa Qais Al-Khafaji ****Trainee Reviewers and Authors** Conor Cudden (Melbourne, Australia) Ryan Leon (Perth, Australia) Himani Murdeshwar (Nottingham, UK) ****Student Reviewers and Authors** Parul Rai (Chicago, USA) Laryssa Kemp (Ottawa, Canada) Luanne Lai (Nottingham, UK) Adebusola Olabiran (London, UK) ****Creative Visuals** Barbara Borko ## JPRAS Journal Club **Early Oral Feeding Following Head and Neck Mucosal Free Flap Recon* 👄 ****Early Oral Feeding After Head & Neck Free Flaps** This week’s feature looks at a systematic review of 13 studies (1,657 patients) evaluating ****when to resume oral feeding following head and neck mucosal free flap reconstruction**. ****Key Takeaway:** Starting oral intake within 5 days post-op was associated with lower fistula rates (3.7% vs 11.4%), fewer pneumonias, and a shorter hospital stay (9.85 vs 13.11 days) — all without compromising flap safety. The findings question the traditional **nil-by-mouth* approach, supporting the inclusion of early oral intake in ERAS protocols for carefully selected patients. Flap failure rates remained consistent (\~3%) regardless of feeding timing, and no increase in wound complications was observed. While protocol variability limits generalisation, this review offers strong support for a shift toward more proactive recovery planning. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Journal-Club-Images--20-.png) Clinical Flowchart: Early Oral Feeding Decision Pathway [Read the Article](https://www.theplasticsfella.com/journal-free-flap-reconstruction/) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Muscle-Sparing Upper Blepharoplasty May Reduce Dry Eye** ([Todorov](https://academic.oup.com/asj/article-abstract/45/6/554/8098106?redirectedFrom=fulltext&ref=theplasticsfella.com), 2025) Skin-only upper blepharoplasty significantly improves dry eye symptoms, while preserving orbicularis muscle reduces the risk of lagophthalmos without compromising aesthetic outcomes. ✅ ****Does Short-Incision Technique in Asian Blepharoplasty Minimize Downtime?** ([Kruavit](https://academic.oup.com/asj/article-abstract/29/4/272/191552?redirectedFrom=fulltext&ref=theplasticsfella.com), 2009) A short central incision with selective anchoring created stable suprapalpebral folds in over 6200 patients, with minimal swelling and a 3.8% complication rate over 18 years. ✅ ****Five-Step Lower Blepharoplasty for Minimizing Risk** ([Rohrich](https://journals.lww.com/prsgo/fulltext/2020/07000/the%5Ffive%5Fstep%5Flower%5Fblepharoplasty%5Ftechnique.16.aspx?ref=theplasticsfella.com), 2020) A structured five-step lower blepharoplasty approach, including fat repositioning, canthopexy, and orbicularis ligament release, achieves natural rejuvenation while reducing lid malposition risk. ## Feedback ### I hope you enjoyed it 😄 --- ### Best AI Scribe, 3 Flaps That Changed Lower Limb Surgery, & PlasticsPro Upgrade URL: https://www.theplasticsfella.com/august-3rd/ Last updated: 2025-08-22T17:29:40.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-3rd/#a-letter-from-pfella) What’s the best AI scribe? depends who you ask. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-3rd/#the-sunday-quiz) How well do you know *Gustilo-Anderson open fractures?* 3. [📈](https://emojipedia.org/chart-increasing?ref=theplasticsfella.com) [****New Feature**](https://www.theplasticsfella.com/august-3rd/#new-feature) An upgraded PlasticsPro is coming! 4. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/august-3rd/#image-of-the-week) Gastroc flap anatomy & planning. 5. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/august-3rd/#technique-tip) Marking the ALT flap. 6. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/august-3rd/#foundations-textbook) First samples checking! 7. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/august-3rd/#jpras-journal-club) Oral feeding following fead and neck mucosal free flap recon. 8. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/august-3rd/#upcoming-events) Recap: You Are On Call Now! 9. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-3rd/#what-does-the-evidence-say) Flap selection. 10. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/august-3rd/#articles-of-the-week) Original Ponten & Gustilo-Anderson publications + propeller & keystone flaps: With 1-sentence summaries. 11. 💕 [****Feedback**](https://www.theplasticsfella.com/august-3rd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **What’s the Best AI Scribe? Depends Who You Ask* 👋 AI scribes are having a moment. Abridge just raised $300 million. Nabla got $70 million. Everyone’s promising to “free you from documentation.” But here’s the thing; most of us are still typing our own notes or fixing EMR messes from home. **What Even *Is* an AI Scribe?** It’s a tool that listens to your consults and writes your notes. No typing. No templates. Just record, review, sign. Sounds ideal. But the reality? Most don’t work well outside big U.S. health systems. And even when they do, they often still need heavy editing or don't integrate into your actual workflow. **The Big Names** - **DAX Copilot:** Microsoft-backed, widely adopted, but clunky. - **Abridge:** Smart, sleek, and climbing fast. - **Nabla/DeepScribe/Suki:** Still finding their lane. But let’s be real — plastic surgeons don’t need 1,000-word primary care notes. We need diagrams, short and sharp summaries, MDT actions, and pre-op plans. That’s not what these tools were built for. Yet. **So, What Actually Works?** It depends on where you work and what you do. In the U.S., DAX might be the default. Elsewhere? Most of us are still waiting for a tool that actually helps — not just hypes. Let’s figure out what’s real and what’s just raising money. With love, P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Gustilo Anderson Open Fractures?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the first round of seven rounds! The ****top** scorer wins one of the first 150 copies of [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) at a discount once it's released! ## New Feature for PlasticsPro **An Upgraded PlasticsPro Is Coming* 📈 A new and improved version of PlasticsPro is on the way — launching this September! It’s designed to be even more useful: whether you're reviewing core content, clarifying niche exam questions, or looking up on-call guidance. This update will help you move faster, think sharper, and feel more confident wherever you are in your training. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Screenshot-2025-08-02-at-13.47.16.png) ## Image of the Week **Gastroc Flap Anatomy & Planning* 🖼️ ****Image of the Week** This week’s images highlight the medial gastrocnemius flap — a workhorse option in lower limb reconstruction. The series below demonstrates: \- Vascular anatomy of the gastrocnemius (Type I muscle flap). \- Axial cross-section, marking key muscular compartments for orientation. \- Clinical planning: flap outline, midline, and pivot point shown on the limb to guide surgical marking. These visuals are ideal for understanding safe dissection zones and orientation for flap design. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/figure-1.jpg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/figure-2.jpg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/figure-3.jpg) Gastroc Flap ## Technique Tip **Marking the ALT Flap* 🚑 ****Technique Tip of the Week** This week’s tip covers how to mark the Anterolateral Thigh (ALT) flap, using key landmarks and planning perforators. Visual breakdown below👇 ## Foundations Textbook **First Samples Checking!* 📘 We’ve officially received the first physical samples of the Foundations textbook and they’re currently under review. The final touches are being made, and we’re on track for a general sales release this September — it's almost here! 0:00 /0:03 1× Foundations Sample Checking ## JPRAS Journal Club **Oral Feeding Following Head and Neck Mucosal Free Flap Recon* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Journal-Club-Images--20-.png) Clinical Flowchart: Early Oral Feeding Decision Pathway 👄 ****Early Oral Feeding After Head & Neck Free Flaps: A Safer Strategy?** This journal club highlights a systematic review (13 studies, 1,657 patients) exploring when to start oral feeding after mucosal free flap reconstruction. The findings challenge the traditional “nil-by-mouth” dogma: patients fed within 5 days had ****fewer fistulas**, ****lower pneumonia rates**, and ****shorter hospital stays** — all without compromising flap safety. [Read the Article](https://bit.ly/4m7J9Zr?ref=theplasticsfella.com) ## Upcoming Events **Recap: You Are On Call Now!* 🧑‍🏫 ****Recap of You Are On Call Now** Our first-ever global webinar, "You Are On Call Now", brought together plastic surgeons and future plastic surgeons from all around the world and every level of training. We covered everything from acute hand injuries and aesthetic complications to research tips and sub-I survival guides. If you missed it, keep an eye out for our future events! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Blue---Pink-Bold-Retro-Pop-Sale-Promotion-Event-Instagram-Square-Post--2-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Blue---Pink-Bold-Retro-Pop-Sale-Promotion-Event-Instagram-Square-Post--3-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/08/Blue---Pink-Bold-Retro-Pop-Sale-Promotion-Event-Instagram-Square-Post--4-.png) Recap: You Are On Call Now ## What Does the Evidence Say? **Flap Selection* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Original Ponten Publication: Reliable Lower Leg Coverage Without Muscle** ([Ponten](https://www.jprasurg.com/article/S0007-1226%2881%2980097-5/pdf?ref=theplasticsfella.com), 1981) Fasciocutaneous flaps offer a simple, well-vascularised coverage for soft tissue defects of the lower leg, with most cases healing fully and avoiding the complexity of muscle or free flap transfer. ✅ ****Propeller and Keystone Flaps in Lower Limb Reconstruction** ([AlMugaren](https://journals.lww.com/prsgo/fulltext/2020/04000/best%5Flocal%5Fflaps%5Ffor%5Flower%5Fextremity.39.aspx?ref=theplasticsfella.com), 2020) Modern local perforator flaps like propeller and keystone designs offer reliable, single-stage coverage with minimal donor-site morbidity, making them preferred options over traditional muscle flaps for many lower limb defects. ✅ ****Gustilo-Anderson’s Original Study: How to Prevent Infection in Open Fractures** ([Gustilo & Anderson](https://pubmed.ncbi.nlm.nih.gov/773941/?ref=theplasticsfella.com), 1976) By implementing early debridement, tailored antibiotic use, and wound-specific closure protocols, Gustilo and Anderson reduced infection rates in Type III open fractures from 44% to just 9%. ## Feedback ### I hope you enjoyed it 😄 --- ### Don’t Always Trust That Summary, 3 Lessons from Breast Reconstruction, & Recap of Live Event URL: https://www.theplasticsfella.com/july-27th/ Last updated: 2025-07-27T06:28:27.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-27th/#a-letter-from-pfella) AI Summaries Are Polluting Plastic Surgery. We're Inhaling Smog 2. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-27th/#image-of-the-week) Types of breast reduction. 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/july-27th/#technique-tip) How to mark the breast. 4. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/july-27th/#jpras-journal-club) Timing of oral feeding following head and neck mucosal free flap reconstruction. 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-27th/#articles-of-the-week) Breast recon systematic review, technique overview, & long-term outcomes: With 1-sentence summaries. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/july-27th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella AI Summaries Are Polluting Plastic Surgery. We're All Inhaling the Smog 👋 Hallucinations aren’t even the biggest problem anymore. Sure, they still happen — but the real danger? ****AI is confidently stitching together legit content with low-grade junk, and surgeons can’t tell the difference.** ### Google’s Playing Surgeon — and You’re the Patient Ron Barbosa ([Twitter](https://x.com/rbarbosa91/status/1944527492024619438?ref=theplasticsfella.com) fame) spotted it first: Google AI summaries are mixing obscure open-access nonsense with a veneer of credibility. They look polished. They read clean. And they’re total trash underneath. But let’s be honest — **they’re not for the layperson anymore.** These summaries are showing up in doctor-facing queries. Clinical ones. Academic ones. And if you don’t already know the answer, you won’t spot the rot. Look at this example below. The sources are on the right. The first reference is a software for practice management 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Screenshot-2025-07-27-at-06.44.46.png) ### And Guess What? We’re Doing It Too This isn’t just a Google issue. Even ChatGPT — the same one we’re training on P’Fella — is pulling in content from Medscape-tier sources, ghost-written reviews, and outdated guidelines. Unless you're an expert *and* a detective, **you’re just as likely to absorb fluff as you are facts.** It’s not that the AI is wrong all the time. It’s worse: it’s *kinda right*. And that’s enough to fool even good surgeons on busy days. ### The Result? A New Kind of Misinformation - **It sounds smarter than it is.** These models can mimic the tone of academic confidence while citing glorified blog posts. - **It looks like evidence but isn’t.** You get summaries with links to “studies” no human would ever quote in real life. **It buries expertise under aesthetics.** Flashy formatting, clean phrasing, and a total lack of critical context. And unless we start curating aggressively — building datasets *we* trust, with sources *we* choose — then AI becomes the new gatekeeper of surgical knowledge. With love (and an actual source list), P’Fella ❤️ ## Image of the Week **Types of Reduction* 🖼️ ****Image of the Week** This week’s image highlights the main ****incision patterns** used in breast reduction and mastopexy. Each type is matched to breast size and degree of ptosis, helping guide technique selection for optimal reshaping and scar placement. ![Key incision patterns used in breast reduction and mastopexy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/image-3.png) Key incision patterns used in breast reduction and mastopexy ## Technique Tip **How to Mark the Breast* 🚑 ****Technique Tip of the Week** This week’s tip walks you through the basics of ****preoperative breast markings**, which are essential for accurate planning in reduction or mastopexy. From sternal notch to IMF, it’s all about symmetry, landmarks, and patient positioning. Watch the demonstration by Madeline Lejour below ▶️ 0:00 /4:22 1× ## JPRAS Journal Club **Timing of Oral Feeding Following Head and Neck Mucosal Free Flap Reconstruction* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/3-1.jpg) #### A systematic review (13 studies, 1657 patients) examined the timing of oral feeding after head and neck mucosal free flap reconstruction. Early feeding (≤5 days) reduced fistulas, pneumonia, and hospital stay without increasing flap failure or dehiscence. Study heterogeneity and selection bias limit generalizability. [****5-Point Summary**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#5-point-summary) A systematic review (13 studies) assessed early (≤5 days) vs late oral feeding post-free flap. Early feeding lowered fistula and pneumonia risk and shortened LOS. Flap complications were unchanged. Study quality and consistency were variable. [****4-Key Findings**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#4-key-findings) Fistulas: 3.7% (early) vs 11.4% (late). Pneumonia: 6.3% (early) vs 12.4% (late). LOS: 9.85 vs 13.11 days. Flap failure: \~3% in both groups. [****3-Critiques**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#3-critiques) Most studies were retrospective. Feeding timing and complication definitions varied. Radiotherapy impact and flap/site factors were inconsistently reported. [****2-Practical Takeaways**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#2-practical-takeaways) Early feeding is safe in selected patients and may reduce complications. Consider integrating early oral intake into ERAS protocols for head and neck recon. [****1-Recommended Reading**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#1-recommended-reading) Kerawala et al. (2021) found early oral intake reduced pneumonia and shortened hospital stay after mucosal free flap surgery without raising fistula risk. [Read the Article](www.theplasticsfella.com/jourrnal-free-flap-reconstruction/) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Measuring Outcomes in Breast Reduction Surgery** ([Waltho](https://academic.oup.com/asj/article-abstract/40/4/383/5611313?redirectedFrom=fulltext&ref=theplasticsfella.com), 2020) Despite over 100 studies on breast reduction, outcome reporting remains inconsistent with complications reported in 82% but quality-of-life outcomes in only 38%, highlighting the need for standardized measures. ✅ ****Core Principles in Breast Reduction Surgery** ([Hall-Findlay](https://journals.lww.com/plasreconsurg/abstract/2015/10000/breast%5Freduction.43.aspx?ref=theplasticsfella.com), 2015) Breast reduction surgery hinges on mastering pedicle design, anatomical landmarks, and skin tailoring, regardless of technique to achieve consistently functional and aesthetic outcomes. ✅ ****Maintaining Satisfaction Years After Breast Reduction** ([Crittenden](https://www.jprasurg.com/article/S1748-6815%2823%2900057-8/abstract?ref=theplasticsfella.com), 2023) Long-term follow-up shows sustained improvements in quality of life and high patient satisfaction up to 12 years after breast reduction surgery. ## Feedback ### I hope you enjoyed it 😄 --- ### Timing of Oral Feeding Following Head and Neck Mucosal Free Flap Reconstruction: Systematic Review & Meta-Analysis URL: https://www.theplasticsfella.com/journal-free-flap-reconstruction/ Last updated: 2025-08-01T22:26:27.000Z #### In this Journal Club A systematic review (13 studies, 1657 patients) examined the timing of oral feeding after head and neck mucosal free flap reconstruction. Early feeding (≤5 days) reduced fistulas, pneumonia, and hospital stay without increasing flap failure or dehiscence. Study heterogeneity and selection bias limit generalizability. [****5-Point Summary**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#5-point-summary) A systematic review (13 studies) assessed early (≤5 days) vs late oral feeding post-free flap. Early feeding lowered fistula and pneumonia risk and shortened LOS. Flap complications were unchanged. Study quality and consistency were variable. [****4-Key Findings**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#4-key-findings) Fistulas: 3.7% (early) vs 11.4% (late). Pneumonia: 6.3% (early) vs 12.4% (late). LOS: 9.85 vs 13.11 days. Flap failure: \~3% in both groups. [****3-Critiques**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#3-critiques) Most studies were retrospective. Feeding timing and complication definitions varied. Radiotherapy impact and flap/site factors were inconsistently reported. [****2-Practical Takeaways**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#2-practical-takeaways) Early feeding is safe in selected patients and may reduce complications. Consider integrating early oral intake into ERAS protocols for head and neck recon. [****1-Recommended Reading**](https://www.theplasticsfella.com/jourrnal-free-flap-reconstruction/#1-recommended-reading) Kerawala et al. (2021) found early oral intake reduced pneumonia and shortened hospital stay after mucosal free flap surgery without raising fistula risk. [Read Full Article ](http://bit.ly/4m7J9Zr?ref=theplasticsfella.com) ✍️ ****Note from the Editor** --- ## 5 Point Summary This systematic review and meta-analysis synthesises 13 studies (1,657 patients) on timing of oral feeding following head and neck mucosal free flap reconstruction, assessing how early oral intake influences complications, recovery, and hospital stay. 1️⃣ ****Hypothesis** Early (≤5 days) oral feeding after mucosal free flap reconstruction reduces postoperative complications and hospital length of stay without increasing flap-related risks. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/2.jpg) Feeding protocol definitions across included studies 2️⃣ ****Method** Systematic review and meta-analysis of 13 studies (1,657 patients) comparing early vs late oral feeding. Outcomes included fistula formation, flap failure, pneumonia, dehiscence, haematoma, and length of stay. 3️⃣ ****Results** Early feeding reduced: Fistulas (3.7% vs 11.4%), Pneumonia (6.3% vs 12.4%), LOS (9.85 vs 13.11 days). Flap failure and dehiscence were equivalent. Data on radiotherapy impact was inconclusive. 4️⃣ ****Conclusion** Early oral feeding is safe and may enhance recovery. It does not increase wound or flap complications, challenging the traditional “nil-by-mouth” approach post-reconstruction. 5️⃣ ****Implication** Evidence supports early feeding in carefully selected patients. A standardised, risk-stratified feeding protocol could improve outcomes and reduce hospital burden. --- ## 4 Key Findings This meta-analysis highlights the impact of oral feeding timing on complications, infection risk, and recovery following head and neck mucosal free flap reconstruction. 1️⃣ ****Fistula Formation** Early feeding significantly reduced fistula rates (3.7%) compared to late feeding (11.4%). This suggests early oral intake may promote mucosal healing and reduce surgical site breakdown. 2️⃣ ****Pneumonia Reduction** Pneumonia occurred in 6.3% of early-fed patients vs 12.4% in late-fed. Reduced NG tube use and earlier swallowing likely improved airway protection and reduced aspiration risk. 3️⃣ ****Flap Safety Maintained** Flap failure and dehiscence rates were similar across both groups (\~3%). Early oral intake did not compromise flap integrity or vascularity, supporting its safety in appropriate patients. 4️⃣ ****Shorter Hospital Stay** Early feeding was associated with a mean LOS reduction of over 3 days (9.85 vs 13.11). This has major implications for recovery, resource use, and ERAS pathway integration. ![Key clinical outcomes of early and late oral feeding](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/3.jpg) Key clinical outcomes of early and late oral feeding --- ## 3 Critiques Although impactful, this review is limited by variability in study quality, feeding protocols, and complication definitions across included studies. 1️⃣ ****Study Quality** The majority of studies were retrospective cohort designs with moderate-to-high risk of bias. Only one RCT was included, limiting the strength of pooled evidence. 2️⃣ ****Outcome Inconsistency** Complication definitions (e.g., fistula, pneumonia) and feeding timelines varied. Radiotherapy exposure and anatomical subsite were inconsistently reported, affecting comparability. 3️⃣ ****Protocol Heterogeneity** Feeding protocols (liquid vs soft diet), swallow assessments, and allied health involvement were inconsistently described, making it difficult to evaluate the true influence of early feeding. --- ## 2 Practical Takeaways This review supports a more proactive approach to post-op care, with early feeding emerging as a safe option in selected head and neck free flap patients. 1️⃣ ****Patient Selection Is Key** Early oral feeding appears safe, but only in well-selected cases with tension-free, well-vascularised mucosal flaps. Caution is still warranted for high-risk reconstructions or irradiated tissue. 2️⃣ ****Pathway Optimisation** Integrating early oral intake into ERAS pathways may reduce complications and hospital stay. Protocols should include swallow assessments, early NG tube removal, and multidisciplinary support. ![Flowchart indicating early oral feeding decision pathway](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/4.jpg) Flowchart indicating early oral feeding decision pathway --- ## 1 Recommended Reading **Kerawala et al. (2021)* examined early oral feeding following head and neck free flap reconstruction in a prospective UK cohort. Early intake was associated with reduced pneumonia and significantly shorter hospital stay, without increasing fistula risk, making it a key reference supporting ERAS-aligned feeding protocols in reconstructive head and neck surgery. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/33242736/?ref=theplasticsfella.com) ### Breast Reduction and Mastopexy: Anatomy, Techniques, & Complications URL: https://www.theplasticsfella.com/breast-reduction-and-mastopexy/ Last updated: 2025-07-18T19:47:35.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/breast-reduction-and-mastopexy/#overview-of-breast-reduction-and-mastopexy) Mastopexy and breast reduction are breast reshaping procedures involving skin excision, NAC repositioning, and pedicle selection, tailored to the degree of ptosis, volume, and patient goals. [****Surgical Anatomy**](https://www.theplasticsfella.com/breast-reduction-and-mastopexy/#surgical-anatomy-for-breast-reduction-and-mastopexy) Pedicle choice is guided by the vascular anatomy — mainly internal mammary, lateral thoracic, and intercostal perforators — with options including superior, inferior, superomedial, and bipedicle designs. [****Surgical Techniques**](https://www.theplasticsfella.com/breast-reduction-and-mastopexy/#surgical-techniques-for-breast-reduction-and-mastopexy) Surgical techniques for mastopexy and reduction include periareolar, vertical, Wise, J-, and L-shaped incisions. These are selected based on the degree of ptosis, breast volume, and skin quality. [****Complications**](https://www.theplasticsfella.com/breast-reduction-and-mastopexy/#complications-of-breast-reduction-and-mastopexy) Complications of mastopexy and reduction mammoplasty include hematoma, wound dehiscence, NAC necrosis, scarring, sensory loss, asymmetry, bottoming out, and recurrent ptosis. ****Primary Contributor:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Breast Reduction and Mastopexy ****Key Point** Mastopexy and breast reduction are breast reshaping procedures involving skin excision, NAC repositioning, and pedicle selection, tailored to the degree of ptosis, volume, and patient goals. Mastopexy and reduction mammoplasty are breast reshaping procedures that share core principles: skin excision and nipple-areola complex (NAC) elevation, but differ in their indications. While mastopexy restores shape and projection without reducing volume, reduction mammoplasty also aims to alleviate symptoms by reducing breast size. ### Core Concepts **Mastopexy** reshapes and elevates the breast by, - Excising redundant skin - Repositioning the NAC - Tightening the skin envelope *(No significant volume change)* **Reduction Mammoplasty** involves, - All the above steps, plus - Glandular and adipose tissue resection *(To reduce breast weight and relieve symptoms)* **Shared Technical Elements** - Skin excision - NAC elevation - Preservation of neurovascular supply - Technique selection based on, - Ptosis grade - Breast volume - Patient aesthetic/functional goals - Surgeon's experience and preference 😎 ****Fun Fact:** The first documented breast reduction dates back to the 6th century AD by Paulus Aegineta—he described breast tissue excision to relieve symptoms of macromastia. Meanwhile, mastopexy only emerged as a standalone aesthetic procedure in the 20th century with the rise of cosmetic surgery! --- ## Surgical Anatomy for Breast Reduction and Mastopexy ****Key Point** Pedicle choice is guided by the vascular anatomy — mainly internal mammary, lateral thoracic, and intercostal perforators — with options including superior, inferior, superomedial, and bipedicle designs. A sound understanding of breast vascular and neural anatomy is essential for safe pedicle design and effective NAC transposition. All pedicles aim to preserve the viability and sensitivity of the nipple-areola complex during breast reshaping procedures. For a comprehensive overview of breast anatomy, refer to our article on [Breast Anatomy](https://www.theplasticsfella.com/breast-anatomy/). **Vascular Supply** The breast receives a rich vascular network primarily from, - **Internal mammary perforators** (medially, 2nd - 3rd intercostal spaces). - **Lateral thoracic artery** (laterally). - **Intercostal perforators** (inferiorly and posteriorly, 3rd to 6th intercostal spaces). - **Subdermal plexus**. These vessels are critical for maintaining perfusion to the **nipple-areola complex (NAC)** during tissue mobilisation and resection. **Innervation** The NAC is primarily innervated by the lateral cutaneous branch of the 4th intercostal nerve, with contributions from the 3rd and 5th intercostals. Variability exists, but the 4th ICN is the most consistent. **Anatomical Basis of Pedicles** All pedicle-based techniques are designed around preserving a vascularized and innervated segment of parenchyma supporting the NAC. Common pedicle types include, - **Superior** - **Inferior** - **Superomedial** - **Central** - **Medial** - **Lateral** - **Horizontally or vertically bipedicled** Each variant is based on different dominant vascular territories. The main pedicle options used in mastopexy and reduction mammoplasty are illustrated below. ![Key pedicle options used in mastopexy and reduction mammoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-18T020557.958.png) Key pedicle options used in mastopexy and reduction mammoplasty 💡 ****Tip:** No single pedicle is universally superior; instead, choice depends on surgeon familiarity, case-specific anatomy, and overall surgical plan. --- ## Surgical Techniques for Breast Reduction and Mastopexy ****Key Point** Surgical techniques for mastopexy and reduction include periareolar, vertical, Wise, J-, and L-shaped incisions. These are selected based on the degree of ptosis, breast volume, and skin quality, with optional parenchymal resection when volume reduction is indicated. Surgical planning for mastopexy and reduction begins with a detailed anatomical assessment of breast tissue, skin quality, and ptosis severity. The incision pattern and pedicle are tailored to support the NAC while achieving functional and aesthetic goals. #### Preoperative Considerations - **Ptosis Assessment:** [Breast ptosis](https://www.theplasticsfella.com/breast-ptosis/) results from attenuation of the Cooper’s ligaments, dermal laxity, and fascial detachment, often secondary to weight fluctuations, aging, pregnancy, and hormonal shifts. - NAC position relative to the inframammary fold (IMF). - Parenchymal descent and contact with the thoracic wall. - **Tissue Quality** - Assessed via stretch marks, pinch test, and mobility. - Influences scar burden and long-term outcome. - **Volume & Projection Needs** - In adipose-dominant or involuted breasts, implants or deep reshaping may be needed for adequate projection. - **Skin Envelope Evaluation** - Informs incision length and pattern. #### Incision Patterns **Periareolar** ([Benelli](https://pubmed.ncbi.nlm.nih.gov/2185619/?ref=theplasticsfella.com), 1990) - **Indication:** Grade I ptosis, good skin tone. - **Marking** - Inner circle (NAC, \~4.2-4.5 cm). - The outer circle defines lift. - **Technique** - Donut-shaped de-epithelialization. - Purse-string suture closure. - **Pros:** Minimal scar, preserves volume. - **Cons:** Limited lift (≤2-3 cm), risk of areolar widening and flattening. Common skin incision patterns used in mastopexy and reduction mammoplasty are summarised below. ![Common skin incision patterns used in mastopexy and reduction mammoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-18T020736.825.png) Common skin incision patterns used in mastopexy and reduction mammoplasty **Vertical** ([Lassus](https://pubmed.ncbi.nlm.nih.gov/3630833/?ref=theplasticsfella.com), 1970; [Lejour](https://pubmed.ncbi.nlm.nih.gov/8016222/?ref=theplasticsfella.com), 1990) - **Indication:** Grade II–III ptosis, moderate skin excess, moderate volume reduction. - **Marking** - Keyhole pattern with vertical limbs (6-8 cm). - Use Aufricht manoeuvre to guide vertical limb alignment. - **Technique** - Parenchymal pillars shaped with internal sutures. - NAC repositioned; vertical closure under mild tension. - **Pros:** Improved projection, less scarring than Wise pattern. - **Cons:** Early pleating, risk of dog-ears, less control in wide breasts. **Wise Pattern** (Inverted-T; [Wise](https://pubmed.ncbi.nlm.nih.gov/13335513/?ref=theplasticsfella.com), 1946) - **Indication:** Grade III-IV ptosis, severe skin laxity, large breasts. - **Marking** - Periareolar circle + vertical limbs + horizontal IMF limb. - Length adjusted to base width. - **Technique** - Full-pattern de-epithelialization, glandular reduction, NAC elevation. - **Pros:** Maximum control over skin and volume. - **Cons:** Longest scar, risk of boxy shape or T-junction necrosis. 💡 ****Tip:** In Wise-pattern designs, the sum of the medial and lateral upper limbs should exceed the length of the horizontal IMF incision. An imbalance may indicate overaggressive medial/lateral traction during the Aufricht maneuver, risking closure under tension. **J-Shaped Incision** - **Indication:** Moderate ptosis, good skin elasticity, desire to avoid IMF scar. - **Technique** - Similar to vertical pattern with optional lateral IMF extension. - Often combined with inferior/central pedicle. - **Pros:** Less scar, good shape. - **Cons:** Limited use in wide breasts; requires intraoperative judgement. **L-Shaped Incision** - **Indication:** Grade II ptosis, mild asymmetry, or lateral fullness. - **Technique** - Vertical incision with short lateral IMF limb. - Closure yields an "L" shaped scar. - **Pros:** Minimal scar, versatile. - **Cons:** Not ideal for wide or severely ptotic breasts. **Autoprosthesis Technique** - **Indication:** Ptotic breasts with good volume but poor projection (e.g., postpartum deflation). - **Technique** - Lower pole tissue mobilised, rotated upward, and fixed to pectoral fascia. - May use vertical or Wise pattern skin envelope. - **Pros:** No implant required, restores projection. - **Cons:** Technically demanding, tissue-dependent. - **Tip:** Combine with fascial anchoring if skin quality is poor to prevent recurrent ptosis. 💡 ****Tip:** When skin quality is poor or parenchymal support is minimal, incision pattern alone cannot compensate. Consider combining skin reduction with deep reshaping techniques or fascial anchoring for durable outcomes. ### Pedicle Selection - **Superior:** Ideal for small lifts or mastopexy; preserves NAC via internal mammary perforators. - **Inferior:** Robust for large reductions; based on posterior intercostal perforators, typically from the 4th–6th spaces. - **Superomedial:** Combines vascular reliability and projection; widely preferred. - **Central/Lateral/Medial:** Reserved for special cases or revisions. - **Bipedicled:** Horizontal or vertical configurations used in massive hypertrophy or vascular-risk scenarios. The choice of incision and pedicle is always patient-specific, integrating ptosis grade, parenchymal volume, and skin redundancy. 😎 ****Fun Fact:** Long-term mastopexy outcomes depend not only on the surgical technique, but also on skin quality and the structural integrity of the glandular-adipose tissue. Always tailor the approach to the underlying anatomy. ### Surgical tips for vertical mastopexy are summarised below. ![Surgical tips for vertical mastopexy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-18T020852.241.png) Surgical tips for vertical mastopexy --- ## Complications of Breast Reduction and Mastopexy ****Key Point** Complications of mastopexy and reduction mammoplasty include hematoma, wound dehiscence, NAC necrosis, scarring, sensory loss, asymmetry, bottoming out, and recurrent ptosis. Risk is influenced by surgical technique, skin quality, volume reduction, and patient comorbidities. Complications can occur early or late in the postoperative course and may affect wound healing, breast shape, nipple viability, and sensory outcomes. Identifying risk factors and tailoring surgical planning, particularly pedicle choice, tension control, and scar placement, can mitigate many of these issues. ### Early Complications - **Hematoma:** Usually within the first 24-48 h; requires prompt evacuation. - **Wound dehiscence:** Often at the T-junction or along the vertical limb; more common with tension or poor vascularity. - **Infection:** Relatively uncommon; managed with oral antibiotics unless an abscess forms. - **NAC Venous Congestion or Ischemia:** Can occur in long pedicle transfers or excessive tension; may resolve or progress to partial/total necrosis. - **Seroma:** Less common in mastopexy, more frequent in large-volume reductions. Early postoperative haematoma following reduction mammoplasty is illustrated below. ![Early postoperative haematoma following reduction mammoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-18T021028.702.png) Early postoperative haematoma following reduction mammoplasty 💡 ****Tip:** Tension-free closure and meticulous hemostasis significantly reduce the risk of both dehiscence and hematoma. ### Late Complications - **Hypertrophic Scarring or Keloid Formation:** More common on vertical and horizontal limbs, especially in darker skin types. - **Bottoming Out:** Due to poor parenchymal support or weak dermis, often associated with vertical and Wise patterns. - **NAC Asymmetry:** Usually from imprecise marking or tissue settling. - **Loss of Nipple Sensation:** Depends on pedicle choice and degree of dissection; more frequent in large reductions. - **Recurrent Ptosis:** Often linked to poor skin elasticity or lack of deep fixation. - **Fat Necrosis:** Seen more in central reductions with aggressive tissue undermining; may present as palpable nodules or calcifications. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** You will understand that mastopexy and breast reduction are surgical procedures designed to reshape the breast through skin excision, NAC repositioning, and pedicle transposition, tailored according to ptosis severity, volume, and patient-specific goals. ****2\. Surgical Anatomy:** You will be able to identify the key vascular and neural structures that guide pedicle selection, including the internal mammary, lateral thoracic, and intercostal perforators, ensuring safe NAC transposition and sensation preservation. ****3\. Surgical Techniques:** You will be able to select the most appropriate incision pattern: periareolar, vertical, Wise, J-, or L-shaped, based on clinical assessment of ptosis grade, skin redundancy, and glandular-adipose ratio, with optional glandular excision when volume reduction is indicated. ****4\. Complications:** You will be aware of both early and late complications, including hematoma, dehiscence, NAC necrosis, asymmetry, bottoming out, and sensory loss, recognizing how patient factors, incision type, and skin quality influence postoperative outcomes. --- ## Further Reading 1. Benelli L. A new periareolar mammaplasty: the "round block" technique. Aesthetic Plast Surg. 1990 Spring;14(2):93-100\. doi: 10.1007/BF01578332\. PMID: 2185619. 2. Lassus C. Breast reduction: evolution of a technique--a single vertical scar. Aesthetic Plast Surg. 1987;11(2):107-12\. doi: 10.1007/BF01575495\. PMID: 3630833. 3. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg. 1994 Jul;94(1):100-14\. doi: 10.1097/00006534-199407000-00010\. PMID: 8016222. 4. WISE RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr Surg (1946). 1956 May;17(5):367-75\. doi: 10.1097/00006534-195605000-00004\. PMID: 13335513. 5. Eroglu S, Duran A, Akalın B. Wise-Pattern Superomedial Dermoglandular Pedicle Technique: Improves Breast Upper Pole Fullness and Breast Proportions. Plast Surg (Oakv). 2023 May;31(2):138-145\. doi: 10.1177/22925503211027046\. Epub 2021 Jun 25\. PMID: 37188141; PMCID: PMC10170636. 6. Adham M, Sawan K, Lovelace C, Jaeger NJ, Adham C. Unfavorable outcomes with vertical reduction mammaplasty: part II. Aesthet Surg J. 2011 Jan;31(1):40-6\. doi: 10.1177/1090820X10390757\. PMID: 21239671. 7. Hall-Findlay EJ. Vertical breast reduction. Semin Plast Surg. 2004 Aug;18(3):211-24\. doi: 10.1055/s-2004-831908\. PMID: 20574477; PMCID: PMC2884717. 8. Lockwood T. Reduction mammaplasty and mastopexy with superficial fascial system suspension. Plast Reconstr Surg. 1999 Apr;103(5):1411-20\. doi: 10.1097/00006534-199904050-00009\. PMID: 10190437. 9. Davison SP, Mesbahi AN, Ducic I, Sarcia M, Dayan J, Spear SL. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg. 2007 Nov;120(6):1466-1476\. doi: 10.1097/01.prs.0000282033.58509.76\. PMID: 18040175. 10. Botti G. *Mastoplastiche estetiche.* Milano: SEE Editrice; 2002. ### P'Fella's First Live Event, 3 Truths About Surgical Training, & Foundations. URL: https://www.theplasticsfella.com/july-20th/ Last updated: 2025-07-19T17:17:43.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-20th/#a-letter-from-pfella) The future won’t be peer-reviewed. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/july-20th/#the-sunday-quiz) Paused this week — we were polishing **Foundations*. 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-20th/#image-of-the-week) Traditional OR: How far we have come. 4. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/july-20th/#jpras-journal-club) When to start mobilisation after ORIF of hand fractures. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/july-20th/#upcoming-events) You’re On Call Now: Live event. 6. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/july-20th/#foundations-textbook) Officially in pre-sale, and open to the public soon! 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-20th/#articles-of-the-week) We need more exposure, AI obviously, & Grassroot programs: With 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/july-20th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Future Won’t Be Peer-Reviewed* 👋 Let’s stop pretending: journals aren’t where the action is anymore. Plastic surgery has always evolved on the margins — inside the OR, not inside the abstract. And now? We’re going live. Next week, we’re running our **first-ever live event.** Not AI-written. Not AI-proofread. Definitely not AI-reviewed. **Just humans, live, and unfiltered. Exactly how surgical education should be.** **Why Live Matters** We’re building something that can’t be faked or filtered: - Real conversations from real surgeons actually doing the work. - Direct takeaways, not summaries. - No edits, no do-overs, and no time delay on what’s changing in the field. If AI is flooding the journals, live events are how we take education back. This is the format we believe in, and it's just the beginning. **So What’s Happening?** - 🔴 **Event:** You’re On Call Now. - 📅 **Date:** Saturday, 26 July. - 🎙️ **Guests:** You’ll see. But we’re not starting small. ![You’re On Call Now: Live Event](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/-WYMW-and--IOTW--10--1.png) You’re On Call Now: Live Event This isn’t just an experiment. It’s a shift. The kind you feel. The kind you remember. Less AI noise. More human signal. You in? With love, P Fella ❤️ ## The Sunday Quiz Too busy prepping **Foundations* this week — back next Sunday! --- ## Image of the Week **Traditional OR: How Far We Have Come* 🖼️ ****Image of the Week** This week’s image reflects how far surgery has come — a striking view of the traditional operating theatre setup. The elevated amphitheatres, antiseptic protocols, and aseptic technique are a reminder of the roots of modern surgery and how the theatre, quite literally, used to be one. ![Traditional Operating Theatre](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/CARNEGIE_4040003-600x420--1-.jpg) Traditional Operating Theatre ## JPRAS Journal Club **When to Start Mobilisation After ORIF of Hand Fractures* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Journal-Club-Images--19-.png) #### In this Journal Club A systematic review (53 studies, 1,822 hand fractures) examined the timing of mobilisation post-ORIF. Immediate mobilisation showed faster healing but higher adverse events. Delayed mobilisation had fewer complications. Heterogeneity and lack of standardised PROMs limit conclusions. [****5-Point Summary**](https://www.theplasticsfella.com/journal-hand-fractures/#5-point-summary) A systematic review (53 studies) assessed when to start moving post-ORIF. Immediate mobilisation sped up healing; delayed reduced adverse events. PROMs varied. Heterogeneity limits conclusions. [****4-Key Findings**](https://www.theplasticsfella.com/journal-hand-fractures/#4-key-findings) Immediate mobilisation healed in 38.7 days. Early mobilisation had 25% adverse events; delayed had 9.3%. PROMs were inconsistent, limiting data synthesis. [****3-Critiques**](https://www.theplasticsfella.com/journal-hand-fractures/#3-critiques) Most studies were retrospective and biased. PROMs and adverse events were inconsistently defined and reported across studies. [****2-Practical Takeaways** ](https://www.theplasticsfella.com/journal-hand-fractures/#2-practical-takeaways) Delayed mobilisation may lower complications. Earlier movement may boost early function. RCTs needed for clarity. [****1-Recommended Reading**](https://www.theplasticsfella.com/journal-hand-fractures/#1-recommended-reading) Feehan & Bassett (2004) found early motion (<21 days) improved recovery and return to work without loss of alignment. [Read the Article](https://www.theplasticsfella.com/journal-hand-fractures/) ## Upcoming Events **You’re On Call Now: Live Event* 📅 Saturday 26 July | 🕛 12:00pm UTC | 📍 Zoom Webinar You're invited to '***You’re On Call Now** *'* — real-life on-call insights packed into one afternoon. On the agenda: \- Red flags you can’t miss in trauma, burns & infections. \- Upskilling sessions on sutures, research, and microsurgery. \- Real stories from fellows, consultants, and top trainees. \- Sneak peeks from [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). \- Networking and live Q&A. 🎟️ Spots are free but limited, so ****register now** to secure yours! ![You’re On Call Now: Live Event](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/-WYMW-and--IOTW--9-.png) You’re On Call Now: Live Event ## Foundations Textbook **Officially in Pre-Sale, and Open to the Public Soon!* 📘 The [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) pre-sale opened on Friday, and the response has been incredible. 👉 If you’re on the waitlist, check your inbox for your one-click access. After months of development, feedback, and fine-tuning, Foundations is finally here for the pre-sale. 🔓 4 bundles to choose from 🔓 500 copies only If you missed the chance to join the waitlist, no stress — the full launch opens to the public very soon. Stay tuned! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/-WYMW-and--IOTW--16-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/-WYMW-and--IOTW--13-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/-WYMW-and--IOTW--17-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/-WYMW-and--IOTW--18-.png) Foundations - Educational Bundles ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****How Training Programs Affect Med Student Plastic Surgery Knowledge** ([Ford](https://pubmed.ncbi.nlm.nih.gov/38984639/?ref=theplasticsfella.com), 2024) In this survey of 306 students, lack of plastic surgery exposure was widespread, but having a home training program didn’t significantly improve students' ability to identify appropriate referrals. ✅ ****Can AI Keep Up with Plastic Surgery Residents?** ([Duran](https://pubmed.ncbi.nlm.nih.gov/39862057/?ref=theplasticsfella.com), 2025) In a CME test of plastic surgery knowledge, ChatGPT-4o and Gemini outperformed residents before and after article review, though only Gemini improved with continued education. ✅ ****Can a Single Event Bridge the Gap for ‘Orphaned’ Med Students?** ([Friedman](https://pubmed.ncbi.nlm.nih.gov/38725106/?ref=theplasticsfella.com), 2024) After attending the "Explore Plastic Surgery" program, students without home residencies showed increased confidence and decreased concern about their chances of entering the specialty. ## Feedback ### I hope you enjoyed it 😄 --- ### Advancement Flap: Design Principles, Indications, & Common Variants URL: https://www.theplasticsfella.com/advancement-flap/ Last updated: 2025-07-15T11:59:34.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/advancement-flap/#overview-of-advancement-flap-design) Advancement flaps are linear, unidirectional local flaps that mobilize tissue directly into a defect. Their simplicity, robust blood supply, and alignment with relaxed skin tension lines (RSTLs) make them ideal for small to moderate facial and extremity defects. [****Indications & Contraindications**](https://www.theplasticsfella.com/advancement-flap/#indications-contraindications-of-advancement-flaps) Used for nasal, forehead, cheek, lip, and limb defects. Contraindicated when tissue mobility is insufficient or the vascular supply is compromised (e.g., smoking, prior radiation). [****Design & Execution**](https://www.theplasticsfella.com/advancement-flap/#design-execution-of-advancement-flaps) Success depends on managing tension vectors, preserving subdermal plexus perfusion, and planning Burow’s triangles or V-Y closures to optimize contour and reduce dog-ears. [****Variants**](https://www.theplasticsfella.com/advancement-flap/#variants-of-advancement-flaps) Includes U-, H-, and T-plasties; V-Y and Y-V flaps; cervicofacial and Karapandzic flaps. Each is tailored to the defect location and cosmetic subunits. [****Complications**](https://www.theplasticsfella.com/advancement-flap/#complications-of-advancement-flaps) Common risks include flap tip necrosis, trapdoor deformity, dog-ears, and microstomia. Most are mitigated with meticulous design and layered closure. ****Primary Contributor:** Dr Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Advancement Flap Design ****Key Point** Advancement flaps are unidirectional, local flaps that mobilize adjacent tissue into a defect with minimal geometric complexity. They are widely used due to their reliable perfusion, alignment with relaxed skin tension lines, and aesthetic integration. Advancement flaps are local, unidirectional flaps that move adjacent tissue in a linear fashion to close a defect ([Shew](https://pubmed.ncbi.nlm.nih.gov/28676160/?ref=theplasticsfella.com), 2017). They rely on skin elasticity and subdermal plexus perfusion, eliminating the need for rotation, transposition, or secondary donor sites ([Krishnan](https://pubmed.ncbi.nlm.nih.gov/16042922/?ref=theplasticsfella.com), 2005). - Tissue is “slid” directly into the defect along a single vector. - Most are random-pattern flaps based on subcutaneous vasculature ([Etzkorn](https://www.ncbi.nlm.nih.gov/books/NBK431081/?ref=theplasticsfella.com), 2024). - Commonly used for facial and limb reconstruction due to design simplicity and aesthetic reliability. They offer several practical advantages over other local flap types. - **Simple Design:** Less geometric complexity compared to Z-plasty or bilobed flaps - **Reliable Vascularity:** Maintain blood supply via the subdermal plexus - **No Secondary Defects:** Avoid donor site morbidity, which is common in free or interpolated flaps Below is a simple schematic showing a linear flap advanced directly into a cutaneous defect. ![Linear advanced flap advanced directly into a cutaneous defect](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-10T195429.560.png) Linear advanced flap advanced directly into a cutaneous defect 😎 ****Fun Fact:** Advancement flaps are the foundation technique behind cosmetic surgeries like facelifts and hairline advancement. Their utility goes far beyond basic wound closure. --- ## Indications & Contraindications of Advancement Flaps ****Key Point** Advancement flaps are preferred when linear closure risks distorting free margins or aesthetic boundaries. They’re contraindicated in patients with insufficient local tissue or compromised perfusion (e.g. scarring, radiation). Advancement flaps are ideal for closing defects where direct linear closure would cause distortion, especially around cosmetic subunits or free margins. Their ability to hide scars within relaxed skin tension lines (RSTLs) makes them especially useful in facial reconstruction. ### Indications Advancement flaps are ideal when, - A linear closure would distort a free margin (e.g., eyelid, lip, alar rim). - A defect lies across a cosmetic subunit junction (e.g., nasolabial fold, orbitomalar groove). - Scar placement can be camouflaged within RSTLs or anatomical creases. - The goal is tissue rearrangement rather than closure (e.g., facelifts, hairline lowering). **Common Anatomical Sites** - Upper and lower cutaneous lip - Nasal dorsum and sidewall - Cheek and periorbital region - Lower eyelid - Forehead - Helical rim ### Contraindications Avoid advancement flaps when, - Local tissue is insufficient for closure without excessive tension. - There is active infection, scarring, or inflammation around the defect. - Prior radiation has compromised skin elasticity or perfusion. - Defect size exceeds the capacity of local advancement (requires grafts or free flaps). 💡 ****Tip:** When operating near aesthetic subunits, redirect incisions into creases (e.g., nasolabial fold, glabellar lines) to hide scars and maintain contour integrity. --- ## Design & Execution of Advancement Flaps ****Key Point** Advancement flap success depends on careful planning of the incision line, preservation of the subdermal plexus, appropriate tension vector management, and proper handling of standing cones. Precise planning and execution are critical to the success of advancement flaps. Proper flap design ensures minimal tension, optimal contour, and preservation of function, particularly in cosmetically sensitive areas like the face and limbs. **Step 1: Design Principles** - Incisions parallel to RSTLs. - Length-to-width ratio ≤ 3:1 (face) or 2:1 (trunk/extremities). - Plan for Burow’s triangle excision or V-Y rearrangement. **Step 2: Elevation** - Subcutaneous elevation (subdermal plexus preserved). - In scalp: subgaleal or subcutaneous plane, depending on laxity. - Undermine 2-4 cm beyond the defect to reduce tension. **Step 3: Flap Movement** - **Primary Movement:** Flap slides into defect. - **Secondary Movement:** Surrounding tissue adjusts. - Distribute tension with deep dermal sutures. 💡 ****Tip:** In high-tension or mobile zones (e.g., periorbital or nasal areas), use tacking sutures anchored to the periosteum (e.g., orbital rim) to offload flap edges and maintain contour integrity. --- ## Variants of Advancement Flaps ****Key Point** Advancement flap techniques vary based on location, defect shape, and surrounding anatomy. Modifications enhance reach, contour, and aesthetic outcomes, particularly in facial, nasal, and auricular reconstruction. Different variants of advancement flaps have evolved to suit specific anatomical zones and reconstructive needs. These modifications improve reach, contour, and aesthetic outcomes, especially on the face, lips, and limbs. **1\. U-Plasty (Unipedicle Flap)** ([Harahap](https://pubmed.ncbi.nlm.nih.gov/11359495/?ref=theplasticsfella.com), 2001) - Single-side advanced. - Common on the forehead and nasal dorsum. - Requires Burow’s triangles to prevent dog-ears. **2\. H-Plasty (Bilateral Advancement)** ([Harahap](https://pubmed.ncbi.nlm.nih.gov/11359495/?ref=theplasticsfella.com), 2001) - Bilateral flaps advance toward midline. - Ideal for forehead, lips, and chin. - Reduces flap tension compared to unipedicle flaps. **3\. T-Plasty (or A-T/O-T Flap)** ([Hirshowitz](https://pubmed.ncbi.nlm.nih.gov/5932035/?ref=theplasticsfella.com), 1966) - Horizontal release for superior mobility. - Useful on the forehead or lip. - Single horizontal limb minimizes scar visibility. **4\. V-Y and Y-V Flaps** ([Narsete](https://pubmed.ncbi.nlm.nih.gov/10845304/?ref=theplasticsfella.com), 2000) - **V-Y:** Flap recoils into defect (e.g., vermillion, glabella). - **Y-V:** Flap advanced into Y-shaped incision. - Used in cleft lip repair, eyelid band release. **5\. Island Advancement Flaps** - Circumferential incision; relies on subcutaneous pedicle. - Allows significant advancement, avoids torsion. - **Example:** Keystone flap (especially for trunk/extremity). **6\. Cervicofacial Flap** - Large cheek/temple defects. - Dissection in the subcutaneous plane. - Incisions hidden in preauricular and neck creases. **7\. Bernard-Burow Flap** - Bilateral cheek advancement for lip reconstruction. - Excise Burow’s triangles in the alar and commissural regions. - Common for near-total lip defects. **8\. Karapandzic Flap** ([Teemul](https://pubmed.ncbi.nlm.nih.gov/28077239/?ref=theplasticsfella.com), 2017) - Myocutaneous advancement for full-thickness lip defects. - Preserves neurovascular bundles. - Excellent oral competence, but may cause microstomia. These commonly used advancement flaps are summarised below. ![Commonly used advancement flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-10T195524.571.png) Commonly used advancement flaps 💡 ****Tip:** Deepen the defect to match the flap’s thickness, especially important after Mohs surgery. This avoids a "pincushion" or step-off effect when the flap is inset. --- ## Complications of Advancement Flaps ****Key Point** Flap necrosis, venous congestion, and tension-related distortion are the most frequent complications. Early identification and meticulous tension management help preserve both function and aesthetic outcomes. While advancement flaps are relatively simple, they are not without risk. The most common issues arise from compromised vascularity or poor tension distribution. Understanding and anticipating these complications is essential for successful outcomes. **Flap Necrosis** - Most common complication ([Shew](https://pubmed.ncbi.nlm.nih.gov/28676160/?ref=theplasticsfella.com), 2017). - **Causes** - Excessive flap length relative to width. - Overstretching or excessive thinning. - Vascular compromise (subdermal plexus disruption). - **Venous Congestion:** Dusky, swollen, firm flap. - **Arterial Insufficiency:** Pale, cool flap. - **Management**: - Loosen tension (release sutures). - Drain hematomas. - Apply nitroglycerin paste to improve perfusion. - Consider medicinal leeches (add fluoroquinolone prophylaxis). **Infection** - Often secondary to necrosis, but may also be primary. - Treated with, - Irrigation and debridement. - Antibiotics. **Hematoma Formation** - Risk increased in anticoagulated patients. - Can cause compression and flap failure. - Prevent with meticulous hemostasis. - Avoid excessive electrocautery — may damage tissue. **Margin Distortion** - Occurs when flap tension pulls on free margins. - Eyelids - Lips - Eyebrow - Nasal ala - **Prevention** - Align the tension vector parallel to the free margin. - Use tacking sutures for stabilization. **Scar-Related Complications** - Hypertrophy, contour irregularities, trapdoor deformity - Managed with, - Intralesional corticosteroids (early). - Laser/Dermabrasion. - Scar revision surgery if persistent. 💡 ****Tip:** Always align tension vectors parallel to mobile structures like the eyelid or lip to prevent functional distortion and poor cosmesis. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Learned that advancement flaps are unidirectional local flaps ideal for small to moderate defects, offering simplicity, reliable perfusion, and alignment with aesthetic lines. 2\. ****Indications & Contraindications:** Understood their suitability for facial and extremity reconstruction, and recognized contraindications like poor tissue mobility or compromised vascular supply. ****3\. Design & Execution:** Grasped the importance of flap geometry, tension vector control, and preserving the subdermal plexus to ensure reliable closure and optimal outcomes. ****4\. Variants:** Explored common modifications such as U-, H-, T-, and V-Y flaps, each suited to specific anatomical regions and tailored for both function and appearance. ****5\. Complications:** Identified key risks including necrosis, trapdoor deformity, and margin distortion, most of which can be minimized with careful planning and layered closure. --- ## Further Reading 1. Etzkorn JR, Zito PM, Hohman MH, et al. Advancement Flaps. \[Updated 2024 Jan 29\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431081/ 2. Krishnan R, Garman M, Nunez-Gussman J, Orengo I. Advancement flaps: a basic theme with many variations. Dermatol Surg. 2005 Aug;31(8 Pt 2):986-94. 3. Hand LC, Maas TM, Baka N, Mercier RJ, Greaney PJ, Rosenblum NG, Kim CH. Utilizing V-Y fasciocutaneous advancement flaps for vulvar reconstruction. Gynecol Oncol Rep. 2018 Nov;26:24-28. 4. Daniel S, Fricke K, Kitcat M. Advancement flap to cover a defect between the junction of the alar base and the upper lip. *JPRAS Open*. 2021;28:33-36\. Published 2021 Jan 26\. doi:10.1016/j.jpra.2021.01.008 5. Shew M, Kriet JD, Humphrey CD. Flap basics II: advancement flaps. *Facial Plast Surg Clin North Am* 2017;25:323-35. 6. Kruter L, Rohrer T. Advancement flaps. *Dermatol Surg* 2015;41 Suppl 10:S239-46. 7. Harahap M. The modified bilateral advancement flap. *Dermatol Surg* 2001;27:463-6. 8. Zhang WC, Liu Z, Zeng A, et al. Repair of cutaneous and mucosal upper lip defects using double V-Y advancement flaps. *J Cosmet Dermatol* 2020;19:211-7. ### Ulnar Nerve Tendon Transfers: Anatomy, Presentation, & Procedure URL: https://www.theplasticsfella.com/ulnar-nerve-tendon-transfers/ Last updated: 2025-07-14T20:18:40.000Z #### Summary Card [****Anatomy**](https://www.theplasticsfella.com/ulnar-nerve-tendon-transfers/#anatomy-of-the-ulnar-nerve) The ulnar nerve innervates muscles in the forearm and the intrinsic muscles of the hand. [****Presentation**](https://www.theplasticsfella.com/ulnar-nerve-tendon-transfers/#presentation-of-ulnar-nerve-palsy) Ulnar nerve palsy can result from an injury at the elbow joint along the forearm. It results in loss of key pinch, clawing of the hand, and the loss of grip strength. [****Assessment**](https://www.theplasticsfella.com/ulnar-nerve-tendon-transfers/#assessment-of-ulnar-nerve-palsy) Ulnar nerve palsy can be assessed by testing finger abduction and thumb adduction using the Froment’s sign. [****Treatment Procedure**](https://www.theplasticsfella.com/ulnar-nerve-tendon-transfers/#procedure-of-ulnar-nerve-tendon-transfers) The primary goals of tendon transfer procedures for ulnar nerve palsy are to restore small and ring finger DIPJ flexion, key pinch, correct clawing, integrate MCPJ and IPJ flexion, and improve grip strength. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow****.** ****Reviewer:** Dr Suzanne Thomson, Educational Fellow****.** --- ## Anatomy of the Ulnar Nerve ****Key Point** The ulnar nerve innervates muscles in the forearm and the intrinsic muscles of the hand. The ulnar nerve innervates muscles in the forearm and the intrinsic muscles of the hand. **Nerve Roots:** C8-T1, branching from the medial cord of the brachial plexus. Below are the muscles innervated by the ulnar nerve. **Forearm** - Flexor carpi ulnaris (FCU) - Flexor digitorum profundus (FDP) to the ring and small fingers **Hand (via deep motor branch)** - Hypothenar muscles - Ulnar two lumbricals - Interossei - Adductor pollicis - Deep head of the flexor pollicis brevis (FPB) The image below illustrates the sensory distribution of the ulnar nerve. ![Sensory distribution of the ulnar nerve.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-20T222743.031.png) Ulnar nerve sensory distribution The anomalies below provide more details on variations in nerve innervation that can influence motor function in the hand. **Martin-Gruber Connection:** In this anomaly, motor fibers from the median nerve contribute to the ulnar nerve in the forearm. This can result in intact intrinsic hand function even after a proximal ulnar nerve injury ([Sameer](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741332/?ref=theplasticsfella.com), 2009). **Riche-Cannieu Anomaly:** A connection between the motor branch of the ulnar nerve and the recurrent motor branch of the median nerve in the hand. This anomaly can preserve thenar function after a median nerve injury at the wrist or higher ([Sameer](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741332/?ref=theplasticsfella.com), 2009). The table below summarises the muscles innervated by the ulnar nerve and their functions. ![Muscles innervated by the ulnar nerve and their functions, ulnar nerve anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-20T222310.962.png) Muscles innervated by the ulnar nerve and their functions. --- ## Presentation of Ulnar Nerve Palsy ****Key Point** Ulnar nerve palsy can be as a result of injury at the elbow joint or along the forearm. It results in loss of key pinch, clawing of the hand, and loss of grip strength. Ulnar nerve palsy often occurs due to injury at the elbow or forearm, leading to loss of key pinch, clawing of the hand, and reduced grip strength. Below are the causes of ulnar nerve palsy. **Damage at the Elbow** - Trauma near the medial epicondyle (e.g., isolated medial epicondyle fracture, supracondylar fracture) - Compression in the cubital tunnel **Damage at the Forearm/Wrist** - Lacerations to the forearm or anterior wrist **Ulnar nerve palsy presents as:** - Loss of key pinch - Clawing of the hand - Loss of grip strength 💡 ****Tip:** In high (proximal) ulnar nerve palsy, paralysis of the profundus tendons to the ring and small fingers ****reduces** clawing compared to low ulnar nerve palsy. This phenomenon is known as the ****ulnar paradox**. --- ## Assessment of Ulnar Nerve Palsy ****Key Point** Ulnar nerve palsy can be assessed by testing finger abduction and thumb adduction using the Froment's sign. Ulnar nerve palsy can be assessed by testing finger abduction and thumb adduction using Froment's sign. **Froment’s Sign** This test assesses ulnar nerve palsy, specifically paralysis of the adductor pollicis. - The patient is asked to hold a piece of paper between the thumb and index finger while the examiner tries to pull the paper away. - If the ulnar nerve is intact, the patient can hold the paper without difficulty by adducting the thumb. - A positive test occurs when the patient cannot adduct the thumb and instead compensates by flexing the thumb at the interphalangeal joint. **Additional Assessments** - **Finger Abduction:** The patient is asked to abduct their fingers to assess the activity of the dorsal interossei. - **Wartenberg’s Sign:** In severe ulnar neuropathy, loss of intrinsic muscle function, particularly the third palmar interosseous muscle, leads to weakened finger adduction. The extensor digiti minimi (EDM), innervated by the radial nerve, becomes unopposed, resulting in extension and abduction of the fifth digit. - **Hypothenar Wasting:** Visible muscle wasting in the hypothenar region is a gross indicator of ulnar nerve palsy. **Assessment of Sensory Innervation** - **Palmar Cutaneous Branch:** Innervates the medial half of the palm. - **Dorsal Cutaneous Branch:** Innervates the dorsal surface of the medial one and a half fingers and the corresponding area of the dorsal hand. - **Superficial Branch:** Innervates the palmar surface of the medial one and a half fingers. --- ## Procedure of Ulnar Nerve Tendon Transfers ****Key Point** The primary goals of tendon transfer procedures for ulnar nerve palsy are to restore small and ring finger DIPJ flexion, ****key pinch**, correct clawing, integrate MCPJ and IPJ flexion, and improve ****grip strength**. The primary goals of tendon transfer procedures for ulnar nerve palsy are: - Restore small and ring finger DIPJ flexion (for high ulnar nerve palsy) - Restore key pinch - Correct clawing - Integrate MCPJ and IPJ flexion - Improve grip strength ### Treatment for Loss of Key Pinch The extensor carpi radialis brevis (ECRB), brachioradialis, or the FDS of the ring or little finger is transferred to the adductor pollicis to restore key pinch. **Loss of key pinch** arises from paralysis of the adductor pollicis and first dorsal interosseous muscles. Typically, restoring adductor pollicis function is sufficient to regain key pinch, as the index finger can stabilize against the adjacent fingers. Not all patients will report loss of key pinch due to compensatory action of the FPL or anomalous median nerve innervation of the adductor pollicis. **A tendon transfer procedure** is only performed if the patient perceives a deficit. **Donor Muscles** - ECRB ([Smith](https://pubmed.ncbi.nlm.nih.gov/6827050/?ref=theplasticsfella.com), 1983) - Brachioradialis ([Boyes](https://scholar.google.com/scholar%5Flookup?title=Bunnell%27s+surgery+of+the+hand&author=JH+Boyes&publication%5Fyear=1970&&ref=theplasticsfella.com), 1964) - Middle or Ring Finger FDS ([Litler](https://pubmed.ncbi.nlm.nih.gov/7419885/?ref=theplasticsfella.com), 1980) **ECRB/Brachioradialis** Both are innervated by the **radial nerve** and do not cause a functional deficit when harvested. Tendon grafts are required to lengthen these muscles, passing them between the **2nd and 3rd metacarpals** into the palm, where they are routed to the thumb and inserted on the adductor pollicis. **FDS Transfer** The ring or long-finger FDS can also be transferred to the adductor pollicis, though it has a less effective line of pull and may reduce grip strength. Not suitable for high ulnar nerve palsy, as the RF FDS is the only functioning tendon for the ring finger in this case. 😎 ****Fun Fact:** Ring FDS transfer should only be used in patients with low ulnar nerve palsy, in whom the ring FDP is functional ([Sameer](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741332/?ref=theplasticsfella.com), 2009). ### Treatment for Clawing Correction of MCPJ hyperextension is essential for treating clawing, with static procedures for simple clawing (MCPJ capsulodesis) and dynamic procedures for complex clawing (superficialis or wrist motor transfers). **Clawing** results from intrinsic muscle paralysis. The unopposed action of extrinsic extensors leads to MCPJ hyperextension and IP joint flexion. **Bouvier Test** ([Gardenier](https://pubmed.ncbi.nlm.nih.gov/32884184/?ref=theplasticsfella.com), 2020) - **Positive (Simple Clawing):** The patient can flex the IP joints after passive MCPJ correction. - **Negative (Complex Clawing):** The patient cannot flex the IP joints even after MCPJ correction. **Static procedure** treatment options include: 1. **An MCPJ capsulodesis:** a distally based flap of the volar plate is advanced proximally and sutured to the metacarpal neck, limiting MCPJ extension 2. **Release of the A1 and A2 pulleys:** which in effect causes bow- stringing of the flexor tendons promoting MP joint flexion and limiting their hyperextension. (29/30 from Gradiner) 3. **Static tenodesis with a tendon graft:** The tendon graft is sutured to the deep transverse intermetacarpal ligament, passed through the lumbrical canal, and sutured to the extensor apparatus or to the lateral band. 4. The FDS may also be utilised to create a static flexion moment arm in by the **Zancolli - Lasso procedure.** In low ulnar nerve pal-sies, the FDS to the ring and small fingers is divided at its insertion or just proximal to it. It is then passed either distal to the A1 pulley or distal to both A1 and A2 pulleys and then brought back and sewn to itself while maintaining the MP joints in the intrinsic plus position of approximately 60 to 70 degrees of flexion ([Gardenier](https://pubmed.ncbi.nlm.nih.gov/32884184/?ref=theplasticsfella.com), 2020). **Complex clawing** treatment options include: Corrective procedure options such as, - Providing dynamic correction of clawing - Integrating MCPJ and IPJ flexion - Augmenting grip strength (in some cases) Divided into, 1. **Superficialis Transfer (Stiles-Bunnell Procedure):** Middle finger FDS is divided and split into four slips to function like lumbricals. This technique does not improve grip strength. 2. **Wrist Motor Transfers:** Donor tendons like FCR, ECRL, ECRB, or brachioradialis are used to augment grip strength and integrate finger flexion. Tendon grafts are split and passed through the intermetacarpal spaces. 😎 ****Fun Fact:** The Stiles-Bunnell procedure can cause PIPJ hyperextension in patients with lax joints, which can be avoided by inserting the tendon into the proximal phalanx instead of the lateral band ([Burkhalter](https://pubmed.ncbi.nlm.nih.gov/4821928/?ref=theplasticsfella.com), 1974). ### Restoration of Little and Ring Finger DIPJ Flexion Restoration of small and ring finger DIPJ flexion is achieved by suturing their FDP tendons to the functioning middle finger FDP. This is typically done in high ulnar nerve palsy cases. The small and ring FDPs are sutured to the middle finger FDP to restore function. 😎 ****Fun Fact:** The index finger FDP is excluded to maintain independent function. Clawing may worsen after restoring ring and small finger FDP function, necessitating further correction. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Ulnar Nerve Anatomy:** Detailed the innervation of the forearm and hand muscles by the ulnar nerve, and its significance in hand function. ****2\. Ulnar Nerve Palsy Symptoms:** Identified key symptoms such as loss of key pinch, clawing of the hand, and reduced grip strength, resulting from ulnar nerve injury. ****3\. Diagnostic Techniques:** Explored Froment's sign among other assessments to diagnose ulnar nerve palsy effectively. ****4\. Surgical Interventions:** Discussed various tendon transfer techniques for restoring finger flexibility, key pinch, and correcting hand clawing. ****5\. Post-Surgical Outcomes:** Highlighted the importance of postoperative care, including rehabilitation and potential complications, to achieve optimal recovery and functionality. --- ## Further Reading 1. Sammer DM, Chung KC. [Tendon transfers: Part II. ](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741332/?ref=theplasticsfella.com)[Transfers for ulnar nerve palsy and median nerve palsy](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741332/?ref=theplasticsfella.com). Plast Reconstr Surg. 2009 Sep;124(3):212e-221e. doi: 10.1097/PRS.0b013e3181b037c7\. PMID: 19730287; PMCID: PMC2741332. 2. Starr BW, Chung KC. [Dynamic Rather than Static Procedures in Correcting Claw Deformities Due to Ulnar Nerve Palsy](https://pubmed.ncbi.nlm.nih.gov/35985755/?ref=theplasticsfella.com). Hand Clin. 2022 Aug;38(3):313-319\. doi: 10.1016/j.hcl.2022.02.008\. PMID: 35985755. 3. Gardenier J, Garg R, Mudgal C. [Upper Extremity Tendon Transfers: A Brief Review of History, Common Applications, and Technical Tips](https://pubmed.ncbi.nlm.nih.gov/32884184/?ref=theplasticsfella.com). Indian J Plast Surg. 2020 Aug;53(2):177-190\. doi: 10.1055/s-0040-1716456\. Epub 2020 Aug 29\. PMID: 32884184; PMCID: PMC7458847\. 4. Smith RJ. [Extensor carpi radialis brevis tendon transfer for thumb adduction--a study of power pinch](https://pubmed.ncbi.nlm.nih.gov/6827050/?ref=theplasticsfella.com). J Hand Surg Am. 1983 Jan;8(1):4-15\. doi: 10.1016/s0363-5023(83)80044-6\. PMID: 6827050. 5. Boyes, J.H., 1964\. [Bunnell's Surgery of the Hand](https://scholar.google.com/scholar%5Flookup?title=Bunnell%27s+surgery+of+the+hand&author=JH+Boyes&publication%5Fyear=1970&&ref=theplasticsfella.com). Academic Medicine, 39(9), p.871\. 6. Hamlin C, [Littler JW.](https://pubmed.ncbi.nlm.nih.gov/7419885/?ref=theplasticsfella.com) [Restoration of power pinch](https://pubmed.ncbi.nlm.nih.gov/7419885/?ref=theplasticsfella.com). J Hand Surg Am. 1980 Jul;5(4):396-401\. doi: 10.1016/s0363-5023(80)80184-5\. PMID: 7419885. 7. Seiler JG 3rd, Desai MJ, Payne SH. [Tendon transfers for radial, median, and ulnar nerve palsy](https://pubmed.ncbi.nlm.nih.gov/24187037/?ref=theplasticsfella.com). J Am Acad Orthop Surg. 2013 Nov;21(11):675-84\. doi: 10.5435/JAAOS-21-11-675\. PMID: 24187037. 8. Sassu, P., Libberecht, K. and Nilsson, A., 2015\. [Nerve transfers of the forearm and hand: a review of current indications](https://scholar.google.com/scholar?hl=en&as%5Fsdt=2005&sciodt=0%2C5&cites=9827013242380751125&scipsc=&q=Nerve+transfers+of+the+forearm+and+hand%3A+a+review+of+current+indications+Paolo+Sassu%2C+Katleen+Libberecht%2C+Anders+Nilsson&btnG=&ref=theplasticsfella.com). Plastic and Aesthetic Research, 2, pp.195-201. ### Radial Nerve Tendon Transfers: Principles, Anatomy, & Surgery URL: https://www.theplasticsfella.com/radial-nerve-tendon-transfers/ Last updated: 2025-07-14T20:14:29.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/radial-nerve-tendon-transfers/#definition-of-radial-nerve-tendon-transfers) Tendon transfers restore function when nerve or tendon repair isn't feasible, but are contraindicated by joint stiffness, inflammation, lack of donor tendons, non-compliance, systemic disease, and advanced age. [****Principles of Tendon Transfer Surgery**](https://www.theplasticsfella.com/radial-nerve-tendon-transfers/#principles-of-tendon-transfer-surgery) Successful tendon transfers require supple joints, stable soft tissue, an expendable donor tendon that restores a single function with adequate power, a proper action vector, and muscle synergy for retraining. [****Workup and Timing**](https://www.theplasticsfella.com/radial-nerve-tendon-transfers/#workup-and-timing-of-tendon-transfer-surgery) Preoperative evaluation reviews injury, physical condition, and readiness. Timing depends on nerve recovery prognosis, ensuring stable anatomy and soft tissue before surgery. [****Functional Anatomy**](https://www.theplasticsfella.com/radial-nerve-tendon-transfers/#radial-nerve-functional-anatomy) The radial nerve innervates key muscles before splitting into sensory and motor branches. Radial nerve palsy affects wrist, MCP joint, and thumb extension, with high palsy requiring wrist extension restoration. [****Surgery**](https://www.theplasticsfella.com/radial-nerve-tendon-transfers/#radial-nerve-tendon-transfer-surgery) Tendon transfers, typically using PT, FCU, and PL, are combined to restore function after radial nerve palsy. Methods are chosen based on surgeon preference and patient needs, with good outcomes. [****Postoperative Care**](https://www.theplasticsfella.com/radial-nerve-tendon-transfers/#postoperative-care) Postoperative care includes splinting, gradual rehabilitation, and functional training. Complications such as adhesions, rupture, and weakness are possible, but success rates are 80-90%. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow****.** ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow****.** --- ## Definition of Radial Nerve Tendon Transfers ****Key Point** Tendon transfers detach a functioning tendon-muscle unit and reattach it to a non-functioning one to restore lost function. Tendon transfers involve partially or completely detaching the insertion of a functioning tendon-muscle unit and reattaching it to a non-functioning one, with the primary goal of restoring lost function. ### Indications Tendon transfers are indicated in the below pathologies ([Gardenier](https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0040-1716456?ref=theplasticsfella.com), 2020): - **Nerve Injury:** The most common indication. Used when primary nerve repair, grafting, or delayed presentation is not feasible or has failed. - **Tendon Injury:** Applied when tendon repair is impossible or has failed, or in cases of combined tendon and nerve injuries. - **Spasticity:** Utilized to correct imbalances across a joint, such as in cerebral palsy, though outcomes are generally less predictable. - **Medical Diseases:** **Rheumatoid Arthritis:** For tendon ruptures due to chronic synovitis.**Poliomyelitis:** Transfers are delayed until no recovery of weakness is observed for at least 6 months.**Leprosy (Hansen’s Disease):** Often needed for issues like clawing, loss of opposition, and key pinch. ### Contraindications Tendon transfers are contraindicated in the following scenarios ([Richards](https://doi.org/10.1016/s0094-1298%2802%2900106-2?ref=theplasticsfella.com), 2003): - Joint contractures or stiff joints unless corrected with restored passive range of motion. - Active inflammation at the wound site. - Absence of an appropriate donor tendon. - Lack of a specific functional deficit. - Insufficient patient commitment to rehabilitation protocols. - Ongoing systemic disease (e.g., uncontrolled rheumatoid arthritis). - Athetoid movements, characterised by involuntary fluctuations between spasticity and flaccidity. - Advanced age, which complicates retraining. 💡 ****Tip:** Tendon transfers are less predictable in cerebral palsy patients, often leading to poorer outcomes ([De Roode](https://journals.lww.com/techhandsurg/fulltext/2010/06000/Tendon%5FTransfers%5Fand%5FReleases%5Ffor%5Fthe%5FForearm,.15.aspx?ref=theplasticsfella.com), 2010). 😎 ****Fun Fact:** Athetoid movements involve involuntary shifts between spasticity and flaccidity, making tendon transfer outcomes more unpredictable ([De Roode](https://journals.lww.com/techhandsurg/fulltext/2010/06000/Tendon%5FTransfers%5Fand%5FReleases%5Ffor%5Fthe%5FForearm,.15.aspx?ref=theplasticsfella.com), 2010). --- ## Principles of Tendon Transfer Surgery ****Key Point** Successful tendon transfer depends on supple joints, stable soft tissue, an expendable donor tendon that restores a single function, with the correct action vector, and muscle synergy. Successful tendon transfer surgery relies on several key factors to ensure optimal outcomes ([Coulet](https://www.sciencedirect.com/science/article/abs/pii/S2468122916000335?ref=theplasticsfella.com), 2016): - **Supple Joints:** Post-transfer range of motion will not exceed the preoperative passive ROM, so ensuring supple joints is crucial. - **Stable Soft Tissue:** Healthy, non-inflamed soft tissue is vital to avoid adhesions and improve healing outcomes. - **Appropriate Donor Tendon:** - **Expendable:** The donor tendon should have sufficient backup to prevent loss of critical function. - **Single Function:** Each tendon transfer should restore only one function to maintain strength and precision of movement. - **Adequate Excursion and Power:** The donor tendon should have comparable power and range of movement to the original. - **Appropriate Vector:** The tendon’s action vector should match the original or be adjusted to ensure proper function. - **Synergy:** Tendons from synergistic groups (e.g., supination with wrist flexion) facilitate easier retraining post-surgery. --- ## Workup and Timing of Tendon Transfer Surgery ****Key Point** Preoperative evaluation and treatment timing depend on injury assessment, patient readiness, and ensuring stable anatomy and soft tissue for optimal outcomes. Successful tendon transfer surgery depends on thorough preoperative evaluation and appropriate timing based on injury assessment and patient readiness. #### Preoperative Evaluation - **History**: - Type and timing of the injury - Previous surgeries or therapies - Specific functional deficits - Status of systemic disease - **Physical Examination**: - Assess nerve and tendon injuries - Evaluate joint range of motion (ROM) - Check scar maturity - Identify potential donor tendons (e.g., palmaris longus) - Evaluate patient motivation and commitment to rehabilitation #### Treatment Timing - **Immediate**: - When nerve recovery prognosis is poor - Provides temporary function while awaiting nerve repair - **Delayed**: - After the expected nerve recovery period - Ensure skeletal stability, soft tissue coverage, joint mobility, adequate sensation, and contracture correction before proceeding 😎 ****Fun Fact:** A pronator teres (PT) to extensor carpi radialis brevis (ECRB) transfer in radial nerve palsy serves as an "internal splint," reducing the need for external support during recovery. --- ## Radial Nerve Functional Anatomy ****Key Point** The radial nerve innervates key muscles before splitting into sensory and motor branches. Radial nerve palsy, classified as high or low, affects the wrist, MCP joint, and thumb extension. The radial nerve plays a crucial role in innervating key muscles and is involved in both motor and sensory functions. Radial nerve palsy, classified as high or low, impacts the wrist, MCP joint, and thumb extension. **Radial Nerve Pathway** - Innervates the **triceps**, **brachialis**, **brachioradialis (BR)**, and **extensor carpi radialis longus (ECRL)** before splitting into two branches: - **Superficial Radial Nerve** (sensory) - **Posterior Interosseous Nerve (PIN)** (motor) - **ECRB** innervation is variable, coming from either the main radial nerve or the PIN. **Superficial Radial Nerve** - Provides sensory innervation to the dorsal and radial aspects of the hand, covering the **thumb**, **index**, **middle**, and part of the **ring fingers**. **Posterior Interosseous Nerve (PIN)** - Innervates the **supinator**, **extensor carpi ulnaris (ECU)**, extrinsic finger extensors (**EIP**, **EDC**, **EDQ**), thumb extensors (**EPL**, **EPB**), and **abductor pollicis longus (APL)**. **Radial Nerve Palsy Classification** - **High Palsy:** Occurs above the elbow, affecting wrist extension. - **Low Palsy:** Occurs below the elbow, sparing wrist extension. **Functional Requirements for Irreparable Radial Nerve Injury** - **High Palsy:** Requires restoration of wrist extension. - **Low Palsy:** Wrist extension remains intact. - **Both High and Low Palsy:** Restoration of MCP joint extension and thumb extension/abduction is needed. Intrinsic muscles maintain IP joint extension. 💡 ****Tip:** Restoring protective sensation is key for functional outcomes, but in radial nerve injuries, tendon transfers can still succeed without sensory recovery ([Brunelli](https://pubmed.ncbi.nlm.nih.gov/15542215/?ref=theplasticsfella.com), 2004). --- ## Radial Nerve Tendon Transfer Surgery ****Key Point** Tendon transfers, often using PT, FCU, and PL, are combined to restore function after radial nerve palsy, with good outcomes across various methods. Tendon transfers, commonly using the Pronator Teres (PT), Flexor Carpi Ulnaris (FCU), and Palmaris Longus (PL), are performed to restore function after radial nerve palsy, with generally good outcomes across various methods. **Common Donor Tendons** - **Pronator Teres (PT):** Restores wrist extension. - **Flexor Carpi Ulnaris (FCU):** Used for finger extension. - **Palmaris Longus (PL):** Utilized for thumb extension. **Surgical Considerations** - **Preoperative Marking:** Identifying the donor and recipient tendons. - **Patient Positioning:** Supine position with the arm on an arm board for full exposure of the forearm and hand. The most common radial nerve tendon transfers are listed in the table below ([Chung](https://journals.lww.com/plasreconsurg/abstract/2009/05000/tendon%5Ftransfers%5F%5Fpart%5Fi%5F%5Fprinciples%5Fof%5Ftransfer.27.aspx?ref=theplasticsfella.com), 2009): ![Common radial nerve tendon transfers](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-19T220336.343.png) Common radial nerve tendon transfers **Common Tendon Transfer Combinations** Tendon transfers are usually done in combination unless addressing a single functional deficit (e.g., EPL rupture in rheumatoid arthritis). Common combinations include: - **Jones (classic) transfer:** PT to ECRB, FCU to EDC, PL to EPL - **Brand:** FCR to EDC, PT to ECRB, PL to EPL - **Boyes:** Middle FDS to EDC, Ring FDS to EIP and EPL, FCR to APL and EPB - **Merle d’Aubigné:** FCU to EPL and EDC, PT to ECRB, PL to APL and EPB All combinations show good results, with the choice of transfer depending on surgeon preference and patient-specific factors ([Chuinard](https://doi.org/10.1016/s0363-5023%2878%2980007-0?ref=theplasticsfella.com), 1978). 💡 ****Tip:** FCR is often preferred over FCU for transfers, as FCU is critical for wrist flexion and ulnar deviation, being the only ulnar-sided wrist muscle spared in radial nerve palsy. --- ## Postoperative Care ****Key Point** Postoperative care for tendon transfers involves splinting, gradual rehabilitation with early mobilisation, strengthening, and functional training. Postoperative care focuses on splinting, gradual rehabilitation, strengthening, and functional training to ensure proper healing and optimal outcomes. **Postoperative Protocol** - **Splinting:** A bulky splint is applied to maintain the transferred tendon at a no-tension length. - **Rehabilitation:** Rehabilitation protocols for tendon transfers differ between each centre and should involve occupational and physical therapists. Below is a suggested standardised rehabilitation protocol ([Cheah](https://www.hand.theclinics.com/article/S0749-0712%2816%2930015-4/abstract?ref=theplasticsfella.com), 2016): - **1 week:** Incisions are checked, and the splint is changed. - **Early Mobilisation (3-4 weeks):** Gentle passive range-of-motion exercises begin, progressing to active mobilisation as healing continues. - **Strengthening Exercises (6-8 weeks):** Gradual strengthening of the transferred tendons, avoiding overuse. - **Functional Training:** Tailored exercises based on the patient’s daily activities, focusing on wrist, finger, and thumb extension. - **Full Activity:** Resumed at 12 weeks post-op. **Complications** - **Tendon Adhesions:** Can occur if the tendon passes through inflamed tissue. Managed with aggressive therapy and, if needed, tenolysis. - **Transfer Rupture:** Results from excessive tension or poor immobilisation. Requires immediate repair. - **Transfer Weakness:** Caused by poor power match, atrophied donor muscle, or incorrect tension. Addressed by resetting tension or adjusting insertion placement ([Tordjman](https://www.sciencedirect.com/science/article/abs/pii/S2468122921001894?ref=theplasticsfella.com), 2022). **Outcomes** - **General:** 80-90% of cases achieve excellent or good outcomes. - **Radial Nerve Transfers:** - **Brand/Modified Boyes Transfers:** 87% good outcomes ([Ropars](https://doi.org/10.1016/j.jhsb.2006.05.020?ref=theplasticsfella.com), 2006). - **Merle d’Aubigné Transfer:** 95% satisfaction in long-term follow-up ([Krishnan](https://doi.org/10.1016/j.jhsa.2007.10.015?ref=theplasticsfella.com), 2008). --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Radial Nerve Tendon Transfers:** Acquired a detailed understanding of the principles, indications, and anatomy essential for radial nerve tendon transfers. ****2\. Surgical Techniques and Donor Selection:** Explored surgical techniques and donor tendon choices, such as Pronator Teres and Flexor Carpi Ulnaris, emphasizing their suitability based on specific functional requirements. ****3\. Preoperative Workup and Timing:** Reviewed the importance of thorough preoperative assessments and optimal timing for surgery to ensure successful outcomes. ****4\. Postoperative Care and Outcomes:** Discussed postoperative protocols and rehabilitation to maximize recovery, highlighting the high success rates of tendon transfer surgeries. ****5\. Contraindications and Surgical Challenges:** Identified key contraindications and surgical challenges that influence the success of tendon transfers. --- ## Further Reading 1. Gardenier, Jason, Rohit Garg, and Chaitanya Mudgal. "[Upper extremity tendon transfers: a brief review of history, common applications, and technical tips.](https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0040-1716456?ref=theplasticsfella.com)" *Indian Journal of Plastic Surgery* 53.02 (2020): 177-190. 2. Richards R. R. (2003). [Tendon transfers for failed nerve reconstruction](https://doi.org/10.1016/s0094-1298%2802%2900106-2?ref=theplasticsfella.com). *Clinics in plastic surgery*, *30*(2), 223–vi. https://doi.org/10.1016/s0094-1298(02)00106-2 3. De Roode, Carolien P., Michelle A. James, and Ann E. Van Heest. "[Tendon transfers and releases for the forearm, wrist, and hand in spastic hemiplegic cerebral palsy](https://journals.lww.com/techhandsurg/fulltext/2010/06000/Tendon%5FTransfers%5Fand%5FReleases%5Ffor%5Fthe%5FForearm,.15.aspx?ref=theplasticsfella.com)." *Techniques in hand & upper extremity surgery* 14.2 (2010): 129-134. 4. Coulet, B. "[Principles of tendon transfers.](https://www.sciencedirect.com/science/article/abs/pii/S2468122916000335?ref=theplasticsfella.com)" *Hand surgery and rehabilitation* 35.2 (2016): 68-80. 5. Brunelli, GA. [Sensory nerves transfers](https://pubmed.ncbi.nlm.nih.gov/15542215/?ref=theplasticsfella.com). J Hand Surg (Edinb). 2004;29(6):557-562. 6. Sammer, Douglas M., and Kevin C. Chung. "[Tendon transfers: part I. Principles of transfer and transfers for radial nerve palsy.](https://journals.lww.com/plasreconsurg/abstract/2009/05000/tendon%5Ftransfers%5F%5Fpart%5Fi%5F%5Fprinciples%5Fof%5Ftransfer.27.aspx?ref=theplasticsfella.com)" *Plastic and reconstructive surgery* 123.5 (2009): 169e-177e. 7. Chuinard, R. G., Boyes, J. H., Stark, H. H., & Ashworth, C. R. (1978). [Tendon transfers for radial nerve palsy: use of superficialis tendons for digital extension](https://doi.org/10.1016/s0363-5023%2878%2980007-0?ref=theplasticsfella.com). *The Journal of hand surgery*, *3*(6), 560–570\. https://doi.org/10.1016/s0363-5023(78)80007-0 8. Cheah, Andre Eu-Jin, Jennifer Etcheson, and Jeffrey Yao. "[Radial nerve tendon transfers.](https://www.hand.theclinics.com/article/S0749-0712%2816%2930015-4/abstract?ref=theplasticsfella.com)" *Hand clinics* 32.3 (2016): 323-338. 9. Tordjman, D., et al. "[Tendon transfer surgery for radial nerve palsy.](https://www.sciencedirect.com/science/article/abs/pii/S2468122921001894?ref=theplasticsfella.com)" *Hand Surgery and Rehabilitation* 41 (2022): S90-S97. 10. Ropars, M., Dréano, T., Siret, P., Belot, N., & Langlais, F. (2006). [Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis](https://doi.org/10.1016/j.jhsb.2006.05.020?ref=theplasticsfella.com). *Journal of hand surgery (Edinburgh, Scotland)*, *31*(5), 502–506\. https://doi.org/10.1016/j.jhsb.2006.05.020 11. Krishnan, K. G., & Schackert, G. (2008). [An analysis of results after selective tendon transfers through the interosseous membrane to provide selective finger and thumb extension in chronic irreparable radial nerve lesions](https://doi.org/10.1016/j.jhsa.2007.10.015?ref=theplasticsfella.com). *The Journal of hand surgery*, *33*(2), 223–231\. https://doi.org/10.1016/j.jhsa.2007.10.015 ### Lower Limb Reconstruction: Clinical Assessment, Decision Algorithm, & Flap Options URL: https://www.theplasticsfella.com/lower-limb-reconstruction/ Last updated: 2025-07-14T20:10:41.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/lower-limb-reconstruction/#overview-of-lower-limb-reconstruction) Soft tissue reconstruction of the lower limb is indicated for trauma, infection, tumor resection, vascular compromise, or congenital/acquired deformities. [****Decision Algorithm**](https://www.theplasticsfella.com/lower-limb-reconstruction/#decision-algorithm-for-lower-limb-reconstruction) Zone of injury, fracture stabilization needs, and vascular patency are the three pillars guiding soft tissue reconstruction decisions in the lower limb. [****Clinical Assessment**](https://www.theplasticsfella.com/lower-limb-reconstruction/#clinical-assessment-for-lower-limb-reconstruction) Patient assessment begins with ATLS principles, followed by detailed history and physical examination to evaluate limb viability, injury severity, & patient-specific factors that influence reconstructive planning. [****Timing of Lower Limb Reconstruction** ](https://www.theplasticsfella.com/lower-limb-reconstruction/#timing-of-lower-limb-reconstruction) Early soft tissue coverage (within 72 hours) improves outcomes, but recent studies show reconstruction up to 10 days remains safe. Beyond 10 days, flap complications increase. [****Wound Bed Preparation**](https://www.theplasticsfella.com/lower-limb-reconstruction/#wound-bed-preparation-for-lower-limb-reconstruction) Adequate debridement, ideally within 12 hours, is essential. Negative pressure wound therapy (NPWT), hydrodissection, and ultrasound-assisted techniques support wound bed optimization. [****Amputation**](https://www.theplasticsfella.com/lower-limb-reconstruction/#amputation-of-the-lower-limb) Amputation decisions must balance injury severity, available reconstructive options, and the patient’s rehabilitation potential. While salvage is ideal, primary amputation is justified in select cases. [****Flap Options**](https://www.theplasticsfella.com/lower-limb-reconstruction/#flap-options-for-lower-limb-reconstruction) Muscle or fascial flaps are the mainstay of soft tissue reconstruction in the lower limb. Adjuncts like bone grafts and dermal matrices enhance outcomes in complex defects. [****Anastomosis**](https://www.theplasticsfella.com/lower-limb-reconstruction/#anastomosis-for-lower-limb-reconstruction) Anastomosis technique: end-to-end or end-to-side, depends on the number and quality of patent distal vessels. Planning must consider injured vs uninjured vessels to maintain limb perfusion and flap survival. [****Postoperative Care**](https://www.theplasticsfella.com/lower-limb-reconstruction/#postoperative-care-for-lower-limb-reconstruction) Postoperative care includes limb elevation, flap monitoring, VTE and antibiotic prophylaxis, pressure-free dressings, and gradual mobilization tailored to orthopedic and flap stability. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Lower Limb Reconstruction ****Key Point** Soft tissue reconstruction of the lower limb is indicated for trauma, infection, tumor resection, vascular compromise, or congenital/acquired deformities. Early orthoplastic collaboration optimizes outcomes. Soft tissue reconstruction in the lower limb is a complex but critical component of limb salvage, with the goal of restoring **function, durability, and quality of life** ([Mansour](https://pubmed.ncbi.nlm.nih.gov/35725037/?ref=theplasticsfella.com), 2022). Reconstruction is often required in the setting of, - **Trauma** (e.g., Gustilo IIIB/C fractures, degloving) - **Infection** (e.g., necrotizing fasciitis, chronic osteomyelitis) - **Oncologic resection** (e.g., sarcoma excision) - **Vascular compromise** (e.g., ischemic ulcers, diabetic foot) - **Chronic or congenital deformities** (e.g., unstable scars, non-healing wounds) In orthoplastic care, **stable bony fixation precedes soft tissue reconstruction**, emphasizing a multidisciplinary approach. Involvement of reconstructive surgeons during the **index procedure** (e.g., pin placement, incision planning) maximizes flap options and minimizes downstream complications ([Merendall](https://pubmed.ncbi.nlm.nih.gov/31456609/?ref=theplasticsfella.com), 2019). **Primary goals** include, - Long-lasting coverage - Pain reduction - Return to work and mobility - Infection control - Avoidance of secondary amputation A traumatic open tibial fracture with extensive soft tissue loss is illustrated below. ![A traumatic open tibial fracture with extensive soft tissue loss](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-10T192049.172.png) A traumatic open tibial fracture with extensive soft tissue loss 💡 ****Tip:** Practical nuance in lower limb reconstruction is developed through surgical experience and interdisciplinary planning. Decision-making should be algorithmic but flexible. --- ## Decision Algorithm for Lower Limb Reconstruction ****Key Point** Zone of injury, fracture stabilization needs, and vascular patency are the three pillars guiding soft tissue reconstruction decisions in the lower limb. Lower limb soft tissue reconstruction, particularly for [**Gustilo-Anderson**](https://www.theplasticsfella.com///////knowledge-base/gustilo-and-anderson-classification/) **IIIB/IIIC injuries,** requires a structured yet flexible decision-making framework. ### Three Clinical Assessments To guide reconstruction strategy, assess, - **Zone of Soft Tissue Injury:** Determines local flap availability and feasibility of primary closure. - **Fracture Stabilization Requirements:** Internal vs external fixation affects incision planning and timing. - **Distal Vascular Status:** Patency of the anterior tibial, posterior tibial, and peroneal arteries informs anastomotic options. ### Four Key Decisions Once the above are evaluated, define, - **Timing:** Immediate (within 72 hours) vs delayed reconstruction (up to 10 days still acceptable). - **Flap Composition:** Muscle, fascia, skin, bone, or combinations thereof, depending on exposed structures and defect type. - **Flap Type:** Local, regional, or free flaps based on zone of injury and recipient vessel availability. - **Anastomosis Plan:** End-to-end vs end-to-side; injured vs uninjured vessel; determined by distal vessel status. ### Standard Limb-Salvage Workflow - **Evaluate Limb** - Clinical exam (perfusion, contamination). - MESS score (Mangled Extremity Severity Score). - **Initial Management** - Thorough debridement. - Fracture stabilization (external or internal). - **Assess Defect** - Location (thigh, knee, leg, foot). - Depth and structures exposed. - **Select Reconstruction Strategy** - Local flap available? - **Yes:** Use local flap. - **No:** Proceed to regional or free flap. - Consider NPWT if staging is needed. - **Consider amputation if,** - MESS > 7 - Irreparable vascular injury or contamination. - Patient is not suitable for complex reconstruction. - **Postoperative Care** - DVT prophylaxis (LMWH unless contraindicated) - Flap checks - Early physiotherapy - Multidisciplinary follow-up 💡 ****Tip:** Algorithms are useful, but experienced judgment remains essential, especially in borderline cases or where patient comorbidities complicate decision-making. --- ## Clinical Assessment for Lower Limb Reconstruction ****Key Point** Patient assessment begins with ATLS principles, followed by detailed history and physical examination to evaluate limb viability, injury severity, and patient-specific factors that influence reconstructive planning. A thorough evaluation ensures timely and appropriate decision-making in lower limb soft tissue reconstruction. The assessment combines systematic trauma protocols with injury-specific analysis ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). ### Primary Survey: ATLS Principles - Address airway, breathing, circulation first. - Control life-threatening hemorrhage before limb concerns. - Document vital signs, Glasgow Coma Scale, and stabilize the patient. ### Detailed History - **Time of Injury:** Duration of ischemia impacts salvageability. - **Mechanism & Location:** High-energy trauma, crush, or blast injuries raise complexity. - **Contamination Source:** Machinery, soil, marine, or chemical exposure. - **Medical History:** Diabetes, peripheral vascular disease, or immunosuppression. - **Smoking:** Compromises healing. - **Social Context** - Home support. - Rehabilitation access. - Occupational dependence on ambulation. - Patient expectations. ### Physical Examination - **Neurovascular Assessment** ([Loh](https://pubmed.ncbi.nlm.nih.gov/34214004/?ref=theplasticsfella.com), 2021) - Palpate pulses; assess capillary refill, motor and sensory function. - Document neurovascular status before and after manipulation. - Consider reversible causes of altered sensation (e.g., neuropraxia or ischemia). - **Skeletal and Joint Stability** - Assess joints above and below injury site. - “Fracture + laceration” should raise suspicion of an open fracture. - **Wound Assessment** - **Extent:** Size, depth, devitalised tissue. - **Structures Exposed:** Bone, tendon, vessels, nerve, joint, hardware. - **Contamination:** Type and severity. - **Chronicity:** Time since injury influences microbial burden and healing potential. Acute compartment syndrome of the lower leg is illustrated below. ![Acute compartment syndrome of the lower leg](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-10T192434.831.png) Acute compartment syndrome of the lower leg 💡 ****Tip:** High suspicion for compartment syndrome or arterial injury mandates urgent intervention. --- ## Timing of Lower Limb Reconstruction ****Key Point** Early soft tissue coverage (within 72 hours) improves outcomes, but recent studies show reconstruction up to 10 days remains safe. Beyond 10 days, flap complications increase. Timely soft tissue reconstruction in lower limb trauma is essential for optimal outcomes. Historically, a strict 72-hour window was recommended, but modern studies support extending this timeframe under controlled conditions. The key determinant is adequate debridement and patient stability. **Evidence on Timing** - [**Godina**](https://pubmed.ncbi.nlm.nih.gov/3737751/?ref=theplasticsfella.com) **(1986):** Advocated flap coverage within **72 hours**.“Golden window” for reduced infection and flap failure. - [**Bosse**](https://pubmed.ncbi.nlm.nih.gov/12477942/?ref=theplasticsfella.com) **(2002),** [**McKenzie**](https://pubmed.ncbi.nlm.nih.gov/16085622/?ref=theplasticsfella.com) **(2005):** Demonstrated **similar outcomes** when coverage was delayed up to **10 days** post-injury. - [**Harbath-Morales**](https://pmc.ncbi.nlm.nih.gov/articles/PMC10775209/?utm%5Fsource=chatgpt.com) **(2024):** Outcomes decline **after 10 days,** infection risk increases, and surgical complexity rises. - [**Karanas**](https://pubmed.ncbi.nlm.nih.gov/18846574/?ref=theplasticsfella.com) **(2008):** Coverage **after 30 days** may be possible in select stable wounds, but predictability decreases. **Practical Approach** - **Aim:** Coverage within **72 hours** when feasible ("fix-and-flap" orthoplastic paradigm). - **Acceptable:** Delay up to **10 days** with proper debridement and stabilization. - **Caution:** After **10 days**, anticipate greater flap failure risk and require enhanced planning and wound care. - **Exception:** Beyond **30 days** only for carefully selected cases with stable wounds and optimal surgical conditions. 💡 ****Tip:** Early reconstruction is ideal, but safe reconstruction depends more on adequate debridement and stabilization than rigid timing. If the wound is clean and the patient is optimized, delayed flaps can succeed ([Karanas](https://pubmed.ncbi.nlm.nih.gov/18846574/?ref=theplasticsfella.com), 2008). --- ## Wound Bed Preparation for Lower Limb Reconstruction ****Key Point** Adequate debridement, ideally within 12 hours, is essential. Negative pressure wound therapy (NPWT), hydrodissection, and ultrasound-assisted techniques support wound bed optimization. Debridement is the cornerstone of successful reconstruction. Removing all nonviable tissue reduces bacterial load, prevents infection, and prepares the wound for reliable coverage ([Mansour](https://pubmed.ncbi.nlm.nih.gov/35725037/?ref=theplasticsfella.com), 2022 & [Loh](https://pubmed.ncbi.nlm.nih.gov/34214004/?ref=theplasticsfella.com), 2021). - **Timing:** Ideally, within **12 hours** of injury ([Joseph](https://pubmed.ncbi.nlm.nih.gov/32186234/?ref=theplasticsfella.com), 2020). - **Goal:** Expose healthy, bleeding tissue while preserving vital structures. - **Technique:** Surgical excision is the gold standard; repeat as needed (“second look”). **Techniques & Adjuncts** - **Fasciotomy Extensions:** Help access deeper planes when assessing for viable tissue ([Nanchahal](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Standards+for+the+Management+of+Open+Fractures+of+the+Lower+Limb+-+Softcover+Nanchahal%2C+Jagdeep+2009&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1750945052912&u=%2Fscholar%3Fq%3Dinfo%3AtprZOxLcX0YJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2009). - **Quantitative Cultures:** Bacterial counts >10⁵ CFU/gram suggest heavy contamination ([Mansour](https://pubmed.ncbi.nlm.nih.gov/35725037/?ref=theplasticsfella.com), 2022). - **Hydrodissection:** High-pressure waterjet devices allow controlled removal of biofilm and necrotic debris ([Granick](https://pubmed.ncbi.nlm.nih.gov/32250443/?ref=theplasticsfella.com), 2020). - **Ultrasound Debridement:** Low-frequency ultrasound devices assist in precision cleaning with minimal trauma. - **Cement Beads/Spacers:** Antibiotic-impregnated materials manage dead space and prevent reinfection ([Mansour](https://pubmed.ncbi.nlm.nih.gov/35725037/?ref=theplasticsfella.com), 2022). - **NPWT:** Serves as a temporizing measure prior to flap coverage, promotes granulation, reduces edema, and contracts the wound. - Avoid prolonged NPWT over exposed tendon or bone without a paratenon or periosteum. It is a bridge, not a substitute, for definitive reconstruction **Antibiotic Guidance** For **Gustilo Grade II & III fractures**, continue systemic antibiotics: - **Until skin closure**, or - **For a maximum of 72 hours**, whichever is sooner ([Nanchahal](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Standards+for+the+Management+of+Open+Fractures+of+the+Lower+Limb+-+Softcover+Nanchahal%2C+Jagdeep+2009&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1750945052912&u=%2Fscholar%3Fq%3Dinfo%3AtprZOxLcX0YJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2009). 💡 ****Tip:** When in doubt, debride again. Delayed reconstruction with a clean, vascular bed outperforms rushed closure over questionable tissue. --- ## Amputation of the Lower Limb ****Key Point** Amputation decisions must balance injury severity, available reconstructive options, and the patient’s rehabilitation potential. While salvage is ideal, primary amputation is justified in select cases. “Life before limb” remains paramount. In cases of devastating trauma, amputation may offer faster recovery, reduced complications, and better functional outcomes than prolonged, uncertain salvage. ### Decision-Making Factors - **Injury Severity:** Massive soft tissue loss, vascular compromise, or unfixable fractures ([Loja](https://pmc.ncbi.nlm.nih.gov/articles/PMC5321791/?ref=theplasticsfella.com#:~:text=A%20MESS%20cutoff%20of%205,amputation%20in%2043.2%25%20of%20patients.), 2017). - **Physiological Status:** Hemodynamic instability, systemic illness, or unmanageable infection. - **Reconstructive Capacity:** Lack of viable flaps, limited microsurgical options. - **Patient Context:** Comorbidities, mobility goals, support systems, psychological readiness. ### [The MESS Score](https://pmc.ncbi.nlm.nih.gov/articles/PMC5321791/?ref=theplasticsfella.com#TFN1) **A. Skeletal/Soft Tissue Injury** - Low Energy (stab wound, simple fracture, low energy gunshot wound) - Medium Energy (open or multiple fractures, dislocation) - High Energy (high-speed motor vehicle collision or rifle gunshot wound) - Very High Energy (above plus gross contamination) **B. Limb Ischemia** 1. Pulse reduced or absent, but perfusion normal 2. Pulseless; paresthesia, diminished capillary refill 3. Cool, paralyzed, insensate, numb **C. Shock** - 0- Systolic blood pressure always > 90 mmHg - 1- Systolic blood pressure transiently < 90 mmHg - 2 - Systolic blood pressure persistently < 90 mmHg **D. Age (years)** - 0 < 30 - 1 30–50 - 2 > 50 The table below provides a breakdown of the MESS scoring system to support salvage versus amputation decisions. ![Breakdown of MESS scoring to aid decisions around limb salvage versus primary amputation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-14T151701.946.png) Breakdown of MESS scoring to aid decisions around limb salvage versus primary amputation 💡 ****Tip:** MESS > 7 has been associated with amputation, but studies (e.g. LEAP) caution against rigid use. It is one of many tools, not a definitive answer. **Indications for Primary Amputation** - Irreversible ischemia >4-6 hours (warm). - Uncontrollable bleeding or gross contamination. - Segmental **muscle** loss: >2 compartments. - Segmental **bone** loss: >⅓ tibial length. - Unsalvageable or avascular limb. - Combined fractures with major burns. **Relative Indications** - High tibial nerve injury (no longer an absolute contraindication to salvage). - Major nerve, joint, or soft tissue involvement. - Elderly, unfit, or neurologically impaired patients. 💡 ****Tip:** The decision to undertake a primary amputation should be made by two consultant surgeons where possible ([Loh](https://pubmed.ncbi.nlm.nih.gov/34214004/?ref=theplasticsfella.com), 2020). **Salvage vs Amputation: What Do the Studies Say?** - **LEAP Study:** Limb salvage is often non-inferior to amputation in long-term function ([Bosse](https://pubmed.ncbi.nlm.nih.gov/12477942/?ref=theplasticsfella.com), 2002 & [McKenzie](https://pubmed.ncbi.nlm.nih.gov/16085622/?ref=theplasticsfella.com), 2005). - **OUTLET Trial:** For complex foot/ankle trauma, amputation may offer better outcomes than protracted reconstruction ([METRIC](https://pubmed.ncbi.nlm.nih.gov/33979309/?ref=theplasticsfella.com), 2021). - **Loja et al.:** MESS has limited predictive accuracy in modern trauma care ([Loja](https://pmc.ncbi.nlm.nih.gov/articles/PMC5321791/?ref=theplasticsfella.com#:~:text=A%20MESS%20cutoff%20of%205,amputation%20in%2043.2%25%20of%20patients.), 2017). 💡 ****Tip:** Multidisciplinary consultation (plastic, ortho, rehab, patient) is vital before proceeding. **Technical Considerations** - **Preserve Length:** Aim for below-knee if feasible (ideal stump: 14 cm below tibial plateau). - **Flap Planning:** Use local fillet flaps or tissue from the amputated part. - **Delayed Closure:** Consider in contaminated wounds (guillotine amputation). - **Prosthesis Readiness:** Ensure stable soft tissue and durable coverage. - **Avoid Through-Knee Amputations** in adults unless specifically indicated. **Plastic Surgery Adjuncts** - **Targeted Muscle Reinnervation (TMR)**. - **Regenerative Peripheral Nerve Interfaces (RPNI)** reduce phantom limb pain and improve prosthetic control. 💡 ****Tip:** When amputation is considered, a multidisciplinary assessment (e.g., orthopaedics, plastic surgery, physical therapy, and rehabilitation medicine) should be carried out with the patient and their family or carers ([Nanchahal](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Standards+for+the+Management+of+Open+Fractures+of+the+Lower+Limb+-+Softcover+Nanchahal%2C+Jagdeep+2009&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1750945052912&u=%2Fscholar%3Fq%3Dinfo%3AtprZOxLcX0YJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2009). ### 😎 ****Fun Fact:** Other beneficial techniques plastic surgeons can offer at the time of amputations include targeted muscle reinnervation and regenerative peripheral nerve interface to help reduce the incidence of phantom limb pain and maintain muscle bulk at the amputation stump ([Valerio](https://pubmed.ncbi.nlm.nih.gov/32537346/?ref=theplasticsfella.com), 2020). --- ## Flap Options for Lower Limb Reconstruction ****Key Point** Muscle or fascial flaps are the mainstay of soft tissue reconstruction in the lower limb. Adjuncts like bone grafts and dermal matrices enhance outcomes in complex defects. **Muscle Flaps** - **Preferred for:** Middle third of the leg and contaminated wounds. - **Advantages** - High vascularity - Effective dead space obliteration - Resistance to infection - **Drawbacks** - Donor site morbidity (e.g., gastrocnemius flap reduces plantarflexion, poor cosmesis if harvested with skin paddle). - **Examples:** Gastrocnemius, soleus, gracilis (local); latissimus dorsi, rectus abdominis (free). **Fascial Flaps** - **Types** - **Fasciocutaneous** (common) - **Adipofascial** (rare, foot recon) - **Advantages** - Preserve muscle function. - Good for low-energy wounds with small defects. - **Examples** - **Propeller Flaps:** Based on perforators of the peroneal, anterior/posterior tibial arteries; genicular system for the knee. - **Keystone Island Flaps:** Multipoint advancement flap with reliable perfusion ([Mohan](https://pubmed.ncbi.nlm.nih.gov/26895582/?ref=theplasticsfella.com), 2016). **Bone Reconstruction Options** Indicated in high-energy injuries with bone loss or debridement. 1. **Vascularised Bone Graft:** Fibula, Iliac Crest (DCIA) 2. **Non-Vascularised Bone Graft** (<6cm defect): Iliac Crest 3. **Limb Shortening** if <6cm of bone loss 4. **Distraction Osteogenesis** 5. **Masquelet Technique:** A two-stage procedure for segmental bone defects - Place a **cement spacer** to induce a vascularised membrane, followed by **bone grafting** within this biologically active membrane to promote bone regeneration. The table below summarises bone reconstruction methods. ![A strategic summary of bone reconstruction methods](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-14T151343.485.png) A strategic summary of bone reconstruction methods **Acellular Dermal Matrix (ADM)** - **Use:** Temporising agent in poorly prepared beds (e.g., lacking periosteum or paratenon). - **Usually Combined With**: Skin grafting + NPWT. - **Indications:** Where skin grafts alone would fail (e.g., exposed tendon/bone) ([Jordan](https://pubmed.ncbi.nlm.nih.gov/25408784/?ref=theplasticsfella.com), 2014). The choice of flap depends on the location of the defect. The table below outlines preferred flap types by anatomical region, from thigh to plantar surface. ![A region-specific guide to soft tissue coverage options](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-14T152129.523.png) A region-specific guide to soft tissue coverage options --- ## Anastomosis for Lower Limb Reconstruction ****Key Point** Anastomosis technique: end-to-end or end-to-side, depends on the number and quality of patent distal vessels. Planning must consider injured vs uninjured vessels to maintain limb perfusion and flap survival. **Pre-operative Planning** - **Perfusion Assessment:** Clinical exam, duplex ultrasound, or CT angiography - **Classify leg status** - Three-vessel run-off - Two-vessel run-off - One-vessel run-off **Recipient Vessel Selection** - Choose vessels **proximal to the injury** with healthy walls. - Common options include, - **Posterior tibial**, **anterior tibial**, **peroneal** arteries. - For knee defects: **popliteal**, **genicular**, **sural branches**. - **Vein Selection**: Deep venae comitantes preferred; **great saphenous vein** acceptable. Anastomotic techniques are summarised below. ![Anastomotic techniques, when to use them, and their pros & cons](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-10T193132.921.png) Anastomotic techniques, when to use them, and their pros & cons **Anastomotic Strategy by Run-Off Pattern** - **3-Vessel Run-Off**: Any technique acceptable - **2-Vessel Run-Off** - EE to the **injured** vessel (proximal to injury). - ES to **uninjured** vessel (preserves 2-vessel run-off). - EE to **uninjured** vessel (results in 1-vessel run-off). - **1-Vessel Run-Off** - ES to the one remaining vessel (preferred). - EE to the injured vessel (only if safe). 💡 ****Tip:** Ensure a gentle, tension-free curve in the pedicle. Splinting the vein loop with the artery helps prevent kinking and thrombosis. --- ## Postoperative Care for Lower Limb Reconstruction ****Key Point** Postoperative care for soft tissue reconstruction includes limb elevation, flap monitoring, VTE and antibiotic prophylaxis, pressure-free dressings, and gradual mobilization tailored to orthopedic and flap stability. A coordinated multidisciplinary approach is essential to support flap survival, prevent complications, and optimize recovery following lower limb soft tissue reconstruction. ### Core Components of Post-Op Care - **Positioning & Immobilization**: Elevate the limb above heart level with no pressure on the flap. Immobilize adjacent joints as needed to protect the reconstruction site. - **Flap Monitoring:** Perform frequent clinical assessments of flap viability. - Color - Capillary refill - Temperature - Turgor Use Doppler monitoring to detect early signs of vascular compromise. - **VTE Prophylaxis** - Start low molecular weight heparin (LMWH) within 6–12 hours post-op, unless contraindicated. - Combine with mechanical methods (e.g., compression devices) when possible. - **Antibiotic Prophylaxis** - Administer perioperative intravenous antibiotics. - Use cefazolin or broad-spectrum agents for contaminated wounds. - **Duration:** 24-72 hours, depending on the level of contamination. - **Dressings** - Flap dressings should remain dry and intact for 5-7 days. - Use VAC (negative pressure therapy) or moist dressings on donor or graft sites as appropriate. - **Mobilization & Rehab** - Initiate isometric exercises early. - Progressively introduce joint mobility and weight-bearing, guided by flap stability and orthopedic fixation. A structured “**dangling protocol**” guides the safe reintroduction of gravity post-flap, as detailed in the table below. ![A day-by-day protocol for gradually introducing limb dependency after free flap reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-14T151858.475.png) A day-by-day protocol for gradually introducing limb dependency after free flap reconstruction 💡 ****Tip:** Pressure on flaps may compromise its vascular supply; thus, ensure that dressings are not too tight. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview of Lower Limb Reconstruction:** Gained an understanding of the indications, principles, and goals of soft tissue reconstruction in the lower limb, emphasizing early orthoplastic collaboration for optimal outcomes. ****2\. Decision-Making Framework:** Learned the key factors guiding reconstruction: zone of injury, stabilization needs, and vascular status, alongside algorithmic approaches to flap choice and timing. ****3\. Comprehensive Patient Evaluation:** Reviewed the importance of ATLS-based assessment, detailed history-taking, and targeted examination to inform timely and safe reconstruction strategies. ****4\. Timing and Wound Preparation:** Understood the evidence behind optimal reconstruction timing and the importance of thorough debridement, NPWT, and adjunctive techniques in wound bed optimization. ****5\. Amputation Criteria and Controversies:** Explored when primary amputation is appropriate, how to interpret MESS scores, and the role of multidisciplinary input in salvage versus amputation decisions. ****6\. Flap Options and Post-Op Care:** Familiarised yourself with local and free flap options, vascular anastomosis strategies, and key postoperative measures to protect reconstruction and promote recovery. ### Abdominoplasty: Clinical Assessment, Surgical Techniques, & Complications URL: https://www.theplasticsfella.com/abdominoplasty-2/ Last updated: 2025-07-14T09:32:36.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/abdominoplasty/#overview-of-abdominoplasty) Abdominoplasty is a contour-restoring procedure that removes excess skin and fat, repairs rectus diastasis, and enhances abdominal wall function, especially after pregnancy or massive weight loss. [****Clinical Indications**](https://www.theplasticsfella.com/abdominoplasty/#clinical-indications-for-abdominoplasty) Abdominoplasty is indicated for patients with skin laxity, excess panniculus, and rectus diastasis, typically postpartum or post–massive weight loss, when skin, fat, and muscle require simultaneous correction. [****Anatomy Review**](https://www.theplasticsfella.com/abdominoplasty/#anatomy-review-for-abdominoplasty) The abdominal wall receives segmental blood supply (Huger zones), contains the rectus muscles enclosed by the rectus sheath, and includes midline structures prone to diastasis. [****Surgical Techniques**](https://www.theplasticsfella.com/abdominoplasty/#surgical-techniques-for-abdominoplasty) Abdominoplasty involves low elliptical skin excision, rectus muscle plication, and umbilical repositioning. Variations like mini-, modified-, or lipoabdominoplasty are selected based on anatomy, Huger zones, and Matarasso classification. [****Complications**](https://www.theplasticsfella.com/abdominoplasty/#complications-of-abdominoplasty) Abdominoplasty presents a distinct complication profile. Local issues like seroma, wound healing delays, and contour irregularities are most common, while venous thromboembolism (VTE) remains the most serious systemic risk. ****Primary Contributor:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Abdominoplasty ****Key Point** Abdominoplasty is a contour-restoring procedure that removes excess skin and fat, repairs rectus diastasis, and enhances abdominal wall function, especially after pregnancy or massive weight loss. **Abdominoplasty**, commonly known as a **tummy tuck**, is a surgical procedure designed to restore **abdominal contour** by removing excess skin and fat and tightening the **rectus abdominis muscles**. It is most commonly performed after **massive weight loss** or **pregnancy**, where skin redundancy and muscle diastasis are present. The procedure improves **aesthetic proportions**, enhances **core stability**, and can improve **functional symptoms** such as posture-related back pain. Variations of the technique allow for tailoring based on **skin laxity**, **fat distribution**, and **patient-specific goals**. 😎 ****Fun Fact:** Beyond cosmetic benefits, abdominoplasty can significantly improve patients’ quality of life by alleviating issues related to skin irritation and poor posture. --- ## Clinical Indications for Abdominoplasty ****Key Point** Abdominoplasty is indicated for patients with skin laxity, excess panniculus, and rectus diastasis, typically postpartum or post–massive weight loss when skin, fat, and muscle require simultaneous correction. Appropriate patient selection is critical to achieving good outcomes. Candidates for abdominoplasty usually present with a combination of soft tissue excess and abdominal wall weakening that cannot be corrected by diet, exercise, or liposuction alone. ### Typical Candidates - **Postpartum Patients** - Rectus diastasis - Infraumbilical skin laxity - Altered umbilical position or contour - **Post-Massive Weight Loss (MWL) Patients** - Redundant pannus - Intertrigo or hygiene difficulties - Poor body image or restricted mobility - May benefit from extended or circumferential excisions - **Involutional (Age-Related) Changes** - Skin ptosis - Muscle attenuation - Lipodystrophy Diastasis of the rectus abdominis muscles is illustrated below. ![Diastasis of the rectus abdominis muscles, clinical indications for abdominoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Abdominoplasty--1--1.png) Diastasis of the rectus abdominis muscles ### Functional vs Aesthetic Indications While often sought for cosmetic improvement, abdominoplasty may offer functional benefits. - Improved **posture** and **core stability** through rectus plication. - Relief of **intertriginous dermatitis** and **ventral hernias**. - Rectus diastasis involves midline fascial stretching without a true fascial defect, distinguishing it from a ventral hernia. - Enhanced **mobility** and physical activity. - Improved **psychological well-being**. ### Contraindications **Absolute** - Active smoking - Uncontrolled diabetes - Coagulopathies - Severe cardiopulmonary comorbidities **Relative** - Significant **intra-abdominal fat** (not treatable via abdominoplasty) - Poor wound healing history - Unrealistic expectations 💡 ****Tip:** Mini-abdominoplasty or liposuction alone may lead to suboptimal results if not properly matched to the patient's anatomy and goals. --- ## Anatomy Review for Abdominoplasty ****Key Point** The abdominal wall receives segmental blood supply (Huger zones), contains the rectus muscles enclosed by the rectus sheath, and includes midline structures prone to diastasis. Key adherence zones influence flap undermining and safety. Safe and effective abdominoplasty depends on a strong understanding of abdominal wall anatomy, particularly vascular territories, muscular layers, and fascial transitions. Respecting these structures guides surgical planning and complication avoidance. ### Vascular Supply - Huger Zones The abdominal wall is divided into three vascular zones, which are critical for flap design and viability. **Zone I** - Supplied by the deep superior and inferior epigastric arcades. - Located between the rectus abdominis muscles, from xiphoid to pubis. **Zone II** - Supplied by superficial epigastric, superficial circumflex iliac, and branches of the inferior epigastric vessels. - Spans from ASIS line down to groin/pubic crease. **Zone III** - Supplied by intercostal, subcostal, and lumbar segmental vessels. - Includes the flanks and lateral abdomen. The Huger zones are composed of **angiosomes** of the source vessels incorporated in each zone. Huger zones of the abdominal wall are illustrated below. ![Huger zones of the abdominal wall](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Abdominoplasty--2--1.png) Huger zones of the abdominal wall 💡 ****Tip:** Preserving perforators in Zone III during dissection helps reduce flap necrosis risk. ### Musculofascial Layer - The **rectus abdominis** muscles run vertically and are enclosed in a rectus sheath - The **linea alba** is the fibrous midline prone to **diastasis recti** - **Plication** of the anterior sheath (xiphoid to pubis) restores core tension - Below the **arcuate line**, the posterior sheath is absent. Careful suture placement is required ### Zones of Adherence & Undermining **Key adherence zones** include, - Umbilicus - Lateral rectus edge - Inguinal ligament region **Dissection Tips** - Perform **inverted V undermining** to preserve lateral perforators. - Avoid extensive undermining to reduce seroma risk and flap ischemia. - In lipoabdominoplasty, use **selective undermining** to balance exposure and vascularity. ### Nerve Supply - Derived from **T7-T12** intercostal nerves + **L1** (iliohypogastric and ilioinguinal). - Injury during dissection may cause **transient suprapubic numbness**. --- ## Surgical Techniques for Abdominoplasty ****Key Point** Abdominoplasty involves low elliptical skin excision, rectus muscle plication, and umbilical repositioning. Variations like mini-, modified-, or lipoabdominoplasty are selected based on anatomy, Huger zones, and Matarasso classification. Abdominoplasty techniques vary according to patient anatomy, skin redundancy, and degree of muscle laxity. Most procedures follow the **abdominolipoplasty system of classification**, from liposuction alone to full lipoabdominoplasty. ### Pre-Operative Planning - **Patient Assessment:** Categorise according to [Matarasso](https://pubmed.ncbi.nlm.nih.gov/2035359/?ref=theplasticsfella.com) Types I-IV (based on skin excess, fat volume, and rectus laxity). - **Medication Review:** Discontinue anticoagulants and nicotine well in advance. - **VTE Prophylaxis:** Apply compression devices; pharmacologic anticoagulation as needed (based on Caprini score). - **Markings:** Plan a low transverse elliptical incision (hip-to-hip), \~6 cm above the introitus. Incorporate previous scars when possible. The Matarasso classification is summarised below. ![The Matarasso classification of abdominal wall anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Abdominoplasty--3--1.png) The Matarasso classification of abdominal wall anatomy ### Standard Technique (Type IV – Full Abdominoplasty) - **Anaesthesia:** General or regional with superwet tumescent infiltration (\~1 L). - **Liposuction:** Perform first (if lipoabdominoplasty), sparing lateral perforators (Zone III). - **Umbilicus:** Circumferential incision and isolation. - **Flap Elevation:** Dissect pannus using a vest-over-pants manoeuvre. Use inverted “V” undermining to preserve blood supply. - **Rectus Plication:** Performed in two layers from xiphoid to pubis ± horizontal waist-narrowing sutures ([Ian Jackson](https://pubmed.ncbi.nlm.nih.gov/622407/?ref=theplasticsfella.com) technique). - Performed using nonabsorbable or long-lasting absorbable sutures (e.g., PDS #1) in a running or interrupted pattern. Some surgeons prefer two-layer closure for tension distribution. - **Excision:** Remove excess infraumbilical skin/fat once flap mobility is confirmed with table flexion. - The table is flexed 30°–45° to facilitate flap advancement before final resection. Flexion should be tested before committing to skin excision to prevent closure under tension. - **Umbilical Transposition:** Via an inverted-V skin incision. - **Closure:** Layered closure with quilting sutures, Scarpa’s fascia approximation, and placement of two drains (more for MWL patients). - Two closed suction drains are typically placed in the lateral gutters, exiting through the pubic mons. They are removed when output is <30–40 mL over 24 hours for two consecutive days. 💡 ****Tip:** The “terrible triangle” (central lower abdomen) is at highest risk of necrosis. Careful undermining and preservation of Huger Zones I and III reduce this risk. ### Modified Techniques - **Mini-Abdominoplasty:** Lower diastasis only, no umbilical repositioning (Type II). - **Modified Abdominoplasty:** Partial diastasis, limited undermining (Type III). - **Fleur-de-lis** or **Circumferential Abdominoplasty:** For MWL with horizontal and vertical excess. ### Post-Operative Management - **Drains:** Removed once output <30–40 mL/day. - **Compression Garment:** Worn for 4–6 weeks continuously. - **Mobilisation:** Same-day ambulation encouraged (initially in walker posture). - **Pain Control:** Local anaesthetic infiltration and multimodal analgesia. - **Wound Care:** Continue antibiotics until drains are removed. - **Activity:** Return to full activity typically after 4–6 weeks. --- ## Complications of Abdominoplasty ****Key Point** Abdominoplasty presents a distinct complication profile. Local issues like seroma, wound healing delays, and contour irregularities are most common, while venous thromboembolism (VTE) remains the most serious systemic risk. While abdominoplasty is a commonly performed procedure with high patient satisfaction, it carries a **distinct profile of risks**, especially when combined with liposuction or performed in **massive weight loss (MWL)** patients. 😎 ****Fun Fact:** Reported complication rates range from 4% to 10%, with seroma being the most frequent, followed by scar-related issues and contour irregularities. ### Local Complications - The most common type (15–40%). - Often linked to extensive undermining, large flaps, and MWL. - **Prevention:** Closed suction drains, progressive tension sutures (quilting sutures), fibrin sealants, limited undermining. - **Seroma** - Seromas arise primarily from disrupted lymphatic drainage during flap elevation; quilting sutures reduce dead space and support lymphatic reattachment. - **Wound Complications** - **Dehiscence** and **skin necrosis** may occur at areas of high tension or poor vascularity. - The central infraumbilical area is particularly vulnerable. - **Risk Factors:** Smoking, tight closure, tension without progressive sutures. - **Umbilical Complications** - Malposition, flattening, or ischemia of the umbilicus. - More common with excessive traction or short stalks. - **Scar Issues** - High-riding scars, hypertrophic scars, or asymmetry. - May require revision in the late post-op period. - **Contour Irregularities** - Dog-ears, bulges, and uneven transitions. - Especially frequent in MWL patients or after overaggressive liposuction. 💡 ****Tip:** Quilting the flap to fascia reduces dead space and lowers seroma rates significantly. ### Systemic Complications While less common, systemic risks can be life-threatening if not anticipated. - **Venous Thromboembolism (VTE)** - Deep vein thrombosis (DVT) and pulmonary embolism (PE) are rare but potentially fatal. - Risk factors include age >40, BMI >25, smoking, prolonged surgery, and combined procedures. - **Prevention:** Caprini score assessment, sequential compression devices, early ambulation, and selective pharmacologic prophylaxis. Caprini score assessment is summarised below. ![Caprini score assessment for abdominoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Abdominoplasty--4-.png) Caprini score assessment for abdominoplasty - **Pulmonary Complications** - Hypoxia and atelectasis, particularly in smokers or high-BMI patients. - Prevented with incentive spirometry, early mobilization, and adequate analgesia. - **Readmission & Reoperation** - Most commonly for seroma drainage, wound care, or aesthetic revision. - More frequent in MWL patients and combined procedures. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Abdominoplasty is a contour-restoring procedure that simultaneously targets excess skin, adipose tissue, and diastasis recti, improving both abdominal shape and functional stability, particularly after pregnancy or massive weight loss. ****2\. Clinical Indications:** Ideal candidates are patients with abdominal wall laxity, redundant pannus, and muscle separation. Recognizing functional symptoms and patient-specific goals guides whether to pursue a full, modified, or limited approach. ****3\. Anatomy Review:** A safe and effective abdominoplasty requires understanding of Huger zones, rectus sheath anatomy, and zones of adherence, knowledge that ensures proper flap elevation, vascular preservation, and structural reinforcement. ****4\. Surgical Techniques:** The procedure involves low horizontal excision, rectus plication, and umbilical transposition. Technical variations, mini, lipo-, or fleur-de-lis, are selected based on Matarasso’s classification and tailored to each patient’s anatomy. ****5.** ****Complications:** Common risks include seroma, wound dehiscence, and contour irregularities; systemic events such as VTE, though rare, remain the most serious. Prevention relies on meticulous technique and appropriate perioperative protocols. --- ## Further Reading 1. Matarasso A, Matarasso DM, Matarasso EJ. Abdominoplasty: classic principles and technique. Clin Plast Surg. 2014 Oct;41(4):655-72\. doi: 10.1016/j.cps.2014.07.005\. PMID: 25283453. 2. Matarasso A. Abdominolipoplasty: a system of classification and treatment for combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg. 1991 Spring;15(2):111-21\. doi: 10.1007/BF02273843\. PMID: 2035359. 3. Jackson IT, Downie PA. Abdominoplasty--the waistline stitch and other refinements. Plast Reconstr Surg. 1978 Feb;61(2):180-3\. doi: 10.1097/00006534-197802000-00004\. PMID: 622407. 4. Martins MRC, Moraes BZF, Fabri DC, Castro HAS, Rostom L, Ferreira LM, Nahas FX. The Effect of Quilting Sutures on the Tension Required to Advance the Abdominal Flap in Abdominoplasty. Aesthet Surg J. 2022 May 18;42(6):628-634\. doi: 10.1093/asj/sjab395\. PMID: 34791039. 5. Sforza M, Husein R, Andjelkov K, Rozental-Fernandes PC, Zaccheddu R, Jovanovic M. Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective? Aesthet Surg J. 2015 Jul;35(5):574-80\. doi: 10.1093/asj/sju103\. Epub 2015 May 7\. Erratum in: Aesthet Surg J. 2015 Sep;35(7):902\. doi: 10.1093/asj/sjv171\. PMID: 25953479. 6. Brower JP, Rubin JP. Abdominoplasty After Massive Weight Loss. Clin Plast Surg. 2020 Jul;47(3):389-396\. doi: 10.1016/j.cps.2020.03.006\. Epub 2020 May 5\. PMID: 32448475. 7. Mendes FH, Donnabella A, Fagotti Moreira AR. Fleur-de-lis Abdominoplasty and Neo-umbilicus. Clin Plast Surg. 2019 Jan;46(1):49-60\. doi: 10.1016/j.cps.2018.08.007\. PMID: 30447828. 8. Nahas FX, Ferreira LM. Management of the Musculoaponeurotic Layer in Abdominoplasty. Clin Plast Surg. 2024 Jan;51(1):59-69\. doi: 10.1016/j.cps.2023.07.007\. Epub 2023 Sep 21\. PMID: 37945076. ### Giving Birth to a Textbook, 3 Local Anaesthetic Tricks, & Live Events URL: https://www.theplasticsfella.com/july-13th/ Last updated: 2025-07-13T12:59:27.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-13th/#a-letter-from-pfella) Giving birth to a textbook (a big one). 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/july-13th/#the-sunday-quiz) Check back next week! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-13th/#image-of-the-week) LA calculations summarised. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/july-13th/#technique-tip) How to inject local by Don Lalonde: Video. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/july-13th/#upcoming-events) Foundations launch event: Happening July 26th. 6. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/july-13th/#foundations-textbook) Take a peek inside! 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-13th/#articles-of-the-week) How to minimise LA pain, does mixing LA work?, & quick LA calculation: With 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/july-13th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **We Are About to Give Birth to the Textbook....* 👋 Creating a textbook from scratch is like trying to do a facelift in a sandstorm — no visibility, constant grit in your eye, and someone's always asking, **“Is this really necessary?”* Yes. It was. And now it’s real. What started as a vague, caffeine-fueled dream — *“Wouldn’t it be cool if residents had a textbook that didn’t suck?”* — somehow turned into hundreds of pages, weekly feedback cycles, too many Google Docs, and something we’re ridiculously proud of. No publisher. No institution. Just us, building what training forgot. ### It Took a Village. And Then Some. Every chapter? Edited, re-edited, and gently (or not-so-gently) torn apart by real trainees and real consultants. Every diagram? Agonized over by a design team who now knows what a keystone flap is — **and probably needs therapy because of it.** Every sentence? Vetted for clarity, relevance, and that mysterious vibe of “useful-but-not-so-dull-you-want-to-die.” The feedback loop never ended. It was a relay race of red pens and existential dread. But it worked. Because every step of the way, *someone cared enough to make it better.* ### This Isn’t Just a Book. It’s a System Reset. See, textbooks are usually written in towers — high up, far away, and years out of date by the time they hit your desk. Ours? Built from the ground up by the people in the trenches: - Residents who actually have to learn this stuff under pressure. - Fellows who still remember what it’s like to fail an OSCE station. - Consultants who want you to understand the *why*, not just memorize the *what*. It’s not perfect. **But it’s built to *keep getting better*. That’s the real flex.** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Textbook.png) Final Draft ### Only 500 Copies. This is just the first edition. Like plastic surgery itself, we built it to evolve quickly, responsively, and in full public view. If you’ve ever thought, *“Why isn’t this in the textbook?”. N*ow’s your chance to fix that. Because if we’re building the next generation of plastic surgery education, we’re doing it *together*. No gatekeepers. No committees. Just people who give a damn. Thanks for sticking with us. With love, P Fella ❤️ ## The Sunday Quiz **Under Development* **Check back next week for the fresh edition* ## Image of the Week **LA Calculations* 🖼️ ****Image of the Week** This week’s image breaks down how to calculate safe doses of local anaesthetic — a must-know for everyone in theatre. \- Maximum safe doses per kg for common LA agents. \- Total allowable dose limits. \- A quick formula for calculating maximum volume based on concentration. ![Maximum Volume of Local Anaesthetic](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-07-11T150705.248.png) Maximum Volume of Local Anaesthetic ## Technique Tip **How to Inject Local by Don Lalonde* 🚑 ****Technique Tip of the Week** This week’s technique tip features a classic from Don Lalonde: how to inject local anaesthetic safely, effectively, and painlessly. ▶️ Watch the video below ## Upcoming Events **Foundations Launch Event: Happening July 26th* 📅 We’re hosting our ****first-ever live event** to celebrate the launch of [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). It’s happening ****Saturday, 26th July**, and you’re invited. What to Expect: \- A look inside the textbook \- Behind-the-scenes insights \- Webinar by our fellows and experts More information coming soon! Sign up below! ## Foundations Textbook **Take a Peek Inside* 📘 Curious about what [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) will actually look like? We're nearly there! While we finalise the full release, here’s a sneak peek at a few sample pages from the textbook. Designed to be ****practical**, ****structured**, and ****easy to revisit** on the job or just before exams. Got feedback or suggestions? We’d love to hear from you. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Screenshot-2025-07-10-at-19.10.42.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Screenshot-2025-07-10-at-19.10.35-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Screenshot-2025-07-10-at-19.10.05-1.png) Foundations - Sample Images ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Minimising Pain During Local Anaesthetic Injection** ([Strazar](https://journals.lww.com/plasreconsurg/abstract/2013/09000/minimizing%5Fthe%5Fpain%5Fof%5Flocal%5Fanesthesia%5Finjection.30.aspx?ref=theplasticsfella.com), 2013) Simple adjustments to technique, such as needle gauge, buffering, slow infiltration, and patient communication, can reduce injection pain to just the initial needlestick, even for large tumescent fields. ✅ ****Ropivacaine Adds No Benefit to WALANT** ([Gricourt](https://www.jhandsurg.org/article/S0363-5023%2825%2900137-6/abstract?ref=theplasticsfella.com), 2025) Combining ropivacaine with lidocaine in WALANT surgery did not improve pain relief, quality of recovery, or reduce analgesia use compared to lidocaine alone. ✅ ****A Simple Method for LA Volume Calculations** ([Ahmed](https://www.jprasurg.com/article/S1748-6815%2823%2900288-7/abstract?ref=theplasticsfella.com), 2023) Calculate safe local anaesthetic volumes on the spot: Multiply the patient’s weight (kg) by the safe dose (mg/kg), then divide by the LA concentration (mg/mL) to get the maximum safe volume ## Feedback ### I hope you enjoyed it 😄 --- ### Rhinoplasty: Nasal Analysis, Assessment, & Surgical Techniques URL: https://www.theplasticsfella.com/rhinoplasty/ Last updated: 2025-07-10T20:32:28.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/rhinoplasty/#overview-of-rhinoplasty) Rhinoplasty is a functional and aesthetic procedure for nasal reshaping while maintaining/improving airway patency. Success relies on anatomical precision, deformity analysis, and surgical technique. [****Key Anatomy & Deformity Analysis**](https://www.theplasticsfella.com/rhinoplasty/#key-anatomy-deformity-analysis-for-rhinoplasty) Rhinoplasty begins with detailed anatomical analysis and deformity classification. Attention to dorsal lines, valve integrity, and skeletal relationships is essential to guide surgical planning. [****Patient Selection & Preoperative Assessment**](https://www.theplasticsfella.com/rhinoplasty/#preoperative-assessment-for-rhinoplasty) Successful rhinoplasty requires careful patient selection, clear functional and aesthetic indications, and thorough preoperative assessment to rule out psychological and medical contraindications. [****Surgical Techniques**](https://www.theplasticsfella.com/rhinoplasty/#surgical-techniques-for-rhinoplasty) Rhinoplasty follows an inside-out, top-down workflow; open approaches allow precise grafting and tip control, while closed approaches suit minor deformities. [****Complications**](https://www.theplasticsfella.com/rhinoplasty/#complications-of-rhinoplasty) Rhinoplasty complications may be functional, aesthetic, hemorrhagic, infectious, or traumatic. Early recognition and tailored management are vital for preserving outcome satisfaction and nasal function. ****Primary Contributor:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Rhinoplasty ****Key Point** Rhinoplasty is a functional and aesthetic procedure aimed at nasal reshaping while maintaining or improving airway patency. Success relies on anatomical precision, deformity analysis, and tailored surgical technique. Rhinoplasty is a surgical procedure that aims to reshape the nose to achieve harmonious facial proportions while maintaining or improving nasal airflow. Surgical success depends on a detailed understanding of nasal anatomy, precise analysis of deformities, and the application of refined surgical techniques. Rhinoplasty is among the most complex facial procedures due to the nose's functional role and central aesthetic importance. Modern approaches integrate structural and preservation principles for long-term stability. Although traditionally associated with cosmetic enhancement, modern rhinoplasty frequently addresses functional issues such as, - Nasal obstruction due to septal deviation or valve collapse. - Post-traumatic deformities. - Congenital or acquired airway compromise. The rise of “preservation rhinoplasty” and minimally invasive approaches has expanded the range of techniques available, offering new possibilities for individualized treatment. The ideal rhinoplasty result, - Appears natural and age-appropriate. - Preserves ethnic and gender-specific features. - Maintains stable internal support structures to avoid late complications (e.g., tip ptosis, saddle nose, airway issues). 😎 ****Fun Fact:** Despite its small size, the nose includes up to 9 aesthetic subunits ([Burget & Menick](https://pubmed.ncbi.nlm.nih.gov/4023097/?ref=theplasticsfella.com), 1985) . Even minor alterations can produce significant visual or functional changes. --- ## Key Anatomy & Deformity Analysis for Rhinoplasty ****Key Point** Successful rhinoplasty begins with detailed anatomical analysis and deformity classification. Attention to dorsal lines, valve integrity, and skeletal relationships is essential to guide surgical planning. A deep understanding of nasal anatomy allows accurate diagnosis of both functional and aesthetic deformities. These insights are crucial for choosing the correct surgical approach. For a comprehensive overview of nasal anatomy, including external subunits and structural relationships, refer to our article on [Anatomy of the Nose](https://www.theplasticsfella.com/anatomy-of-the-nose/). The nose is typically divided into three anatomical thirds. - **Upper Third:** Bony nasal vault. - **Middle Third:** Cartilaginous midvault (upper lateral cartilages + septum). - **Lower Third:** Nasal tip complex (lower lateral cartilages). **Functional Anatomy** - **Internal Nasal Valve (INV):** The narrowest portion of the nasal airway, formed by, - Septum. - Upper lateral cartilages (ULCs). - Inferior turbinates: A common site of obstruction. - **External Nasal Valve:** Includes the alar rim and lateral crura. Susceptible to collapse during inspiration, especially in post-op or structurally weak noses. The internal and external valves are illustrated below. ![Internal and external valves of the nose](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Rhinoplasty-.png) Internal and external valves of the nose **Common Nasal Deformities** Clear terminology aids communication and surgical planning. The table below summarises key classifications. ![Common nasal deformities](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Copia-di-Chemical-Peels.png) Common nasal deformities **Morphologic Classifications** - **Twisted Nose:** Long-axis deviation with rotational component. - **Deviated Nose:** Linear deviation of bony and cartilaginous structures. - **C-Shaped/S-Shaped:** Septal curvature, typically post-traumatic. - **Short Nose/Long Nose:** Assessed via dorsal length and nasolabial angle. - **Underprojected/Overprojected Tip:** Influences tip-lip balance and harmony. - **Wide/Narrow Alar Base:** Ethnically variable; critical for alar base management. 💡 ****Tip:** Assessment of aesthetic lines (brow-tip line, dorsal aesthetic line), tip rotation/projection, and nasal symmetry forms the backbone of preoperative analysis. --- ## Preoperative Assessment for Rhinoplasty ****Key Point** Successful rhinoplasty requires careful patient selection, clear functional and aesthetic indications, and thorough preoperative assessment to rule out psychological and medical contraindications. Rhinoplasty addresses both appearance and airway function. Careful evaluation of the patient’s goals, anatomy, and expectations is crucial for achieving safe and satisfying outcomes. ### Indications **Aesthetic** - Dorsal hump or irregular profile. - Nasal deviation or asymmetry. - Bulbous, boxy, or underprojected tip. - Wide alar base or flare. **Functional** - Septal deviation. - Internal or external valve collapse. - Airway obstruction (congenital, traumatic, or post-surgical). **Other** - Gender-affirming facial surgery. - Post-oncologic or post-traumatic reconstruction. - Revision after previous rhinoplasty. ### Preoperative Assessment A meticulous **history and examination** help define patient needs and detect red flags. **Functional History** - Nasal obstruction, congestion, or breathing difficulty. - Sleep apnea symptoms. - History of trauma, allergies, and sinusitis. **Aesthetic History** - Nature of dissatisfaction (specific vs vague). - Previous nasal surgeries or filler use. **Psychosocial Factors** - Unrealistic expectations. - Body dysmorphic disorder (BDD). - Life stressors, anxiety, & perfectionism. **Physical Examination** - **External:** Symmetry, projection, rotation, alar flare, dorsal lines. - **Internal:** Septal deviation, turbinate size, & valve area. - **Photographs:** Standard 5-view series for preoperative planning. - **Imaging:** CT scan if history of trauma or suspected structural pathology. 💡 ****Tip:** Use standardized 5-view photography to assess dorsal profile, alar flare, and tip symmetry. ### Contraindications **Psychological** - Suspected or confirmed BDD. - Inflexible expectations. - Poor understanding of limitations. **Medical** - Active nasal drug use (e.g., cocaine). - Uncontrolled systemic disease. - Poor wound healing or coagulopathy. - Incomplete skeletal maturity. - Recent nasal surgery (<12 months). 😎 ****Fun Fact:** The acronyms ****SIMON** (Single, Immature, Male, Over-expectant, Narcissistic) and ****SYLVIA** (Secure, Young, Listens, Verbal, Intelligent, Attractive) were once used to describe high-risk vs ideal rhinoplasty candidates, highlighting the importance of psychological screening. --- ## Surgical Techniques for Rhinoplasty ****Key Point** Rhinoplasty follows an inside-out, top-down workflow; open approaches allow precise grafting and tip control, while closed approaches suit minor deformities. Surgical steps differ in structural versus preservation techniques. The surgical strategy must match the patient’s anatomy and deformity. A logical sequence, inside-out and top-down, helps maintain orientation, control bleeding, and improve outcomes. ### General Workflow Most rhinoplasty procedures follow a top-down, inside-out order. - Start with **turbinate surgery**, if indicated. Proceeds with septal remodeling and then management of lateral walls and nasal tip, following a logical path that reduces redundancy and preserves structural integrity. - While some surgeons prefer to perform **septoplasty** first via a separate hemitransfixion incision, in this workflow, the septum is approached after **nasal exposure** has been obtained, especially in open rhinoplasty, which provides better access and avoids redundant incisions. - Then address the **bony vault** and **nasal tip**. 💡 ****Tip:** In open rhinoplasty, septoplasty is often done ****after** nasal exposure, allowing better access and fewer incisions. In closed rhinoplasty, septoplasty may require a separate hemitransfixion incision. ### Structural vs Preservation Rhinoplasty The order of surgical steps differs notably between structural and preservation techniques. **Structural Rhinoplasty** - Begins with **dorsal hump reduction** (cartilage then bone). - Then **septoplasty**, preserving a 10–15 mm L-strut. - Ensures a strong framework for tip support and grafting. 💡 ****Tip:** Resect the hump first to better assess septal integrity and avoid dorsal collapse. **Preservation Rhinoplasty** - Starts with **septal strip excision** to allow dorsum descent. - Then performs **osteotomies** to lower the dorsum en bloc. - Preserves dorsal lines, ligaments, and the keystone area. - Preservation rhinoplasty aims to lower the dorsum while maintaining its natural contour, using maneuvers that preserve soft tissue and cartilage continuity. In revision cases, the surgical plan often diverges from the standard workflow. Scar tissue, graft remnants, or altered anatomy may dictate changes in the sequence of dissection and reconstruction. ### Choosing the Surgical Approach **Open Rhinoplasty** - **Access:** Transcolumellar + marginal incisions. - **Pros:** Excellent exposure, accurate graft placement, & reproducibility. - **Cons:** Edema, longer healing, and a possible visible scar. - **Use:** Structural rhinoplasty, complex cases, revision, thick skin, major tip work, severe deviation. Incision options for open rhinoplasty are illustrated below. ![Incision options for open rhinoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Copia-di-Chemical-Peels-1.png) Incision options for open rhinoplasty **Closed Rhinoplasty** Also known as the endonasal approach, this technique avoids external incisions by accessing nasal structures through intranasal incisions (intercartilaginous or intracartilaginous). - **Access:** Intranasal incisions (endonasal). - **Pros:** No external scar, faster recovery, less soft tissue disruption. - **Cons:** Limited visibility, difficult grafting, technically more demanding. - **Use:** Minor aesthetic corrections, dorsal hump removal without major reconstruction. ### ### Septoplasty & Dorsal Hump Management Septoplasty improves airway function, corrects deviations, and supplies graft material; dorsal hump reduction shapes the nasal profile and must balance aesthetics with structural integrity. These two foundational steps shape the internal support and external contour of the nose. Performed early in the rhinoplasty workflow, they establish both form and function. **Septoplasty** - **Objectives** - Improve airflow. - Straighten the nasal dorsum. - Harvest cartilage for grafts. - **Technique** - In **open rhinoplasty**, the anterior septal angle is visualized after tip retraction. - In **closed rhinoplasty**, access is through a hemitransfixion incision. - Dissection is performed in the **submucoperichondrial plane**, preserving flap integrity and minimizing bleeding. - Deviated cartilage and bone are resected; straight septal cartilage is harvested. The L-strut is illustrated below. ![The L-strut](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Rhinoplasty-ok--1-.png) The L-strut 😎 ****Fun Fact:** Septoplasty is critical for dorsal straightening and as a foundation for tip projection. **Dorsal Hump Management** A dorsal hump may involve cartilage, bone, or both. Choose your approach based on the hump’s composition and the preservation or structural philosophy. - **Dorsal Resection (Structural Rhinoplasty)** - **Cartilage Resection:** Wedge removed from anterior septal angle to rhinion. - **Bone Reduction:** Done with rasp, osteotome, or piezotome. - **Risks** - Over-resection → Pollybeak deformity. - Incomplete bony removal → Step-off. - **Post-Resection:** Lateral osteotomies are often needed to close the open roof and restore vault symmetry. 💡 ****Tip:** Over-resection can lead to pollybeak deformity; insufficient bony reduction can leave a dorsal step-off. - **Dorsal Preservation** - Maintains the natural dorsum and continuity of key structures. - **Techniques** - **Push-Down:** A subdorsal septal strip is removed; the dorsum descends as a unit. - **Let-Down:** Adds lateral bony wedge resections to allow more significant lowering. Both techniques require precise osteotomies, often performed with a piezoelectric device to limit trauma and preserve bone edges. These resection techniques are illustrated below. ![Dorsal resection techniques](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Rhinoplasty-ok--2-.png) Dorsal resection techniques 💡 ****Tip:** These techniques preserve dorsal lines and require precise, symmetric osteotomies. ### Osteotomies Osteotomies reshape and realign the bony nasal vault, crucial for correcting width, deviation, asymmetry, and open roof deformities. These are controlled bone cuts that mobilize the nasal bones for repositioning. They follow dorsal hump reduction or facilitate en bloc descent in preservation rhinoplasty. Types of osteotomies include lateral osteotomies and medial osteotomies. **Lateral Osteotomies** Used to narrow the nasal vault, close open roofs, or correct asymmetries.Patterns include, - **High-Low-High** - Most common pattern. - Begins high at the nasofrontal suture. - Drops low along the nasofacial groove. - Curves back up near the piriform aperture. - Preserves the **Webster triangle** (supports the external valve). - Avoids **rocker deformity.** - **Other Patterns** - **Low-Low:** For stability, used in preservation or minor narrowing. - **High-Low:** For aggressive narrowing or realignment. Lateral osteotomy technique is illustrated below. ![Lateral osteotomy technique](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Rhinoplasty-ok--3-.png) Lateral osteotomy technique - **Approaches** - **Percutaneous (postage-stamp technique):** 2-3 mm osteotome through small external incisions. - **Endonasal:** Via mucosal incisions at the piriform rim. **Medial Osteotomies** - Placed **paramedian** to the septum. - Help collapse the dorsal vault. - Kept separate from lateral osteotomies to form **greenstick fractures** — flexible yet stable. Osteotomies in **dorsal preservation** are used to **mobilize the dorsum intact** rather than after resection. - **In Push-Down Techniques** - Medial and lateral osteotomies allow descent of the whole dorsum. - **In Let-Down Techniques** - **Intermediate osteotomies** remove bony wedges to create space for lowering. - Requires **precise symmetry** to avoid dorsal irregularity. 💡 ****Tip:** ****Piezoelectric devices** are favored in preservation for precise cuts and reduced trauma. **Realignment in Deviated Bony Vault** Additional steps for when the bony vault is significantly deviated. - **Transverse Root Osteotomy:** At the nasion to mobilize the nasal root. - **Intermediate Osteotomies:** On the opposite side of the deviation to allow realignment. - **Dorsal Septotomy:** If the perpendicular plate of the ethmoid obstructs full realignment. ### Nasal Tip Management Tip refinement balances projection, rotation, and contour. Techniques include cartilage-sparing excisions, suture modulation, and grafts for definition and support. Managing the nasal tip is one of the most intricate steps in rhinoplasty. Success relies on preserving structural support while reshaping cartilage for symmetry, projection, and aesthetic flow. **Anatomy and Common Deformities** - The **lower lateral cartilages (LLCs),** especially the **lateral crura,** influence tip width, contour, and alar support. - **Common Concerns:** Bulbous tip, boxy shape, tip ptosis, over- or under-projection, asymmetry. **Cephalic Trim** Removes excess cartilage from the upper (cephalic) lateral crus to narrow the tip and improve contour. - **Complete Strip:** Preserves 7–8 mm of cartilage for alar support. - **Incomplete Strip:** Removes additional cartilage (often wedge-shaped) to allow tip rotation. 💡 ****Tip:** Over-resection can cause long-term ****alar collapse**, especially in revision or thin-skinned patients. **Cephalic Turn-In Flap** An alternative to excision: the cephalic portion is folded inwards and sutured to itself. - Preserves structural support. - Narrows the supratip. - Reinforces the lateral crus for dynamic support. **Suture Techniques** Suture-based reshaping allows precise, reversible, and structural tip refinement. Common techniques include, - **Transdomal Sutures:** Narrow domal angle. - **Interdomal Sutures:** Improve symmetry. - **Columellar-Septal Sutures:** Adjust projection and rotation. - **Lateral Crural Steal/ Spanning Sutures:** Refine shape and strength. Suture types and their functions are summarised below. ![Suture types and their functions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Rhinoplasty-ok--4-.png) Suture types and their functions Transdomal and interdomal sutures are illustrated below. ![Transdomal and interdomal sutures](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Rhinoplasty-ok--5-.png) Transdomal and interdomal sutures 💡 ****Tip:** Suture techniques reduce the need for aggressive cartilage excision and provide durable results. ### Modifying the Alar Base The nasal base significantly influences overall nasal proportions, especially in frontal view. Alar base refinement is often the final step of rhinoplasty and requires conservative, symmetric adjustments to maintain harmony. **Indications** - Wide or flared nostrils. - Disproportionate base width in relation to the upper two-thirds of the nose. - Ethnic or congenital variants. - Over-widening after dorsal reduction or tip refinement. **Techniques** - **Sill Excision** - Removes a small wedge of tissue at the nasal sill (floor of nostril). - Primarily narrows the nostril base. - Must preserve the internal nasal valve. - **Weir Excision** - Crescent-shaped excision at the alar-facial groove. - Reduces alar flare and lateral fullness. - Can be combined with sill excision for greater effect. **Key Surgical Considerations** - Always plan with preoperative markings and photographs. - Ensure symmetric excision to avoid notching or visible asymmetry. - Incisions should follow natural creases to minimize visible scarring. - Conservative resection is critical. Overcorrection is difficult to reverse. ### Cartilage Grafting in Rhinoplasty Cartilage grafting enhances both the form and function of the nose. Grafts reinforce weakened structures, correct deformities, and improve nasal airflow, especially in structural rhinoplasty and revision cases. **Common Cartilage Sources** - **Septal Cartilage:** First choice; straight, strong, and easily accessible. - **Auricular (ear) Cartilage:** Curved and elastic; ideal for rim grafts and minor tip work. - **Costal (rib) Cartilage:** Used for major structural reconstructions. - **Cadaveric Cartilage (allograft):** Optional in select cases; risk of resorption or infection. Types of grafts and functions are summarised below. - **Spreader Grafts** - Placed between septum and upper lateral cartilages. - Restore internal valve angle and improve midvault symmetry. - Used in dorsal augmentation and to prevent inverted-V deformity. - **Dorsal Onlay Grafts** - Augment or restore the nasal dorsum in underprojected or saddle nose deformities. - Solid or diced cartilage wrapped in fascia (e.g., diced cartilage fascia graft). - **Extension Grafts** - Secured to caudal septum to project and stabilize the nasal tip. - Critical when medial crura are weak or absent. - **Columellar Strut Grafts** - Positioned between medial crura. - Passive support for the tip post-manipulation. - Does not significantly affect rotation unless combined with suture techniques. - **Shield Grafts** - Triangular grafts in front of the tip domes. - Increase tip projection and shape the infratip lobule. - Must be beveled to prevent contour irregularities. - **Cap Grafts** - Small grafts placed atop the domes. - Fine-tune symmetry and smooth contour. - Helpful in thin-skinned patients. - **Alar Rim Grafts** - Inserted along the alar margin in subalar tunnels. - Prevent or correct alar retraction and external valve collapse. - **Batten Grafts** - Reinforce lateral nasal walls to resist collapse during inspiration. - Positioned over LLCs and anchored to the piriform rim. - **Lateral Crural Strut Grafts** - Positioned underneath the lateral crura. - Straighten, support, and stabilize convex or weak LLCs. - Enhance tip definition and prevent alar collapse. 💡 ****Tip:** Always bevel visible graft edges, avoid overcorrection, and secure grafts with minimal tension to prevent displacement or warping. --- ## Complications of Rhinoplasty ****Key Point** Rhinoplasty complications may be functional, aesthetic, hemorrhagic, infectious, or traumatic. Early recognition and tailored management are vital for preserving outcome satisfaction and nasal function. Despite being a highly rewarding procedure, rhinoplasty carries a wide range of potential complications. These can arise intraoperatively, during recovery, or even years later. Understanding their mechanisms and early signs is essential for both prevention and management. ### Functional Complications **Nasal Obstruction** - **Causes:** Internal valve collapse, residual septal deviation, lateral wall insufficiency, poorly positioned grafts (e.g. spreaders or batten grafts). - **Less Common:** Synechiae, atrophic rhinitis, or empty nose syndrome after turbinate surgery. **Septal Perforation** - Typically iatrogenic, due to bilateral mucoperichondrial trauma during septoplasty. - **Small Perforations:** Asymptomatic. - **Large Perforations:** Whistling, crusting, bleeding, saddle deformity. **Hyposmia** - Temporary loss of smell due to trauma near olfactory mucosa. - Persistent cases may benefit from olfactory retraining therapy. **Rhinorrhoea** - Common in early recovery phase. - **Persistent or Clear Rhinorrhoea:** evaluate for cerebrospinal fluid (CSF) leak. ### Aesthetic Complications **Upper Third** - **Open Roof Deformity:** Inadequate osteotomy closure post-hump reduction. - **Step-Off or Rocker Deformity:** Due to asymmetrical or misplaced osteotomies. **Middle Third** - **Saddle Nose:** Over-resection of the septum. - **Inverted-V Deformity:** Collapse at ULC-septum junction. - **Pollybeak:** Excessive supratip fullness due to under-resection or scar buildup. **Lower Third** - **Alar Retraction or Notching:** Typically from over-resection of LLCs. - **Pinched Tip or Bossae:** From aggressive suture techniques or cartilage warping. - **Tip Malrotation or Asymmetry:** Improper grafting or suture imbalance. - **Tombstone Deformity:** Excessively prominent medial crura. ### Hemorrhagic Complications **Epistaxis** - Mild bleeding is expected early post-op. - Significant bleeding is rare and may require packing or cautery. **Septal Hematoma** - Requires urgent drainage to prevent cartilage necrosis and perforation. ### Infectious Complications **Cellulitis** - Rare (<1%); managed with antibiotics. - **Severe:** Consider toxic shock syndrome (urgent). **Wound Infection** - More likely with poor hygiene or manipulation. - Emphasize postoperative care and compliance. ### Traumatic & Neurologic Complications **Lacrimal Injury** - May occur with aggressive lateral osteotomies. - Presents as persistent tearing (epiphora). **Sensory Nerve Injury** - Numbness of the upper lip or maxillary incisors post-septoplasty. - Usually self-limiting. **Intracranial Complications** - Extremely rare (e.g., CSF leak, pneumocephalus, meningitis). - Require immediate neurosurgical referral. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Understand that rhinoplasty addresses both form and function, and success depends on respecting natural proportions while ensuring stable, long-term airway patency. ****2\. Key Anatomy & Deformity Analysis:** Surgical planning starts with detailed anatomical analysis. Learn to assess dorsal lines, tip support, and valve competence, and recognize common deformities like saddle nose, pollybeak, or twisted dorsum. ****3\. Patient Selection & Preoperative Assessment:** Success begins before the first incision. Identify surgical indications, rule out contraindications, and manage expectations through structured evaluation and communication. ****4\. Surgical Techniques:** Understanding the standard workflow; inside-out, top-down. Choose between open and closed approaches based on exposure needs. Understand the differences between structural and preservation. ****5\. Complications:** Complications can be functional, aesthetic, hemorrhagic, infectious, or traumatic. Learn to recognize the signs early, understand their anatomical basis, and manage them proactively to prevent long-term dissatisfaction or dysfunction. --- ## Further Reading 1. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985 Aug;76(2):239-47\. doi: 10.1097/00006534-198508000-00010\. PMID: 4023097. 2. Dibelius G, Hohman MH. Rhinoplasty Tip-Shaping Surgery. 2023 Mar 1\. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 33620827. 3. Daniel RK, Palhazi P. The Nasal Ligaments and Tip Support in Rhinoplasty: An Anatomical Study. Aesthet Surg J. 2018 Mar 14;38(4):357-368\. doi: 10.1093/asj/sjx192\. PMID: 29365051. 4. Rettinger G. Risks and complications in rhinoplasty. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2007;6:Doc08\. Epub 2008 Mar 14\. PMID: 22073084; PMCID: PMC3199839. 5. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984 Feb;73(2):230-9\. PMID: 6695022. 6. Friedman O, Ulloa FL, Kern EB. Preservation Rhinoplasty: The Endonasal Cottle Push-Down/Let-Down Approach. Facial Plast Surg Clin North Am. 2021 Feb;29(1):67-75\. doi: 10.1016/j.fsc.2020.08.006\. PMID: 33220845. 7. Mohebbi A, Azizi A, Tabatabaiee S. Repositioned lateral crural flap technique for cephalic malposition in rhinoplasty. Plast Surg (Oakv). 2015 Fall;23(3):183-8\. doi: 10.4172/plastic-surgery.1000933\. PMID: 26361626; PMCID: PMC4557710. 8. Carlos Neves J, Toriumi DM, Göksel A. Dorsal Preservation Rhinoplasty. Facial Plast Surg Clin North Am. 2024 Nov;32(4):585-602\. doi: 10.1016/j.fsc.2024.06.010\. Epub 2024 Aug 10\. PMID: 39341675. 9. Toriumi DM, Kovacevic M, Kosins AM. Structural Preservation Rhinoplasty: A Hybrid Approach. Plast Reconstr Surg. 2022 May 1;149(5):1105-1120\. doi: 10.1097/PRS.0000000000009063\. Epub 2022 Mar 9\. PMID: 35259146. 10. Çakır B, Genç B, Finocchi V, Haack S. My Approach to Preservation Rhinoplasty. Facial Plast Surg Clin North Am. 2023 Feb;31(1):25-43\. doi: 10.1016/j.fsc.2022.08.014\. PMID: 36396287. 11. Spataro EA, Most SP. Tongue-in-Groove Technique for Rhinoplasty: Technical Refinements and Considerations. Facial Plast Surg. 2018 Oct;34(5):529-538\. doi: 10.1055/s-0038-1670647\. Epub 2018 Sep 14\. PMID: 30216946. ### Financial Incentives Only Work in the Short Term, 3 Scalp Flap Tips, & Quiz Winners URL: https://www.theplasticsfella.com/july-6th/ Last updated: 2025-07-05T18:14:31.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-6th/#a-letter-from-pfella) Financial Incentives Only Work in the Short Term 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/july-6th/#the-sunday-quiz) \*Drumroll🥁\* announcing new winners! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/july-6th/#image-of-the-week) Scalp layers in cross-section. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/july-6th/#technique-tip) Rotation flap step 2: Identify the pivot point. 5. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/july-6th/#the-fellows-corner) This week's feature: Scalp recon**.* 6. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/july-6th/#foundations-textbook) Timeline update 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/july-6th/#articles-of-the-week) Type of skin graft for the scalp, algorithm for scalp recon, & Orticochea original description: With 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/july-6th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella ****Financial Incentives Only Work in the Short Term** 👋 If your system needs a bonus to function, it’s already broken? A new BMJ review of the UK’s pay-for-performance scheme (QOF) just confirmed it—financial incentives boost activity in year one, then flatline. Remove the cash, and quality crashes. ### The Short-Term Game - **Immediate Uptick, No Loyalty** Throw money at a metric and you’ll get activity—fast. QOF saw a 6% jump in year one. But was the care better, or just the record-keeping? - **Year Three? Back to Business As Usual** By year three, those gains disappeared. In some cases, quality dropped below baseline. Once incentives ended, the decline was sharper than the initial bump. - **Paperwork ≠ Care** The review nailed it: better documentation doesn’t mean better outcomes. Just like counting letters doesn’t measure surgical skill. It’s metric theatre. - **The Plastic Surgery Problem** Our field is full of “performance” goals that look good but change nothing. Antibiotics within 60 minutes? Fine. But did it help the wound heal? Did the flap survive? We’re measuring what’s easy, not what matters. And when money leads, culture follows—in the wrong direction. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Screenshot-2025-07-05-at-19.14.03.png) Financial incentives give a quick sugar hit, then fade. They don’t fix culture, build quality, or improve training. Worse—they distract us from the real work and crowd out intrinsic motivation. **These schemes don’t build habits—they rent behaviour.** With love, P Fella ❤️ ## The Sunday Quiz **\*Drumroll🥁\* Announcing New Winners!* ****Congratulations to the Winners** of The Weekly Quiz! We're thrilled to announce the winners of this edition's quiz. After seven rounds of questions on plastic surgery, our top scorers are ****AL** and ****Elektra**. They’ll each receive a copy of our upcoming textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com), once it’s released. Thanks to everyone who took part, and stay tuned for the next round! ![Leaderboard - July](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Leaderboard-Team-Post-Template--6-.png) Leaderboard - July ## Image of the Week **Scalp Layers in Cross-Section* 🖼️ ****Image of the Week** This week’s image breaks down the layered anatomy of the scalp — a key concept in reconstruction planning. From skin to dura: ****\- Skin** ****\- Subcutaneous tissue** ****\- Galea aponeurotica** ****\- Pericranium** ****\- Cranial bone** ****\- Dura, arachnoid, and pia mater** Knowing where to and where not to dissect matters when designing flaps, elevating tissue, or managing trauma. ![Scalp Layers in Cross-Section](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/image-1.png) Scalp Layers in Cross-Section ## Technique Tip **Rotation Flap Step 2: Identify the Pivot Point* 🚑 ****Technique Tip of the Week** This week’s technique tip focuses on the second step in designing a rotation flap: Identifying the pivot point 📍 Your pivot point is a geometric anchor that determines the arc of movement, tension vectors, and success of closure. \- The ****true pivot** lies at the centre of the semicircle. \- The ****functional pivot** dictates tension and flap excursion. \- An ****anteriorly displaced pivot** makes closure tougher. ****✏️ Pro Tip:** Extending the flap radius by adjusting triangle length improves reach and reduces closure tension. ![Rotation Flap: Identifying the Pivot Point](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/image-2.png) Rotation Flap: Identifying the Pivot Point ## the Fellows' Corner **This Week's Feature: Scalp Reconstruction* 🎓 ****the Fellows' Corner** This week’s feature dives into the principles and challenges of reconstructing the scalp, from anatomy to flap design, grafts, and strategies for dealing with avulsion injuries. Check out the full article breakdown below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Main-Article-Images---2025-06-17T170855.578.png) #### Scalp Reconstruction [****Overview**](https://www.theplasticsfella.com/scalp-reconstruction/#overview-of-scalp-reconstruction) The scalp is hair-bearing, thick, and inelastic skin covering the convex cranium; its reconstruction is uniquely challenging due to its anatomy, vascularity, and cosmetic implications. [****Anatomy**](https://www.theplasticsfella.com/scalp-reconstruction/#anatomy-of-the-scalp) The scalp is composed of five distinct anatomical layers: Skin, connective tissue, aponeurosis (galea), loose areolar tissue, and pericranium; each with surgical relevance. [****Surgical Technique**](https://www.theplasticsfella.com/scalp-reconstruction/#surgical-technique-for-scalp-reconstruction) Scalp reconstruction follows the reconstructive ladder, with closure method chosen based on defect size and complexity, ranging from primary closure and grafts to local, regional, or free flaps. [****Adjunctive Techniques**](https://www.theplasticsfella.com/scalp-reconstruction/#adjunctive-techniques-for-scalp-reconstruction) Allografts, tissue expanders, and scalp replantation techniques serve as vital adjuncts or salvage strategies when standard reconstructive options are limited by tissue quality, defect size, or traumatic presentation. [Read the Article](https://www.theplasticsfella.com/scalp-reconstruction/) ## Foundations Textbook **Timeline Update* 📘 We’re now planning to release the textbook in ****August**, slightly later than the original target of July. The extra time is going toward making some improvements and finishing work on the ****web companion** that will go alongside the book. Thanks for bearing with us — we’re making sure to deliver the best-quality textbook to your hands! ![Student Guide Progress Update - July](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/07/Student-Guide-Progress-Update--3-.png) Student Guide Progress Update - July 📅 ****Save the Date** We’re planning a live online event ahead of [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) launch, so mark your calendars for ****26th July**. This will be P'fells's first official event, and we’d love to see you there. More details coming soon! ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Full- vs Split-Thickness Grafts for Scalp Defects** ([Zhao](https://www.jprasurg.com/article/S1748-6815%2823%2900612-5/abstract?ref=theplasticsfella.com), 2024) Full-thickness grafts outperform split-thickness grafts in scalp reconstruction, especially over exposed bone, with higher integration rates & fewer complications when a vascular bed is ensured. ✅ ****A Roadmap for Scalp Tumor Reconstruction** ([Iblher](https://journals.lww.com/plasreconsurg/abstract/2010/08000/an%5Falgorithm%5Ffor%5Foncologic%5Fscalp%5Freconstruction.13.aspx?ref=theplasticsfella.com), 2010) This 10-year study proposes a stepwise algorithm for scalp reconstruction, guiding when to opt for local flaps, primary closure, or free tissue transfer to optimize oncologic and functional outcomes. ✅ ****Original Publication: Four-Flap Technique for Large Scalp Defects** ([Orticochea](https://www.jprasurg.com/article/S0007-1226%2867%2980032-8/pdf?ref=theplasticsfella.com)) Orticochea's geometric four-flap method enables tension-free closure of extensive occipital scalp defects without skin grafts, using overlapping rotational flaps to redistribute pressure & preserve vascular supply. ## Feedback ### I hope you enjoyed it 😄 --- ### Upper Eyelid Anatomy: Layers, Neurovascular Supply, & Clinical Applications URL: https://www.theplasticsfella.com/upper-eyelid-anatomy/ Last updated: 2025-06-30T18:35:01.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/upper-eyelid-anatomy/#overview-of-upper-eyelid-anatomy) The upper eyelid is a tri-lamellar structure composed of anterior, middle, and posterior layers, each contributing to protection, elevation, and lubrication of the eye. [****Anterior Lamella**](https://www.theplasticsfella.com/upper-eyelid-anatomy/#anterior-lamella) The anterior lamella includes the skin and orbicularis oculi muscle. It plays a central role in eyelid movement, protection, and facial expression. [****Middle Lamella**](https://www.theplasticsfella.com/upper-eyelid-anatomy/#middle-lamella) The middle lamella of the upper eyelid includes the pre-septal fat, orbital septum, and post-septal fat pads. It separates the anterior and posterior lamellae and plays a crucial role in structure and pathology. [****Posterior Lamella**](https://www.theplasticsfella.com/upper-eyelid-anatomy/#posterior-lamella) The posterior lamella comprises the upper eyelid retractors (levator palpebrae superioris and Müller’s muscle), the tarsal plate, and the palpebral conjunctiva. [****Neurovascular Supply**](https://www.theplasticsfella.com/upper-eyelid-anatomy/#naurovascular-supply-of-the-upper-eyelid) The upper eyelid receives dual blood supply from the internal and external carotid systems and is innervated by cranial nerves III, V, and VII. Infections here can spread intracranially, posing serious risks. [****Clinical Applications**](https://www.theplasticsfella.com/upper-eyelid-anatomy/#clinical-applications-of-upper-eyelid-anatomy) Understanding upper eyelid anatomy is critical in oculoplastic surgery to preserve function, avoid complications, and achieve aesthetic outcomes. ****Primary Contributor:** Dr Carissa J. Jacobs ****Verified by thePlasticsFella ✅** --- ## Overview of Upper Eyelid Anatomy ****Key Point** The upper eyelid is a tri-lamellar structure composed of anterior, middle, and posterior layers, each contributing to protection, elevation, and lubrication of the eye. The eyelids are thin, highly mobile structures critical for protecting the eye, maintaining corneal hydration, and contributing to facial aesthetics. Blinking distributes the tear film evenly and supports drainage via the lacrimal system. Anatomically, the eyelids are divided into upper and lower components, which meet at the medial and lateral canthi. The space between them is the palpebral aperture. The upper eyelid has a tri-lamellar structure: anterior, middle, and posterior, each containing specific elements that serve mechanical and physiological roles. Layers of the upper eyelid are illustrated below. ![Layers of the upper eyelid](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T140445.895.png) Layers of the upper eyelid **Layers of the Upper Eyelid from Superficial to Deep** 1. Skin 2. Orbicularis Oculi 3. Pre-septal Fat 4. The Orbital Septum 5. Post-Septal Fat 6. Levator Palpebrae Superioris 7. Müller’s Muscle (Superior Tarsal Muscle) 8. Tarsal Plate 9. Conjunctiva The lamellae, their structures, and functions are summarised below. ![The lamellae, their structures, and functions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T135611.710.png) The lamellae, their structures, and functions 💡 ****Tip:** ****Mnemonic:** Anatomy of the upper eyelid is best remembered by the “Rule of 1, 2, 3 4”. ****1 Eye** ****2 Eyelids:** Upper & Lower ****3 Lamellae:** Anterior, Middle, Posterior ****4 Structures per lamella:** \- ****Anterior:** Skin, Orbital Orbicularis, Palpebral Orbicularis, Lacrimal portion \- ****Middle:** Pre-septal fat, Orbital septum, Medial & Central Post-Septal Fat \- ****Posterior:** Levator aponeurosis, Müller’s muscle, Tarsal plate, Conjunctiva --- ## Anterior Lamella ****Key Point** The anterior lamella includes the skin and orbicularis oculi muscle. It plays a central role in eyelid movement, protection, and facial expression. The anterior lamella is the most superficial layer of the upper eyelid. It consists of thin, mobile skin and the orbicularis oculi muscle, both of which are vital to normal eyelid function and relevant in aesthetic and functional eyelid surgery. ### Skin - Among the **thinnest skin** in the human body (\~1 mm). - **Loosely adherent** to the underlying muscle. - **Lacks subcutaneous fat**, making it prone to oedema and bruising. - Contains, - **Eyelashes**. - **Glands of Moll** (modified sweat glands). - **Glands of Zeis** (sebaceous glands). **Clinical Note: Dermatochalasis** (excess eyelid skin) may mimic ptosis by creating upper lid heaviness and visual field obstruction (**pseudoptosis**). Surface anatomy of the eye is illustrated below. ![Surface anatomy of the eye](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T141107.675.png) Surface anatomy of the eye 😎 ****Fun Fact:** The upper eyelid crease is formed by the insertion of anterior levator aponeurosis fibres into the skin and pretarsal orbicularis oculi. The eyelid fold (superior palpebral sulcus) is a skin drape above the crease, influenced by, \- Orbital septum attachment to the levator. \- Preaponeurotic fat pad position and volume. ### Orbicularis Oculi Muscle A concentric **striated muscle** encircling the palpebral fissure, the orbicularis oculi is divided into functional parts. - **Orbital Part** - **Location:** Outermost portion surrounding the orbital rim. - **Function:** **Voluntary eyelid closure** (e.g., squinting). - **Palpebral Part** - **Pre-Septal:** Lies over the orbital septum - Voluntary and involuntary blinking. - **Pre-Tarsal:** Lies over the tarsal plate - Involuntary blinking and tear film spread. - **Lacrimal Part** - **Location:** Deep at the medial canthus. - **Function:** **Compresses the lacrimal sac**, aiding tear drainage. **Attachments** - **Origin** - Medial orbital margin - Medial palpebral ligament - Lacrimal bone - **Insertion** - Lateral palpebral raphe - Skin around the orbit and tarsal plates - **Innervation** - **Facial Nerve (CN VII):** Temporal & zygomatic branches The orbicularis oculi is illustrated below. ![The orbicularis oculi](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T141803.335.png) The orbicularis oculi --- ## Middle Lamella ****Key Point** The middle lamella of the upper eyelid includes the pre-septal fat, orbital septum, and post-septal fat pads. It separates the anterior and posterior lamellae and plays a crucial role in structure and pathology. The middle lamella sits between the anterior (skin and orbicularis) and posterior (tarsus and retractors) lamellae. It provides structural separation and contains key fat compartments that influence upper eyelid contour. ### Pre-Septal Fat - Located between the orbital septum and the orbicularis oculi muscle. - In the upper lid, this is called **retro-orbicularis oculi fat (ROOF)**. - Contributes to upper lid **hooding and puffiness**. ### Orbital Septum - A **thin, fibrous membrane** and extension of the orbital periosteum. - Originates at the **orbital rim** (arcus marginalis). - Inserts into the **levator aponeurosis** or directly onto the **tarsal plate** (anatomical variation — more common in Asian populations). - Functions of the orbital septum include, - Physically separates **pre-septal** from **post-septal** space (key in distinguishing pre-septal vs orbital cellulitis). - Contains the **orbital fat pads**. - Serves as an **insertion point** for the levator aponeurosis. - Contributes to the division between the **anterior and posterior lamellae**. - **Clinical Note:** Weakening of the septum may allow **pseudoherniation of intra-orbital fat**, leading to visible eyelid “bags”. The orbital septum is illustrated below. ![The orbital septum](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T142032.429.png) The orbital septum ### Post-Septal Fat (Pre-Aponeurotic Fat) - Lies between the **orbital septum** and **levator aponeurosis**. - Composed of two distinct compartments. - **Medial fat pad** - **Central fat pad** - These are separated by the **trochlea of the superior oblique muscle**. - **Clinical Relevance:** The position and volume of post-septal fat are important in pre-op evaluation of **ptosis** and are carefully managed in **blepharoplasty** to avoid contour deformity. 💡 ****Tip:** The ****gray line** along the eyelid margin is a vital surgical landmark, marking the natural division between anterior and posterior lamellae, useful for eyelid margin repair. --- ## Posterior Lamella ****Key Point** The posterior lamella comprises the upper eyelid retractors (levator palpebrae superioris and Müller’s muscle), the tarsal plate, and the palpebral conjunctiva. This deep lamella houses the key functional components that control eyelid elevation, shape, and eyelid-globe contact. Understanding this layer is essential in ptosis repair, reconstruction, and oculoplastic surgery. ### Levator Palpebrae Superioris (LPS) - A **triangular muscle** responsible for voluntary eyelid elevation. - **Origin:** Lesser wing of the sphenoid (superior to the optic foramen). - **Course:** Runs anteriorly along the orbit, **above the superior rectus**, then fans out into the **levator aponeurosis**. - **Insertion** - Deep fibres insert onto the **superior tarsal plate**. - Superficial fibres insert onto the **upper eyelid skin** via the aponeurosis. - **Innervation:** Superior division of the oculomotor nerve (CN III). - **Function** - Elevates the upper eyelid. - Opposed by the orbicularis oculi muscle. - **Whitnall's ligament** (superior transverse ligament) is a fibrous band formed by condensation of LPS sheaths. - Located \~14–20 mm above the tarsus. - Acts as a fulcrum, redirecting muscle force from horizontal to vertical. The levator palpebrae superioris is illustrated below. ![The levator palpebrae superioris](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T142158.075.png) The levator palpebrae superioris ### Müller’s Muscle (Superior Tarsal Muscle) - A **smooth muscle** that lies deep to the levator aponeurosis. - **Origin:** From the **deep surface of the LPS**. - **Insertion:** Onto the **superior tarsal plate**. - **Innervation: Sympathetic fibres** from the **superior cervical ganglion**. - **Function** - Provides **\~2 mm of eyelid elevation**. - Maintains **baseline eyelid tone**. 💡 ****Tip:** Damage to sympathetic input (e.g., in ****Horner’s syndrome**) leads to ****mild ptosis** due to Müller’s muscle paralysis. ### Superior Tarsal Plate - **Dense, crescent-shaped connective tissue structure**. - Lies deep to the orbicularis oculi, providing mechanical support and shape. - **Dimensions** - **Width:** \~25-30 mm. - **Height:** \~10-12 mm centrally. - **Thickness:** \~1 mm. - **Content:** Contains **30–40 meibomian glands**, producing the **lipid layer** of the tear film. - **Attachments** - **Medially and Laterally:** Anchored by the canthal tendons to the orbital rim. - **Superiorly:** Insertion site of the **levator aponeurosis**. The superior tarsal plate is illustrated below. ![The superior tarsal plate](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T142600.908.png) The superior tarsal plate 😎 ****Fun Fact:** The ****tarsal plate** gives the eyelid its shape and rigidity, while ****Müller’s muscle** (attached to it) helps with eyelid lift. Don’t confuse the two! ### Conjunctiva - **Innermost layer** of the eyelid. - A thin, transparent **mucous membrane**. - Composed of **non-keratinised stratified columnar epithelium** and **lamina propria**. - **Divisions** - **Palpebral Conjunctiva**: Lines the posterior eyelid. - **Bulbar Conjunctiva**: Reflects onto the globe, covering the sclera. - **Function** - Secretes **mucin** via goblet cells (essential for tear film stability). - Maintains a **lubricated surface** for smooth eyelid-globe interaction. Conjunctival anatomy is illustrated below. ![Conjunctival anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T142737.211.png) Conjunctival anatomy --- ## Neurovascular Supply of the Upper Eyelid ****Key Point** The upper eyelid receives dual blood supply from internal and external carotid systems and is innervated by cranial nerves III, V, and VII. Infections here can spread intracranially, posing serious risks. The rich vascular and neural network of the upper eyelid supports its mobility, sensation, and healing capacity. Surgical planning must preserve these structures to avoid complications such as ptosis, ischemia, or sensory loss. ### Arterial Supply - **Main Supply:** **Ophthalmic artery** (branch of the internal carotid artery), which gives rise to, - **Marginal arcade** along the **tarsal border**. - **Peripheral arcade** located more **superficially**. - These arcades anastomose medially and laterally with branches of the external carotid artery. - **Facial artery** → Angular artery (medial canthus). - **Superficial temporal artery** (lateral canthus). - **Infraorbital artery** (lower eyelid). ### Venous Drainage - **Follows arterial pathways**. - Major drainage routes - **Superior ophthalmic vein** → **Cavernous sinus**. - **Facial vein** (via angular vein) → **Internal jugular vein**. - **Clinical relevance:** Infection in the **medial upper eyelid** can track through the **angular vein** to the **cavernous sinus**, potentially causing **cavernous sinus thrombosis** — a life-threatening condition. The sensory innervation of the upper eyelid is primarily by the ophthalmic division of CN V (V1). ![The sensory innervation of the upper eyelid](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-25T143023.950.png) The sensory innervation of the upper eyelid ### Sensory Innervation - Supplied primarily by **CN V1** (ophthalmic division of the trigeminal nerve). - **Supraorbital Nerve:** Upper central eyelid. - **Supratrochlear Nerve:** Upper medial eyelid. - **Lacrimal Nerve:** Upper lateral eyelid. - These provide fine touch, temperature, and pain sensation to the upper eyelid skin and conjunctiva. ### Motor Innervation - **Orbicularis Oculi:** **Facial nerve (CN VII)** — temporal and zygomatic branches. - **Levator Palpebrae Superioris:** **Oculomotor nerve (CN III)** — superior division. - **Müller’s Muscle:** **Sympathetic fibres** from the **superior cervical ganglion**. --- ## Clinical Applications of Upper Eyelid Anatomy ****Key Point** Understanding upper eyelid anatomy is critical in oculoplastic surgery to preserve function, avoid complications, and achieve aesthetic outcomes. The upper eyelid’s layered anatomy and neurovascular supply guide surgical planning and technique. Common procedures like blepharoplasty, ptosis repair, and reconstruction require precise anatomical knowledge to minimise complications and optimise results. ### Blepharoplasty - **Goal:** Rejuvenate the eyelid by removing excess skin, muscle, and/or fat. - Over-resection of skin or orbicularis oculi may cause lagophthalmos (inability to close the eye). - Identifying and preserving preaponeurotic fat pads prevents a hollowed appearance. - Avoid damaging the levator aponeurosis to prevent iatrogenic ptosis. ### Ptosis Repair - **Goal:** Restore upper eyelid elevation. - Requires accurate identification of the levator aponeurosis and its insertion on the tarsal plate. - Important to distinguish true ptosis (levator dysfunction) from pseudoptosis (due to dermatochalasis). - Müller’s muscle procedures (e.g. MMCR) may be used for mild ptosis. ### Eyelid Reconstruction - **Goal:** Reconstruct the eyelid after trauma or tumour excision using a lamellar approach. - Both anterior (skin, muscle) and posterior (tarsus, conjunctiva) lamellae must be reconstructed. - **Posterior Lamella Options:** Tarsoconjunctival grafts, hard palate mucosa. - **Anterior Lamella Options:** Skin grafts, local flaps. - Maintain lid-globe apposition and levator function. ### Aesthetic Considerations - The supratarsal crease forms where the levator aponeurosis inserts into the skin. - \~8-10 mm above lash line in Caucasians - \~6-8 mm in Asians - Excessive fat removal leads to a sunken eye appearance. - Preserving orbicularis tone prevents lid laxity or ectropion. ### Neurovascular Considerations - Facial nerve (CN VII) injury → impaired orbicularis function → exposure keratopathy. - Oculomotor nerve (CN III) supplies LPS; damage causes ptosis. - Sympathetic fibres innervate Müller’s muscle; disruption causes mild ptosis. - Preserve the internal and external carotid branches to avoid ischemia. 😎 ****Fun Fact:** The earliest known eyelid surgery was described in Ancient India around 600 BCE in the Sushruta Samhita — an early reference to reconstructive eyelid surgery. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** The upper eyelid is a tri-lamellar structure (anterior, middle, posterior) essential for eye protection, blinking, tear distribution, and facial aesthetics. ****2\. Anterior Lamella:** Composed of skin and orbicularis oculi muscle, it controls blinking and protects the eye; also forms the upper lid crease. ****3\. Middle Lamella:** Includes pre- and post-septal fat and the orbital septum, separating lid layers and influencing contour & fat herniation. ****4\. Posterior Lamella:** Contains the levator muscle, Müller’s muscle, tarsal plate, and conjunctiva—responsible for eyelid elevation, shape, and lubrication. ****5\. Neurovascular Supply:** Supplied by branches of CN III, V1, VII and dual arterial arcades; infections in this area risk cavernous sinus thrombosis. ****6\. Clinical Significance:** Key anatomy for safe and aesthetic surgery underpins blepharoplasty, ptosis repair, and eyelid reconstruction techniques. --- ## Further Reading 1. Gray H. [Anatomy of the human body](https://www.bartleby.com/lit-hub/anatomy-of-the-human-body/pages-380?ref=theplasticsfella.com). 20th ed. 1918\. 2. Hwang K. Surgical anatomy of the upper eyelid relating to upper blepharoplasty or blepharoptosis surgery. Anat Cell Biol. 2013 Jun;46(2):93-100\. doi: 10.5115/acb.2013.46.2.93\. Epub 2013 Jun 30\. PMID: 23869256; PMCID: PMC3713284. 3. Cochran ML, Lopez MJ, Czyz CN. [Anatomy, Head and Neck: Eyelid](https://www.ncbi.nlm.nih.gov/books/NBK482304/?ref=theplasticsfella.com). \[Updated 2023 Aug 14\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. 4. Tong J, Lopez MJ, Fakoya AO, Patel BC. Anatomy, Head and Neck: Orbicularis Oculi Muscle. 2024 May 25\. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 28722936. 5. Ludwig PE, Aslam S, Czyz CN. Anatomy, Head and Neck: Eye Muscles. 2023 Aug 7\. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 29262013. 6. Chang EI, Esmaeli B, Butler CE. Eyelid Reconstruction. Plast Reconstr Surg. 2017 Nov;140(5):724e-735e. doi: 10.1097/PRS.0000000000003820\. PMID: 29068942. 7. Dave T, Sabeti S, Patel BC. [Anatomy, Head and Neck: Eye, Superior Tarsal Muscle (Müller Muscle)](https://www.ncbi.nlm.nih.gov/books/NBK540964/?ref=theplasticsfella.com) \[Updated 2024 Oct 5\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. 8. Harris, G. J., & Logani, S. C. (2011). [Reconstructive designs for the eyelids](https://doi.org/10.1016/j.otot.2011.01.001?ref=theplasticsfella.com). Operative Techniques in Otolaryngology–Head and Neck Surgery, 22(1), 2–10\. 9. [Upper Eyelid Blepharoplasty: An Approach for a Simplified, Safe and Effective Procedure](https://www.researchgate.net/figure/Anatomy-of-the-eyelids-and-periorbital-area-1%5Ffig1%5F383856271?ref=theplasticsfella.com) \- Scientific Figure on ResearchGate. ### Velopharyngeal Dysfunction (VPD): Anatomy, Clinical Assessment, & Surgical Management URL: https://www.theplasticsfella.com/velopharyngeal-dysfunction/ Last updated: 2025-06-30T18:28:46.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/velopharyngeal-dysfunction/#overview-of-velopharyngeal-dysfunction) Velopharyngeal dysfunction (VPD) is the inability to close the velopharyngeal sphincter during speech, resulting in hypernasal speech, nasal air escape, poor oral pressure, and reduced intelligibility. [****Relevant Anatomy**](https://www.theplasticsfella.com/velopharyngeal-dysfunction/#relevant-anatomy-for-velopharyngeal-dysfunction) The velopharyngeal (VP) sphincter is a dynamic muscular valve made up of the soft palate (velum) and the lateral and posterior pharyngeal walls. [****Aetiology**](https://www.theplasticsfella.com/velopharyngeal-dysfunction/#aetiology-of-velopharyngeal-dysfunction) VPD arises from structural, neuromuscular, or functional causes. Structural causes, particularly cleft palate and post-surgical changes are the most common, but multiple overlapping factors may contribute. [****Clinical Assessment**](https://www.theplasticsfella.com/velopharyngeal-dysfunction/#clinical-assessment-for-velopharyngeal-dysfunction) Assessment of VPD involves detailed perceptual speech analysis and imaging studies (nasoendoscopy and/or videofluoroscopy), ideally performed in a multidisciplinary setting. [****Management**](https://www.theplasticsfella.com/velopharyngeal-dysfunction/#management-of-velopharyngeal-dysfunction) Successful VPD management requires a multidisciplinary approach. Surgical correction of structural deficits is often combined with speech therapy to restore normal speech while preserving airway function. ****Primary Contributor:** Dr Rob Browne. ****Verified by thePlasticsFella ✅** --- ## Overview of Velopharyngeal Dysfunction ****Key Point** Velopharyngeal dysfunction (VPD) is the inability to close the velopharyngeal sphincter during speech, resulting in hypernasal speech, nasal air escape, poor oral pressure, and reduced intelligibility. Early diagnosis and multidisciplinary treatment are essential, but outcomes remain variable despite optimal care. VPD describes the clinical presentation of incomplete closure of the velopharyngeal sphincter, unlike older terms such as “incompetence,” “insufficiency,” or “mislearning”, which imply a specific cause. VPD is a neutral umbrella term that focuses on functional impairment, regardless of origin.¹ Functionally, VPD leads to, - Hypernasal speech. - Audible nasal airflow. - Cleft-type articulation patterns. - Reduced production of oral pressure consonants. - Overall decreased speech intelligibility. This can affect VPD is notoriously difficult to manage. Even with early access to multidisciplinary cleft teams (speech therapy, ENT, and surgery), outcomes can vary depending on the underlying cause, anatomy, and patient-specific factors. 😎 ****Fun Fact:** Children with VPD often develop compensatory articulation patterns (e.g., glottal stops, pharyngeal fricatives) that persist even after surgical correction. Early speech therapy is critical to retrain correct articulation and maximize surgical outcomes. --- ## Relevant Anatomy for Velopharyngeal Dysfunction ****Key Point** The velopharyngeal (VP) sphincter is a dynamic muscular valve made up of the soft palate (velum) and the lateral and posterior pharyngeal walls. Closure of this sphincter separates the oral and nasal cavities, and is essential for normal speech. The velopharyngeal (VP) sphincter is a dynamic muscular valve that regulates airflow between the oral and nasal cavities. Its function is essential for producing normal speech and maintaining pressure for consonant articulation. During speech, the soft palate elevates while the lateral and posterior pharyngeal walls constrict, creating a temporary seal that directs airflow and sound through the oral cavity. The sphincter also adjusts dynamically for nasal sounds and breathing. #### Muscles Involved in VP Closure - **Levator veli palatini** elevates the soft palate. - **Tensor veli palatini** tenses the soft palate; opens the Eustachian tube. - **Musculus uvulae** adds bulk and midline stiffening to the soft palate. - **Palatoglossus** depresses the palate and elevates the tongue. - **Palatopharyngeus** narrows the pharynx and aids in palatal movement. - **Superior constrictor** assists in pharyngeal wall contraction. #### Coordination During Speech - Complete closure for most consonants and all vowels. - Partial opening for nasal consonants (e.g., m, n, ng). - Full opening during nasal breathing. #### Innervation - **Pharyngeal plexus (CN X):** Motor innervation to all VP muscles. - **Exception:** Tensor veli palatini is innervated by the mandibular branch of the trigeminal nerve (CN V3). Anatomy of the VP sphincter is illustrated below. ![Anatomy of the velopharyngeal sphincter](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-26T134445.899.png) Anatomy of the velopharyngeal sphincter 😎 ****Fun Fact:** The levator veli palatini muscle forms a functional sling that elevates the soft palate. In cleft palate patients, this sling is often misoriented, running abnormally along the posterior hard palate instead of forming a proper loop, which is a major contributor to VPD. --- ## Aetiology of Velopharyngeal Dysfunction ****Key Point** VPD arises from ****structural**, ****neuromuscular**, or ****functional** deficits. While structural causes, especially cleft palate and post-surgical changes are most common, many patients have overlapping contributions, particularly in syndromic conditions. ### VPD Subtypes - **Structural**Most common cause, particularly after cleft palate repair.Post-op VPD rates vary (\~20% across cleft types) due to,Surgical technique and experience.Severity of cleft (syndromic vs. non-syndromic).Palatal length and mobility.Presence of oronasal fistula.**High-Risk Group:** *22q11.2 deletion syndrome* — VPD incidence up to **65%** due to combined structural and neuromuscular deficits. - **Neuromuscular**Often occurs in isolation or alongside syndromic clefts.Involves poor muscle tone or innervation affecting the levator sling or pharyngeal walls.Common in 22q11.2, cerebral palsy, and Moebius syndrome. - **Functional (Mislearning)**Learned articulation errors despite structurally competent anatomy.Requires targeted speech therapy, not surgery. VPD causes are broadly classified into **three subtypes**, as summarised below. ![Types of VPD causes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-26T134733.086.png) Types of VPD causes ### Pathophysiology in Cleft Palate - **Before Repair** - *Levator veli palatini* inserts abnormally into the posterior hard palate. - Fails to form a functioning muscular sling. - Results in poor velar elevation → VPD. - **After Repair** - Persistent VPD may result from, - Shortened or scarred soft palate. - Residual oronasal fistula. - Hypoplastic adenoids (common in 22q11.2). ### Associated Conditions - Cleft lip and palate (especially bilateral). - Submucous cleft palate. - 22q11.2 deletion syndrome. - Van der Woude syndrome (IRF6 mutation). - Other syndromic and neuromuscular disorders. ### Risk Factors **Environmental/Maternal** - Smoking - Diabetes - Hypertension - Obesity - Teratogens: **Steroids**, **Phenytoin** **Post-Operative Risk Factors** - **Patient-Related** - Large pre-op cleft width. - Bilateral cleft lip and palate. - Short palatal length. - **Surgical-Related** - Post-op palatal fistula. **Genetic** - 22q11.2 deletion syndrome. - Van der Woude syndrome (**IRF6** mutation). 💡 ****Tip:** Children with 22q11.2 deletion syndrome often require tailored VPD surgery due to dual deficits—structural (cleft or hypoplastic velum) and neuromuscular (poor lateral wall movement). --- ## Clinical Assessment for Velopharyngeal Dysfunction ****Key Point** Assessment of VPD involves detailed perceptual speech analysis and imaging studies (nasoendoscopy and/or videofluoroscopy), ideally performed in a multidisciplinary setting. Suspected VPD should be assessed at a specialist cleft/velopharyngeal dysfunction clinic by a team including surgeons, speech therapists, and other specialists. **Assessment components** include, - Comprehensive **medical and developmental history**. - Physical examination of the **palate**. - **Perceptual speech analysis** (initial and ongoing). - **Lateral video fluoroscopy** and/or **nasoendoscopy** for dynamic assessment. 💡 ****Tip:** Perceptual speech analysis is the first and most essential diagnostic step. Children with ****hypernasal speech** but no cleft history may have a submucous cleft, neuromuscular condition, or syndrome. **Ongoing Follow-up in Cleft Palate Patients** - Post-cleft palate repair, children require **regular speech evaluations**. - Monitoring should continue into **adolescence**. **Perceptual Speech Analysis – Key VPD Features** - **Resonance:** Tonal speech quality – hypernasal speech is common in VPD (low intensity, muffled). - **Nasal Airflow:** Turbulence and/or emission. - **Cleft Type Articulation Characteristics:** Obligatory distortions – corrected with surgery. - **Decreased oral pressure consonant production** (e.g., inability to say p in “pop”). **Physical Examination** Focuses on identifying, - **Submucous cleft** - **Neuromuscular signs** - **Syndromic features** Other relevant features to document include, - **Occlusion and dentition** - **Presence/size of oronasal fistula** - **Tonsillar/adenoidal hypertrophy** **Imaging Studies** - **Lateral Video Fluoroscopy** - Dynamic **x-ray** of speech using **barium contrast**. - Measures VP gap size. - **Does not assess closure pattern**. - Some centres use this as the sole imaging modality (esp. in Europe). - **Radiation exposure** is a limitation. - **Nasoendoscopy** - Direct visualisation of VP sphincter function during speech. - Useful in identifying **closure patterns**, which may inform surgical planning. - May be **poorly tolerated** in young children. The image below summarises the closure patterns and VP wall motions. ![Closure patterns and VP wall motions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-26T135734.056.png) Closure patterns and VP wall motions 😎 ****Fun Fact:** Passavant’s ridge is a bulge in the posterior pharyngeal wall, formed. 💡 ****Tip:** Passavant’s ridge is a bulge of the posterior pharyngeal wall from the superior constrictor muscle that narrows the VP gap. Not present in all patients and functionally variable. **Other Tools (Less Common)** - **Nasometry:** Objective acoustic analysis of nasality. - **MRI:** Offers anatomical detail but is less widely used due to limited dynamic function imaging. --- ## Management of Velopharyngeal Dysfunction ****Key Point** Successful VPD management requires a multidisciplinary approach. Surgical correction of structural deficits is often combined with speech therapy to restore normal speech while preserving airway function. Management is tailored individually and typically involves, - **Cleft/craniofacial surgeon**. - **Speech and language therapist**. - **ENT or audiology input**, if required. Structural problems require surgery; speech therapy alone is insufficient. Conversely, speech therapy is essential for functional recovery postoperatively. **Surgical Goals** 1. **Restore normal speech** without compromising airway patency. 2. **Enable controlled separation** of the oral and nasal cavities during speech. ### Surgical Approaches There are **three main surgical strategies**. Some surgeons tailor their surgical technique based on **nasoendoscopy closure pattern**, though in practice, many rely on personal experience. **Palatoplasty Procedures** - Focus: **Lengthen the soft palate** and **reposition velar muscles**. - **Principles** - Tension-free closure. - Three-layered closure (nasal mucosa, muscle, oral mucosa), - Preservation of palatal mobility. - **Techniques** - **Furlow Double Opposing Z-Plasty** - Described in cleft palate section. - Z-plasties reorient muscle fibres and lengthen the velum. - **Intravelar Veloplasty (IVV)** - Muscle dissection and reorientation, described by Sommerlad. - Useful in restoring the levator sling. - **Buccal Myomucosal Flaps** - **Indication:** Short or scarred palates with moderate-to-large gaps. - **Technique:** Soft palate is freed and repositioned posteriorly; buccal flaps are used to fill the resulting defect. - **Benefits:** Preserves velar mobility. - **Limitations:** May need a second stage to divide flap pedicle if speech/feeding are affected. **Pharyngoplasty Procedures** - **Pharyngeal Flap** - **Indications:** Long velum with inconsistent or weak movement (e.g., 22q11 syndrome). - Superiorly based flap from the posterior pharyngeal wall. - Inserted into the soft palate to narrow midline defect. - Allows lateral airflow; often preferred in non-cleft VPD. - **Benefits:** Good speech outcomes. - **Limitations:** Low revision rate. - **Sphincter Pharyngoplasty** - **Indications:** Lateral wall dysfunction/lateral gaps. - Bilateral palatopharyngeus flaps are inset transversely. - Designed for lateral closure defects. - **Benefits:** More dynamic closure using palatopharyngeus muscles. - **Limitation:** Increased risk of obstructive sleep apnoea (OSA). **Posterior Pharyngeal Wall Augmentation** - **Technique:** Autologous (fat/cartilage) or alloplastic (e.g., silicone) material is implanted behind the posterior pharyngeal mucosa. - **Indications** - Small residual VP gaps. - To **supplement** other procedures (e.g., pharyngoplasty). - **Benefits:** Minimal airway obstruction risk. - **Limitation:** Less effective for larger VP gaps. ### Outcomes & Considerations - **All procedures improve VPD features**, but not all eliminate them. - **Speech improvements are gradual**. - **Noticeable Change:** \~12 months post-op. - Further improvements can occur for 3–4 years. - **OSA risk** is highest with pharyngeal flap and sphincter pharyngoplasty. Lower with palatoplasty or augmentation. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** VPD is the failure of velopharyngeal closure during speech, leading to hypernasality, nasal air escape, and poor speech intelligibility. ****2\. Anatomy:** The VP sphincter is formed by the soft palate and pharyngeal walls, closing dynamically during speech via CN X-innervated muscles (except the tensor via CN V3). ****3\. Aetiology:** Causes include structural (e.g., cleft palate), neuromuscular, or functional deficits — often overlapping; cleft repair remains the most common contributor. ****4\. Assessment:** Diagnosis involves speech analysis, physical exam, and imaging (nasoendoscopy or videofluoroscopy); multidisciplinary input is essential. ****5\. Management:** Treatment combines surgery and speech therapy. Surgical options include palatoplasty, pharyngoplasty, and augmentation, tailored to gap type. ****6\. Outcomes:** Speech improves gradually post-op (12+ months); success varies by anatomy and cause. Pharyngeal flaps and sphincteroplasty carry higher OSA risk. --- ## Further Reading 1. Woo AS. Velopharyngeal dysfunction. *Semin Plast Surg*. Nov 2012;26(4):170-7\. doi:10.1055/s-0033-1333882 2. Kummer AW. Speech evaluation for patients with cleft palate. *Clin Plast Surg*. Apr 2014;41(2):241-51\. doi:10.1016/j.cps.2013.12.004 3. Sainsbury DCG, Williams CC, Butterworth S, et al. Patient Factors Influencing Speech Outcomes in Velopharyngeal Function Following Initial Cleft Palate Repair: A Systematic Review and Meta-Analysis. *The Cleft Palate Craniofacial Journal*. 2024;61(12):2022-2037\. doi:10.1177/10556656231191384 4. McDonald-McGinn DM, Sullivan KE, Marino B, et al. 22q11.2 deletion syndrome. *Nat Rev Dis Primers*. Nov 19 2015;1:15071\. doi:10.1038/nrdp.2015.71 5. Sweeney WM, Lanier ST, Purnell CA, Gosain AK. Genetics of Cleft Palate and Velopharyngeal Insufficiency. *J Pediatr Genet*. Mar 2015;4(1):9-16\. doi:10.1055/s-0035-1554978 6. Ács M, Cavalcante BGN, Bănărescu M, et al. Maternal factors increase risk of orofacial cleft: a meta-analysis. *Scientific Reports*. 2024/11/15 2024;14(1):28104\. doi:10.1038/s41598-024-79346-7 7. Garland K, Dworschak-Stokan A, Matic D. Patient and surgical factors that affect the development of velopharyngeal insufficiency. *J Plast Reconstr Aesthet Surg*. Oct 2022;75(10):3813-3816\. doi:10.1016/j.bjps.2022.06.036 8. Perry JL, Kuehn DP, Sutton BP, Fang X. Velopharyngeal Structural and Functional Assessment of Speech in Young Children Using Dynamic Magnetic Resonance Imaging. *Cleft Palate Craniofac J*. Jul 2017;54(4):408-422\. doi:10.1597/15-120 ### Lower Eyelid Anatomy: Anatomical Layers & Surgical Relevance URL: https://www.theplasticsfella.com/lower-eyelid-anatomy/ Last updated: 2025-06-30T18:21:00.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/lower-eyelid-anatomy/#overview-of-lower-eyelid-anatomy) The lower eyelid is a complex structure composed of three anatomical lamellae: anterior, middle, and posterior, each contributing to protection, movement, and structural support. [****Anterior Lamella Anatomy**](https://www.theplasticsfella.com/lower-eyelid-anatomy/#anterior-lamella-anatomy) The anterior lamella is composed of the skin and orbicularis oculi muscle. The orbicularis has three components: pretarsal, preseptal, and orbital. [****Periorbital Supporting Structures**](https://www.theplasticsfella.com/lower-eyelid-anatomy/#periorbital-supporting-structures) The orbital retaining ligament (ORL) and arcus marginalis are key anatomical structures defining the eyelid–cheek junction. Both play a crucial role in midface support, contour, and age-related changes. [****Middle Lamella Anatomy**](https://www.theplasticsfella.com/lower-eyelid-anatomy/#middle-lamella-anatomy) The middle lamella comprises the orbital septum and the post-septal fat compartments and functions as a protective barrier for orbital contents and a structural contributor to eyelid-cheek contour. [****Posterior Lamella Anatomy**](https://www.theplasticsfella.com/lower-eyelid-anatomy/#posterior-lamella-anatomy) The posterior lamella consists of the tarsal plate, palpebral conjunctiva, & lower eyelid retractors. It provides structural rigidity, maintains eyelid-globe apposition, & facilitates coordinated eyelid movement. [****Blood Supply**](https://www.theplasticsfella.com/lower-eyelid-anatomy/#lower-eyelid-blood-supply) The lower eyelid receives blood from branches of both the internal and external carotid arteries. Venous drainage occurs via a single venous arcade — the inferior peripheral venous arcade. [****Lacrimal System**](https://www.theplasticsfella.com/lower-eyelid-anatomy/#lacrimal-system) The lacrimal system of the lower eyelid includes the lacrimal punctum and inferior canaliculus, which drain tears into the lacrimal sac and ultimately the nasal cavity via the nasolacrimal duct. [****Ligaments**](https://www.theplasticsfella.com/lower-eyelid-anatomy/#ligaments-of-the-lower-eyelid) The lower eyelid contains several key ligamentous structures, including the medial and lateral canthal tendons, orbital retaining ligament, tear trough ligament, and Lockwood's ligament. ****Updated by:** Dr Waruguru Wanjau, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview of Lower Eyelid Anatomy ****Key Point** The lower eyelid is composed of anterior, middle, and posterior lamellae that collectively protect the globe and contribute to facial expression. Functions include Globe protection, Tear distribution and ocular hydration, and Aesthetic contouring. The lower eyelid protects the globe, distributes tears, and maintains ocular hydration. Its trilamellar structure and surrounding support systems are critical to function and aesthetics. Surgical precision demands detailed knowledge of each lamella and adjacent anatomy to avoid complications. **Anatomical Layers (Lamellae)** The lower eyelid mirrors the upper eyelid’s layered anatomy but is structurally simpler and less mobile ([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com), 2009). - **Anterior Lamella:** Skin (thin, mobile, no subcutaneous fat) and orbicularis oculi muscle (preseptal and pretarsal parts) – key in blinking and lid excursion. - **Middle Lamella:** Orbital septum (inserts on inferior tarsal plate) and two orbital fat pads (medial and central), separated by the inferior oblique muscle. - **Posterior Lamella:** Tarsal plate (\~4 mm tall, provides rigidity) and palpebral conjunctiva (mucosal layer maintaining hydration). **Lower Eyelid Retractors** The lower eyelid is a trilammellar structure consisting of skin, muscle, septum and fat pads, retractors tarsus, and conjunctiva ([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com), 2009&[Kotha](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com), 2025& [Memon](https://pubmed.ncbi.nlm.nih.gov/39585706/?ref=theplasticsfella.com), 2025). The anatomy of the lower eyelid leads to associated aesthetic concerns and surgical complications: Lid laxity, ectropion, retraction, festoons ([Kotha](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com), 2025). - **Capsulopalpebral Fascia:** Primary retractor, analogous to the levator in the upper lid. - **Inferior Tarsal Muscle:** Smooth muscle contributing to lower lid tone. - These insert on the inferior tarsal border and conjunctiva. **Support Structures** - **Lateral Canthal Tendon:** Anchors the lid to Whitnall’s tubercle. - **Medial Canthal Tendon:** Anterior and posterior limbs attach to the anterior and posterior lacrimal crest, respectively. A 3D understanding of these structures is essential for safe and effective blepharoplasty and lower lid/midface reconstruction ([Kotha](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com), 2025). 💡 ****Tip:** Lower eyelid surgery carries risks such as lid malposition, orbicularis paresis, retraction, and poor aesthetic outcomes, including residual fat, hollowing, and eyelid distortion ([Terella](https://pubmed.ncbi.nlm.nih.gov/23426754/?ref=theplasticsfella.com), 2013). --- ## Anterior Lamella Anatomy ****Key Point** The anterior lamella is composed of the skin and orbicularis oculi muscle. The orbicularis has three components: pretarsal, preseptal, and orbital. The anterior lamella, the outermost layer of the lower eyelid, comprises delicate skin and the orbicularis oculi muscle. Together, they enable eye closure, blinking, tear film distribution, and facial expression, making their preservation essential in lower eyelid surgery. ### Skin - Thinnest skin in the body. - Loosely adherent, highly mobile. - No subcutaneous fat. - Facilitates surgical access([Kotha](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com), 2025). ### Orbicularis Oculi Muscle - Striated, concentric muscle innervated by the zygomatic branch of CN VII. - Divided into: - **Pretarsal:** Over the tarsus, aids involuntary blinking and tear flow. - **Preseptal:** Over the septum, involved in voluntary/involuntary blinking. - **Orbital:** Outermost, responsible for forceful eyelid closure ([Kotha](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com), 2025). 💡 ****Tip:** Orbicularis does not form the lateral canthal tendon. Instead, it is formed by the periosteum of the lateral orbital rim and Whitnall's Ligament and merges with the tarsal plates. **Attachments** - **Origin:** Medial orbital margin, medial palpebral ligament, nasal frontal bone - **Insertion:** Lateral palpebral raphe and surrounding skin ([Schiller](https://pubmed.ncbi.nlm.nih.gov/22456384/?ref=theplasticsfella.com), 2012). **Function** - Closes the eye to protect the globe. - Facilitates blinking, tear drainage, and corneal hydration. - Contributes to facial expression (smiling, squinting). **Aging Changes** - Muscle atrophy and reduced tone lead to, - Eyelid laxity and descent. - Crow’s feet, festoons, and periorbital hollowing. The orbicularis oculi is illustrated below. ![A labelled diagram showing the Orbicularis Oculi and its role in Eyelid Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-11T193054.299.png) Orbicularis oculi eyelid anatomy ### Surgical Relevance - **Blepharoplasty:** Orbicularis is either preserved or partially excised ([Schiller](https://pubmed.ncbi.nlm.nih.gov/22456384/?ref=theplasticsfella.com), 2012). - **Facelift:** Integrated within the SMAS, may be suspended for midface lift. - **Reconstruction:** Key in ptosis and ectropion repairs. - **Botulinum Toxin:** Targets dynamic wrinkles, but overuse may cause lid malposition. ### Medial Canthal Tendon Relationship Pretarsal and preseptal orbicularis fibers contribute to, - **Superficial Head:** Inserts into the anterior lacrimal crest with the tarsal plate. - **Deep Head:** Inserts into the posterior lacrimal crest posterior to the lacrimal sac. ✍️ ****Note:** The orbicularis oculi does **not* contribute to the lateral canthal tendon. The lateral tendon arises from the periosteum of the lateral orbital rim and Whitnall’s ligament and merges with the tarsus. --- ## Periorbital Support Structures ****Key Point** The orbital retaining ligament (ORL) and arcus marginalis are key anatomical structures defining the eyelid-cheek junction. Both play a crucial role in midface support, contour, and age-related changes. The lower eyelid-cheek interface is supported by retaining ligaments that separate mobile facial tissues from fixed periosteal structures. These ligaments shape the palpebromalar groove and nasojugal sulcus, and are essential considerations in lower eyelid rejuvenation. **Orbital Retaining Ligament (ORL)** - **True osteocutaneous ligament**, deep to orbicularis oculi, at the inferior orbital rim. - **Origin:** Inferior orbital rim periosteum. - **Insertion:** Dermis of the lower eyelid and midface. - **Function:** Anchors skin and orbicularis to the rim, defines the palpebromalar groove, and prevents orbital fat descent ([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com), 2009). - **Ageing:** Laxity and volume loss exaggerate malar bags, festoons, and junctional hollowing. - **Surgical Relevance:** Can be released or blended to smooth the lid–cheek transition; facilitates muscle flap mobilisation ([Kotha](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com), 2025; [Schiller](https://pubmed.ncbi.nlm.nih.gov/22456384/?ref=theplasticsfella.com), 2012). **Arcus Marginalis** - **Fibrous condensation** where the orbital septum fuses with the inferior orbital rim periosteum. - **Continuity:** Superiorly with orbital septum, inferiorly with capsulopalpebral fascia. - **Function:** Anchors septum, reinforces orbital boundary, defines tear trough and palpebromalar grooves. - **Ageing:** Septal weakening allows fat pseudoherniation, accentuating contour deformities. - **Surgical Relevance:** Must be released carefully during tear trough correction to avoid scleral show and injury to the inferior oblique ([Kotha](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com), 2025). 😎 ****Fun Fact:** The nasojugal groove (tear trough) is formed by the TTL and lies more medially and obliquely, while the palpebromalar groove, shaped by the ORL, is more lateral and horizontal. --- ## Middle Lamella Anatomy ****Key Point** The middle lamella includes the orbital septum and post-septal fat (including SOOF), functioning as a protective barrier and contributing to eyelid-cheek contour. The middle lamella lies between the anterior and posterior lamellae, containing the orbital septum, fat pads, and SOOF — all central to lower blepharoplasty and midface rejuvenation. ### Orbital Septum - **Fibrous membrane** spanning from the arcus marginalis to the tarsus ([Brémond-Gignac D](https://pubmed.ncbi.nlm.nih.gov/8047962/?ref=theplasticsfella.com), 1994). - **Function:** Separates preseptal tissues from orbital contents; maintains fat pad position ([Meyer](https://pubmed.ncbi.nlm.nih.gov/1863562/?ref=theplasticsfella.com), 1991). - **Anatomy** - **Origin:** Arcus marginalis at the orbital rim. - **Insertion:** Tarsus - either via fusion with the **capsulopalpebral fascia (CPF)** or directly (especially in some Asian patients) ([Kotha](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com), 2025; [Memon](https://pubmed.ncbi.nlm.nih.gov/39585706/?ref=theplasticsfella.com), 2025). - **Microscopic Structure:** The upper portion is reinforced by fusion with the CPF; the lower portion remains separate ([Hwang](https://pubmed.ncbi.nlm.nih.gov/17119415/?ref=theplasticsfella.com), 2006). - **Aging:** Thins with age → fat pseudoherniation - **Surgical Relevance:** Opened or repositioned in blepharoplasty; important in defining surgical planes ([Shorr](https://pubmed.ncbi.nlm.nih.gov/8056359/?ref=theplasticsfella.com), 1994). ### Fat Compartments **Preaponeurotic Fat Pads** Three post-septal fat pads lie between the orbital septum and the lower lid retractors. - **Medial, central, and lateral fat pads** lie between the septum and retractors. - Separated by the inferior oblique muscle and fibrous septa ([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com), 2009). - **Aging:** Herniation and descent of orbital contents from septal laxity and bony resorption ([Cotofana](https://pubmed.ncbi.nlm.nih.gov/30589776/?ref=theplasticsfella.com), 2019). - **Surgical Relevance:** Repositioned or removed during blepharoplasty; care near the inferior oblique to avoid diplopia. **Suborbicularis Oculi Fat (SOOF)** - **Deep fat pad** beneath orbicularis, below infraorbital rim, above zygoma, - **Tethered** by the ORL and malar septum ([Rohrich](https://pubmed.ncbi.nlm.nih.gov/17519724/?ref=theplasticsfella.com), 2007)*.* - **Function:** Adds midface volume and smooths the lid–cheek junction. - **Aging:** Atrophies and descends, causing festoons and hollowing ([Cotofana](https://pubmed.ncbi.nlm.nih.gov/30589776/?ref=theplasticsfella.com), 2019). - **Surgical Relevance:** Augmented via fat grafting or repositioned in SOOF lift or deep-plane facelift. ### *Additional Notes* - Fat in the infraorbital/cheek region contributes to contour and is affected by skeletal ageing. - A **variable pre-tarsal fat pad** has been reported but is less consistent ([Memon](https://pubmed.ncbi.nlm.nih.gov/39585706/?ref=theplasticsfella.com), 2025). Lower eyelid fat pads are illustrated below. ![Fat Pads of the Lower Eyelid, Lower Eyelid Anatomy, Middle Lamella Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-11T192815.143.png) Lower eyelid fat pads 😎 ****Fun Fact:** Age-related maxillary bone resorption contributes to the inferior displacement of midfacial fat compartments, exaggerating lower eyelid-cheek demarcation ([Cotofana](https://pubmed.ncbi.nlm.nih.gov/30589776/?ref=theplasticsfella.com), 2019). --- ## Posterior Lamella Anatomy ****Key Point** The posterior lamella comprises the tarsal plate, palpebral conjunctiva, and retractors, providing eyelid rigidity, globe apposition, and coordinated movement. The posterior lamella forms the structural backbone of the lower eyelid. It includes the **tarsal plate**, **palpebral conjunctiva**, and **retractors** (including the **capsulopalpebral fascia**, CPF), all crucial for both function and surgical reconstruction. **Tarsal Plate** - **Fibrocartilaginous support** (25 × 5 × 1 mm), housing **meibomian glands** ([Memon](https://pubmed.ncbi.nlm.nih.gov/39585706/?ref=theplasticsfella.com), 2025). - Anchored medially/laterally by **canthal tendons**, and superiorly by **CPF**. - Maintains lid-globe contour and movement. - Laxity may occur when combined with attenuation of canthal tendons([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com), 2009). - **Surgical Use:** Landmark in blepharoplasty; reconstructed with grafts (e.g., hard palate, Hughes flap). The tarsal plate can be visualised in the image below. ![The tarsal plate is a support structure for the eyelids.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-11T192542.134.png) Tarsal plate **Palpebral Conjunctiva** - **Thin mucosal layer** lining the posterior eyelid. - Contains **goblet cells** → mucin for the tear film. - **Surgical access** via transconjunctival blepharoplasty. - **Considerations:** Avoid trauma near the fornix; monitor for dry eye or chemosis. **Lower Eyelid Retractors** - Coordinate lid descent during downgaze. - **Anterior layer:** From Lockwood’s ligament → inserts into the orbicularis. - **Posterior layer:** Smooth muscle (inferior tarsal muscle) → inserts into the tarsus. - The **posterior layer is the key tractional component** and should be addressed in retractor surgery ([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com), 2009). 💡 ****Tip:** The posterior layer is the key tractional component and should be addressed during retractor advancement in malposition procedures. **Capsulopalpebral Fascia (CPF)** - **Lower eyelid analogue** of the levator aponeurosis. - Originates near Lockwood’s ligament → inserts into the inferior tarsus and skin([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com), 2009; [Memon](https://pubmed.ncbi.nlm.nih.gov/39585706/?ref=theplasticsfella.com), 2025). - Coordinates the lid motion with the inferior rectus. - **Aging:** Laxity or dehiscence can lead to entropion, retraction, and fat prolapse. - **Surgical Relevance:** Requires preservation or advancement in blepharoplasty and eyelid repositioning. 💡 ****Tip:** The main tractional component of the lower eyelid retractors lies in the posterior layer. Thus, when the lower eyelid retactors are targeted in some forms of eyelid malposition surgery, the posterior layer should always be addressed ([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com), 2009). --- ## Lower Eyelid Blood Supply ****Key Point** The lower eyelid is supplied by branches of both the internal and external carotid systems, with venous drainage via the inferior peripheral venous arcade. Understanding vascular anatomy is critical for minimizing bleeding and preserving perfusion during eyelid surgery. **Arterial Supply** The arterial blood supply arises from both the **internal** and **external carotid systems**, with multiple communicating arcades ensuring redundancy. - **Internal carotid artery system** (via the **ophthalmic artery**) - **Medial Canthus:** Angular artery (a terminal branch of the facial artery). - **Lateral Canthus:** Superficial temporal artery. - **Lower Eyelid:** Infraorbital artery. - **Ophthalmic artery** branches - Gives rise to **medial and lateral palpebral arteries**. - These contribute to, - **Marginal Arcade:** Along the inferior tarsal border. - **Peripheral Arcade:** More superficial. - **External carotid artery system** - **Lacrimal Artery:** Anastomoses with the marginal arcade, provides **lateral palpebral arteries**([Memon](https://pubmed.ncbi.nlm.nih.gov/39585706/?ref=theplasticsfella.com), 2025; [Erdogmus](https://pubmed.ncbi.nlm.nih.gov/17293279/?ref=theplasticsfella.com), 2007). These vessels anastomose along the tarsal plate to form, - **Superior and inferior marginal arcades** (within or adjacent to the tarsus). - **Peripheral arcade** (more superficial). **Venous Drainage** - Primarily via the **inferior peripheral venous arcade.** - **Medial:** Drains to angular vein. - **Lateral:** Drains via inferior palpebral vein. - Ultimately drains to the **facial vein** ([Lee](https://pubmed.ncbi.nlm.nih.gov/27054444/?ref=theplasticsfella.com), 2016). **Surgical Relevance** - **Transconjunctival blepharoplasty** avoids major vessels, reducing hematoma risk. - **Infraorbital artery** requires cautious dissection during fat manipulation - **Tarsal arcades** must be preserved in flaps/grafts. - **Angular artery** lies \~1.7 mm deep at medial canthus—avoid injury during fillers or incisions ([Shin](https://pubmed.ncbi.nlm.nih.gov/37104463/?ref=theplasticsfella.com), 2023). The lower eyelid arteries and veins are visualised below. ![Arteries and Veins of the Eyelid, Lower Eyelid Blood Supply](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-11T192226.597.png) Arteries and veins of the eyelid 💡 ****Tip:** The superficial position of the angular artery, \~1.7 mm deep at the medial canthus and is vulnerable to iatrogenic injury ([Shin](https://pubmed.ncbi.nlm.nih.gov/37104463/?ref=theplasticsfella.com), 2023)**.* --- ## Lacrimal System ****Key Point** The lower eyelid’s lacrimal system includes the punctum and inferior canaliculus, draining tears into the lacrimal sac and then the nasal cavity via the nasolacrimal duct. The lacrimal system maintains ocular hydration, facilitates blinking, and protects against infection. ### Secretion The tear film is **trilaminar**, - **Mucin Layer:** Goblet cells (palpebral conjunctiva). - **Aqueous Layer:** Lacrimal and accessory glands (main hydrating component). - **Lipid Layer:** Meibomian, Zeis, and Moll glands (reduces evaporation). ### Drainage Tears are directed medially across the eye and drained via a coordinated “lacrimal pump” mechanism. - **Punctum:** At the posterior lid margin near the medial canthus. - **Inferior Canaliculus:** \~2 mm vertical, \~8 mm horizontal → forms ampulla. - **Common Canaliculus:** Union of upper and lower canaliculi. - **Lacrimal Sac:** In the lacrimal fossa, surrounded by Horner’s muscle ([Ali](https://pubmed.ncbi.nlm.nih.gov/32730907/?ref=theplasticsfella.com), 2020). - **Nasolacrimal Duct:** Opens into the inferior nasal meatus. 😎 ****Fun Fact:** The lacrimal caruncle has direct anatomical connections to the lower eyelid retractors and may move antagonistically to the medial rectus via capsulopalpebral fascia ([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/20871465/?ref=theplasticsfella.com), 2010). ### Surgical Relevance - **Preserve drainage structures** to prevent postoperative epiphora. - **Canthoplasty/Canthopexy**: Avoid MPL and lacrimal sac injury. - **Transconjunctival Blepharoplasty:** Preferred for fat access while sparing the lacrimal system. The lacrimal duct is illustrated below. ![Lacrimal Duct System, Lacrimal System](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-11T191845.084.png) Lacrimal duct system --- ## Ligaments of the Lower Eyelid ****Key Point** Key ligamentous structures: medial and lateral canthal tendons, ORL, tear trough ligament, and Lockwood’s ligament maintain lower lid position and contour, crucial in surgery. The lower eyelid’s ligaments provide structural support and integrate with midfacial anatomy. Understanding their attachments and functions is vital for blepharoplasty, canthopexy, canthoplasty, and reconstruction. Disruption risks ectropion, scleral show, and epiphora ([Kakizaki](https://pubmed.ncbi.nlm.nih.gov/20871465/?ref=theplasticsfella.com), 2010). **Key Ligamentous Structures** - **Medial Canthal Tendon:** Anchors tarsus to anterior/posterior lacrimal crests; intimately related to lacrimal sac, preserved during surgery. - **Lateral Canthal Tendon:** Anchors to lateral orbital rim; formed by periosteum and Whitnall’s ligament; maintains horizontal lid tension. - **Orbital Retaining Ligament (ORL):** Osteocutaneous ligament from rim periosteum to dermis; defines lid-cheek junction; contributes to festoons with age. - **Tear Trough Ligament (TTL):** Fibrous medial attachment forming the nasojugal groove; key in tear trough correction. - **Lockwood’s Ligament:** Fascia supporting the globe; connects to capsulopalpebral fascia; assists with lid and globe support. The ligamentous structures of the lower eyelid, their location, function, and surgical relevance are summarised below. ![The ligamentous structures of the lower eyelid, their location, function and surgical relevance](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-11T191212.077.png) The ligamentous structures of the lower eyelid, their location, function and surgical relevance --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Lower Eyelid Anatomy:** Gained comprehensive knowledge of the bilamellar structure of the lower eyelid, including its anterior and posterior lamellae, which consist of skin, muscle, tarsus, and conjunctiva. ****2\. Eyelid's Functional Components:** Learned about the detailed anatomy of the anterior lamella, which includes the skin and orbicularis oculi muscle, and the posterior lamella, noted for the tarsal plate and palpebral conjunctiva, highlighting their roles in eyelid stability and function. ****3\. Middle Lamella Structures:** Explored the middle lamella’s role in containing the orbital contents, specifically noting the orbital septum, three fat pads, and the capsulopalpebral fascia. ****4\. Vascular and Lacrimal Systems:** Acquired an understanding of the vascular supply to the lower eyelid provided by branches of both the internal and external carotid arteries and learned the structure and function of the lacrimal system essential for eye lubrication and protection. --- ## Further Reading 1. Kotha VS, Janssen PL, Vecchio RR, Zins JE. [Applied Anatomy of the Lower Eyelid](https://pubmed.ncbi.nlm.nih.gov/39505474/?ref=theplasticsfella.com). Clin Plast Surg. 2025 Jan;52(1):1-6\. doi: 10.1016/j.cps.2024.08.002\. Epub 2024 Sep 10\. PMID: 39505474. 2. Memon SF, Wilde CL, Ezra DG. [Lower Eyelid Surgical Anatomy and the Implications for Blepharoplasty Surgery: A Systematic Review of Anatomic Studies in the Literature](https://pubmed.ncbi.nlm.nih.gov/39585706/?ref=theplasticsfella.com). J Craniofac Surg. 2024 Nov 25\. doi: 10.1097/SCS.0000000000010928\. Epub ahead of print. PMID: 39585706. 3. Kakizaki H, Malhotra R, Madge SN, Selva D. [Lower eyelid anatomy: an update](https://pubmed.ncbi.nlm.nih.gov/19602948/?ref=theplasticsfella.com). Ann Plast Surg. 2009 Sep;63(3):344-51\. doi: 10.1097/SAP.0b013e31818c4b22\. PMID: 19602948. 4. Shorr N. [Madame Butterfly procedure with hard palate graft: management of postblepharoplasty round eye and scleral show](https://pubmed.ncbi.nlm.nih.gov/8056359/?ref=theplasticsfella.com). Facial Plast Surg. 1994 Jan;10(1):90-118\. doi: 10.1055/s-2008-1064559\. PMID: 8056359. 5. Hwang K, Kim DJ, Hwang SH, Chung IH. [The relationship of capsulopalpebral fascia with orbital septum of the lower eyelid: an anatomic study under magnification](https://pubmed.ncbi.nlm.nih.gov/17119415/?ref=theplasticsfella.com). J Craniofac Surg. 2006 Nov;17(6):1118-20\. doi: 10.1097/01.scs.0000235113.38730.47\. PMID: 17119415. 6. Rohrich RJ, Pessa JE. [The fat compartments of the face: anatomy and clinical implications for cosmetic surgery](https://pubmed.ncbi.nlm.nih.gov/17519724/?ref=theplasticsfella.com). Plast Reconstr Surg. 2007 Jun;119(7):2219-2227\. doi: 10.1097/01.prs.0000265403.66886.54\. PMID: 17519724. 7. Brémond-Gignac DS, Deplus S, Cussenot O, Lassau JP. [Anatomic study of the orbital septum](https://pubmed.ncbi.nlm.nih.gov/8047962/?ref=theplasticsfella.com) (22.10.93). Surg Radiol Anat. 1994;16(1):121-4\. doi: 10.1007/BF01627937\. PMID: 8047962. 8. Erdogmus S, Govsa F. [The arterial anatomy of the eyelid: importance for reconstructive and aesthetic surgery](https://pubmed.ncbi.nlm.nih.gov/17293279/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2007;60(3):241-5\. doi: 10.1016/j.bjps.2006.01.056\. Epub 2006 Nov 20\. PMID: 17293279. 9. Shin HJ, Kim HJ, Song WC. [Superimposition Study to Determine the Angular Arterial Distribution and Its Clinical Application](https://pubmed.ncbi.nlm.nih.gov/37104463/?ref=theplasticsfella.com). Plast Reconstr Surg. 2024 Mar 1;153(3):706-711\. doi: 10.1097/PRS.0000000000010596\. Epub 2023 Apr 26\. PMID: 37104463. 10. Lee SH, Lee HJ, Kim YS, Tansatit T, Kim HJ. [Novel Anatomic Description of the Course of the Inferior Palpebral Vein for Minimally Invasive Aesthetic Treatments](https://pubmed.ncbi.nlm.nih.gov/27054444/?ref=theplasticsfella.com). Dermatol Surg. 2016 May;42(5):618-23\. doi: 10.1097/DSS.0000000000000700\. PMID: 27054444. 11. Kakizaki H, Valenzuela AA. [Lacrimal caruncle: continuation to the lower eyelid retractors](https://pubmed.ncbi.nlm.nih.gov/20871465/?ref=theplasticsfella.com). Ophthalmic Plast Reconstr Surg. 2011 May-Jun;27(3):198-200\. doi: 10.1097/IOP.0b013e3181ed3573\. PMID: 20871465. 12. Ali MJ, Zetzsche M, Scholz M, Hahn D, Gaffling S, Heichel J, Hammer CM, Bräuer L, Paulsen F. [New insights into the lacrimal pump](https://pubmed.ncbi.nlm.nih.gov/32730907/?ref=theplasticsfella.com). Ocul Surf. 2020 Oct;18(4):689-698\. doi: 10.1016/j.jtos.2020.07.013\. Epub 2020 Jul 28\. PMID: 32730907. 13. Terella AM, Wang TD, Kim MM. [Complications in periorbital surgery](https://pubmed.ncbi.nlm.nih.gov/23426754/?ref=theplasticsfella.com). Facial Plast Surg. 2013 Feb;29(1):64-70\. doi: 10.1055/s-0033-1333838\. Epub 2013 Feb 20\. PMID: 23426754. 14. Schiller JD. [Lysis of the orbicularis retaining ligament and orbicularis oculi insertion: a powerful modality for lower eyelid and cheek rejuvenation](https://pubmed.ncbi.nlm.nih.gov/22456384/?ref=theplasticsfella.com). Plast Reconstr Surg. 2012 Apr;129(4):692e-700e. doi: 10.1097/PRS.0b013e31824423c7\. PMID: 22456384. 15. Alghoul M. [Blepharoplasty: Anatomy, Planning, Techniques, and Safety](https://pubmed.ncbi.nlm.nih.gov/29474509/?ref=theplasticsfella.com). Aesthet Surg J. 2019 Jan 1;39(1):10-28\. doi: 10.1093/asj/sjy034\. PMID: 29474509. 16. Meyer DR, Linberg JV, Wobig JL, McCormick SA. [Anatomy of the orbital septum and associated eyelid connective tissues](https://pubmed.ncbi.nlm.nih.gov/1863562/?ref=theplasticsfella.com). Implications for ptosis surgery. Ophthalmic Plast Reconstr Surg. 1991;7(2):104-13\. doi: 10.1097/00002341-199106000-00004\. PMID: 1863562. 17. Cotofana S, Gotkin RH, Frank K, Koban KC, Targosinski S, Sykes JM, Schlager M, Schlattau A, Schenck TL. [The Functional Anatomy of the Deep Facial Fat Compartments: A Detailed Imaging-Based Investigation](https://pubmed.ncbi.nlm.nih.gov/30589776/?ref=theplasticsfella.com). Plast Reconstr Surg. 2019 Jan;143(1):53-63\. doi: 10.1097/PRS.0000000000005080\. PMID: 30589776. ### Abdominal Wall Anatomy: Surface Landmarks, Skeletal Structure, & Layers URL: https://www.theplasticsfella.com/abdominal-wall-anatomy/ Last updated: 2025-06-30T18:18:27.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/abdominal-wall-anatomy/#overview-of-abdominal-wall-anatomy) The abdominal wall, divided into anterolateral and posterior, supports and protects abdominal organs, facilitates trunk movement, and adjusts to visceral volume changes and pressure. [****Surface Anatomy**](https://www.theplasticsfella.com/abdominal-wall-anatomy/#surface-anatomy-of-the-abdominal-wall) Divided into quadrants and regions using palpable landmarks such as the linea alba, umbilicus (T10), and inguinal ligament (L1). [****Skeletal Structure**](https://www.theplasticsfella.com/abdominal-wall-anatomy/#skeletal-structure-of-the-abdominal-wall) The abdominal wall is bounded superiorly by the thoracic cage, posteriorly by the lumbar vertebrae, and inferiorly by the pelvic brim. [****Layers and Musculature**](https://www.theplasticsfella.com/abdominal-wall-anatomy/#layers-and-musculature-of-the-abdominal-wall) Includes 5 paired anterolateral muscles. Critical surgical landmarks include the neurovascular plane (between internal oblique and transversus abdominis) and arcuate line. Knowledge of vascular supply (e.g., DIEA for flaps) is essential for safe dissection. [****Clinical Significance**](https://www.theplasticsfella.com/abdominal-wall-anatomy/#clinical-significance-of-abdominal-wall-anatomy) Vital for flap harvest (e.g., TRAM, DIEP, SIEA), hernia repair, and component separation techniques (CST). Direct hernias = medial to inferior epigastric vessels (via Hesselbach’s triangle). Indirect hernias = lateral to vessels (congenital path) ****Primary Contributor:** Dr Carissa J. Jacobs ****Verified by thePlasticsFella ✅** --- ## Overview of Abdominal Wall Anatomy ****Key Point** The abdominal wall, divided into anterolateral and posterior regions, supports and protects abdominal organs, enables trunk movement, and adjusts to changes in intra-abdominal volume and pressure. The abdominal wall forms the boundary of the abdominal cavity and is anatomically divided into two key sections. - **Anterolateral abdominal wall** - **Posterior abdominal wall** It extends from the **thoracic cage superiorly** to the **pelvic bones inferiorly**, enclosing the abdominal contents and contributing to core function. Unlike the thorax and pelvis, the abdominal wall lacks a complete bony framework, which allows it to accommodate changes in intra-abdominal volume. For example, during digestion, respiration, and pregnancy. It also stabilizes the spine and facilitates trunk motion. Functionally, the abdominal wall plays a crucial role in essential physiological processes by increasing intra-abdominal and intrathoracic pressure through muscular contraction. This action supports: - Expulsion of air (e.g., coughing, sneezing) - Emesis (vomiting) - Defecation - Micturition - Parturition Plastic surgeons commonly harvest flaps from the abdominal wall for reconstructive procedures (especially breast reconstruction) and are often involved in complex abdominal wall repairs. These flaps vary by **vascular supply**, **tissue composition**, and **anatomical origin**. Accordingly, a solid grasp of abdominal wall anatomy is fundamental for, - Flap design and elevation. - Ensuring vascular reliability. - Avoiding functional deficits or complications during reconstruction. 😎 ****Fun Fact:** In states of increased respiratory demand, whether due to exercise, illness, or stress, the anterolateral abdominal muscles act as accessory expiratory muscles, aiding active exhalation by depressing the rib cage. The anterior abdominal wall is illustrated below. ![The anterior abdominal wall](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-14T202735.855.png) The anterior abdominal wall The posterior abdominal wall is illustrated below. ![The posterior abdominal wall](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-14T203227.686.png) The posterior abdominal wall ### Embryology The abdominal wall forms through lateral folding of the embryonic disc, with contributions from mesoderm and ectoderm. - Around week 4 of gestation, the trilaminar embryonic disc folds laterally, fusing the left and right body walls at the midline. - Mesoderm forms the muscles and connective tissue; ectoderm forms the skin. - Somites (paraxial mesoderm) differentiate into myotomes, which become abdominal wall muscles. - Ventral body wall closure is completed by week 6. - Failure results in congenital defects such as omphalocele or gastroschisis. --- ## Surface Anatomy of the Abdominal Wall ****Key Point** The arcuate line is a horizontal landmark signifying the lower boundary of the posterior rectus sheath and represents the point where the inferior epigastric vessels send perforators into the rectus abdominis. the cal and horizontal planes. The nine regions are: epigastric, umbilical, and hypogastric in the midline, and paired left and right hypochondriac, lumbar, and iliac regions. There are a number of important surface landmarks on the anterior abdomen. - **The Linea Alba:** A midline fibrous structure running from the xiphoid process to the pubic symphysis. - **Rectus Abdominis:** Palpable as paired vertical muscles on either side of the linea alba. - **Rectus Sheath:** Encloses the rectus abdominis and is divided into anterior and posterior layers, with the posterior layer ending at the arcuate line (about midway between the umbilicus and pubic symphysis). - **Linea Semilunaris:** A paired vertical fibrous structure that runs along the lateral edge of the rectus abdominis. An important distinction occurs above and below the arcuate line. - **Above the Arcuate Line:** The posterior rectus sheath is composed of aponeuroses from the internal oblique (posterior layer) and transversus abdominis muscles. - **Below the Arcuate Line:** All aponeurotic fibres (from external oblique, internal oblique, and transversus abdominis) pass anterior to the rectus abdominis, leaving only transversalis fascia and peritoneum behind it. Additional landmarks include, - **Umbilicus:** Located at the level of the L3–L4 vertebrae, serving as a central surface landmark. The umbilical dermatome corresponds to T10, a key surface marker commonly used in trauma and neurological assessment. Other important dermatomal landmarks include T4 at the nipple line and L1 at the inguinal ligament. - **Inguinal Ligament:** Runs from the anterior superior iliac spine (ASIS) to the pubic tubercle, marking the lower border of the abdominal wall. The posterior abdominal wall is located at the back of the abdomen, extending from the 12th rib and lumbar vertebrae down to the iliac crests and sacrum. The surface anatomy is less distinct than the anterolateral wall. The posterior wall forms the boundary between the abdominal cavity and the intrinsic muscles of the back, providing protection and support for retroperitoneal organs. These key regions, their landmarks, and main structures are summarised below. ![Key regions of the abdominal wall, their landmarks, and main structures](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-15T185557.100.png) Key regions of the abdominal wall, their landmarks, and main structures The anterior trunk is illustrated below. ![Anterior trunk of the abdominal wall](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-14T203427.761.png) Anterior trunk of the abdominal wall --- ## Skeletal Structure of the Abdominal Wall ****Key Point** The abdominal wall is bounded superiorly by the thoracic cage, posteriorly by the lumbar vertebrae, and inferiorly by the pelvic brim. The skeletal framework of the abdominal wall provides essential structural support and serves as a scaffold for muscular and fascial attachments. The boundaries can be described as follows. **Superiorly** - **Inferior Ribs (7th–12th ribs):** Provide attachment for the external oblique and transversus abdominis. - **Costal Cartilages:** Contribute to the costal margin. - **Xiphoid Process of the Sternum:** Serves as an attachment point for the rectus abdominis and the linea alba. **Posteriorly** - **Lumbar Vertebrae (L1–L5):** Provide major support for the posterior abdominal wall. Psoas major, quadratus lumborum, and iliacus originate or insert here. - **12th Rib:** Anchors the quadratus lumborum and transversus abdominis. **Inferiorly** - **Iliac Crest:** Attachment site for the external oblique, internal oblique, and transversus abdominis. - **Anterior Superior Iliac Spine (ASIS):** Serves as a landmark and origin for the inguinal ligament. - **Pubic Symphysis and Pubic Crest:** Inferior attachment for rectus abdominis and insertion for the pyramidalis muscle. - **Inguinal Ligament:** A fibrous band from the ASIS to the pubic tubercle, acting as a key landmark in lower abdominal anatomy and hernia surgery. Bones of the abdominal wall are illustrated below. ![Bones of the abdominal wall](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-14T203849.960.png) Bones of the abdominal wall --- ## Layers and Musculature of Abdominal Wall Anatomy ****Key Point** There are 5 paired muscles in the anterolateral abdominal wall and 4 paired muscles in the posterior abdominal wall and the diaphragm. Understanding the muscular and fascial structure of the abdominal wall is critical in both flap harvest and reconstruction. Anatomical precision enables safe dissection, preservation of perfusion, and reduction of complications such as necrosis, donor site morbidity, and functional loss. **Clinical Applications of Flaps** - **TRAM (Transverse Rectus Abdominis Myocutaneous) Flap:** Involves the rectus abdominis and overlying skin/fat. Knowledge of the rectus sheath, perforators, and vascular zones is vital. - **DIEP (Deep Inferior Epigastric Perforator) Flap:** Muscle-sparing; requires familiarity with intramuscular perforator anatomy. - **SIEA (Superficial Inferior Epigastric Artery) Flap:** Less invasive, based on superficial vasculature; anatomy is variable. - **VRAM (Vertical Rectus Abdominis Myocutaneous) Flap:** Useful in pelvic or perineal reconstruction; based on the superior epigastric artery. **Abdominal Wall Reconstruction** In trauma, hernia, or tissue defects, layer restoration is essential. Surgeons may employ, - Component separation to mobilize muscle layers. - Mesh (prosthetic or biologic) in appropriate fascial planes. - Flaps to restore function and form. Muscle-sparing techniques (e.g. DIEP over TRAM) preserve abdominal wall strength and reduce hernia risk. - **Neurovascular Plane** - Intercostal nerves and vessels run between the internal oblique and transversus abdominis muscles, forming the neurovascular plane. - This anatomical space is the target of the Transversus Abdominis Plane (TAP) block, a regional anesthesia technique used for postoperative analgesia. - Accurate identification of muscle layers is essential for safe and effective nerve blockade. **Layers of the Anterolateral Abdominal Wall (Superficial to Deep)** - Skin - Subcutaneous tissue - Muscles, investing fascia, and aponeuroses - Transversalis fascia - Extraperitoneal fat - Parietal peritoneum The subcutaneous tissue has two layers. - **Camper’s Fascia:** Superficial fatty layer. - **Scarpa’s Fascia:** Deeper membranous layer. **Muscles of the Anterolateral Abdominal Wall (5 paired)** - External oblique. - Internal oblique. - Transversus abdominis. - Rectus abdominis. - Pyramidalis (present in \~80% of people). The table below summarises the origin, insertion, vascular supply, and clinical relevance of the key muscles that form the anterolateral abdominal wall. ![The origin, insertion, vascular supply, and clinical relevance of muscles of the anterolateral abdominal wall](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-30T234724.839.png) The origin, insertion, vascular supply, and clinical relevance of muscles of the anterolateral abdominal wall 😎 ****Fun Fact:** The rectus abdominis muscle, known for forming the "six-pack," actually varies in the number of tendinous intersections. Some people naturally have four, eight, or even ten-pack abs depending on their genetics. **Muscles of the Posterior Abdominal Wall (4 paired + diaphragm)** - Psoas major - Iliacus - Quadratus lumborum - Psoas minor (present in \~40% of people) A cross-section of the abdominal wall is illustrated below. ![Cross-section of the abdominal wall](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-15T184047.004.png) Cross-section of the abdominal wall ### The Inguinal Triangle and Inguinal Canal **Boundaries of Hesselbach’s Triangle** - **Medial:** Lateral border of rectus abdominis. - **Anterolateral:** Inferior epigastric vessels. - **Inferoposterior:** Inguinal ligament. **Hesselbach’s Triangle** - Located within the anterior abdominal wall, Hesselbach’s triangle is a key anatomical region and a common site for direct inguinal hernias, which pass medial to the inferior epigastric vessels — a distinction important in clinical examinations. - In contrast, indirect inguinal hernias are congenital and pass lateral to the inferior epigastric vessels through the deep inguinal ring. - Hesselbach’s triangle also holds surgical relevance during lower abdominal flap harvests such as the TRAM or DIEP flap, where careful dissection is required near or within this area. 😎 ****Fun Fact:** Frank Hesselbach, a German anatomist, first described this triangle in 1806. The vascular anatomy of the DIEP flap is centered on the deep inferior epigastric artery (DIEA), which arises from the external iliac artery. It traverses deep to the transversalis fascia and then passes superficially to the arcuate line to supply the anterior rectus sheath through perforators. Hesselbach’s triangle is illustrated below. ![Hesselbach’s triangle, abdominal wall anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-15T184303.935.png) Hesselbach’s triangle **Anatomical Boundaries of the Inguinal Canal** - **Anterior:** External oblique aponeurosis (reinforced by internal oblique laterally). - **Posterior:** Transversalis fascia, conjoint tendon. - **Roof:** Transversalis fascia, internal oblique, transversus abdominis. - **Floor:** Inguinal ligament (from external oblique aponeurosis), lacunar ligament. The inguinal canal runs inferiorly and medially through the lower abdominal wall, just above and parallel to the inguinal ligament. It acts as a conduit for structures passing between the abdominal cavity and the external genitalia. Clinically, it is another vulnerable point in the abdominal wall and is a frequent site for indirect inguinal hernias. The inguinal canal is illustrated below. ![The inguinal canal, abdominal wall anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-15T184433.959.png) The inguinal canal --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** The abdominal wall plays a vital dynamic role beyond structural support, contributing to organ protection, trunk stability, and physiological functions such as respiration, pressure regulation, and visceral accommodation. It can be subdivided into anterolateral and posterior. ****2\. Embryology:** Proper embryological development of the abdominal wall is characterised by lateral folding, mesodermal differentiation, and ventral closure. It is essential for forming the muscular structure and preventing congenital defects. ****3.** ****Surface Anatomy:** The anterolateral abdominal wall spans the front and sides of the abdomen and is divided into regions using palpable landmarks and lines relevant for clinical examination. The posterior abdominal wall protects the retroperitoneal organs and lies deep to the intrinsic muscles of the back. ****4\. Skeletal Structure:** The ribs, vertebrae, and pelvis provides structural support and attachment sites for muscles. ****5\. Layers and Musculature:** A thorough understanding of the muscle layers, fascial planes, and vascular supply, is essential for designing safe, functional flaps and performing effective abdominal wall reconstruction with minimal morbidity. ****6\. The Inguinal Triangle and Inguinal Canal:** Hesselbach’s triangle is clinically significant because of its association with hernias, its proximity to critical vascular structures, and thus its relevance during lower abdominal flap harvest and reconstruction. ****7\. Clinical Significance:** Anatomical knowledge guides surgical incisions, flap design, component separation, and hernia repair, directly impacting patient outcomes in terms of function, aesthetics, and complication rates. --- ## Further Reading 1. Gray H. [Anatomy of the human body](https://www.bartleby.com/lit-hub/anatomy-of-the-human-body/6d-the-muscles-and-fasci-of-the-abdomen?ref=theplasticsfella.com). 20th ed. 1918\. 2. Flynn W, Vickerton P. [Anatomy, abdomen and pelvis: abdominal wall](https://www.ncbi.nlm.nih.gov/books/NBK551649/?ref=theplasticsfella.com) \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. \[Updated 2023 Jul 24\]. 3. Hope WW, Abdul W, Winters R. [Abdominal wall reconstruction](https://www.ncbi.nlm.nih.gov/books/NBK431108/?ref=theplasticsfella.com) \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. \[Updated 2023 Jul 24\]. 4. Lopez-Monclus J, Muñoz-Rodríguez J, San Miguel C, Robin A, Blazquez LA, Pérez-Flecha M, et al. [Combining anterior and posterior component separation for extreme cases of abdominal wall reconstruction](https://pubmed.ncbi.nlm.nih.gov/32140964/?ref=theplasticsfella.com). Hernia. 2020 Apr;24(2):369–379\. doi: 10.1007/s10029-020-02152-3\. Epub 2020 Mar 5\. Erratum in: Hernia. 2021 Feb;25(1):251\. doi: 10.1007/s10029-020-02343-y. PMID: 32140964; PMCID: PMC7674336. 5. Stylianides N, Slade DAJ. Abdominal wall reconstruction. Br J Hosp Med (Lond). 2016 Mar;77(3):151–156\. doi: 10.12968/hmed.2016.77.3.151. 6. Laguna Hernández P, Díaz Pedrero R, Córdova García D, Alvarado Hurtado R, Allaoua Mouissaoui Y, Bru Aparicio M, et al. The importance of anatomical study of abdominal wall for general surgeons: a transversus abdominis release (TAR) eventroplasty serie. Br J Surg. 2024 May;111(Suppl\_5):znae122.356\. doi: 10.1093/bjs/znae122.356. 7. Nunn JF, Khan YS. [Anatomy, abdomen and pelvis, posterior abdominal wall nerves](https://www.ncbi.nlm.nih.gov/books/NBK557605/?ref=theplasticsfella.com) \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. \[Updated 2022 Oct 24\]. 8. Bissell MB, Greenspun DT, Levine J, Rahal W, Al-Dhamin A, AlKhawaji A, et al. [The lumbar artery perforator flap: 3-dimensional anatomical study and clinical applications](https://pubmed.ncbi.nlm.nih.gov/26545217/?ref=theplasticsfella.com). Ann Plast Surg. 2016 Oct;77(4):469–476\. doi: 10.1097/SAP.0000000000000646\. PMID: 26545217. 9. Heller L, McNichols CH, Ramirez OM. [Component separations](https://pubmed.ncbi.nlm.nih.gov/23372455/?ref=theplasticsfella.com). Semin Plast Surg. 2012 Feb;26(1):25–28\. doi: 10.1055/s-0032-1302462\. PMID: 23372455; PMCID: PMC3348738. 10. Shokrollahi K, Whitaker IS, Nahai F. Flaps: practical reconstructive surgery. 1st ed. 2017\. p. 184–209, 405–416, 502–524. 11. Thieme. Atlas of anatomy. 2nd ed. p. 132–143. 12. Grant JCB. Grant's atlas of anatomy. 1962. 13. Mast BA. Plastic surgery. 1st ed. New York: Thieme; 2021\. p. 30–39, 412–420. 14. Elsevier. Gray’s anatomy for students. 3rd ed. Chapter 4. ### Perineal Reconstruction: Indications, Principles, & Flap Options URL: https://www.theplasticsfella.com/perineal-reconstruction/ Last updated: 2025-07-02T19:10:14.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/perineal-reconstruction/#overview-of-perineal-reconstruction) Perineal reconstruction addresses soft tissue defects with the aim of restoring anatomy, preserving function, and reducing postoperative complications, particularly in complex or contaminated wounds. [****Indications**](https://www.theplasticsfella.com/perineal-reconstruction/#indications-of-perineal-reconstruction) Malignancy is the most common indication for perineal reconstruction, often following oncologic resection and radiation. Other causes include trauma, infection, and congenital or functional defects. [****Reconstructive Principles**](https://www.theplasticsfella.com/perineal-reconstruction/#principles-of-perineal-reconstruction) Perineal reconstruction is uniquely challenging due to the complex anatomy, high bacterial burden, risk of pressure necrosis, and involvement of critical urogenital and anorectal functions. [****Procedure**](https://www.theplasticsfella.com/perineal-reconstruction/#procedure-of-perineal-reconstruction) The reconstructive approach to perineal defects must be guided by defect complexity, prior radiation, risk of contamination, and patient-specific functional needs. [****Complications**](https://www.theplasticsfella.com/perineal-reconstruction/#complications-and-outcome-of-perineal-reconstruction) Perineal reconstruction carries a high risk of wound-related complications due to the region’s bacterial load, mobility, and proximity to the gastrointestinal and urogenital tracts. ****Primary Contributor:** Dr Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Perineal Reconstruction ****Key Point** Perineal reconstruction addresses soft tissue defects with the aim of restoring anatomy, preserving function, and reducing postoperative complications, particularly in complex or contaminated wounds. Perineal reconstruction is the surgical restoration of defects in the **perineal region** using local, regional, or free flaps. The goal is to provide durable, vascularised perineal reconstruction to restore anatomy, eliminate dead space, and enable early mobilisation. These defects may result from: - **Oncologic resections** (e.g., abdominoperineal resection, pelvic exenteration) - **Infective conditions** (e.g., Fournier’s gangrene) - **Traumatic injuries** - **Congenital or chronic inflammatory diseases** The boundaries of the perineum include: - **Anterior:** Pubic arch and arcuate ligament - **Posterior:** Tip of the coccyx - **Lateral/Medial:** Inferior pubic rami and ischial tuberosities - **Superior:** Pelvic floor - **Inferior:** Perineal skin and fascia **Gender-Specific Structures** - **Female:** Vulva (mons, labia, clitoris, vestibule), vagina - **Male:** Penis (root, shaft, glans), scrotum (testes, epididymis, ductus deferens) 💡 ****Tip:** The perineum's complex anatomy, constant motion, and proximity to vital structures make durable flap selection critical for successful reconstruction. --- ## Indications of Perineal Reconstruction ****Key Point** Malignancy is the most common indication for perineal reconstruction, often following oncologic resection and radiation. Other causes include trauma, infection, and congenital or functional defects. Perineal defects occur in a range of conditions and require tailored reconstructive strategies ([Salgado](https://pubmed.ncbi.nlm.nih.gov/22547973/?ref=theplasticsfella.com), 2011). The goal is to provide durable, vascularised coverage to support healing and restore function. ### Oncologic **This is the most frequent and complex indication** for reconstruction. It often involves **skin, anus, vulva, vagina, penis**, and adjacent soft tissue and frequently complicated by **radiation therapy,** impairing wound healing. Key scenarios include, - Abdominoperineal resection (APR) for low rectal or anal cancer. - Pelvic exenteration (removal of pelvic organs). - Vulvectomy or penectomy requiring genital reconstruction. - Rectovaginal or rectourethral fistulae, often from malignancy or radiation. ### Traumatic These injuries are typically due to severe mechanisms such as pelvic fractures or industrial accidents. They may involve: - **Crush injuries** or **degloving wounds**, with exposure of pelvic organs and structures. ### Infective Commonly seen in diabetic or immunocompromised patients, these infections include: - **Fournier’s gangrene** is the most frequent cause in this group. - **Necrotising fasciitis** requires staged wound management and infection clearance prior to definitive repair. ### Congenital and Functional - **Anorectal malformations**, such as **cloacal anomalies**, requiring staged flap-based procedures. - **Chronic radiation wounds**. Seen in cancer survivors, often complicated by fibrosis and ulceration. The table below summarises aetiologies of perineal defects and their reconstructive implications. ![Aetiologies of perineal defects and their reconstructive implications](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-24T001353.971.png) Aetiologies of perineal defects and their reconstructive implications 💡 ****Tip:** When dealing with rectovaginal fistulae, a core principle is to excise the fistula tract and interpose well-vascularised tissue between the cavities. Muscle flaps like gracilis are often ideal in these scenarios. --- ## Principles of Perineal Reconstruction ****Key Point** Perineal reconstruction is uniquely challenging due to the complex anatomy, high bacterial burden, risk of pressure necrosis, and involvement of critical urogenital and anorectal functions. Effective perineal reconstruction balances three key demands: **matching the flap to the defect**, **withstanding hostile wound environments**, and **minimizing donor site complications**. Every choice should reflect this balance between defect needs and donor site trade-offs. ### General Considerations Perineal reconstruction presents distinct challenges compared to other regions, such as the lower limb, due to the following unique factors. 1. **Multisystem Involvement:** Often includes the anus, vulva, vagina, or penis (Butler, 2005). 2. **Dual Goals:** Requires restoration of both form and function. 3. **High Bacterial Load:** Increases risk of infection and wound breakdown. 4. **Pressure Risk:** Recumbent/sitting positions can cause ischemia and flap necrosis. 5. **Mechanical Tension:** Ambulation stresses incisions and closures. 6. **Dead Space:** Especially after pelvic resections, requires careful obliteration. 7. **Local Environment**: Moisture, friction, and proximity to urine/feces complicate healing ([Salgado](https://pubmed.ncbi.nlm.nih.gov/22547973/?ref=theplasticsfella.com), 2011). The table below summarises foundational goals guiding flap selection and surgical design in perineal reconstruction. ![foundational goals guiding flap selection and surgical design in perineal reconstruction, with emphasis on function, reliability, and patient quality of life.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-13T143828.973.png) Foundational goals guiding flap selection and surgical design ### Specific Considerations **Tissue Selection by Defect and Function** Flap choice must balance structural needs with long-term donor site impact. - **Superficial Defects** (e.g., hidradenitis, minor trauma): Use local advancement or fasciocutaneous flaps. Minimal morbidity, fast recovery. - **Deep/Complex Defects** (e.g., malignancy, trauma): Require muscle or myocutaneous flaps to fill dead space and withstand radiation. - **Gracilis:** Reliable, low functional loss. - **VRAM:** High bulk, suited for major resections; risk of abdominal wall weakness. - **Gluteal:** Posterior coverage; may limit sitting/mobility. **Contamination, Radiation, and Oncologic Fields** - **Infected/Irradiated Fields:** Muscle flaps are preferred for perfusion and resistance to infection ([Nelson](https://pubmed.ncbi.nlm.nih.gov/19116551/?ref=theplasticsfella.com), 2009). Gracilis: Ideal for moderate contaminated defects, VRAM: Best for extensive, irradiated, or composite loss. - **Benign Cases:** Delay reconstruction until wound is clean and stable ([Salgado](https://pubmed.ncbi.nlm.nih.gov/22547973/?ref=theplasticsfella.com), 2011). - **Malignant Cases:** Require multidisciplinary input and flaps that restore compartmental integrity and resist breakdown. 😎 ****Fun Fact:** Flap choice must account for defect characteristics, contamination, functional demands, and donor morbidity. Gracilis and VRAM are preferred in contaminated or irradiated fields for their vascularity and reliability. --- ## Procedure of Perineal Reconstruction ****Key Point** The reconstructive approach to perineal defects must be guided by defect complexity, prior radiation, risk of contamination, and patient-specific functional needs. Pedicled flaps remain the cornerstone due to their reliability, proximity, and ability to fill pelvic dead space with vascularised tissue. ### Pre-Operative Planning **Optimisation** - **Nutrition:** Optimise in all patients; low albumin correlates with poor healing. - **Bowel Prep:** Recommended prior to oncologic resections. - **Stoma Planning:** Diverting stoma should be considered in high-risk or contaminated wounds. **Multidisciplinary Coordination** - Involve colorectal, gynaecologic oncology, and urology teams. - Joint planning anticipates: Pelvic dead space, Flap design, Stoma location relative to flap pedicles ### Flap Design **Defect Assessment** Key factors to evaluate in perineal reconstruction: - **Size and Depth** of the defect. - **Exposure** of critical structures (e.g., urethra, bowel, sacrum). - **Radiation History** or presence of chronic infection. - **Volume of Pelvic Dead Space**. - **Anatomic Location:** Anterior, posterior, or circumferential. **Reconstructive Planning** - **Superficial, Dry, Non-Irradiated Wounds:** Consider skin grafts or local fasciocutaneous flaps. - **Deep, Contaminated, or Irradiated Wounds:** Muscle or myocutaneous flaps preferred for bulk and perfusion. ### Technique **Skin Grafts** - Suitable for uncomplicated superficial wounds only. - Poor durability in moist or high-shear areas. - Avoid over-bone, vessels, or irradiated tissue. **Regional and Pedicled Flaps** - **Gracilis Muscle Flap** - **Indication:** Moderate defects in contaminated/irradiated fields. - **Blood Supply:** Medial circumflex femoral artery. - **Pros:** Easy to harvest, low donor morbidity, effective for fistulae. - **Cons:** Limited arc of rotation; may need bilateral flaps for large volumes. - **Vertical Rectus Abdominis Myocutaneous (VRAM) Flap** - **Indication:** Large or post-APR perineal/vaginal defects. - **Blood Supply:** Deep inferior epigastric artery. - **Design:** Vertical, transverse, or oblique. - **Applications** - Vaginal wall reconstruction (can be tubed). - Obliterating pelvic dead space. - **Notes** - Preserve the anterior rectus sheath to reduce hernia risk. - Preserve the contralateral rectus if a stoma is planned. - Can be tunneled or rotated retroperitoneally. - **Anterolateral Thigh (ALT) Flap** - **Blood Supply:** Descending branch of the lateral femoral circumflex artery. - **Use:** Large, irradiated, or abdominally inaccessible defects. - **Technique Tip:** Tunnel deep to the rectus femoris to increase reach. - **Considerations:** Perforator variability; may be bulky in obese patients. - **Gluteal and Posterior Thigh Flaps** - **Blood Supply:** Inferior gluteal artery or profunda perforators. - **Indication:** When abdominal options are contraindicated. - **Use:** Posterior perineal coverage; V-Y or rotation flaps for unilateral defects. - **Pudendal Thigh (Singapore) Flap** - **Blood Supply:** Branches of pudendal artery. - **Indication:** Vulvar, labial, or periclitoral reconstruction. - **Advantage:** Sensation preserved, which is important for function and quality of life. - **Use:** Ideal for Type IA vaginal defects ([Nelson](https://pubmed.ncbi.nlm.nih.gov/19116551/?ref=theplasticsfella.com), 2009). **Free Flap Reconstruction** - Reserved for complex or salvage cases - Circumferential vaginal defects. - Failed prior reconstruction. - **Examples** - **Free Jejunal Flap:** Used for Type IIB defects (total vaginal loss). - **Recipient Vessels:** Gluteal or femoral; may require vein grafts. The table below summarises key flap types by indication, vascular supply, major benefits, and technical challenges. ![Key flap types by indication, vascular supply, major benefits, and technical challenges](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-24T001501.542.png) Key flap types by indication, vascular supply, major benefits, and technical challenges ### Vaginal Defect Classification When vaginal reconstruction is required — particularly following oncologic resection, radiation, or extensive perineal injury — the **Cordeiro classification** helps guide flap selection based on the **extent and location of tissue loss** ([Cordeiro](https://pubmed.ncbi.nlm.nih.gov/12198418/?ref=theplasticsfella.com), 2002). - **Type I:** Partial defects - **IA:** Anterior or lateral wall - **IB:** Posterior wall - **Type II:** Circumferential defects - **IIA:** Upper two-thirds - **IIB:** Total vaginal loss The image below illustrates the Cordeiro system for classifying acquired vaginal defects. ![the Cordeiro system for classifying acquired vaginal defects based on extent and location.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-12T152346.163.png) The Cordeiro system for classifying acquired vaginal defects **Reconstructive Options by Type** - **Type IA:** Singapore flap or local perforator-based fasciocutaneous flaps. - **Type IB and IIA:** Pedicled VRAM flap (tubed or inset). - **Type IIB:** Bilateral gracilis or VRAM flaps, or free jejunal flap for full neovaginal tube. ### Post-Operative Care **Positioning and Pressure Management** - Avoid **direct pressure** over the flap (especially posteriorly). - Place in **low Fowler’s or lateral decubitus** positions early post-op. - Minimise sitting for the first 10-14 days. **Drain Management** - Insert **closed-suction drains** under the flap and in the pelvic dead space. - Prevents seroma, promotes adherence of flap to bed. **Stoma Considerations** - Plan the ostomy away from flap pedicles. - Ensure **stoma appliance adhesion** is not compromised by adjacent incisions. **Mobilization** - Early ambulation is encouraged once flap integrity is confirmed. - Use foam cushions or pressure-relieving supports ([Salgado](https://pubmed.ncbi.nlm.nih.gov/22547973/?ref=theplasticsfella.com), 2011). 💡 ****Tip:** The VRAM flap is preferred for obliterating pelvic dead space post-APR. Preserve the anterior rectus sheath during harvest to reduce hernia risk, and coordinate with general surgery for optimal pedicle orientation if a colostomy is planned. --- ## Complications and Outcomes of Perineal Reconstruction ****Key Point** Perineal reconstruction carries a high risk of wound-related complications due to the region’s bacterial load, mobility, and proximity to the gastrointestinal and urogenital tracts. Vigilant post-operative care and pressure avoidance are essential to reduce morbidity and flap loss. ### Common Complications **Wound Dehiscence** The **most frequent postoperative complication**, especially in irradiated fields, often caused by shear, pressure, or patient mobility. - **Small dehiscences** may heal secondarily with conservative management. - **Larger wounds** or those compromising adjuvant therapy may require surgical revision. **Infection** The perineum's **high bacterial burden** makes infection a significant risk. - **Closed-suction drains** should be maintained as long as needed to avoid seroma and abscess. - If **sepsis** occurs, deep pelvic abscesses must be excluded and drained. **Flap Necrosis** Total flap loss is rare with pedicled options, but requires prompt recognition. Partial necrosis may occur due to venous congestion or pedicle compression, especially in, - **VRAM Flaps:** Vulnerable to **venous outflow issues** in deep pelvic tunnels. - **Gracilis Flaps:** Large skin paddles may develop **fat necrosis**; muscle belly may retract if disrupted. - **Singapore Flaps:** Tip necrosis is a known risk, especially with poor perfusion. **Perineal Hernia** This occurs when the pelvic dead space is **inadequately obliterated**, especially post-APR. Prevention includes: - Use of **bulky flaps** (e.g., VRAM). - **Layered closure of pelvic floor fascia** if intact. ### Flap-Related Considerations - Patients must be **positioned to avoid direct pressure** on the flap site post-operatively. - **Early ambulation is encouraged**, but sitting should be avoided for **4-6 weeks** to prevent shear-related ischemia. - Vigilant **monitoring of flap perfusion** is necessary, particularly in the first 48-72 hours. ### Functional Outcomes Long-term functional success extends beyond wound closure. - **Urinary and fecal continence** may be impacted, especially if pelvic floor support is inadequate. - **Vaginal reconstruction** complications include, - Inadequate neovaginal dimensions. - Vaginal stenosis or dryness. - **Hypertrophic scarring** or psychological distress impacting sexual function. - **Sexual outcomes** may not correlate with anatomical reconstruction alone. Psychosocial support is often necessary. 😎 ****Fun Fact:** Without flap-based reconstruction, perineal wound complications following abdominoperineal resection can reach 40-66%, particularly in patients who received neoadjuvant chemoradiation. Flaps like the VRAM significantly reduce this risk by filling dead space and improving healing in irradiated fields. --- ## Conclusion ****Upon completing this article, you will have accomplished the following:** ****1\. Overview:** Perineal reconstruction restores anatomy and function after oncologic resection, trauma, or infection, using vascularised tissue to reduce complications. ****2\. Indications and Anatomy:** Most common after pelvic cancer surgery, the perineum’s complex anatomy and high contamination risk demand tailored reconstructive approaches. ****3\. Reconstructive Principles & Flap Selection:** Flap choice depends on depth, contamination, and functional goals—VRAM and gracilis are mainstays; ALT and Singapore flaps suit select cases. ****4\. Procedure & Post-Op Care:** Surgical planning must address dead space, flap orientation, and stoma sites; avoid pressure on flaps and mobilise early post-op. ****5\. Complications & Outcomes:** Risks include wound dehiscence, infection, flap failure, and functional issues; long-term outcomes depend on technique and post-op care. --- ## Further Reading 1. Cordeiro PG, Pusic AL. A Classification System and Reconstructive Algorithm for Acquired Defects of the Vagina. *Plast Reconstr Surg.* 2005;116(5):1058–1065\. doi:10.1097/01.prs.0000181385.19011.52 2. Fix RJ, TerKonda SP, Zinsser J, Vasconez LO. Reconstruction of the abdomen and perineum in cancer surgery. Surg Oncol Clin N Am. 1997;6(1):115-132. 3. Nelson RA, Butler CE. Surgical Outcomes of VRAM Flap Reconstruction for Perineal and Pelvic Defects: A 10-Year Experience. *Ann Surg Oncol.* 2009;16(8):2263–2271\. doi:10.1245/s10434-009-0502-1 4. van Ramshorst GH, Young JM, Solomon MJ. Complications and Impact on Quality of Life of Vertical Rectus Abdominis Myocutaneous Flaps for Reconstruction in Pelvic Exenteration Surgery. Dis Colon Rectum. 2020;63(9):1225-1233\. doi:10.1097/DCR.0000000000001632 5. Chim H, Salgado CJ, Mardini S. Reconstruction of Perineal and Genitourinary Defects. In: Neligan PC, ed. *Plastic Surgery*. 4th ed. Vol 6\. Philadelphia, PA: Elsevier; 2017:407–430. 6. Koshy JC, Goldberg JS, Agarwal S, et al. Perineal and Lower Extremity Reconstruction. In: Thorne CH, ed. *Grabb and Smith’s Plastic Surgery*. 7th ed. Philadelphia, PA: Wolters Kluwer; 2014:872–880. 7. Losken A, Carlson GW, Jones GE, et al. Perineal and Posterior Vaginal Wall Reconstruction Using the Gluteal Fold Flap. *Plast Reconstr Surg.* 2001;107(3):734–739\. doi:10.1097/00006534-200103000-00020 8. Weichman KE, Matros E, Disa JJ. Reconstruction of Peripelvic Oncologic Defects. Plast Reconstr Surg. 2017;140(4):601e-612e. doi:10.1097/PRS.0000000000003703 9. Lin CT, Chang SC, Chen SG, Tzeng YS. Reconstruction of perineoscrotal defects in Fournier's gangrene with pedicle anterolateral thigh perforator flap. ANZ J Surg. 2016;86(12):1052-1055\. doi:10.1111/ans.12782 10. Mughal M, Baker RJ, Muneer A, Mosahebi A. Reconstruction of perineal defects. *Ann R Coll Surg Engl*. 2013;95(8):539-544\. doi:10.1308/rcsann.2013.95.8.539 ### Blepharoplasty: Anatomy, Evaluation, & Surgical Technique URL: https://www.theplasticsfella.com/blepharoplasty/ Last updated: 2025-06-30T17:56:31.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/blepharoplasty/#overview-of-blepharoplasty) Blepharoplasty is a periorbital rejuvenation procedure. Upper blepharoplasty addresses eyelid dermatochalasis, while lower blepharoplasty corrects eyelid fat herniation & laxity. [****Surgical Anatomy**](https://www.theplasticsfella.com/blepharoplasty/#surgical-anatomy-for-blepharoplasty) The anterior lamella consists of the skin and orbicularis oculi muscle, while the posterior lamella includes the tarsal plate and conjunctiva, and receives a dual vascular supply. [****Preoperative Evaluation** ](https://www.theplasticsfella.com/blepharoplasty/#preoperative-evaluation-for-blepharoplasty) Screen for dry eye, assess MRD1, vector, lid laxity (snap-back/distraction tests), brow position, and identify prolapsed fat or ptosis to guide blepharoplasty planning. [****Surgical Technique**](https://www.theplasticsfella.com/blepharoplasty/#surgical-technique-for-blepharoplasty) Upper blepharoplasty focuses on skin excision and conservative fat handling; lower blepharoplasty uses transconjunctival/transcutaneous access to manage fat, release ligaments, & support lid position. [****Complications**](https://www.theplasticsfella.com/blepharoplasty/#complications-of-blepharoplasty) Retrobulbar hematoma is the most feared complication due to the risk of vision loss; other issues such as lagophthalmos, lid malposition, dry eye, and chemosis are rare and usually preventable with technique. ****Primary Contributor:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Blepharoplasty ****Key Point** Blepharoplasty is a periorbital rejuvenation procedure. Upper blepharoplasty addresses eyelid dermatochalasis with skin and fat excision, while lower blepharoplasty corrects eyelid fat herniation and laxity via either a transcutaneous or transconjunctival approach. Blepharoplasty is a periorbital rejuvenation procedure that addresses skin, fat, and muscle changes associated with aging. **Upper Eyelid Changes** - Dermatochalasis and hooding - Fat pseudoherniation - Leads to a tired or heavy appearance **Lower Eyelid Changes** - Orbital septum attenuation - Fat prolapse and lid laxity - Midface descent → tear trough deformity, scleral show **Surgical Approaches** - **Upper Blepharoplasty:** Skin and fat excision ± orbicularis debulking - **Lower Blepharoplasty:** - **Transconjunctival**: Fat access without skin incision - **Transcutaneous**: Allows ligament release and skin tightening - ± Canthal support depending on vector and laxity 😎 ****Fun Fact:** Blepharoplasty is the third most performed aesthetic surgical procedure worldwide, with 1,746,946 cases—a 24% increase in popularity. According to the ISAPS 2023 report, liposuction ranks first, followed by breast augmentation ([ISAPS report](https://www.isaps.org/media/rxnfqibn/isaps-global-survey%5F2023.pdf?ref=theplasticsfella.com), 2023). --- ## Surgical Anatomy for Blepharoplasty ****Key Point** The eyelid is a layered structure composed of anterior and posterior lamellae, including skin, orbicularis oculi muscle, tarsal plates, and conjunctiva — and receives a dual vascular supply from both the internal and external carotid systems. A detailed understanding of periorbital anatomy is critical for safe and effective blepharoplasty. Evaluation begins with surface topography, which guides aesthetic goals and surgical planning. - **Youthful Eyes** are defined by a balanced anterior projection of the globe relative to surrounding structures, particularly the malar eminence and brow. - **Negative Vector** occurs when the globe projects anterior to the malar eminence, often due to midface hypoplasia or descent. This anatomical configuration, - Increases the risk of lid malposition postoperatively. - Contributes to ocular prominence, brow and cheek volume loss, and a tired or hollow appearance. Negative vector is illustrated below. ![Negative vector, Surgical Anatomy for Blepharoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Blepharoplasty.png) Negative vector ### Upper Eyelid Zones - **Supratarsal Area:** Between the eyebrow and the lid crease. - **Pretarsal Area:** Between the crease and the lash line. The aesthetic balance of the upper eyelid depends on the **fold-to-pretarsal ratio** and **volume distribution**. Loss of upper lid fullness, particularly from **age-related fat atrophy**, contributes to the classic “sunken eye” appearance. ### Lower Eyelid Zones - **Pretarsal Zone:** Shows dynamic convexity during smiling or blinking, shaped by orbicularis activity. - **Preseptal Zone:** Contains the orbital septum and fat pads; herniation here appears as defined bulges. - **Eyelid-Cheek Junction:** Defined medially by the tear trough and laterally by the malar mound, crucial for assessing lid-cheek blending. A well-defined almond-shaped palpebral fissure with a positive canthal tilt, where the lateral canthus lies slightly above the medial, enhances lateral eye aesthetics. The image below illustrates the surface topography of the periorbital area. ![The surface topography of the periorbital area](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Blepharoplasty.zip---2.png) The surface topography of the periorbital area ### Bony Framework The **orbit** is a rigid, cone-shaped cavity composed of seven bones: frontal, zygomatic, maxillary, lacrimal, ethmoid, sphenoid, and palatine bones. Bony key surgical landmarks include, - **Superior orbital rim** - **Inferior orbital rim** 😎 ****Fun Fact:** The orbit is a confined structure, so even minor bleeding or edema can cause significant increases in intraorbital pressure. ### Eyelid Layers The eyelid is composed of multiple anatomical layers, organized into anterior and posterior lamellae. These vary slightly between the tarsal and pretarsal regions but follow the same basic lamellar principles. **Tarsal Portion** This region lies over the tarsal plate and includes 4 key layers. - **Skin** (with minimal subcutaneous tissue) - **Orbicularis oculi muscle (OOM)** - **Tarsal plate** - **Conjunctiva** (palpebral and bulbar) - **Anterior Lamella** \= Skin + OOM (Layers 1–2) - **Posterior Lamella** \= Tarsus + Conjunctiva (Layers 3–4) **Pretarsal Portion** This extends above/below the tarsus and includes 7 anatomical layers, differing slightly between the upper and lower lids. - **Skin** - **Orbicularis oculi muscle (OOM, palpebral portion)** - **Orbital septum** - **Fat pads** - Upper lid: preaponeurotic (medial, central) - Lower lid: medial, central, lateral - **Retractor layer** - Levator aponeurosis (upper lid) - Capsulopalpebral fascia (lower lid) - **Müller’s muscle** (upper) / **Inferior tarsal muscle** (lower) - **Conjunctiva** These eyelid layers are illustrated below. ![Layers of the eyelid in sagittal view, blepharoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Blepharoplasty.zip---3.png) Layers of the eyelid in sagittal view ### Muscles - **Orbicularis Oculi (OOM):** Encircles the eye; divided into orbital and palpebral portions. The palpebral portion further divides into preseptal and pretarsal components, the latter critical for blinking and lid tone. - **Levator Palpebrae Superioris:** Elevates the upper eyelid; innervated by the oculomotor nerve (CN III). It divides into an anterior aponeurosis and posterior Müller’s muscle, the latter under sympathetic control. - **Frontalis Muscle:** Elevates the brow, indirectly affecting upper eyelid position. - **Capsulopalpebral Fascia:** Functions as the lower lid retractor, analogous to the upper levator. ### Canthal Tendons and Ligaments - **Medial Canthal Tendon:** Anchors the tarsal plates (upper and lower) to the medial orbit; critical for lid position and lacrimal drainage. - **Lateral Canthal Tendon and Ligament:** The ligament connects the upper and lower tarsal plates, whereas the tendon anchors them to the orbital rim. - **Whitnall’s Ligament:** Fascial pulley for the levator muscle. - **Lockwood’s Ligament:** Globe and lower lid stabiliser. - **Orbicularis Retaining Ligament (ORL):** Defines the tear trough and palpebromalar groove, must be released in lower lid rejuvenation. - **Tear Trough Ligament:** Medial component of the ORL. 💡 ****Tip:** It is crucial to distinguish between the lateral canthal ligament and tendon, as each has different surgical implications: the ligament is disrupted during a tarsal strip procedure, while the tendon is involved in canthopexy or canthoplasty techniques. ### Orbital Septum and Fat Pads The **orbital septum** is a fibrous membrane extending from the orbital rim (arcus marginalis) to the tarsal plates. Age-related attenuation leads to fat prolapse. The medial fat is typically more fibrous and white. - **Upper Eyelid:** Contains two fat pads, **medial (nasal)** and **central (preaponeurotic)**. - **Lower Eyelid:** Contains three; **medial**, **central**, and **lateral**. - **ROOF (Retro-Orbicularis Oculi Fat):** superficial fat above the orbital septum in the upper lid-brow transition zone. - **SOOF (Suborbicularis Oculi Fat):** deep to OOM in the lower lid-cheek junction; blending improves the lid-cheek transition. ### Vascular Supply The eyelid region benefits from dual supply via the **internal** and **external carotid systems**, allowing robust collateral circulation. - The **ophthalmic artery** (from ICA) gives rise to, - **Supraorbital**, **supratrochlear**, and **dorsal nasal** arteries. - **Zygomaticofacial artery**, which anastomoses with the **transverse facial artery** (from ECA). - Key anastomoses occur with the **angular artery** (terminal branch of the facial artery). ### Innervation - **Sensory** - **Upper Eyelid:** Supratrochlear and supraorbital nerves (from V1). - **Lower Eyelid:** Infraorbital nerve (from V2). - **Motor** - **Facial Nerve (CN VII):** Orbicularis oculi, frontalis, procerus. - **Oculomotor Nerve (CN III):** Levator palpebrae superioris. - **Sympathetic System:** Müller’s muscle. ### Lacrimal System - **Lacrimal Gland:** Situated in the superolateral orbit. - **Caruncle**, **Puncta**, and **Canaliculi:** Located medially, adjacent to the medial canthal tendon. - The **canaliculi** lie deep to the tendon, a key consideration during medial dissection. The lacrimal system is illustrated below. ![Anatomy of the lacrimal system, blepharoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Blepharoplasty.zip---4.png) Anatomy of the lacrimal system --- ## Preoperative Evaluation for Blepharoplasty ****Key Point** Screen for dry eye, assess MRD1, vector, lid laxity (snap-back/distraction tests), brow position, and identify prolapsed fat or ptosis to guide blepharoplasty planning. A thorough preoperative assessment is essential for planning safe and effective blepharoplasty. This involves evaluating patient expectations, identifying risk factors, and documenting anatomical variables that influence surgical approach and outcomes. **History** - **Systemic Conditions:** Hypertension, bleeding disorders, use of anticoagulants, thyroid disease, glaucoma. - **Ocular History:** Dry eye symptoms, prior eyelid or corneal surgery. 💡 ****Tip:** Delay blepharoplasty at least ****6 months after LASIK** to allow corneal nerve regeneration and reduce risk of postoperative dry eye. **Dry Eye Screening** - **Schirmer Test:** <5 mm = dry eye. - **Fluorescein Stain:** punctate erosions = surface damage. - **Bell’s Phenomenon:** absence = ↑ risk of corneal exposure. **Physical Exam** - **Brow Position** (with frontalis relaxed): At the rim for men and slightly above for women, especially laterally. - **Upper Eyelid:** Assess MRD1, ptosis, dermatochalasis, fat/lacrimal prolapse - **Lower Eyelid** - Skin excess, fat herniation, and tear trough - **Snap-Back Test:** delayed = laxity - **Distraction Test:** \>6 mm = abnormal - **Vector:** ***Negative = globe posterior to rim → ↑ risk of ectropion/dry eye*** 💡 ****Tip:** A brow in normal position doesn't always rule out the need for a brow lift. Brow ptosis must be assessed in upper blepharoplasty planning. The [****Orbital Oval Balance principle**](https://pubmed.ncbi.nlm.nih.gov/29979364/?ref=theplasticsfella.com) can guide surgical indication. **Documentation** - Pre-op photos (frontal, lateral, oblique, gaze variations). - Mirror exam with the patient to identify asymmetries or areas of concern. - Set expectations with the patient. --- ## Surgical Technique for Blepharoplasty ****Key Point** Upper blepharoplasty focuses on skin excision and conservative fat handling; lower blepharoplasty uses transconjunctival or transcutaneous access to manage fat, release ligaments, and support lid position. Blepharoplasty techniques vary based on the anatomical site, vector, and patient goals. Precision and tissue preservation are essential for natural, functional outcomes. ### Upper Eyelid Blepharoplasty Upper eyelid blepharoplasty is performed to treat **dermatochalasis**, with or without fat prolapse or ptosis. In modern blepharoplasty, preservation of structures is key. **Indications:** Primarily performed for dermatochalasis, with or without fat prolapse or ptosis. **Preoperative Markings** - Made in the sitting position with the brow at rest. - Mark the natural lid crease if visible ( 6-10 mm above the lash line centrally). - **Men:** 6-8 mm. - **Women:** 8-10 mm. - **Lateral Extension:** Follow a crow’s feet crease, max 10 mm beyond canthus and 4-5 mm above it. - Preserve ≥10 mm of skin between the brow and upper excision line. - Marking is confirmed with a skin pinch to assess redundancy. Upper blepharoplasty surgical marking is illustrated below. ![Upper blepharoplasty surgical marking](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Blepharoplasty.zip---5.png) Upper blepharoplasty surgical marking **Technique** - The procedure is typically performed under **local anesthesia**. - Skin alone is removed unless orbicularis debulking is required to reduce fullness or define the supratarsal crease. When needed, a 3-5 mm **strip of orbicularis** can be excised with careful hemostasis. - **Orbital fat** management is patient-specific and can be conservative. - After opening the orbital septum, the central (preaponeurotic) and medial fat pads can be identified. - Gentle pressure on the globe helps prolapse the fat, which can be carefully cauterized and resected. - **Retro-orbicularis oculi fat (ROOF)** can be addressed if it contributes to lateral fullness, but brow volume should be preserved when possible. - In cases of **lacrimal gland** **prolapse**, repositioning to the lacrimal fossa using non-absorbable sutures is possible; excision is avoided due to the risk of dry eye. - **Closure** is performed with **6-0 to 8-0** interrupted or running sutures, either absorbable or non-absorbable, and typically removed on postoperative day 7. **Adjunct Procedures** - **Transpalpebral Browpexy:** Fixation of lateral OOM to deep temporal fascia. - **Fat grafting** or **redraping** for sulcus restoration. - **Supratarsal Fixation:** Optional stitch (e.g., 6-0 Vicryl) from pretarsal orbicularis to levator aponeurosis to stabilize the crease. - **Corrugator resection** can be added in selected cases. ### Lower Eyelid Blepharoplasty Lower eyelid blepharoplasty can be performed using a **transconjunctival** or **transcutaneous** approach. The choice depends on, - Skin excess - Fat prominence - Lid laxity - Vector (globe-to-rim relationship) The **transconjunctival approach** preserves the **anterior lamella** (skin and orbicularis oculi), making it ideal for patients with good skin tone and isolated fat herniation. There are **two primary dissection planes**. **Preseptal Approach** - **Incision:** Within 5 mm of the inferior tarsal border. - **Plane:** Between the orbicularis oculi and orbital septum. - **Access:** Orbital fat pads after incising the septum. - **Advantages:** Direct release of key retaining structures. - Tear trough ligament. - Orbital portion of the OOM. - Orbicularis retaining ligament. - Ideal for **s**oft tissue tethering and volume contouring. **Postseptal Approach** - **Incision:** 5-6 mm below the tarsus. - **Plane:** Behind the capsulopalpebral fascia; orbital septum is preserved. - **Access:** Fat pads posteriorly, with subperiosteal dissection to arcus marginalis. - **Effect:** Lifts the tear trough zone **indirectly** by elevating its periosteal origin. - Ideal for patients needing volume redistribution without septal violation. The image below illustrates lower eyelid anatomy and surgical approaches. ![Lower eyelid anatomy and surgical approaches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Blepharoplasty.zip---6.png) Lower eyelid anatomy and surgical approaches Fat is gently prolapsed with globe pressure and either partially resected or redraped over the infraorbital rim. After fat handling, lateral canthal support is rarely needed, as OOM tone is preserved. Skin redundancy, if present, can be addressed via a separate **pinch excision** or **skin-only flap**, without violating the OOM. 💡 ****Tip:** Avoid injuring the ****inferior oblique muscle**, which separates medial and central fat compartments, otherwise we risk diplopia. **Transcutaneous Approach** The transcutaneous approach provides anterior access via a subciliary incision (1-2 mm below the lash line), extended laterally along a crow’s feet crease. Dissection is carried through OOM in a preseptal plane, preserving \~4 mm of pretarsal muscle. The **orbitomalar** and **orbicularis retaining ligaments** are released, enabling redraping of the OOM and soft tissue over the infraorbital rim. The septum is opened to access and manage fat pads. Skin and muscle are conservatively excised and redraped laterally. **Lateral canthal support** is key in patients with laxity or a negative vector. - **Canthopexy:** For mild laxity. - **Canthoplasty** or **Lateral Tarsal Strip:** For moderate/severe cases. - The canthus should sit \~2 mm above the medial canthus to preserve shape and avoid rounding. --- ## Complications of Blepharoplasty ****Key Point** Retrobulbar hematoma is the most feared complication due to risk of vision loss; other issues such as lagophthalmos, lid malposition, dry eye, and chemosis are rare and usually preventable with proper technique. While generally safe, blepharoplasty can lead to **functional or aesthetic complications**, broadly classified as **acute** or **late**. Early recognition and prevention are key to optimal outcomes. ### Acute Complications **Retrobulbar Hematoma** The most feared complication of blepharoplasty — **vision-threatening** due to the risk of **orbital compartment syndrome**. - **Clinical Features** (within hours post-op) - Sudden, severe **pain** - **Proptosis** - **Tense eyelids** - Decreased **visual acuity** - Limited **extraocular movements (EOMs)** - Relative afferent pupillary defect (**RAPD**) **Immediate Management:** This is a **surgical emergency**. Do not delay intervention for imaging. - **Urgent Canthotomy and Cantholysis** - Performed at bedside or in OR. - **Goal:** Relieve pressure and restore perfusion within **60–90 minutes**. - Technique - **Lateral Canthotomy:** Horizontal incision at the lateral canthus. - **Inferior Cantholysis:** Vertical cut through the inferior crus of the lateral canthal tendon. - **Medical Adjuncts (if available while preparing for surgery)** - **IV Acetazolamide** 500 mg to reduce intraocular pressure (IOP). - **Topical timolol** drops. - **IV steroids** (e.g., dexamethasone 10 mg). - **Mannitol** 1–2 g/kg IV if IOP remains high. - **Ophthalmology Referral** - Post-decompression monitoring. - Further evaluation of the optic nerve and IOP. **Corneal Abrasion** - Pain, tearing - **Diagnosis:** Fluorescein stain - **Management:** Antibiotic ointment **Lagophthalmos** - Early postoperative findings. - Usually resolves with **lubrication**. - Persistent cases may need **skin grafts or revision**. **Chemosis (Conjunctival Edema)** - Common after lower lid or lateral canthal surgery. - Management: **Lubricants, steroids, vasoconstrictors** **Dry Eye** - Often transient; may worsen post-op. - **Management:** Lubrication ± ophthalmology referral. **Diplopia** - Rare, usually temporary. - Often due to traction or injury to the **inferior/superior oblique**. **Epiphora** - Due to lid contour changes or inflammation. - Usually self-limited. **Infection** - Rare. - Managed with topical or systemic **antibiotics**. ### Late Complications **Asymmetry** - From unequal fat handling or scarring. - May require **revision surgery**. **Lower Lid Malposition** (e.g., retraction, ectropion, scleral show) - **Causes:** Over-resection or inadequate canthal support. - **Prevention:** Use **canthopexy/canthoplasty** in patients with **negative vector or laxity**. **Persistent Lagophthalmos** - May need surgical correction if unresolved. **Dry Eye Syndrome** - Lasts >2 weeks in high-risk patients. - **Causes:** Blink issues, Meibomian dysfunction, exposure. - **Treatment:** Lubricants, **punctal plugs**, ophthalmology referral. **Unsightly Scars or Webbing** - Prevented by respecting natural crease lines and avoiding overextension medially/laterally. 💡 ****Tip:** In suspected retrobulbar hematoma, do not delay for imaging. Perform bedside canthotomy/cantholysis within 60–90 minutes to preserve vision. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Blepharoplasty rejuvenates the periorbital region by excising excess skin and managing fat in the upper and lower eyelids using transcutaneous or transconjunctival approaches. ****2\. Surgical Anatomy:** Understanding eyelid layers, fat compartments, ligaments, and dual vascular supply is essential for safe surgical planning and avoiding complications. ****3\. Preoperative Evaluation:** Assessment includes MRD1, vector, lid laxity, brow position, and dry eye screening to tailor the surgical approach and manage patient expectations. ****4\. Surgical Technique:** Upper blepharoplasty removes skin and conservatively addresses fat; lower blepharoplasty uses various approaches to manage fat, release ligaments, and support the canthus. ****5\. Complications:** Retrobulbar hematoma is the most critical risk; others like lid malposition, dry eye, chemosis, and asymmetry are rare and mostly preventable with proper technique. --- ## Further Reading 1. Codner MA, Kikkawa DO, Korn BS, Pacella SJ. Blepharoplasty and brow lift. Plast Reconstr Surg. 2010 Jul;126(1):1e-17e. doi: 10.1097/PRS.0b013e3181dbc4a2\. PMID: 20595828. 2. Alghoul M. Blepharoplasty: Anatomy, Planning, Techniques, and Safety. Aesthet Surg J. 2019 Jan 1;39(1):10-28\. doi: 10.1093/asj/sjy034\. PMID: 29474509. 3. Rosenberg DB, Lattman J, Shah AR. Prevention of lower eyelid malposition after blepharoplasty: anatomic and technical considerations of the inside-out blepharoplasty. Arch Facial Plast Surg. 2007 Nov-Dec;9(6):434-8\. doi: 10.1001/archfaci.9.6.434\. PMID: 18025355. 4. Gülbitti HA, Bouman , Marten TJ, van der Lei B. The Orbital Oval Balance Principle: A Morphometric Clinical Analysis. Plast Reconstr Surg. 2018 Oct;142(4):451e-461e. doi: 10.1097/PRS.0000000000004805\. PMID: 29979364. 5. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg. 1998 Oct;102(5):1646-57\. doi: 10.1097/00006534-199810000-00051\. PMID: 9774027. 6. Smith B, Petrelli R. Surgical repair of prolapsed lacrimal glands. Arch Ophthalmol. 1978 Jan;96(1):113-4\. doi: 10.1001/archopht.1978.03910050069017\. PMID: 623540. 7. Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg. 2011 Jan;127(1):386-395\. doi: 10.1097/PRS.0b013e3181f95c66\. PMID: 21200234. 8. Ghavami A, Pessa JE, Janis J, Khosla R, Reece EM, Rohrich RJ. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg. 2008 Mar;121(3):994-1001\. doi: 10.1097/01.prs.0000299941.62645.4e. PMID: 18317148. ### Cleft Palate: Anatomy, Classification, & Surgical Repair URL: https://www.theplasticsfella.com/cleft-palate/ Last updated: 2025-06-30T17:22:27.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/cleft-palate/#overview-of-cleft-palate) A cleft palate is a congenital defect of the secondary palate (hard and/or soft palate posterior to the incisive foramen). It may be overt or submucous, complete or incomplete, and syndromic or non-syndromic. [****Anatomy**](https://www.theplasticsfella.com/cleft-palate/#anatomy-of-cleft-palate) The primary palate refers to the lip, alveolus, and hard palate anterior to the incisive foramen. The secondary palate is the hard and soft palate posterior to the incisive foramen. [****Classification**](https://www.theplasticsfella.com/cleft-palate/#classification-of-cleft-palate) Isolated cleft palate can be classified descriptively (complete, incomplete, or submucous) and by syndromic status. Submucous clefts may be clinically occult but cause velopharyngeal dysfunction. [****Surgical Repair**](https://www.theplasticsfella.com/cleft-palate/#surgical-repair-of-cleft-palate) Timing, technique, and the goals of repair must balance speech outcomes, growth preservation, and prevention of fistulae. [****Complications**](https://www.theplasticsfella.com/cleft-palate/#complications-of-cleft-palate-repair) Cleft palate repair complications include both immediate and delayed issues, such as bleeding, airway obstruction, fistula formation, velopharyngeal dysfunction (VPD), and maxillary growth disturbances. ****Primary Contributor:** Dr Rob Browne. ****Verified by thePlasticsFella ✅** --- ## Overview of Cleft Palate ****Key Point** A cleft palate is a congenital defect of the secondary palate (hard and/or soft palate posterior to the incisive foramen). It may be overt or submucous, complete or incomplete, and syndromic or non-syndromic. A cleft palate (CP) refers to a failure of fusion of the secondary palate, which includes the hard and soft palate posterior to the incisive foramen. It may occur in isolation or in association with a cleft lip. - **Types** - **Overt:** Visible mucosal separation, complete or incomplete. - **Submucous:** Intact mucosa with muscular discontinuity. - **Syndromic** or **non-syndromic**. - **Isolated CP** vs. **CL ± CP:** Different embryological timing and genetic profiles. This article will focus on isolated CP. The surgical approaches to managing a palatal cleft are similar, whether it occurs in the context of a cleft lip or in isolation. ### Epidemiology - Isolated cleft palate occurs in approximately 1/2000 live births (0.05%). There is less variability between racial groups in isolated CP than in CL +/- CP, which has significant ethnic variability. - Children of parents with isolated cleft palate are up to 54 times more likely to have a cleft than the general population. - Siblings of people with an isolated cleft palate are up to 58 times more likely to have a cleft than the general population. The table below summarises recurrence risks for cleft lip with or without palate and cleft palate alone, based on family history. ![Recurrence risks for cleft lip with or without palate and cleft palate alone](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-30T223608.788.png) Recurrence risks for cleft lip with or without palate and cleft palate alone ### Aetiology Cleft palate arises from a combination of genetic and environmental factors. Isolated CP is more common in females and has distinct causes compared to CL ± CP. **Genetic Factors** Some genes implicated in cleft formation include, - TGF-alpha - TGF-beta - MSX-1 Isolated CP is more common in females than males, but the exact reason for this is unknown. **Environmental** - Maternal - **Smoking:** higher in passive (2.5x risk) versus active (1.15x risk) smoking, but this may be due to maternal under-reporting. - **Co-morbidities:** Diabetes (2x risk), HTN (1.5x risk), Obesity (1.5x risk for CL +/-CP, but no significant association with isolated CP). - **Teratogens:** Corticosteroids, phenytoin. - **Nutritional Deficiency:** Particularly folic acid deficiency. **Associated Syndromes** - 22q11.2 microdeletion syndrome. - **Van der Woude Syndrome:** Interferon regulatory factor (IRF) 6. The table below outlines high-yield genetic syndromes associated with cleft palate, including inheritance patterns and distinguishing clinical features. ![Genetic syndromes associated with cleft palate](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-30T224038.083.png) Genetic syndromes associated with cleft palate 😎 ****Fun Fact:** Over 400 syndromes have been associated with cleft palate, making it one of the most syndromically diverse craniofacial anomalies. --- ## Anatomy of Cleft Palate ****Key Point** The primary palate consists of structures anterior to the incisive foramen, including the lip and alveolus. The secondary palate comprises the hard and soft palate posterior to the incisive foramen. Cleft palate affects the secondary palate and results from failed fusion of the palatal shelves during embryonic development. **Primary vs Secondary Palate** - **Primary Palate:** Lip, alveolus, and hard palate *anterior* to the incisive foramen. - **Secondary Palate:** Hard and soft palate *posterior* to the incisive foramen. - This article focuses on defects of the secondary palate. ### Hard Palate - **Anatomy:** Anterior 2/3 of the secondary palate. - **Structures** - Palatine processes of the maxilla (anteriorly). - Horizontal plates of the palatine bones (posteriorly). - **Functions** - Separates oral and nasal cavities. - Provides a rigid platform for suckling, feeding, and articulation. - **Landmark:** The incisive foramen marks the junction between the primary and secondary palate, used in cleft classification systems (e.g., Veau). ### Soft Palate (Velum) - **Anatomy:** Posterior 1/3 of the secondary palate; lacks bony support. - **Composition:** Muscular structure crucial for **velopharyngeal closure**. The table below outlines the five principal muscles of the soft palate, detailing their roles in speech, swallowing, and Eustachian tube function, along with their cranial nerve innervation. ![Five principal muscles of the soft palate](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-30T224455.079.png) Five principal muscles of the soft palate - **Vascular Supply** - Greater palatine artery (from the descending palatine, a branch of the maxillary artery). - Lesser palatine and ascending pharyngeal arteries (soft palate). - Venous drainage parallels arterial supply. ### Cleft Palate Pathoanatomy - **Hard Palate Cleft** - Failure of palatal shelves to fuse at midline. - May result in a full-thickness gap involving mucosa, bone, and periosteum. - **Soft Palate Cleft** - Disruption of the midline muscular sling. - Levator and tensor muscles insert abnormally onto the posterior edge of the hard palate instead of forming a functional loop. - Leads to velopharyngeal dysfunction (VPD) and impaired speech. ### Embryology - **Facial Formation:** Occurs via fusion of five prominences. - 1x frontonasal → primary palate. - 2x maxillary → secondary palate. - 2x mandibular → lower jaw and lip. - **Palate Development Timeline** - **Week 4-8:** Primary palate fuses. - **Week 6-9:** Palatal shelves grow vertically alongside the tongue. - **Week 8-9:** Tongue descends, allowing palatal shelves to reorient horizontally. - **Week 9-12/13:** Medial fusion of palatal shelves occurs, starting at the **incisive foramen** and progressing posteriorly. Midline epithelial seams undergo apoptosis. Failure of any step, including shelf formation, elevation, contact, or fusion, results in clefting. 😎 ****Fun Fact:** The tensor veli palatini muscle wraps around the pterygoid hamulus before inserting into the palate. This pulley-like action is essential for opening the Eustachian tube, which explains the high rate of otitis media in cleft palate patients. --- ## Classification of Cleft Palate ****Key Point** Isolated cleft palate can be classified by extent (complete, incomplete, or submucous), syndromic status, and functional impact. Submucous clefts are often underdiagnosed yet clinically significant, especially in velopharyngeal dysfunction. ### Descriptive Classification Cleft palate may be **complete**, **incomplete**, or **submucous**, each with distinct anatomical and clinical features. - **Complete Cleft Palate** - Involves the soft and hard palate, extending to the incisive foramen. - Associated with significant feeding and speech impairment. - **Incomplete Cleft Palate** - Partial involvement of soft ± hard palate; does not reach the incisive foramen. - Severity of symptoms depends on muscular integrity. - **Submucous Cleft Palate** - The mucosa appears intact, but there is muscular discontinuity, particularly of the levator veli palatini. - Characterized by Calnan’s triad - Midline translucency (zona pellucida) - Bifid uvula - Notch in the posterior hard palate (palpable) - Requires speech evaluation to assess for velopharyngeal dysfunction (VPD). - If asymptomatic, no treatment is needed. - If symptomatic (\~33% of cases), treatment involves palatoplasty, often via Furlow double-opposing Z-plasty to reconstruct the levator sling. ### Functional and Anatomic Consequences Cleft palate reflects both visible mucosal separation and deep **muscular malorientation**. - The levator veli palatini inserts abnormally into the posterior hard palate instead of forming a midline sling, impairing soft palate elevation. - The tensor veli palatini, which normally opens the Eustachian tube, is also maloriented. - This results in, - Velopharyngeal dysfunction (hypernasality, nasal air emission, articulation errors) - Eustachian tube dysfunction and chronic otitis media—seen in 96–100% of cleft palate patients ### Syndromic vs Non-Syndromic - **Syndromic CP:** Seen in up to 50% of cases; often part of broader craniofacial or systemic syndromes (e.g., 22q11.2, Van der Woude, Stickler). - **Non-Syndromic CP:** Multifactorial inheritance. Emerging evidence supports a spectrum model with shared gene involvement (e.g., *IRF6*, *TBX1*). ### Classification Systems Several standardized systems are used in cleft assessment. - **Veau Classification** (I–IV) - **I:** Soft palate only - **II:** Soft and hard palate - **III:** Unilateral cleft lip + palate - **IV:** Bilateral cleft lip + palate - **Kernahan “Y” Classification** - Uses a diagrammatic “Y” shape to describe cleft involvement by segment. - Helpful in surgical documentation and interdisciplinary communication. ### Clinical Features - **Feeding:** Nasal regurgitation; may require specialized cleft bottles. - **Speech:** Hypernasality, compensatory articulation, poor pressure consonants. - **Hearing:** High incidence of otitis media due to tensor dysfunction; tympanostomy tubes often needed. - **Associated Craniofacial Signs:** Micrognathia (Pierre Robin), lip pits (Van der Woude), wide U-shaped cleft (Stickler). 💡 ****Tip:** In any child with a suspected cleft palate (especially those with recurrent otitis media or hypernasal speech), always assess muscle orientation and velopharyngeal function, not just mucosal integrity. Submucous clefts may appear structurally intact but often require imaging or nasoendoscopy to confirm muscular discontinuity. Surgical repair is indicated only if functional deficits are present. --- ## Surgical Repair of Cleft Palate ****Key Point** The goals of cleft palate repair include optimizing speech outcomes, minimizing maxillary growth disturbance, and preventing oronasal fistulae. Timing and technique must be balanced to achieve these objectives. Multiple techniques exist for soft and hard palate closure, with the approach tailored to cleft type, width, and surgeon preference. ### Timing of Repair - **Early Repair** (before 12–18 months) - Favors speech development and reduces the risk of velopharyngeal insufficiency (VPI). - **Delayed Repair** - May better preserve midfacial growth, especially in wide clefts. - **TOPS Trial Findings** - Cleft repair at 6 months resulted in lower VPI rates at age 5 compared to repair at 12 months. - However, more children in the 6-month group required secondary surgery for VPI, raising questions about the interpretation of long-term outcomes. - Most centres aim to perform **palatoplasty by 12-18 months**. ### Goals of Palate Repair - Restore **velopharyngeal competence** for speech. - Prevent **fistula formation** between the oral and nasal cavities. - Minimize interference with **maxillary growth** (e.g., reduce periosteal stripping). - Reconstruct the **levator veli palatini sling** for functional palatal elevation. ### Core Principles of Repair - **Tension-free closure** in multiple layers (nasal, muscular, oral). - **Muscle reorientation** (levator sling) for dynamic function. - **Soft palate lengthening** to support velopharyngeal closure. - **Minimize denuded bone** to reduce scarring and growth restriction. ### Primary vs Secondary Repair - **Primary Palate Repair:** Initial closure of the cleft. - **Secondary Palate Repair:** Performed for, - Residual VPI. - Palatal fistulae. - Failed primary repair. ### Surgical Approaches **Soft Palate Repair Techniques** **1\. Furlow Double-Opposing Z-Plasty** - **Indication:** Narrow to moderate-width clefts. - **Technique:** Posterior flaps contain muscle; anterior limbs are mucosal. Flaps are transposed to **reorient the muscle transversely** and **lengthen the velum**. - **Benefits:** Anatomical muscle repositioning, good speech outcomes. - **Limitations:** Technically difficult in **wide clefts**. **2\. Intravelar Veloplasty (IVV) – Sommerlad** - **Indication:** Functional muscle reconstruction. - **Technique** - Nasal mucosa separated and closed. - Levator muscle dissected and **released from its abnormal bony insertion**. - Muscle is then **reoriented transversely and sutured**. - Oral mucosa closed over muscle repair. - **Benefits:** Precise anatomical reconstruction of velar sling. - **Limitations:** Not ideal for very wide clefts. **3\. Malek Repair** - **Technique** - Muscle is **dissected but not transversely reoriented**. - Closure in three layers: nasal, muscular, oral. - **Benefits:** Reduced dissection, useful in specific cases. - **Limitations:** Theoretically higher VPI risk due to lack of muscular reorientation, though this is not always clinically apparent. ### Hard Palate Repair Techniques **1\. Vomer Flap** - **Technique:** Mucoperiosteal flap from the vomer bone is raised and used to close the nasal side of the cleft. - **Benefits:** Effective for the **nasal lining** in hard palate closure. - **Limitations:** Limited flap size; risk of affecting the **nasal septal blood supply**. **2\. Von Langenbeck Repair** - **Technique:** Bipedicled mucoperiosteal flaps with lateral relaxing incisions. - **Benefits:** Reduces midline tension; low fistula rate. - **Limitations:** Exposed lateral bone may **impair growth** and promote scarring. **3\. Bardach Two-Flap Palatoplasty** - **Technique:** Posteriorly based mucoperiosteal flaps elevated on **greater palatine arteries**. - Nasal layer closed, then the muscle repaired, followed by oral mucosa closure. - **Benefits:** Reduced bare bone exposure. - **Limitations:** Risk to the **hard palate blood supply** with extensive dissection. 👍 ****Note:** These procedures are often ****combined in different ways** and at ****different stages**. ### Surgical Planning by Cleft Type **Isolated or Submucous Cleft Palate (Soft Palate Only)** - **Techniques:** Furlow, IVV, or Malek **Complete Cleft of Soft + Hard Palate** - **Hard Palate:** Vomer flap - **Soft Palate:** One of the above techniques **Unilateral Cleft Lip and Palate (Staged Approach)** - **Stage 1:** Lip repair + **vomer flap** (hard palate closure) - **Stage 2:** Soft palate repair (Furlow or IVV) **Bilateral Cleft Lip and Palate (Multistage Protocols)** - Example (Dublin 4-stage protocol) - **Stage 1:** Unilateral lip adhesion + vomer flap - **Stage 2:** Contralateral lip adhesion + vomer flap - **Stage 3:** Soft palate repair - **Stage 4:** Definitive lip repair This table compares major cleft palate repair techniques by anatomical focus, muscle reconstruction, ideal cleft type, and surgical strengths and limitations. ![Comparison of major cleft palate repair techniques by anatomical focus, muscle reconstruction, ideal cleft type, and surgical strengths and limitations](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-30T225043.672.png) Comparison of major cleft palate repair techniques by anatomical focus, muscle reconstruction, ideal cleft type, and surgical strengths and limitations 😎 ****Fun Fact:** The Furlow Z-plasty was originally developed for scar revision. Its adaptation to cleft palate surgery not only reorients the muscle but also lengthens the soft palate — a crucial biomechanical advantage in achieving competent speech. --- ## Complications of Cleft Palate Repair ****Key Point** Cleft palate repair complications include both immediate and delayed issues, such as bleeding, airway obstruction, fistula formation, velopharyngeal dysfunction (VPD), and maxillary growth disturbances. ### Immediate Complications - **Bleeding** - Rarely significant; typically self-limited. - Return to theatre is uncommon. - **Respiratory Obstruction** - Particularly in syndromic patients (e.g., Pierre Robin sequence). - Requires careful post-op airway monitoring. - **Wound Dehiscence / Early Oronasal Fistula** - Often occurs at the **junction of the hard and soft palate**. - May result from tension, infection, or poor vascularity. ### Delayed Complications - **Persistent Oronasal Fistula** - A challenging problem to correct. - Common sites: junction of hard and soft palate, or incisive foramen. - Management options - **Local revision** (repeat palatoplasty) - **Buccal myomucosal flap** - **Tongue flap** (for anterior defects) - **Free tissue transfer** (for large or failed cases) - **Velopharyngeal Dysfunction (VPD)** - Results from inadequate velar length or poor muscle reorientation. - May require secondary pharyngoplasty or speech therapy. - **Maxillary Growth Restriction** - Due to scarring and periosteal stripping of the hard palate. - May manifest as class III malocclusion in adolescence. - Often requires orthognathic surgery later in life. - **Dental Issues** - Associated with cleft alveolus. - May require secondary alveolar bone grafting (typically around 8–11 years) to, - Support canine eruption - Stabilize the arch - Close residual fistulae - **Hearing Loss / Otitis Media** - Due to Eustachian tube dysfunction from disrupted tensor veli palatini insertion. - High incidence of middle ear effusions. - Many require tympanostomy tubes (grommets). - Rarely significant; typically self-limited. - Return to theatre is uncommon. - **Respiratory Obstruction** - Particularly in syndromic patients (e.g., Pierre Robin sequence). - Requires careful post-op airway monitoring. - **Wound Dehiscence / Early Oronasal Fistula** - Often occurs at the junction of the hard and soft palate. - May result from tension, infection, or poor vascularity. 💡 ****Tip:** Always examine the junction between the hard and soft palate during follow-up. It’s the most common site for oronasal fistula formation. Meticulous, tension-free closure and layered reconstruction in this area during primary repair significantly reduce the risk of fistulae and later VPD. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Cleft palate is a congenital defect of the secondary palate, occurring in isolation or with a cleft lip, and may be overt or submucous, complete or incomplete. It affects \~1 in 2000 live births and differs epidemiologically from cleft lip ± palate. ****2\. Aetiology:** Isolated cleft palate results from genetic and environmental factors, including syndromes like 22q11.2 and Van der Woude, maternal smoking, diabetes, and folate deficiency, and is more common in females. ****3\. Anatomy & Classification:** The secondary palate consists of hard and soft palate structures posterior to the incisive foramen. Clefts are classified as complete, incomplete, or submucous, and may present with feeding, speech, and hearing issues. ****4\. Surgical Repair:** Palatoplasty is ideally performed before 18 months to improve speech outcomes. Techniques for soft palate repair include Furlow, IVV, and Malek, while hard palate repair may use vomer or von Langenbeck flaps. ****5\. Treatment Planning:** Surgical choice depends on cleft width, anatomy, and surgeon preference. Goals include restoring velopharyngeal function, preserving growth, and avoiding fistulae, often requiring staged or combined approaches. ****6\. Complications:** Common issues include bleeding, airway obstruction, fistulae, velopharyngeal dysfunction, growth restriction, and hearing loss, which may require revision surgery, grommets, or orthognathic correction. --- ## Further Reading 1. Burg ML, Chai Y, Yao CA, Magee W, 3rd, Figueiredo JC. Epidemiology, Etiology, and Treatment of Isolated Cleft Palate. *Front Physiol*. 2016;7:67\. doi:10.3389/fphys.2016.00067 2. Baillie L, Sell D. Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique. *The Cleft Palate Craniofacial Journal*. 2020;57(10):1197-1215\. doi:10.1177/1055665620923925 3. van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: Nonsyndromic cleft palate. *Plast Reconstr Surg*. Jan 2008;121(1 Suppl):1-14\. doi:10.1097/01.prs.0000294706.05898.f3 4. Ács M, Cavalcante BGN, Bănărescu M, et al. Maternal factors increase risk of orofacial cleft: a meta-analysis. *Scientific Reports*. 2024/11/15 2024;14(1):28104\. doi:10.1038/s41598-024-79346-7 5. Slavec L, Karas Kuželički N, Locatelli I, Geršak K. Genetic markers for non-syndromic orofacial clefts in populations of European ancestry: a meta-analysis. *Scientific Reports*. 2022/01/24 2022;12(1):1214\. doi:10.1038/s41598-021-02159-5 6. Naidu P, Yao CA, Chong DK, Magee WP, 3rd. Cleft Palate Repair: A History of Techniques and Variations. *Plast Reconstr Surg Glob Open*. Mar 2022;10(3):e4019\. doi:10.1097/gox.0000000000004019 7. Gamble C, Persson C, Willadsen E, et al. Timing of Primary Surgery for Cleft Palate. *N Engl J Med*. Aug 31 2023;389(9):795-807\. doi:10.1056/NEJMoa2215162 8. Tse R, Jackson O. Mind the Gap - Timing of Cleft Palate Repair. *N Engl J Med*. Aug 31 2023;389(9):857-858\. doi:10.1056/NEJMe2308435 9. Baillie L, Sell D. Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique. *The Cleft Palate Craniofacial Journal*. 2020;57(10):1197-1215\. doi:10.1177/1055665620923925 ### Compartment Syndrome of the Hand: Clinical Assessment, Investigations, & Management URL: https://www.theplasticsfella.com/hand-compartment-syndrome/ Last updated: 2025-06-30T17:00:19.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/hand-compartment-syndrome/#overview-of-compartment-syndrome-of-the-hand) Compartment syndrome of the hand is a rare but urgent surgical condition caused by increased pressure within osseofascial compartments, leading to neurovascular compromise. [****Pathogenesis**](https://www.theplasticsfella.com/hand-compartment-syndrome/#pathogenesis-of-hand-compartment-syndrome) The aetiology of this syndrome centres on raised intracompartmental pressure caused by increased contents or decreased space. Both traumatic and non-traumatic mechanisms may trigger this process. [****Clinical Assessment**](https://www.theplasticsfella.com/hand-compartment-syndrome/#clinical-assessment-of-hand-compartment-syndrome) Compartment syndrome of the hand is primarily a clinical diagnosis. The earliest and most reliable sign is pain out of proportion, especially on passive stretch. [****Investigations**](https://www.theplasticsfella.com/hand-compartment-syndrome/#investigations-for-hand-compartment-syndrome) Compartment syndrome is primarily a clinical diagnosis. Pressure monitoring and other tests may support the diagnosis, but should never delay intervention if suspicion is high. [****Management**](https://www.theplasticsfella.com/hand-compartment-syndrome/#management-of-hand-compartment-syndrome) Management hinges on early recognition, immediate decompression, and careful post-operative care. Delays can result in permanent disability or limb loss. [****Outcomes**](https://www.theplasticsfella.com/hand-compartment-syndrome/#outcomes-of-hand-compartment-syndrome) Early fasciotomy, ideally within 6 hours, offers the best chance of preserving function. Postoperative wound care, early mobilisation, and structured rehabilitation are essential to maximise recovery. ****Updated by:** Dr Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Compartment Syndrome of the Hand ****Key Point** Compartment syndrome of the hand is a time-sensitive condition caused by elevated pressure within fascial compartments, leading to vascular and nerve compromise. Compartment syndrome of the hand is defined as elevated pressure within a closed osseofascial space, resulting in impaired microcirculation. This occurs when the pressure within one or more of the hand’s ten osseofascial compartments exceeds capillary perfusion pressure, impairing blood flow to muscles and nerves. This can rapidly progress to ischemia, necrosis, and permanent functional loss if not promptly addressed. Although more common in the leg and forearm, the hand remains a high-risk site due to, - **Dense compartmental anatomy**. - **Delicate vascular supply** required for **fine motor function**. Most cases are associated with **trauma**, but **non-traumatic causes,** including infections, vascular events, and tight dressings. Compartment syndrome of the hand may result from, - **Increased contents** (e.g., bleeding, swelling, infection). - **Decreased space** (e.g., tight dressings, external compression). The resulting vascular compromise can cause, - **Tissue hypoxia**. - **Muscle and nerve ischemia**. - **Irreversible necrosis if not treated urgently**. Progression from reversible ischemia to irreversible necrosis may occur within 6 to 8 hours ([Hargens](https://pubmed.ncbi.nlm.nih.gov/9742417/?ref=theplasticsfella.com), 1998). ### Epidemiology **Incidence** - 7.3 per 100,000 in males ([McQueen](https://pubmed.ncbi.nlm.nih.gov/10755426/?ref=theplasticsfella.com), 2000). - 0.7 per 100,000 in females ([McQueen](https://pubmed.ncbi.nlm.nih.gov/10755426/?ref=theplasticsfella.com), 2000). **Demographics** - Most common in males under 35, likely due to larger muscle mass and higher trauma exposure ([McQueen](https://pubmed.ncbi.nlm.nih.gov/10755426/?ref=theplasticsfella.com), 2000). **Most Common Causes** - Fractures (especially distal radius and ulna) - Crush injuries - Burns - High-pressure injection injuries **Anatomical Sites** - While the leg remains the most common location, the hand, forearm, and foot are also recognized as high-risk sites. 💡 ****Tip:** Irreversible muscle and nerve damage can occur in as little as 6 hours; always escalate promptly. Do not delay surgical referral while waiting for investigations. --- ## Pathogenesis of Hand Compartment Syndrome ****Key Point** Compartment syndrome of the hand is caused by raised intracompartmental pressure, whether from increased contents or reduced space, leading to vascular compromise and tissue ischemia. Compartment syndrome of the hand can arise from **traumatic** or **non-traumatic** mechanisms. Regardless of the trigger, the underlying process is the same: **elevated pressure within a closed fascial compartment impairs microvascular flow**, threatening tissue viability ([Hargens](https://pubmed.ncbi.nlm.nih.gov/9742417/?ref=theplasticsfella.com), 1998). ### Causes Compartment syndrome of the hand may arise from traumatic or non-traumatic mechanisms. **Traumatic Causes** Trauma is the **most common cause**, including, - **Fractures** - **Distal radius and ulna fractures**. - **Carpometacarpal dislocations**. - **Paediatric supracondylar fractures** of the humerus (Especially in the pediatric population). - **Crush Injuries:** Prolonged compression or high-energy blunt trauma. - **Burns:** Circumferential thermal or electrical burns cause skin tightening and swelling. - **High-Pressure Injection Injuries:** Paint, grease, or air injected into tissues under pressure. - **Vascular Injuries:** Associated with revascularisation procedures or trauma *(especially with reperfusion injuries).* **Non-Traumatic Causes** Less common but clinically important. - **Infections:** Abscess formation, necrotising fasciitis. - **Reperfusion Injury:** Post-ischemic swelling following vascular repair. - **Seizure-Induced Muscle Overuse:** Prolonged muscle contractions during seizures. - **Constrictive Dressings or Splints:** Tight casts or bandages causing external compression. - **Drug Overdose or Prolonged Immobilisation:** Unconscious patients in one position for prolonged periods. The mechanisms leading to hand compartment syndrome are summarised below. ![Mechanisms leading to hand compartment syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-29T155923.484.png) Mechanisms leading to hand compartment syndrome ### Pathophysiology Compartment syndrome develops when raised interstitial pressure compromises capillary perfusion, initiating a cycle of ischemia, tissue damage, and escalating pressure. Compartment syndrome arises when intracompartmental pressure increases to a level that exceeds capillary perfusion pressure, impeding oxygen and nutrient delivery to tissues. This results in progressive ischemia, particularly affecting muscles and nerves. **Pathological Process** - Interstitial pressure rises due to either **internal swelling** (e.g., bleeding, edema) or **external compression** (e.g., tight casts). - Once **capillary perfusion pressure is exceeded**, oxygen delivery falls. - **Tissue hypoxia** triggers cellular swelling, acidosis, and metabolic failure. - A **positive feedback loop** ensues: ischemia → cell damage → more edema → rising pressure. - If untreated, this leads to **irreversible necrosis** of nerves and muscles. The stages of progression are summarised below. ![Stages of progression in hand compartment syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-29T160322.092.png) Stages of progression in hand compartment syndrome #### Consequences of Unrelieved Pressure - **Venous Congestion:** Impairs outflow and worsens swelling. - **Arterial Inflow Restriction:** Worsens ischemia. - **Neuromuscular Damage:** Ischemic injury to nerves and muscles. - **Fibrosis and Contractures:** e.g., Volkmann’s contracture from chronic ischemic damage. 💡 ****Tip:** Always remove constrictive dressings or casts in suspected cases. This may reverse early ischemia and prevent surgery. --- ## Clinical Assessment of Hand Compartment Syndrome ****Key Point** Compartment syndrome of the hand is primarily a clinical diagnosis. The earliest and most reliable sign is pain out of proportion, especially on passive stretch. A thorough clinical assessment is essential, especially because delay in diagnosis can lead to irreversible damage. The syndrome can develop within hours, so high clinical suspicion is vital. ### History - **Mechanism of Injury:** Fractures, crush injuries, burns, high-pressure injection. - **Timing:** Onset usually within 6-48 hours ([Whitesides](https://journals.lww.com/jaaos/abstract/1996/07000/acute%5Fcompartment%5Fsyndrome%5F%5Fupdate%5Fon%5Fdiagnosis.5.aspx?ref=theplasticsfella.com), 1996). - **Symptoms** - Severe, escalating, and disproportionate pain. - Pain worsened by passive stretch. - Deep ache, burning, or tightness. - Numbness or tingling (paraesthesia). - **The Rule of A’s (Paediatric Red Flags):** These may indicate pain out of proportion in non-verbal or young children. - Analgesia requirement. - Anxiety. - Agitation. ### Physical Examination **Early Clinical Signs** - Pain with passive stretch ([Leversedge](https://linkinghub.elsevier.com/retrieve/pii/S0363502310015510?ref=theplasticsfella.com), 2011). - Tense, swollen compartments (wood-like feel). - Intrinsic minus hand posture. **Progressive or Late Signs** - Paraesthesia. - Motor weakness or paralysis. - Pallor and pulselessness (very late and unreliable). These clinical signs and diagnostic features are summarised below. ![Clinical signs and diagnostic features of hand compartment syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-29T155443.368.png) Clinical signs and diagnostic features of hand compartment syndrome ### Risk Factors - Unresponsive or sedated patients. - Children with limited communication. - Polytrauma patients. - Patients after vascular repair. - Tight splints, dressings, or casts. - Coagulopathies or bleeding disorders. - Prolonged immobilisation (e.g., drug overdose). ### Differential Diagnosis - Severe crush injury without compartment syndrome. - Cellulitis or deep abscess. - Peripheral nerve compression. - Arterial or venous occlusion. - Rhabdomyolysis without compartment syndrome. 💡 ****Tip:** Do not rely on the presence of pulses to exclude compartment syndrome — capillary perfusion fails before arterial flow ceases. --- ## Investigations for Hand Compartment Syndrome ****Key Point** Compartment syndrome is primarily a clinical diagnosis. Pressure monitoring and other tests may support the diagnosis, but should never delay intervention if suspicion is high. In cases where the diagnosis is uncertain, such as in sedated or unresponsive patients, objective measurements can provide valuable guidance. However, clinical judgement remains paramount. **Clinical Diagnosis** The diagnosis of compartment syndrome is clinical and should be based on, - **History of at-risk injury** (e.g., fracture, crush, burn, vascular repair). - **Classic clinical signs**. - Severe **pain out of proportion**. - **Pain on passive stretch**. - **Tense swelling** of the hand. Sole reliance on pulses or skin color is misleading, as these may remain normal until late stages. **Physiological Pressure Thresholds** - **Normal Pressure:** 0–10 mmHg. - **Ischemic Threshold:** \>30 mmHg. - **Critical Delta Pressure:** ≤30 mmHg ([Whitesides](https://journals.lww.com/jaaos/abstract/1996/07000/acute%5Fcompartment%5Fsyndrome%5F%5Fupdate%5Fon%5Fdiagnosis.5.aspx?ref=theplasticsfella.com), 1996). *(Delta pressure = Diastolic BP − Compartment pressure).* Key pressure parameters and their clinical implications are summarised below. ![Key pressure parameters and their clinical implications in hand compartment syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-29T154654.659.png) Key pressure parameters and their clinical implications in hand compartment syndrome ### Compartment Pressure Monitoring When to measure, - Unresponsive or sedated patients. - Polytrauma with unreliable exams. - Equivocal clinical findings. **Diagnostic Thresholds** - **Absolute pressure ≥30 mmHg** ([Leversedge](https://linkinghub.elsevier.com/retrieve/pii/S0363502310015510?ref=theplasticsfella.com), 2011). - **Delta pressure ≤30 mmHg** *(Diastolic BP – Compartment Pressure)* **Techniques for Measurement** - **Needle or Slit Catheter Manometry**: Measures resistance to saline injection or continuous pressure. - **Arterial Line Transducer Systems**: Allows continuous monitoring. **Adjunct Investigations** While **not diagnostic**, these can support **case assessment**. - **Imaging** - **X-Rays:** Identify fractures or foreign bodies. - **Ultrasound with Doppler:** Evaluate for vascular occlusion or thrombosis. - **MRI / CT Angiography** (rarely required): Assess vascular or soft tissue status in complex cases. - **Laboratory Tests** - **Creatine Phosphokinase (CPK):** Elevated in muscle damage or rhabdomyolysis. - **Renal Function Tests and Urinalysis:** Check for myoglobinuria and kidney injury. - **Full Blood Count and Coagulation Panel:** Pre-operative assessment, rule out bleeding disorders. - **MRI** - Evaluates **soft tissue viability** and **degree of myonecrosis**. - Used **post-operatively** in **selected cases** for **surgical planning** or **rehabilitation strategy** ([Leversedge](https://linkinghub.elsevier.com/retrieve/pii/S0363502310015510?ref=theplasticsfella.com), 2011). 😎 ****Fun Fact:** The delta pressure is often more accurate than absolute pressure — especially useful in hypotensive patients. --- ## Management of Hand Compartment Syndrome ****Key Point** Management hinges on early recognition, immediate decompression, and careful post-operative care. Delays can result in permanent disability or limb loss. Compartment syndrome of the hand is a surgical emergency. Initial bedside measures can slow progression, but definitive treatment is urgent fasciotomy. **Initial (Non-Surgical) Management** While preparing for surgery, immediate **bedside interventions** can **prevent worsening ischemia**. - Urgent surgical team consultation. - Remove all constrictive dressings or splints. - Keep the limb at heart level: Elevation **too high** may **reduce arterial inflow**. - Monitor hemodynamics: Prevent **hypotension** with fluid resuscitation if needed. - Repeat neurovascular assessments: Document changes every **30-60 minutes**. - Consider pressure monitoring if the patient is unresponsive or the diagnosis is unclear. **Systemic Monitoring** - **Renal Function:** Monitor for rhabdomyolysis-related kidney injury (check creatinine, urine myoglobin). - **Electrolytes:** Correct imbalances to reduce risk of arrhythmias or muscle dysfunction. - **Coagulopathy Screening:** Check coagulation panels in bleeding risk patients. - **Urinalysis:** Detect myoglobinuria. ### Surgical Management: Fasciotomy **Indications** - Clinical diagnosis of compartment syndrome. - Compartment pressure ≥30 mmHg or Delta pressure ≤30 mmHg. **Surgical Anatomy and Compartments** The hand contains **ten compartments**. - **Thenar**. - **Hypothenar**. - **Adductor pollicis**. - **Four dorsal interosseous**. - **Three volar interosseous**. Releasing all compartments is not always necessary. Targeted release should be guided by intraoperative assessment. **Surgical Techniques and Incisions** - **Volar Incisions (Palmar)** - **Extended Carpal Tunnel Incision:** Releases the carpal tunnel, volar interossei, and adductor pollicis. - **Thenar Release:** Longitudinal incision along the radial side of the thenar eminence. - **Hypothenar Release:** Longitudinal incision along the ulnar border of the hand. - **Dorsal Incisions** - **First Webspace Incision:** Releases the adductor pollicis and first dorsal interosseous. - **Dorsal Metacarpal Incisions:** Between the 2nd-3rd and 4th-5th metacarpals to release remaining dorsal interossei. The surgical anatomy of hand compartments is summarised below. ![Surgical anatomy and decompression of hand compartments](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-29T154211.796.png) Surgical anatomy and decompression of hand compartments - **Digit Dermotomies** - **Mid-axial incisions** on **tense, swollen fingers**, - Ulnar side of index/middle/ring. - Radial side of thumb/little finger. The surgical incisions are illustrated below. ![Surgical incision landmarks diagram](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-29T142410.913.png) Surgical incision landmarks diagram ### Post-Operative Care **Wound Management** - Leave wounds **open** with sterile dressings or **negative-pressure wound therapy**. - Re-assess wounds at **24-48 hours** for, - **Viability of tissues**. - **Need for further debridement**. Intraoperative exposure of hand compartments is illustrated below. ![Intraoperative exposure of hand compartments](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-29T150409.262.png) Intraoperative exposure of hand compartments **Rehabilitation** - **Elevate the limb** and avoid constrictive dressings. - **Start early hand therapy** to maintain the range of motion. - **Splint in functional position** (wrist extended, MCPs flexed, IPs straight). - **Plan delayed closure or skin grafting** once swelling resolves. Closure strategies are summarised below. ![Closure strategies following hand fasciotomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-29T152134.920.png) Closure strategies following hand fasciotomy **Monitoring for Complications** - Infection. - Rhabdomyolysis. - Acute kidney injury. - Delayed wound healing. 💡 ****Tip:** Not all ten compartments need to be released. Base your surgical plan on intraoperative findings and clinical assessment. --- ## Outcomes of Hand Compartment Syndrome ****Key Point** Early fasciotomy, ideally within 6 hours, offers the best chance of preserving function. Postoperative wound care, early mobilisation, and structured rehabilitation are essential to maximise recovery. ### Prognosis Prognosis depends on **timing of diagnosis** and **intervention**. - **Fasciotomy within 6 hours:** Nearly 100% limb function recovery. - **Fasciotomy after 6-12 hours:** Two-thirds retain good function, some residual nerve damage expected. - **Fasciotomy after 36 hours:** Poor outcomes, risk of non-salvageable tissue, infection, or amputation. **Functional Outcomes** If treated promptly, - **Full recovery** of strength, sensation, and dexterity is possible. - **Return to daily activities and work** without significant limitations. If treated late or incompletely, - **Stiffness and weakness** of the fingers or hand. - **Chronic pain** and **cold intolerance**. - **Permanent sensory or motor deficits**. Long-term follow-up with hand therapy is crucial to maximise functional outcomes. ### Common Complications Complications may arise even with timely management. These include, - **Infection:** Especially if necrotic tissue is present or closure is delayed. - **Rhabdomyolysis:** Muscle breakdown leading to **kidney injury**. - **Contractures:** Permanent flexion deformities of the fingers (Volkmann’s contracture). - **Nerve Damage:** Persistent numbness or weakness. - **Wound Healing Issues:** Delayed closure or need for **skin grafting**. - **Amputation:** In cases of uncontrolled infection or tissue death. - **Chronic Pain or Complex Regional Pain Syndrome (CRPS)**. 💡 ****Tip:** Early rehabilitation after fasciotomy is essential to prevent stiffness, preserve function, and optimise recovery. ### Post-Operative and Rehabilitation Care Post-operative care is as important as the surgery itself. Careful wound management, early mobilisation, and a structured rehabilitation program are key to optimising long-term function. **Wound Care** After fasciotomy, wounds are **left open** to accommodate swelling and prevent further ischemia. Key steps include, - **Sterile, Non-Constrictive Dressings:** Or negative-pressure wound therapy (NPWT) to promote granulation tissue and manage exudate. - **Daily or 48-Hourly Wound Inspections:** Look for signs of infection or tissue necrosis. - **Debridement of Non-Viable Tissue:** Performed as needed based on wound assessment. - **Delayed Primary Closure:** Once swelling reduces (typically 3–5 days post-op). - **Skin Grafting:** May be required if primary closure is not possible. **Physical and Occupational Therapy** Rehabilitation goals, - Prevent joint stiffness and tendon adhesions. - Preserve range of motion. - Strengthen muscles after recovery. **Key Interventions** - **Splinting in a Functional Position:** Wrist in extension, MCP joints flexed, IP joints extended. - **Early Passive and Active Mobilisation:** Initiated once pain and swelling allow. - **Progressive Strengthening and Dexterity Exercises**. - **Scar Management:** Including massage, silicone therapy, and stretching. **Follow-up Considerations** - Monitor for late complications, including, - **Chronic Pain**. - **Cold Intolerance**. - **Nerve Dysfunction**. - **Contractures**. - **Functional Impairment**. - **Psychosocial Support:** For patients with **amputation** or **persistent disability**. - **Return-to-Work Assessments:** Particularly for manual labourers. Regular outpatient review with therapy updates ensures that any setbacks are identified early and managed proactively. 😎 ****Fun Fact:** Negative-pressure wound therapy (NPWT) not only manages swelling but can speed up the timing to definitive wound closure. --- ## Conclusion ****Upon completing this article, you will have accomplished the following:** ****1\. Overview:** Compartment syndrome of the hand is a rare but time-sensitive surgical emergency. It results from raised pressure within the hand’s compartments, leading to vascular compromise, nerve ischemia, and potential tissue loss if untreated. ****2\. Aetiology:** Compartment syndrome arises from trauma or non-traumatic factors that increase compartment contents or reduce compartment space. ****3\. Pathophysiology:** Understanding the mechanical process by which increased pressure impairs venous outflow, collapses capillary perfusion, and triggers a positive feedback loop of tissue ischemia, progressing to irreversible necrosis if untreated. ****4\. Clinical Features:** Early warning signs include pain out of proportion, pain on passive stretch, and tense compartments, while late signs include paralysis and pulselessness indicating severe or irreversible damage. ****5\. Diagnosis:** The diagnosis is primarily clinical, supported by pressure monitoring (≥30 mmHg or delta ≤30 mmHg) when needed, and pulses and skin colour can remain deceptively normal until late. ****6\. Management:** Initial management involves removing constrictive dressings, maintaining limb position, and monitoring for deterioration, while definitive treatment requires urgent fasciotomy using targeted incisions based on the hand’s compartmental anatomy. ****7\. Post-operative Care:** Understanding the importance of wound management, early mobilisation, and structured rehabilitation, including hand therapy, splinting, and scar management. ****8\. Outcomes and Complications:** You recognise that early intervention can achieve near-complete recovery, but delayed diagnosis increases the risk of infection, contracture, nerve damage, chronic pain, and amputation. ****9\. Follow-up and Multidisciplinary Care:** You are prepared to coordinate long-term follow-up, involving occupational therapy, physical therapy, and psychosocial support, ensuring the best possible outcome. --- ## Further Reading 1. Matsen FA. Compartmental syndrome: a unified concept. Clin Orthop Relat Res. 1975;(113):8-14\. [https://www.ncbi.nlm.nih.gov/pubmed/1192678](https://www.ncbi.nlm.nih.gov/pubmed/1192678?ref=theplasticsfella.com) 2. Leversedge FJ, Moore TJ, Peterson BC, Seiler JG III. Compartment syndrome of the upper extremity. J Hand Surg Am. 2011;36(3):544-559\. doi:10.1016/j.jhsa.2010.12.008 3. Hargens AR, Mubarak SJ. Current concepts in the pathophysiology, evaluation, and diagnosis of compartment syndrome. Hand Clin. 1998;14(3):371-383\. [https://www.ncbi.nlm.nih.gov/pubmed/9742417](https://www.ncbi.nlm.nih.gov/pubmed/9742417?ref=theplasticsfella.com) 4. DiFelice A, Seiler JG III, Whitesides TE Jr. The compartments of the hand: an anatomic study. J Hand Surg Am. 1998;23(4):682-686\. doi:10.1016/S0363-5023(98)80055-5 5. Matava MJ, Whitesides TE Jr, Seiler JG III, Hewan-Lowe K, Hutton WC. Determination of the compartment pressure threshold of muscle ischemia in a canine model. J Trauma. 1994;37(1):50-58\. doi:10.1097/00005373-199407000-00010 6. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82(2):200-203\. doi:10.1302/0301-620X.82B2.9799 7. Whitesides TE Jr, Heckman MM. Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg. 1996;4(4):209-218\. doi:10.5435/00124635-199607000-00005 8. Seiler JG III, Olvey SP. Compartment syndromes of the hand and forearm. J Am Soc Surg Hand. 2003;3(4):184-198\. doi:10.1016/S1531-0914(03)00072-X 9. Szabo RM, Gelberman RH. Peripheral nerve compression: etiology, critical pressure threshold, and clinical assessment. Orthopedics. 1984;7(9):1461-1466\. doi:10.3928/0147-7447-19840901-11 10. Mehta V, Chowdhary V, Lin C, Jbara M, Hanna S. Compartment syndrome of the hand: a case report and review of literature. Radiol Case Rep. 2018;13(1):212-215\. doi:10.1016/j.radcr.2017.11.002 ### External Ear Anatomy: Neurovascular Supply, Landmarks, & Aesthetic Subunits URL: https://www.theplasticsfella.com/anatomy-of-the-ear/ Last updated: 2025-07-01T19:25:50.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/anatomy-of-the-ear/#overview-of-ear-anatomy) The external ear is a specialised composite structure composed of cartilage, skin, and soft tissue. It plays vital roles in hearing, facial aesthetics, and protecting the auditory system. [****Neurovascular Supply**](https://www.theplasticsfella.com/anatomy-of-the-ear/#neurovascular-supply-of-the-ear) The ear receives a complex neurovascular supply derived from cranial nerves, cervical plexus branches, and the external carotid artery system. [****Anatomical Landmarks**](https://www.theplasticsfella.com/anatomy-of-the-ear/#anatomical-landmarks-of-the-ear) The auricle (pinna) has distinct anatomical substructures that assist in sound conduction and serve as critical reference points in clinical and surgical settings. [****Aesthetic Subunits**](https://www.theplasticsfella.com/anatomy-of-the-ear/#aesthetic-subunits-of-the-auricle) Dividing the auricle into aesthetic subunits improves surgical planning and ensures natural and harmonious reconstruction. [****Auricular Muscles**](https://www.theplasticsfella.com/anatomy-of-the-ear/#muscles-of-the-auricle) The auricle contains vestigial striated muscles innervated by the facial nerve, with minimal functional role in most individuals. [****External Auditory Canal**](https://www.theplasticsfella.com/anatomy-of-the-ear/#external-auditory-canal) The external auditory canal is a 25 mm S-shaped passageway that directs sound waves to the tympanic membrane. It comprises cartilaginous and osseous segments and is lined with skin containing ceruminous glands. ****Primary Contributor:** Dr Mustafa Qais Al-Khafaji. ****Verified by thePlasticsFella ✅** --- ## Overview of Ear Anatomy ****Key Point** The external ear is a specialised composite structure composed of cartilage, skin, and soft tissue. It plays vital roles in hearing, facial aesthetics, and protecting the auditory system. The external ear (auricle) is a specialised structure essential for sound conduction, aesthetic contouring, and surgical reference — composed of elastic cartilage, skin, and soft tissue. **Structural Composition** - Elastic cartilaginous framework provides shape and flexibility. - Covered by tightly adherent skin, especially on the anterior surface. - Contains ceruminous and sebaceous glands, neurovascular bundles, and vestigial muscles. **Functional Roles** - Directs sound waves into the external auditory canal, enhancing auditory localization. - Contributes to facial symmetry and contour, particularly relevant in aesthetic and reconstructive surgery. - Acts as a surgical landmark due to its predictable anatomy and topography. **Clinical Importance** - Serves as a guide in reconstructive surgery, especially for, - Auricular defects - Microtia repair - Otoplasty - Used to assess cutaneous malignancies (e.g., BCC, SCC) due to sun-exposed position. - Involved in nerve distribution zones, relevant for regional blocks and flap planning. - The Arnold Reflex (via vagus nerve) may trigger cough or nausea during otologic exams. The image below illustrates the ear and its external and middle structures. ![Ear anatomy - external and middle structures](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-20T171400.196.png) Ear anatomy - external and middle structures 😎 ****Fun Fact:** The auricle continues to grow throughout life, primarily due to cartilage elasticity and gravitational pull, hence the common “droopy ear” appearance in elderly patients ([Heathcote, 1995](https://pubmed.ncbi.nlm.nih.gov/8541753/?ref=theplasticsfella.com)). --- ## Neurovascular Supply of the Ear ****Key Point** The ear receives a complex neurovascular supply derived from cranial nerves, cervical plexus branches, and the external carotid artery system. The external ear receives a complex neurovascular supply critical for its function, sensory innervation, and safe surgical manipulation. Understanding this anatomy is essential in trauma repair, local flap design, and regional anesthesia. ### Motor Innervation - **Temporal branch of the facial nerve (CN VII)** innervates the auricular muscles. - These striated muscles (anterior, superior, and posterior auricular) are vestigial in humans, with minimal voluntary movement in most individuals. - During flap elevation or cartilage scoring, preserving these nerve branches minimizes postoperative distortion or synkinesis. ### Sensory Innervation The auricle’s sensory innervation is richly sourced from cranial and cervical nerves. - **Auriculotemporal Nerve** (branch of CN V3): Anterior auricle and anterior canal walls. - **Great Auricular Nerve** (C2, C3): Lower posterior auricle. - **Lesser Occipital Nerve** (C2): Upper posterior auricle. - **Auricular Branch of the Vagus Nerve (Arnold’s Nerve)** (CN X): Posterior canal wall. - **Facial Nerve** (CN VII): Contributes to canal innervation via communication with CN X. Key nerves regarding ear anatomy are illustrated below. ![Sensory innervation of the ear](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-20T172029.225.png) Sensory innervation of the ear ### Glands & Secretions Glandular structures in the external ear serve a protective and lubricating role, especially within the auditory canal. - **Ceruminous glands** - Modified apocrine sweat glands located in the cartilaginous portion of the external auditory canal. - Secrete cerumen (earwax) — a mixture of cerumen, sebum, and desquamated keratinocytes. - Functions: Antimicrobial barrier, moisture regulation, and protection against foreign bodies. - **Sebaceous glands** - Found adjacent to ceruminous glands. - Contribute sebum, enhancing lubrication and preventing canal dryness. ### Arterial Supply The external ear is supplied predominantly by branches of the external carotid artery, ensuring perfusion for tissue viability and surgical flaps. - **Posterior Auricular Artery:** Supplies the posterior auricle and lobule. - **Superficial Temporal Artery:** Provides anterior and superior auricular supply. - **Maxillary Artery:** Minor branches contribute, particularly to the deep auricular canal. These vessels are often involved in **postauricular flaps**, **composite grafts**, and **helical rim reconstructions**. Preserving arterial branches reduces the risk of flap necrosis. ### Venous Drainage - Mirrors the arterial supply, with drainage into the **external jugular venous system** via, - **Pterygoid venous plexus** - **Maxillary vein** - This pathway is clinically relevant in **facial infections** that may retrogradely spread via valveless connections. Blood supply to the ear is derived from the external carotid artery system. Drainage and lymphatic routes are clinically important for infection and malignancy spread. ### Lymphatic Drainage Lymphatic drainage routes are essential in the spread of infections and cutaneous malignancies. This includes preauricular nodes, mastoid (postauricular) nodes, and superficial cervical lymph nodes. The lymphatic drainage of the auricle follows a predictable pattern, with each node group responsible for specific regions. This is summarised below. ![Lymphatic drainage of the auricle with each node group and specific regions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-30T221722.703.png) Lymphatic drainage of the auricle with each node group and specific regions Lymphatic drainage of the head and neck is illustrated below. ![Lymphatic drainage of the head and neck, ear anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-20T171733.332.png) Lymphatic drainage of the head and neck 💡 ****Tip:** Complete auricular anesthesia requires blocking the auriculotemporal (V3), great auricular (C2–C3), and lesser occipital (C2) nerves. Each supplies a distinct zone of the auricle: anterior, lower/posterior, and upper/posterior respectively. This triple block is ideal for procedures like otoplasty, trauma repair, and skin excisions, providing broad sensory coverage with local anesthesia. --- ## Anatomical Landmarks of the Ear ****Key Point** The auricle (pinna) has distinct anatomical substructures that assist in sound conduction and serve as critical reference points in clinical and surgical settings. The auricle (pinna) constitutes the visible portion of the external ear. Structurally, it is composed of a cartilaginous framework covered by tightly adherent skin and delineated by anatomically distinct elevations and depressions. These features function to collect and direct sound toward the external auditory canal and serve as critical references in surgical reconstruction, trauma repair, and oncologic excision. ### Principal Landmarks - **Helix:** The outermost convex margin of the auricle, originating superior to the external auditory canal and arching posteriorly along the lateral ear. - **Cauda Helicis:** The inferior terminal portion of the helix, merging with the lobule. - **Antihelix:** An inner, C-shaped cartilaginous ridge anterior and parallel to the helix. It bifurcates into, - **Crus Superior** and **Crus Inferior:** Superior and inferior limbs enclosing the fossa triangularis. - **Fossa Triangularis:** A triangular concavity located between the two crura of the antihelix. - **Scapha:** A longitudinal groove situated between the helix and antihelix. - **Tragus:** A prominent cartilaginous projection situated anterior to the external auditory meatus; functions in partially occluding the canal. - **Antitragus:** A cartilaginous eminence located inferior to the antihelix and opposite the tragus. - **Concha:** The central, concave depression leading directly into the external auditory canal. It is subdivided into: - **Cymba Conchae:** The superior component. - **Cavum Conchae:** The inferior component adjacent to the canal entrance. - **Lobule:** The soft, inferior portion of the auricle lacking cartilage; composed primarily of adipose and fibrous tissue. ### Supplementary Landmarks - **Auricular Tubercle (Darwin’s tubercle):** A vestigial prominence occasionally observed along the posterior helix—an evolutionary remnant. - **Spine of Helix:** A subtle protuberance located near the caudal curvature of the helix. - **External Auditory Meatus:** The aperture of the external auditory canal leading to the tympanic membrane. - **Preauricular Region:** An anatomically significant area anterior to the tragus, commonly implicated in congenital anomalies (e.g., preauricular pits), infections, and neoplastic processes. 😎 ****Fun Fact:** The auricular tubercle (Darwin’s tubercle) is a small cartilaginous projection found on the posterior aspect of the helix in approximately 10% of the population. It is considered a vestigial trait linked to ancestral mobility of the ear. --- ## Aesthetic Subunits of the Auricle ****Key Point** Dividing the auricle into aesthetic subunits improves surgical planning and ensures natural and harmonious reconstruction. The auricle can be conceptualized into distinct aesthetic subunits based on its natural topography. This subunit-based approach is especially helpful in reconstructive and aesthetic surgery, allowing for the restoration of form and contour with minimal distortion. **Commonly Recognised Aesthetic Subunits** Each subunit and their components are summarised below. - **Helical Rim:** The outer margin of the ear, from the root to cauda helicis. - **Antihelix Complex:** Includes the antihelix and its crura, and the triangular fossa. - **Conchal Bowl:** The cymba and cavum conchae, forming the central depression. - **Tragus/Antitragus Unit:** The paired anterior projections flanking the concha. - **Lobule:** The inferior, non-cartilaginous portion of the auricle. Surgeons may also consider adjacent zones, such as the preauricular skin and mastoid region, when designing flaps or incisions to maintain contour and conceal scars. 💡 ****Tip:** When reconstructing auricular defects (e.g., after trauma or tumour excision), try to replace lost tissue with matching contour, texture, and thickness from the same aesthetic unit. --- ## Muscles of the Auricle ****Key Point** The auricle contains vestigial striated muscles innervated by the facial nerve, with minimal functional role in most individuals. The auricle is connected to the surrounding soft tissues and the scalp by several small striated muscles. These are generally rudimentary in humans and have limited voluntary function. Auricular muscles, their location, and function are summarised below. ![Auricular muscles, their location, and function](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-20T172906.345.png) Auricular muscles, their location, and function - All auricular muscles are innervated by the **temporal branch of the facial nerve (CN VII)**. - In most individuals, these muscles are underdeveloped and non-functional. - Some people can voluntarily move their ears using these muscles — a trait with no known clinical significance but notable for its rarity. 😎 ****Fun Fact:** Although functionally insignificant, the presence and location of these muscles must be considered during flap elevation or cartilage scoring to avoid unintended injury. --- ## External Auditory Canal ****Key Point** The external auditory canal is a 25 mm S-shaped passageway that directs sound waves to the tympanic membrane. It comprises cartilaginous and osseous segments and is lined with skin containing ceruminous glands. The external auditory canal, or the external acoustic meatus, serves as the conduit between the auricle and the tympanic membrane. It plays a vital role in sound conduction and the protection of the middle and inner ear. **Anatomy and Structure** - **Length:** \~25 mm (2.5 cm) in adults. - **Shape:** S-shaped, curving anteriorly then posteriorly. - **Subdivisions** - **Outer third (≈8–10 mm)** - Composed of **elastic cartilage.** - **Mobile**, with hair follicles, sebaceous and ceruminous glands. - **Inner two-thirds (≈15–17 mm)** - Composed of **bone (tympanic part of temporal bone)**. - **Fixed** and narrower. - Lined by thin skin tightly adherent to the periosteum. The image below illustrates the external auditory canal. ![External auditory canal, Ear anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-20T172258.837.png) External auditory canal 💡 ****Tip:** During otoscopy, the auricle is gently pulled ****upward and backward** to straighten the S-curve and allow clear visualization of the tympanic membrane. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** The external ear is a complex structure of cartilage, skin, and soft tissue that aids hearing and facial aesthetics. Anatomical knowledge is essential for reconstructive, congenital, and trauma-related procedures. ****2\. Neurovascular Anatomy:** The auricle is innervated by cranial and cervical nerves and vascularised by branches of the external carotid. Ceruminous glands produce protective earwax, and vagal stimulation may trigger the Arnold reflex. ****3\. Auricular Landmarks:** The auricle features distinct ridges and depressions (e.g. helix, concha, tragus) that direct sound and guide surgical reconstruction. Each substructure has clinical and aesthetic relevance. ****4\. Aesthetic Subunits:** Dividing the ear into aesthetic zones such as the helical rim, conchal bowl, and lobule, guides reconstruction to restore natural form and conceal scars effectively. ****5\. Auricular Muscles:** The ear contains vestigial intrinsic and extrinsic muscles, innervated by CN VII. Though functionally minimal, they should be preserved during surgery to avoid tissue distortion. ****6\. External Auditory Canal:** The 25 mm S-shaped auditory canal transmits sound to the tympanic membrane. Its outer third is cartilaginous with glands, and the inner two-thirds are bony and fixed. --- ## Further Reading 1. White HJ, Helwany M, Biknevicius AR, Peterson DC. Anatomy, head and neck, ear organ of Corti. In: StatPearls \[Internet\]. Treasure Island, FL: StatPearls Publishing; January 14, 2023. 2. Altafulla J, Iwanaga J, Lachkar S, et al. The great auricular nerve: anatomical study with application to nerve grafting procedures. World Neurosurg. 2019;125:e403-e407. 3. Young AS, Rosengren SM, Welgampola MS. Disorders of the inner-ear balance organs and their pathways. Handb Clin Neurol. 2018;159:385-401. 4. Hohman MH, Jamal Z, Krogmann RJ, King KC. Auricular hematoma. In: StatPearls \[Internet\]. Treasure Island, FL: StatPearls Publishing; May 1, 2024. 5. Szmuilowicz J, Young R. Infections of the ear. Emerg Med Clin North Am. 2019;37(1):1-9. 6. Osborn HA, Goldsmith TA, Varvares MA. Assessing functional outcomes in head and neck surgical oncology. Head Neck. 2019;41(7):2051-2057. 7. Markkanen S, Niemi P, Rautiainen M, et al. Craniofacial and occlusal development in 2.5-year-old children with obstructive sleep apnoea syndrome. Eur J Orthod. 2019;41(3):316-321. 8. Birgfeld C, Heike C. Craniofacial microsomia. Clin Plast Surg. 2019;46(2):207-221. 9. Szymanski A, Geiger Z. Anatomy, Head and Neck, Ear. \[Updated 2023 Jul 24\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470359/ ### Systematic Review and Meta-Analysis of Mobilisation Following Open Reduction and Internal Fixation of Hand Fractures URL: https://www.theplasticsfella.com/journal-hand-fractures/ Last updated: 2025-06-27T19:28:02.000Z #### In this Journal Club A systematic review (53 studies, 1,822 hand fractures) examined the timing of mobilisation post-ORIF. Immediate mobilisation showed faster healing but higher adverse events. Delayed mobilisation had fewer complications. Heterogeneity and lack of standardised PROMs limit conclusions. [****5-Point Summary**](https://www.theplasticsfella.com/journal-hand-fractures/#5-point-summary) A systematic review (53 studies) assessed when to start moving post-ORIF. Immediate mobilisation sped up healing; delayed reduced adverse events. PROMs varied. Heterogeneity limits conclusions. [****4-Key Findings**](https://www.theplasticsfella.com/journal-hand-fractures/#4-key-findings) Immediate mobilisation healed in 38.7 days. Early mobilisation had 25% adverse events; delayed had 9.3%. PROMs were inconsistent, limiting data synthesis. [****3-Critiques**](https://www.theplasticsfella.com/journal-hand-fractures/#3-critiques) Most studies were retrospective and biased. PROMs and adverse events were inconsistently defined and reported across studies. [****2-Practical Takeaways** ](https://www.theplasticsfella.com/journal-hand-fractures/#2-practical-takeaways) Delayed mobilisation may lower complications. Earlier movement may boost early function. RCTs needed for clarity. [****1-Recommended Reading**](https://www.theplasticsfella.com/journal-hand-fractures/#1-recommended-reading) Feehan & Bassett (2004) found early motion (<21 days) improved recovery and return to work without loss of alignment. [Read Full Article ](https://www.sciencedirect.com/science/article/pii/S1748681525003109?ref=theplasticsfella.com) ✍️ ****Note from the Editor** --- ## 5 Point Summary This systematic review and meta-analysis synthesises 53 studies on hand fracture ORIF, assessing how timing of postoperative mobilisation influences healing, function, and complications. 1️⃣ ****Hypothesis** Earlier mobilisation after ORIF of hand fractures leads to improved functional outcomes without increasing complication rates. ![Isolated metacarpal shaft fracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/5-2.png) Isolated metacarpal shaft fracture 2️⃣ ****Method** A systematic review and meta-analysis of 53 studies (1,822 fractures) evaluating mobilisation timing post-ORIF: immediate (≤1 day), early (≤7 days), and delayed (>7 days). Outcomes included PROMs, bone healing time, and adverse events. 3️⃣ ****Results** Immediate mobilisation had the fastest mean healing time (38.7 days), but early mobilisation showed the highest adverse events (25%). Delayed mobilisation had the lowest complications (9.3%). PROMs were inconsistently reported across studies. ![Breakdown of adverse events](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/3.png) Breakdown of adverse events 4️⃣ ****Conclusion** Timing of mobilisation post-ORIF affects healing and complication profiles. Immediate mobilisation may accelerate recovery, but variability in study design limits strong recommendations. 5️⃣ ****Implication** There is no definitive evidence to guide mobilisation timing after hand fracture ORIF. A multicentre RCT with standardised outcomes is needed to inform best practice. ![Immobilisation following hand fracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/6-1.png) Immobilisation following hand fracture --- ## 4 Key Findings This meta-analysis highlights the impact of mobilisation timing on bone healing, complications, and functional recovery following hand fracture ORIF. 1️⃣ ****Bone Healing** Immediate mobilisation (≤1 day) was associated with the shortest mean healing time (38.7 days), compared to early (49.6 days) and delayed (48.8 days) mobilisation. Confidence intervals overlapped, and statistical significance was not established. ![Mean bone healing time by group](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/2.png) Mean bone healing time by group 2️⃣ ****Adverse Events** Delayed mobilisation (>7 days) had the lowest adverse event rate (9.3%), while early mobilisation (≤7 days) had the highest (25%). Most reported events were stiffness, return to theatre, and wound issues. ![Adverse event rates by mobilisation timing](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/1.png) Adverse event rates by mobilisation timing 3️⃣ ****Patient-Reported Outcomes** PROMs such as QuickDASH, DASH, and VAS were inconsistently reported and measured at varied follow-up points, making comparisons difficult. QuickDASH scores tended to improve with earlier mobilisation but lacked standardisation. 4️⃣ ****Study Variability** There was marked heterogeneity in study design, mobilisation protocols, and outcome reporting. Most studies were retrospective and at high risk of bias, limiting the strength of pooled conclusions. --- ## 3 Critiques Although comprehensive, the review is limited by heterogeneity in study quality, outcome reporting, and rehabilitation protocols. 1️⃣ ****Study Quality** Most included studies were retrospective and rated high risk of bias. Only one randomised controlled trial was identified, reducing the reliability of pooled results. 2️⃣ ****Outcome Inconsistency** PROMs were not uniformly applied, and follow-up durations varied widely. This limited the ability to compare functional outcomes across mobilisation groups. 3️⃣ ****Rehabilitation Reporting** Few studies clearly described the type, frequency, or compliance with therapy regimens, making it difficult to assess the true impact of mobilisation timing. --- ## 2 Practical Takeaways This review supports clinical caution and individualised rehabilitation planning following hand fracture ORIF, with key implications for patient safety and recovery. 1️⃣ ****Rehabilitation Strategy** While early mobilisation may speed up functional recovery, the increased risk of complications — particularly with early movement — calls for tailored approaches based on fracture stability and patient factors. 2️⃣ ****Shared Decision-Making** Clinicians should counsel patients on the trade-offs between faster recovery and potential complications, ensuring realistic expectations and encouraging early engagement with hand therapy services. ![Risk–benefit spectrum of mobilisation timing post-ORIF](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/4.png) Risk–benefit spectrum of mobilisation timing post-ORIF --- ## 1 Recommended Reading **Feehan & Bassett’s systematic review (2004)* analysed early mobilisation (<21 days) in extraarticular hand fractures. Among 459 patients, early motion improved mobility and return to work without affecting fracture alignment. Despite low-quality evidence, the study highlights the potential benefits and supports the need for high-quality RCTs in hand fracture rehabilitation. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/15162112/link?ref=theplasticsfella.com) ### AI Beats Journal's Copyright? 3 Hand Fracture Lessons, & Foundations Web Companion URL: https://www.theplasticsfella.com/june-29th/ Last updated: 2025-06-28T11:55:49.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-29th/#a-letter-from-pfella) AI Beats Journal's Copyright? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-29th/#the-sunday-quiz) How well do you know **Thumb Fractures*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-29th/#image-of-the-week) Seymour fracture anatomy X-ray. 4. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/june-29th/#foundations-textbook) Sneak peek: The online companion. 5. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/june-29th/#jpras-journal-club) When to start mobilisation after ORIF of hand fractures. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-29th/#articles-of-the-week) PIPJ fracture outcomes, original Seymour's study, & hand fracture recon strategies: With 1-sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/june-29th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella AI Beats Journal's Copyright? 👋 I thought this was a bombshell. A federal judge just ruled that training AI on books—even paywalled ones—is fair use. In the judge’s words, charging someone every time they recall what they’ve read would be “unthinkable.” **Why? Because Anthropic *bought* physical copies, scanned them, and fed them to Claude. According to the judge, this is no different from a human reading, remembering, and remixing ideas into something new.** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/image-4.png) Judge's Ruling **What Does This Mean for Journals?** Honestly, who knows. But some thoughts: - **The Paywall Fantasy is Over:** AI can digest every paywalled article legally and regurgitate new insights instantly. - **Peer Review Has Competition:** AI can spot statistical flaws and sloppy methodology in minutes. - **Subscription Model? Dead on Arrival:** Why pay thousands when AI already read the paper and can summarize it for you? The judge’s logic was blunt: once you’ve legally purchased a book, you can do what you want with it—including feeding it to an algorithm. Journals have spent decades gatekeeping knowledge with committees, fees, and bureaucracy. That grip just slipped, maybe. With love, P Fella ❤️ ## The Sunday Quiz **How Well Do You Know Thumb Fractures* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. This is the final round of seven rounds! The ****top** scorer wins a copy of our upcoming textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). ## Image of the Week **Seymour Fracture Anatomy X-Ray* 🖼️ ****Image of the Week** This week’s image features a classic Seymour fracture. It typically presents with a nailbed injury and flexed DIP joint, with the fracture line extending through the physis. ****Image 1:** Clinical image showing nail avulsion and volar displacement. ****Image 2:** X-ray confirming displaced juxta-epiphyseal fracture. **Note: Seymour fractures are open fractures until proven otherwise. Urgent washout, reduction, and antibiotics are essential.* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/gox-9-e3797-g002.jpg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/gox-9-e3797-g003.jpg) [Source](https://pmc.ncbi.nlm.nih.gov/articles/PMC8448075/?ref=theplasticsfella.com) ## Foundations Textbook **Sneak Peek: The Online Companion* 📘 Here’s a quick look at what the digital companion to the **Foundations*. 1\. Live article updates so you can read more than the textbook 2\. Curated videos and audio companion ps - look at the other stuff in the screenshot 😉 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Images-for-Textbook.png) ## JPRAS Journal Club **When to Start Mobilisation After ORIF of Hand Fractures* 🎓 This week’s Journal Club explores mobilisation after open reduction and internal fixation (ORIF) of hand fractures. Immediate mobilisation speeds up radiographic healing, but comes with more complications. Delayed mobilisation reduces risk, but may slow functional recovery. No clear winner... yet. ****Key Stats:** \- Immediate mobilisation: healing in 38.7 days. \- Delayed mobilisation: lowest adverse event rate (9.3%). \- Early mobilisation (≤7 days): highest complications (25%). \- PROMs were inconsistently reported and hard to compare. ![Mobilisation after open reduction and internal fixation of hand fractures](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/6-1.png) Mobilisation after open reduction and internal fixation of hand fractures [Read the Article](https://www.theplasticsfella.com/journal-hand-fractures/) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Surgical Outcomes in PIPJ Fracture-Dislocations** ([Demino](https://pmc.ncbi.nlm.nih.gov/articles/PMC8283102/?ref=theplasticsfella.com), 2019) Across five common techniques for proximal interphalangeal joint fracture-dislocations, no single approach consistently outperformed others in postoperative function. ✅ ****Seymour Fracture: Early Recognition of a Unique Juxta-Epiphyseal Injury** ([Seymour](https://pubmed.ncbi.nlm.nih.gov/5939484/?ref=theplasticsfella.com), 1966) First described in 1966, the Seymour fracture is a juxta-epiphyseal injury of the terminal phalanx that mimics mallet finger but requires urgent recognition and nailbed management to prevent complications . ✅ ****Evolving Hand Fracture Recon Strategies for a Common but Complex Injury** ([Meals](https://www.jhandsurg.org/article/S0363-5023%2813%2900243-8/abstract?ref=theplasticsfella.com), 2013) The current principles in managing metacarpal and phalangeal fractures, emphasizing surgical indications, complication prevention, and the benefits of early mobilization in preserving soft tissue function. ## Feedback ### I hope you enjoyed it 😄 --- ### Rhomboid Flap: Design, Surgical Technique, & Complications URL: https://www.theplasticsfella.com/rhomboid-flap/ Last updated: 2025-06-23T18:37:54.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/rhomboid-flap/#overview-of-rhomboid-flaps) The rhomboid (Limberg) flap is a geometric local transposition flap that pivots 120° to close adjacent defects under minimal tension. It preserves contour and offers predictable results. [****Indications & Contraindications**](https://www.theplasticsfella.com/rhomboid-flap/#indications-contraindications-of-rhomboid-flaps) Rhomboid flaps are versatile, tension-minimizing transposition flaps suitable for a wide range of cutaneous defects. Limitations include insufficient adjacent tissue or patient-specific risk factors like smoking and diabetes. [****Design & Execution**](https://www.theplasticsfella.com/rhomboid-flap/#design-execution-of-rhomboid-flaps) Successful rhomboid flaps depend on geometric precision, appropriate orientation to relaxed skin tension lines (RSTLs), and tension-free inset through adequate undermining and vascular preservation. [****Variations**](https://www.theplasticsfella.com/rhomboid-flap/#variations-of-rhomboid-flap-design) Modified rhomboid flaps, such as Dufourmental, Webster, and Quaba-Sommerlad designs, improve mobility, reduce tension, and adapt the classic Limberg flap to different anatomical needs. [****Complications**](https://www.theplasticsfella.com/rhomboid-flap/#complications-of-rhomboid-flaps) Complications of rhomboid flaps are uncommon but typically arise from excess tension, poor design, or impaired vascularity. Prevention and early recognition are key to preserving flap viability and aesthetic outcome. ****Updated by:** Dr Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Rhomboid Flaps ****Key Point** The rhomboid (Limberg) flap is a geometric local transposition flap that pivots 120° to close adjacent defects under minimal tension. It preserves contour, offers predictable results, and is widely used in cutaneous reconstruction. The rhomboid flap, also called the Limberg flap, is a geometric local transposition flap that enables lateral movement of tissue into adjacent defects with minimal tension. Designed by Prof. Alexander Limberg in 1928 in Leningrad; first English description appeared in *Modern Trends in Plastic Surgery* (1963) ([Kang](https://pmc.ncbi.nlm.nih.gov/articles/PMC8278203/?ref=theplasticsfella.com), 2021) Key points include, - The rhomboid flap is a **local transposition flap** that rotates laterally into adjacent defects using a fixed geometric design. - It moves tissue around a pivot point, typically 120°, distinct from rotation flaps that arc around a broader curve. - The donor site is typically closed directly in a straight line, under minimal tension. The image below illustrates a classic Limberg rhombic flap design. ![A classic Limberg rhombic flap design](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Template-2.png) A classic Limberg rhombic flap design 😎 ****Fun Fact:** “Flap” comes from the Dutch **flappe*, meaning “to hang loose”, highlighting its partially attached nature with preserved blood supply. --- ## Indications & Contraindications of Rhomboid Flaps ****Key Point** Rhomboid flaps are versatile, tension-minimizing transposition flaps suitable for a wide range of cutaneous defects. Limitations include insufficient adjacent tissue or patient-specific risk factors like smoking and diabetes. ### Indications Rhomboid flaps are used across numerous anatomical regions and patient demographics. Their geometric predictability and broad applicability make them a staple in reconstructive surgery ([Aydin OE et al.](https://pubmed.ncbi.nlm.nih.gov/25610151/?ref=theplasticsfella.com), 2011). Common clinical uses include, - **Facial Defects:** Cheek, temple, chin, eyelid, nasal sidewall, alar rim. - **Trunk:** Thoracic, scapular, lumbar, lumbosacral. - **Extremities:** Hand, upper/lower limbs, thigh. - **Perineal/Perianal:** Pilonidal sinus, inguinoscrotal defects. - **Post-Oncologic Excision:** BCC, SCC. - **Other Aetiologies:** Trauma, spina bifida, cystic acne, lupus. This flap has demonstrated success across a wide demographic. - All age groups — pediatric to geriatric. - Any gender and skin type. - Suitable for outpatient or inpatient settings. ### Contraindications Despite its versatility, the rhomboid flap has limitations that warrant careful consideration in surgical planning. **Absolute Contraindication:** Persistent malignancy at margins. Full excision is essential before flap reconstruction. **Relative Contraindications** - **Low BMI or limited adjacent skin laxity** may preclude safe flap transposition. - **Large defects** in tight-skin regions (e.g., nasal dorsum) may require alternate flaps like bilobed or keystone designs. - **Patient Factors** - Active smoking impairs perfusion and wound healing. - Uncontrolled diabetes increases the risk of infection and delayed healing. **Situational Limitations** - In extremely large defects, rhomboid flaps may be combined, or the defect may be downsized via margin mobilization. - In nasal reconstruction, bilobed flaps may offer superior curvature and inset. - In cases with residual malignancy, ensure complete excision (e.g., Mohs surgery) prior to flap planning. The table below summarises the differences between the rhomboid flap and other local flaps. ![Comparison of the rhomboid flap and other local flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-18T105601.229.png) Comparison of the rhomboid flap and other local flaps 💡 ****Tip:** For facial reconstructions, rhomboid flaps can often outperform skin grafts or primary closure in both aesthetic outcome and contour preservation. --- ## Design & Execution of Rhomboid Flaps ****Key Point** Successful rhomboid flaps depend on geometric precision, appropriate orientation to relaxed skin tension lines (RSTLs), and tension-free inset through adequate undermining and vascular preservation. **Step 1: Design the Rhombus** The procedure begins with a precise rhomboid design. The rhomboid (or “Limberg”) flap is based on a parallelogram with angles of 120° and 60°, and four equal sides ([Kang AS et al](https://pmc.ncbi.nlm.nih.gov/articles/PMC8278203/?ref=theplasticsfella.com)., 2021). - Identify the short diagonal. This becomes the axis of transposition and should be oriented perpendicular to relaxed skin tension lines (RSTLs). - Choose the flap vector based on adjacent tissue laxity, ideally along lines of maximal extensibility (LMEs). - The flap's first limb extends from one corner of the rhomboid at a 60° angle, equal in length to the rhombus side. The second limb is drawn parallel to the adjacent rhomboid edge. The design of the rhomboid flap is illustrated below. ![Rhomboid flap design](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-18T105847.834.png) Rhomboid flap design **Step 2: Mark and Prepare the Flap** - After cleansing and anesthetizing the area (commonly using 1% lidocaine with 1:100,000 epinephrine), mark the defect as a rhomboid, and outline the flap from the corner of greatest tissue mobility. - For large defects, consider Doppler-assisted design to preserve perforators, allowing axial elevation. - Drawing the flap, - The rhomboid flap has a “leg” to stand on, which is bent at the knee. There are two important measurements to allow for an easy closure. - Distance 1 is the thigh = distance between the 120° angles. - Distance 2 is the shin = distance between the 120° to 60° angle. Marking and preparing a rhomboid flap. ![Marking and preparing a rhomboid flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-18T110156.407-1.png) Marking and preparing a rhomboid flap **Step 3: Incision & Elevation** - Incise through the skin and subcutaneous tissue, keeping a 2-3 mm cuff of subcutaneous fat to preserve the subdermal plexus. - Elevate the flap in a superficial subcutaneous plane using scissors, preserving vascularity and ensuring flap thickness is even. - Once the lesion is excised, elevate the flap and join the letters. This will allow closure under minimal tension. - There are two letters to connect: A-A, B-B. Incision & elevation of a rhomboid flap are illustrated below. ![Incision & elevation of a rhomboid flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-18T110940.187.png) Incision & elevation of a rhomboid flap **Step 4: Transposition and Undermining** - Transpose the flap into the defect gently. Rotate along the pivot without kinking the base. - Undermine 2–4 cm beyond the flap and defect to enable mobility and reduce closure tension. - Address any standing cutaneous cones near the base with minor excision. - Avoid undermining beyond 4 cm unless required. Excess undermining can paradoxically increase tension and compromise blood supply. **Step 5: Inset and Closure** - Begin closure at the donor site’s point of maximal tension (usually point F to C in classic diagrams). - Use buried 4-0 or 5-0 absorbable sutures in the dermis and non-absorbable 5-0 or 6-0 interrupted sutures for the skin. - On the face, cyanoacrylate glue may be added for scar minimization and wound support. - Keep the flap base at least 1/3 of the flap length on the face, or 1/2 on the trunk/extremities, to maintain vascular supply. Insertion and closure of a rhomboid flap are illustrated below. ![Insertion and closure of a rhomboid flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-18T111926.671.png) Insertion and closure of a rhomboid flap **Step 6: Postoperative Management** - Apply a light compressive dressing for 24-48 hours. - Remove sutures within 6-7 days to avoid track marks. - Educate patients about sun protection, edema prevention, and scar care to enhance healing. 😎 ****Fun Fact:** The rhomboid flap was first described by ****Alexander Limberg** in 1946 and its design is so geometrically precise that early versions were taught using compass and protractor exercises in surgical textbooks. To this day, the Limberg rhombus remains one of the few flaps rooted in pure mathematics! --- ## Variations of Rhomboid Flap Design ****Key Point** Modified rhomboid flaps, such as Dufourmental, Webster, and Quaba-Sommerlad designs, improve mobility, reduce tension, and adapt the classic Limberg flap to different anatomical needs. ### Dufourmental Rhombic Flap (1962) Claude Dufourmental’s modification narrows the flap and adjusts the rotation arc to improve closure and reduce contour deformities. - **Flap Shape:** Less geometric match with the defect, but achieves full closure through **secondary movement** of surrounding tissue. - **Flap Angle (α):** Ranges from **60° to 75°**, providing a smoother transposition arc. - **Advantages** - Improved blood supply via wider pedicle. - Easier donor site closure. - Reduced standing cutaneous cone deformities. - Ideal for locations with pliable skin and where minimal tension at the pivot point is crucial (e.g., lower back, gluteal region). The dufourmental rhombic flap is illustrated below. ![Dufourmental rhombic flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-18T105024.596.png) Dufourmental rhombic flap ### Webster Rhombic Flap (1978) This variant uses a **30° flap angle** and an **M-plasty** closure at the base to improve tension distribution. - **Design Highlights** - Narrower flap creating a more focused arc of rotation. - M-plasty divides base tension into smaller angles, reducing tissue distortion. - **Clinical Outcome** - Reduced scar widening. - Less “dog-ear” formation at the base. - **Use Case:** Particularly useful where balanced closure is critical, such as the chin or temple regions. The image below illustrates the Webster rhombic flap. ![Webster rhombic flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-18T104913.765.png) Webster rhombic flap ### Quaba-Sommerlad Flap (1987) Designed for **circular defects**, the Quaba-Sommerlad modification utilizes a rhomboid design to preserve healthy skin and simplify flap planning ([Quaba](https://www.sciencedirect.com/science/article/abs/pii/0007122687901895?ref=theplasticsfella.com), 1987). - **Geometry:** Flap side = two-thirds the defect diameter, maintaining a 60° flap angle. - **Benefits** - Avoids sacrificing uninvolved skin to create a rhombus. - Excellent for head and neck reconstruction. - Easier to transpose than the classic Limberg design. **Note Flap (1985)** Named for its resemblance to a musical note, this variant features a quadrilateral flap and a tangential first incision to close circular defects. - **Flap Side:** 1.5× the diameter of the defect. - **Unique Feature:** Incision is tangential rather than radial. - **Advantage:** Increased reach with aesthetic blending in convex surfaces like cheeks or forehead. **Multi-Flap Rhomboid Variants** To address large or complex defects, surgeons have employed **double, triple, or quadruple rhomboid flaps**. - **Applications** - Pilonidal sinus disease. - Myelomeningocele closures. - Areas with limited adjacent skin mobility. - **Outcomes:** Low recurrence rates, preserved perfusion, and simplified execution. - Double rhomboid flaps are especially useful in midline defects (e.g., sacral region) where unilateral flaps would leave excessive tension. **Clinical Pearls** - Choose Dufourmental when minimizing pivot tension is a priority. - Use Webster in cosmetic zones needing optimized tension vectors. - Select Quaba-Sommerlad or Note flaps for round defects where geometric rhomboids are impractical. - Consider multi-flap techniques when reconstructing wide or irregular surfaces. A comparison of the rhomboid flap and other widely used local flaps, highlighting their classification, geometric design, ideal application areas, and anatomical strengths. ![A comparison of the rhomboid flap and other widely used local flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-18T105246.037.png) A comparison of the rhomboid flap and other widely used local flaps 😎 ****Fun Fact:** The Dufourmental flap was designed in 1962 by a French surgeon aiming to optimize aesthetics and reduce dog-ears in posterior body defects. Yet, it remains one of the most versatile flaps used today, especially in chronic pilonidal disease surgery. --- ## Complications of Rhomboid Flaps ****Key Point** Complications of rhomboid flaps are uncommon but typically arise from excess tension, poor design, or impaired vascularity. Prevention and early recognition are key to preserving flap viability and aesthetic outcome. Although rhomboid flaps are highly reliable, complications can occur and should be thoroughly discussed during preoperative consent. These include **general surgical risks** and **flap-specific issues**, particularly related to perfusion and tension dynamics. **1\. Hematoma Formation** - **Timing:** Typically within the first 24 hours. - **Impact:** Compresses the flap, disrupts venous outflow → flap congestion and ischemia. - **Management:** Prompt evacuation ± pressure dressing. **2\. Venous Congestion / Vascular Compromise** - **Etiology:** Tension, hematoma, or tight closure. - **Signs:** Cyanotic discoloration, progressive swelling. - **Treatment Options** - **Topical nitroglycerin** (vasodilation). - **Leech therapy** for venous decompression (ensure **fluoroquinolone prophylaxis** due to *Aeromonas hydrophila*). **3\. Flap Necrosis (Partial or Complete)** - **Cause:** Over-thinning, aggressive undermining, or poor flap planning. - **Management** - **Conservative debridement** — retain eschar as “biological dressing”. - **Secondary intention healing** or **re-advancement** of viable flap tissue. **4\. Trapdoor Deformity** - **Cause:** Disrupted lymphatic drainage or superiorly based flap. - **Appearance:** Flap protrudes above the surrounding skin with a "puffy" contour. - **Management** - **Steroid injections** (e.g., triamcinolone). - **Flap revision** in severe cases. **5\. Pincushioning** - **Cause:** Oversized flap or postoperative contraction. - **Treatment:** Flap thinning or debulking at a later stage. **6\. Tethering & Scar Distortion** - **Cause:** Poor orientation or inappropriate flap axis. - **Anatomic Risk Areas:** Eyelids, lips, eyebrows, temple region. - **Management:** Early intervention or revision surgery if function or aesthetics are compromised. 💡 ****Tip:** Inferiorly based rhomboid flaps typically drain better and have fewer trapdoor or edema-related issues. Prioritize these orientations when feasible. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Rhomboid flaps are geometric, transposition flaps rooted in precise angular design, ideal for closing skin defects across a wide range of anatomical regions with reliable vascularity and cosmetic outcomes. ****2\. Indications & Contraindications:** Suitable for defects on the face, trunk, limbs, and perianal region. Contraindications include limited adjacent tissue, high-tension closures, active smoking, or poorly controlled diabetes. ****3\. Flap Design & Execution:** Success relies on correct rhomboid planning, proper flap orientation, and preservation of the subdermal plexus. Tension is managed through flap geometry, undermining, and alignment with skin tension lines. ****4\. Postoperative Care & Complications:** Meticulous care reduces risks of hematoma, venous congestion, and contour deformities. Early intervention prevents scar tethering and maintains both function and aesthetics. ****5\. Flap Variants:** Modifications such as Dufourmental, Webster, and Quaba-Sommerlad expand versatility, enabling improved mobility, reduced tension, and adaptability to various defect shapes and anatomical challenges. --- ## Further Reading 1. Macneal P, Hohman MH, Adlard RE. Rhombic Flaps. \[Updated 2024 Apr 18\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558931/ 2. Chasmar LR. The versatile rhomboid (Limberg) flap. *Can J Plast Surg.* 2007;15(2):67-71\. doi:10.1177/229255030701500207 3. Aithal S, Rajan C, Reddy N. Limberg flap for sacrococcygeal pilonidal sinus: a safe and sound procedure. *Indian J Surg.* 2013;75(4):298-301\. doi:10.1007/s12262-012-0489-5 4. Aydin OE, Tan O, Algan S, Kuduban SD, Cinal H, Barin EZ. Versatile use of rhomboid flaps for closure of skin defects. *Eurasian J Med.* 2011;43(1):1-8\. doi:10.5152/eajm.2011.01 5. Ertas N. Rhomboid flap for postburn digital contractures. *Burns.* 2011;37(5):910-911\. doi:10.1016/j.burns.2011.02.013 6. Becker FF. Rhomboid flap in facial reconstruction: new concept of tension lines. *Arch Otolaryngol.* 1979;105(10):569-573\. \[PubMed: 485927\] 7. Aydin OE, Tan O, Algan S, Kuduban SD, Cinal H, Barin EZ. Versatile use of rhomboid flaps for closure of skin defects. *Eurasian J Med.* 2011;43(1):1-8\. \[PMC free article: PMC4261361\] \[PubMed: 25610151\] 8. Fee WE, Gunter JP, Carder HM. Rhomboid flap principles and common variations. *Laryngoscope.* 1976;86(11):1706-1711\. \[PubMed: 790060\] 9. Quaba AA, Sommerlad BC. “A square peg into a round hole”: a modified rhomboid flap and its clinical application. *Br J Plast Surg.* 1987;40(2):163-170\. \[PubMed: 3567448\] 10. Kang AS, Kang KS. Rhomboid flap: indications, applications, techniques and results. A comprehensive review. *Ann Med Surg (Lond).* 2021;68:102544\. \[PMC free article: PMC8278203\] \[PubMed: 34285803\] ### Scalp Reconstruction: Anatomy, Surgical Technique, & Reconstructive Options URL: https://www.theplasticsfella.com/scalp-reconstruction/ Last updated: 2025-11-02T20:37:03.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/scalp-reconstruction/#overview-of-scalp-reconstruction) The scalp is hair-bearing, thick, and inelastic skin covering the convex cranium; its reconstruction is uniquely challenging due to its anatomy, vascularity, and cosmetic implications. [****Anatomy**](https://www.theplasticsfella.com/scalp-reconstruction/#anatomy-of-the-scalp) The scalp is composed of five distinct anatomical layers: Skin, connective tissue, aponeurosis (galea), loose areolar tissue, and pericranium; each with surgical relevance. [****Surgical Technique**](https://www.theplasticsfella.com/scalp-reconstruction/#surgical-technique-for-scalp-reconstruction) Scalp reconstruction follows the reconstructive ladder, with closure method chosen based on defect size and complexity, ranging from primary closure and grafts to local, regional, or free flaps. [****Adjunctive Techniques**](https://www.theplasticsfella.com/scalp-reconstruction/#adjunctive-techniques-for-scalp-reconstruction) Allografts, tissue expanders, and scalp replantation techniques serve as vital adjuncts or salvage strategies when standard reconstructive options are limited by tissue quality, defect size, or traumatic presentation. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Scalp Reconstruction ****Key Point** The scalp is hair-bearing, thick, and inelastic skin covering the convex cranium; its reconstruction is uniquely challenging due to its anatomy, vascularity, and cosmetic implications. The scalp presents a complex reconstructive challenge due to its unique anatomical and functional features. It is thick and inelastic, bears hair, lies over a convex bony surface, and is the only soft tissue covering the skull ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2021). These characteristics influence reconstructive decision-making and limit closure options, particularly in tightly bound regions ([Brawley](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Scalp+reconstructive+flaps+Craig+Cameron+Brawley%2C+Douglas+Sidle&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1749522303937&u=%2Fscholar%3Fq%3Dinfo%3APn2NjtOEyCsJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2022). Preserving hairlines and accommodating skull contour further add to the complexity. Reconstruction strategies must be tailored to defect size, depth, and surrounding tissue quality. - The skull is primarily convex, with regional and patient-specific variability. - The inelastic galea aponeurotica restricts mobility in many areas. - Maintaining the natural hairline poses a significant cosmetic challenge. Reconstructive strategies for the management of scalp wounds are varied and determined by defect size, depth, and quality of regional tissue ([Johnson](https://pmc.ncbi.nlm.nih.gov/articles/PMC5096526/?ref=theplasticsfella.com), 2016). Scalp reconstruction is illustrated below. ![Scalp reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-17T170855.578.png) Scalp reconstruction 💡 ****Tip:** The lack of elasticity of the scalp makes the repair of even small defects difficult ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2021). --- ## Anatomy of the Scalp ****Key Point** The scalp is composed of five distinct anatomical layers: Skin, connective tissue, aponeurosis (galea), loose areolar tissue, and pericranium; each with surgical relevance. ### Layers of the Scalp The five layers of the scalp are remembered using the mnemonic **SCALP:** **S**kin**, C**onnective tissue, **A**poneurosis (galea), **L**oose areolar tissue, and **P**ericranium. - **Skin (3-8 mm thick):** Thickest in the body; varies with age and peaks during active hair growth (Baker 2021; Brawley 2022). - **Dense Connective Tissue:** Anchors hair follicles, glands, fat, vessels, nerves, lymphatics, and emissary veins; fixed to bone by tough septae, so cut vessels retract poorly and bleed freely. - **Aponeurosis (galea):** Tough, inelastic fibrous sheet continuous with frontalis, occipitalis, and temporoparietal fascia; part of the facial SMAS (Brawley 2022). - **Loose Areolar Tissue (subgalea):** Mobile layer that lets the scalp glide over skull; typical cleavage plane in avulsion injuries and favoured pocket for tissue expanders. - **Pericranium:** Firm collagenous periosteum tightly bound to skull; essential bed for skin-graft take during reconstruction. Layers of the scalp in its anatomy are illustrated below. ![Scalp anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-17T171013.465.png) Layers of the scalp #### ### Vascular Supply The scalp receives blood from both **external** and **internal carotid systems**, enabling large, random-pattern local flaps. However, **limited anastomotic flow across the midline** means flaps extending far across may benefit from a **delay procedure** to improve perfusion. - **External Carotid:** Superficial temporal artery, Posterior auricular artery, Occipital artery - **Internal Carotid:** Supraorbital artery, Supratrochlear artery Main vessels run within the **galea** and **temporoparietal fascia**, so preserve these layers during elevation ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2021). **Venous & Lymphatic Drainage** - **Veins** mirror arterial pathways. - **Lymph Nodes:** Parotid, anterior/posterior auricular, occipital. 💡 ****Tip:** When designing flaps, incorporate known arterial branches into the flap base to maximize perfusion and flap viability ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2021). ### Scalp Innervation Scalp innervation includes motor supply from cranial nerves (primarily the facial and trigeminal nerves) and sensory input from both cranial and cervical spinal nerves. **Motor Innervation** - **Frontalis:** Frontal branch of facial nerve (CN VII) - **Occipitalis:** Posterior auricular branch of facial nerve (CN VII) - **Temporalis:** Deep temporal branch of mandibular nerve (CN V3) **Sensory Innervation** - **Forehead & Anterior Scalp:** Supratrochlear and supraorbital nerves (V1) - **Frontoparietal Scalp:** Deep branch of supraorbital nerve (V1) - **Forehead & Anterior Hairline:** Superficial branch of supraorbital nerve (V1) - **Temporal Region:** Zygomaticotemporal (V2) and auriculotemporal nerves (V3) - **Posterior Scalp:** Greater and lesser occipital nerves (C2-C3) - **Ear & Postauricular Region:** Great auricular nerve (C2-C3, cervical plexus) --- ## Surgical Technique for Scalp Reconstruction ****Key Point** Scalp reconstruction follows the reconstructive ladder, with closure method chosen based on defect size and complexity, ranging from primary closure and grafts to local, regional, or free flaps. Scalp reconstruction follows the principles of the **reconstructive ladder**, with all options considered based on the defect’s size, depth, and complexity. The table below provides an overview of these options. ![Structured approach for selecting reconstructive methods in scalp reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-24T000132.368.png) Structured approach for selecting reconstructive methods in scalp reconstruction ### Primary Closure - Ideal for defects **<3 cm** in diameter ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2024 & [Brawley](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Scalp+reconstructive+flaps+Craig+Cameron+Brawley%2C+Douglas+Sidle&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1749522303937&u=%2Fscholar%3Fq%3Dinfo%3APn2NjtOEyCsJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2022). - Requires **wide undermining** in the subgaleal plane to mobilize tissue. - Galeal scoring allows further advancement but may impair perfusion. - Closure tension should be absorbed primarily by the galea, not the skin, to reduce alopecia risk. ### Skin Grafts Split- or full-thickness skin grafting are reliable options in the setting of an intact periosteum or granulation tissue supplied by a vascular bed ([Brawley](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Scalp+reconstructive+flaps+Craig+Cameron+Brawley%2C+Douglas+Sidle&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1749522303937&u=%2Fscholar%3Fq%3Dinfo%3APn2NjtOEyCsJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2022). - **Indication:** Defects with a vascularized bed (pericranium, muscle, granulation tissue). Not suitable for exposed cortical bone unless burred down. - **Advantages:** Covers large areas, good survival on less vascular beds. - **Disadvantages:** Poor aesthetic match, prone to contraction, lacks hair, requires meticulous wound care. 💡 ****Tip:** Use of skin grafts should be limited in patients who require postoperative radiation therapy because of the propensity of the graft to break down during or after radiation treatments ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2021). ### Local Flaps Flaps offer vascularized coverage, restoring contour, hair-bearing skin, or protecting bone, hardware, or irradiated tissue. Local scalp flaps—advancement, rotation, transposition, and interpolation—are chosen based on defect size, location, and tissue laxity. - **Advancement Flaps:** For small defects, especially lateral or loose scalp ([Brawley](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Scalp+reconstructive+flaps+Craig+Cameron+Brawley%2C+Douglas+Sidle&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1749522303937&u=%2Fscholar%3Fq%3Dinfo%3APn2NjtOEyCsJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2022). - **Rotation Flaps:** For curved surfaces; useful for vertex and circular defects (e.g., O-to-Z flap) ([Buckingham](https://pubmed.ncbi.nlm.nih.gov/12533148/?ref=theplasticsfella.com), 2005). - **Transposition Flaps:** For anterior/temporal coverage (e.g., Orticochea’s three-flap technique) ([Orticochea](https://pubmed.ncbi.nlm.nih.gov/4932092/?ref=theplasticsfella.com), 1971). Avoid early excision of standing cutaneous deformities (SCDs) at the flap base—they often flatten naturally. - **Juri Flap:** Large monopedicled option for anterior defects; based on superficial temporal artery ([Juri](https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-2005-871728?ref=theplasticsfella.com), 2005). - **Other Options:** V-Y flaps, rhomboid flaps, bilobed flaps for medium-sized defects ([Brawley](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Scalp+reconstructive+flaps+Craig+Cameron+Brawley%2C+Douglas+Sidle&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1749522303937&u=%2Fscholar%3Fq%3Dinfo%3APn2NjtOEyCsJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2022). ![Local flap options for scalp reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-17T172457.570.png) Local flap options for scalp reconstruction 💡 ****Tip:** For larger defects, the ****crane principle** uses temporary flap coverage to promote granulation, followed by flap return and grafting; grafts can later be excised serially or in one stage before final closure (Baker, 2021). ### Regional Flaps Regional pedicled flaps provide robust, vascularized tissue for moderate-to-large scalp defects when local flaps are insufficient or free flaps are not feasible. - **Temporoparietal Fascial Flap (TPF):** Thin, pliable, based on the superficial temporal artery; good for small-to-medium anterior/lateral defects and skin graft beds. - **Temporalis Muscle Flap:** Bulky, pedicled on deep temporal vessels; covers lateral/superior scalp but lacks hair. - **Occipital Artery Flap:** Posteriorly based; suited for occipital defects with limited arc of rotation. - **Trapezius/Latissimus Dorsi Flaps:** Large flaps for posterior/lateral defects; based on transverse cervical or thoracodorsal arteries. - **Submental/Supraclavicular Flaps:** Thin, pliable options for lower lateral defects; pedicle length and neck mobility are limiting factors. These regional flap options are summarised in the table below. ![Regional flap options in scalp reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-24T000256.360.png) Regional flap options in scalp reconstruction ### Free Flaps Free tissue transfer isn’t routine but is useful for large scalp defects with exposed bone, prior radiation, infection, or cranial involvement. These flaps handle radiotherapy well, and muscle atrophy helps restore contour over time. - **Latissimus Dorsi:** Most common; large surface area, long pedicle (thoracodorsal); muscle, musculocutaneous, or myocutaneous options; low donor morbidity. - **ALT (Anterolateral Thigh):** Large, thin fasciocutaneous flap ± muscle; long pedicle; primary closure often feasible. - **Radial Forearm:** Thin, pliable flap for smaller or contour-sensitive areas; requires skin graft at donor site. - **Scapular/Parascapular:** Good skin match; useful in combination with latissimus for very large reconstructions. - **Rectus Abdominis:** High-volume flap (muscle or musculocutaneous); based on deep inferior epigastric vessels; suitable for deep or bulky defects. The image below illustrates a radial forearm free flap used for scalp recon. ![Radial forearm free flap used for scalp reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-17T171434.972.png) Radial forearm free flap used for scalp reconstruction --- ## Adjunctive Techniques for Scalp Reconstruction ****Key Point** Allografts, tissue expanders, and scalp replantation techniques serve as vital adjuncts or salvage strategies when standard reconstructive options are limited by tissue quality, defect size, or traumatic presentation. These techniques either **supplement** primary reconstruction (e.g., expanders, allografts) or **address rare, severe presentations** (e.g., avulsion). ### Allografts Dermal substitutes are useful for scalp defects with exposed bone or poor vascular beds, especially when immediate autologous reconstruction isn’t feasible ([Johnson](https://pubmed.ncbi.nlm.nih.gov/27826471/?ref=theplasticsfella.com), 2016). **Indications** - Scalp defects with exposed bone lacking periosteum. - Temporary coverage while awaiting definitive reconstruction. - Poor wound beds (e.g., post-infection, post-radiation) needing vascularization before skin grafting. **Technique** - **Bone Prep:** Burr outer cortex to expose diploë and enhance vascularity. - **Placement:** Apply dermal matrix (e.g., Integra®) to support cellular ingrowth. - **VAC Therapy:** Enhances adherence, perfusion, and granulation. - **Definitive Coverage:** Skin graft placed once neovascularization occurs (2–3 weeks). 💡 ****Tip:** Preoperative radiotherapy is a relative contraindication to the use of dermal substitute. However, postoperative irradiation after dermal substitute scalp reconstruction appears to be well tolerated ([Johnson](https://pmc.ncbi.nlm.nih.gov/articles/PMC5096526/?ref=theplasticsfella.com), 2016). ### Tissue Expander Tissue expansion uses continuous tension to induce **mechanical creep**, gradually stretching thick, vascular scalp tissue. Ideal for large defects, it can cover up to 50% of the scalp ([Radovan](https://pubmed.ncbi.nlm.nih.gov/6484035/?ref=theplasticsfella.com), 1984), with external or internal systems leveraging the scalp’s stable cranial base and perfusion resilience. **Design & Placement** - **Plane:** Inserted in the subgaleal plane (deep to galea, superficial to periosteum) ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2021 & [Brawley](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Scalp+reconstructive+flaps+Craig+Cameron+Brawley%2C+Douglas+Sidle&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1749522303937&u=%2Fscholar%3Fq%3Dinfo%3APn2NjtOEyCsJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2022). - **Incision:** Small, perpendicular incision used for insertion. - **Shape:** Expanders should match the intended flap shape. - **Sizing Strategies:** Base twice the size of the defect. Use largest expander possible to reduce closure tension. Alternatively, algorithms may guide selection. **Expansion Protocol** ([Hudson](https://pubmed.ncbi.nlm.nih.gov/15639357/?ref=theplasticsfella.com), 2005) - **Start:** Begin 7-14 days after insertion. - **Frequency:** Injections every 5-7 days. - **Volume:** Add \~10% of expander volume per session. - **Duration:** Full expansion may take several weeks to months. **Considerations** - **Hair Density:** Decreases as area increases — follicles remain constant. - **Complications:** Includes expander extrusion, infection, discomfort, temporary disfigurement, and multiple surgical stages. - **Contraindications:** Not suitable in infected, irradiated, or unstable wounds. The image below illustrates a tissue expander being used in scalp reconstruction. ![Tissue expander being used in scalp reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-17T171608.443.png) Tissue expander being used in scalp reconstruction **VAC (Negative Pressure Therapy)** ([Marathe](https://pubmed.ncbi.nlm.nih.gov/15179195/?ref=theplasticsfella.com), 2004 & [Zens](https://pubmed.ncbi.nlm.nih.gov/33038929/?ref=theplasticsfella.com), 2020) - Enhances granulation, reduces bacterial load, removes exudate, and supports wound contraction. - Especially helpful in promoting vascularity over bone or hardware before reconstruction. - Useful as a temporizing or adjunctive measure in complex or infected wounds. 💡 ****Tip:** Rectangular base expanders provide the greatest tissue yield and may facilitate optimal flap design ([van Happard](https://pubmed.ncbi.nlm.nih.gov/3078698/?ref=theplasticsfella.com), 1988). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Scalp reconstruction is challenging due to its inelastic, hair-bearing skin and convex bony base. Strategies depend on defect size, depth, and location, with key goals including tension-free closure and cosmetic restoration. ****2\. Anatomy:** The scalp comprises five layers (SCALP), with regional variation in mobility and vascularity. Its rich blood supply and nerve innervation must be respected during flap design and elevation. ****3\. Reconstructive Considerations:** Successful reconstruction requires tailoring technique to defect features, accounting for prior radiation, infection, exposed bone, and the need for aesthetic outcomes such as hairline preservation. ****4\. Closure Options:** Small defects may be managed with primary closure, secondary intention, VAC therapy, or skin anchors, depending on periosteal integrity and patient-specific factors. ****5\. Grafts and Flaps:** Skin grafts are suitable for vascular beds but avoid in irradiated patients. Local, regional, and free flaps provide vascularized coverage for larger defects, with each choice guided by location, tissue availability, and patient health. ****6\. Adjunct Techniques:** Dermal substitutes, tissue expanders, and scalp replantation are used for complex or staged reconstructions, offering solutions for large, infected, or avulsive defects when standard approaches are limited. --- ## Further Reading 1. Baker, S.R., 2021\. [Local Flaps in Facial Reconstruction](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2022, p.641-666.e2 E-book. 2. Orticochea M. [New three-flap reconstruction technique](https://pubmed.ncbi.nlm.nih.gov/4932092/?ref=theplasticsfella.com). Br J Plast Surg. 1971 Apr;24(2):184-8\. doi: 10.1016/s0007-1226(71)80038-3\. PMID: 4932092. 3. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. [The lower trapezius musculocutaneous flap revisited](https://pubmed.ncbi.nlm.nih.gov/11818818/?ref=theplasticsfella.com): versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery. Plast Reconstr Surg. 2002 Feb;109(2):444-50\. doi: 10.1097/00006534-200202000-00005\. PMID: 11818818. 4. Tanaka Y, Miki K, Tajima S, Akamatsu J, Tsukazaki Y, Inomoto T. [Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap](https://pubmed.ncbi.nlm.nih.gov/9664886/?ref=theplasticsfella.com). Br J Plast Surg. 1998 Apr;51(3):250-4\. doi: 10.1054/bjps.1997.0030\. PMID: 9664886. 5. Brawley, C.C. and Sidle, D., 2022\. [Scalp reconstructive flaps](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Scalp+reconstructive+flaps+Craig+Cameron+Brawley%2C+Douglas+Sidle&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1749522303937&u=%2Fscholar%3Fq%3Dinfo%3APn2NjtOEyCsJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den). Plastic and Aesthetic Research, 9, pp.N-A. 6. Marathe US, Sniezek JC. [Use of the vacuum-assisted closure device in enhancing closure of a massive skull defect](https://pubmed.ncbi.nlm.nih.gov/15179195/?ref=theplasticsfella.com). Laryngoscope. 2004 Jun;114(6):961-4\. doi: 10.1097/00005537-200406000-00001\. PMID: 15179195. 7. Zens Y, Barth M, Bucher HC, Dreck K, Felsch M, Groß W, Jaschinski T, Kölsch H, Kromp M, Overesch I, Sauerland S, Gregor S. [Negative pressure wound therapy in patients with wounds healing by secondary intention](https://pubmed.ncbi.nlm.nih.gov/33038929/?ref=theplasticsfella.com): a systematic review and meta-analysis of randomised controlled trials. Syst Rev. 2020 Oct 10;9(1):238\. doi: 10.1186/s13643-020-01476-6\. PMID: 33038929; PMCID: PMC7548038. 8. Juri, J. and Valotta, M.F., 2005, May. [The use of the Juri temporo-parieto-occipital flap](https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-2005-871728?ref=theplasticsfella.com). In Seminars in Plastic Surgery(Vol. 19, No. 02, pp. 128-136). Copyright© 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001 USA.. 9. Buckingham ED, Quinn FB, Calhoun KH. [Optimal design of O-to-Z flaps for closure of facial skin defects](https://pubmed.ncbi.nlm.nih.gov/12533148/?ref=theplasticsfella.com). Arch Facial Plast Surg. 2003 Jan-Feb;5(1):92-5\. doi: 10.1001/archfaci.5.1.92\. PMID: 12533148. 10. Radovan C. [Tissue expansion in soft-tissue reconstruction](https://pubmed.ncbi.nlm.nih.gov/6484035/?ref=theplasticsfella.com). Plast Reconstr Surg. 1984 Oct;74(4):482-92\. doi: 10.1097/00006534-198410000-00005\. PMID: 6484035. 11. van Rappard JH, Sonneveld GJ, Borghouts JM. [Geometric planning and the shape of the expander](https://pubmed.ncbi.nlm.nih.gov/3078698/?ref=theplasticsfella.com). Facial Plast Surg. 1988 Jul;5(4):287-90\. doi: 10.1055/s-2008-1064765\. PMID: 3078698. 12. Steiner D, Horch RE, Eyüpoglu I, Buchfelder M, Arkudas A, Schmitz M, Ludolph I, Beier JP, Boos AM. [Reconstruction of composite defects of the scalp and neurocranium-a treatment algorithm from local flaps to combined AV loop free flap reconstruction](https://pubmed.ncbi.nlm.nih.gov/30404625/?ref=theplasticsfella.com). World J Surg Oncol. 2018 Nov 7;16(1):217\. doi: 10.1186/s12957-018-1517-0\. PMID: 30404625; PMCID: PMC6223072. 13. Brown D. [Michigan Manual of Plastic Surgery](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian) 3rd edition 2023 Oct page 223-227 14. The Plastics Fella. [Rotational flap](https://www.theplasticsfella.com/rotation-flap/). Published 2024\. Accessed on 8th June 2024 15. Hudson DA, Grob M. [Optimising results with tissue expansion: 10 simple rules for successful tissue expander insertion](https://pubmed.ncbi.nlm.nih.gov/15639357/?ref=theplasticsfella.com). Burns. 2005 Feb;31(1):1-4\. doi: 10.1016/j.burns.2004.08.008\. PMID: 15639357. ### War and Plastic Surgery, Gillies' Reconstruction, & Foundations Web Companion URL: https://www.theplasticsfella.com/june-22nd/ Last updated: 2025-06-22T11:19:15.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-22nd/#a-letter-from-pfella) Plastic surgery's bloodline. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-22nd/#the-sunday-quiz) How well do you know Wounds**?* 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-22nd/#image-of-the-week) Harold Gillies' reconstruction. 4. 📚 [****Book Review**](https://www.theplasticsfella.com/june-22nd/#book-review) The Facemaker: A Visionary Surgeon's Battle to Mend the Disfigured Soldiers of World War I. 5. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/june-22nd/#behind-the-fella) 28 days in Gaza with Ms Victoria Rose. 6. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/june-22nd/#upcoming-events) Browse what’s on or share your own. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-22nd/#articles-of-the-week) 3 recommended reads on plastic surgery and war: With 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/june-22nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Plastic Surgery's Bloodline* 👋 Plastic surgery wasn’t born in boardrooms. It was forced into existence on battlefields. From WWI trenches to Gaza today, surgeons have faced unimaginable trauma not because war inspires progress, but because someone had to restore what violence destroyed. This isn’t about glorifying conflict. It’s about honoring the people who chose to rebuild in its wake. **Surgery in the Shadow of Conflict** Sir Harold Gillies pioneered modern reconstructive surgery during WWI. In WWII, his cousin Archibald McIndoe advanced these principles, treating burned RAF pilots and helping establish the Guinea Pig Club — a community built on restoring not just faces but identity and dignity. At Valley Forge General Hospital during WWII, surgeons and medical artists reshaped the future of facial reconstruction. Though Joseph Murray's groundbreaking skin grafts came later, they laid the groundwork for the first successful organ transplant. Artists like Virginia McCall played vital roles in restoring appearance and hope through detailed facial prosthetics. Plastic surgery didn’t start with aesthetics. It started with survival. Take a look at the work Victoria Rose is doing in Gaza: > [ View this post on Instagram ](https://www.instagram.com/reel/DKfgvB1tv9w/?utm%5Fsource=ig%5Fembed&utm%5Fcampaign=loading) > > [A post shared by Dr. Victoria Rose (@rosieplasticsurgeon)](https://www.instagram.com/reel/DKfgvB1tv9w/?utm%5Fsource=ig%5Fembed&utm%5Fcampaign=loading) **Let’s Ditch the Myth** War doesn’t drive innovation. People do. McIndoe’s saline baths and McCall’s plaster masks weren’t academic experiments. They were urgent, human responses to catastrophe. Even today, surgeons in Gaza, Ukraine, and Syria innovate under extreme pressure, working with what little they have to do what must be done. These stories aren’t fringe. They’re foundational. **So, What Now?** If you’ve worked in these environments or know someone who has, we want to hear from you. Their techniques, systems, and stories matter. They shaped us once. They still can. **Would love to chat — maybe even record a super important podcast episode on this.** Let’s get these voices heard. With love, P Fella ❤️ ## The Sunday Quiz **How Well Do You Know Wounds?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. Tackle one question per week for seven rounds! The ****top** scorer wins a copy of our upcoming textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). ## Image of the Week **Harold Gillies Reconstruction* 🖼️ ****Image of the Week** This week’s image features an early and foundational example of facial reconstruction by Sir Harold Gillies, often regarded as the “**father of plastic surgery*.” It demonstrates staged surgical repair using a ****pedicled tubed flap**, a cornerstone technique that paved the way for modern reconstructive surgery. ![Harold Gillies Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/image-2.png) Harold Gillies Reconstruction - [Source](https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/abs/sir-harold-delf-gillies-the-otolaryngologist-and-father-of-modern-facial-plastic-surgery-review-of-his-rhinoplasty-case-notes/8C53320757FC829CF4268B677CD5C67A?ref=theplasticsfella.com) ## Book Review **The Facemaker: A Visionary Surgeon's Battle to Mend the Disfigured Soldiers of World War I* 📚 **Not exactly a review this week; just a strong recommendation!* ****The Facemaker: A Visionary Surgeon's Battle to Mend the Disfigured Soldiers of World War I** explores the incredible life and innovations of Harold Gillies, one of the most influential pioneers in plastic and reconstructive surgery. If you’re looking to dive deeper into the history of our specialty, this is a must-read. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/image-3.png) [Amazon.com![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/faviconV2-1)](https://a.co/d/b05TpSw?ref=theplasticsfella.com) ## Behind the 'Fella **28 Days in Gaza with Ms Victoria Rose* 🎧 ****28 Days in Gaza** Catch up on our episode with Victoria Rose reporting from Gaza. Victoria shares powerful, firsthand experiences from the frontlines of humanitarian surgery, offering an insightful and eye-opening perspective on the experiences of healthcare workers in conflict zones. **What’s it like to handle complex trauma and reconstructive cases in such challenging conditions?* **How do surgeons manage under intense pressure and with limited resources?* Listen now on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/28-days-in-gaza-with-ms-victoria-rose-surgery/id1746377600?i=1000674637339&ref=theplasticsfella.com). 0:00 /0:54 1× 28 Days in Gaza with Ms Victoria Rose ## Upcoming Events **Browse What’s on or Share Your Own* 📅 ****Here you’ll find the latest webinars, courses, and conferences that matter to plastic surgeons — all in one place.** Have an event of your own? Doesn't matter if it's a small journal club or a national meeting, we’re happy to have it on our calendar! This page is here to help the whole community stay connected. Explore our recommendations or submit your event below 👇 ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Scope of Plastic Surgery in Modern Military Conflicts** ([Fox](https://academic.oup.com/milmed/article/186/3-4/e327/5989495?ref=theplasticsfella.com), 2021) Most combat-related reconstructions, including microsurgery for extremity and craniofacial injuries, are performed at Role 4/5 facilities, highlighting the need for military plastic surgeons to maintain broad reconstructive expertise. ✅ ****Surgical Innovation at Bangour During WWII** ([Stewart](https://www.sciencedirect.com/science/article/pii/S1748681521000450?ref=theplasticsfella.com), 2021) Early reconstructive work at Scotland’s Bangour Unit (1941–42) reveals foundational plastic surgery techniques, including cross-leg flaps, forehead flaps, and lymphatic reconstruction guided by Gillies’ mentorship and principles still reflected in modern practice. ✅ ****Wartime as a Catalyst for Surgical Progress** ([Stark](https://www.sciencedirect.com/science/article/abs/pii/S0094129820302674?ref=theplasticsfella.com), 1975) Conflicts from antiquity to WWII drove major advances in reconstructive surgery, with wartime innovation shaping the foundations of modern plastic surgery practice. ## Feedback ### I hope you enjoyed it 😄 --- ### AI Replaces Dermatology, Benign Lesions & Diagnostic Tips. URL: https://www.theplasticsfella.com/june-15th/ Last updated: 2025-06-14T20:18:10.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-15th/#a-letter-from-pfella) Support your local dermatologist — they’re about to be replaced. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-15th/#the-sunday-quiz) How well do you know **Lipoma*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-15th/#image-of-the-week) Identifying Seb K (with a syndrome) 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/june-15th/#technique-tip) Dermoscopy: Sebaceous hyperplasia vs BCC. 5. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/june-15th/#jpras-journal-club) A 20-year overview of upper limb nec fasc in England. 6. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/june-15th/#upcoming-events) This calendar isn’t just ours, it’s yours too! 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-15th/#articles-of-the-week) PRS CME on benign lesions, graft vs flap, & don't punch biopsy a pigmented lesion: with 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/june-15th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Support Your Local Dermatologist — They’re About to Be Replaced* 👋 Let’s be honest: Dermatologists who don’t operate are on borrowed time. The AI bots are here, they’re clinically safe (ish), and most importantly… they’re **cheap*. The NHS is already trialling them to triage skin lesions. Five minutes per mole. No complaints, no clinics running late, no pre-coffee tantrums. And unlike your derm mate, the algorithm doesn’t mind reviewing 400 seborrhoeic keratoses a day. **This Is a Layoff Letter, Lightly Wrapped in ‘Innovation’** We dress it up as “augmenting clinical care,” but let’s not kid ourselves. It’s about cost and convenience. If you don’t operate, you are, in the eyes of the system, replaceable. Not next year. Now. First, it’s derm. Then maybe path. Then radiology (unless they touch a needle). It’s not a wave, it’s a quiet restructuring. And the bots don’t need office space. **Second-Order Effect: Hands-On Jobs Just Got More Competitive** Here’s the twist nobody’s talking about: when non-operative specialties get hollowed out, guess where all those smart, ambitious doctors will pivot? Yep, surgery. Plastics. Hands-on work. The stuff AI can’t touch YET... That’s more CVs. More competition. More people scrubbing in who weren’t even *in the room* two years ago. **Takeaway** If you work with your hands, you’re safe... for now. But don’t relax. The floodgates are opening, and the OR is about to get crowded. With love, Support your derm colleagues. Give them a smile. Maybe lend them a suture kit. P Fella ❤️ ## The Sunday Quiz **How Well Do You Know Lipoma* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. Tackle one question per week for seven rounds! The ****top** scorer wins a copy of our upcoming textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). ## Image of the Week **Identifying Seb K* 🖼️ ****Image of the Week** This week’s image highlights seborrhoeic keratoses (Seb K) — benign, pigmented lesions with a characteristic “stuck-on” appearance. Often mistaken for melanoma, they can appear in large numbers in older adults and occasionally erupt suddenly (Leser–Trélat sign), warranting further investigation. ![Identifying Seborrhoeic Keratoses](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/images--4--1.jpeg) Identifying Seborrhoeic Keratoses ## Technique Tip Dermoscopy: Sebaceous Hyperplasia vs BCC 🚑 ****Technique Tip of the Week** Look for crown vessels: Groups of bending, scarcely branching vessels extending toward the center without crossing it. This pattern is classic for ****sebaceous hyperplasia**, helping distinguish it from ****BCC**, which shows arborising vessels and lacks this central symmetry. ![Dermoscopy: Sebaceous Hyperplasia vs BCC](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/SHcrown1.png) Dermoscopy: Sebaceous Hyperplasia vs BCC ## JPRAS Journal Club A 20-Year Overview of Upper Limb Nec Fasc in England 📑 ****Summary: Upper limb necrotising fasciitis** cases tripled between 1998 and 2013, and then flatlined. Most patients were healthy, working-age men from deprived areas. Despite surgery, 16% didn’t survive past 90 days. 👉 ****The takeaway?** Recognise early. Act fast. 📚 This large UK study (728 patients) sheds light on who gets upper limb NF and why prompt intervention is still our best shot. 🔍 Read the full Journal Club breakdown below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Your-paragraph-text--5-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Your-paragraph-text--6-.png) Journal Club: Upper Limb Necrotising Fasciitis [Read the Article](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/) ## Upcoming Events **This Calendar Isn’t Just Ours, It’s Yours Too!* ![Upcoming Events Calendar](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Your-paragraph-text--4--1.png) Upcoming Events Calendar 📅 ****Looking for webinars, courses, or upcoming conferences in plastic surgery?** You’ll find them here — all curated to be practical, relevant, and genuinely useful. 📣 ****Running something yourself?** Your next journal club, teaching session, or hands-on course, we’d love to feature it. Because this calendar isn’t just ours, it’s yours too. See what’s coming up, or submit your own event below: ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****How Should Plastic Surgeons Approach Skin Lesions?** ([Lee](https://journals.lww.com/plasreconsurg/abstract/2010/05000/benign%5Fand%5Fpremalignant%5Fskin%5Flesions.31.aspx?ref=theplasticsfella.com), 2010) Benign and premalignant skin lesions require careful clinical and histologic assessment to determine when surgical treatment is necessary. ✅ ****Grafts or Flaps for Facial Skin Cancer?** ([Faenza](https://pubmed.ncbi.nlm.nih.gov/39308747/?ref=theplasticsfella.com), 2024) Local flaps offer better cosmetic and functional outcomes than skin grafts for facial reconstruction after non-melanoma skin cancer surgery. ✅ ****The Pitfalls of Punch Biopsies in Melanoma** ([Lorusso](https://pubmed.ncbi.nlm.nih.gov/15748548/?ref=theplasticsfella.com), 2005) Incisional biopsies can misjudge melanoma depth, leading to flawed staging and potentially misguided treatment decisions. ## Feedback ### I hope you enjoyed it 😄 --- ### Special Edition: Sub-Internships and Electives in Plastic Surgery URL: https://www.theplasticsfella.com/june-8th/ Last updated: 2025-06-08T08:10:22.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-8th/#a-letter-from-pfella) Are sub-internships education or a job interview? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-8th/#the-sunday-quiz) How well do you know TENS? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-8th/#image-of-the-week) How to design a rotation flap. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/june-8th/#technique-tip) Know your dressings. 5. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/june-8th/#jpras-journal-club) How much does a sub-internship actually cost? 6. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/june-8th/#upcoming-events) We welcome contributions from you! 7. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/june-8th/#foundations-textbook) Help us decide what’s next. 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-8th/#articles-of-the-week) Perspectives of sub-I, influences to pursue plastic surgery, & what attendees think of students: with 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/june-8th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Are Sub-Internships Education or a Job Interview?* 👋 Let’s be real. Sub-internships might look like learning experiences on paper, but in practice, they often feel more like ****auditions**. Especially in plastic surgery. We ask students, many of whom have barely seen a scalpel, to fly across the country, pay a small fortune in fees, juggle clunky admin systems, and then quietly perform under pressure while never appearing too eager. And somehow, we still call that education. It’s a system built on vibe checks, whispers, and quietly shifting expectations. **Have We Turned Electives Into Gatekeeping?** These rotations aren’t always about clinical growth. They’re often silent interviews with invisible rules. The best-prepared student tends to stand out. Not necessarily the most promising one. What did you learn on your Sub-I or elective? **Let’s Not Confuse Testing With Teaching** We’ve accepted this setup for too long. And now we act surprised when burnout begins before residency even starts. The students aren’t the problem. The system is. We’re launching a Sub-I Survival Guide to help students find their footing. **Want early access?** Drop your name, email, and location below. With love (and a gentle wink), P Fella ❤️ ps - check out this now blog post on [Sub-Is](https://www.theplasticsfella.com/10-essential-tips-to-prepare-for-your-plastic-surgery-sub-internship-sub-i/). ## The Sunday Quiz **How Well Do You Know TENS?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. Tackle one question per week for seven rounds! The ****top** scorer wins a copy of our upcoming textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). ## Image of the Week **How to Design a Rotation Flap* 🖼️ ****Image of the Week** This week’s image highlights the design of a ****rotation flap** for a lateral cheek squamous cell carcinoma excision. The flap is drawn with its apex positioned superior to the lateral canthus, ensuring tension redistribution and natural vector alignment. A back-cut may be added if needed to facilitate rotation and minimize dog-ear formation. This AI-generated diagram demonstrates key planning principles, ideal for those brushing up on facial flap design. ![How to Design a Rotation Flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/image.png) How to Design a Rotation Flap ## Technique Tip **Know Your Dressings* 🚑 ****Technique Tip of the Week** This week’s tip focuses on matching wound characteristics to the right dressing strategy. From dry eschar to exudative wounds, choosing the appropriate dressing improves healing outcomes, prevents complications, and supports tissue regeneration. This breakdown gives you a quick reference for clinical decision-making — perfect for ward rounds, on-calls, and OSCE prep. ![Know Your Dressings](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/image-1.png) Know Your Dressings ## JPRAS Journal Club **How Much Does a Sub-Internship Actually Cost?* 🎓 ****How Much Does a Sub-Internship Actually Cost?** This JPRAS Journal Club review uncovers the true financial burden of plastic surgery sub-internships, especially for international applicants. 📊 The Inequity in Numbers: \- IMGs pay 17x more than US students. \- Median cost for \~4.5 rotations: $9,114 for IMGs vs $410 for US students. \- IMGs also face 80% fewer program opportunities. It’s a wake-up call for the system, and a must-read for any student planning their path to residency. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/How-much-does-a-sub-internship-actually-cost---Journal-Club--1-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/How-much-does-a-sub-internship-actually-cost---Journal-Club.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/How-much-does-a-sub-internship-actually-cost---Journal-Club--2-.png) How Much Does a Sub-Internship Actually Cost? [Read the Article](https://www.theplasticsfella.com/journal-sub-internships/) ## Upcoming Events **We Welcome Contributions from You!* 📅 ****Looking for upcoming webinars, courses, or conferences?** We keep the calendar updated with events that are practical, relevant, and worth your time. If you're running something yourself, whether it's a teaching session, journal club, or surgical course, you can submit it too. We welcome contributions from the community. 👇 Check out what’s coming up, or add your own event below: ## Foundations Textbook **Help Us Decide What’s Next* 📙 With our June update, we’re getting close to finishing the chapters for [Foundations](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). As we prepare for print, we’re deciding between two formats: ****hard cover** or ****soft cover**. In your bag, on your desk, or next to you in theatre: ****Which format would you prefer?** 🗳️ Cast your vote below! ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Are Plastic Surgery Sub-Is Fairly Judged?** ([Qiu](https://www.sciencedirect.com/science/article/abs/pii/S1931720420303706?ref=theplasticsfella.com), 2021) Program directors say letters matter more than actual performance, meaning who writes your recommendation may matter more than how you perform. ✅ ****What Influences Students to Pursue Plastic Surgery?** ([Glynou](https://www.jprasopen.com/article/S2352-5878%2824%2900052-4/fulltext?ref=theplasticsfella.com), 2024) Social media is the strongest influence shaping medical students’ interest in plastic surgery, more than formal teaching or personal experience. ✅ ****What Do Attendees Think of Students Interested in Plastic Surgery?** ([Oliver](https://academic.oup.com/asj/article-abstract/39/5/NP159/5373028?redirectedFrom=fulltext&ref=theplasticsfella.com), 2019) Senior surgeons view early student participation at aesthetic meetings as a sign of strong commitment and a smart career move in a competitive specialty. ## Feedback ### I hope you enjoyed it 😄 --- ### 10 Essential Tips to Prepare for Your Plastic Surgery Sub-Internship (Sub-I) URL: https://www.theplasticsfella.com/10-essential-tips-to-prepare-for-your-plastic-surgery-sub-internship-sub-i/ Last updated: 2025-06-06T07:06:29.000Z --- #### ****1\. Fail to Prepare and Prepare to Fail: Master the VSLO Application Early and Completely** VSLO **(Visiting Student Learning Opportunities)* is your gateway to ‘most’ away rotations. Prepare and upload your documents early and meticulously. - Craft a tailored ****personal statement** specific to plastic surgery. - Update your ****CV** thoroughly, highlighting relevant USMLE step scores, clerkship grades, presentations, awards, research, and extracurriculars. - Secure a strong ****letter of recommendation** early; consider mentors familiar with your research, clinical skills, and dedication to plastic surgery. - Ensure your immunization records, Step 1 completion, and certification (BLS/ACLS) are readily available and up-to-date. - The steps are: ****CV → Personal Statement → LOR → Upload** **Double-check all submissions to avoid delays due to missing documentation or minor errors.* **For a detailed step-by-step guide, refer to the full handbook.* #### ****2\. Strategically Select Away Rotations** Choose rotations with clear ****goals** in mind: - If you are interested in specific residency programs, prioritize rotations at these institutions. - Mix rotations at prestigious academic centers and smaller programs where your performance might stand out more distinctly. - Plan geographically diverse rotations to signal your willingness and ability to relocate for residency. #### 3\. Administrative Preparations: Smooth Out Logistical Hurdles - Complete all required training modules and hospital onboarding early. - Actively communicate with IT departments to guarantee EHR access from day one. - Keep a detailed checklist of completed administrative tasks and proactively address any potential issues. **The handbook provides an extensive administrative checklist to ensure nothing slips through the cracks.* #### ****4\. Early Connection with Residents: Gather Insightful Information** Contact junior residents **(if possible)* ahead of your rotation to clarify: - Specific daily schedules, rounds times, and expectations for Sub-Is. - Preferences and quirks of attendings or senior residents you will work with. - The exact expectations regarding dress code in different clinical settings. #### ****5\. Roles Change Along the Journey: Clearly Understand and Execute Your Role as a Sub-Intern** You will essentially function as an intern: - Take ownership of patient lists, daily notes, and updates. - Prepare thoroughly for surgical procedures by reviewing patient history, indications, and procedural steps beforehand. - Proactively anticipate team needs (e.g. pre-rounding preparations, dressing changes, patient positioning in the OR). - Always be ready to assist in procedures or with patient care tasks without needing explicit instructions repeatedly. **Refer to the handbook for the three A’s.* #### 6\. Optimize Your Study Techniques and Resources Prioritize efficient, high-yield resources: - ****Handbooks:** Keep the Michigan Manual or Essentials of Plastic Surgery with you for quick reviews. - ****Online Platforms:** Regularly utilize The Plastics Fella, StatPearls or Microsurgeon.org for focused, concise refreshers. - ****Videos:** Frequently watch concise anatomy and procedure tutorials (e.g. Susan Mackinnon’s YouTube channel). **Create structured digital notes organized by categories (hand, craniofacial, microsurgery) for rapid review before each case.* **Full resource recommendations are extensively covered in the handbook.* #### 7\. Develop and Refine Surgical Skills Beforehand Sharpen practical skills in advance: - Practice various suturing techniques (simple interrupted, running subcuticular). - Master basic knot-tying under timed conditions. - Rehearse surgical instrument handling to demonstrate familiarity and comfort in the OR setting. - Remember, you do not need to be an expert on day 1 of your first sub-I. #### 8\. Professionalism: Maintain High Standards at All Times - Always dress neatly and professionally, tailored to the situation (clinic vs. OR). - Avoid discussing sensitive or controversial topics even if the residents are. - Maintain a polite, respectful demeanour towards all staff, from administrative personnel to attendings. - Clearly communicate your busy schedule and limited availability to family and friends to set realistic expectations during your rotation. #### 9\. Network Effectively with Program Leadership - Proactively arrange professional meetings with the Program Director, Chair, or other senior leaders. - Prepare concise, informed questions and clearly articulate your professional goals and how the program aligns with them. - Use email scheduling to ensure timely. #### 10\. Collaborate, Don't Compete: Foster Strong Team Dynamics - Build supportive relationships with fellow Sub-Is; coordinate roles and tasks to enhance team efficiency. It is not a zero sum game. - Demonstrate teamwork clearly and positively, as this directly reflects on your professional maturity and residency readiness. - Avoid behaviors that undermine teammates; instead, actively seek opportunities to help peers shine. --- ## ****Final Thoughts** Remember, your sub-I is essentially an extended residency interview. Prioritize plastic surgery wholeheartedly, prepare thoroughly in advance, stay professional, and use your time strategically to maximize your chances of success. For an in-depth exploration of each of these areas and further insights to navigate your plastic surgery sub-I, reference the comprehensive handbook authored by Michael Edgar for The Plastics Fella. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Modern-Minimal-Step-by-Step-Project-Checklist.png) --- 🧑‍⚕️ ****About the Author:** Michael Edgar is a medical student at the University of Illinois College of Medicine and Educational Fellow at The Plastics Fella. He leads the Plastic Surgery Medical Student Textbook and Anki Flashcard Project, creating open-access, evidence-based resources for aspiring plastic surgeons. ### Toxic Epidermal Necrolysis (TEN): Risk Factors, Clinical Features, & Management URL: https://www.theplasticsfella.com/toxic-epidermal-necrolysis-ten/ Last updated: 2025-06-04T11:24:34.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/toxic-epidermal-necrolysis-ten/#overview-of-toxic-epidermal-necrolysis) TEN is a severe dermatologic condition involving >30% TBSA, characterized by extensive skin and mucosal detachment, with high morbidity and mortality. [****Pathophysiology**](https://www.theplasticsfella.com/toxic-epidermal-necrolysis-ten/#pathophysiology-of-toxic-epidermal-necrolysis) TEN is a drug-triggered, T-cell-mediated type IV hypersensitivity reaction that leads to widespread keratinocyte apoptosis and full-thickness epidermal necrosis. [****Risk Factors**](https://www.theplasticsfella.com/toxic-epidermal-necrolysis-ten/#risk-factors-of-toxic-epidermal-necrolysis) Drug-induced cases dominate, with triggers like antibiotics, antiepileptics, NSAIDs, and allopurinol. Risk factors include genetic predisposition, HIV, and polypharmacy. [****Clinical Features**](https://www.theplasticsfella.com/toxic-epidermal-necrolysis-ten/#clinical-features-of-toxic-epidermal-necrolysis) TEN presents with fever, malaise, painful erythematous macules, blisters, and mucosal erosions, often leading to multiorgan dysfunction. [****Differential Diagnosis**](https://www.theplasticsfella.com/toxic-epidermal-necrolysis-ten/#differential-diagnosis-of-toxic-epidermal-necrolysis) Conditions mimicking TEN, such as SSSS and drug-induced linear IgA dermatosis, must be excluded to guide treatment. [****Management**](https://www.theplasticsfella.com/toxic-epidermal-necrolysis-ten/#management-of-toxic-epidermal-necrolysis) Focuses on discontinuing causative drugs, supportive care, fluid replacement, and wound care, with adjunct therapies like IVIG and cyclosporine as potential options. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Toxic Epidermal Necrolysis ****Key Point** TEN is a life-threatening dermatologic emergency characterized by widespread epidermal and mucosal detachment, with high morbidity and mortality. Toxic epidermal necrolysis (TEN) and Stevens-Johnson Syndrome (SJS) are immunologically driven conditions on the same disease spectrum. Both result from keratinocyte apoptosis, typically triggered by medications. The extent of skin detachment (TBSA) defines severity and guides classification ([Harris](https://www.mdpi.com/1422-0067/17/12/2135?ref=theplasticsfella.com), 2016; [Schwartz](https://www.sciencedirect.com/science/article/abs/pii/S0190962213005100?ref=theplasticsfella.com), 2013). This is explained in the table below. ![The extent of skin detachment (TBSA)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Main-Article-Images---2025-06-04T164653.847.png) The extent of skin detachment (TBSA) IMPORTANT Erythema Multiforme Major is no longer considered part of this spectrum, as it has a distinct pathogenesis. ![Epidermal sloughing, toxic epidermal necrolysis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-05T151954.767.png) Extensive epidermal detachment in a patient with toxic epidermal necrolysis. Despite sharing the same underlying mechanism, TEN is far deadlier than SJS due to greater skin loss and systemic complications. 😎 ****Fun Fact:** SJS and TEN share the same pathological process, but TEN has a higher mortality (25–50%). --- ## Pathophysiology of Toxic Epidermal Necrolysis ****Key Point** TEN is a drug-triggered, T-cell-mediated type IV hypersensitivity reaction that leads to widespread keratinocyte apoptosis and full-thickness epidermal necrosis. Toxic epidermal necrolysis results from an immune-mediated cytotoxic assault on the skin, triggered primarily by certain medications. The process is orchestrated by activated T lymphocytes and natural killer (NK) cells, leading to massive epidermal cell death and skin detachment. Despite understanding the key pathways, the precise mechanism by which specific drugs initiate this cascade remains unclear. **Immune Mechanisms** TEN is driven by cytotoxic immune cells that directly induce keratinocyte death. - **Granulysin:** A major mediator released by CD8+ T cells and NK cells that causes direct keratinocyte apoptosis. - **Perforin/Granzyme B:** Cytotoxic proteins released by CD8+ T cells that enter target cells and trigger programmed cell death. - **Fas–Fas Ligand Interaction:** Fas ligand on immune cells binds to Fas receptors on keratinocytes, initiating extrinsic apoptosis ([Pereira](https://pubmed.ncbi.nlm.nih.gov/17224365/?ref=theplasticsfella.com), 2007; [Kinoshita](https://pubmed.ncbi.nlm.nih.gov/28133001/?ref=theplasticsfella.com), 2016). **Apoptosis Pathways** Keratinocyte apoptosis in TEN occurs via intrinsic and extrinsic mechanisms. - **Intrinsic Pathway:** Triggered by mitochondrial damage and oxidative stress, leading to caspase activation. - **Extrinsic Pathway:** Involves death receptors (e.g., Fas, TNF-α) on keratinocytes initiating apoptosis via downstream signaling cascades ([Kinoshita](https://pubmed.ncbi.nlm.nih.gov/28133001/?ref=theplasticsfella.com), 2016). **Histopathology** Microscopic analysis reveals hallmark features of epidermal destruction. - **Full-Thickness Epidermal Necrosis:** A defining histological feature of TEN. - **Subepidermal Blistering:** Separation between dermis and epidermis due to extensive cell death. - **Minimal Dermal Inflammation:** Despite severe epidermal damage, the dermis typically shows sparse inflammatory infiltrates ([Harris](https://www.mdpi.com/1422-0067/17/12/2135?ref=theplasticsfella.com), 2016). TEN is initiated by immune activation, primarily CD8+ T cells and NK cells, which target keratinocytes through direct cytotoxic mechanisms. The resulting cell death leads to rapid epidermal detachment and mucocutaneous injury. The exact mechanism by which the triggering agent activates the proposed pathways remains unclear. --- ## Risk Factors of Toxic Epidermal Necrolysis ****Key Point** Drug-induced cases dominate, triggered within the first 8 weeks of therapy. Genetic predisposition, comorbidities, and polypharmacy amplify risk. TEN is most often drug-induced, with causative agents typically identified within 1-3 weeks of initiating therapy. Non-drug causes are rare but significant, especially in children. **Drug Causes** - **Antibiotics:** Sulfonamides, macrolides, penicillins, quinolones. - **Antiepileptics:** Phenytoin, carbamazepine, lamotrigine. - **NSAIDs:** Oxicam derivatives. - **Allopurinol:** Common in gout management. **Non-Drug Causes** - Viral infections (e.g., herpes, Mycoplasma pneumoniae). - Post-vaccination reactions. - Organ transplantation. ### Risk Factors - **Genetic Predisposition:** HLA-B1502 and HLA-A3101 (high prevalence in Southeast Asians). - **Medical Conditions:** HIV, autoimmune diseases, malignancies. - **Polypharmacy:** Increases difficulty in identifying causative agents. 💡 ****Tip:** A causal link is often established when TEN occurs 1-3 weeks after starting a new medication. --- ## Clinical Features of Toxic Epidermal Necrolysis ****Key Point** TEN begins with flu-like symptoms and rapidly progresses to painful skin detachment, mucosal erosions, and systemic involvement, often resulting in multi-organ failure. TEN presents with a distinct progression: a short prodromal phase followed by extensive cutaneous and mucosal damage, with high risk for sepsis and organ dysfunction. Prompt recognition of these signs is critical for early diagnosis and supportive care. **Prodromal Phase** Fever, malaise, sore throat, cough, myalgia, and arthralgia typically appear 1–3 days before skin involvement ([Schwartz](https://www.sciencedirect.com/science/article/abs/pii/S0190962213005100?ref=theplasticsfella.com), 2013). **Cutaneous Findings** - **Pain**: Severe skin pain often precedes visible blistering and is initially out of proportion to skin findings ([Pereira](https://pubmed.ncbi.nlm.nih.gov/17224365/?ref=theplasticsfella.com), 2007). - **Macules**: Painful erythematous macules with purpuric centers, starting on the face and trunk. - **Bullae**: Lesions coalesce into flaccid bullae and large sheets of epidermal detachment (>30% TBSA). - **Nikolsky’s sign:** Positive (epidermal sloughing with gentle pressure) ([Gerull](https://journals.lww.com/ccmjournal/abstract/2011/06000/toxic%5Fepidermal%5Fnecrolysis%5Fand%5Fstevens%5Fjohnson.41.aspx?ref=theplasticsfella.com), 2011). **Mucosal Involvement (>90% of cases)** - **Oral/lips:** Cheilitis, painful ulcers, stomatitis. - **Eyes:** Conjunctivitis, corneal ulcers, anterior uveitis. - **Genital/urinary tract:** Erosions, ulcers, dysuria, urinary retention. - **Respiratory tract:** Tracheobronchial erosions causing cough, respiratory distress. - **Gastrointestinal tract:** Diarrhoea and mucosal damage. **Systemic Manifestations** - **Renal:** Hypoperfusion, acute tubular necrosis. - **Pulmonary:** Respiratory compromise from mucosal sloughing and secondary infection. - **Gastrointestinal:** Diarrhoea, malabsorption, mucosal necrosis ([Harris](https://www.mdpi.com/1422-0067/17/12/2135?ref=theplasticsfella.com), 2016). - **Sepsis:** Common and often fatal, due to loss of skin barrier and immune suppression. Typical cutaneous findings in the early stages of toxic epidermal necrolysis are illustrated below. ![Toxic epidermal necrolysis, macules](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-05T151856.677-1.png) Typical cutaneous findings in early stages of toxic epidermal necrolysis ### Investigations Laboratory and histological tests aid in diagnosis and monitoring complications. - **Blood Tests:** CBC, renal and liver panels, CRP/ESR, albumin, and autoantibodies. - **Typical Findings:** Lymphopenia, anaemia, hypoalbuminaemia ([Gerull](https://journals.lww.com/ccmjournal/abstract/2011/06000/toxic%5Fepidermal%5Fnecrolysis%5Fand%5Fstevens%5Fjohnson.41.aspx?ref=theplasticsfella.com), 2011). - **Histopathology:** Full-thickness epidermal necrosis, subepidermal bullae ([Harris](https://www.mdpi.com/1422-0067/17/12/2135?ref=theplasticsfella.com), 2016). - **Direct Immunofluorescence:** Negative for IgG and C3, ruling out autoimmune blistering disorders ([Harris](https://www.mdpi.com/1422-0067/17/12/2135?ref=theplasticsfella.com), 2016). ### Severity Score for TENS The SCORTEN (Severity-of-Illness Score for Toxic Epidermal Necrolysis) evaluates seven independent risk factors within the first 24 hours of hospital admission to estimate a patient's mortality risk ([Bastuji-Garin](https://doi.org/10.1046/j.1523-1747.2000.00061.x?ref=theplasticsfella.com), 2000). The table below summarizes this scoring system. ![Severity-of-Illness Score for Toxic Epidermal Necrolysis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-05T153427.175.png) Severity-of-Illness Score for Toxic Epidermal Necrolysis --- ## Differential Diagnosis of Toxic Epidermal Necrolysis ****Key Point** Accurate and timely differentiation from clinically similar conditions is essential, especially in children, to avoid mismanagement and ensure appropriate care. TEN can mimic several dermatologic disorders that also present with widespread blistering or skin detachment. Distinguishing features such as mucosal involvement, depth of epidermal damage, and histologic findings help clarify the diagnosis. Conditions with overlapping clinical features must be carefully excluded using history, physical examination, and diagnostic tests. **Staphylococcal Scalded Skin Syndrome (SSSS)** - Primarily affects neonates and young children. - Caused by exfoliative toxins from *Staphylococcus aureus*. - Features superficial epidermal cleavage and lacks mucosal involvement ([Schwartz](https://www.sciencedirect.com/science/article/abs/pii/S0190962213005100?ref=theplasticsfella.com), 2013). - Triggered by infection rather than drugs ([Pereira](https://pubmed.ncbi.nlm.nih.gov/17224365/?ref=theplasticsfella.com), 2007). **Drug-Induced Linear IgA Dermatosis** - Presents with bullous lesions and annular erythema. - Direct immunofluorescence shows linear IgA deposition at the dermoepidermal junction ([Harris](https://www.mdpi.com/1422-0067/17/12/2135?ref=theplasticsfella.com), 2016). **Acute Generalized Exanthematous Pustulosis (AGEP):** - Sudden eruption of non-follicular sterile pustules. - Minimal epidermal necrosis and mucosal involvement. - Resolves quickly upon withdrawal of the causative drug ([Schwartz](https://www.sciencedirect.com/science/article/abs/pii/S0190962213005100?ref=theplasticsfella.com), 2013). **Graft-versus-Host Disease (GVHD):** - Occurs after hematopoietic stem cell transplantation. - Skin findings may resemble TEN but usually include lichenoid or sclerodermoid changes. - Often accompanied by systemic signs of graft rejection. **Erythema Multiforme Major (EM Major):** - Target lesions with limited mucosal involvement. - Commonly triggered by infections (e.g. herpes simplex virus). - Considered a distinct condition, not part of the SJS/TEN spectrum ([Pereira](https://pubmed.ncbi.nlm.nih.gov/17224365/?ref=theplasticsfella.com), 2007). 😎 ****Fun Fact:** Erythema multiforme major typically presents with classic “target” lesions, while TEN involves extensive epidermal detachment with blisters forming on flat, purpuric macules—mainly on the trunk and face. Mucosal involvement is also a key distinguishing factor. --- ## Management of Toxic Epidermal Necrolysis ****Key Point** Management is primarily supportive, focusing on wound care and preventing complications. Therapeutic strategies focus on supportive measures until skin regeneration occurs, alongside emerging adjunct therapies. 1. **Initial Steps** - Immediate discontinuation of the offending drug. - Transfer to a burn or intensive care unit (reduces risk of infection, mortality, and length of stay) ([Schwartz](https://www.sciencedirect.com/science/article/abs/pii/S0190962213005100?ref=theplasticsfella.com), 2013). 1. **Supportive Care** - Aggressive fluid and electrolyte replacement guided by central venous pressure and urine output. - Nutritional support via enteral feeding. - Pain management. - Non-adherent dressings with daily wound care ([Gerull](https://journals.lww.com/ccmjournal/abstract/2011/06000/toxic%5Fepidermal%5Fnecrolysis%5Fand%5Fstevens%5Fjohnson.41.aspx?ref=theplasticsfella.com), 2011). - Plasmapheresis to clear offending drug and active metabolites. 1. **Specific Therapies** - **IVIG within 72 hours of bulla onset:** Blocks Fas-mediated keratinocyte apoptosis; efficacy remains debated ([Schwartz](https://www.sciencedirect.com/science/article/abs/pii/S0190962213005100?ref=theplasticsfella.com), 2013). - **Cyclosporine:** Reduces T-cell activation, with emerging evidence supporting its use ([Hoetzenecker](https://pubmed.ncbi.nlm.nih.gov/27239294/?ref=theplasticsfella.com), 2016). - **Corticosteroids:** Controversial; may benefit early-stage TEN, but some studies have shown steroids to increase mortality ([Avakian](https://pubmed.ncbi.nlm.nih.gov/1880257/?ref=theplasticsfella.com), 1991). 1. **Rehabilitation** - Encourage early mobilization. - Involve physiotherapists and occupational therapists. 😎 ****Fun Fact:** Since these patients are usually managed in a Burns unit, plastic surgeons are involved in their care, ranging from wound care to debridement of areas of skin necrosis as indicated. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition and Severity:** TEN is a life-threatening dermatologic condition with >30% skin detachment, extensive mucosal involvement, and high mortality (25–50%). ****2\. Pathophysiology:** TEN results from T-cell-mediated keratinocyte apoptosis, driven by granulysin, perforin, and Fas-Fas ligand interactions. ****3\. Risk Factors and Triggers:** Drugs like sulfonamides, antiepileptics, and NSAIDs are common triggers, with genetic predisposition and HIV increasing risk. ****4\. Clinical Features and Diagnosis:** Painful skin detachment, positive Nikolsky’s sign, and mucosal erosions confirm TEN, with histology showing full-thickness epidermal necrosis. ****5\. Management:** Supportive care (fluid replacement, wound care) is essential, with adjuncts like IVIG or cyclosporine; corticosteroids remain controversial. ****6\. Differentiation and Prognosis:** TEN requires differentiation from SSSS and erythema multiforme; early intervention improves outcomes in specialized care units. --- ## Further Reading 1. Harris, Victoria, Christopher Jackson, and Alan Cooper. "[Review of toxic epidermal necrolysis.](https://www.mdpi.com/1422-0067/17/12/2135?ref=theplasticsfella.com)" *International Journal of Molecular Sciences* 17.12 (2016): 2135. 2. Schwartz, Robert A., Patrick H. McDonough, and Brian W. Lee. "[Toxic epidermal necrolysis: Part I. Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis](https://www.sciencedirect.com/science/article/abs/pii/S0190962213005100?ref=theplasticsfella.com)." *Journal of the American Academy of Dermatology* 69.2 (2013): 173-e1. 3. Gerull, Roland, Mathias Nelle, and Thomas Schaible. "[Toxic epidermal necrolysis and Stevens-Johnson syndrome: a review.](https://journals.lww.com/ccmjournal/abstract/2011/06000/toxic%5Fepidermal%5Fnecrolysis%5Fand%5Fstevens%5Fjohnson.41.aspx?ref=theplasticsfella.com)" *Critical care medicine* 39.6 (2011): 1521-1532. 4. Avakian R, Flowers FP, Araujo OE, Ramos-Caro FA. [Toxic epidermal necrolysis: a review](https://pubmed.ncbi.nlm.nih.gov/1880257/?ref=theplasticsfella.com). J Am Acad Dermatol. 1991 Jul;25(1 Pt 1):69-79\. doi: 10.1016/0190-9622(91)70176-3\. PMID: 1880257. 5. Pereira FA, Mudgil AV, Rosmarin DM. [Toxic epidermal necrolysis](https://pubmed.ncbi.nlm.nih.gov/17224365/?ref=theplasticsfella.com). J Am Acad Dermatol. 2007 Feb;56(2):181-200\. doi: 10.1016/j.jaad.2006.04.048\. PMID: 17224365. 6. Kinoshita Y, Saeki H. [A Review of the Pathogenesis of Toxic Epidermal Necrolysis](https://pubmed.ncbi.nlm.nih.gov/28133001/?ref=theplasticsfella.com). J Nippon Med Sch. 2016;83(6):216-222\. doi: 10.1272/jnms.83.216\. PMID: 28133001. 7. Bastuji-Garin, S., Fouchard, N., Bertocchi, M., Roujeau, J. C., Revuz, J., & Wolkenstein, P. (2000). [SCORTEN: a severity-of-illness score for toxic epidermal necrolysis](https://doi.org/10.1046/j.1523-1747.2000.00061.x?ref=theplasticsfella.com). The Journal of investigative dermatology, 115(2), 149–153. 8. Bastuji-Garin S, Rzany B, Stern RS, Shear NH, Naldi L, Roujeau JC.[ Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. ](https://pubmed.ncbi.nlm.nih.gov/8420497/?ref=theplasticsfella.com)Arch Dermatol. 1993 Jan;129(1):92-6\. PMID: 8420497. 9. Schwartz RA, McDonough PH, Lee BW. [Toxic epidermal necrolysis: Part II. Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment.](https://pubmed.ncbi.nlm.nih.gov/23866879/?ref=theplasticsfella.com) J Am Acad Dermatol. 2013 Aug;69(2):187.e1-16; quiz 203-4\. doi: 10.1016/j.jaad.2013.05.002\. PMID: 23866879. 10. Hoetzenecker W, Mehra T, Saulite I, Glatz M, Schmid-Grendelmeier P, Guenova E, Cozzio A, French LE. [Toxic epidermal necrolysis](https://pubmed.ncbi.nlm.nih.gov/27239294/?ref=theplasticsfella.com). F1000Res. 2016 May 20;5:F1000 Faculty Rev-951\. doi: 10.12688/f1000research.7574.1\. PMID: 27239294; PMCID: PMC4879934. ### Chemical Peels: Classification, Indications, & Complications URL: https://www.theplasticsfella.com/chemical-peels/ Last updated: 2025-06-04T11:03:55.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/chemical-peels/#overview-of-chemical-peels) Chemical peels are controlled applications of caustic agents to induce skin regeneration through targeted epidermal and dermal injury, improving texture, pigmentation, and overall appearance. [****Classification**](https://www.theplasticsfella.com/chemical-peels/#classification-of-chemical-peels) Chemical peels induce keratocoagulation and protein denaturation, activating wound healing and collagen remodeling. They are classified by depth, which determines both clinical effect and complication risk. [****Superficial Chemical Peels**](https://www.theplasticsfella.com/chemical-peels/#superficial-chemical-peels) Superficial peels act within the epidermis. Common agents include glycolic, lactic, mandelic, salicylic, pyruvic acids, and Jessner’s solution. [****Medium-Depth Chemical Peels**](https://www.theplasticsfella.com/chemical-peels/#medium-depth-chemical-peels) Medium-depth peels penetrate into the papillary dermis. Common agents include TCA 30–35%, Jessner’s + TCA, glycolic + TCA, and layered salicylic or pyruvic acid. [****Deep Chemical Peels**](https://www.theplasticsfella.com/chemical-peels/#deep-chemical-peels) Deep peels like the phenol-croton oil formulation penetrate to the mid-reticular dermis, offering dramatic rejuvenation for severe photoaging and deep wrinkles, but require cardiac monitoring and IV hydration. [****Complications**](https://www.theplasticsfella.com/chemical-peels/#complications-of-chemical-peels) While generally safe, chemical peels carry risks, including prolonged erythema, pigmentary changes, and infection. These are largely influenced by peel depth, agent selection, skin type, and technique. ****Primary Contributor:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Chemical Peels ****Key Point** Chemical peels are controlled applications of caustic agents to induce skin regeneration through targeted epidermal and dermal injury, improving texture, pigmentation, and overall appearance. Chemical peels, also called **chemoexfoliation,** trigger skin rejuvenation by causing controlled chemical injury to the epidermis and/or dermis. This initiates a wound-healing cascade that stimulates keratinocyte turnover, dermal remodeling, and collagen neosynthesis. The outcome is improved skin tone, texture, and radiance. Peels are classified based on **depth of penetration**: Superficial, medium, or deep. They can treat a wide range of conditions, including photoaging, acne, melasma, actinic keratoses, and dyschromia. Their efficacy depends on agent concentration, pH, skin preparation, and application technique. 😎 ****Fun Fact:** Glycolic acid, a commonly used alpha hydroxy acid, is naturally derived from sugar cane and fruits such as grapes, also used in winemaking ([Kligman](https://www.ccjm.org/content/ccjom/64/6/327.full.pdf?utm%5Fsource=chatgpt.com), 1994) --- ## Classification of Chemical Peels ****Key Point** Chemical peels induce keratocoagulation and protein denaturation, activating wound healing and collagen remodeling. They are classified by depth, which determines both clinical effect and complication risk. Chemical peels work by inducing **controlled keratocoagulation** and **protein denaturation** within the epidermis and/or dermis. This injury triggers the release of pro-inflammatory cytokines and chemokines, activating the skin's natural wound-healing cascade. The resulting response includes, - **Regeneration of keratinocytes.** - **Stimulation of fibroblasts → new collagen and elastin deposition.** - **Remodelling of dermal matrix proteins.** - **Increased epidermal thickness and dermal volume.** As a result of treatment, two visual signs can occur. - **Frosting:** A white **crystal residue** seen with agents like salicylic acid and Jessner’s solution. It’s **superficial**, caused by precipitation, and **can be wiped away**. - **Blanching:** A true tissue response. It’s due to **protein coagulation** in the skin. Seen with TCA, phenol, or high-strength AHAs. It **cannot be wiped off**, and reflects **deeper penetration**. The difference between frosting and blanching is clarified in the image below. ![Difference between frosting and blanching](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Chemical-Peels.png) Difference between frosting and blanching 💡 ****Tip:** Frosting and blanching are often confused. Frosting is a surface residue; blanching is a sign of deeper dermal interaction. ### Depth-Based Classification Chemical peels are typically **classified** by the **depth** of skin injury they induce: **superficial**, **medium**, or **deep**. This classification is clinically relevant as it directly correlates with the degree of skin remodelling, expected downtime, and potential for complications. The depth of penetration depends on multiple factors, including, - **Type and concentration of the agent**. - **Application technique and duration**. - **Pre-treatment protocols** (e.g., retinoids, degreasing). - **Skin characteristics**, such as thickness, sebaceous activity, and phototype. Each peel depth has distinct indications, mechanisms, and safety profiles, guiding its use in both aesthetic and therapeutic settings. Penetration of chemical peels according to their types is summarised below. ![Penetration of chemical peels according to type](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Chemical-Peels--1-.png) Penetration of chemical peels according to type --- ## Superficial Chemical Peels ****Key Point** Superficial peels act within the epidermis, improving mild photoaging, dyschromia, and acne with minimal downtime. Common agents include glycolic, lactic, mandelic, salicylic, pyruvic acids, and Jessner’s solution. Superficial chemical peels induce controlled exfoliation limited to the **epidermis**, from the stratum corneum to the basal layer. They aim to improve, - Mild photoaging. - Superficial dyschromia/Melasma. - Comedonal acne. - Early fine rhytides. They are characterised by **minimal downtime** and **low risk** of adverse effects. Superficial peels rely on **low-concentration acids** that produce mild, predictable keratocoagulation. The most commonly used superficial peeling agents are discussed below. **Glycolic Acid** Most widely used superficial peeling agent. It is a small, hydrophilic alpha-hydroxy acid (AHA) derived from sugar cane, offering **high bioavailability** and effective epidermal penetration. - **Concentration:** Typically 20-50% for superficial effects; ≥70% may approach medium-depth peeling. - **Mechanism:** Decreases keratinocyte cohesion, leading to uniform exfoliation and stimulation of dermal fibroblasts. - **Indications:** Photoaging, melasma, post-inflammatory hyperpigmentation (PIH), and fine wrinkles. - **Considerations:** Non-self-neutralizing (it requires careful timing and alkaline neutralization). Reaction is exothermic; transient burning may occur. **Lactic Acid** Structurally similar to glycolic acid, but slightly larger as a molecule and less penetrative, but also **more tolerable** for sensitive skin types. - **Concentration:** 10-30% for superficial peeling. - **Mechanism:** More gentle than glycolic acid; suitable for gradual exfoliation. - **Indications:** Mild photoaging, superficial pigmentary changes, and dry or sensitive skin types. - **Considerations:** Requires neutralization. Lower pH allows effective exfoliation at lower concentrations, minimizing downtime. **Mandelic Acid** Aromatic AHA with both **lipophilic** and **hydrophilic properties**, allowing for more uniform penetration, particularly in sebaceous, acne-prone skin. - **Concentration:** 20-40%. - **Mechanism:** Slower, more controlled penetration with gentle exfoliation. - **Indications:** Rosacea-prone skin, post-acne erythema, mild dyschromia. - **Considerations:** Minimal visible peeling; short recovery (3-5 days). Can be repeated more frequently than other agents. **Salicylic Acid** Beta-hydroxy acid (BHA) is **lipophilic**, making it ideal for comedonal and inflammatory acne due to its ability to penetrate sebaceous follicles. - **Concentration:** 20-30%. - **Mechanism:** Disrupts intercellular connections, unclogs pores, and has intrinsic anti-inflammatory properties. - **Indications:** Acne vulgaris, seborrheic skin, mild PIH. - **Considerations:** Self-neutralizing. Risk of deeper penetration with multiple layers. Exfoliation usually occurs within 5-7 days. **Pyruvic Acid** Alpha-keto acid with both **lipophilic and hydrophilic characteristics**, combining the exfoliative properties of both AHAs and BHAs. - **Concentration:** 40-50%. - **Mechanism:** Induces keratolysis and promotes dermal stimulation. - **Indications:** Acne, seborrhea, and early signs of photoaging. - **Considerations:** Not self-neutralizing - requires alkaline neutralization. Slightly more irritating than mandelic acid. **Jessner’s Solution** Jessner’s solution is a **combination peel** composed of salicylic acid, lactic acid, and resorcinol in an ethanol base. It is used either alone for superficial peeling or to **augment the depth of TCA peels**. - **Mechanism:** Causes keratolysis and facilitates penetration. - **Indications:** Acne, melasma, PIH, and pre-treatment for deeper chemical peels. - **Considerations:** Depth of penetration depends on the number of coats applied. Peeling begins around day 3 and resolves by day 7. **Over-the-Counter (OTC) Superficial Peels** Low-concentration formulations (e.g., 3-10% glycolic acid or fruit-derived acids) are available in cosmetic products. These are used for **gradual exfoliation**, often as pre-treatment primers to enhance professional peels. They offer minimal efficacy but are widely used due to accessibility and low irritation. The types of superficial chemical peels are summarised below. ![Types of superficial chemical peels](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Chemical-Peels--2-.png) Types of superficial chemical peels ### Technique Tips - **Pre-Treatment:** Cleanse and degrease skin with alcohol or acetone to improve penetration. Consider prepping with topical retinoids or hydroquinone for 2-4 weeks. - **Application:** Use gauze or a brush for even application. Start on the forehead and proceed symmetrically. - **Timing:** Monitor based on agent-specific recommendations (e.g., 2-5 min for glycolic). Watch for signs of reaction; clinically, **mild frosting** (patchy, stringy white areas) may be observed, while blanching should be avoided, as it indicates unintended dermal penetration. - **Neutralization:** Required for most AHAs (e.g., glycolic, lactic); use alkaline neutralizers. - **Note:** Neutralization is exothermic - transient warmth/stinging is normal. - **Avoid layering** unless specifically indicated. ### Postoperative Care Healing is typically complete within **5-10 days**, and repeated treatments may be performed to achieve incremental improvements. - **Day 0-1:** Mild erythema, tightness, tingling. Patients may feel slight stinging or burning for a few hours. - **Days 2-5:** Light flaking or microdesquamation; usually self-limited. - **Days 5-7:** Re-epithelialization completed. Patients may resume active skincare. **Patient Instructions** - Use a **gentle cleanser** and bland **emollient** (e.g., petrolatum or hyaluronic acid-based cream). - **Strict Photoprotection:** No sun exposure for at least 2 weeks after treatment. - **Avoid** active ingredients (e.g., retinoids, AHAs, exfoliants) until peeling is complete. 💡 ****Tip:** Redness or dryness persisting beyond one week may indicate overexposure or irritation. Consider topical corticosteroids or delaying next session. --- ## Medium-Depth Chemical Peels ****Key Point** Medium-depth peels penetrate into the papillary dermis. Common agents include TCA 30–35%, Jessner’s + TCA, glycolic + TCA, and layered salicylic or pyruvic acid. They may require analgesics before treatment. Medium-depth peels penetrate through the **full epidermis** and into the **papillary dermis**. This induces dermal collagen remodeling, epidermal renewal, and reorganization of the extracellular matrix. They are particularly effective for, - Moderate photoaging. - Actinic premalignant skin changes. - Epidermal and superficial dermal pigmentation. - Fine rhytides. - Chronic actinic photodamage. - Atrophic acne scars. These peels have a greater risk of discomfort, post-inflammatory dyschromia, and scarring, and require more precise application. Types of medium-depth chemical peels are discussed below. **Trichloroacetic Acid (TCA)** TCA is the cornerstone of medium-depth peels. It causes **coagulation necrosis** through protein denaturation and cellular injury. Depth is concentration-dependent. - **20-25%:** Superficial peel. - **30-35%:** Medium-depth (most used). - **\>45%:** High risk of scarring; rarely used. The goal is a uniform white frost with visible erythema underneath, indicating dermal penetration without excessive injury. 💡 ****Tip:** The ****"accordion sign"** (epidermal sliding on cotton tip) confirms epidermal detachment and it should be present. **Combination Peels (Jessner’s + TCA / Glycolic + TCA)** Combination regimens use a priming agent to **disrupt the stratum corneum** and facilitate more uniform and deeper penetration of TCA. - **Jessner’s solution (3-4 coats) + TCA 35%** → Improves consistency of frost, reduces hot spots. - **Glycolic acid 70% + TCA 35%** → Well tolerated, safer than high-concentration TCA monotherapy. These combinations replicate the depth of 50% TCA peels with **fewer complications** and better control. **Other Agents** Though not classic medium-depth agents, **salicylic acid** and **pyruvic acid** in **multiple layers** or **high concentrations** can achieve medium-depth effects. - **Salicylic Acid 30-40% (layered):** For acne with post-inflammatory pigmentation. - **Pyruvic Acid 50% (layered):** Moderate photoaging and acne-prone skin. Their use as medium peels is **less predictable** and generally for selected cases. ### Pain Management & Technique Tips - Medium-depth peels are **painful** → consider **NSAIDs pre-treatment**. - Peel the face **sequentially.** Start with the forehead and temples, finish with the lips and eyelids. - Avoid excessive overlap or reapplication. - Leave a **2-3 mm safety margin** on eyelids. ### Postoperative Care Healing occurs by **secondary intention**, with re-epithelialization typically complete within **10-14 days**. - **Day 0-1:** Burning, erythema, edema (especially around eyes). - **Day 2-5:** Peak erythema + start of desquamation. - **Day 10-14:** Re-epithelialization completed. Care includes, - Cool compresses, vinegar soaks, emollients. - **HSV prophylaxis** if needed. - **Strict Photoprotection:** No sun exposure for at least 2 weeks after treatment. - Introduce skincare gradually. --- ## Deep Chemical Peels ****Key Point** Deep peels like the phenol-croton oil formulation penetrate to the mid-reticular dermis, offering dramatic rejuvenation for severe photoaging and deep wrinkles, but require cardiac monitoring and IV hydration. Deep chemical peels cause **keratocoagulation** into the **mid-reticular dermis**, resulting in the most intense level of skin rejuvenation. They’re used to treat, - Severe photoaging. - Deep rhytides (perioral and periorbital). - Extensive dyschromia and dermal pigmentation. They typically show **long-lasting clinical results,** but at the cost of **greater risk**, longer downtime, and potential systemic toxicity. Types of deep chemical peels are discussed below. **Phenol-Croton Oil Peel (Baker-Gordon Formulation)** The most widely used deep peel. Phenol causes **rapid protein denaturation**, while croton oil induces **epidermolysis** and **dermal inflammation,** together producing **deep, uniform exfoliation** into the mid-reticular dermis. - Formulation includes, - **USP Phenol 88%**. - **Croton oil**. - **Septisol (soap surfactant)**. - **Water (vehicle)**. - **Clinical Endpoint:** Uniform, persistent blanching with deep erythema and immediate crusting. **Systemic toxicity** is a major concern. Phenol is **arrhythmogenic** and hepatotoxic. Perform in monitored settings with **cardiac monitoring** and **IV hydration**. **TCA ≥50%** Once used for deep peeling, **high-concentration TCA is no longer standard**. Current practice favors phenol-based or staged combination peels. 😎 ****Fun Fact:** Deep chemical peels have been largely replaced by ablative lasers due to better depth control and reduced systemic toxicity. ([Soleymani](https://pmc.ncbi.nlm.nih.gov/articles/PMC6122508/?ref=theplasticsfella.com), 2018) ### Technique Tips - **Pre-treatment** - Degrease skin thoroughly. - Avoid pre-existing skin barrier disruption. - Retinoids/hydroquinone pre-treatment if appropriate. - **Application** - Treat face in **small zones (15–20 min apart)**. - Allow full absorption and observe for blanching. - Occlude to enhance penetration only when appropriate (e.g., Vaseline or waterproof tape). - **Monitoring** - Cardiac monitoring required. - IV hydration reduces serum phenol levels. ### Postoperative Care - **Day 0-2** - Intense dusky erythema, edema, and crusting. - Eye swelling is common. - Use **cool compresses**, **vinegar soaks**, and **NSAIDs**. - **Day 3-14+** - Re-epithelialization begins after 72-96h. - Maintain a **moist wound environment** (emollients, occlusion). - Avoid crust formation to reduce scarring. - **Infection Prophylaxis** - **HSV:** Start antivirals 1–2 days before. - **Bacterial:** Topical mupirocin. - **Candida:** Fluconazole if suspected. 😎 ****Fun Fact:** Re-epithelialization completes around Day 14, but collagen remodeling and dermal thickening continue for **up to 6 months** post-treatment. --- ## Complications of Chemical Peels ****Key Point** While generally safe, chemical peels carry risks, including prolonged erythema, pigmentary changes, and infection. These are largely influenced by peel depth, agent selection, skin type, and technique. Chemical peels are generally safe when performed correctly. However, the **type, concentration, and depth** of the agent, **patient skin type**, and **application technique** all influence complication risk. **Common Complications** - **Prolonged Erythema:** Can persist for weeks post-peel; more common with medium/deep peels. - **Post-Inflammatory Hyperpigmentation (PIH):** Frequent in Fitzpatrick IV–VI; often transient. - **Hypopigmentation:** Especially with phenol and deep TCA; can be permanent. - **Infection:** Bacterial (e.g., Staph, Strep), viral (HSV reactivation), fungal (Candida). - **Acneiform Eruptions:** Triggered by occlusive dressings or emollients. - **Milia:** Common during the re-epithelialization phase. The complications of chemical peels are summarised below. ![Complications of chemical peels](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Chemical-Peels--3-.png) Complications of chemical peels 💡 ****Tip:** Most complications are ****preventable** with good technique and proper patient selection. Always evaluate Fitzpatrick type, history of HSV, and healing tendency before peeling. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Chemical Peels Overview:** Understand the principles behind chemical peels as controlled skin injuries aimed at regenerating the epidermis and dermis, improving texture, pigmentation, and overall skin quality. ****2\. Mechanism of Action and Classification:** Learn the biological mechanisms induced by chemical peels, including keratocoagulation and protein denaturation, and their classification by depth; superficial, medium, and deep, each with specific indications and risk profiles. ****3\. Superficial Peels:** Review the characteristics and indications of superficial peels that act within the epidermis, using agents such as glycolic, lactic, mandelic, salicylic, and pyruvic acids, as well as Jessner’s solution, offering minimal downtime and mild rejuvenation. ****4\. Medium-Depth Peels:** Understand medium-depth peels, which reach the papillary dermis, including commonly used formulations like TCA 30–35%, Jessner’s + TCA, and layered acid techniques, and their application protocols and analgesia requirements. ****5\. Deep Peels:** Gain insight into deep peels, such as the phenol-croton oil formulation, that penetrate to the mid-reticular dermis and provide significant improvement in severe photoaging, but necessitate close systemic monitoring due to potential toxicity. ****6\. Complications:** Identify the most common and serious complications of chemical peels, such as pigmentary changes, scarring, and infection. Understanding their correlation with peel depth, technique, and patient-specific factors. --- ## Further Reading 1. Soleymani T, Lanoue J, Rahman Z. A Practical Approach to Chemical Peels: A Review of Fundamentals and Step-by-step Algorithmic Protocol for Treatment. J Clin Aesthet Dermatol. 2018 Aug;11(8):21-28\. Epub 2018 Aug 1\. PMID: 30214663; PMCID: PMC6122508. 2. Kligman AM, Grove GL, Hirose R, Leyden JJ. The use of alpha hydroxy acids (AHA) in cosmetic dermatology. Journal of the American Academy of Dermatology. 1994 Aug;31(2 Pt 2):S105-12. 3. Samargandy S, Raggio BS. Chemical Peels for Skin Resurfacing. \[Updated 2023 Oct 29\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547752/ 4. O'Connor AA, Lowe PM, Shumack S, Lim AC. Chemical peels: A review of current practice. Australas J Dermatol. 2018 Aug;59(3):171-181\. doi: 10.1111/ajd.12715\. Epub 2017 Oct 24\. PMID: 29064096. 5. Lee KC, Wambier CG, Soon SL, Sterling JB, Landau M, Rullan P, Brody HJ; International Peeling Society. Basic chemical peeling: Superficial and medium-depth peels. J Am Acad Dermatol. 2019 Aug;81(2):313-324\. doi: 10.1016/j.jaad.2018.10.079\. Epub 2018 Dec 11\. PMID: 30550830. 6. Khunger N; IADVL Task Force. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008 Jan;74 Suppl:S5-12\. PMID: 18688104. 7. Sarkar R, Katoch S. Chemical Peels in Treatment of Melasma. Dermatol Clin. 2024 Jan;42(1):21-32\. doi: 10.1016/j.det.2023.06.003\. Epub 2023 Jul 18\. PMID: 37977681. ### Prominent Ear Deformity: Assessment, Surgical Techniques, & Otoplasty Outcomes URL: https://www.theplasticsfella.com/prominent-ear/ Last updated: 2025-06-03T17:41:10.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/prominent-ear/#overview-of-prominent-ears) Prominent ear (projection >2 cm or auriculocephalic angle >30°) is surgically corrected by otoplasty. The most common causes are antihelical fold deficiency and/or conchal hypertrophy. [****Aetiology**](https://www.theplasticsfella.com/prominent-ear/#aetiology-of-prominent-ears) Prominent ear deformities arise from a combination of congenital cartilage anomalies, neonatal molding factors, and potential genetic inheritance. [****Auricular Anatomy**](https://www.theplasticsfella.com/prominent-ear/#auricular-anatomy) The auricle is divided into subunits: helix, antihelix, concha, and lobule. Accurate subunit identification is essential for tailored surgical correction. [****Clinical Assessment**](https://www.theplasticsfella.com/prominent-ear/#clinical-assessment-of-prominent-ear) Evaluation includes auricular measurements and analysis of subunit-specific abnormalities. Algorithmic assessment guides surgical planning. [****Decision Making**](https://www.theplasticsfella.com/prominent-ear/#decision-making-for-prominent-ear-treatment) Effective correction of prominent ears relies on identifying the dominant anatomical deformity and selecting a tailored surgical technique. [****Surgical Technique (Otoplasty)**](https://www.theplasticsfella.com/prominent-ear/#surgical-technique-otoplasty-for-prominent-ear) Surgical correction of prominent ears relies on a subunit-based approach; tailoring techniques like Mustardè, Converse, Argamaso, and Furnas to specific auricular deformities for natural results. [****Post-Operative Care & Complications**](https://www.theplasticsfella.com/prominent-ear/#post-operative-care-complications-of-prominent-ear) Postoperative otoplasty care includes short-term compression, soft headband use, antibiotics, activity restrictions, and monitoring for complications like hematoma and wound dehiscence. ****Updated by:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Prominent Ears ****Key Point** Prominent ear (ear projection >2 cm or auriculocephalic angle >30°) is surgically corrected by otoplasty. The most common causes are antihelical fold deficiency and/or conchal hypertrophy. **Prominent ears** are characterized by an auriculocephalic angle exceeding 30° or an auricular projection greater than 2 cm from the mastoid surface. Despite **normal anatomical structures**, these ears appear **overly protruding** due to specific morphological imbalances; most frequently, an underdeveloped antihelical fold and/or conchal hypertrophy. The **three key pathological features** of this deformity are, - **Absent or underdeveloped antihelical fold**. - **Conchal excess >1.5 cm**. - **Conchoscaphal angle >90°**. **Otoplasty** refers to the surgical reshaping or repositioning of the auricle to correct these abnormalities. 😎 ****Fun Fact:** Prominent ears affect approximately ****5%** of the population, making them the commonest congenital auricular deformity ([Kelley](https://pubmed.ncbi.nlm.nih.gov/14501322/?ref=theplasticsfella.com), 2003). Often bilateral, can lead to psychosocial distress. --- ## Aetiology of Prominent Ears ****Key Point** Prominent ear deformities arise from a combination of congenital cartilage anomalies, neonatal molding factors, and potential genetic inheritance. The development of prominent ears involves both intrinsic cartilage anomalies and extrinsic molding influences. - **Congenital Cartilage Anomalies:** The most common cause includes an underdeveloped antihelical fold or an enlarged conchal bowl. - **Perinatal Molding:** External pressure during vaginal delivery or in utero can temporarily alter ear shape. - **Neonatal Cartilage Malleability:** High estrogen levels in the first weeks of life make auricular cartilage soft and moldable. - **Familial Traits:** An autosomal dominant inheritance pattern has been observed in some cases. - **Postural Factors:** Consistent lateral sleeping positions in infancy may exacerbate or contribute to deformity. 💡 ****Tip:** Ear molding devices can be effective when started early due to the temporary estrogen-induced softness of neonatal cartilage. --- ## Auricular Anatomy ****Key Point** The auricle is divided into subunits: helix, antihelix, concha, and lobule. Accurate subunit identification is essential for tailored surgical correction. **Embryology** - **Developmental Origin:** The auricle arises from six hillocks — three from the mandibular arch (forms tragus, helical crus) and three from the hyoid arch (forms 85%, including helix, antihelix, lobule). - **Timing:** Antihelical folding occurs between 12-16 weeks gestation; incomplete folding can cause prominent ear deformity. - **Structure:** Made of elastic cartilage with thin skin; divided into subunits important for surgical planning. **Auricular Subunits and Landmarks** For surgical analysis, the auricle is divided into four anatomical subunits (A–D), assessed from the periphery inward. This aids in identifying deformities and selecting appropriate techniques. - **Subunit A:** Helical rim and scapha — the outer contour of the ear. - **Subunit B:** Antihelix — the inner ridge, often deficient in prominent ears. - **Subunit C:** Conchal bowl — includes cymba and cavum, adjacent to the auditory canal. - **Subunit D:** Lobule — the soft, cartilage-free lower portion of the auricle. These key auricular landmarks are illustrated below. ![Key auricular landmarks, Otoplasty, Prominent Ear](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Template-4.png) Key auricular landmarks 💡 ****Tip:** Begin assessment from Subunit A and proceed inward. Overlooking peripheral deformities (e.g., macrotia or cup ear, subunits B or C) may result in incomplete or unnatural correction. --- ## Clinical Assessment of Prominent Ear ****Key Point** Evaluation includes auricular measurements and analysis of subunit-specific abnormalities. Algorithmic assessment guides surgical planning. The external ear anatomical subunits should be examined in a **concentric fashion**, from the outermost to the innermost. - **Subunit A - Helical & Scaphal Region:** Look for flattening of the helix (folding defects) or excessive scaphal width (macrotia). - **Subunit B - Antihelical Fold:** Assess the degree of cartilage folding between the triangular fossa and antitragus. - **Subunit C - Conchal Bowl (Cymba + Cavum):** Evaluate the depth and projection of the concha from the mastoid. - **Subunit D - Lobule:** Inspect for hypertrophy, eversion, poor definition, or bifid lobe. The clinical presentation of otapostasis is illustrated below. ![Clinical presentation of otapostasis. Prominent ear](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/06/Prominent-Ears--4-.png) Clinical presentation of otapostasis **Objective Measurements** Normal auricular measurements serve as essential reference points in the preoperative evaluation. These measurements are summarised below. ![Normal auricular measurements for otoplasty, prominent ear](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Prominent-Ears.png) Normal auricular measurements 😎 ****Fun Fact:** The helical rim naturally protrudes more as it descends, about ****10-12 mm** in the upper third, ****16-18 mm** in the middle, and up to ****20-22 mm** in the lower third! --- ## Decision Making for Prominent Ear Treatment ****Key Point** Effective correction of prominent ears relies on identifying the dominant anatomical deformity and selecting a tailored surgical technique. Prominent ear correction requires identifying the underlying deformity (e.g., antihelical underdevelopment, conchal hypertrophy) and applying targeted techniques. This ensures balanced, aesthetic results without overcorrection. **Indications** - Ear projection >2 cm or auriculo-cephalic angle >30°. - Poorly formed antihelical fold and/or enlarged concha. - Patient concern, psychosocial impact, or bullying. - Auricular maturity (typically ≥3–4 years old). **Timing** - Best performed after age 3–4, when ear growth is nearly complete. - Early correction is safe and does not impair further development. **Technique Selection** This is based on dominant deformity and discussed in more detail in the section below. - **Mustardè** for antihelical fold creation. - **Furnas** for conchal setback. - **Converse/Argamaso** for combined or complex corrections. 😎 ****Fun Fact:** By age 3-4, the external ear reaches approximately 85% of its adult size. --- ## Surgical Technique (Otoplasty) for Prominent Ear ****Key Point** A subunit-based surgical approach allows tailored correction of prominent ears using techniques like Mustardè, Converse, Argamaso, and Furnas for natural, balanced results. Prominent ear correction is optimized by assessing specific auricular subunits (A–D) and selecting techniques accordingly. This strategy helps avoid overcorrection and ensures aesthetic outcomes. #### Subunit A – Helical and Scaphal Region **Target:** Flat helix, excessive folding (cup ear), or macrotia due to scaphal hypertrophy. **Preferred Approach:** Anterior - [**Lykoudis**](https://pubmed.ncbi.nlm.nih.gov/21576663/?ref=theplasticsfella.com) **Technique:** Radial incisions to contour a flat helix; non-absorbable sutures maintain shape. - [**Tanzer**](https://pubmed.ncbi.nlm.nih.gov/1118500/?ref=theplasticsfella.com) **Correction:** Reshapes excess cartilage in cup ear deformity. - [**Argamaso**](https://pubmed.ncbi.nlm.nih.gov/24173864/?ref=theplasticsfella.com) **Technique:** For macrotia; wedge excision of scaphal cartilage with helical advancement. 💡 ****Tip:** The need for an anterior approach in Subunit A defects dictates the approach to Subunits B and C as well. #### Subunit B – Antihelical Fold **Target:** Insufficient or absent antihelical folding. **Preferred Approach:** Posterior (unless combined with Subunit A). - [**Mustardè**](https://www.ncbi.nlm.nih.gov/pubmed/13936895?ref=theplasticsfella.com) **Technique:** Posterior mattress sutures create a fold; ideal for soft cartilage. - [**Converse**](https://pubmed.ncbi.nlm.nih.gov/14022738/?ref=theplasticsfella.com) **Technique:** Cartilage incisions from behind to aid folding in firmer cartilage. - [**Chongchet**](https://www.ncbi.nlm.nih.gov/pubmed/14042756?ref=theplasticsfella.com)**/**[**Stenstroem**](https://www.ncbi.nlm.nih.gov/pubmed/14078273?ref=theplasticsfella.com) **Techniques:** Posterior cartilage scoring to induce curvature. 😎 ****Fun Fact:** Scoring techniques rely on the [Gibson (and Davis) Principle](https://doi.org/10.1016/s0007-1226%2857%2980042-3?ref=theplasticsfella.com): cartilage warps away from the injured side, enabling reshaping. #### Subunit C – Auricular Concha **Target:** Conchal hypertrophy (cymba or cavum). **Preferred Approach:** Posterior (or anterior if combined with Subunit A). - [**Furnas**](https://www.ncbi.nlm.nih.gov/pubmed/4878456?ref=theplasticsfella.com) **Sutures:** Anchor concha to mastoid fascia to reduce projection. - [**Horlock**](https://pubmed.ncbi.nlm.nih.gov/11711914/?ref=theplasticsfella.com) **Fascial Flap:** Reinforces support and vascularity, reducing recurrence risk. - **Cartilage Resection/Scoring:** Directly reduces and reshapes the conchal bowl. ### #### Subunit D – Lobule **Target:** Lobular prominence, poor definition, or redundancy. **Preferred Approach:** Posterior or anterior (technique-dependent). - **Lobule Suspension:** Anchoring to mastoid fascia to prevent "telephone ear." - **Wedge/Curvilinear Excision:** Removes excess tissue. - **Y-V Setback Technique:** Advances skin and rotates lobule medially for symmetry. ### Non-operative Management In **neonates ≤72 hours old**, auricular cartilage remains pliable due to maternal estrogens. Splinting with materials such as **SteriStrips**, **rubber-coated wire**, or **polyethylene suction catheters** can realign auricular shape if maintained for **1–2 months**. This early intervention **can correct prominent ears** non-surgically and should be considered in perinatal assessments. --- ## Post-operative Care & Complications of Prominent Ear ****Key Point** Postoperative otoplasty care includes short-term compression, soft headband use, antibiotics, activity restrictions, and monitoring for complications like hematoma and wound dehiscence. Postoperative care is a critical component of successful otoplasty and directly impacts surgical outcomes, patient satisfaction, and complication rates. - **Immediate Care** - Compression dressing applied intraoperatively. - Dressing removal after 24-48 hours. - Application of a soft, non-compressive headband for **2-4 weeks**, worn continuously for the first week, then at night only. - **Medications** - Prophylactic antibiotics (e.g., cefazolin IV during hospitalization; cefixime PO post-discharge for 5 days). - Analgesics as needed. - Elevation of the head to reduce edema. - **Activity Restrictions** - Avoid physical activities or trauma to the ears for at least **3-4 weeks**. - Return to school or light activity after 7-10 days. ### Common Complications - **Hematoma:** Early recognition is crucial. It may require prompt surgical evacuation to avoid vascular compromise and eventual skin necrosis. - **Suture Extrusion:** More common with non-absorbable suture; minimized with proper technique. - **Overcorrection:** Can result in an unnatural, "pinned-back" appearance. - **Asymmetry:** Typically mild; requires careful intraoperative planning. - **Wound Dehiscence:** Rare, managed with conservative wound care or minor revision. - **Recurrence of Protrusion:** Often due to undercorrection or cartilage memory. - **Infections:** (e.g., by Staphylococcus or Streptococcus) are managed with IV antibiotics and topical mafenide acetate if chondritis risk is high. - **Telephone Ear**: Occurs when upper and lower thirds protrude after isolated mid-third correction. Results in a receiver-like deformity. --- ## Conclusions Upon completing this article, you will have accomplished the following: ****1\. Overview:** Otoplasty corrects prominent ears, usually caused by underdeveloped antihelical fold and/or conchal hypertrophy, improving auricular shape and reducing ear projection. ****2\. Relevant Anatomy:** The auricle consists of helix, antihelix, concha, and lobule subunits. Precise identification of these areas is crucial for tailored surgical correction. ****3.** ****Clinical Assessment & Indications:** Assessment includes auricular measurements and subunit-specific deformities. Surgery is indicated for ears projecting >2 cm or angle >30°, with psychological impact or patient request. ****4.** ****Surgical Techniques:** Techniques such as Mustardè, Converse, Argamaso, and Furnas are adapted to the dominant deformity based on the affected subunit, aiming for natural, symmetric results. ****5\. Postoperative Care & Complications:** Care involves compression dressings, headband use, antibiotics, activity restriction, and monitoring for hematoma, suture extrusion, asymmetry, and wound issues. --- ## Further Readings 1. Kelley P, Hollier L, Stal S. Otoplasty: evaluation, technique, and review. J Craniofac Surg. 2003 Sep;14(5):643-53\. doi: 10.1097/00001665-200309000-00008\. PMID: 14501322. 2. Siliprandi M, Battistini A, Agnelli B, Bandi V, Vinci V, Lisa A, Maione L, Siliprandi L. Algorithm-Assisted Decision Making in Otoplasty. Aesthetic Plast Surg. 2022 Feb;46(1):207-219\. doi: 10.1007/s00266-021-02368-3\. Epub 2021 Jun 8\. PMID: 34105004. 3. Gibson T, Davis WB. The distortion of autogenous cartilage grafts: Its cause and prevention. *British Journal of Plastic Surgery*. 1957:257-274\. doi:10.1016/s0007-1226(57)80042-3 4. STENSTROEM SJ. A "NATURAL" TECHNIQUE FOR CORRECTION OF CONGENITALLY PROMINENT EARS. Plast Reconstr Surg. 1963 Nov;32:509-18\. PMID: 14078273. 5. CHONGCHET V. A METHOD OF ANTIHELIX RECONSTRUCTION. Br J Plast Surg. 1963 Jul;16:268-72\. doi: 10.1016/s0007-1226(63)80120-4\. PMID: 14042756. 6. MUSTARDE JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg. 1963 Apr;16:170-8\. doi: 10.1016/s0007-1226(63)80100-9\. PMID: 13936895. 7. Mustardé JC. The treatment of prominent ears by buried mattress sutures: a ten-year survey. Plast Reconstr Surg. 1967 Apr;39(4):382-6\. PMID: 5336910. 8. Furnas DW. Correction of prominent ears by conchamastoid sutures. Plast Reconstr Surg. 1968 Sep;42(3):189-93\. doi: 10.1097/00006534-196809000-00001\. PMID: 4878456. 9. Spira M, McCrea R, Gerow FJ, Hardy SB. Correction of the principal deformities causing protruding ears. Plast Reconstr Surg. 1969 Aug;44(2):150-4\. PMID: 5799297. 10. Lykoudis EG, Seretis K, Spyropoulou GA. A 6-year experience in flat helix correction with a simple procedure. Arch Facial Plast Surg. 2011 May-Jun;13(3):168-72\. doi: 10.1001/archfacial.2011.31\. PMID: 21576663. 11. Tanzer RC. The constricted (cup and lop) ear. Plast Reconstr Surg. 1975 Apr;55(4):406-15\. PMID: 1118500. 12. Argamaso RV, Lewin ML. The lateral transhelical approach for correction of deformities of the external ear. Aesthetic Plast Surg. 1978 Dec;2(1):357-62\. doi: 10.1007/BF01577972\. PMID: 24173864. 13. CONVERSE JM, WOOD-SMITH D. Technical details in the surgical correction of the lop ear deformity. Plast Reconstr Surg. 1963 Feb;31:118-28\. doi: 10.1097/00006534-196302000-00002\. PMID: 14022738. 14. Horlock N, Misra A, Gault DT. The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty. Plast Reconstr Surg. 2001 Nov;108(6):1487-90; discussion 1491\. doi: 10.1097/00006534-200111000-00005\. PMID: 11711914. 15. Gosain AK, Recinos RF (2003) A Novel Approach to Correction of the Prominent Lobule during Otoplasty. Plast Reconstr Surg 112(2):575–583 ### Textbooks That Talk Back, 3 Cleft Lip Lessons, & A Debate on Implant Illness URL: https://www.theplasticsfella.com/june-1st/ Last updated: 2025-06-01T07:37:11.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-1st/#a-letter-from-pfella) Your textbook should talk back to you. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-1st/#the-sunday-quiz) How well do you know cleft lip? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/june-1st/#image-of-the-week) Blood supply to the lip. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/june-1st/#technique-tip) Marking the cleft lip. 5. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/june-1st/#jpras-journal-club) Breast implant illness and its comorbid conditions. 6. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/june-1st/#foundations-textbook) Waiting list closed! Considering a second waitlist. 7. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/june-1st/#what-does-the-evidence-say) Optimal timing for cleft lip and palate repair. 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/june-1st/#articles-of-the-week) Anatomical subunits in cleft lip repair, HA filler for cleft lip and nose, & 3D-printed cleft lip simulator: with 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/june-1st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Your Textbook Should Talk Back to You* 👋 Let’s call it what it is: flipping through an index to answer a clinical question is outdated, frustrating, and borderline ridiculous in 2025. We’ve all been there. You need to check something quickly. But instead, you're diving into four chapters, scanning diagrams, and cross-referencing outdated pages. It kills your momentum and slows down your learning. [Foundations](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) was built to change that. Now, we're about to take it one step further. **The Textbook Is Already Alive** Foundations already updates in real-time. Scan a QR code, and the most current information appears instantly. Everyone sees the same version. No logins. No expired editions. No outdated errors lingering for a decade. But what if you didn’t even need to scan anything? **We’re Building a Textbook That Chats** Here’s the vision: You have a question about a flap, a classification, or a post-op protocol. You ask. And the textbook answers. Whether you're prepping for exams or reviewing cases on the ward, Foundations will act like a smart, responsive assistant, giving you the clarity you need without slowing you down. This isn’t about bells and whistles. It’s about making the information *actually usable*. **What Do You Think?** If this works like we think it will, it changes everything: It’s the difference between *reading a textbook* and *talking to one*. And it’s only possible because we built [Foundations](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) to be alive from Day One. Reply to the poll or drop us a message. If enough of you want this, we’ll roll it out sooner than planned. **Closing Note** This isn’t about making a clever product. It’s about building the resource we always wished we had. Foundations exists because we got tired of the status quo. And if you're tired too — good. That means you’re ready for something better. With love, P Fella ❤️ ## The Sunday Quiz **How Well Do You Know Cleft Lip?* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. Tackle one question per week for seven rounds! The ****top** scorer wins a copy of our upcoming textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). ## Image of the Week **Blood Supply to the Lip* 🖼️ ****Image of the Week** This week’s image highlights the labial vascular anatomy, showing the ****superior and inferior labial arteries** running within the orbicularis oris muscle. Understanding this vascular pattern is critical for procedures like cleft lip repair, lip lifts, or filler injections, where preserving arterial integrity reduces complications and optimizes perfusion. The red-highlighted course in this illustration emphasizes the ****submucosal arterial arcades** — a key detail for planning safe incisions and flap designs. ![Blood supply to the lip](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/image-7.png) Blood supply to the lip ## Technique Tip **Marking the Cleft Lip* 🚑 ****Technique Tip of the Week** This week’s tip highlights preoperative marking for a complete unilateral cleft lip using the Fisher technique, which follows anatomical subunit principles for optimal aesthetic outcome. 📍 Key landmarks include: ****\- Cupid’s bow peak and trough** ****\- Columellar base and philtral column heights (cleft vs non-cleft)** ****\- White roll–cutaneous junctions and vermilion border** ****\- Alar base and nasal sill symmetry points** ****\- Cutaneous and vermilion back cuts for triangular flaps** These markings are critical to ensure symmetry, preserve subunit integrity, and avoid vermillion notching or nasal base asymmetry. ![Marking a cleft lip ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/fisher-unilateral-6-780x439.webp) Marking a cleft lip - [Source](https://www.chop.edu/centers-programs/cleft-lip-and-palate-program/fisher-unilateral-cleft-lip-repair-surgical-tutorial-professionals?ref=theplasticsfella.com) ## JPRAS Journal Club **Breast Implant Illness and Its Comorbid Conditions* 🎓 ****10-Second Snippet from Our Latest Journal Club Entry** 49% of breast implant recipients report symptoms like fatigue, joint pain, and brain fog. After explantation, 57% improve. The cause? Still unclear. Autoimmune and psychiatric comorbidities are common, but diagnosis remains controversial. What does this mean for your practice? What role do explants actually play? And is this a real clinical entity, or just misunderstood? Read the full article below to explore our take on the data from over 7,000 patients in 48 studies. ![Breast implant illness and its comorbid conditions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Journal-Club-Images--18--1.png) Breast implant illness and its comorbid conditions [Exploring Breast Implant Illness and Its Comorbid Conditions: A Systematic Review & Meta-AnalysisSystematic review (48 studies, 7,045 patients) found 49 % of breast-implant recipients reported BII symptoms: fatigue, joint pain, brain fog. After explantation, 57 % improved. Autoimmune, psychiatric, and cancer comorbidities were common; diagnosis remains unclear.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/Logo-Small-2-11.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/Lunchtime-Lessons-1-1.png)](https://www.theplasticsfella.com/journal-breast-implant-illness/) ## Foundations Textbook **Waiting List Closed! Considering a Second Waitlist* 📙 ****Waiting List Closed! We're Considering a Second Waitlist** Thank you to everyone who joined the Foundations waitlist — it’s now officially closed. We’ve had a flood of messages asking if we’ll open a second wave. If you missed out but still want a copy, respond to this email with 'Foundations' and let us know. If there's enough interest, we’ll open a final round. Stay tuned, and thank you for the incredible support! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/image--7-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/image--8-.png) Foundations Textbook ## What Does the Evidence Say? **Optimal Timing for Cleft Lip and Palate Repair* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The optimal timing for cleft lip and palate repair remains controversial, with studies showing varied impacts on facial growth and outcomes. Early lip repair (before 3 months) may reduce the need for later ****orthognathic surgery** (Dalle Ore et al., 2017; Wlodarczyk et al., 2022). However, palate repair timing is more debated, with some studies suggesting ****delayed hard palate repair** may benefit ****maxillary growth** (Farronato et al., 2014; Shi & Losee, 2014). Surgical protocols and sequences vary widely among centers (Slator et al., 2020). ****Complication rates appear similar** between early and standard repair timings (Bluher et al., 2020). Sociodemographic factors can influence repair timing, with certain ****racial groups** and ****patients with comorbidities** experiencing later interventions (Lynn et al., 2020). Despite these variations, most studies agree that palate repair significantly impacts ****maxillofacial growth** (Young et al., 2021; Shi & Losee, 2014). ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Do Anatomical Subunits Matter in Cleft Lip Repair?** ([Sisti](https://journals.lww.com/plasreconsurg/fulltext/2017/12000/principles%5Fof%5Fcleft%5Flip%5Frepair%5F%5Fconventions,.57.aspx?ref=theplasticsfella.com), 2017) The Fisher technique in unilateral cleft lip repair aligns incision lines with anatomical subunits to preserve philtral integrity and achieve more natural outcomes. ✅ ****Hyaluronic Acid Filler as a Nonsurgical Option for Cleft Lip and Nose** ([Derderian](https://academic.oup.com/asjopenforum/article/doi/10.1093/asjof/ojac069/6670771?ref=theplasticsfella.com), 2022) Cross-linked hyaluronic acid improves residual lip and nasal asymmetries in cleft patients, offering a minimally invasive alternative to fat grafting or surgery. ✅ ****3D-Printed Cleft Lip Simulator to Enhance Surgical Training** ([Chen](https://www.jprasurg.com/article/S1748-6815%2824%2900197-9/abstract?ref=theplasticsfella.com), 2024) A personalized silicone cleft lip model significantly improved students’ confidence and performance in cleft lip surgery training compared to traditional methods. ## Feedback ### I hope you enjoyed it 😄 --- ### Exploring Breast Implant Illness and Its Comorbid Conditions: A Systematic Review & Meta-Analysis URL: https://www.theplasticsfella.com/journal-breast-implant-illness/ Last updated: 2025-05-25T12:48:04.000Z #### In this Journal Club **A 2018–2024 systematic review of 7045 breast implant patients found that 49% reported Breast Implant Illness (BII) symptoms, mainly fatigue, joint pain, and brain fog. Over half improved after explantation. Autoimmune, psychiatric, and cancer-related comorbidities were common. Diagnosis remains unclear, stressing the need for thorough assessment and shared decision-making.* [****5-Point Summary**](https://www.theplasticsfella.com/journal-breast-implant-illness/#5-point-summary) BII is a systemic symptom cluster linked to breast implants. Among 7045 patients in 48 studies, 49% reported symptoms (fatigue, joint pain, brain fog). Of those explanted, 57% improved. Autoimmune and psychiatric comorbidities were common. [****4-Key Findings**](https://www.theplasticsfella.com/journal-breast-implant-illness/#4-key-findings) Of the patients, 49% had symptoms: fatigue (24%), joint pain (34%), and brain fog (21%). Explantation was done in 63%, with 57% noting improvement. Autoimmune (6%), psychiatric (5%), and cancer histories (3%) were common. Complete symptom resolution occurred in 10%. [****3-Critiques**](https://www.theplasticsfella.com/journal-breast-implant-illness/#3-critiques) BII lacks diagnostic criteria, and symptoms often overlap with other conditions. Study quality varied, with many small or retrospective reports. Self-selection likely inflated symptom prevalence. [****2-Practical Takeaways** ](https://www.theplasticsfella.com/journal-breast-implant-illness/#2-practical-takeaways) BII should be considered in patients with vague symptoms and implants. For ongoing symptoms, explantation may help and should be discussed as part of patient-centred care. [****1-Recommended Reading**](https://www.theplasticsfella.com/journal-breast-implant-illness/#1-recommended-reading) Glicksman et al.’s ASERF study (2022) explores the impact of capsulectomy type on symptom resolution after explantation, offering detailed guidance on surgical approach and outcomes. [Read Full Article ](https://bit.ly/june-jpras?ref=theplasticsfella.com) ✍️ ****Note from the Editor** Breast implant illness (BII) has not been designated as a defined disease entity by the World Health Organisation and is therefore very difficult to review systematically. This paper by Trabilsy **et al* used a search strategy designed to select ‘BII’ cohorts and sought to identify the common self-reported symptoms in those patients; therefore, frequency of symptoms and rate of explantation should be interpreted in that context. Arthralgia, fatigue and cognitive dysfunction were the most common complaints, which are also symptoms frequent to other disease entities and the general population. Extensive prospective data collection of patients with breast implants will be required to provide evidence of causation. This is a valuable paper to raise awareness in plastic surgeons that patients with breast implants and symptoms of BII should be taken seriously and a differential diagnosis considered prior to surgical intervention. **Adam Reid* **JPRAS Editors* --- ## 5 Point Summary This systematic review and meta-analysis synthesises data from 48 studies on breast implant illness (BII), evaluating symptom prevalence, associated comorbidities, and post-explantation outcomes in a global patient population. 1️⃣ ****Hypothesis** Patients with breast implants report systemic symptoms associated with BII, and these symptoms may improve following explantation. 2️⃣ ****Method** A systematic review and meta-analysis of 48 studies (2018–2024) including 7045 patients, evaluating presenting symptoms, associated comorbidities, and explantation outcomes. 3️⃣ ****Results** 49% of patients reported BII symptoms, with fatigue, joint pain, and brain fog most common. 63% underwent explantation; 57% experienced improvement and 10% had complete resolution. 4️⃣ ****Conclusion** BII represents a complex, multifactorial syndrome often overlapping with autoimmune, psychiatric, and oncologic conditions. Symptom relief is common post-explant. 5️⃣ ****Implication** Clinicians should consider BII in symptomatic patients and support shared decision-making, particularly when nonspecific symptoms persist without a clear medical cause. ## 4 Key Findings This global review highlights the symptom burden and clinical outcomes associated with breast implant illness, with important patterns in presentation, comorbidities, and surgical management. 1️⃣ ****Symptom Profile** The most common BII symptoms were arthralgia/myalgia (34%), fatigue/malaise (24%), and cognitive dysfunction such as brain fog (21%). Many patients reported more than one symptom, forming a consistent clinical cluster. Symptom clusters reported by patients often reflect systemic or inflammatory patterns. ![Common clinical features of BII](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Journal-Club-Images--18-.png) Common clinical features of BII 2️⃣ ****Comorbid Conditions** Comorbidities were frequently observed: 14% had a history of smoking, 6% had autoimmune diseases, and 5% had psychiatric conditions such as anxiety or depression. A smaller subset (3%) had a history of malignancy. ![Distribution of comorbidities among BII patients](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Journal-Club-Images--17-.png) Distribution of comorbidities among BII patients 3️⃣ ****Explantation and Improvement** 63% of symptomatic patients underwent implant removal. Among those, 57% reported symptom improvement and 10% had complete resolution. The association between explantation and relief was statistically significant across the studies. ![Comorbid conditions and symptom resolution rates](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Journal-Club-Images--16-.png) Comorbid conditions and symptom resolution rates 4️⃣ ****Controversy and Complexity** BII remains poorly defined, with subjective reporting, overlapping diagnoses, and varied study quality. Despite this, the consistent post-explant improvement seen in multiple studies reinforces the need for patient-centred management. --- ## 3 Critiques While comprehensive and globally representative, the review is limited by variability in study design, subjective symptom reporting, and potential bias in patient selection. 1️⃣ ****Diagnostic Ambiguity** BII lacks a standardised definition or objective diagnostic criteria, leading to heterogeneity in how symptoms were identified and reported across studies. 2️⃣ ****Study Quality Variability** The review included case reports, small case series, and non-randomised studies with differing methodologies, limiting the strength of pooled conclusions and meta-analysis accuracy. 3️⃣ ****Self-Selected Cohorts** Many included studies involved patients who already associated their symptoms with implants or were seeking explantation, introducing bias in symptom prevalence and explantation outcomes. --- ## 2 Practical Takeaways This review offers important guidance for recognising and managing breast implant illness, emphasising the value of symptom pattern recognition and the role of explantation in patient care. 1️⃣ ****Recognition** Patients presenting with vague but persistent symptoms—such as fatigue, joint pain, and brain fog—should prompt consideration of BII, especially when no alternative diagnosis is found. 2️⃣ ****Management** Explantation may lead to meaningful symptom improvement in selected patients. Shared decision-making and appropriate counselling are essential when discussing treatment options. ![Proposed clinical framework for suspecting BII](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Journal-Club-Images--15-.png) Proposed clinical framework for suspecting BII ## 1 Recommended Reading Glicksman et al.’s ASERF study (2022) investigates the impact of capsulectomy type on symptom resolution after explantation in BII patients, offering valuable guidance on surgical approach and outcome expectations. [Read the Article](https://academic.oup.com/asj/article/42/7/809/6463587?ref=theplasticsfella.com) ### Waitlist Closing, JPRAS Journal Club + Breast Implant Everything. URL: https://www.theplasticsfella.com/may-25th/ Last updated: 2025-05-24T20:18:07.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-25th/#a-letter-from-pfella) You Don’t Need More Content. You Need the Right Framework 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-25th/#the-sunday-quiz) How well do you know breast ptosis. 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-25th/#image-of-the-week) Clinical presentation of BIA-ALCL. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-25th/#technique-tip) Breast implant placement options. 5. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/may-25th/#jpras-journal-club) Breast implant illness and its comorbid conditions. 6. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/may-25th/#foundations-textbook) Last call for the waiting list! 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-25th/#articles-of-the-week) Surgeon awareness of BIA-ALCL, history of breast implants, & choosing breast implants: with 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/may-25th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella ****You Don’t Need More Content. You Need the Right Framework** 👋 ****Do you agree?** Some days, it feels like learning plastic surgery is less about curiosity and more about navigating clutter. You start off with good intentions. Maybe it’s to revise flaps, brush up on anatomy, or prep for tomorrow’s list. But five minutes in, you’re buried in a maze of half-finished PDFs, conflicting explanations, and lecture recordings with no timestamp on what actually matters. And no one really teaches you how to make sense of it all. The volume grows. The structure never comes. And somehow, we call this learning. ### What Most of Us Are Missing If you’ve ever felt like you’re working harder than necessary just to get a basic grasp of something, you’re not alone. What’s missing usually isn’t motivation or intelligence...it’s a system. A clear way of thinking. A framework that says: this is the core, this is how it connects, and this is where to go next. ### What We’re Working On We’ve been exploring this exact issue for a while now. How to bring order to the chaos without oversimplifying. How to teach the fundamentals without flattening the nuance. The result is something we’ve been quietly building in the background. A structured way of learning, designed with the same discipline we bring to surgery itself. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Screenshot-2025-05-24-at-21.13.11-1.png) [Source](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) [Waitlist Closes Tomorrow](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) No pressure. No hard sell. Just something that might make things a little clearer. With love, P Fella ❤️ ## The Sunday Quiz **How Well Do You Know Implant Ptosis* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. Tackle one question per week for seven rounds! The ****top** scorer wins a copy of our upcoming textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). ## Image of the Week **Clinical Presentation of BIA-ALCL* 🖼️ ****Image of the Week** This week’s image features a classic clinical presentation of ****BIA-ALCL:** A late-onset seroma causing visible asymmetry and swelling in a patient with textured breast implants. Key points: ****1\.** Most common presentation: delayed peri-implant effusion (typically >1 year post-op). ****2.** May also present with capsular contracture, mass, or regional lymphadenopathy. ****3\.** Diagnosis requires ultrasound-guided aspiration and CD30-positive, ALK-negative cytology. Prompt recognition and referral for oncologic assessment and en bloc capsulectomy are crucial. ![Clinical presentation of BIA-ALCL](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/image-5.png) Clinical presentation of BIA-ALCL ## Technique Tip **Breast Implant Placement Options* 🚑 ****Technique Tip of the Week** This week’s tip breaks down the key differences between subglandular, subfascial, and dual plane breast implant placements, each with distinct clinical pros and cons. 📌 Quick comparison: ****1\. Subglandular:** Simple access, no animation deformity, but higher risk of palpability and capsular contracture. ****2\. Subfascial:** Reduced animation, lower contracture rates vs. subglandular, though technically more demanding. ****3\. Dual Plane:** Optimal lower pole fill and soft tissue coverage, but requires IMF access and greater surgical precision. ![Differences between subglandular, subfascial, and dual plane breast implant placements](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/image-6.png) Differences between subglandular, subfascial, and dual plane breast implant placements ## JPRAS Journal Club **Breast Implant Illness and Its Comorbid Conditions* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Lunchtime-Lessons-1.webp) #### ****Exploring Breast Implant Illness and its Comorbid Conditions: A Systematic Review & Meta-Analysis** Data from a systematic review show that ****49%** of 7045 patients with ****breast implants** reported symptoms consistent with Breast Implant Illness (****BII**), most commonly ****fatigue**, ****joint pain**, and ****brain fog**. Symptom improvement followed by explantation in over half of the cases. Autoimmune, psychiatric, and oncologic comorbidities were frequently observed. ****Clear diagnosis remains challenging**, highlighting the need for patient-centred care, thorough assessment, and shared decision-making. [Read More](https://www.theplasticsfella.com/journal-breast-implant-illness/) ## Foundations Textbook **Last Call for the Waiting List!* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/image--6-.png) **Foundations* waitlist deadline extended 📙 ****Last 24-hour call!** Your response to the **Foundations* waitlist has been amazing, and there are still many of you signing up. So we decided to extend our waitlist closing date to ****May 26th** at 11:59 PM EST. Don't miss out on this **final chance to secure early access**. **Foundations* is designed to be the only textbook that evolves as our field grows. We are here to make a change in medical education and invite you to be a part of it! This isn’t just about innovation. It’s about necessity. Plastic surgery moves fast. The resources we learn from should too. ****Sign up for the waitlist below!** [Reserve Your Copy!](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com#reserve-copy) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Surgeon Practices Shift in Response to BIA-ALCL Awareness Across Europe** ([Santanellidi Pompeo](https://www.jprasurg.com/article/S1748-6815%2824%2900712-5/fulltext?ref=theplasticsfella.com), 2025) Surgeon awareness of BIA-ALCL has driven a shift from macrotextured to smooth implants, with many also reporting changes in patient counseling and greater consideration of autologous reconstruction. ✅ ****Historical Evolution and Safety Controversies of Breast Implants** ([Santanelli di Pompeo](https://www.jprasopen.com/article/S2352-5878%2822%2900013-4/fulltext?ref=theplasticsfella.com), 2022) The evolution of breast implants was shaped by innovations in filler and shell design, regulatory interventions, and safety crises, including capsular contracture, PU degradation, PIP fraud, and BIA-ALCL. ✅ ****Decision Making in Breast Implant Selection for Reconstruction** ([Eijsink](https://www.jprasopen.com/article/S2352-5878%2823%2900071-2/fulltext?ref=theplasticsfella.com), 2023) Breast implant selection varies widely and is influenced by both evidence and non-clinical factors, including frequent patient-driven deviations, which highlights the need for shared decision making. ## Feedback ### I hope you enjoyed it 😄 --- ### Principles of Chest Wall Reconstruction: Anatomy, Indications, & Reconstructive Options URL: https://www.theplasticsfella.com/chest-wall-reconstruction/ Last updated: 2025-05-21T10:13:46.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/chest-wall-reconstruction/#overview-of-chest-wall-reconstruction) Chest wall reconstruction restores structural support, protects thoracic organs, preserves respiratory mechanics, and improves aesthetics, often after oncologic resection, trauma, or infection. [****Chest Wall Anatomy**](https://www.theplasticsfella.com/chest-wall-reconstruction/#anatomy-of-the-chest-wall) There are 3 main anatomical areas to be aware of in chest wall reconstruction: muscles, blood supply, and nerve innervation. [****Principles of Chest Wall Reconstruction**](https://www.theplasticsfella.com/chest-wall-reconstruction/#principles-of-chest-wall-reconstruction) Successful chest wall reconstruction requires adequate debridement followed by obliteration of thoracic dead space, skeletal stabilization, and soft tissue coverage. [****Indications**](https://www.theplasticsfella.com/chest-wall-reconstruction/#indications-of-chest-wall-reconstruction) Chest wall reconstruction is indicated for defects >5 cm, or when structural support, protection of intrathoracic contents, respiratory function, or aesthetics are compromised. [****Assessment**](https://www.theplasticsfella.com/chest-wall-reconstruction/#assessment-of-chest-wall-defects) The assessment of the chest wall defect can be simplified into defect characteristics (size, location, depth), surrounding tissue quality, and patient-specific factors, within a multidisciplinary framework. [****Skeletal Reconstruction**](https://www.theplasticsfella.com/chest-wall-reconstruction/#skeletal-reconstruction-options) Skeletal reconstruction materials must balance rigidity, malleability, and biocompatibility. Options include autologous grafts and alloplastic materials such as mesh, PTFE, titanium plates, and biologic scaffolds. [****Soft Tissue Reconstruction**](https://www.theplasticsfella.com/chest-wall-reconstruction/#soft-tissue-reconstruction-of-the-chest) Main muscles for soft tissue reconstruction are pectoralis major, latissimus dorsi, and rectus abdominis. Omentum can also be used. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview of Chest Wall Reconstruction ****Key Point** Chest wall reconstruction restores structural support, protects thoracic organs, preserves respiratory mechanics, and improves aesthetics, often after oncologic resection, trauma, or infection. Chest wall reconstruction is a complex and multidisciplinary process required when the thoracic cage is compromised in structure or function. This can occur due to cancer resection, trauma, infection, congenital anomalies, or prior surgical complications. Reconstruction aims to achieve four primary goals. - **Restore stability and support** to the chest wall to prevent flail segments or paradoxical motion. - **Protect intrathoracic structures** such as the lungs and mediastinum from external trauma or infection. - **Preserve respiratory mechanics**, minimizing restrictive impairment. - **Provide soft-tissue coverage** that is durable, vascularised, and resistant to infection, especially over exposed organs or prosthetic material. Defect characteristics such as size, location, and depth guide reconstructive planning, along with patient comorbidities, prior treatment (e.g., radiation), and available reconstructive options. Flap selection is based on local anatomy, vascular pedicles, and donor site morbidity, while skeletal defects may require rigid reconstruction using prosthetic materials or titanium supports. Early cases relied on muscle flaps such as the latissimus dorsi (Tansini, 1906), but modern approaches integrate advanced techniques including 3D printing, custom implants, and acellular dermal matrices. Successful outcomes rely on sound surgical planning, a biomimetic approach, and close collaboration with thoracic surgery, oncology, and intensive care teams. Pre- and post-operative macroscopic presentation is illustrated below. ![Pre- and postoperative macroscopic presentation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-02T021955.008.png) Pre- and postoperative macroscopic presentation --- ## Anatomy of the Chest Wall ****Key Point** Chest wall reconstruction relies on an understanding of three core anatomical elements: ****muscles**, ****blood supply**, and ****nerve innervation**. A full anatomical review is beyond scope, but a working knowledge of chest wall structures is essential for flap design and preserving respiratory function. ### Musculature Muscles are grouped based on their relation to the thoracic cage. - **Thoracic Cage Muscles:** Intercostals, subcostals, and transversus thoracis support ventilation and structural integrity. - **Muscles Inserting onto the Cage:** Pectoralis major/minor, serratus anterior, and scalenes are key for both function and reconstruction. Respiratory roles include, - **Inspiratory:** Diaphragm, scalenes, sternocleidomastoid. - **Expiratory:** Abdominals, obliques. ### Vascular Supply - **Arterial:** Primarily from internal thoracic arteries; with input from posterior intercostals, lateral thoracic, and thoracoacromial branches. - **Venous:** Mirrors arterial pathways; posterior drainage via the azygous system. ### Nerve Supply - **Intercostal nerves (T1-T11):** Innervate muscles and overlying skin; crucial to preserve when possible. The arterial supply of the chest wall and their reconstructive role is summarised below. ![Arterial supply of the chest wall and their importance in reconstruction.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-02T014017.932.png) Arterial supply of the chest wall and their importance in reconstruction. --- ## Principles of Chest Wall Reconstruction ****Key Point** Effective chest wall reconstruction depends on thorough debridement, elimination of dead space, skeletal stabilization, and soft tissue coverage. ### The aim of chest wall reconstruction is to restore both function and form—achieving **biomimesis** or anatomical mimicry of the native chest wall ([Rocco](https://pubmed.ncbi.nlm.nih.gov/20974440/?ref=theplasticsfella.com), 2010). Restoring skeletal integrity prevents paradoxical movement, protects intrathoracic contents, and supports respiratory mechanics. This is guided by fundamental reconstructive principles, each tailored to defect size, location, and patient physiology. 1. **Anatomical and Structural Restoration:** Respect native planes and geometry. Skeletal defects, especially anterior or large, require rigid or semi-rigid fixation to preserve chest mechanics and respiratory function. 2. **Tissue Coverage and Organ Protection:** Well-vascularised flaps (preferably locoregional) provide soft tissue coverage, eliminate dead space, and protect vital organs. Avoid rigidity that compromises lung or diaphragm movement. 3. **Precision and Planning:** Optimal outcomes depend on meticulous technique, multidisciplinary coordination, and thoughtful material selection, balancing function, aesthetics, and complication risk ([Anikin](https://shc.amegroups.org/article/view/6037/html?ref=theplasticsfella.com), 2020). Advanced tools like 3D printing and NPWT can support complex reconstructions. In 1906, Tansini pioneered chest wall reconstruction using a pedicled latissimus dorsi flap to repair an anterior thoracic defect ([Tansini](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Tansini+I.+Sopra+il+mio+processo+di+amputazione+della+mammella.+Gazz+Med+Ital+Torino+1906%3B57%3A141&btnG=&ref=theplasticsfella.com), 1906). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/04/Screenshot-2021-04-20-at-21.52.08-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/04/Screenshot-2021-04-20-at-21.52.34-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/04/Screenshot-2021-04-20-at-21.52.17-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/04/Screenshot-2021-04-20-at-21.52.24-1.png) 1908 Lancet Publication translating the work of Tansini ‌ ‌ --- ## Indications of Chest Wall Reconstruction ****Key Point** Chest wall reconstruction is indicated for defects >5 cm, or when structural support, protection of intrathoracic contents, respiratory function, or aesthetics are compromised due to oncologic, traumatic, congenital, or iatrogenic causes. Reconstruction is required when the thoracic cage loses its structural integrity, stability, or soft tissue coverage, regardless of the underlying cause. These defects can arise from resection, trauma, infection, or prior surgery, and often demand a tailored approach based on anatomical and functional needs. ### General Indications - **Defect Size >5 cm:** Often requires skeletal reconstruction, particularly if full-thickness ([Anikin](https://shc.amegroups.org/article/view/6037/html?ref=theplasticsfella.com), 2020). - **Loss of ≥4 Ribs:** Associated with paradoxical chest movement and risk of lung herniation; rigid support may be required ([Anikin](https://shc.amegroups.org/article/view/6037/html?ref=theplasticsfella.com), 2020). - **Sternal Resection:** Especially involving the manubrium; reconstruction prevents anterior instability. - **Exposed Lung, Pleura, or Mediastinum:** Necessitates robust flap coverage to protect vital organs. The indications for stabilisation are summarised below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/04/Chest-Wall-Reconstruction.png) Indications for stabilisation 💡 ****Tip:** Anterolateral defects more frequently require reconstruction due to the lack of inherent bony support in this region ([Anikin](https://shc.amegroups.org/article/view/6037/html?ref=theplasticsfella.com), 2020). ### Individualised Decision-Making Indications should not be applied rigidly. Surgical judgment, patient factors, and resource availability all play a role. Expert variation in practice includes, - **Apicoposterior defects** may be left unreconstructed if the scapula provides natural support ([Deschamps](https://pubmed.ncbi.nlm.nih.gov/10047664/?ref=theplasticsfella.com), 1999). - **Cartilage-level resections (4–6 ribs)** are sometimes managed conservatively without reconstruction ([Deschamps](https://pubmed.ncbi.nlm.nih.gov/10047664/?ref=theplasticsfella.com), 1999). - **Some surgeons reconstruct nearly all defects** to pre-empt instability or patient dissatisfaction ([Hughes](https://pubmed.ncbi.nlm.nih.gov/9326775/?ref=theplasticsfella.com), 1997). 💡 ****Tip:** Radiation-induced fibrosis may provide sufficient rigidity, making stabilisation unnecessary in some large defects ([Losken](https://pubmed.ncbi.nlm.nih.gov/15145731/?ref=theplasticsfella.com), 2004). --- ## Assessment of Chest Wall Defects ****Key Point** Assessment should focus on defect characteristics, surrounding tissue condition, and patient-specific factors, ideally within a multidisciplinary team setting. A thorough evaluation informs timing, feasibility, and the overall strategy for reconstruction. It determines the need for skeletal support, flap selection, and perioperative planning. **Defect: Size, Location, and Depth** The reconstruction decision algorithm is strongly influenced by the size, location, and depth of the chest wall defect. - **Size:** Large defects (>5 cm) often require skeletal reconstruction, especially if full thickness. - **Location** - **Anterolateral:** Greater impact on respiratory mechanics due to lack of sternal or spinal support; structural restoration usually necessary. - **Anterior:** Suitable for pectoralis major or latissimus dorsi flaps. - **Superoposterior:** Often supported by the scapula; may not require skeletal stabilization. - **Depth** - **Partial-Thickness:** May only require skin grafts. - **Full-Thickness:** Usually requires both skeletal and soft tissue reconstruction. **Surrounding Tissue** - **Infection** may necessitate staged reconstruction with initial debridement. - **Radiation** impairs vascularity—flaps should be sourced from non-irradiated areas. - **Oncologic resection** requires clear margins and reliable coverage. - **Dead space** must be assessed and obliterated, especially when vital structures are exposed. 💡 ****Tip:** Irradiated tissues are stiffer, but less likely to have paradoxical chest movements post-resection. **Patient Factors** - Assess overall **suitability** for surgery, cardiopulmonary and nutritional status are key. - **Comorbidities** like diabetes or hypertension must be optimised preoperatively. - **Smoking cessation** should occur at least 4 weeks before surgery. - Review **surgical history**, including prior internal mammary artery harvest. - Factor in **adjuvant therapies**, especially radiotherapy, which impacts flap selection. The use of flaps for chest wall reconstruction is illustrated below. ![The use of flaps for chest wall reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-02T014558.446.png) The use of flaps for chest wall reconstruction 💡 ****Tip:** After sternal resection, muscle flaps may shift reliance to abdominal breathing. This is well tolerated by most, but impactful for patients with pre-existing pulmonary disease ([Netcher](https://pubmed.ncbi.nlm.nih.gov/20009799/?ref=theplasticsfella.com), 2009). --- ## Skeletal Reconstruction Options ****Key Point** Skeletal reconstruction materials must balance rigidity, malleability, and biocompatibility. Options include autologous grafts and alloplastic materials such as mesh, PTFE, titanium plates, and biologic scaffolds. The goal is to **restore chest wall rigidity**, **prevent paradoxical motion**, and **protect intrathoracic organs**. The ideal material should be strong enough to stabilise the defect, yet flexible enough to contour to complex anatomy. It must also be **biocompatible**, **radiolucent**, and **inert** to minimise complications ([Losken](https://pubmed.ncbi.nlm.nih.gov/15145731/?ref=theplasticsfella.com), 2004). There is **no universal consensus** on the best material ([Momeni](https://pubmed.ncbi.nlm.nih.gov/26969557/?ref=theplasticsfella.com), 2016) Selection depends on, - **Defect size, location, and contamination** - **Surgeon preference and experience** - **Institutional resources** (Momeni, 2016) ### ### Alloplastic Materials More commonly used due to their versatility and predictable performance. Each has specific indications and limitations, as summarised in the table below. ![Alloplastic materials for skeletal reconstruction, their features, and pros & cons.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Prominent-Ears--2-.png) Alloplastic materials for skeletal reconstruction, their features, and pros & cons. ### Autologous Materials Now rarely used, autologous options include, - **Split rib grafts**, **iliac crest**, **fibula**, and **fascia**. - Limitations: increased donor-site morbidity, limited shaping, and unpredictable resorption. 💡 ****Tip:** ADM does not create a rigid reconstruction but offers enough support to prevent paradoxical motion ([Butler](https://pubmed.ncbi.nlm.nih.gov/16217466/?ref=theplasticsfella.com), 2005). --- ## Soft-Tissue Reconstruction of the Chest ****Key Point** Main muscles for soft tissue reconstruction are pectoralis major, latissimus dorsi, and rectus abdominis. Omentum can also be used. Soft tissue reconstruction aims to provide robust, vascularised coverage of vital thoracic structures, particularly when skeletal reconstruction is not sufficient to restore protection or contour. Flap selection depends on defect location, size, prior surgeries, and available donor sites. Commonly used flaps include, - **Pectoralis Major Flap** - Ideal for anterior defects, especially post-sternotomy. - Reliable vascularity via thoracoacromial vessels. - Can be advanced, turned over, or islanded. - **Latissimus Dorsi Flap** - Versatile muscle, suitable for anterolateral or posterior defects. - Large surface area, long pedicle (thoracodorsal vessels). - Can be used as a muscle or musculocutaneous flap. - **Rectus Abdominis Flap** - Pedicled superiorly via superior epigastric artery. - Suitable for lower anterior chest wall defects. - Can be raised even if internal mammary arteries are sacrificed (via eighth subcostal artery) (Fernando 1988). - **External Oblique and Serratus Anterior Flaps** - Useful for lateral and posterolateral defects. - External oblique has broad surface but less bulk. - Serratus anterior is thin, pliable, and based on thoracodorsal vessels. - **Omental Flap** - Excellent vascularity and immune properties. - Best for infected or irradiated fields, mediastinal coverage, or irregular dead spaces. - Harvested via laparotomy or laparoscopy. The use of these flaps for chest wall reconstruction is illustrated below. ![Flap options for chest wall reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-02T020947.510.png) Flap options for chest wall reconstruction 💡 ****Tip:** The rectus abdominis muscle can still be used even if the internal mammary artery has been taken, thanks to its collateral supply from the eighth subcostal artery ([Fernando](https://pubmed.ncbi.nlm.nih.gov/2906793/?ref=theplasticsfella.com), 1988). --- ## Further Reading 1. Rocco G. [Chest wall surgery](https://pubmed.ncbi.nlm.nih.gov/20974440/?ref=theplasticsfella.com). Thorac Surg Clin 20:xiii, 2010 2\. Rocco G: Overview on current and future materials for chest wall reconstruction. Thorac Surg Clin 20:559-562, 2010 2. Din AM, Evans GR. [Chest wall reconstruction](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Din+AM%2C+Evans+GR.+Chest+wall+reconstruction.+In%3A+McCarthy+JB%2C+Galiano+RD%2C+Boutros+S%2C+editors.+Current+therapy+in+plastic+surgery.+Philadelphia%3A+Saunders%3B+2006.+p.+362&btnG=&ref=theplasticsfella.com). In: McCarthy JB, Galiano RD, Boutros S, editors. Current therapy in plastic surgery. Philadelphia: Saunders; 2006\. p. 362 3. Seder CW, Rocco G. [Chest wall reconstruction after extended resection](https://pubmed.ncbi.nlm.nih.gov/27942408/?ref=theplasticsfella.com). J Thorac Dis 2016;8:S863-S871. 4. Ferraro P, Cugno S, Liberman M, et al. [Principles of chest wall resection and reconstruction](https://pubmed.ncbi.nlm.nih.gov/20974430/?ref=theplasticsfella.com). Thorac Surg Clin 2010;20:465-73. 5. Mahabir RC, Butler CE. [Stabilization of the chest wall: autologous and alloplastic reconstructions](https://pubmed.ncbi.nlm.nih.gov/22294941/?ref=theplasticsfella.com). Semin Plast Surg 2011;25:34-42. 6. Deschamps C, Tirnaksiz BM, Darbandi R, et al. [Early and long-term results of prosthetic chest wall reconstruction](https://pubmed.ncbi.nlm.nih.gov/10047664/?ref=theplasticsfella.com). J Thorac Cardiovasc Surg 1999;117:588-91\. 13. 7. Arnold PG, Pairolero PC. [Chest wall reconstructions: an account of 500 consecutive cases](https://pubmed.ncbi.nlm.nih.gov/8823018/?ref=theplasticsfella.com). Plast Reconstr Surg 1996; 98(5):804 8. Rocco G. [Chest wall resection and reconstruction according to the principles of biomimesis](https://pubmed.ncbi.nlm.nih.gov/22443650/?ref=theplasticsfella.com). Semin Thorac Cardiovasc Surg 2011;23:307-13. 9. Losken A, Thourani VH, Carlson GW, Jones GE, Culbertson JH, Miller JI, Mansour KA. [A reconstructive algorithm for plastic surgery following extensive chest wall resection](https://pubmed.ncbi.nlm.nih.gov/15145731/?ref=theplasticsfella.com). Br J Plast Surg. 2004 Jun;57(4):295-302\. doi: 10.1016/j.bjps.2004.02.004\. PMID: 15145731. 10. Bostwick J, Nahai F, Wallace JG, et al. [Sixty latissimus dorsi flaps](https://pubmed.ncbi.nlm.nih.gov/155253/?ref=theplasticsfella.com). Plast Reconstr Surg 1979;63:31. 11. Tansini I. [Sopra il mio processo di amputazione della mammella](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Tansini+I.+Sopra+il+mio+processo+di+amputazione+della+mammella.+Gazz+Med+Ital+Torino+1906%3B57%3A141&btnG=&ref=theplasticsfella.com). Gazz Med Ital Torino 1906;57:141 \[in Italian\] 12. Deschamps C, Timaksiz BM, Darbandi R, et al. [Early and long-term results of prosthetic chest wall reconstruction](https://pubmed.ncbi.nlm.nih.gov/10047664/?ref=theplasticsfella.com). J Thorac Cardiovasc Surg 1999;117:588. 13. Weyant MJ, Bains MS, Venkatraman E, et al. [Results of chest wall resection and reconstruction with and without rigid prosthesis](https://pubmed.ncbi.nlm.nih.gov/16368380/?ref=theplasticsfella.com). Ann Thorac Surg 2006;81:279-85. 14. Losken A, Thourani VH, Carlson GW, Jones GE, Culbertson JH, Miller JI, Mansour KA. [A reconstructive algorithm for plastic surgery following extensive chest wall resection](https://pubmed.ncbi.nlm.nih.gov/15145731/?ref=theplasticsfella.com). Br J Plast Surg. 2004 Jun;57(4):295-302\. doi: 10.1016/j.bjps.2004.02.004\. PMID: 15145731. 15. Jones G, Jurkiewicz MJ, Bostwick J, et al. [Management of the infected median sternotomy wound with muscle flaps](https://pubmed.ncbi.nlm.nih.gov/9230817/?ref=theplasticsfella.com). The Emory 20-year experience. Ann Surg 1997;225:766. 16. Nahai F, Morales L Jr, Bone DK, et al. [Pectoralis major muscle turnover flaps for closure of the infected sternotomy wound with preservation of form and function](https://pubmed.ncbi.nlm.nih.gov/7111501/?ref=theplasticsfella.com). Plast Reconstr Surg 1982;70:471 17. Jurkiewicz MJ, Arnold PG. [The omentum: an account of its use in reconstruction of the chest wall](https://pubmed.ncbi.nlm.nih.gov/324413/?ref=theplasticsfella.com). Ann Surg 1977;185:548. 18. Hughes KC, Henry MJ, Turner J, Manders EK. [Design of the cyclops flap for chest-wall reconstruction](https://pubmed.ncbi.nlm.nih.gov/9326775/?ref=theplasticsfella.com). Plast Reconstr Surg. 1997 Oct;100(5):1146-51; discussion 1152\. doi: 10.1097/00006534-199710000-00011\. PMID: 9326775. 19. Bogossian N. [A system for accessing our valuable human resources](https://pubmed.ncbi.nlm.nih.gov/8532796/?ref=theplasticsfella.com). Plast Reconstr Surg. 1996 Jan;97(1):253\. doi: 10.1097/00006534-199601000-00055\. PMID: 8532796. 20. Moschella F, Cordova A. [A new extended external oblique musculocutaneous flap for reconstruction of large chest-wall defects](https://pubmed.ncbi.nlm.nih.gov/10190434/?ref=theplasticsfella.com). Plast Reconstr Surg. 1999 Apr;103(5):1378-85\. doi: 10.1097/00006534-199904050-00006\. PMID: 10190434. 21. Anikin, V., 2020\. [Principles of complex chest wall reconstruction](https://shc.amegroups.org/article/view/6037/html?ref=theplasticsfella.com). Shanghai Chest, 4. 22. Kerrigan CL, Daniel RK. [The intercostal flap: an anatomical and hemodynamic approach](https://pubmed.ncbi.nlm.nih.gov/543605/?ref=theplasticsfella.com). Ann Plast Surg. 1979 May;2(5):411-21\. PMID: 543605. 23. Clemens MW, Evans KK, Mardini S, Arnold PG. [Introduction to chest wall reconstruction: anatomy and physiology of the chest and indications for chest wall reconstruction](https://pubmed.ncbi.nlm.nih.gov/22294938/?ref=theplasticsfella.com). Semin Plast Surg. 2011 Feb;25(1):5-15\. doi: 10.1055/s-0031-1275166\. PMID: 22294938; PMCID: PMC3140236. 24. Minabe T, Harii K. [Dorsal intercostal artery perforator flap: anatomical study and clinical applications](https://pubmed.ncbi.nlm.nih.gov/17700119/?ref=theplasticsfella.com). Plast Reconstr Surg. 2007 Sep;120(3):681-689\. doi: 10.1097/01.prs.0000270309.33069.e5\. PMID: 17700119. 25. Fernando B, Muszynski C, Mustoe T. [Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries](https://pubmed.ncbi.nlm.nih.gov/2906793/?ref=theplasticsfella.com). Ann Plast Surg. 1988 Nov;21(5):468-71\. doi: 10.1097/00000637-198811000-00013\. PMID: 2906793. 26. Momeni A, Kovach SJ. [Important considerations in chest wall reconstruction](https://pubmed.ncbi.nlm.nih.gov/26969557/?ref=theplasticsfella.com). J Surg Oncol. 2016 Jun;113(8):913-22\. doi: 10.1002/jso.24216\. Epub 2016 Mar 9\. PMID: 26969557. 27. Netscher DT, Baumholtz MA. [Chest reconstruction: I. Anterior and anterolateral chest wall and wounds affecting respiratory function](https://pubmed.ncbi.nlm.nih.gov/20009799/?ref=theplasticsfella.com). Plast Reconstr Surg. 2009 Nov;124(5):240e-252e. doi: 10.1097/PRS.0b013e3181b98c9c. PMID: 20009799. 28. Deschamps C, Tirnaksiz BM, Darbandi R, Trastek VF, Allen MS, Miller DL, Arnold PG, Pairolero PC. [Early and long-term results of prosthetic chest wall reconstruction](https://pubmed.ncbi.nlm.nih.gov/10047664/?ref=theplasticsfella.com). J Thorac Cardiovasc Surg. 1999 Mar;117(3):588-91; discussion 591-2\. doi: 10.1016/s0022-5223(99)70339-9\. PMID: 10047664. 29. le Roux BT, Shama DM. [Resection of tumors of the chest wall](https://pubmed.ncbi.nlm.nih.gov/6851629/?ref=theplasticsfella.com). Curr Probl Surg. 1983 Jun;20(6):345-86\. doi: 10.1016/s0011-3840(83)80007-0\. PMID: 6851629. 30. Losken A, Thourani VH, Carlson GW, Jones GE, Culbertson JH, Miller JI, Mansour KA. [A reconstructive algorithm for plastic surgery following extensive chest wall resection](https://pubmed.ncbi.nlm.nih.gov/15145731/?ref=theplasticsfella.com). Br J Plast Surg. 2004 Jun;57(4):295-302\. doi: 10.1016/j.bjps.2004.02.004\. PMID: 15145731. 31. Butler CE, Langstein HN, Kronowitz SJ. [Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications](https://pubmed.ncbi.nlm.nih.gov/16217466/?ref=theplasticsfella.com). Plast Reconstr Surg. 2005 Oct;116(5):1263-75; discussion 1276-7\. doi: 10.1097/01.prs.0000181692.71901.bd. PMID: 16217466. 32. Mahabir RC, Butler CE. [Stabilization of the chest wall: autologous and alloplastic reconstructions](https://pubmed.ncbi.nlm.nih.gov/22294941/?ref=theplasticsfella.com). Semin Plast Surg. 2011 Feb;25(1):34-42\. doi: 10.1055/s-0031-1275169\. PMID: 22294941; PMCID: PMC3140239. 33. Garcia VF, Seyfer AE, Graeber GM. [Reconstruction of congenital chest-wall deformities](https://pubmed.ncbi.nlm.nih.gov/2551052/?ref=theplasticsfella.com). Surg Clin North Am. 1989 Oct;69(5):1103-18\. doi: 10.1016/s0039-6109(16)44941-8\. PMID: 2551052. 34. Corkum JP, Garvey PB, Baumann DP, Abraham J, Liu J, Hofstetter W, Butler CE, Clemens MW. [Reconstruction of massive chest wall defects: A 20-year experience](https://pubmed.ncbi.nlm.nih.gov/32269009/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2020 Jun;73(6):1091-1098\. doi: 10.1016/j.bjps.2020.02.010\. Epub 2020 Feb 17\. PMID: 32269009. ### Congenital Haemangioma: Clinical Presentation, Diagnosis, & Management URL: https://www.theplasticsfella.com/congenital-haemangioma/ Last updated: 2025-05-19T10:59:18.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/congenital-haemangiomas/#overview-of-congenital-haemangiomas) Congenital haemangiomas are rare vascular tumors present at birth that resemble, but are distinct from, infantile haemangiomas. [****Clinical Presentation**](https://www.theplasticsfella.com/congenital-haemangiomas/#clinical-presentation-of-congenital-haemangiomas) Congenital haemangiomas (CHs) are fully formed at birth and present as solitary vascular lesions. They are classified into three types: RICH, PICH, and NICH, based on their involution behaviour and clinical features. [****Involution**](https://www.theplasticsfella.com/congenital-haemangiomas/#involution-of-congenital-haemangiomas) RICHs involute rapidly, starting from 1 month and resolving by 1 year; PICHs show partial involution and stabilize by 12 months. Involution patterns help differentiate subtypes. [****Diagnosis**](https://www.theplasticsfella.com/congenital-haemangiomas/#diagnosis-of-congenital-haemangiomas) Diagnosis is clinical, but ultrasound & MRI are used as adjuncts for imaging. Clinical presentation, histology, and immunohistochemistry (IHC) are important for differentiating CH from IH. [****Management**](https://www.theplasticsfella.com/congenital-haemangiomas/#management-of-congenital-haemangiomas) Observation is first-line for most congenital haemangiomas. Surgery is reserved for complications or persistent lesions. Lasers may address residual telangiectasia. [****Complications**](https://www.theplasticsfella.com/congenital-haemangiomas/#complications-of-congenital-haemangiomas) Early complications include ulceration, haemorrhage, thrombocytopenia, and high-output cardiac failure. Late complications include pain, thrombosis, and tissue necrosis. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Congenital Haemangioma ****Key Point** Congenital haemangiomas are rare vascular tumors present at birth that resemble, but are distinct from, infantile haemangiomas. Congenital haemangiomas are rare vascular tumors that are fully developed at birth.Although they can resemble infantile haemangiomas, congenital haemangiomas (CHs) are a separate entity with distinct biological and clinical features. Their diagnosis and management depend on recognizing these differences early. - **Fully Formed at Birth:** CHs are present and mature at delivery, unlike infantile haemangiomas which appear postnatally and proliferate. - **GLUT1-Negative:** This immunohistochemical marker is absent in CHs, helping distinguish them from other vascular lesions ([Atheron](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - **Do Not Grow After Birth:** CHs do not undergo postnatal proliferation and instead follow one of three involution patterns ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). - **RICH:** Rapidly involuting. - **PICH:** Partially involuting. - **NICH:** Non-involuting. - **Uncommon and Poorly Understood:** Their exact pathophysiology remains unclear, and they are significantly rarer than infantile haemangiomas. - **Male Predominance:** Observed more frequently in males, with a reported sex ratio of around 1.7:1. A congenital haemangioma of the lower limb is illustrated below. ![A congenital haemangioma of the lower limb](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-14T023149.172.png) A congenital haemangioma of the lower limb 😎 ****Fun Fact:** Rarely, some NICHs can show ****tardive expansion** (postnatal growth), which may represent a separate CH subtype under ongoing investigation ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). --- ## Clinical Presentation of Congenital Haemangioma ****Key Point** Congenital haemangiomas (CHs) are fully formed at birth and present as solitary vascular lesions. They are classified into three types: RICH, PICH, and NICH, based on their involution behaviour and clinical features. CHs are rare vascular tumours that resemble infantile haemangiomas but are fully developed at birth and follow distinct clinical courses. They present as solitary, well-demarcated lesions (red-purple) with telangiectasia and often a pale peripheral halo ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). ### General Features - **Location:** Most CHs occur on the **extremities**, followed by the **head and neck**, then the **trunk** ([Enjolras](https://pubmed.ncbi.nlm.nih.gov/16997442/?ref=theplasticsfella.com), 2006). - **RICHs:** On the head and neck or extremities ([Atheron](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - **PICHs:** On the head and neck, trunk, and extremities, - **NICHs:** Typically found on the trunk and extremities. - **Size:** Most are **\>2 cm**; around one-third, especially NICHs, exceed **5 cm** (Braun, 2020). - **Shape & Number:** Typically solitary lesions with a discoid or plaque-like appearance. - **Halo:** More than **50%** show **peripheral vasoconstrictive halos**. ### Features by Subtype Congenital haemangiomas are classified based on their natural history and clinical behaviour. While RICH, PICH, and NICH show distinct outcomes, overlapping features suggest these variants exist along a pathological continuum ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). **Rapidly Involuting Congenital Haemangioma (RICH)** - **At Birth:** Appears as a **bulky, exophytic mass**, resembling a raised tumour ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020; [Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - Begins involution within the first month of life and typically completes by 1 year. - May be associated with **transient thrombocytopenia** due to **localised intravascular consumptive coagulopathy**. - Primarily found on the head, neck, and extremities ([Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - Cannot be reliably distinguished from PICH at birth, only two-thirds undergo complete involution ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). **Partially Involuting Congenital Haemangioma (PICH)** - **Clinically Resembles RICH at Birth:** bulky, red to violaceous patches, plaques, or masses with telangiectasia and surrounding pallor ([Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - Undergoes **partial involution**, then stabilises in size ([Nasseri](https://pubmed.ncbi.nlm.nih.gov/24176519/?ref=theplasticsfella.com), 2014). - May exhibit **s**ubcutaneous draining channels and develop central ulceration, which is more common in PICH and may predict incomplete involution ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). - Can cause neuropathic pain, likely due to intralesional nerve bundles ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). - Often stabilises at a median age of 12 months ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). - Found on the head, neck, trunk, and extremities. **Non-Involuting Congenital Haemangioma (NICH)** - **At Birth:** Appears as a **flat, solitary** plaque. - Lesions are pink to violaceous with coarse telangiectasia, bluish discolouration, and a blanching peripheral halo ([Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - Does **not regress**; may grow proportionately with the child. - May present with delayed-onset neuropathic pain due to nerve dystrophy ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). - Typically located on the trunk and extremities. - May result from **in utero involution** of RICH ([Enjolras](https://pubmed.ncbi.nlm.nih.gov/16997442/?ref=theplasticsfella.com), 2006). ### Infantile vs Congenital Haemangioma IH and CH are both vascular tumours but have distinct features in their presentation, course of involution, and treatment approaches. Below is a comparison of key features of [infantile haemangiomas](https://www.theplasticsfella.com/infantile-haemangioma/) vs congenital haemangiomas. ![Comparison of key features of infantile haemangiomas vs congenital haemangiomas](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-14T022529.420.png) Comparison of key features of infantile haemangiomas vs congenital haemangiomas --- ## Involution of Congenital Haemangioma ****Key Point** RICHs involute rapidly, starting from 1 month and resolving by 1 year; PICHs show partial involution and stabilize by 12 months. Involution patterns help differentiate subtypes. The timing and pattern of involution are central to distinguishing congenital haemangioma subtypes. **One-­third** of CHs that appeared RICH at birth undergo incomplete involution to become PICHs ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). - **RICH** - Involution begins at a median age of **4 weeks**. - Lesions completely regress by a median age of **13 months**. - One-third of CHs that appear as RICH at birth ultimately undergo only partial involution. - **PICH** - Involution begins around **7 weeks**. - Lesions stabilize at a median of **12 months** without complete regression. - Often evolve from lesions initially resembling RICH. 😎 ****Fun Fact:** In utero involution has also been documented in antenatally diagnosed CHs ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). --- ## Diagnosis of Congenital Haemangiomas ****Key Point** The main modality of diagnosis is clinical, but ultrasound and MRI can be used as adjuncts for imaging. Clinical presentation, histology, and immunohistochemistry (IHC) are important for differentiating CH from IH. **Congenital haemangiomas (CHs)** are usually diagnosed based on clinical presentation. However, when features are atypical, **biopsy and imaging** are essential to rule out other vascular tumours such as kaposiform haemangioendothelioma or tufted angioma ([Putra](https://pubmed.ncbi.nlm.nih.gov/28438388/?ref=theplasticsfella.com), 2017). The imaging and histological data of the three CH subtypes are rather similar ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). Adjuncts to clinical diagnosis are imaging and echocardiography & coagulation studies. ### Imaging **Ultrasound** CHs are well-circumscribed, highly vascularised tumours with enlarged arteries and veins, and high-velocity flow ([Nasseri](https://pubmed.ncbi.nlm.nih.gov/24176519/?ref=theplasticsfella.com), 2014). - Hypoechoic, homogeneous, or heterogeneous. - **Calcifications** may appear (seen in 2 RICHs and 1 PICH). - **Microshunts** are more frequent in NICH. An ultrasound of a congenital haemangioma is illustrated below. ![An ultrasound of a congenital haemangioma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-14T023153.555.png) An ultrasound of a congenital haemangioma **MRI** - **T1-weighted:** Well-defined, homogeneous lesions with gadolinium enhancement (Braun, 2020). - **T2-weighted:** Hyperintense, patchy or homogeneous signals with flow voids and fat stranding ([Nasseri](https://pubmed.ncbi.nlm.nih.gov/24176519/?ref=theplasticsfella.com), 2014). ### Echocardiography & Coagulation Studies Used in large CHs to assess high-output cardiac states and thrombocytopenia ([Hinen](https://pubmed.ncbi.nlm.nih.gov/33194900/?ref=theplasticsfella.com), 2020). **Histopathology** - CHs consist of capillary lobules with draining arteries and normal or dysplastic veins in fibrous stroma ([El Zein](https://pubmed.ncbi.nlm.nih.gov/32281140/?ref=theplasticsfella.com), 2020). - Arteriovenous fistulae may be seen. - Epidermis is atrophic with loss of dermal appendages ([Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). **Immunohistochemistry** - **GLUT-1 Negative:** Unlike infantile haemangiomas. - **PS100 Positive:** Identifies variable intralesional nerve bundles and nerve hypertrophy. ### Distinguishing CH from IH - CH is **present at birth**, IH appears postnatally. - CH is **GLUT-1 negative**, IH is GLUT-1 positive. - CH may show **heterogeneous imaging**, thrombi, aneurysms, or ill-defined margins ([Sheikh](https://radiopaedia.org/articles/congenital-haemangioma?lang=gb&ref=theplasticsfella.com), 2023). 😎 ****Fun Fact:** Arteriovenous shunts have been reported in PICH ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). --- ## Management of Congenital Haemangiomas ****Key Point** Observation is first-line for most congenital haemangiomas. Surgery is reserved for complications or persistent lesions. Lasers may address residual telangiectasia. **Observation** is the mainstay of treatment for most congenital haemangiomas (CHs), as many regress spontaneously without intervention ([Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). When treatment is considered, options include surgery and laser therapy. **Indications for Surgery** Surgical excision (with or without preoperative embolisation) may be required in specific clinical situations, - Life-threatening haemorrhage or hemodynamic instability. - Significant arteriovenous shunting causing heart failure, anaemia, or thrombocytopenia ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020; [Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022; [Sheikh](https://radiopaedia.org/articles/congenital-haemangioma?lang=gb&ref=theplasticsfella.com), 2023). - Liver CHs with high-output cardiac failure ([Hinen](https://pubmed.ncbi.nlm.nih.gov/33194900/?ref=theplasticsfella.com), 2020). - Persistent or severe ulceration ([Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - Cosmetic or functional impairment. - Residual atrophic tissue following partial involution ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). **Laser Therapy** **Pulsed dye laser** may be used to treat associated **telangiectasias** ([Hinen](https://pubmed.ncbi.nlm.nih.gov/33194900/?ref=theplasticsfella.com), 2020). 💡 ****Tip:** Unlike infantile haemangiomas, CHs do not respond to propranolol. Medical therapy is generally ineffective ([Sheikh](https://radiopaedia.org/articles/congenital-haemangioma?lang=gb&ref=theplasticsfella.com), 2023). --- ## Complications of Congenital Haemangiomas ****Key Point** Early complications include ulceration, haemorrhage, thrombocytopenia, and high-output cardiac failure. Late complications include pain, thrombosis, and tissue necrosis. Congenital haemangiomas (CHs) may result in both local and systemic complications depending on lesion size, location, and vascular dynamics. #### Early Complications - **Ulceration:** Most frequently associated with PICH; also a predictor of partial involution. - **Haemorrhage:** Particularly in large CHs ([Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - **Thrombocytopenia:** Transient, mild to moderate; associated with RICH due to localized intravascular consumptive coagulopathy ([Atherton](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com), 2022). - **High-Output Cardiac Failure:** Seen in large, highly vascular CHs; typically transient and resolves after involution. #### Late Complications - **Neuropathic Pain:** Seen in NICH; may result from intralesional nerve dystrophy ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). - **Superficial Thrombosis:** Involves vessels close to the lesion surface. - **Tissue Necrosis:** Due to compromised perfusion of overlying skin. 💡 ****Tip:** Thrombocytopenia in RICH and NICH is usually transient and should not be confused with Kasabach–Merritt phenomenon, which requires a different clinical approach ([Braun](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com), 2020). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Congenital haemangiomas (CHs) are rare, benign vascular tumors, fully developed at birth. They are GLUT1-negative and present in three clinical types: RICH, PICH, and NICH, based on their involution behaviour. ****2\. Clinical Presentation:** CHs are solitary, red-to-violaceous lesions with telangiectasia and often a pale halo. RICH involutes rapidly, PICH partially regresses, and NICH remains stable or grows proportionately. Lesions commonly occur on the extremities, head, neck, or trunk. ****3\. Diagnosis and Involution:** Diagnosis is primarily clinical, supported by imaging (ultrasound, MRI) and histopathology. Involution patterns differ: RICH resolves by 1 year, PICH stabilizes by 12 months, and NICH persists. CHs are GLUT1-negative, distinguishing them from infantile haemangiomas. ****4\. Treatment and Complications:** Most CHs are managed conservatively. Surgery is reserved for complications like bleeding, ulceration, or cardiac issues. Laser therapy may improve residual telangiectasia. Complications include ulceration, haemorrhage, pain, and high-output cardiac failure in large lesions. --- ## Further Reading 1. Atherton K, Hinen H. [Vascular Anomalies: Other Vascular Tumors](https://pubmed.ncbi.nlm.nih.gov/36243428/?ref=theplasticsfella.com). Dermatol Clin. 2022 Oct;40(4):401-423\. doi: 10.1016/j.det.2022.06.011\. Epub 2022 Sep 16\. PMID: 36243428. 2. North PE, Waner M, James CA, Mizeracki A, Frieden IJ, Mihm MC Jr. [Congenital nonprogressive hemangioma: a distinct clinicopathologic entity unlike infantile hemangioma](https://pubmed.ncbi.nlm.nih.gov/11735711/?ref=theplasticsfella.com). Arch Dermatol. 2001 Dec;137(12):1607-20\. doi: 10.1001/archderm.137.12.1607\. PMID: 11735711. 3. Nasseri E, Piram M, McCuaig CC, Kokta V, Dubois J, Powell J. [Partially involuting congenital hemangiomas: a report of 8 cases and review of the literature](https://pubmed.ncbi.nlm.nih.gov/24176519/?ref=theplasticsfella.com). J Am Acad Dermatol. 2014 Jan;70(1):75-9\. doi: 10.1016/j.jaad.2013.09.018\. Epub 2013 Oct 29\. PMID: 24176519. 4. Braun V, Prey S, Gurioli C, Boralevi F, Taieb A, Grenier N, Loot M, Jullie ML, Léauté-Labrèze C. [Congenital haemangiomas: a single-centre retrospective review](https://pubmed.ncbi.nlm.nih.gov/33324762/?ref=theplasticsfella.com). BMJ Paediatr Open. 2020 Dec 7;4(1):e000816\. doi: 10.1136/bmjpo-2020-000816\. PMID: 33324762; PMCID: PMC7722829. 5. Enjolras O, Picard A, Soupre V. [Hémangiomes congénitaux et autre tumeurs vasculaires infantiles rares](https://pubmed.ncbi.nlm.nih.gov/16997442/?ref=theplasticsfella.com) \[Congenital haemangiomas and other rare infantile vascular tumours\]. Ann Chir Plast Esthet. 2006 Aug-Oct;51(4-5):339-46\. French. doi: 10.1016/j.anplas.2006.07.006\. Epub 2006 Sep 25\. PMID: 16997442. 6. Sheikh Z, Weerakkody Y, Ashraf A, et al. [Congenital haemangioma](https://radiopaedia.org/articles/congenital-haemangioma?lang=gb&ref=theplasticsfella.com). Reference article, Radiopaedia.org (Accessed on 08 May 2025). 7. Putra J, Gupta A. [Kaposiform haemangioendothelioma: a review with emphasis on histological differential diagnosis](https://pubmed.ncbi.nlm.nih.gov/28438388/?ref=theplasticsfella.com). Pathology. 2017 Jun;49(4):356-362\. doi: 10.1016/j.pathol.2017.03.001\. Epub 2017 Apr 21\. PMID: 28438388. 8. .El Zein S, Boccara O, Soupre V, Vieira AF, Bodemer C, Coulomb A, Wassef M, Fraitag S. [The histopathology of congenital haemangioma and its clinical correlations: a long-term follow-up study of 55 cases](https://pubmed.ncbi.nlm.nih.gov/32281140/?ref=theplasticsfella.com). Histopathology. 2020 Aug;77(2):275-283\. doi: 10.1111/his.14114\. Epub 2020 Jul 26\. PMID: 32281140. 9. Hinen HB, Trenor CC 3rd, Wine Lee L. [Childhood Vascular Tumors](https://pubmed.ncbi.nlm.nih.gov/33194900/?ref=theplasticsfella.com). Front Pediatr. 2020 Oct 22;8:573023\. doi: 10.3389/fped.2020.573023\. Erratum in: Front Pediatr. 2021 Feb 24;9:649610\. doi: 10.3389/fped.2021.649610\. PMID: 33194900; PMCID: PMC7642460. 10. The Plastics Fella. [Infantile Hemangiomas](https://www.theplasticsfella.com/infantile-haemangioma/). November 2024\. Accessed on 7th May 2025. ### Facelift: Anatomy, Clinical Assessment, & Techniques URL: https://www.theplasticsfella.com/facelift/ Last updated: 2025-05-19T10:55:54.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/facelift/#overview-of-facelift) Facelift, or rhytidectomy, addresses facial aging by lifting and repositioning the SMAS and soft tissues to improve midface, jawline, and neck definition. [****Relevant Anatomy**](https://www.theplasticsfella.com/facelift/#relevant-anatomy-for-facelift) The SMAS is the key layer in facelift surgery, surrounding the mimetic muscles, while the facial nerve (CN VII) and retaining ligaments are critical landmarks, with the nerve requiring careful preservation. [****Clinical Assessment & Indications**](https://www.theplasticsfella.com/facelift/#clinical-assessment-indications-for-facelift) A thorough assessment considers medical history, medications, prior treatments, and facial anatomy. Goals include restoring contours, volume, and tightening for a natural, refreshed appearance. [****Surgical Techniques**](https://www.theplasticsfella.com/facelift/#surgical-techniques-for-facelift) Multiple facelift techniques exist, differing in dissection depth, SMAS handling, and lift vector. Ranging from skin-only to deep plane and preservation methods, with distinct indications, risks, and outcomes. [****Postoperative Care & Complications**](https://www.theplasticsfella.com/facelift/#postoperative-care-complications-of-facelift) Post-op care involves head elevation, cold compresses, antibiotics, and activity restrictions. Complications include hematoma, skin necrosis, nerve injury, infection, and scarring, with varying risks. ****Primary Contributor:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Facelift ****Key Point** Facelift or rhytidectomy, addresses facial aging by lifting and repositioning the SMAS and soft tissues to improve midface, jawline, and neck definition. Facelift surgery (rhytidectomy) rejuvenates facial contours by repositioning deep tissues and removing or redraping excess skin to correct laxity, soft tissue descent, and volume changes. It has the ability to, - Enhance the jawline. - Reduce nasolabial folds. - Lift the midface and neck. Techniques have progressed from simple skin excisions to advanced multilayered methods targeting the SMAS, deep fat compartments, and retaining ligaments. 😎 ****Fun Fact:** Described by [Mitz and Peyronie](https://pubmed.ncbi.nlm.nih.gov/935283/?ref=theplasticsfella.com) in 1976, the SMAS revolutionized the approach to facelift - though its anatomical distinctness remains debated ([Minelli et al.](https://pubmed.ncbi.nlm.nih.gov/37039509/?ref=theplasticsfella.com), 2023). --- ## Relevant Anatomy for Facelift ****Key Point** The SMAS is the key layer in facelift surgery, surrounding the mimetic muscles, while the facial nerve (CN VII) and retaining ligaments are critical landmarks, with the nerve requiring careful preservation. The soft tissues of the face are organized in concentric layers, similar to the scalp. The **five** anatomic layers are ([Mendelson](https://pubmed.ncbi.nlm.nih.gov/12172155/?ref=theplasticsfella.com), 2002), 1. Layer 1: **Skin**. 2. Layer 2: **Subcutaneous fat**. 3. Layer 3: **Superficial musculoaponeurotic system (SMAS)**. 4. Layer 4: **Loose areolar tissue** (contains retaining ligaments + glide planes). 5. Layer 5: **Deep fascia**. The image below illustrates these five soft tissue layers of the face. ![The five anatomic layers of the face, facelift surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Facelift--1-.png) The five anatomic layers of the face ### SMAS The **SMAS** (layer 3) is the key layer for facelift procedures. It invests the mimetic muscles and is continuous with the platysma muscle inferiorly and the temporoparietal fascia and galea aponeurotica superiorly. It can be divided into two main portions. - **Fixed Lateral SMAS:** Tightly adherent to the parotid gland. - **Mobile Medial SMAS:** Thinner and areolar in nature; easier to dissect. The SMAS layers are illustrated below. ![SMAS layers of the face, Facelift surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Facelift--2-.png) SMAS layers of the face Areas where the SMAS is fused to the deep fascia or anchored to underlying structures are known as **retaining ligaments;** they function as, - True osteocutaneous ligaments (e.g., zygomatic, mandibular) - Fusion zones between superficial and deep fascial layers (e.g., masseteric) ### Facial Nerve The facial nerve (CN VII) exits the stylomastoid foramen and enters the parotid gland, dividing into five branches. - **Temporal:** Follows Pitanguy’s line; at risk during high-SMAS or temple dissection. - **Zygomatic** - **Buccal** - **Marginal Mandibular:** Emerges 1–2 cm from the gonial angle; typically runs above the mandible but is vulnerable due to its superficial course. - **Cervical:** Innervates platysma; enters subplatysmal plane early and is at risk during neck dissection. Branches run deep to the parotid-masseteric fascia and enter the sub-SMAS plane to innervate muscles, except the levator anguli oris, buccinator, and mentalis, which receive superficial innervation. They remain protected deep within the retaining ligaments until those structures are released during dissection. IMPORTANT Crucially, facial nerve branches lie deep to the retaining ligaments, providing protection during early dissection. However, once these ligaments are released, the nerves become more superficial and increasingly vulnerable to injury ([Charafeddine](https://pubmed.ncbi.nlm.nih.gov/31514803/?ref=theplasticsfella.com), 2019). The facial nerve is illustrated below. ![The facial nerve, Facelift, Facial anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Facelift--3-.png) The facial nerve 😎 ****Fun Fact:** The ****frontal** and ****marginal mandibular branches** have a lower potential for functional recovery if damaged, owing to their limited interconnections with respect to other facial nerve branches. --- ## Clinical Assessment & Indications for Facelift ****Key Point** A thorough assessment considers medical history, medications, prior treatments, and facial anatomy. Goals include restoring contours, volume, and tightening for a natural, refreshed appearance. Successful facelift surgery starts with a thorough **patient assessment**. This includes, ### History - **Detailed Medical History:** Particular attention should be paid to: cardiovascular diseases, diabetes mellitus, history of bleeding disorders or poor wound healing, and smoking and alcohol use. - **Medications:** Anticoagulants, antiplatelet agents, NSAIDs, corticosteroids, and herbal supplements may increase the risk of bleeding or delay healing. - **Prior Facial Treatments:** Facial surgeries, injectables, or energy-based treatments may alter tissue quality and intraoperative handling, leading to increased fibrosis, reduced pliability, and unpredictable dissection planes. ### Examination: The **physical exam** focuses on evaluating the degree and pattern of facial aging. Key aspects include, - **Skin Quality:** Texture, elasticity, photodamage. - **Soft Tissue Laxity:** Midface descent, jowling, platysmal banding. - **Fat Volume:** Loss in the malar area or accumulation along the jawline. - **Bone Support:** Mandibular and malar projection. - **Neck Anatomy:** Cervicomental angle, subplatysmal fullness. - **Dynamic Activity:** Overactive depressors, facial asymmetries. Aesthetic evaluation is conducted in both static and dynamic states, often with photographic documentation. Patients should be assessed in upright and supine positions to simulate intraoperative tissue repositioning. The aim of a modern facelift is **restoration, not transformation**. Key objectives include, - **Repositioning** midface and lower face ptosis. - **Restoring** gonial angle, cervicomental angle, and mandibular border. - **Volumization** with fat grafting or redraping, avoiding excessive skin tension. - **Tightening** of the SMAS layer while maintaining a natural appearance. - **Neck contouring**, when indicated, via subplatysmal or anterior approaches. ### Contraindications Certain conditions may contraindicate facelift surgery, either absolutely or relatively. These include, - **Uncontrolled Comorbidities:** Hypertension, diabetes, or cardiac disease. - **Active Smoking:** Increases the risk of flap necrosis and poor wound healing. - **Coagulopathy or Anticoagulants:** Unless managed preoperatively. - **Psychological Instability:** Body dysmorphia or unrealistic expectations. - **Prior Radiation to the Face or Neck:** May impair vascularity and healing. - **Poor Skin Quality:** May limit aesthetic outcomes. Each case should be evaluated individually, with surgical planning adapted to minimize risk and optimize results. --- ## Surgical Techniques for Facelift ****Key Point** Multiple facelift techniques exist, differing in dissection depth, SMAS handling, and lift vector. Ranging from skin-only to deep plane and preservation methods, each with distinct indications, risks, and outcomes. Over the years, a variety of techniques have been developed, reflecting the evolving understanding of facial anatomy, ageing physiology, and aesthetic ideals. Surgical approaches vary in complexity, depth of dissection, extent of SMAS manipulation, and vector of lift. ### Superficial Techniques 1. **Skin-Only Facelift** This is the most limited form of facelift, involving only skin undermining and redraping. There is no SMAS manipulation. While the procedure is fast and associated with a short recovery, results are generally less durable and natural due to the skin bearing all the tension. Main indication is for older patients with comorbidities or those seeking minimal downtime. 1. **SMAS Plication** This technique involves subcutaneous dissection with folding (plicating) the SMAS using sutures without excision. It enhances midface and jawline contour without entering the deep plane, although it may not sufficiently address advanced aging or volume descent. 1. **SMAS Imbrication** The technique consists of incision, advancement, and overlapping SMAS with suture fixation. The cheek and neck are suspended upward and laterally without SMAS undermining. Drawbacks and advantages similar to plication. 1. **SMASectomy** ([Baker](https://pubmed.ncbi.nlm.nih.gov/19331867/?ref=theplasticsfella.com), 2001) A strip of SMAS is excised, usually from the lateral cheek, and the edges are sutured under tension to elevate the underlying tissues. It presents the risk of contour irregularities and limited midface effect. 1. **Minimal Access Cranial Suspension (MACS) Facelift** ([Tonnard](https://pubmed.ncbi.nlm.nih.gov/19341646/?ref=theplasticsfella.com), 2007) A variation of the plication method. Subcutaneous tissues are dissected from the underlying SMAS-platysma layer and then suspended via long looping sutures with multiple bites (microimbrication) in a vertical vector. ### Deep Plane and High SMAS Techniques 1. **High SMAS Facelift** ([Barton](https://pubmed.ncbi.nlm.nih.gov/1409995/?ref=theplasticsfella.com), 1992) Involves elevating the SMAS flap more medially, over the zygomatic eminence, allowing better control of midface volume and nasolabial fold softening. The dissection stays in the sub-SMAS plane and does not routinely involve ligamentous release. Advantages include improved midface and jowl correction with a vertical vector of lift. Although it is technically demanding, with risk of injury to the facial nerve if improperly executed. 1. **Deep Plane Facelift** ([Hamra](https://pubmed.ncbi.nlm.nih.gov/2359803/?ref=theplasticsfella.com), 1990) Consists of sub-SMAS dissection with release of the zygomatic and upper masseteric retaining ligaments. The skin, SMAS, and malar fat pad are mobilized en bloc, which allows for a natural vector of repositioning. It offers profound and long-lasting midface and lower face rejuvenation with minimal skin tension. Presents a steep learning curve, with a higher risk of nerve injury in inexperienced hands and longer operative time. 1. **Lamellar High SMAS** ([Marten](https://pubmed.ncbi.nlm.nih.gov/18922311/?ref=theplasticsfella.com), 2008) Presents a more extended skin flap dissection. It is based on two vectors: One for the SMAS (almost vertical) and another for the skin flap (instead diagonal/superolateral), for an optimal correction of nasolabial folds. ### Subperiosteal Facelift Introduced by [Tessier](https://pubmed.ncbi.nlm.nih.gov/2473674/?ref=theplasticsfella.com), it involves dissection in a deep subperiosteal plane over the facial skeleton, primarily targeting the midface. It allows for elevation of the malar fat pad by releasing deep retaining ligaments. Its use is limited due to technical complexity, risk of nerve injury, and minimal impact on the lower face and neck. ### Composite Facelift The **composite facelift**, also developed by [Hamra](https://pubmed.ncbi.nlm.nih.gov/1615067/?ref=theplasticsfella.com), extends the deep plane dissection to include the **orbicularis oculi muscle**, elevating it in continuity with the SMAS. This allows for superior rejuvenation of the periorbital and malar regions, effectively treating tear trough deformity and eyelid-cheek junction descent. ### Preservation Facelift Initially described by [Gordon](https://pubmed.ncbi.nlm.nih.gov/38049109/?ref=theplasticsfella.com), this technique combines **limited subcutaneous delamination** with strategic release of retaining ligaments, allowing the mobilization of a **composite SMAS flap** with preserved anatomical integrity and improved biomechanical properties. By avoiding wide subcutaneous undermining, the preservation facelift offers several theoretical advantages: reduced risk of vascular compromise, shorter recovery times, and maintenance of native fat compartments and ligamentous architecture, which may contribute to a more natural and long-lasting result, particularly in younger patients or those with favourable soft tissue tone. ### Endoscopic Facelift The **endoscopic facelift** represents a minimally invasive approach to facial rejuvenation, primarily applied to the **upper third** of the face, particularly in **endoscopic brow lifting**. More advanced applications have extended endoscopic techniques to the **midface**, allowing mobilization of the **malar fat pad** and **orbicularis oculi complex** through subperiosteal dissection. Key advantages include **reduced incision length** and **quicker recovery** compared to open techniques. However, outcomes may be more modest; the technique requires significant expertise, and it is indicated only for patients with minimal skin excess. These facelift techniques are summarised below. ![Surgical techniques of facelift](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Facelift-1.png) Surgical techniques of facelift --- ## Post Operative Care & Complications of Facelift ****Key Point** Post-op care involves head elevation, cold compresses, antibiotics, and activity restrictions; complications include hematoma, skin necrosis, nerve injury, infection, and scarring, with risks varying by surgical plane. Post-operative management is essential to optimize healing, reduce complications, and ensure patient satisfaction. Standard care protocols include, - **Head elevation** and **rest**. - **Cold compresses** during the first 48 h can reduce swelling and bruising. - **Antibiotics**, short-term prophylactic to prevent infection. - **Drains** may be applied. - **Activity restrictions** for at least 3–4 weeks. - **Follow-up.** ### Complications - **Hematoma** (1.9–3%): The **most common** complication, typically within the first 24 h. It requires prompt evacuation to prevent flap compromise. - **Skin Necrosis** (\~1%): More common in smokers or where excessive tension is applied to the skin. - **Facial Nerve Injury:** Transient facial nerve weakness is relatively common, especially with deep plane procedures. Instead, permanent injury is rare. - **Asymmetries** or **Recurrence** (3.9%): Revisions are sometimes required due to asymmetry, recurrence of skin laxity, or dissatisfaction with the results. - **Infection:** Although rare, infection can occur. Early signs include fever, redness, and swelling. Prophylactic antibiotics help mitigate the risk. - **Scarring:** While most scars heal well, they can be hypertrophic in some cases, especially if the patient has a history of poor scarring. The complications of facelift, along with the associated techniques, are summarised below. ![Complications of facelift and associated techniques](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Facelift--1--1.png) Complications of facelift and associated techniques 💡 ****Tip:** To differentiate a cervical branch injury from a Marginal Mandibular Nerve (MMN) injury, ask the patient to pucker or evert the lower lip; if eversion is possible, the MMN is intact. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Facelift surgery repositions facial soft tissues to correct aging-related descent, improving jawline, midface, and neck contour. It’s a key procedure in facial rejuvenation, often combined with fat grafting or blepharoplasty. ****2\. Relevant Anatomy:** Understanding the SMAS, facial nerve branches, retaining ligaments, and the transition from fixed to mobile SMAS is essential for safe and effective dissection. ****3\. Preoperative Assessment & Indications:** Candidates present with ptosis, jowling, and neck laxity. Assessment includes skin quality, facial volume, and expectations. Planning defines dissection plane, lift vector, and combined procedures. ****4\. Surgical Techniques:** Techniques range from skin-only to deep plane and high SMAS. Deep approaches lift the SMAS-malar complex en bloc, offering more natural and lasting results. Most recent techniques include composite facelift, preservation facelift and endoscopic techniques. ****5\.** ****5\. Postoperative Care & Complications:** Head elevation, limited activity, and antibiotics reduce risks. Complications include hematoma, nerve injury, skin necrosis, asymmetry, and scarring. --- ## Further Reading 1. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002 Sep 1;110(3):885-96; discussion 897-911\. doi: 10.1097/00006534-200209010-00026\. PMID: 12172155. 2. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976 Jul;58(1):80-8\. doi: 10.1097/00006534-197607000-00013\. PMID: 935283. 3. Minelli L, van der Lei B, Mendelson BC. The Superficial Musculoaponeurotic System: Does It Really Exist as an Anatomical Entity? Plast Reconstr Surg. 2024 May 1;153(5):1023-1034\. doi: 10.1097/PRS.0000000000010557\. Epub 2023 Apr 11\. PMID: 37039509; PMCID: PMC11027987. 4. Charafeddine AH, Drake R, McBride J, Zins JE. Facelift: History and Anatomy. Clin Plast Surg. 2019 Oct;46(4):505-513\. doi: 10.1016/j.cps.2019.05.001\. Epub 2019 Jul 17\. PMID: 31514803. 5. Alghoul M, Bitik O, McBride J, Zins JE. Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the Sub-SMAS danger zone. Plast Reconstr Surg. 2013 Feb;131(2):245e-252e. doi: 10.1097/PRS.0b013e3182789c5c. PMID: 23358020. 6. Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg. 1992 Oct;90(4):601-7\. doi: 10.1097/00006534-199210000-00008\. PMID: 1409995. 7. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992 Jul;90(1):1-13\. doi: 10.1097/00006534-199207000-00001\. PMID: 1615067. 8. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990 Jul;86(1):53-61; discussion 62-3\. PMID: 2359803. 9. Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy. Aesthet Surg J. 2007 Mar-Apr;27(2):188-98\. doi: 10.1016/j.asj.2007.01.008\. PMID: 19341646. 10. Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001 Jan;21(1):14-26\. doi: 10.1067/maj.2001.113557\. PMID: 19331867. 11. Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg. 2008 Oct;35(4):569-603, vi-vii. doi: 10.1016/j.cps.2008.04.002\. PMID: 18922311. 12. Gordon NA, Sawan TG. Deep-Plane Rhytidectomy: Pearls in Maximizing Outcomes while Minimizing Recovery. Facial Plast Surg. 2025 Feb;41(1):2-11\. doi: 10.1055/s-0043-1777312\. Epub 2023 Dec 4\. Erratum in: Facial Plast Surg. 2025 Feb;41(1):e1\. doi: 10.1055/s-0044-1779261\. PMID: 38049109. 13. Tessier P. Le lifting facial sous-périosté \[Subperiosteal face-lift\]. Ann Chir Plast Esthet. 1989;34(3):193-7\. French. PMID: 2473674. 14. Roskies M, Bray D, Gordon NA, Gualdi A, Nayak LM, Talei B. Limited Delamination Modifications to the Extended Deep Plane Rhytidectomy: An Anatomical Basis for Improved Outcomes. Facial Plast Surg Aesthet Med. 2024 Nov-Dec;26(6):657-664\. doi: 10.1089/fpsam.2024.0018\. Epub 2024 Jul 29\. PMID: 39072376. 15. Botti G, Botti C, Cella A, Gualdi A. Correction of the naso-jugal groove. Orbit. 2007 Sep;26(3):193-202\. doi: 10.1080/01676830701539430\. PMID: 17891647. ### Committees are Stagnant, Last Chance to Join Waitlist, & 4 Nasal Anatomy Essentials URL: https://www.theplasticsfella.com/may-18th/ Last updated: 2025-05-17T12:20:38.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-18th/#a-letter-from-pfella) Grassroots Will Save Surgical Education—Not Committees 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-18th/#the-sunday-quiz) How well do you know nasal anatomy. 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-18th/#image-of-the-week) Landmarks and surface anatomy of the nose. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-18th/#technique-tip) Rhinoplasty incision options. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/may-18th/#upcoming-events) Share your event with plastic surgeons around the world! 6. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/may-18th/#foundations-textbook) Waiting List close this Monday! 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-18th/#articles-of-the-week) Recommended anatomy reads for rhinoplasty & blepharoplasty: with 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/may-18th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella Grassroots Will Save Surgical Education—Not Committees 👋 ****Hey Team!** Let’s call it out: ****The best surgical education doesn’t come from committees.** It comes from whiteboards in theatre, from WhatsApp groups, from the first five minutes of morning handover. It’s fast, personal, and built on trust, not bureaucracy. ### Traditional systems remain stuck. Committees meet often, but execute rarely. They build frameworks no one reads and publish textbooks that are out-of-date before they’re even printed. ### The Problem with Top-Down Learning Centralised education is slow, generic, and disconnected from reality. Surgical trainees are left refreshing outdated PDFs while actual teaching happens in the shadows: side-room chats, case-based group threads, weekend workshops. That’s the grassroots model. And it works. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Screenshot-2025-05-17-at-13.10.19.png) In fact, **over 70% of our users say The Plastics Fella is their main learning resource.** That’s not just a win, it’s a warning. If education becomes too centralised, it becomes fragile. We need structure but we also need speed and relevance. ### The Solution: Localised, Decentralised, Community-Driven We don’t need more global committees. We need **global frameworks** that allow for **local voices**. Education should reflect the trauma load in Nairobi as much as the melanoma protocols in Melbourne. That’s the only way to scale quality without losing relevance. And yes tech can help. But only if it follows the educators, not replaces them. In the future, you department will be able to buy [**Foundations**](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com)specific to your local region to reflect local protocols and realities. ### What Do You Think? Is grassroots the future—or do we still need committees steering the ship? Reply. Or better yet—tell us what’s working in your unit. Because surgical education should belong to all of us, not just those with a seat at the table. With ❤️ and zero bureaucracy, **P’Fella** ## The Sunday Quiz **How Well Do You Know Nasal Anatomy* ****Ready to climb the leaderboard?** Join **The Weekly Quiz* in each edition of thePlasticsPaper. Tackle one question per week for seven rounds The ****top** scorer wins a copy of our upcoming textbook, [**Foundations*](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com). ## Image of the Week **Landmarks and Surface Anatomy of the Nose* 🖼️ ****Image of the Week** This week’s image breaks down the key external landmarks of the nose, crucial for preoperative planning in rhinoplasty and nasal reconstruction. From the ****nasion** to the ****infratip lobule**, each structure is labelled to support accurate assessment of dorsal aesthetics, tip projection, and columellar-labial relationships. ![Landmarks and Measurements of the Nose](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Your-paragraph-text--1-.png) Landmarks and Measurements of the Nose ## Technique Tip **Rhinoplasty Incision Options* 🚑 ****Technique Tip of the Week** This week’s tip explores incision selection in rhinoplasty, demonstrated through a clinical case featuring standard rhinoplasty pre-op views. These photographs illustrate the ****frontal, lateral, base, and top views** used to assess nasal asymmetry, tip definition, and columellar-labial angle — all of which influence the ****choice between open and closed approaches**. \- Open rhinoplasty allows direct visualisation of tip structures, ideal for complex reconstructions or major asymmetries. \- Closed (endonasal) rhinoplasty may be preferable for minor dorsal adjustments with minimal visible scarring. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/image-4.png) [Source](https://www.rhinoplastyarchive.com/?ref=theplasticsfella.com) ## Upcoming Events **Share Your Event With Plastic Surgeons Around the World!* 📅 ****Stay in the loop with P’Fella’s curated calendar** All the good stuff in one place: Impactful conferences, high-yield webinars, and carefully curated courses for you. Got an event coming up at your unit? Hosting a teaching session or journal club? **Add it in** and we’ll share it with **plastic surgeons around the world!** Check out what’s on or add your own to the mix👇 ## Foundations Textbook **Waiting List Close This Monday!* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Your-paragraph-text-1.png) 📙 ****Waiting List Closes This Monday: Ships This July** P’Fella spent years in plastic surgery education, refining based on how you learn, what sticks, and what doesn’t. ****Foundations** is the result of all that feedback, trial, and refinement. It’s not a regular textbook; rather, a tool built for the way **you* actually study, recall, and operate. 👉 ****Short-form chapters** for high-yield recall 👉 ****Curriculum-mapped** content with ****clinical focus** 👉 ****QR codes** for live updates, new visuals, or technique refreshers 👉 ****AI-powered visuals** designed for effective learning styles This is the only plastic surgery textbook that evolves with you. ****Pre-orders close on Monday!** [Reserve Your Copy!](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com#reserve-copy) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Anatomy and Biomechanics of the Hand and Wrist** ([Chim](https://journals.lww.com/plasreconsurg/fulltext/2017/10000/hand%5Fand%5Fwrist%5Fanatomy%5Fand%5Fbiomechanics%5F%5Fa.43.aspx?ref=theplasticsfella.com), 2017) Hand and wrist function relies on surface anatomy and joint kinematics of the forearm, wrist, and hand, with joint-specific structure guiding both diagnostic accuracy and therapeutic planning. ✅ ****Rhinoplasty: Aesthetic, Functional, and Historical Perspectives** ([Hohman](https://www.ncbi.nlm.nih.gov/books/NBK558970/?ref=theplasticsfella.com), 2024) Rhinoplasty integrates aesthetic refinement and functional restoration, and its success depends on anatomical insight, operative planning, and patient selection, while techniques span from reduction to structural grafting. ✅ ****Modern Principles of Blepharoplasty Emphasize Tissue Preservation and Volume Enhancement** ([Alghoul](https://academic.oup.com/asj/article-abstract/39/1/10/4883186?redirectedFrom=fulltext&ref=theplasticsfella.com), 2019) Successful blepharoplasty relies on detailed anatomical knowledge and conservative technique, shifting away from volume excision toward tissue preservation to avoid hollowing and achieve natural periorbital rejuvenation. ## Feedback ### I hope you enjoyed it 😄 --- ### Anatomy of the Nose: Landmarks, Structure, & Surgical Considerations URL: https://www.theplasticsfella.com/anatomy-of-the-nose/ Last updated: 2025-05-12T11:28:36.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/anatomy-of-the-nose/#overview-of-anatomy-of-the-nose) The nose is a complex, layered structure composed of skin, muscles, bones, and cartilage, with key external landmarks guiding clinical assessment and anthropometric measurements for surgical planning. [****Landmarks and Measurements**](https://www.theplasticsfella.com/anatomy-of-the-nose/#landmarks-and-measurements-of-the-nose) Key nasal landmarks guide rhinoplasty planning; ideal angles include a nasofrontal angle of 115-130° and a nasolabial angle of 90-105°, with tip projection and length assessed via Goode’s ratio and facial thirds. [****Skin and Soft Tissue Envelope**](https://www.theplasticsfella.com/anatomy-of-the-nose/#skin-and-soft-tissue-envelope) The nasal skin-soft tissue envelope includes key layers: Skin, superficial and deep fat, nasal SMAS, and periosteum/perichondrium. Muscles are functionally grouped into four categories. [****The Bony Vault** ](https://www.theplasticsfella.com/anatomy-of-the-nose/#bony-vault-of-the-nose) The bony vault, formed by nasal bones and maxilla, connects with frontal and ethmoid bones; the keystone area which is crucial for dorsal support, is the bone-cartilage overlap on the dorsum. [****The Cartilaginous Vault**](https://www.theplasticsfella.com/anatomy-of-the-nose/#cartilaginous-vault-of-the-nose) The middle third includes ULCs and dorsal septum, forming dorsum and the internal valve. The lower third has LLCs, accessory cartilages, and fibrofatty tissue, shaping tip, columella, and alae. [****Internal Anatomy of the Nose**](https://www.theplasticsfella.com/anatomy-of-the-nose/#internal-anatomy-of-the-nose) The internal nose consists of the septum, which divides the nasal cavity; the internal valve, formed between the ULCs and septum; and the turbinates, which filter and humidify inspired air. [****Blood Supply**](https://www.theplasticsfella.com/anatomy-of-the-nose/#blood-supply-to-the-nose) The nose is vascularized by branches of the internal and external carotid arteries, mainly the facial and ophthalmic arteries, which form rich anastomoses across the dorsum and sidewalls. [****Nerve Supply**](https://www.theplasticsfella.com/anatomy-of-the-nose/#nerve-supply-to-the-nose) The external nose is innervated by the trigeminal nerve (CN V), with V1 supplying the cephalic regions and V2 the caudal lateral areas. ****Updated by:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Anatomy of the Nose ****Key Point** The nose is a complex, layered structure composed of skin, muscles, bones, and cartilage, with key external landmarks guiding clinical assessment and anthropometric measurements for surgical planning. The nose serves both aesthetic and functional roles and is one of the most structurally and anatomically intricate regions of the face. It is composed of layered components, including **skin**, **fat**, **soft tissue**, **muscles**, **cartilage**, and **bone**. Each of these contributes to nasal form, symmetry, and airway function. The nasal framework is broadly divided into, - **Upper Third (Bony Vault):** Formed by paired nasal bones. - **Middle Third (Cartilaginous Vault):** Shaped by the upper lateral cartilages and the septum. - **Lower Third (Tip Complex):** Formed by the lower lateral cartilages and surrounding soft tissue. From an external perspective, key surface landmarks such as the **radix**, **dorsum**, **tip**, and **alar margins** guide both aesthetic assessment and surgical planning. Internally, the **nasal septum and turbinates** regulate airflow, humidification, and filtration. --- ## Landmarks and Measurements of the Nose ****Key Point** Key nasal landmarks guide rhinoplasty planning; ideal angles include a nasofrontal angle of 115-130° and a nasolabial angle of 90-105°, with tip projection and length assessed via Goode’s ratio and facial thirds. External nasal anatomy provides a crucial reference for both aesthetic evaluation and surgical intervention. Surface landmarks not only reflect underlying anatomical structures but also help determine the proportion, symmetry, and balance of the nose relative to the rest of the face. The nose is commonly divided into thirds, from cephalic to caudal: **nasion**, **rhinion**, and **tip**. Important anatomical landmarks include, - **Nasion (Radix region):** Midpoint of the nasofrontal suture. - **Sellion:** Deepest point of the nasofrontal angle; soft tissue correlate of the nasion. - **Kyphion:** Most prominent point of the bony nasal dorsum. - **Rhinion:** Caudal edge of the nasal bones, marking transition to cartilage. - **Pronasale (Tip):** Most anterior projecting point of the nose. - **Supratip Breakpoint:** Junction between dorsum and tip. - **Supratip Lobule:** Region between pronasale and supratip breakpoint. - **Infratip Lobule:** Area between the tip and nostril apex (columellar-lobular junction). The image below illustrates external surface landmarks of the nose. ![Surface landmarks of the nose](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-12T163040.076.png) Surface landmarks of the nose To achieve nasal-facial harmony, several anthropometric ideals are considered. - **Nasofrontal Angle:** 115°–130°. - **Nasolabial Angle:** \~90°–95° in men; 95°–105° in women. - **Tip Projection:** Goode’s ratio = \~0.55–0.6 × nasal length. - **Nasal Length:** Ideally, **two-thirds** of total facial length. - **Frontal View:** Nose should fall within vertical lines from the medial canthi; alar base width should match intercanthal distance. These measurements help guide surgical decision-making in rhinoplasty and contribute to achieving both functional and aesthetic goals. ![Measurements of dorsal profile](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Nasal-Anatomy--5-.png) Measurements of dorsal profile --- ## Skin and Soft Tissue Envelope ****Key Point** The nasal skin – soft tissue envelope includes key layers: skin, superficial and deep fat, nasal SMAS, and periosteum/perichondrium. Muscles are functionally grouped into four categories. The skin and soft tissue envelope (STE) of the nose determines how underlying structural changes manifest externally. Understanding its composition and variability is essential for surgical planning, especially in rhinoplasty, where skin thickness influences the predictability of outcomes. ### Skin **Skin thickness** is one of the most important factors to evaluate preoperatively. It directly affects the extent to which underlying structural changes will be visible externally. - Upper Two-Thirds: **Thinner, more mobile skin** ([Lessard](https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/612001?ref=theplasticsfella.com), 1985). - Lower Third: **Thicker, more sebaceous** ([O'Neal](https://www.sciencedirect.com/science/article/abs/pii/S0030666505701195?via%3Dihub&ref=theplasticsfella.com), 1999). The soft tissue layers between the skin and the osteocartilaginous skeleton are, - **Superficial fatty layer (panniculus adiposus).** - **Fibromuscular layer** (**nasal SMAS** \- subcutaneous musculoaponeurotic system). - **Deep fatty layer.** - **Periosteum** or **perichondrium.** 💡 ****Tip:** The deep fatty layer is of particular surgical importance, as it contains the major superficial blood vessels and motor nerves. The ideal plane of surgical dissection lies just beneath this layer. ### Muscle The **nasal muscles** are categorized into **four functional groups** ([Griesman](https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/575346?ref=theplasticsfella.com), 1944 & [Letourneau](https://pubmed.ncbi.nlm.nih.gov/3380925/?ref=theplasticsfella.com), 1988). - **Elevator muscles** (shorten the nose, dilate the nostrils). - Procerus. - Levator labii superioris alaeque nasi. - Anomalous nasi. - **Depressor muscles** (lengthen the nose, dilate the nostrils). - Depressor septi. - Alar part of the nasalis (dilator naris posterior). - **Compressor muscles** (lengthen the nose, narrow the nostrils). - Transverse portion of the nasalis. - Compressor narium minor. - **Minor dilator muscle**. - Dilator naris anterior. All nasal muscles are innervated by branches of the **zygomaticotemporal** division of the facial nerve. The nasal musculature is summarised in the table below ([Griesman](https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/575346?ref=theplasticsfella.com), 1944). ![The four functional groups of nasal muscles](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Nasal-Anatomy--2--1.png) The four functional groups of nasal muscles --- ## Bony Vault of the Nose ****Key Point** The bony vault, formed by nasal bones and maxilla, connects with frontal and ethmoid bones; the keystone area, crucial for dorsal support, is the bone-cartilage overlap on the dorsum. The upper third of the nose is the rigid bony framework that provides dorsal support and defines the nasal profile. Its integrity and shape are essential considerations in both functional and aesthetic rhinoplasty. The **bony vault** represents the **upper 1/3** of the nose whichconsists of, - **Paired nasal bones**. - **Ascending (frontal) processes of the maxilla**. In relation to **adjacent bones**, the nasal bone interdigitates with, - **Superior:** Nasal process of the **frontal bone**. - **Lateral:** Frontal process of the **maxilla**. - **Posterior:** **Perpendicular plate** of the ethmoid. - **Medial:** Paired nasal bones at midline forming the roof of nasal cavity. A crucial structural region, known as the **keystone area**, lies just caudal to the intercanthal line. It includes the overlap of four major elements, - **Nasal bones** - **Upper lateral cartilages** - **Cartilaginous septum** - **Perpendicular plate of the ethmoid** This confluence provides **essential support** to the nasal dorsum and is a critical consideration in rhinoplasty. The bony vault of the nose is illustrated below. ![Bony vault of the nose, Nose anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Nasal-Anatomy--6-.png) Bony vault of the nose --- ## Cartilaginous Vault of the Nose ****Key Point** The middle third includes ULCs and dorsal septum, forming dorsum and internal valve. The lower third has LLCs, accessory cartilages, and fibrofatty tissue, shaping the tip, columella, and alae, supported by interdomal and dermocartilaginous ligaments. The cartilaginous vault forms the structural and aesthetic core of the mid and lower nose. It contributes to dorsal contour, tip definition, and internal valve competence, and is composed of distinct but interrelated units. The **middle 1/3** of the nasal cavity is a cartilaginous structure which includes, - **Upper Lateral Cartilages (ULCs):** Paired, connected medially to the dorsal septum and superiorly to the nasal bones. These define the upper cartilaginous dorsum and contribute to the internal valve angle. Laterally, the ULCs are unsupported by bone and held in place by soft tissue attachments. - **Dorsal Cartilaginous Septum (Quadrangular Cartilage):** Central support structure of the nose, extending anteriorly from the perpendicular plate of the ethmoid. - **External Lateral Triangle:** A mucosa-lined lateral recess that may contain sesamoid cartilages and impact nasal airflow. These structures form a rigid yet flexible vault that contributes to the nasal dorsum and internal nasal valve. The cartilaginous vault of the nose is illustrated below. ![Middle 1/3 cartilaginous vault of the nose](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Nasal-Anatomy--3--1.png) Middle 1/3 cartilaginous vault of the nose 💡 ****Tip:** Preserving the mucoperichondrium between ULCs and septum is vital to maintain internal valve function during surgery. The **lower 1/3** of the nose comprises, - **Lower Lateral Cartilages (LLCs)** are divided into, - **Medial Crura:** Contribute to the columellar shape and projection. - **Middle (Intermediate) Crura:** Domal and lobular segments, critical for tip definition. - **Lateral Crura:** Support the alar rim and shape the nostril sidewalls. - **Accessory Cartilages:** Small, often variable pieces between the LLCs and piriform aperture. - **Fibrofatty Tissue:** Completes the contour of the nasal tip and nostrils. **Ligamentous Support** - **Interdomal Ligament:** Connects medial and middle crura anteriorly. - **Dermocartilaginous Ligament (Pitanguy Ligament):** Vertical fibers anchoring the tip to the skin, contributing to tip stability and definition. - **Scroll Area:** The junction between the lateral crura and ULCs. Each component must be considered in tip rotation, projection, and support during rhinoplasty. The lower 1/3 cartilaginous vault of the nose is illustrated below. ![Lower 1/3 cartilaginous vault of the nose](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Nasal-Anatomy--5-.png) Lower 1/3 cartilaginous vault of the nose --- ## Internal Anatomy of the Nose ****Key Point** The internal nose consists of the septum, which divides the nasal cavity; the internal valve, formed between the ULCs and septum; and the turbinates, which filter and humidify inspired air. A clear understanding of internal nasal anatomy is essential in rhinoplasty and septoplasty to preserve or restore nasal airflow. The internal structures contribute significantly to nasal function and must be carefully evaluated in both functional and aesthetic procedures. #### Nasal Septum The septum divides the nasal cavity and consists of, - **Cartilaginous Component:** The quadrangular cartilage anteriorly. - **Bony Components:** Perpendicular plate of the ethmoid superiorly, and the vomer inferiorly, articulating with the nasal crest of the maxilla and palatine bones. The **anterior nasal spine** represents the caudal attachment of the septum. #### Internal Nasal Valve Formed by the junction of the **upper lateral cartilages (ULCs)** and the **septum**, the internal nasal valve is the narrowest segment of the nasal airway. Its angle, normally between **10–15°**, critically affects nasal airflow. #### Turbinates The **superior**, **middle**, and **inferior turbinates** are scroll-like bony structures lined with vascularized mucosa. They humidify and filter inspired air and may become hypertrophic in response to septal deviations. The inferior turbinate, in particular, is frequently addressed in nasal surgeries to improve airflow and exposure. Internal nose anatomy is illustrated below. ![Internal nose anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Nasal-Anatomy--6-.png) Internal nose anatomy --- ## Blood Supply to the Nose ****Key Point** The nose is vascularized by branches of the internal and external carotid arteries, mainly the facial and ophthalmic arteries, which form rich anastomoses across the dorsum and sidewalls. Venous drainage mirrors arterial pathways via facial, pterygoid, and ophthalmic veins. The nose receives a rich vascular supply from both the **internal and external carotid arteries** ([Letourneau](https://pubmed.ncbi.nlm.nih.gov/3380925/?ref=theplasticsfella.com), 1988). **Arterial Supply** The nose receives blood from both the **external** and **internal carotid** systems. - **External Carotid System** - Facial artery gives rise to, - **Superior Labial Artery:** Contributes **columellar** branches to the tip. - **Angular Artery:** Supplies the sidewalls and dorsum. - **Internal Carotid System** - Ophthalmic Artery (branch of internal carotid) gives off, - Anterior Ethmoidal Artery - Dorsal Nasal Artery - External Nasal Branch - The **dorsal nasal artery** anastomoses with the angular artery, forming a robust **subdermal plexus** across the dorsum. ![Arterial supply to the nose](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Nasal-Anatomy--7-.png) Arterial supply to the nose These extensive **anastomoses** create a **rich axial vascular network**, essential for, - Skin flap viability - Healing post-rhinoplasty - Avoiding ischemic complications **Venous Drainage** Venous return follows a path similar to the arterial system. - **Facial vein** - **Pterygoid venous plexus** - **Ophthalmic veins** --- ## Nerve Supply to the Nose ****Key Point** The external nose is innervated by branches of the trigeminal nerve (CN V), with V1 supplying the cephalic regions and V2 the caudal lateral areas. The external nose receives its **sensory innervation** primarily from branches of the trigeminal nerve (CN V), specifically, - **Ophthalmic Nerve (V1):** Radix, upper dorsum, and sidewalls of the nose (supratrochlear and infratrochlear nerves, branches of V1). - **Maxillary Nerve (V2): Infraorbital nerve**, a branch of V2, supplies the lower lateral sidewalls of the nose, portions of the columella, and the lateral vestibule. This nerve is frequently targeted with an infraorbital nerve block in rhinoplasty procedures performed under local anesthesia. Together, these branches provide a rich and overlapping sensory network. 😎 ****Fun Fact:** The external nasal nerve, emerging at the keystone area, supplies the nasal tip and caudal dorsum, and it is often injured during rhinoplasty, causing temporary or persistent numbness. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Nasal Anatomy Overview:** Understanding of the nose's complex structure, including its skin, muscles, bones, and cartilage, essential for clinical assessment and surgical planning. ****2\. Landmarks and Ideal Measurements:** Learn about key nasal landmarks for rhinoplasty, including ideal angles and measurements, such as the nasofrontal angle, nasolabial angle, and Goode’s ratio for tip projection and length. ****3\. Skin and Soft Tissue Envelope:** Review the layers of the nasal skin-soft tissue envelope, including the skin, fat, SMAS, and periosteum/perichondrium, along with the functional grouping of muscles. ****4\. The Bony Vault:** Understanding the structure of the bony vault, including the nasal bones and maxilla, and the importance of the keystone area for dorsal support. ****5\. The Cartilaginous Vault:** Understanding the cartilaginous components, including ULCs, LLCs, and fibrofatty tissue, and their role in shaping the tip, columella, and alae. ****6\. Internal Anatomy of the Nose:** Identify the components of the internal nose, including the septum, internal valve, and turbinates, which are critical for airflow filtration and humidification. ****7\. Blood Supply to the Nose: U**nderstand the vascularization of the nose, focusing on the arterial supply from the internal and external carotid arteries, along with venous drainage. ****8\. Nerve Supply to the Nose:** Learn about the sensory innervation of the external nose, provided by the trigeminal nerve (CN V), with V1 innervating the cephalic regions and V2 the caudal lateral areas. --- ## Further Reading 1. Lessard M-L, Daniel RK. [Surgical Anatomy of Septorhinoplasty](https://doi.org/10.1001/archotol.1985.00800030059006?ref=theplasticsfella.com). *Archives of Otolaryngology – Head and Neck Surgery*. Published online January 1, 1985:25-29\. doi:10.1001/archotol.1985.00800030059006 2. Oneal RM, Beil RJ Jr, Schlesinger J. [SURGICAL ANATOMY OF THE NOSE](https://doi.org/10.1016/s0030-6665%2805%2970119-5?ref=theplasticsfella.com). *Otolaryngologic Clinics of North America*. Published online February 1999:145-181\. doi:10.1016/s0030-6665(05)70119-5 3. Letourneau A, Daniel R. The superficial musculoaponeurotic system of the nose. *Plast Reconstr Surg*. 1988;82(1):48-57\. 4. Griesman B. [Muscles And Cartilages Of The Nose From The Standpoint Of A Typical Rhinoplasty](https://doi.org/10.1001/archotol.1944.00680010348009?ref=theplasticsfella.com). *Archives of Otolaryngology – Head and Neck Surgery*. Published online April 1, 1944:334-341\. doi:10.1001/archotol.1944.00680010348009 5. Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM, Kosins AM. Rhinoplasty: the nasal bones - anatomy and analysis. Aesthet Surg J. 2015 Mar;35(3):255-63\. doi: 10.1093/asj/sju050\. PMID: 25805278. 6. Fonseca E, Baldini N, Alomani M, Saban Y. Nasal Bones Anatomy and Analysis for Dorsal Preservation Rhinoplasty. Aesthet Surg J. 2023 Feb 21;43(3):NP227-NP228\. doi: 10.1093/asj/sjac300\. PMID: 36402140; PMCID: PMC9942437. 7. Sowder JC, Thomas AJ, Ward PD. Essential Anatomy and Evaluation for Functional Rhinoplasty. Facial Plast Surg Clin North Am. 2017 May;25(2):141-160\. doi: 10.1016/j.fsc.2016.12.001\. PMID: 28340646. 8. Lane AP. Nasal anatomy and physiology. Facial Plast Surg Clin North Am. 2004 Nov;12(4):387-95, v. doi: 10.1016/j.fsc.2004.04.001\. PMID: 15337106. ### Hartrampf’s Zones of Perfusion: Anatomy, Clinical Applications, & Modifications URL: https://www.theplasticsfella.com/hartrampfs-zones-of-perfusion/ Last updated: 2025-05-12T10:37:24.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/hartrampfs-zones-of-perfusion/#overview-of-hartrampfs-zones-of-perfusion) Hartrampf’s Zones provide a reliable framework for understanding perfusion gradients in abdominal flaps. This system divides the flap into four anatomically based zones. [****Clinical Applications**](https://www.theplasticsfella.com/hartrampfs-zones-of-perfusion/#clinical-applications-of-hartrampfs-zones-of-perfusion) The abdominal flap is divided into four zones based on their spatial relationship to the dominant perforator. Zone I is the most reliable; Zone IV is the least. [****Evolution & Modifications**](https://www.theplasticsfella.com/hartrampfs-zones-of-perfusion/#evolution-of-hartrampfs-zones-of-perfusion) Hartrampf’s original four-zone model has evolved through imaging-based refinements. Holm reversed Zones II and III, while Saint-Cyr demonstrated that perfusion depends on the perforator row. ****Updated by:** Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Hartrampf's Zones of Perfusion ****Key Point** Hartrampf’s Zones provide a reliable framework for understanding perfusion gradients in abdominal flaps. This system divides the flap into four anatomically based zones and helps in reconstructive planning. **Hartrampf’s Zones of Perfusion** divide the lower abdominal flap into four zones based on vascular perfusion *(Hartrampf et al., 1990; Holm et al., 2006)*. This system helps predict flap viability when using TRAM or DIEP flaps for breast reconstruction. It is especially relevant when considering the vascular anatomy of musculocutaneous flaps in breast reconstruction. **Clinical Relevance** This classification guides flap design by identifying regions with higher or lower perfusion. It is particularly useful in guiding, - Flap orientation and design during reconstruction. - Anticipation of perfusion-related complications. - Decision-making on partial flap discard or deepithelialisation. **History and Origin** - Originally introduced by **Scheflan and Dinner** in 1983, during refinements of the TRAM flap technique. The zones became widely associated with **Hartrampf,** following his 1990 publication. - His clinical observations and surgical outcomes helped standardize this approach. - Later refinements by **Holm et al.** and **Saint-Cyr** introduced imaging-based updates and the concept of perforasomes *(Saint-Cyr et al., 2011)*. 😎 ****Fun Fact:** The classification was originally designed for unipedicled TRAM flaps and has since informed DIEP flap design as well. --- ## Clinical Applications of Hartrampf's Zones of Perfusion ****Key Point** The abdominal flap is divided into four zones based on their spatial relationship to the dominant perforator. Zone I is the most reliable; Zone IV is the least. This classification helps guide flap orientation, inset, and decisions about partial flap use or discard. ### Identifying the Zones The lower abdominal flap is divided vertically at the midline into right and left hemi-abdomens. Zones are labeled I through IV in relation to the selected perforator (typically medial row). - **Zone I:** Ipsilateral to the dominant perforator. Centrally located and best perfused. - **Zone II:** Contralateral and medial. Adjacent to Zone I across the midline. - **Zone III:** Ipsilateral and lateral to Zone I. - **Zone IV:** Contralateral and lateral to Zone II; most peripheral and least perfused. These four zones are illustrated below. ![The four zones of the abdominal flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-21T185207.233.png) The four zones of the abdominal flap ### Practical Implications - **Zone I:** Forms the core of most flap reconstructions due to excellent perfusion. - **Zone II:** Has variable perfusion; suitable for inclusion if perforator mapping supports it. - **Zone III:** May be more reliable than Zone II in certain perforator configurations (e.g., lateral row). - **Zone IV:** High risk of fat necrosis. Often discarded or deepithelialised. These zones and their clinical use are summarised below. ![Four zones of the abdominal flap, their location, relation to the perforator, perfusion reliability, and clinical use](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-21T185542.157.png) Four zones of the abdominal flap, their location, relation to the perforator, perfusion reliability, and clinical use 💡 ****Tip:** Intraoperative ICG angiography can help assess zone viability in real time and guide tailored flap planning. --- ## Evolution of Hartrampf's Zones of Perfusion ****Key Point** Hartrampf’s original four-zone model has evolved through imaging-based refinements. Holm reversed Zones II and III based on perfusion studies, while Saint-Cyr demonstrated that perfusion depends on the perforator row, forming the basis for the perforasome concept. ### Hartrampf’s Original Concept (1990) - Based on perfusion patterns observed in unipedicled TRAM flaps, Hartrampf defined a consistent medial-to-lateral hierarchy of blood supply. - His work reflected the reliance on musculocutaneous vascular pedicles without perforator mapping, leading to his four-zone model. - Proposed a **medial-to-lateral gradient** of perfusion. - Zone I (ipsilateral medial): best perfused. - Zone II (contralateral medial). - Zone III (ipsilateral lateral). - Zone IV (contralateral lateral): least perfused. ### Holm’s Modification (2006) - **Dinner** initially noted a perfusion mismatch between Zones II and III, prompting re-evaluation. - **Holm et al.** confirmed that Zone III (ipsilateral lateral) may be better perfused than Zone II (contralateral medial), especially in DIEP flaps. - Their use of **fluorescent dye perfusion** demonstrated that lateral zones on the same side as the perforator are often safer than assumed. ### Saint-Cyr’s Refinement (2011) - Through **3D and 4D CTA studies**, Saint-Cyr et al. showed that perfusion is **perforator-row-dependent**. - **Medial Row Perforators:** Central perfusion pattern aligns with Hartrampf's model. - **Lateral Row Perforators:** Shift perfusion laterally, aligning with Holm's reversed classification. - They also introduced the **perforasome concept**. - Defined as the vascular territory of a single perforator. - Emphasizes interconnections between territories. - Supports individualized flap planning based on CTA imaging rather than fixed zones. The table below summarises the evolution of Hartrampf’s original zones of perfusion. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-21T193752.795.png) The evolution of Hartrampf’s original zones of perfusion 😎 ****Fun Fact:** The perforasome model was inspired by Taylor and Palmer’s angiosome theory, but focuses on ****microvascular perfusion** of skin and fat, rather than muscle. ### Supporting Evidence Landmark studies by Scheflan, Hartrampf, Holm, and Saint-Cyr shaped and validated the zone classification system, evolving it from anatomical observation to a perforator-specific, imaging-guided planning model. - **Scheflan & Dinner (1983):** Described transverse abdominal island flap design refinements. - **Hartrampf et al. (1990):** Popularized four-zone perfusion classification. - **Holm et al. (2006):** Fluorescent perfusion studies re-evaluated zone reliability. - **Saint-Cyr (2011):** Used CTA to validate perforator-dependent perfusion patterns and introduced the perforasome theory. 💡 ****Tip:** While Hartrampf’s zones provide a useful starting point, ****modern flap planning should incorporate imaging** to assess individual vascular anatomy. Rigid adherence to zone models may overlook patient-specific perfusion nuances. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Understood that Hartrampf’s Zones of Perfusion divide the lower abdominal flap into four anatomical regions based on vascular reliability, essential for flap planning in TRAM and DIEP reconstruction. ****2\. Clinical Use:** Learned how to identify and apply the four zones (I–IV) in relation to the dominant perforator. Recognised Zone I as the most reliable and Zone IV as the least perfused and often excluded from reconstruction. ****3\. Mechanism & Evolution:** Traced the evolution of zone theory from Hartrampf’s original model to Holm’s data-driven modification and Saint-Cyr’s imaging-based validation using 3D/4D CTA and the perforasome concept. ****4\. Supporting Evidence:** Reviewed landmark studies that validated and refined the perfusion zone concept, reinforcing the value of imaging, anatomy, and perforator-specific planning in modern reconstructive surgery. --- ## Further Reading 1. Dinner MI, Dowden RV, Scheflan M. Refinements in the use of the transverse abdominal island flap for postmastectomy reconstruction. *Ann Plast Surg.* 1983 Nov;11(5):362–72. 2. Hartrampf CR Jr, Michelow BJ. *Hartrampf’s Breast Reconstruction with Living Tissue.* New York: Raven Press; 1990. 3. Holm C, Mayr M, Höfter E, Becker A, Pfeiffer UJ, Mühlbauer W. Perfusion zones of the DIEP flap revisited: a clinical study. *Plast Reconstr Surg.* 2006 Jan;117(1):37–43. 4. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. *Clin Plast Surg.* 2011 Apr;38(2):175–202\. doi:10.1016/j.cps.2011.03.015. ### Microsurgical Principles & Techniques: Setup, Instrumentation & Anastomosis Techniques URL: https://www.theplasticsfella.com/microsurgical-principles-techniques/ Last updated: 2025-05-10T11:45:30.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/microsurgical-principles-techniques/#overview-of-microsurgical-principles-techniques) Microsurgery enables precise anastomosis of small vessels and nerves, forming the foundation of modern reconstructive techniques including free flaps, nerve repair, replantation, & lymphatic surgery. [****Clinical Use**](https://www.theplasticsfella.com/microsurgical-principles-techniques/#clinical-use-of-microsurgical-principles) Microsurgical reconstruction enables vascularised tissue transfer and nerve repair for functional and aesthetic restoration, especially when simpler options are unavailable or inadequate. [****Microsurgical Principles & Surgical Environment**](https://www.theplasticsfella.com/microsurgical-principles-techniques/#core-microsurgical-principles-surgical-environment) Successful microsurgery depends as much on the setup and environment as the anastomosis itself; ergonomic posture, precise planning, & optical system minimise fatigue to maximise precision. [****Instrumentation**](https://www.theplasticsfella.com/microsurgical-principles-techniques/#instrumentation-equipment) Microsurgical success depends on fine-tipped, atraumatic instruments, ultra-thin sutures, and adjunct tools like couplers and background mats that enhance precision and reduce operative time. [****Technique**](https://www.theplasticsfella.com/microsurgical-principles-techniques/#microvascular-technique) Success in microsurgery hinges on meticulous vessel preparation, selecting the correct anastomotic technique, and tailoring your suturing strategy to minimize flow disturbances and technical failure. [****Monitoring & Complications**](https://www.theplasticsfella.com/microsurgical-principles-techniques/#complications-patency-optimisation) Flap failure in microsurgery is most commonly due to technical errors or thrombosis. A systematic approach to patency testing, flap monitoring, & early re-exploration can significantly improve outcomes. ****Primary Contributor:** Dr Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Microsurgical Principles & Techniques ****Key Point** Microsurgery enables precise reconstructions by anastomosing small vessels and nerves under magnification, forming the backbone of modern free flap, nerve, replantation, and lymphatic surgery. Microsurgery involves operating on vessels and nerves ≤2 mm using loupes or microscopes, fine instruments, and microsutures (8-0 to 11-0). It is the cornerstone of reconstructive plastic surgery, that enables free flaps, nerve repair, replantation, and lymphatic surgery when local tissue or function needs precise restoration. It has evolved into 3 major domains: - **Microvascular Surgery**: Vessel repair and free flap transfer. - **Microneural Repair**: Direct nerve repair or grafting with functional recovery. - **Supermicrosurgery**: For vessels <0.8 mm, used in lymphatic and perforator flap surgery. **Evolution of Microsurgery** - **1902 – Carrel**: Introduced vascular triangulation for anastomosis (Nobel Prize) ([Carrel](https://cir.nii.ac.jp/crid/1571980075614739968?ref=theplasticsfella.com), 1912). - **1960 – Jacobson & Suarez**: First microvascular anastomosis using a microscope. - **1964–68 – Replantation Era**: Arm (Malt & McKhann) and digit (Komatsu & Tamai) reattachments. - **1973 – Daniel & Taylor**: First clinical free flap (groin flap). - **1989 – Koshima & Soeda**: Introduced DIEP flap; start of perforator flap era. - **2000s–Present**: Advances in supermicrosurgery, robotics, and face/hand transplantation. 😎 ****Fun Fact:** Microsurgery routinely uses 8-0 to 11-0 monofilament sutures, which are thinner than a human hair. --- ## Clinical Use of Microsurgical Principles ****Key Point** Microsurgical reconstruction enables vascularised tissue transfer and nerve repair for functional and aesthetic restoration, especially when simpler options are unavailable or inadequate. Microsurgery allows complex reconstructions with precision and versatility, enabling the transfer of vascularised tissue and the restoration of function through nerve and muscle coaptation. It is now often the first-line solution; an evolution from the traditional “reconstructive ladder” to the more direct “reconstructive elevator” model ([Khouri](https://pubmed.ncbi.nlm.nih.gov/9727436/?ref=theplasticsfella.com), 1998). ### Indications Microsurgery is indicated when local or regional options cannot achieve sufficient coverage, contour, or function. Common clinical scenarios include, - **Composite defects** (e.g., mandibulectomy, open fractures). - **Extensive oncologic resections** (e.g., head & neck, breast, sarcoma). - **Traumatic limb injuries** requiring bone, nerve, or soft tissue reconstruction. - **Functional restoration** (e.g., free functioning muscle transfers). - **Replantation** of digits or limbs. - **Lymphedema management** via supermicrosurgical lymphovenous anastomosis ([Koshima](https://pubmed.ncbi.nlm.nih.gov/10993089/?ref=theplasticsfella.com), 2000). The image below illustrates signs of microvascular trauma. ![Signs of microvascular trauma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-10T023844.649.png) Signs of microvascular trauma ### Functional & Aesthetic Roles Microsurgical techniques not only restore anatomical coverage but also provide, - **Functionality:** Through nerve coaptation and dynamic muscle transfers. - **Aesthetic Matching:** “Like with like” tissue replacement (e.g., DIEP flap in breast reconstruction). - **Structural Integrity:** Using composite flaps that include skin, fat, fascia, muscle, and bone. This makes microsurgery uniquely suited for regions where form and function are both critical, like the face, hand, and lower limb. ### Contraindications and Patient Selection There are **no** **absolute contraindications** to microsurgical reconstruction, but several factors demand caution. - **Systemic Health:** Prolonged surgery requires a stable cardiac and pulmonary status. - **Smoking:** Not an absolute contraindication, but associated with a 50% higher risk of wound complications; **90% failure rate** in digital replantation. - **Hypercoagulable States:** History of thromboembolism or miscarriage warrants screening. - **Age Extremes**: Elderly and pediatric patients can still be suitable with appropriate optimization. - **Irradiated Tissue**: Not a contraindication. Free flaps are often preferred for coverage over previously irradiated tissue. Preoperative planning and multidisciplinary collaboration ensures safe case selection. 💡 ****Tip:** The classic “reconstructive ladder” has evolved into a “reconstructive elevator,” where microsurgery is now often the first choice for complex reconstructions — not the last resort. --- ## Core Microsurgical Principles & Surgical Environment ****Key Point** Successful microsurgery depends as much on the setup and environment as the anastomosis itself; ergonomic posture, precise planning, and the right optical system minimise fatigue and maximise precision. Microsurgery demands sustained precision and consistency. Outcomes are strongly influenced not only by the surgeon’s technique but also by the operative environment, ergonomics, and intraoperative planning. Even subtle factors such as posture or microscope placement can affect success. ### Ergonomics and Surgeon Positioning Microsurgical procedures demand hours of sustained precision. Poor posture leads to tremor, fatigue, and long-term musculoskeletal strain. **Ideal Positioning** - Seated with feet flat, knees/hips/elbows at 90°. - Back straight and neck neutral. - Forearms supported on armrests, towel stacks, or the patient’s body. - Hands stable, ideally resting while suturing under magnification. ### Planning and Operative Setup A calm, structured environment is essential for microvascular success. Preoperative planning includes, - Marking donor and recipient vessels clearly. - Avoiding IVs, A-lines, or BP cuffs in the donor limb (e.g., radial forearm flap). - Pre-op discussion with anesthesia team to manage temperature, perfusion, and vasoactive drugs. **OR Setup Tips** - Microscope in optimal position before starting. - Light blue or green background mats to contrast with vessels and sutures. - Minimal OR traffic and vibration. - Dedicated micro-instrument table, arranged by sequence of use. ### Operating Microscope vs Loupes Both are used in microsurgery and the choice depends on the task, magnification required, and surgeon comfort. **Microscope** - Standard for anastomosis. - Binocular, 10x-40x magnification (usually 12.5x for anastomosis). - Double-headed models allow assistant visualization. - Advanced models may include ICG angiography for perfusion assessment. **Surgical Loupes** - 2.5x–4.5x magnification, often used for dissection and flap inset. - Useful in vessel preparation, but limited depth of field at higher power. - Portable and ergonomic, but less precise than a microscope for fine suturing. 💡 ****Tip:** Use loupes for macro tasks and the microscope for the microvascular anastomosis phase. --- ## Instrumentation & Equipment ****Key Point** Microsurgical success depends on fine-tipped, atraumatic instruments, ultra-thin sutures, and adjunct tools like couplers and background mats that enhance precision and reduce operative time. Microsurgical instruments are purpose-designed for delicate handling of vessels and nerves. Their use requires familiarity with fine motor control and visual alignment under magnification. Proper setup and organisation improve workflow and reduce the risk of technical errors. ### Essential Microsurgical Tools Microsurgical instruments are designed for minimal tissue trauma, maximal precision, and comfortable handling under magnification. **Forceps** - Jeweler’s forceps (No. 2–5): Fine, non-toothed, smooth-tipped. - Adventitia forceps (e.g., Pearce): Fine teeth to grip the vessel sheath. **Scissors** - Curved microscissors for vessel dissection and adventitia trimming. - Straight scissors for suture cutting. **Needle Holders** - Straight or curved, non-locking preferred. - Some surgeons use jeweler’s forceps instead for better tactile feedback. **Vessel Dilators** - Smooth-tipped for gentle dilation to relieve vasospasm or correct size mismatch. **Clamps & Backgrounds** - Microvascular clamps: <30 g/mm² closing pressure to protect endothelium. - MicroMat background sheets: Improve contrast (usually light blue/green). - Elastic stay hooks: Retract tissue and improve field exposure. ### Microstructure Types & Needles **Suture Material** - Monofilament nylon or polypropylene. - Non-absorbable, low tissue reactivity. **Suture Sizes** - Range from 8-0 to 11-0 - Choice depends on vessel size (smaller size for finer vessels) Suture sizes, diameters, and common applications are summarised below. ![Suture sizes, diameters, and common applications, microsurgical principles and techniques](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-10T024111.624.png) Suture sizes, diameters, and common applications **Microneedle Design** - Three-eighths or half-circle curvature. - Taper-point preferred for vascular work. - Swaged (eyeless) with a diameter matched to suture size. - Needle diameter determines hole size; larger needles can leak. ### Microvascular Couplers & Adjunct Devices **Venous Couplers** (e.g., GEM System) - Sutureless, rigid ring system for end-to-end or end-to-side venous anastomoses. - **Sizes:** 1.5–4.0 mm. - Reduces ischemia time, minimal learning curve. - <1% thrombosis rate in large series ([Chang](https://pubmed.ncbi.nlm.nih.gov/21630338/?ref=theplasticsfella.com), 2011). **Other Adjuncts** - **Bipolar Coagulation:** Precise hemostasis >2 mm from vessel. - **ICG Angiography:** Real-time flap perfusion assessment. - **Heparinized Saline & Papaverine:** Prevent thrombosis and vasospasm. - **Bird Bath:** Instrument rinse with heparin-soaked gauze. 💡 ****Tip:** Always verify that your microvascular clamps exert <30 g/mm² pressure to avoid crushing the endothelium. --- ## Microvascular Technique ****Key Point** Success in microsurgery hinges on meticulous vessel preparation, selecting the correct anastomotic technique, and tailoring your suturing strategy to minimize flow disturbances and technical failure. Microsurgical anastomosis is a stepwise, technically demanding process. Each component, including vessel preparation, orientation, and suture placement must be optimised to avoid thrombosis, leakage, or flap loss. Variations in technique accommodate size discrepancies and anatomical challenges. ### Vessel Preparation Proper preparation of both donor and recipient vessels is critical before any microanastomosis.Key steps include, - **Adventitia Trimming** - Removes obstructive connective tissue and reduces turbulence at the anastomosis. Use adventitia scissors or fine forceps. - Do not strip too aggressively as it can damage the vasa vasorum and cause vasospasm. - **Lumen Inspection:** Check for thrombi, plaques, or intimal flaps. Use heparinized saline to flush and irrigate. - **Dilation:** Use vessel dilators or forceps to gently dilate the lumen and reduce vasospasm. - **Length Adjustment** - Ensure adequate vessel length without tension. Avoid sharp bends, twisting, or redundancy. - A short, tense vessel is a common cause of flap failure due to kinking or anastomotic tension. ### Anastomotic Techniques: End-to-End vs End-to-Side **End-to-End Anastomosis** - Most common technique in flap surgery and replantation. - Simpler alignment, ideal for similar-caliber vessels. - Interrupted sutures placed radially around the circumference. - Stay sutures at 12 and 6 o’clock help maintain orientation. - **Pros:** Simplicity, fast learning curve. - **Cons:** Sacrifices vessel continuity; size mismatch increases leak/thrombosis risk. **End-to-Side Anastomosis** - Used when preserving distal flow is necessary or when vessel size mismatch exists. - Involves making a slit or arteriotomy in the recipient vessel and attaching the donor vessel at an angle. - Stay sutures placed at proximal and distal edges of the slit help center the donor lumen. - **Pros:** Maintains distal perfusion; good for size discrepancy. Stay sutures placed at proximal and distal edges of the slit help center the donor lumen. - **Cons:** Technically more demanding; increased risk of turbulence if not done precisely. Comparison of end-to-end and end-to-side techniques is summarised below. ![Comparison of end-to-end and end-to-side techniques](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-10T024322.926.png) Comparison of end-to-end and end-to-side techniques ### Suturing Strategies & Size Discrepancy Management - **Interrupted vs Continuous Sutures** - **Interrupted** (gold standard): Offers better control, leak management, and easier revision. - **Continuous:** Faster and best for larger vessels with minimal mismatch. - **Open-loop Technique:** A hybrid of continuous and interrupted, offers faster closure with improved visibility. - **Back-wall First vs Front-wall First** - *Controversial*. Most favor back-wall first to prevent catching the posterior wall during closure. - **Managing Size Discrepancy** - **Spatulation:** Lengthens smaller vessel lumen to match the larger. - **Fish-mouth Incision:** Expands small vessel circumference. - **Oblique Cuts:** Prevent step-offs. - **End-to-side or vein grafts** if the difference is extreme. 💡 ****Tip:** Insert needles perpendicular to the vessel wall and exit smoothly to avoid creating internal flaps or intimal tearing. ### Intraoperative & Postoperative Patency Testing **Intraoperative Techniques** - **Milking Test:** Compress the vessel, release. The vessel should refill. - **Empty & Refill Test:** Drain vein and watch for refill with pulsation. - **Acland Test:** Observe pulsation proximal/distal to clamps after suturing. - **Indocyanine Green (ICG) Angiography:** Real-time flow visualization in high-risk cases. **Postoperative Monitoring** - **Clinical Parameters:** Color, capillary refill, temperature, turgor, and bleeding on pinprick. - **Handheld Doppler:** Most widely used tool, though prone to false positives. - **Implantable Doppler:** Continuous flow monitoring; high sensitivity. - **Laser Doppler:** Provides perfusion mapping, not routinely available. --- ## Complications & Patency Optimisation ****Key Point** Flap failure in microsurgery is most commonly due to technical errors or thrombosis. A systematic approach to patency testing, flap monitoring, and early re-exploration can significantly improve outcomes. While microsurgical success rates exceed 96-99%, complications, when they occur, it can lead to flap loss. Early recognition and prompt intervention are essential. This section outlines causes of failure, patency testing methods, and strategies for monitoring and salvage. ### Causes of Flap Failure **Technical Causes** - Inaccurate suture placement (e.g., through back wall). - Vessel twist, tension, or redundancy. - Poor adventitia trimming or improper needle angle. - Inadequate vessel length or inappropriate clamp positioning. **Systemic & Local Factors** - Hypotension, hypothermia, or vasospasm. - Hematoma, external compression, or tight closure. - Hypercoagulable states (e.g., Factor V Leiden). **Timing of Failure** - **Early (within 48 hrs):** Most commonly due to venous thrombosis. - **Late (>48 hrs):** Often related to infection, poor recipient bed, or mechanical disruption. Common technical, systemic, and local causes of microvascular compromise are summarised below. ![Common technical, systemic, and local causes of microvascular compromise](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-10T024635.717.png) Common technical, systemic, and local causes of microvascular compromise ### ### Anticoagulation, Flap Monitoring & Salvage Protocols **Anticoagulation Strategy** - **Intraoperative:** Flush with **heparinized saline (100–500 U/mL).** - **Postoperative:** Low-dose **aspirin** or **LMWH** commonly used (varies by center). - **Avoid systemic heparin** unless clotting disorders are suspected. The key drugs used in microvascular surgery and their considerations are summarised below. ![Key drugs used in microvascular surgery and their mechanisms, clinical use, & considerations](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-10T025206.416.png) Key drugs used in microvascular surgery and their mechanisms, clinical use, & considerations **Flap Monitoring** - **First 48 hours are critical.** Perform hourly checks. - **High-risk flaps** (e.g., perforators, replantations) may benefit from implantable Doppler or nurse-driven scoring systems. ![Flap ischemia and clinical signs of arterial insufficiency and venous congestion, microsurgical principles and techniques](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-10T025843.721.png) Flap ischemia and clinical signs of arterial insufficiency and venous congestion IMPORTANT Urgent re-exploration is required for sudden Doppler loss, skin changes, or absent pinprick bleeding, as flap salvage rates decline sharply after 6–8 hours of ischemia. An overview of flap monitoring methods are summarised below. ![Free flap monitoring methods, their reliability, invasiveness, and limitations](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-10T025706.491.png) Free flap monitoring methods, their reliability, invasiveness, and limitations 😎 ****Fun Fact:** Free flap success rates today exceed 96-99%, with most re-explorations occurring in the first 24 hours ([Khouri](https://pubmed.ncbi.nlm.nih.gov/9727436/?ref=theplasticsfella.com), 1998). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Microsurgery enables precise repair of vessels and nerves ≤2 mm using magnification and fine instruments. It underpins major reconstructive advances including free flaps, nerve coaptation, replantation, and lymphatic surgery. ****2\. Clinical Use:** Microsurgery is indicated for complex reconstructions following trauma, cancer resection, or congenital defects. It provides functional and aesthetic restoration, and is often a first-line approach. ****3\. Surgical Setup:** Success depends on a structured operative environment, proper posture, and optimized magnification. Loupes are useful for dissection, while microscopes are essential for fine suturing and anastomosis. ****4\. Instrumentation:** Microsurgical tools include fine-tipped forceps, non-locking needle holders, and vessel dilators. Sutures range from 8-0 to 11-0, with adjuncts like couplers, background mats, and ICG angiography enhancing precision. ****5\. Technique:** Vessel preparation is critical, involving adventitia trimming, dilation, & length optimization. End-to-end is standard; end-to-side helps in size mismatch. Interrupted sutures remain the gold standard for patency. ****6\. Monitoring & Complications:** Flap monitoring includes clinical exam, Doppler, and ICG. Most failures occur early due to venous thrombosis; re-exploration within 6–8 hours maximizes salvage. --- ## Further Reading 1. Wei FC, Mardini S. Flaps and Reconstructive Surgery. 2nd ed. Elsevier; 2016. 2. Neligan PC, Song DH, eds. Plastic Surgery: Volume 5 - Principles. 4th ed. Elsevier; 2018. 3. Buncke HJ, ed. Microsurgery: Transplantation and Replantation. Lea & Febiger; 1991. 4. Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg. 2000;16(6):437-442\. doi:10.1055/s-2006-947150 5. Khouri RK, Cooley BC, Kunselman AR, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg. 1998;102(3):711-721\. doi:10.1097/00006534-199809030-00012 6. Chang EI, Mehrara BJ, Festekjian JH, Da Lio AL, Crisera CA. Vascular complications and microvascular free flap salvage: the role of thrombolytic agents. Plast Reconstr Surg. 2013;132(4):795-803\. doi:10.1097/PRS.0b013e31829f4c76 7. Acland RD. ACLAND’s Video Atlas of Human Anatomy: Microsurgical Techniques. Wolters Kluwer; 2020. 8. American Society for Reconstructive Microsurgery. ASRM Core Curriculum Modules. ASRM; 2023\. Accessed March 4, 2025\. https://www.microsurg.org/education/core-curriculum 9. Kappen, I., Cornelissen, A., Shan-Qiu, S. (2024). Fundamentals of Microsurgery. In: De-Luna-Gallardo, D., Marquez-Espriella, C., Cienfuegos-Monroy, R. (eds) Plastic and Reconstructive Surgery Fundamentals. Springer, Cham. https://doi.org/10.1007/978-3-031-61894-9\_125 10. Villavisanis DF, Zhang D, Shay PL, Taub PJ, Venkatramani H, Melamed E. Assisting in Microsurgery: Operative and Technical Considerations. *J Hand Surg Glob Online*. 2023;5(3):358-362\. Published 2023 Apr 4\. doi:10.1016/j.jhsg.2023.01.011 ### Textbook Images are Useless, 3 Cartilage Grafting Tips, & Foundations Pre-Orders Open URL: https://www.theplasticsfella.com/may-11th/ Last updated: 2025-05-10T12:55:01.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-11th/#a-letter-from-pfella) Textbook images are useless. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-11th/#the-sunday-quiz) \*Drumroll🥁\* new winner announced! 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-11th/#image-of-the-week) Blood supply of long bones. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-11th/#technique-tip) Cartilage scoring for controlled bending. 5. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/may-11th/#the-fellows-corner) Journal review: Epidemiology of upper limb necrotising fasciitis. 6. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/may-11th/#foundations-textbook) Pre-orders open now! 7. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/may-11th/#what-does-the-evidence-say) Cortical vs cancellous bone. 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-11th/#articles-of-the-week) Original Gibson principle, upper limb bone graft options, & basic properties of cartilage grafts: with 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/may-11th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Textbook Images are Useless* 👋 ****Hey Team!** ****Most Surgical Diagrams Are Useless** Let’s call it what it is—most textbook flap diagrams are trash. They’re either oversimplified cartoons or overcomplicated messes. You can’t teach real surgery with that. And yet, we’ve accepted it for decades. Why? ### We’re Fixing That—with AI That image blow? It’s not clipart. It’s AI-generated. Built *for* surgeons. Designed to *actually teach*. We’re now using AI to create surgical visuals that finally do justice to the procedures: - Skin markings that look like the real thing - Planes you can actually follow - No filler, no fluff—just clarity This isn’t gimmicky tech. It’s a new standard for how we visualise plastic surgery. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Screenshot-2025-05-10-at-13.48.09-1-1.png) From our [Foundations](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com) Textbook --- ### Why It Matters Surgery is visual. Always has been. So why are we still relying on sketches from 1996? With AI, we’re done waiting for illustrators. Done guessing what’s happening in that blurry intra-op photo. We’re generating what we need, when we need it—and making it *look* how it should. --- ### It’s All Going Into *Foundations* This is the type of content going into our new textbook. But *Foundations* isn’t just a book—it’s a statement. Surgical education should be clear. Visual. Modern. And we’re done settling for less. [Request a Copy](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com#reserve-copy) With love (and decent diagrams, finally), P’Fella ❤️ ## The Sunday Quiz **\*Drumroll*🥁**\* New Winners on Board!* ****Congratulations to the Winners** of The Weekly Quiz! We're thrilled to announce the winners of this edition's quiz. After six rounds of questions on plastic surgery, our winner is ****Anna from Denver**! Please reply to this email or drop us a message to claim your prize! Thanks to everyone who took part — we’ll be back with more challenges in the next edition 🧠 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Leaderboard-Team-Post-Template.png) ## Image of the Week **Blood Supply of Long Bones* 🖼️ ****Image of the Week** This week’s image is a feature from our upcoming textbook [****Foundations**](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com): The ****vascular anatomy of a long bone**, a fundamental concept in trauma, orthoplastics, and flap planning. Key components: ****\- Nutrient artery** for primary diaphyseal supply ****\- Cortical and periosteal network** ****\- Metaphyseal and epiphyseal vessels** essential for healing and growth ****\- Descending branches** contributing to inner cortical supply ![Blood supply of long bones](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Bone-Anatomy-1.png) Blood supply of long bones ## Technique Tip **Cartilage Scoring for Controlled Bending* 🚑 ****Technique Tip of the Week** This week’s tip comes from our upcoming textbook, [****Foundations**](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com), and highlights a fundamental surgical principle in cartilage manipulation. The ****Gibson Principle** demonstrates that when cartilage is scored on one side, it will bend ****away** from the scored surface. This controlled bending technique is particularly useful in ****rhinoplasty**, ****auricular reconstruction**, and ****costal cartilage shaping**. ![Cartilage scoring for controlled bending](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Gibson-Principle--1--1.png) Cartilage scoring for controlled bending ## the Fellows' Corner **Journal Review: Epidemiology of Upper Limb Necrotising Fasciitis in England* 📑 P'fella's educational fellow, Dr. Hatan Mortada explores the ****Epidemiology of Upper Limb Necrotising Fasciitis** using a national study done in England over 20 years (1998-2018). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Lunchtime-Lessons.png) #### In this Journal Club **Epidemiology of upper limb necrotising fasciitis in England: A national study (1998-2018). Ky-Leigh Ang et al.* [**JPRAS*](https://bit.ly/jpras-may?ref=theplasticsfella.com) *2025 May* [****5-Point Summary**](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#5-point-summary) Upper limb necrotising fasciitis (NF) is a rare, aggressive infection with rising incidence in England. This national cohort study of 728 patients highlights key demographic trends and clinical outcomes, with a 16% mortality rate despite treatment. [****4-Key Findings**](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#4-key-findings) Incidence increased 250% between 1998 and 2013, stabilising thereafter. Most patients were male (64%), mean age of 55, and from deprived areas. Average hospital stay was 28 days. Mortality was 14% at 30 days and 16% at 90 days. [****3-Critiques**](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#3-critiques) HES data excludes patients who died pre-hospital, underestimating incidence. Lack of IV drug use data limits risk factor analysis. Coding limitations may result in missed or misclassified cases. [****2-Practical Takeaways** ](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#2-practical-takeaways) NF should be considered in otherwise healthy patients presenting with severe limb pain and systemic symptoms. Early intervention and addressing socioeconomic risk factors are key to reducing mortality. [****1-Recommended Reading**](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#1-recommended-reading) Uehara et al.’s retrospective study (116 patients) identifies risk factors for death and amputation in upper limb NF, offering global context to national findings. [Read Full Article ](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/) ## Foundations Textbook **Pre-Orders Open Now!* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Screenshot-2025-05-10-at-13.54.28-1.png) 📙 ****Pre-Orders Now Open: Ships This July** ****Foundations** is the only plastic surgery textbook that keeps itself ****up to date after it’s printed**. Our built-in ****QR codes** link directly to live article updates, new visuals, and the latest clinical evidence. No logins. No app. Just scan and learn. 👉 140+ essential topics 👉 Clinical-first, curriculum-mapped content 👉 Short-form chapters for rapid recall 👉 AI-powered visuals designed to teach ****Reserve Your Copy Today!** [Join the Waitlist!](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com#reserve-copy) ## What Does the Evidence Say? **Cortical vs Cancellous Bone* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Cortical and cancellous bone healing processes differ in their ****inflammatory responses** and ****healing rates**. Cancellous bone healing exhibits a more ****acute inflammation and faster healing**, while cortical healing shows a ****chronic inflammatory pattern** (Tätting et al., 2018). In metaphyseal bone environments, cancellous screws generally demonstrate ****superior biomechanical properties** compared to cortical screws, particularly in lower-density bone (Wang et al., 2016). However, this advantage may not be significant in ****osteoporotic cortical bone** (Wall et al., 2010). For scaphoid nonunion repairs, packed cancellous grafts show more ****robust early healing** than corticocancellous grafts when used with volar locking plates (Stoltz et al., 2024). In contrast, cancellous grafting leads to earlier union than corticocancellous grafting when combined with headless compression screws (Kim et al., 2017). The choice between structural and nonstructural grafting for scaphoid nonunion may depend on the severity of ****scaphoid deformity** (Hegazy et al., 2021). ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Original Gibson Principle on The Distortion of Autogenous Cartilage Grafts** ([Gibson](https://www.sciencedirect.com/science/article/abs/pii/S0007122657800423?ref=theplasticsfella.com), 1957) Cartilage warping in nasal grafts stems from intrinsic tension within rib cartilage, not the perichondrium, and can be prevented by carving grafts with a balanced cross-section to maintain structural equilibrium. ✅ ****Bone Graft Options in Upper-Extremity Surgery** ([Klifto](https://www.jhandsurg.org/article/S0363-5023%2817%2930120-X/fulltext?ref=theplasticsfella.com), 2018) Successful upper-extremity bone grafting depends on matching graft type to biological properties with autografts offering the highest healing potential, while vascularized and synthetic options support complex or large-volume defects. ✅ ****Cartilage Grafts: The Basic Properties of the Tissue and the Components** ([Fry](https://journals.lww.com/plasreconsurg/citation/1967/11000/cartilage%5Fand%5Fcartilage%5Fgrafts%5F%5Fthe%5Fbasic.2.aspx?ref=theplasticsfella.com), 1967) Cartilage graft distortion can be prevented by applying the principle of balanced cross-sections, with nasal septal cartilage providing a model for understanding intrinsic stress patterns and the role of matrix composition in graft behavior. ## Feedback ### I hope you enjoyed it 😄 --- ### Lipoma: Aetiology, Clinical Presentation, & Management URL: https://www.theplasticsfella.com/lipoma/ Last updated: 2025-05-05T21:06:07.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/lipoma/#overview-of-lipoma) Lipomas are common benign tumours composed of mature fat cells. Though often asymptomatic and discovered incidentally, their clinical relevance lies in accurate diagnosis, exclusion of malignancy, and management of symptomatic or atypical lesions. [****Aetiology**](https://www.theplasticsfella.com/lipoma/#aetiology-of-lipoma) Lipomas arise from mature adipocytes and are usually idiopathic, though some are linked to trauma, genetics, or syndromic associations. Histologically, they are benign with several defined variants. [****Clinical Presentation**](https://www.theplasticsfella.com/lipoma/#clinical-presentation-of-lipoma) Lipomas are often painless, soft, mobile swellings. Deeper or larger lesions may cause compression symptoms, and red flags such as rapid growth or deep location should raise suspicion for malignancy. [****Imaging**](https://www.theplasticsfella.com/lipoma/#imaging-for-lipoma) Ultrasound is the first-line imaging modality for lipomas. MRI is the gold standard for deep or atypical lesions and helps distinguish lipomas from liposarcomas. [****Management**](https://www.theplasticsfella.com/lipoma/#management-of-lipoma) Management of lipomas depends on their size, location, symptoms, and diagnostic certainty. While many can be observed, symptomatic or uncertain lesions may warrant excision. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Lipoma ****Key Point** Lipomas are common benign tumours composed of mature fat cells. Though often asymptomatic and discovered incidentally, their clinical relevance lies in accurate diagnosis, exclusion of malignancy, and management of symptomatic or atypical lesions. Lipomas are benign soft tissue tumours originating from mesenchymal tissue and composed of mature adipocytes. According to the WHO classification, they fall under the category of adipocytic soft tissue tumours, which includes several histologic variants with differing biological behaviours ([Choi](https://journals.lww.com/anatomicpathology/abstract/2021/01000/the%5F2020%5Fwho%5Fclassification%5Fof%5Ftumors%5Fof%5Fsoft.5.aspx?ref=theplasticsfella.com), 2021). Lipomas have distinct histological variants based on cellular composition and location. These include, - **Angiolipoma:** Painful; rich in capillaries; typically affects young adults. - **Spindle Cell Lipoma:** Contains spindle cells; common in older men, especially on the posterior neck/back ([Dabak](https://link.springer.com/chapter/10.1007/978-3-319-20777-3%5F36?ref=theplasticsfella.com), 2011). - **Myelolipoma:** Adipose and hematopoietic tissue; usually found in the adrenal glands. - **Pleomorphic Lipoma:** Features floret-like giant cells; may mimic sarcomas ([Creytens](https://journals.lww.com/ajsp/abstract/2017/11000/%5Fatypical%5F%5Fpleomorphic%5Flipomatous%5Ftumor%5F%5Fa.1.aspx?ref=theplasticsfella.com), 2017). - **Fibrolipoma:** Characterised by prominent fibrous tissue. - **Hibernoma:** Rare; composed of brown fat; often intermuscular. - **Chondroid Lipoma:** Contains cartilage-like matrix; can resemble sarcomas. The image below shows two large lipomas on the back. ![Two large lipomas on the back, overview of lipoma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-22T151314.010.png) Two large lipomas on the back ### 😎 ****Fun Fact:** Lipoma variants differ in stromal elements, vascularity, and fibrous content; but all share an adipocytic origin ([Choi](https://journals.lww.com/anatomicpathology/abstract/2021/01000/the%5F2020%5Fwho%5Fclassification%5Fof%5Ftumors%5Fof%5Fsoft.5.aspx?ref=theplasticsfella.com), 2021). --- ## Aetiology of Lipoma ****Key Point** Lipomas arise from mature adipocytes and are usually idiopathic, though some are linked to trauma, genetics, or syndromic associations. Histologically, they are benign with several defined variants. Lipomas are benign mesenchymal tumours composed of **mature adipocytes**, typically surrounded by a thin fibrous capsule. Lipomas are **commonly idiopathic** ([Marques](https://link.springer.com/chapter/10.1007/978-3-662-07859-4%5F12?ref=theplasticsfella.com), 1997), but several associated risk factors include, - **Genetic predisposition** *Familial multiple lipomatosis* is an **autosomal dominant** condition where multiple lipomas develop ([Lemaitre](https://www.sciencedirect.com/science/article/abs/pii/S0755498221000166?ref=theplasticsfella.com), 2021). - **Obesity:** May increase visibility, but is **not causative.** - **Trauma: Blunt trauma** is occasionally reported as a trigger, possibly through disruption of **preadipocytes** ([Aust](https://pubmed.ncbi.nlm.nih.gov/17975353/?ref=theplasticsfella.com), 2007). - **Syndromes** assoicated with lipomas include, - **Familial Multiple Lipomatosis:** Autosomal dominant; multiple painless lipomas; no systemic features. - **Dercum’s Disease (Adiposis Dolorosa):** Rare; **painful** lipomas; linked to obesity, fatigue, neuropsychiatric symptoms; middle-aged women. - **Roch-Leri Lipomatosis:** Symmetric, painless subcutaneous lipomas; limbs and trunk; rare, non-inflammatory. - **Bannayan-Riley-Ruvalcaba Syndrome:** PTEN mutation; macrocephaly, intestinal hamartomas, multiple lipomas. - **Gardner’s Syndrome:** FAP variant; cutaneous/subcutaneous lipomas, desmoid tumours, gastrointestinal polyps. 💡 ****Tip:** Lipomas are benign and distinct from ****liposarcomas**, which are malignant and require different treatment strategies. --- ## Clinical Presentation of Lipoma ****Key Point** Lipomas are slow-growing, soft, mobile swellings. While usually asymptomatic, deeper or larger lesions can cause compressive symptoms. Features like rapid growth or deep location raise concern for malignancy. ### History **Symptoms and Onset** - **Typical Presentation:** Gradually enlarging, painless mass. - **Pain:** Uncommon, but may occur in angiolipomas, Dercum’s disease, or with nerve involvement. - **Functional Issues:** Deep lesions may compress adjacent structures, leading to discomfort or dysfunction (e.g., nerve impingement). - **Cosmetic Concerns:** Common driver for presentation, particularly in visible locations. The clinical presentation of a lipoma is illustrated below. ![Clinical presentation of a lipoma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-06T022017.298.png) Clinical presentation of a lipoma **Risk Factors in the History** - **Age:** Most common in adults aged 40–60 years; rare in children. - **Sex:** Equal overall distribution; angiolipomas and spindle cell lipomas show a slight male predominance (Dabak, 2011). - **Family History:** Multiple lipomas may indicate familial lipomatosis or genetic syndromes (e.g., MEN1). - **Associated Conditions:** Consider syndromic associations in patients with multiple, deep, or atypical lipomas (e.g., Madelung’s disease). - **Rapid Growth or Recent Change:** Raises suspicion for liposarcoma and warrants further investigation. 😎 ****Fun Fact:** Lipomas are rarely painful unless associated with nerve involvement or in specific variants like angiolipomas or Dercum’s disease ([Charifa](https://europepmc.org/article/NBK/nbk482343?ref=theplasticsfella.com), 2018). ### Examination **General Characteristics** - **Location:** Commonly on neck, shoulders, back, and proximal limbs; can appear anywhere, including viscera. - **Number:** Usually solitary; multiple lesions suggest syndromic or familial background. - **Size:** Varies from millimetres to over 10 cm ("giant lipomas"). - **Surface and Shape:** Smooth or lobulated; discoid or hemispherical. - **Mobility:** Freely mobile in superficial lipomas — demonstrates the “slip sign.” - **Consistency:** Soft or rubbery; fluctuant in larger lesions. **Superficial Lipomas** - Subcutaneous, painless, soft, mobile masses. - Easily palpable with well-defined margins. **Deep-Seated Lipomas** - Less mobile; may involve intramuscular or retroperitoneal spaces. - More likely to cause compressive symptoms (e.g., paraesthesia, restricted movement). - Often requires imaging for full assessment. ⚠️ ****Red Flags Suggesting Malignancy** ****\-** Rapid growthSize \- >5 cm \- Deep anatomical location \- Pain or neurological symptoms \- Fixation to underlying structures 💡 ****Tip:** The "slip sign" refers to the way a mobile lipoma tends to slide away from the examining finger under gentle pressure. ### Differential Diagnosis for Lipoma Radiologic features, clinical behavior, and histopathology are key to an accurate diagnosis. The following conditions can resemble a lipoma, especially in the initial stages. - **Liposarcoma (Well-Differentiated)** - May mimic lipomas but typically shows non-fatty components, thickened internal septa, or nodular areas on imaging. - Requires histological confirmation to rule out malignancy. - **Epidermoid or Sebaceous Cysts** - Often tethered to the skin and may have a visible punctum. - Imaging can show internal debris or calcifications. - **Neurofibromas** - Frequently involve peripheral nerves and may be part of neurofibromatosis. - MRI may demonstrate a T2 hyperintense signal with a target sign. - **Dermoid Cysts** - Congenital lesions that may contain skin appendages, fat, or even bone or teeth. - Often appear in midline or periorbital locations and require imaging and histology for confirmation. - **Hematoma** - Usually associated with a history of trauma. - MRI features change over time depending on blood degradation products. - **Abscess** - Typically painful, erythematous, and warm. - Imaging reveals a fluid collection with rim enhancement, and aspiration confirms infection 💡 ****Tip:** The skin is usually mobile over a lipoma, unlike a sebaceous cyst, where it may be tethered. In intramuscular lipomas, the mass may become less palpable or disappear on muscle contraction. --- ## Imaging for Lipoma ****Key Point** Ultrasound is the preferred initial imaging tool for superficial lipomas, while MRI remains the gold standard for evaluating deep, atypical, or potentially malignant lesions. Imaging plays a pivotal role in confirming the diagnosis of lipomas, particularly when the presentation is unusual or when the lesion is located deep within soft tissues. It also assists in surgical planning and excluding liposarcoma, a key differential. - **Ultrasound (US)** - First-line modality due to accessibility and cost-effectiveness. Lipomas typically appear as well-circumscribed, hyperechoic or isoechoic masses. - It helps delineate lesion borders and guide procedures when needed. - **Magnetic Resonance Imaging (MRI)** - Gold standard for deep, atypical, or complex lesions ([Gaskin](https://ajronline.org/doi/full/10.2214/ajr.182.3.1820733?ref=theplasticsfella.com), 2004). - Displays homogeneous high signal on T1-weighted images and fat suppression on fat-saturated sequences, indicating a benign fatty nature. It is highly sensitive to tissue composition. - **Computed Tomography (CT)** - Particularly useful in deep or retroperitoneal locations. - Lipomas show as low-density, well-defined masses and can aid in detecting calcification or deeper invasion not evident on US or MRI. The image below illustrates the identification of a lipoma in ultrasound. ![The identification of a lipoma in ultrasound](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-06T022328.675.png) The identification of a lipoma in ultrasound 💡 ****Tip:** Lipomas typically show a uniform appearance across imaging modalities. In contrast, liposarcomas may present with thick septa, nodules, or heterogeneous signal patterns-features that warrant biopsy and further investigation ([Kransdorf](https://pubs.rsna.org/doi/abs/10.1148/radiol.2241011113?ref=theplasticsfella.com), 2002). --- ## Management of Lipoma ****Key Point** Most lipomas are benign and require no treatment unless symptomatic, enlarging, or cosmetically concerning; surgical excision is the standard treatment when indicated. ### Indications for Treatment While many lipomas are managed conservatively, certain clinical features prompt surgical or procedural intervention. - **Symptomatic Lesions:** Pain, tenderness, or restriction of movement may indicate the need for removal. These symptoms often result from compression of adjacent structures. - **Cosmetic Concerns:** Patients may request removal for aesthetic reasons, especially for visible or enlarging lipomas. - **Rapid Growth or Atypical Features:** Suggestive of malignancy and warrant further evaluation with imaging and possibly biopsy. These cases often proceed to excision for both diagnosis and treatment. - **Large Size or Deep Location:** Lipomas in deep or less accessible areas may require imaging-guided assessment and surgical planning. - **Functional Impairment:** Lesions that interfere with muscle function, joint movement, or daily activities may justify intervention. ### Treatment Modalities The primary treatment for lipomas is surgical excision, although other options may be considered in select cases. - **Surgical Excision:** Most common and definitive treatment. A complete excision, including the capsule, is crucial to prevent recurrence—particularly for deep or intramuscular lipomas, where incomplete removal is more likely. - **Liposuction:** Considered for soft, superficial lipomas, especially for cosmetic improvement. May leave residual capsule and has a slightly higher recurrence rate ([Boyer](https://web.archive.org/web/20180601223952id%5F/https://www.clinicaldermatology.eu/common/php/portiere.php?ID=932659960c23712522fec9c42c17fbe5), 2015). - **Observation:** Appropriate for asymptomatic, stable lesions. Regular monitoring ensures early detection of any change in behavior or appearance. The image below illustrates a well-encapsulated lipoma excised from the subcutaneous tissue. ![A well-encapsulated lipoma excised from the subcutaneous tissue](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-06T022825.413.png) A well-encapsulated lipoma excised from the subcutaneous tissue 💡 ****Tip:** Lipomas larger than 5 cm should be evaluated more thoroughly and are often excised or biopsied to confirm diagnosis ([Johnson](https://journals.lww.com/jaaos/abstract/2018/11150/lipomatous%5Fsoft%5Ftissue%5Ftumors.1.aspx?ref=theplasticsfella.com), 2018). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Lipomas are benign tumours of mature fat cells, typically slow-growing and painless. They may be asymptomatic or cause cosmetic or compressive issues depending on size and location. ****2\. Aetiology:** Most lipomas are idiopathic, though some are linked to trauma or genetic syndromes. Histologically, they consist of mature adipocytes and may have variant forms. ****3\. Clinical Presentation:** Lipomas present as soft, mobile, subcutaneous swellings. Deep or rapidly growing lesions, especially those >5 cm, warrant further evaluation for possible malignancy. ****4\. Imaging:** Ultrasound is the first-line tool for superficial lesions, while MRI is used for deeper or atypical cases. Imaging helps rule out liposarcoma by identifying red flag features like nodularity or septations. ****5\. Differential Diagnosis:** Lipomas must be distinguished from liposarcoma, sebaceous cysts, and neurofibromas. Clinical signs, imaging, and histology help confirm diagnosis and rule out malignancy. ****6\. Management:** Small, asymptomatic lipomas can be monitored. Surgical excision is curative and recommended for symptomatic, enlarging, or uncertain lesions; liposuction is an alternative for select cases. ****7\. Associated Syndromes:** Multiple or painful lipomas may signal syndromic associations like Dercum’s disease, familial lipomatosis, or Madelung’s disease. These require systemic evaluation and possible genetic counselling. --- ## Further Reading 1. Choi, Joon Hyuk, and Jae Y. Ro. "[The 2020 WHO classification of tumors of soft tissue: selected changes and new entities](https://journals.lww.com/anatomicpathology/abstract/2021/01000/the%5F2020%5Fwho%5Fclassification%5Fof%5Ftumors%5Fof%5Fsoft.5.aspx?ref=theplasticsfella.com)." *Advances in anatomic pathology* 28.1 (2021): 44-58. 2. Yücetürk, G., Sabah, D., Kececi, B., Kara, A. D., & Yalcinkaya, S. (2011). [Prevalence of bone and soft tissue tumors](https://dergipark.org.tr/en/download/article-file/169975?ref=theplasticsfella.com). *Acta Orthop Traumatol Turc*, *45*(3), 135-43. 3. Dabak, N., Yıldız, Y., Demiralp, B., & Keskinbora, M. (2016). [Soft tissue tumors](https://link.springer.com/chapter/10.1007/978-3-319-20777-3%5F36?ref=theplasticsfella.com). *Musculoskeletal Research and Basic Science*, 631-638. 4. Lemaitre, M., Chevalier, B., Jannin, A., Bourry, J., Espiard, S., & Vantyghem, M. C. (2021). [Multiple symmetric and multiple familial lipomatosis](https://www.sciencedirect.com/science/article/abs/pii/S0755498221000166?ref=theplasticsfella.com). *La Presse Médicale*, *50*(3), 104077. 5. Aust MC, Spies M, Kall S, Jokuszies A, Gohritz A, Vogt P. [Posttraumatic lipoma: fact or fiction?](https://pubmed.ncbi.nlm.nih.gov/17975353/?ref=theplasticsfella.com) Skinmed. 2007 Nov-Dec;6(6):266-70\. doi: 10.1111/j.1540-9740.2007.06361.x. PMID: 17975353. 6. Marques, M. C., and H. Garcia. "[Lipomatous tumors.](https://link.springer.com/chapter/10.1007/978-3-662-07859-4%5F12?ref=theplasticsfella.com)" *Imaging of soft tissue tumors*. Berlin, Heidelberg: Springer Berlin Heidelberg, 1997\. 191-207. 7. Creytens, David, et al. "[Atypical” pleomorphic lipomatous tumor: a clinicopathologic, immunohistochemical and molecular study of 21 cases](https://journals.lww.com/ajsp/abstract/2017/11000/%5Fatypical%5F%5Fpleomorphic%5Flipomatous%5Ftumor%5F%5Fa.1.aspx?ref=theplasticsfella.com), emphasizing its relationship to atypical spindle cell lipomatous tumor and suggesting a morphologic spectrum (atypical spindle cell/pleomorphic lipomatous tumor)." *The American Journal of Surgical Pathology* 41.11 (2017): 1443-1455. 8. Charifa, Ahmad, Chaudhary Ehtsham Azmat, and Talel Badri. "[Lipoma pathology](https://europepmc.org/article/NBK/nbk482343?ref=theplasticsfella.com)." (2018). 9. Gaskin CM, Helms CA. [Lipomas, lipoma variants, and well-differentiated liposarcomas: Results of MRI evaluations of 126 consecutive fatty masses](https://ajronline.org/doi/full/10.2214/ajr.182.3.1820733?ref=theplasticsfella.com). *AJR Am J Roentgenol*. 2004;182(3):733-739. 10. Kransdorf, Mark J., et al. "[Imaging of fatty tumors: distinction of lipoma and well-differentiated liposarcoma](https://pubs.rsna.org/doi/abs/10.1148/radiol.2241011113?ref=theplasticsfella.com)." *Radiology* 224.1 (2002): 99-104. 11. Boyer, M., Monette, S., Nguyen, A., Zipp, T., Aughenbaugh, W. D., & Nimunkar, A. J. (2015). [A review of techniques and procedures for lipoma treatment.](https://web.archive.org/web/20180601223952id%5F/https://www.clinicaldermatology.eu/common/php/portiere.php?ID=932659960c23712522fec9c42c17fbe5) *Clin Dermatol*, *3*(4), 105-112. 12. Johnson, C. N., Ha, A. S., Chen, E., & Davidson, D. (2018). [Lipomatous soft-tissue tumors.](https://journals.lww.com/jaaos/abstract/2018/11150/lipomatous%5Fsoft%5Ftissue%5Ftumors.1.aspx?ref=theplasticsfella.com) *JAAOS-Journal of the American Academy of Orthopaedic Surgeons*, *26*(22), 779-788. 13. Dupuis, H., Lemaitre, M., Jannin, A., Douillard, C., Espiard, S., & Vantyghem, M. C. (2024, June). [Lipomatoses.](https://www.sciencedirect.com/science/article/pii/S0003426624000581?ref=theplasticsfella.com) In *Annales d'Endocrinologie* (Vol. 85, No. 3, pp. 231-247). Elsevier Masson. ### The Textbook That Doesn’t Expire, 3 Aesthetic Surgery Tips, & PRF Tutorial URL: https://www.theplasticsfella.com/may-4th/ Last updated: 2025-05-03T21:03:27.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-4th/#a-letter-from-pfella) The textbook that doesn’t expire! 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-4th/#the-sunday-quiz) How well do you know **liposuction*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/may-4th/#image-of-the-week) Blood supply of the abdominoplasty. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/may-4th/#technique-tip) Danger zone in gluteal fat grafting. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/may-4th/#upcoming-events) New event added! 6. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/may-4th/#the-fellows-corner) PRF prep tutorial. 7. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/may-4th/#foundations-textbook) Pre-orders open now! 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-4th/#articles-of-the-week) US guiding gluteal fat grafting, post-op abdominoplaty pain control, & TXA to treat liposuction blood loss: with 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/may-4th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Textbook That Doesn’t Expire* 👋 ****Hey Team!** Most textbooks have a silent expiration date. You just don’t see it printed on the spine. The second they hit the shelf, they start aging. And it shows. Protocols change. Guidelines evolve. But your copy? Still stuck in 2016, teaching Swanson Classification instead of OMT. We are building *Foundations* to fix that. **What If Print Didn’t Mean Static?** Foundations will be the only textbook that keeps you up-to-date *after* it’s printed. Every month, new content drops. Aligned to your textbook. Built around what’s changing — and what matters. Here’s how it works: - You open a chapter. There’s a QR code. You scan it. - Boom — latest updates, live. - No logins. No portals. Just tap and read. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Textbook-Design-alytout-2.png) [Waiting List](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com#reserve-copy) Foundations is still a real book. You can underline it. Highlight it. Spill coffee on it. But it’s not frozen in time like everything else. **A New Standard: Living Print** This isn’t about gimmicks. It’s about not getting trained on outdated info. When your book evolves with the field, you don’t have to second-guess your knowledge. You stay sharp, not stuck. Whether you’re prepping for exams, seeing patients, or teaching juniors, the information in your hands is *right*. And if something changes? You change with it. With love, P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Liposuction?* ****Are you ready to make it to the leaderboard?** Welcome to the ****final round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ## Image of the Week **Blood Supply of the Abdominoplasty* 🖼️ ****Image of the Week** This week’s image illustrates the vascular anatomy relevant to abdominoplasty, highlighting key perforators and arterial supply zones. This anatomical map is foundational for both safe flap elevation and minimising vascular compromise during abdominal contouring procedures. ![Blood Supply of the Abdominoplasty](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/455807_1_En_6_Fig2_HTML.png) [Source](https://link.springer.com/chapter/10.1007/978-3-319-71219-2%5F6?ref=theplasticsfella.com) ## Technique Tip **Danger Zone in Gluteal Fat Grafting* 🚑 ****Technique Tip of the Week** This week’s tip highlights a critical anatomical consideration in gluteal fat grafting: avoiding the danger zone to reduce the risk of fat embolism. Check the image below for: \- The gluteal vascular anatomy, including the superior and inferior gluteal veins and sciatic nerve. \- The ****"danger zone",** located in the ****superomedial quadrant** of the gluteus maximus, where major veins lie deep and are vulnerable. \- Safe zones for superficial fat deposition to minimise risk. 🚫 Deep intramuscular injection in this region is associated with a higher risk of pulmonary fat embolism and should be strictly avoided. ![Danger Zone in Gluteal Fat Grafting](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/10.1177_07488068231215113-fig4.jpg) [Source](https://journals.sagepub.com/doi/10.1177/07488068231215113?ref=theplasticsfella.com) ## Upcoming Events **New Event Added!* 📅 ****P’Fella’s event calendar** highlights the most impactful conferences, high-yield webinars, and carefully curated courses for you. You can also ****submit your event** and get it featured! We've just added some new events to our calendar; sign up below👇 ## the Fellows' Corner **PRF Prep Tutorial* 📹 This week in the Fellows’ Corner, educational fellow ****Benedetta Agnelli** walks us through the preparation of ****Platelet-Rich Fibrin (PRF)** — a biologic used to enhance wound healing, graft take, and tissue regeneration in reconstructive and aesthetic surgery. The video covers: \- Blood collection technique. \- Centrifugation parameters. \- PRF isolation and handling. PRF offers a scaffold rich in growth factors without the use of anticoagulants, making it a simple yet powerful adjunct in surgical practice. ▶️ Watch the full technique breakdown below. 0:00 /1:36 1× The preparation of Platelet-Rich Fibrin (PRF) ## Foundations Textbook **Pre-Orders Open Now!* 📙 Plastic surgery is evolving, so your textbook should too! Most resources are outdated, overwhelming, or disconnected from real-life clinical practice. This is why we're building ****the only textbook that keeps you up-to-date** after it’s printed. Foundations is mapped to your international curriculum and built to skip the fluff. We map directly to what you’re tested on and what you actually do. [****Pre-order now**](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com#reserve-copy) to be among the first to receive it when it ships this July! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Textbook-Design--1-.png) [Join the Waitlist!](https://foundations.theplasticsfella.com/?ref=theplasticsfella.com#reserve-copy) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Is Ultrasound-Guided Gluteal Fat Grafting a Safer Standard for BBL?** ([Milani](https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjaf059/8109477?ref=theplasticsfella.com), 2025) Ultrasound guidance in gluteal fat grafting has shown zero reported deaths or fat emboli, making it one of the most evidence-backed safety upgrades in modern aesthetic surgery. ✅ ****Multimodal Pain Control in Abdominoplasty: The Gold Standard for Opioid-Sparing Surgery** ([Shauly](https://academic.oup.com/asj/article/44/Supplement%5F1/S22/7730407?ref=theplasticsfella.com), 2024) Multimodal regimens incorporating TAP blocks, NSAIDs, and ketamine significantly reduce opioid use, pain scores, and recovery time in abdominoplasty, highlighting their role in modern, opioid-sparing perioperative care. ✅ ****The Effect of Tranexamic Acid Administration During Liposuction on Bleeding Complications and Ecchymosis** ([ElAbd](https://academic.oup.com/asj/article-abstract/45/2/171/7750416?redirectedFrom=fulltext&ref=theplasticsfella.com), 2025) Tranexamic acid (whether intravenous or local) consistently reduces intraoperative blood loss and postoperative bruising in liposuction, with no reported increase in complications across prospective studies. ## Feedback ### I hope you enjoyed it 😄 --- ### Cold Burns: Causes, Clinical Presentation, & Treatment URL: https://www.theplasticsfella.com/cold-burns/ Last updated: 2025-05-01T19:40:06.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/cold-burns/#overview-of-cold-burns) Frostbite (coldburn) is a freezing cold injury caused by prolonged exposure to subzero temperatures, where tissue heat loss exceeds local perfusion, leading to cellular freezing and damage. [****Causes**](https://www.theplasticsfella.com/cold-burns/#causes-of-cold-burns) The rate of tissue cooling and whether ice crystals form determine the type of cold injury. Heat loss occurs through evaporation, conduction, convection, and radiation. [****Pathogenesis**](https://www.theplasticsfella.com/cold-burns/#pathogenesis-of-cold-burns) Cold injuries result from direct cellular and vascular damage caused by extreme cold exposure, with intrinsic and extrinsic risk factors increasing susceptibility. [****Clinical Presentation**](https://www.theplasticsfella.com/cold-burns/#clinical-presentation-of-cold-burns) Early recognition of deep frostbite, particularly the presence of hemorrhagic blisters, hard skin, or delayed capillary refill, is critical for initiating advanced imaging and interventions like thrombolysis. [****Treatment**](https://www.theplasticsfella.com/cold-burns/#treatment-of-cold-burns) Timely frostbite treatment hinges on rapid rewarming, pain control, and wound care. Surgical intervention should be delayed until clear tissue demarcation, typically after 4–6 weeks. [****Complications**](https://www.theplasticsfella.com/cold-burns/#complications-of-cold-burns) Frostbite may result in long-term complications, including infection, chronic pain, cold intolerance, neuropathy, autoamputation, and deep vein thrombosis. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview of Cold Burns ****Key Point** Frostbite (coldburn) is a freezing cold injury caused by prolonged exposure to subzero temperatures, where tissue heat loss exceeds local perfusion, leading to cellular freezing and damage. Early recognition and treatment aim to preserve viable tissue and function. Frostbite, or freezing cold injury (FCI), is tissue damage caused by exposure to extreme cold, usually below zero degrees Celsius ([Basit](https://www.ncbi.nlm.nih.gov/books/NBK536914/?ref=theplasticsfella.com), 2023). It develops when the body loses heat faster than blood flow can replenish it, allowing soft tissues to freeze. The risk increases with colder temperatures and longer exposure times. ([McIntosh](https://pubmed.ncbi.nlm.nih.gov/38577729/?ref=theplasticsfella.com), 2024).This is because the body loses heat in four main ways ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). - **Evaporation:** Sweat turns to vapor, drawing heat away. - **Conduction:** Direct contact with cold surfaces pulls heat out. - **Convection:** Wind or water moving across the skin accelerates cooling. - **Radiation:** Heat radiates directly into the colder surroundings. When these losses exceed the body’s defenses, frostbite sets in. The rate of cooling changes the type of damage: - **Rapid freezing** causes ice to form inside cells, leading to rupture and immediate cell death. - **Slow freezing** leads to ice outside cells, which draws water out, causing dehydration and secondary injury The image below illustrates frostbite of the feet. ![Frostbite of the plantar aspect of the feet](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-12T015746.904.png) Frostbite of the plantar aspect of the feet --- ## Causes of Cold Burns ****Key Point** The rate of tissue cooling and whether ice crystals form determine the type of cold injury. Heat loss occurs through evaporation, conduction, convection, and radiation. Cold injuries occur when heat loss exceeds the body’s ability to maintain adequate blood flow. The severity depends on how rapidly tissues cool and whether ice crystals form. Clinical presentations range from mild, reversible vasospasm to permanent tissue damage. **Classification** reflects both the mechanism and severity of injury ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). - **Frostnip:** Mild, reversible. Fast cooling, no ice crystal formation. Caused by intense vasoconstriction in exposed skin. Presents with pallor, pain, and numbness. - **Pernio/Chilblains:** Nonfreezing injury caused by repeated exposure to near-freezing temperatures. Slow cooling with no ice crystals. This results in nodules or plaques with pain and pruritus. - **Flash Freeze Injury:** Caused by very rapid cooling, leading to intracellular ice crystals and structural cell damage. - **Frostbite:** Caused by slower cooling with ice formation within tissues, leading to vascular and cellular injury. Slow cooling with ice crystals. Types of cold injuries associated with the cooling rate and site of ice crystals are summarised below. ![Types of cold injuries associated with the cooling rate and site of ice crystals](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-02T005246.789.png) Types of cold injuries associated with the cooling rate and site of ice crystals 💡 ****Tip:** Frostnip is not frostbite. It involves no ice crystal formation, and symptoms such as numbness and pallor resolve quickly with simple rewarming methods like covering the area or using warm hands. No tissue loss or long-term damage occurs ([McIntosh](https://pubmed.ncbi.nlm.nih.gov/38577729/?ref=theplasticsfella.com), 2024). --- ## Pathogenesis of Cold Burns ****Key Point** Cold injuries result from direct cellular and vascular damage caused by extreme cold exposure, with intrinsic and extrinsic risk factors increasing susceptibility. Cold burns follow a biphasic pattern of tissue injury: direct cellular damage from freezing, followed by progressive vascular impairment and ischemic necrosis. ### Direct Cellular Injury (Freeze–Thaw Damage) Tissue freezing begins around 0 °C; damaging cells through, - **Ice Crystal Formation:** Intracellular and extracellular crystals physically disrupt cells. - **Intracellular Dehydration:** Osmotic gradients draw water out, causing shrinkage and lysis. - **Lipid Membrane Disruption:** Leads to structural collapse of cell membranes. - **Protein Denaturation:** Results in irreversible functional loss of essential proteins. 😎 ****Fun Fact:** Blisters will form at 6-24 hours when extravasated fluid collects beneath the detached epidermal sheet. If the dermal vascular plexus is disrupted, hemorrhagic blisters will be present. ### Vascular Injury and Ischemic Necrosis The combination of vascular stasis, inflammatory edema, and thrombotic occlusion culminates in **tissue ischemia** and, if severe or prolonged, **cell death and necrosis**. The extent of necrosis depends on exposure severity and speed of rewarming. - **Initial Vasoconstriction:** Cold exposure triggers vasospasm, limiting heat delivery to extremities. - **Endothelial Damage:** Increased permeability leads to edema, leukocyte infiltration, and microvascular stasis. - **Platelet Aggregation and Microthrombosis:** Impair perfusion, furthering ischemic injury. - **Reperfusion Injury:** On rewarming, inflammatory mediators (e.g., prostaglandins, thromboxane) cause: - **Vasodilation and Capillary Leak:** Resulting in blister formation and tissue swelling. - **Continued Microthrombosis:** Leading to irreversible necrosis. The pathophysiology of frostbite can be seen below. ![The pathophysiology of frostbite](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-12T020043.459.png) The pathophysiology of frostbite 😎 ****Fun Fact:** Normal skin perfusion is \~250 ml/min. During frostbite, this drops below 20–50 ml/min. Venous systems freeze before arteries ([Basit](https://www.ncbi.nlm.nih.gov/books/NBK536914/?ref=theplasticsfella.com), 2023). ### --- ## Clinical Presentation of Cold Burns ****Key Point** Accurate classification and early recognition of deep frostbite, particularly the presence of hemorrhagic blisters, hard skin, or delayed capillary refill, are critical for initiating advanced imaging and considering interventions like thrombolysis to prevent tissue loss. Frostbite injuries exist on a clinical spectrum and evolve over time. A structured approach starting with history, classification, and examination, followed by imaging, is essential to assess severity, predict outcomes, and guide timely treatment. ### Clinical Classification Systems Frostbite is classified to assess severity, guide management, and predict outcomes. Two main systems are used depending on the setting: a detailed **four-degree** classification and a simplified **two-tier** field **classification**. **Four-Degree Classification (Clinical Use)** Mirrors burn depth and is commonly used in hospital settings. 1. **First-Degree (Frostnip):** Reversible vasoconstriction without ice crystal formation. Pale, numb skin that fully recovers with rewarming. 2. **Second-Degree:** Partial-thickness injury. Clear fluid-filled blisters; erythematous and swollen skin post-thaw. 3. **Third-Degree:** Full-thickness skin and subcutaneous tissue damage. Hemorrhagic blisters may develop; tissue is anesthetic. 4. **Fourth-Degree:** Involves muscle, tendon, and bone. Skin becomes hard, insensate; eventual mummification and autoamputation may occur. **Two-Tier Field Classification (Prehospital/Remote Settings)** Useful post-rewarming, before imaging ([McIntosh](https://pubmed.ncbi.nlm.nih.gov/38577729/?ref=theplasticsfella.com) 2024). 1. **Superficial Frostbite:** Soft, pale, or waxy skin; may form clear blisters. Minimal long-term damage expected. Corresponds to **1st and 2nd degree** injuries**.** 2. **Deep Frostbite:** Skin is hard, woody, with hemorrhagic blisters. Suggests irreversible injury and likely tissue loss. Corresponds to **3rd and 4th degree** injuries. The clinical presentation of each degree of cold burns is summarised below. ![Clinical presentation of each degree of cold burns](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-12T021233.581.png) Clinical presentation of each degree of cold burns ### History and Risk Factor Assessment A comprehensive history identifies severity and contributing factors. - **Cold Exposure:** Duration, temperature, wind chill, wet conditions. - **Freeze–Thaw Cycles:** Multiple cycles worsen injury. - **Protective Measures:** Inadequate clothing, loss of shelter. - **Medical Risk Factors:** Diabetes, peripheral vascular disease, Raynaud’s, smoking. - **Behavioral and Social Factors:** Substance use, mental health issues, homelessness. - **Activities:** Military operations, mountaineering, and outdoor occupations. 💡 ****Tip:** ****Mnemonic Tip – The “I’s” of Frostbite** ([Mohr](https://pubmed.ncbi.nlm.nih.gov/19801122/?ref=theplasticsfella.com), 2009): **Intoxicated, Incompetent, Infirm, Insensate, Inducted, Inexperienced, Indigent.* ### Physical Examination **General Principles** - Early appearance may underestimate tissue damage. - Final tissue demarcation may take days to weeks. **Phases of Examination** - **Pre-Thaw (Early Phase)** - Skin is pale, waxy, or gray. - Numbness or heaviness in affected areas. - Discoloration (bluish or purplish) from vascular stasis. - **Post-Thaw (Progressive Phase)** - Swelling, pain, or anesthesia. - **Superficial Injuries:** Clear blisters, erythema, preserved capillary refill. - **Deep Injuries:** Hemorrhagic blisters, hard skin, absent sensation. - **Delayed Findings (Days to Weeks)** - **Eschar Formation:** By 10–15 days. - **Mummification and Demarcation:** Develop over 3–8 weeks. **Associated Signs** - Edema within 3–5 hours post-rewarming. - Blisters form typically 4–24 hours later. - Severe cases may show mottled, cyanotic, or blackened skin. **Commonly Affected Areas** Cold injuries most often occur in areas with poor insulation and high exposure ([Basit](https://www.ncbi.nlm.nih.gov/books/NBK536914/?ref=theplasticsfella.com), 2023; [Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). - **Distal Extremities:** Fingers, toes, feet, and hands. - **Exposed Skin:** Nose, ears, cheeks, chin, lips. - **Genitalia:** Rare, but may occur in extreme exposures. ### Investigations Imaging aids in evaluating tissue viability and planning interventions, especially in deep frostbite. - **X-ray:** To detect fractures, retained foreign bodies, or trauma. - **Technetium-99m Bone Scintigraphy** - Evaluates perfusion and viability. - Recommended between days 2–4 and repeated on day 7–8 for 2nd–4th degree frostbite ([Twomey](https://pubmed.ncbi.nlm.nih.gov/16394908/?ref=theplasticsfella.com), 2005). - Helps determine candidacy for thrombolysis or need for amputation planning. - **Doppler Ultrasound:** Assesses vascular flow in superficial and deeper structures. - **MRI / CT Angiography** - Used in severe or ambiguous cases to define the extent of soft tissue and vascular injury. - Post-thrombolytic angiography should be repeated every 12–24 hours to assess response ([Zaramo](https://pubmed.ncbi.nlm.nih.gov/36299821/?ref=theplasticsfella.com), 2023). An X-ray image of a hand frostbite is shown below. ![X-ray image of a hand frostbite, clinical presentation of frostbite](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-02T004544.461.png) X-ray image of a hand frostbite --- ## Treatment of Cold Burns ****Key Point** Timely frostbite treatment hinges on rapid rewarming, pain control, and wound care; and in deep injuries, consideration of thrombolysis and vasodilators to salvage tissue. Surgical intervention should be delayed until clear tissue demarcation, typically after 4-6 weeks. ### Initial and Supportive Management **Hypothermia Management** ([Dow](https://pubmed.ncbi.nlm.nih.gov/31740369/?ref=theplasticsfella.com), 2019) - **Mild hypothermia** may be treated concurrently with frostbite. - **Moderate to severe hypothermia** must be addressed **before frostbite**, using warmed IV fluids to restore core temperature >35 °C (Dow, 2019). **Rapid Rewarming** - **Warm water immersion (37–39°C)** for 15–30 minutes until erythema returns. - Use a thermometer and regularly replace cooled water to maintain the temperature. - **Avoid temperatures >40°C** to prevent thermal burns. - Rewarm **only if refreezing can be avoided**, as repeat freeze–thaw cycles worsen tissue injury ([McIntosh](https://pubmed.ncbi.nlm.nih.gov/38577729/?ref=theplasticsfella.com), 2024). 💡 ****Tip:** Watch for ****afterdrop** — a core temperature drop from recirculating cold blood during rewarming ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). ### Pharmacologic Interventions **Pain Control** - **NSAIDs** (e.g., ibuprofen) reduce both pain and harmful prostaglandin/thromboxane activity. - **Narcotics** may be required in moderate-to-severe cases. **Wound Care** - **Clear Blisters:** Leave intact to reduce infection. - **Hemorrhagic Blisters:** Drain to reduce pressure necrosis. - **Aloe Vera Cream:** Apply every 6 hours; inhibits prostaglandins and reduces thrombosis ([McCauley](https://pubmed.ncbi.nlm.nih.gov/6827634/?ref=theplasticsfella.com), 1983). - **Dressings:** Use sterile, non-adherent gauze. Place cotton between digits to reduce friction (Zaramo, 2023). **Antibiotics and Tetanus** - **Indicated** only with open wounds, signs of infection, or concurrent trauma. - Administer **tetanus toxoid** if immunization is incomplete. **Low Molecular Weight Dextran (LMWD)** - **IV LMWD** reduces blood viscosity and prevents microthrombi. Can be started in the field once warmed ([McIntosh](https://pubmed.ncbi.nlm.nih.gov/38577729/?ref=theplasticsfella.com), 2024). 💡 ****Tip:** Emollients do ****not** protect against frostbite and may even ****increase** risk ([Lehmuskallio](https://pubmed.ncbi.nlm.nih.gov/10998829/?ref=theplasticsfella.com), 2000). ### Vascular Salvage Therapies **Thrombolysis** - **tPA (tissue plasminogen activator)** — IV or intra-arterial — may salvage tissue in **deep frostbite (Grade 3–4)** when given within 24 hours. - Consider follow-up **aspirin and heparin** therapy post-thrombolysis (Chung, 2024). **Vasodilator Therapy** - **Iloprost** (prostacyclin analog): Reduces inflammation, promotes vasodilation, inhibits platelet aggregation (Roche-Nagle, 2008). - Other agents include **prostaglandin E1, nitroglycerin, nifedipine, pentoxifylline**, and **reserpine** (McIntosh, 2024). ### Surgical Management Surgical decisions should be deferred until necrotic tissue clearly demarcates (typically 4-6 weeks post-injury) to avoid premature loss of viable tissue. - **Debridement:** Delayed to allow accurate tissue viability assessment via imaging (scintigraphy, MRI, angiography). - **Amputation:** Only once mummification or necrosis is clearly established. Premature surgery risks unnecessary morbidity ([Zaramo](https://pubmed.ncbi.nlm.nih.gov/36299821/?ref=theplasticsfella.com), 2023). - **Reconstructive Options:** Flaps or grafts may be required for function or cosmesis. 💡 ****Tip:** If refreezing is a risk, do not thaw the affected tissue. Repeated freeze–thaw cycles cause greater damage than leaving the tissue frozen until continuous warming is possible ([McIntosh](https://pubmed.ncbi.nlm.nih.gov/38577729/?ref=theplasticsfella.com), 2024). --- ## Complications of Cold Burns ****Key Point** Frostbite may result in long-term complications, including infection, chronic pain, cold intolerance, neuropathy, autoamputation, and deep vein thrombosis. Cold burn patients may have an intolerance to cold in previously frostbitten areas, which may be a consequence of vasospasm and abnormal autonomic tone following cold injury. Complications from cold burns include local tissue swelling, tissue necrosis, gangrene, compartment syndrome, joint immobility, and contractures, amongst other physical deformities ([Basit](https://www.ncbi.nlm.nih.gov/books/NBK536914/?ref=theplasticsfella.com), 2023). Frostbite injury is associated with morbidity, which is worse in the presence of hemorrhagic blisters, ongoing mottling, frank presence of frozen tissue, and no oedema ([Basit](https://www.ncbi.nlm.nih.gov/books/NBK536914/?ref=theplasticsfella.com), 2023). The image below summarises the complications of cold burns, their mechanism, and management methods. ![Complications of cold burns](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-12T020500.609.png) Complications of cold burns ### Managing Complications Management of these long-term complications is challenging and include the below strategies ([Zaramo](https://pubmed.ncbi.nlm.nih.gov/36299821/?ref=theplasticsfella.com), 2023). - For **chronic pain management**, early use of chronic pain specialists and medications such as amitriptyline, gabapentin, duloxetine, and topical capsaicin are beneficial. - **Surgical and chemical sympathectomies,** as well as **Botox** injections, have been proven to decrease pain and Raynaud-associated symptoms. 😎 ****Fun Fact:** Complications of frostbite can include loss of nails, anhidrosis, and hyperhidrosis ([Basit](https://www.ncbi.nlm.nih.gov/books/NBK536914/?ref=theplasticsfella.com), 2023). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Frostbite is a freezing injury caused by prolonged cold exposure below 0°C, where heat loss exceeds perfusion. Management aims to salvage tissue and function. ****2\. Causes:** Cold burns result from rapid or prolonged tissue cooling. Heat loss occurs via conduction, convection, radiation, and evaporation. ****3\. Types of Cold Injury:** Cold injury types vary by freezing speed and ice crystal formation. Frostnip, chilblains, flash freeze, and frostbite are the main categories. ****4\. Pathophysiology:** Cold exposure leads to ice crystal formation, cellular dehydration, and endothelial injury. Reperfusion causes inflammation, edema, and thrombosis. ****5\. Clinical Presentation:** Frostbite is classified from first to fourth degree, ranging from superficial pallor and numbness to deep necrosis and mummification. ****6\. Diagnosis:** Clinical diagnosis is supported by imaging (X-ray, bone scan, MRI) to assess tissue viability and plan surgical intervention. ****7\. Initial Management:** Treat hypothermia, rapidly rewarm in 37–39°C water, control pain, use aloe vera, sterile dressings, and consider tPA or iloprost in deep frostbite. ****8\. Surgical Management:** Surgical debridement or amputation is delayed until 4–6 weeks post-injury, when demarcation is complete. Early surgery is reserved for compartment syndrome. ****9\. Complications:** Cold burns can lead to infection, neuropathy, chronic pain, autoamputation, joint stiffness, and cold intolerance. Management may be surgical or medical. --- ## Further Reading 1. Basit H, Wallen TJ, Dudley C. [Frostbite](https://www.ncbi.nlm.nih.gov/books/NBK536914/?ref=theplasticsfella.com). \[Updated 2023 Jun 26\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536914/ 2. McIntosh SE, Freer L, Grissom CK, Rodway GW, Giesbrecht GG, McDevitt M, Imray CH, Johnson EL, Pandey P, Dow J, Hackett PH. [Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update](https://pubmed.ncbi.nlm.nih.gov/38577729/?ref=theplasticsfella.com). Wilderness Environ Med. 2024 Jun;35(2):183-197\. doi: 10.1177/10806032231222359\. Epub 2024 Apr 5\. PMID: 38577729. 3. Rintamäki H. [Predisposing factors and prevention of frostbite](https://pubmed.ncbi.nlm.nih.gov/10998828/?ref=theplasticsfella.com). Int J Circumpolar Health. 2000 Apr;59(2):114-21\. PMID: 10998828. 4. Twomey JA, Peltier GL, Zera RT. [An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite](https://pubmed.ncbi.nlm.nih.gov/16394908/?ref=theplasticsfella.com). J Trauma. 2005 Dec;59(6):1350-4; discussion 1354-5\. doi: 10.1097/01.ta.0000195517.50778.2e. PMID: 16394908. 5. Roche-Nagle G, Murphy D, Collins A, Sheehan S. [Frostbite: management options](https://pubmed.ncbi.nlm.nih.gov/18460961/?ref=theplasticsfella.com). Eur J Emerg Med. 2008 Jun;15(3):173-5\. doi: 10.1097/MEJ.0b013e3282bf6ed0\. PMID: 18460961. 6. Handford C, Buxton P, Russell K, Imray CE, McIntosh SE, Freer L, Cochran A, Imray CH. [Frostbite: a practical approach to hospital management](https://pubmed.ncbi.nlm.nih.gov/24764516/?ref=theplasticsfella.com). Extrem Physiol Med. 2014 Apr 22;3:7\. doi: 10.1186/2046-7648-3-7\. PMID: 24764516; PMCID: PMC3994495. 7. Petrone P, Kuncir EJ, Asensio JA. [Surgical management and strategies in the treatment of hypothermia and cold injury](https://pubmed.ncbi.nlm.nih.gov/14708823/?ref=theplasticsfella.com). Emerg Med Clin North Am. 2003 Nov;21(4):1165-78\. doi: 10.1016/s0733-8627(03)00074-9\. PMID: 14708823. 8. Chung 2024\. [Grabb and Smith's Plastic Surgery: 9th Edition](https://shop.lww.com/Grabb-and-Smith-s-Plastic-Surgery--Print---eBook-with-Multimedia/p/9781975214265?ref=theplasticsfella.com) September 2024 page 153 9. Cauchy E, Chetaille E, Marchand V, Marsigny B. [Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme](https://pubmed.ncbi.nlm.nih.gov/11769921/?ref=theplasticsfella.com). Wilderness Environ Med. 2001 Winter;12(4):248-55\. doi: 10.1580/1080-6032(2001)012\[0248:rsocos\]2.0.co;2\. PMID: 11769921. 10. Lehmuskallio E. [Emollients in the prevention of frostbite](https://pubmed.ncbi.nlm.nih.gov/10998829/?ref=theplasticsfella.com). Int J Circumpolar Health. 2000 Apr;59(2):122-30\. PMID: 10998829. 11. Dow J, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, Auerbach PS, McIntosh SE, Némethy M, McDevitt M, Schoene RB, Rodway GW, Hackett PH, Zafren K, Bennett BL, Grissom CK. [Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia](https://pubmed.ncbi.nlm.nih.gov/31740369/?ref=theplasticsfella.com): 2019 Update. Wilderness Environ Med. 2019 Dec;30(4S):S47-S69\. doi: 10.1016/j.wem.2019.10.002\. Epub 2019 Nov 15\. PMID: 31740369. 12. Mohr WJ, Jenabzadeh K, Ahrenholz DH. [Cold injury](https://pubmed.ncbi.nlm.nih.gov/19801122/?ref=theplasticsfella.com). Hand Clin. 2009 Nov;25(4):481-96\. doi: 10.1016/j.hcl.2009.06.004\. PMID: 19801122. 13. Zaramo TZ, Green JK, Janis JE. [Practical Review of the Current Management of Frostbite Injuries](https://pubmed.ncbi.nlm.nih.gov/36299821/?ref=theplasticsfella.com). Plast Reconstr Surg Glob Open. 2022 Oct 24;10(10):e4618\. doi: 10.1097/GOX.0000000000004618\. PMID: 36299821; PMCID: PMC9592504. 14. McCauley RL, Hing DN, Robson MC, Heggers JP. [Frostbite injuries: a rational approach based on the pathophysiology](https://pubmed.ncbi.nlm.nih.gov/6827634/?ref=theplasticsfella.com). J Trauma. 1983 Feb;23(2):143-7\. PMID: 6827634 ### Epidemiology of Upper Limb Necrotising Fasciitis in England: A National Study (1998–2018) URL: https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/ Last updated: 2025-05-03T21:15:15.000Z #### In this Journal Club **Epidemiology of upper limb necrotising fasciitis in England: A national study (1998-2018). Ky-Leigh Ang et al.* [**JPRAS*](https://bit.ly/jpras-may?ref=theplasticsfella.com) *2025 May* [****5-Point Summary**](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#5-point-summary) Upper limb necrotising fasciitis (NF) is a rare, aggressive infection with rising incidence in England. This national cohort study of 728 patients highlights key demographic trends and clinical outcomes, with a 16% mortality rate despite treatment. [****4-Key Findings**](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#4-key-findings) Incidence increased 250% between 1998 and 2013, stabilising thereafter. Most patients were male (64%), mean age of 55, and from deprived areas. Average hospital stay was 28 days. Mortality was 14% at 30 days and 16% at 90 days. [****3-Critiques**](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#3-critiques) HES data excludes patients who died pre-hospital, underestimating incidence. Lack of IV drug use data limits risk factor analysis. Coding limitations may result in missed or misclassified cases. [****2-Practical Takeaways** ](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#2-practical-takeaways) NF should be considered in otherwise healthy patients presenting with severe limb pain and systemic symptoms. Early intervention and addressing socioeconomic risk factors are key to reducing mortality. [****1-Recommended Reading**](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/#1-recommended-reading) Uehara et al.’s retrospective study (116 patients) identifies risk factors for death and amputation in upper limb NF, offering global context to national findings. [Read Full Article ](https://bit.ly/jpras-may?ref=theplasticsfella.com) ✍️ ****Note from the Editor** [Ang et al](https://www.sciencedirect.com/science/article/pii/S1748681525001871?ref=theplasticsfella.com) report on the national incidence, clinical features and outcomes from necrotising fasciitis (NF) of the upper limb using NHS Hospital Episode Statistics data over a 20 year period. Including 728 patients, this is the largest epidemiological study of upper limb NF and is striking by identifying that the majority of NF patients do not have significant co-morbidities (Charlson co-morbidity index 0-1). This alerts us to consider upper limb NF as a diagnosis to enable early intervention and impact the high mortality (16% at 90 days) reported in this excellent JPRAS paper. --- ## 5 Point Summary This study evaluates the national epidemiology of upper limb necrotising fasciitis (NF) in England, examining incidence trends, patient demographics, and clinical outcomes over a 20-year period. 1️⃣ ****Hypothesis** NF of the upper limb is increasing in incidence and associated with significant mortality despite surgical management. 2️⃣ ****Method** A retrospective analysis of 728 patients using Hospital Episode Statistics (1998–2018), assessing incidence, demographics, length of stay, complications, and mortality. 3️⃣ ****Results** Incidence rose 250% from 1998 to 2013\. Patients were predominantly male (64%), mean age of 55, with a 90-day mortality rate of 16%. 4️⃣ ****Conclusion** NF remains a high-risk condition with rising incidence and poor outcomes, particularly in socioeconomically deprived populations. 5️⃣ ****Implication** Vigilant recognition and prompt intervention are critical, with a need to address socioeconomic disparities in outcomes. ## 4 Key Findings This national dataset reveals an increasing burden of upper limb necrotising fasciitis, with key trends in incidence, demographics, and clinical outcomes. 1️⃣ ****Incidence** Incidence rose 250% from 1998 (0.004/10,000) to 2013 (0.01/10,000), then plateaued through 2018. ![Advanced necrotising fasciitis of the lower limb showing extensive skin necrosis, blistering, and tissue discoloration.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Journal-Club-Images--11-.png) Advanced necrotising fasciitis of the lower limb 2️⃣ ****Demographics** Most patients were male (64%) with a mean age of 55 years; 67% were from the lowest five deprivation deciles. ![Demographics of the study cohort - Upper limb necrotising fasciitis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Journal-Club-Images--13-.png) Demographics of the study cohort - Upper limb necrotising fasciitis 3️⃣ ****Complications** Average hospital stay was 28 days. Early complications included renal failure (1.1%) and UTIs (1.1%), with 30-day mortality at 14%. 4️⃣ ****Mortality** Ninety-day complications increased slightly, including renal failure (3.15%) and a 90-day mortality of 16%, underscoring disease severity. ![Comparison of mortality rates reported in previous international studies on upper limb necrotising fasciitis. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Journal-Club-Images--12-.png) Comparison of mortality rates - Upper limb necrotising fasciitis --- ## 3 Critiques While large and nationally representative, the study is limited by potential underestimation of mortality, lack of IV drug use data, and reliance on coding accuracy for case identification. 1️⃣ ****Underreporting** HES data excludes patients who died before hospital admission, potentially underestimating true incidence and mortality. 2️⃣ ****Missing Data** No data was available on intravenous drug use; a known risk factor for upper limb NF, limiting analysis of patient risk profiles. 3️⃣ ****Coding** ICD/OPCS coding may result in misclassification or missed cases, affecting the accuracy of case identification. --- ## 2 Practical Takeaways This study provides actionable insights for early detection and risk stratification of upper limb NF, highlighting the need for clinical vigilance even in low-comorbidity patients and the impact of socioeconomic deprivation on outcomes. 1️⃣ ****Diagnosis** NF should be considered even in healthy patients with severe limb pain and systemic symptoms, as many had minimal comorbidities. 2️⃣ ****Equity** Socioeconomic deprivation is a key risk factor. Early recognition and intervention in high-risk populations are essential. ## 1 Recommended Reading Uehara et al.’s retrospective analysis (116 patients, Japan) identifies predictors of mortality and amputation in upper limb NF, supporting global relevance of early diagnosis and aggressive treatment. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/25371469/?ref=theplasticsfella.com) ### Upper Limb Nec Fasc on the Rise, 3 Necrotising Fasciitis Diagnoses, & the Debridement Drill URL: https://www.theplasticsfella.com/april-27th-2/ Last updated: 2025-04-26T21:05:07.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/april-27th-2/#a-letter-from-pfella) P'Fella on vacation mode! 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/april-27th-2/#the-sunday-quiz) How well do you know **necrotising fasciitis*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/april-27th-2/#image-of-the-week) Dishwater fluid in nec fasc 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/april-27th-2/#technique-tip) How to debride necrotising fasciitis. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-27th-2/#upcoming-events) New event added! 6. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/april-27th-2/#jpras-journal-club) Epidemiology of upper limb necrotising fasciitis in England. 7. ****🚨** [****Case of the Week**](https://www.theplasticsfella.com/april-27th-2/#case-of-the-week) Nec fasc clinical scenario. 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/april-27th-2/#articles-of-the-week) LRINEC score, "3Ds" for diagnosing nec fasc, & a practical review of necrotising fasciitis: with 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/april-27th-2/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **P'Fella on Vacation!* 👋 ****Hey Team!** No letter today as I’m officially on vacation mode. Shades on, drink in hand, and pretending I don’t know what “post-op day 5” means. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/4172ed28-190e-447b-b686-ae40dd14e82e.png) P'fella on vacay-mode But while I’m away, let’s flip the script — I want to hear from you. P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Necrotising Fasciitis?* ****Are you ready to make it to the leaderboard?** Welcome to the ****next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ## Image of the Week **Dishwater Fluid in Nec Fasc* 🖼️ ****Image of the Week** This week’s image shows a classic operative finding in necrotising fasciitis: The presence of ****dishwater fluid.** A thin, grey, turbid exudate tracking along fascial planes. This sign reflects ****tissue liquefaction** and ****bacterial spread**. Early identification is critical as delayed debridement significantly increases morbidity and mortality. 📍Seen below: Undermined fascia, poor tissue perfusion, and hallmark dishwater fluid pooling in the fascial compartment. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/bjs9371-fig-0004-m.jpg) [Source](https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.9371?ref=theplasticsfella.com) ## Technique Tip **How to Debride Necrotising Fasciitis* 🚑 ****Technique Tip of the Week** This week’s tip focuses on the ****surgical approach to debriding necrotising fasciitis**, using zone-based skin assessment to guide excision. See image below for a breakdown of the technique. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Screenshot-2025-04-24-at-10-09-27.png) [Source](https://pubmed.ncbi.nlm.nih.gov/18614147/?ref=theplasticsfella.com) ## Upcoming Events **New Event Added!* 📅 ****P’Fella’s event calendar** highlights the most impactful conferences, high-yield webinars, and carefully curated courses for you. You can also ****submit your event** and get it featured! We've just added some new events to our calendar; sign up below👇 ## JPRAS Journal Club **Epidemiology of Upper Limb Necrotising Fasciitis in England* 📑 ****Epidemiology of Upper Limb Necrotising Fasciitis in England** **Upper limb necrotising fasciitis is rising in incidence, with a 250% increase from 1998 to 2013\. Most cases affect males (64%) and socioeconomically deprived individuals. Despite surgical management, 30-day mortality is 14%, rising to 16% by 90 days. Early recognition and aggressive treatment remain crucial.* P'fella's educational fellow, Dr. Hatan Mortada explores the ****Epidemiology of Upper Limb Necrotising Fasciitis** using a national study done in England over 20 years (1998-2018). [Epidemiology of Upper Limb Necrotising Fasciitis in England: A National Study (1998–2018)Data (1998-2018) from a UK study show upper-limb necrotising fasciitis tripled, then plateaued; 64 % of 728 patients were men and mostly from deprived areas. Despite surgery, 30- and 90-day mortality rates were 14 % and 16 %. Early diagnosis & action remain vital, especially in high-risk groups.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/Logo-Small-2-10.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/Lunchtime-Lessons-3.png)](https://www.theplasticsfella.com/journal-upper-limb-necrotising-fasciitis/) ## Case of the Week **Nec Fasc Clinical Scenario* 🚨 Our case of the week focuses on a high-stakes emergency: ****Necrotising fasciitis**. ****Learning Objectives:** ****1\.** Recognise pathognomonic signs of necrotising fasciitis. ****2\.** Identify major risk factors. ****3\.** Know which investigations aid diagnosis. ****4\.** Formulate an urgent management plan. ****5\.** Consider adjunctive therapies. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis---Clinical-Case.png) #### Clinical Scenario A 45-year-old male arrives at the emergency department with severe pain in his right leg, which has increased in intensity over the past 24 hours. The leg is swollen, erythematous, and warm to the touch. There are also some dark, blistering areas on the skin. The patient mentions a minor cut on his leg from gardening a few days ago. He has a history of poorly controlled diabetes mellitus type 2. **Parameters:* Heart rate 145 bpm, Blood pressure 85/60, Temperature 38.4, Confused. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow, Malta. ****Reviewer**: Dr Waraguru Wanjau, Educational Fellow, South Africa. [Read the Article](https://www.theplasticsfella.com/necrotising-fasciitis-clinical-scenario/) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****The LRINEC Score: A Lab-Based Tool for Early Detection of Necrotizing Fasciitis** ([Wong](https://pubmed.ncbi.nlm.nih.gov/15241098/?ref=theplasticsfella.com), 2004) The LRINEC score is based on routine labs like CRP & sodium and it flags necrotizing fasciitis with a 92% positive predictive value — a game-changer in distinguishing NF from cellulitis. ✅ ****The "3Ds" for Diagnosing Necrotizing Fasciitis in Frontline Care** ([Haykal](https://www.jprasurg.com/article/S1748-6815%2823%2900270-X/abstract?ref=theplasticsfella.com), 2023) The “3Ds” of necrotizing fasciitis: Disproportionate pain, Dermatological signs, and Disorganized physiology, is a memorable triage tool that identified 66% of confirmed cases at presentation. ✅ ****Review of Necrotizing Fasciitis: Diagnosis, Surgical Principles, & Reconstructive Strategies** ([Guliyeva](https://journals.lww.com/prsgo/fulltext/2024/01000/practical%5Freview%5Fof%5Fnecrotizing%5Ffasciitis%5F.23.aspx?ref=theplasticsfella.com), 2024) This practical review maps the full NF journey, highlighting the “4 Ds” of successful management: Diagnose early, Debride aggressively, Dress wisely, and Design the reconstruction to match the defect. ## Feedback ### I hope you enjoyed it 😄 --- ### Injectable Fillers: Classification, Indications, & Injection Techniques URL: https://www.theplasticsfella.com/fillers/ Last updated: 2025-04-21T20:17:02.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/fillers/#overview-of-injectable-fillers) Injectable fillers are essential tools in nonsurgical facial rejuvenation, offering tailored solutions for restoring volume, contouring, and smoothing wrinkles. [****Classification**](https://www.theplasticsfella.com/fillers/#classification-of-injectable-fillers) Injectable fillers are primarily divided into physical fillers, which provide immediate volume (e.g., HA), and biostimulatory fillers, which promote long-term collagen production (e.g., PLLA, CaHA, PCL). [****Indications and Filler Selection**](https://www.theplasticsfella.com/fillers/#indications-and-filler-selection) Filler choice depends on anatomy, patient goals, and material properties. Common indications include volume restoration, wrinkle correction, lip shaping, skin rejuvenation, and scar treatment. [****Injection Technique**](https://www.theplasticsfella.com/fillers/#injection-technique-of-fillers) Filler injections require a thorough pre-treatment evaluation, detailed anatomical planning, and tailored use of needles or cannulas depending on the target area, injection depth, and vascular risk. [****Contraindications and Adverse Effects** ](https://www.theplasticsfella.com/fillers/#contraindications-and-adverse-effects-of-fillers) Injectable fillers are contraindicated in certain medical conditions and carry a risk of adverse effects ranging from mild swelling to serious complications like vascular occlusion and, rarely, blindness. ****Primary Contributor:** Dr Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Injectable Fillers ****Key Point** Injectable fillers are versatile, noninvasive treatments used to restore volume, contour the face, and reduce wrinkles. Fillers offer a customizable solution for facial rejuvenation by either filling tissue directly or stimulating collagen production, depending on the material and placement depth. ![Injectable filler](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-22T013300.937.png) Injectable filler While no filler meets every ideal trait, most aim to strike a balance between safety, performance, and natural results. - **Biocompatible and Non-immunogenic:** Minimizes inflammation - **Safe and Predictable:** Consistent results with minimal complications. - **Durable but Reversible:** Long-lasting with reversibility (e.g., hyaluronidase) - **Easy to Inject and Natural Feeling:** smooth and feel undetectable. - **Ages with the Patient:** Should adapt with facial changes over time. Fillers can be **classified** by how long they last and their mechanism of action. - **Temporary (e.g., Hyaluronic Acid):** Most commonly used; hydrating, reversible, and ideal for fine lines and lips. - **Semi-Permanent (e.g., CaHA, PLLA):** Longer-lasting; adds volume and stimulates collagen. - **Permanent (e.g., PMMA):** Long-term results but less forgiving; reserved for select cases. 😎 ****Fun Fact:** About half of the 15 grams of hyaluronic acid in a 70 kg human is found in the skin ([Juncan](https://pubmed.ncbi.nlm.nih.gov/34361586/?ref=theplasticsfella.com), 2021). --- ## Classification of Injectable Fillers ****Key Point** Injectable fillers are categorized as physical fillers (immediate volume), biostimulatory fillers (collagen stimulation), and autologous fillers (from the patient’s own tissue) Classification of fillers is essential for selecting the appropriate product based on desired duration, mechanism of action, and anatomical site. While physical and biostimulatory fillers dominate non-autologous options, autologous fillers ([fat grafting](https://www.theplasticsfella.com/fat-grafting/)) are discussed separately due to their unique surgical handling. - **Physical Fillers:** Provide immediate volume replacement. - **Biostimulatory Fillers:** Promote collagen synthesis. ### Physical Fillers Physical fillers provide immediate volume restoration by physically occupying space within soft tissues. **Hyaluronic Acid (HA)** Naturally occurring GAG that maintains skin hydration and elasticity. Modified via crosslinking to extend durability when used as a filler — endogenous HA has a very short half-life. The structure of hyaluronic acid is illustrated below. ![The structure of hyaluronic acid](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-22T013542.359.png) The structure of hyaluronic acid The physicochemical properties of HA fillers shape their clinical performance, with variations tailored to different anatomical areas and goals - **Rheology:** The elastic modulus (G′) determines stiffness—high G′ for deep support (e.g., jawline), low G′ for dynamic areas (e.g., lips). - **Cohesivity:** Indicates the gel’s ability to hold together; higher cohesivity resists migration and retains shape. - **Extrusion Force:** Affects ease of injection; influenced by particle size and crosslinking. - **Swelling Factor:** Measures water absorption post-injection; more crosslinking means less swelling and more predictable volume. These properties of fillers are illustrated below. ![Properties of fillers that determine their behaviour, tissue integration, and clinical suitability](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-22T013725.231.png) Properties of fillers that determine their behaviour, tissue integration, and clinical suitability 💡 ****Tip:** Adding lidocaine to HA fillers enhances comfort without significantly changing their physical properties ([Guo](https://pmc.ncbi.nlm.nih.gov/articles/PMC10413051/?ref=theplasticsfella.com), 2023). **Collagen Fillers** Collagen is a key structural protein of the ECM, and its loss contributes to the visible signs of aging. The fillers restore dermal structure but are less commonly used due to short duration and immunogenicity risks in animal-derived forms. Recombinant collagen is gaining attention for better safety. 😎 ****Fun Fact:** Isologen involves culturing a patient’s own fibroblasts from a skin biopsy to produce injectable collagen—a personalized autologous filler. ### Biostimulatory Fillers Bio-stimulatory fillers induce a **controlled foreign body response** that promotes fibroblast activation and type I collagen deposition, gradually improving tissue structure and volume. **Poly(L-lactic acid) (PLLA)** - **Definition:** Semipermanent, biocompatible synthetic polymer. - **Mechanism of Action:** Stimulation of collagen production through fibroblast activation. Gradual volume restoration over several months, as the microspheres are broken down by macrophages, leads to collagen deposition. - **Duration:** Up to 2 years. - **Example: Sculptra** is FDA-approved for facial wrinkles and HIV-associated lipoatrophy. **Calcium hydroxylapatite (CaHA)** - **Definition:** Semipermanent, naturally occurring substance, primarily found in human bone. - **Mechanism of Action:** CaHA provides an immediate volumizing effect followed by long-term collagen stimulation as fibroblasts grow around the microspheres. - **Duration:** Up to 18 months. - **Example:** **Radiesse** (CaHA suspended in a carrier gel) to treat moderate to severe facial wrinkles and folds. The product is injected deep into the dermis using a linear technique. **Polycaprolactone (PCL)** - **Definition:** Biocompatible, biodegradable, and bioresorbable polymer. - **Mechanism of Action:** Like PLLA, PCL degrades into CO2 and H2O, which are eliminated from the body. - **Duration:** Up to 4 years. - **Example:** **Ellanse**, a filler containing 30% PCL microspheres and 70% carboxymethylcellulose (CMC) gel, offers both immediate (volumizing) and long-lasting effects (collagen production and neovascularization). **Poly(methyl methacrylate) (PMMA)** - **Definition:** Non-resorbable synthetic material, providing permanent tissue augmentation. - **Mechanism of Action:**PMMA microspheres are encapsulated by fibroblasts and collagen fibers. - **Duration:** Up to 5 years. - **Example:** **Artecoll**, made of 20% PMMA microspheres suspended in a bovine collagen solution. Similarly, **ArteFill** (BellaFill) provides permanent volumization. These biostimulatory fillers are summarised in the table below. ![Biostimulatory filler types and characteristics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-22T014621.402.png) Biostimulatory filler types and characteristics 💡 ****Tip:** Understanding the physicochemical characteristics of fillers (like G′, cohesivity, and swelling) helps match the right product to each anatomical site and patient goal. --- ## Indications and Filler Selection ****Key Point** Filler selection is tailored to anatomical region, patient goals, and filler characteristics, optimizing outcomes in volume restoration, wrinkle treatment, lip shaping, skin rejuvenation, and scar correction. Successful filler outcomes rely on individualized treatment, matching product properties to anatomical demands, tissue dynamics, and patient goals. The selection of injectable fillers is guided by: - Facial anatomy and injection depth - Rheological properties of the filler (e.g., G′, cohesivity, extrusion force) - Patient preferences and the desired results #### Volume Restoration and Contour Enhancement - **Areas:** Midface, temples, chin, jawline, and periorbital hollows. - **Use:** Deep injections with volumizing fillers. - **Filler Characteristics:** High G′, high viscosity, and good lift capacity. - **Preferred Fillers:** HA, CaHA, or PCL. - **Outcome:** Structural support, definition, and long-lasting contour improvement. #### Fine Lines and Superficial Wrinkles - **Areas:** Perioral lines, crow’s feet, and forehead lines. - **Use:** Superficial placement using micro-aliquots. - **Filler Characteristics:** Low G′ HA for smooth integration. - **Advantage:** Maintains mobility and subtle correction without lumpiness. #### Lips and Perioral Region - **Challenge:** High mobility requires a filler that is both durable and flexible. - **Filler Characteristics:** Medium G′, moderate cohesivity. - **Preferred Use:** Soft HA fillers to enhance vermilion border, volume, and symmetry. - **Goal:** Subtle augmentation with natural movement and minimized migration. #### Skin Quality Improvement - **Indications:** Crepey texture, dullness, and mild laxity. - **Filler Type:** Biostimulatory agents such as PLLA and PCL. - **Mechanism:** Stimulates neocollagenesis and elastin formation. - **Effect:** Progressive improvement in skin tone, firmness, and elasticity. - **Note:** Requires multiple sessions with clear patient education on gradual results. #### Scar Correction - **Indications:** Atrophic or rolling scars (e.g., acne scars). - **Filler Options:** HA and CaHA for temporary lifting; PMMA for long-term correction. - **Technique:** Subcision followed by subdermal bolus or fanning technique. - **Outcome:** Smoother skin surface through elevation and stimulation of dermal remodeling. Below is an anatomically based chart for filler selection. ![Anatomically based chart for filler selection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-17T020456.510.png) Anatomically based chart for filler selection --- ## Injection Technique of Fillers ****Key Point** Safe and effective filler injections require thorough patient evaluation, precise anatomical planning, and a strategic choice between needles and cannulas based on treatment goals and vascular risk. ### Pre-Treatment Considerations Proper assessment and preparation are foundational to successful outcomes. - **Medical History:** Screen for allergies, medications, and autoimmune disorders. - **Contraindications:** Avoid treatment in cases of infection, recent dental work, or active inflammation. - **Facial Assessment:** Analyze symmetry, skin quality, and volume loss. - **Patient Expectations:** Discuss goals clearly and manage expectations. - **Photography:** Capture baseline images for reference and documentation. Needle and cannula selection is guided by anatomical location, filler rheology, and depth of injection. - **Needles:** Allow precision in tight planes but carry higher vascular risk. - **Cannulas:** Blunt tips reduce trauma and intravascular risk—ideal for high-risk areas. - **Anesthesia:** Use topical agents, nerve blocks, or lidocaine-containing fillers; adjuncts include ice or vibration tools to enhance comfort. The table below compares the use of needles and cannulas in dermal filler injections. ![Needle and cannula selection for injectable fillers, based on their intrinsic characteristics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-17T020714.460.png) Needle and cannula selection for injectable fillers ### Injection Techniques by Facial Region **Upper Face** - **Forehead and Glabella:** Commonly considered danger zones. Inject at least 2 cm above the eyebrow, in a deep plane (supraperiosteal). Pay close attention to supratrochlear, supraorbital, and superficial temporal vessels ([Ahn](https://pubmed.ncbi.nlm.nih.gov/38837504/?ref=theplasticsfella.com), 2024). - **Temples:** Injections can be performed at various depths, from superficial to deep planes, depending on clinical indications. Care must be taken to avoid superficial temporal vessels and the middle temporal vein ([De Maio](https://pubmed.ncbi.nlm.nih.gov/28746271/?ref=theplasticsfella.com), 2017). **Midface** - **Tear Trough:** Use of low G′ HA with minimal swelling potential. Injections should be deep, at the supraperiosteal level or underneath the orbicularis oculi muscle. avoiding the superficial vasculature ([Sharad](https://pubmed.ncbi.nlm.nih.gov/23378704/?ref=theplasticsfella.com), 2012). - **Malar Region:** Injections can be performed at various depths, either with bolus or linear threading techniques. Pay attention to infraorbital vessels and nerves. - **Nose:** Injections should be performed on the midline, in a supraperiosteal/supraperichondral plane, keeping fingers on the sides to avoid filler lateral displacement. Be alert to the presence of anastomosis of periorbital vessels in the subcutaneous plane ([Singh](https://pmc.ncbi.nlm.nih.gov/articles/PMC6484576/?ref=theplasticsfella.com), 2019). 💡 ****Tip:** In nasal filler injections, use boluses of ****0.05–0.1 mL** and avoid exceeding 1 mL total, to minimize the risk of vascular compression and necrosis due to HA’s hydrophilic effect. **Lower Face** - **Lips:** Multiplanar approach using medium G′ HA for both volume and definition. Injection must consider dynamic movement and vascular anatomy. - **Chin and Jawline:** Deep structural augmentation using high G′ fillers, often with a cannula for linear threading along mandibular border ([Vazirnia](https://pubmed.ncbi.nlm.nih.gov/31889377/?ref=theplasticsfella.com), 2020). - **Nasolabial Folds and Marionette Lines:** Combination of deep structural support and superficial softening using appropriate filler rheology. Beyond facial applications, several fillers, especially biostimulatory agents such as PLLA or high-viscosity HA, are used for **body contouring**. Common off-label indications include the volumisation of hands, correction of skin laxity in the neck and décolleté, and gluteal augmentation using diluted or layered injection techniques. --- ## Contraindications and Adverse Effects of Fillers ****Key Point** Injectable fillers are contraindicated in specific medical conditions and can cause adverse effects ranging from mild swelling to serious complications like vascular occlusion and, in rare cases, blindness While fillers are generally safe and well-tolerated, patient selection and clinical vigilance are critical. A comprehensive understanding of contraindications and potential complications allows for safer outcomes and timely management when issues arise ### Contraindications Recognizing absolute and relative contraindications helps reduce the risk of complications and ensures ethical, informed treatment decisions. - **Absolute Contraindications:** - **Allergy:** Known hypersensitivity to any filler component. - **Infection:** Active infection or inflammation at the treatment site. - **Pregnancy/Breastfeeding:** Lack of safety data; avoid use. - **Severe Allergies/Anaphylaxis:** High risk of adverse immune reactions. - **Uncontrolled Autoimmune Disease:** Heightened risk of immune-related complications. - **Systemic Infections or Recent Dental Work:** Increased infection risk (defer treatment for ≥2 weeks post dental procedures). - **Relative Contraindications:** - **Anticoagulant or Antiplatelet Use:** Higher risk of bruising or hematoma. - **Immunosuppression:** Slower healing, increased infection risk. - **Psychological Concerns:** Unrealistic expectations or body dysmorphic disorder may lead to dissatisfaction and over-treatment. ### Adverse Effects Adverse reactions can be classified by timing—immediate, early, or delayed. Most are self-limiting, but serious events require prompt intervention. #### Immediate and Early Adverse Effects - **Local Reactions:** Redness, swelling, tenderness, or bruising at the injection site. - **Nodules/Irregularities:** Often due to superficial injection or improper technique. - **Hypersensitivity Reactions:** Can range from localized swelling to generalized allergic response. - **Infection:** Uncommon but potentially serious; may require antibiotics or drainage. - **Vascular Compromise:** - **Cause:** Intravascular injection or compression of vessels. - **Outcome:** Ischemia, necrosis, or blindness (via retrograde embolization into the ophthalmic artery). - **Signs:** Blanching, severe pain, livedo reticularis, delayed capillary refill. - **Emergency Protocol for HA Fillers:** - Immediate injection of **hyaluronidase** - **Warm compresses** and **massage** - Consider **vasodilators** like nitroglycerin paste - Refer urgently if vision is affected #### Delayed Adverse Effects - **Granulomas:** Immune-mediated nodular inflammation that may appear weeks to months later. - **Filler Migration:** Displacement of filler, often in highly mobile or overfilled areas. - **Tyndall Effect:** Bluish discoloration from superficial HA placement, more common under thin skin. The adverse effects of fillers are illustrated and described below. ![The adverse effects of fillers](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-17T020827.368.png) The adverse effects of fillers --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Injectable fillers are essential tools in nonsurgical facial rejuvenation, offering immediate or progressive aesthetic enhancement depending on the product type. ****2.** ****Classes of Injectable Fillers:** Fillers can be broadly classified as volumising agents or biostimulatory agents that stimulate collagen production for long-term improvement. ****3\. Filler selection and Indications:** Optimal filler choice is guided by anatomical considerations, patient goals, and rheological properties. Common indications include contour restoration, fine line correction, lip enhancement, skin quality improvement, and scar revision. ****4\. Injection Techniques:** Effective treatment requires thorough pre-injection assessment, anatomical planning, and the strategic use of needles or cannulas based on target depth and vascular risk. ****5\. Contraindications and Adverse Effects:** Fillers are contraindicated in patients with allergies, infections, or uncontrolled systemic conditions. While most side effects are mild and self-limited, serious complications such as vascular occlusion and, rarely, blindness may occur. --- ## Further Reading 1. Juncan AM, Moisă DG, Santini A, Morgovan C, Rus LL, Vonica-Țincu AL, Loghin F. Advantages of Hyaluronic Acid and Its Combination with Other Bioactive Ingredients in Cosmeceuticals. Molecules. 2021 Jul 22;26(15):4429\. doi: 10.3390/molecules26154429\. PMID: 34361586; PMCID: PMC8347214. 2. Guo J, Fang W, Wang F. Injectable fillers: current status, physicochemical properties, function mechanism, and perspectives. RSC Adv. 2023 Aug 10;13(34):23841-23858\. doi: 10.1039/d3ra04321e. PMID: 37577103; PMCID: PMC10413051. 3. Alster TS, West TB. Human-derived and new synthetic injectable materials for soft-tissue augmentation: current status and role in cosmetic surgery. Plast Reconstr Surg. 2000 Jun;105(7):2515-25; discussion 2526-8\. doi: 10.1097/00006534-200006000-00034\. PMID: 10845309. 4. Watson D, Keller GS, Lacombe V, Fodor PB, Rawnsley J, Lask GP. Autologous fibroblasts for treatment of facial rhytids and dermal depressions. A pilot study. Arch Facial Plast Surg. 1999 Jul-Sep;1(3):165-70\. doi: 10.1001/archfaci.1.3.165\. PMID: 10937098. 5. Rostan E. Collagen fillers. Facial Plast Surg Clin North Am. 2007 Feb;15(1):55-61, vi. doi: 10.1016/j.fsc.2006.11.001\. PMID: 17317556. 6. Kapoor KM, Chatrath V, Li CQ, Bertossi D. Pinch Anatomy of Forehead: An Injection Guide for Forehead Filler Treatment. Facial Plast Surg. 2022 Apr;38(2):156-162\. doi: 10.1055/a-1730-8436\. Epub 2022 Mar 10\. PMID: 34983076. 7. Ahn HS, Kim HM, Oh W, Yi KH, Kim J, Kim HJ. Singular entry point technique for forehead and temple filler augmentation: Anatomical and clinical perspectives. J Cosmet Dermatol. 2024 Oct;23(10):3195-3201\. doi: 10.1111/jocd.16411\. Epub 2024 Jun 4\. PMID: 38837504. 8. de Maio M, Swift A, Signorini M, Fagien S; Aesthetic Leaders in Facial Aesthetics Consensus Committee. Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Upper Face. Plast Reconstr Surg. 2017 Aug;140(2):265e-276e. doi: 10.1097/PRS.0000000000003544\. PMID: 28746271. 9. Sharad J. Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes. J Cutan Aesthet Surg. 2012 Oct;5(4):229-38\. doi: 10.4103/0974-2077.104910\. PMID: 23378704; PMCID: PMC3560162. 10. Singh S. Practical Tips and Techniques for Injection Rhinoplasty. J Cutan Aesthet Surg. 2019 Jan-Mar;12(1):60-62\. doi: 10.4103/JCAS.JCAS\_137\_18\. PMID: 31057272; PMCID: PMC6484576. 11. Vazirnia A, Braz A, Fabi SG. Nonsurgical jawline rejuvenation using injectable fillers. J Cosmet Dermatol. 2020 Aug;19(8):1940-1947\. doi: 10.1111/jocd.13277\. Epub 2019 Dec 31\. PMID: 31889377. ### Dead Textbooks, 3 DIEP Complication Tips, & Surgical Studio Updates URL: https://www.theplasticsfella.com/april-20th/ Last updated: 2025-04-19T22:03:01.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/april-20th/#a-letter-from-pfella) Why are we still learning from dead textbooks? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/april-20th/#the-sunday-quiz) How well do you know v**enous congestion*? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/april-20th/#behind-the-fella) Suggest any questions for our next guest. 4. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-20th/#upcoming-events) New event added! 5. ****🚀**[ **New Features**](https://www.theplasticsfella.com/april-20th/#new-features) AI Surgical Studio updates! 6. 📚 [****Book Review**](https://www.theplasticsfella.com/april-20th/#book-review) Feedback on Foundations by The Plastics Fella. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/april-20th/#articles-of-the-week) NPWT helps breast recon?, predicting DIEP complications, & a classic publication on free flaps: with 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/april-20th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **We’re Still Learning from Dead Textbooks* 👋 ****Hey Team!** Let’s stop pretending this isn’t a problem. Most plastic surgery textbooks haven’t been updated in years. Some haven’t meaningfully changed in over a decade. Yet we’re still assigning them, quoting them, and building exams around them like they’re gospel. They’re not. They’re outdated — and in some cases, outright wrong. **What’s Broken** Here’s the honest truth. - **Techniques evolve. Textbooks don’t.** You’re learning from operations that aren’t done anymore. Or worse — missing the ones that actually are. - **They never get corrected.** An error in the 2014 edition is still sitting there in the 2023 one. We’ve normalized reading around the mistakes. - **Outdated copies never go away.** You can still buy a textbook from 2007 on Amazon. That’s what students are studying from. That’s what trainees are downloading as PDFs. - **It’s a closed system.** No transparency. No accountability. And definitely no way to challenge what’s written, even when it’s obviously flawed. This isn’t just a publishing issue. It’s a training issue. And it’s making us worse. **So We’re Doing It Differently** We're building a new textbook — **Foundations by The Plastics Fella** — and here’s what we’re refusing to replicate: - **Every chapter gets reviewed annually.** Not in theory. In practice. A full update cycle every 12 months, with tracked changes and transparent version control. - **There are no outdated versions.** You can’t buy an old edition. Everyone sees the same current version. If something changes, everyone benefits. - **Mistakes get fixed. Fast.** There’s a feedback system. If something’s wrong, unclear, or outdated, it doesn’t sit there for another decade. It gets addressed. - **It’s built by the community.** Trainees and surgeons contribute, review, and refine it. It reflects how people actually learn and operate, not just how they publish. **This Isn’t About Innovation. It’s About Necessity.** Plastic surgery moves fast. The resources we learn from should too. We're not trying to be clever. We’re just done accepting that a textbook published in 2012 is still acceptable in 2025. This is the fix. And it starts now. 👉 Join the waiting list if you want early access, or if you just want to see what a modern textbook *should* look like. P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Venous Congestion?* ****Are you ready to make it to the leaderboard?** Welcome to the ****next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ## Behind the 'Fella **Questions for Our Next Guest* 🎧 ****Releasing Soon: Behind the 'Fella Season Two** Our recordings are in progress! For the next guest, we're interviewing a DIEP expert. Whether it's about technique, complications, or training, submit your question below 👇 ## Upcoming Events **New Event Added!* 📅 ****P’Fella’s event calendar** highlights the most impactful conferences, high-yield webinars, and carefully curated courses for you. You can also ****submit your event** and get it featured! We've just added ****ASPS Advocacy Summit** to our calendar; sign up below👇 ## New Features **AI Surgical Studio Version 2.0 Is Here* 🩹 Our ****AI Surgical Studio** just got its newest update: Version 2.0\. We’ve just rolled out a new of the ****AI Surgical Studio** — our interactive, AI-powered tool designed to help you visualise, plan, and refine surgical techniques with precision. Want ****early access to upcoming features**? Join the waitlist below👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/sutdiooo.png) ## Book Review **Foundations by The Plastics Fella* 📘 The design of our new textbook is in the works, and we want your input. Your feedback helps shape a textbook that fits what you need. ****We are currently testing out different cover designs.** Share your thoughts below 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/ChatGPT-Image-Apr-18--2025--08_23_14-PM.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/ChatGPT-Image-Apr-19--2025--11_01_23-PM.png) Foundations by The Plastics Fella ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Does ciNPT Reduce Donor-Site Complications in DIEP Flap Breast Recon?** ([Escobar-Domingo](https://www.jprasurg.com/article/S1748-6815%2825%2900250-5/abstract?ref=theplasticsfella.com), 2025) In a large cohort study of 1125 flaps, closed-incision negative pressure therapy significantly lowered infection and dehiscence rates at DIEP donor sites, particularly among patients with a BMI >30. ✅ ****Predictors of Complications in DIEP Flap Breast Reconstruction** ([Wu](https://journals.lww.com/plasreconsurg/abstract/2023/10000/predictors%5Fof%5Fcomplications%5Fin%5Fautologous%5Fbreast.5.aspx?ref=theplasticsfella.com), 2023) Each additional hour in theatre increases overall complication risk by 16% in DIEP reconstructions, highlighting operative time as a key modifiable factor in flap success. ✅ ****What Comes After a Failed Free Flap? Insights from 3361 Reconstructions** ([Wei](https://journals.lww.com/plasreconsurg/abstract/2001/10000/the%5Foutcome%5Fof%5Ffailed%5Ffree%5Fflaps%5Fin%5Fhead%5Fand%5Fneck.7.aspx?ref=theplasticsfella.com), 2001) In one of the largest series to date, a second free flap proved more reliable than regional or conservative approaches in salvaging failed reconstructions, especially in the head and neck. ## Feedback ### I hope you enjoyed it 😄 --- ### Ischaemic and Congested Flap: Diagnosis, Management, & Outcomes URL: https://www.theplasticsfella.com/ischaemic-and-congested-flap/ Last updated: 2025-04-11T20:18:01.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/ischaemic-and-congested-flap/#overview-of-ischaemic-and-congested-flaps) Flap vascular compromise (arterial ischaemia or venous congestion) is a time‑critical surgical emergency that most often arises within the first 72 hours post‑operatively and requires rapid recognition to maximise salvage. [****Aetiology**](https://www.theplasticsfella.com/ischaemic-and-congested-flap/#aetiology-of-ischaemic-and-congested-flaps) Flap compromise results from mechanical obstruction, thrombosis, or rheological disturbances. Venous congestion is more common and often more insidious than arterial ischaemia, demanding urgent intervention. [****Pathophysiology**](https://www.theplasticsfella.com/ischaemic-and-congested-flap/#pathophysiology-of-ischaemic-and-congested-flaps) Flap compromise initiates a cascade of hypoxia, capillary leak, microvascular thrombosis, and inflammation, progressing rapidly within hours and exacerbated by delayed choke vessel recruitment and non-occlusive flow disturbances. [****Classification**](https://www.theplasticsfella.com/ischaemic-and-congested-flap/#classification-of-flap-compromise) Although no single, universally accepted system exists, grouping flap compromise by timing, type of vascular insufficiency, and extent of tissue involvement provides a practical framework for diagnosis and management. [****Clinical Assessment**](https://www.theplasticsfella.com/ischaemic-and-congested-flap/#clinical-assessment-for-flap-compromise) Early, structured clinical assessment including history, examination, and adjunct monitoring remains the cornerstone of detecting vascular compromise and maximising flap salvage. [****Investigations**](https://www.theplasticsfella.com/ischaemic-and-congested-flap/#investigations-for-flap-compromise) Clinical assessment is key to flap monitoring, but real-time modalities such as Doppler and NIRS can detect early compromise. Blood tests and imaging play supportive roles in select cases, and should never delay surgical re-exploration if acute compromise is strongly suspected. [****Management**](https://www.theplasticsfella.com/ischaemic-and-congested-flap/#management-of-flap-compromise) Flap salvage depends on early recognition and prompt action. Surgical re-exploration remains the mainstay for mechanical causes, while non-surgical strategies may support venous drainage when revision is not feasible or no structural issue is found. [****Prognosis**](https://www.theplasticsfella.com/ischaemic-and-congested-flap/#prognosis-of-flap-compromise) Flap salvage is time-dependent. Early recognition and revision within 6 hours offer the best chance of success, while delayed intervention or repeated compromise significantly lowers survival. ****Primary Contributor:** Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Ischaemic and Congested Flaps ****Key Point** Flap vascular compromise (arterial ischaemia or venous congestion) is a time‑critical surgical emergency that most often arises within the first 72 hours post‑operatively and requires rapid recognition to maximise salvage. Flap vascular compromise refers to insufficient arterial inflow (ischaemia) or impaired venous outflow (congestion) in a surgical flap. Flap vascular compromise typically occurs early in the post-operative period (<72 hours), is the most frequent cause of early flap failure, and demands urgent surgical attention to preserve flap viability. These complications can affect both **free and pedicled flaps**, each with distinct clinical features. - **Ischaemia:** Pale, cold, delayed capillary refill, no bleeding on needle prick. - **Congestion:** Purplish hue, rapid refill (<3s), dark venous bleeding, tense swelling. Venous congestion is more common than arterial ischaemia and is often more challenging to manage ([Shen](https://pubmed.ncbi.nlm.nih.gov/33395711/?ref=theplasticsfella.com), 2021; [Coriddi](https://pmc.ncbi.nlm.nih.gov/articles/PMC8810672/?ref=theplasticsfella.com), 2023). 😎 ****Fun Fact:** In 1972, surgeons performed the first successful free flap, transplanting vascularized tissue from the groin to the ankle, revolutionizing reconstructive surgery with microsurgical precision. --- ## Aetiology of Ischaemic and Congested Flaps ****Key Point** Flap compromise results from mechanical obstruction, thrombosis, or rheological disturbances. Venous congestion is more common and often more insidious than arterial ischaemia, demanding urgent intervention. Flap vascular compromise arises due to disruptions in either arterial inflow or venous outflow, often dictated by intraoperative technique, flap design, and patient-specific factors. ### Arterial Ischaemia **Thrombosis at the Arterial Anastomosis** typically stems from technical errors such as poor suture placement, tension, or rough handling that causes intimal trauma. - **Vasospasm:** Provoked by vessel manipulation, hypothermia, or trauma. Particularly relevant in small-calibre vessels. - **Pedicle Kinking or Torsion:** Results from improper flap positioning, especially when the vascular pedicle is looped or twisted during inset. - **Clot Propagation:** May follow intimal injury or occur secondary to inadequate anticoagulation, progressing proximally or distally along the vessel. ### Venous Congestion - **Mechanical Compression:** Caused by tight dressings, bulky hematomas, or pressure from tunneled pathways. - **Pedicle Twisting:** A frequent complication in propeller or island flaps, where flap rotation places torque on the venous system. - **Venous Thrombosis:** Often occurs at the anastomosis or within small venules, leading to rapid flap congestion and failure. - **Inadequate Venous Outflow:** Poor vein selection, size mismatch, or anatomic variation can hinder drainage and promote stasis. The table below summarises the differences between arterial ischaemia and venous congestion. ![Comparison of arterial ischaemia and venous congestion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-10T015520.410.png) Comparison of arterial ischaemia and venous congestion --- ## Pathophysiology of Ischaemic and Congested Flaps ****Key Point** Flap compromise initiates a cascade of hypoxia, capillary leak, microvascular thrombosis, and inflammation, progressing rapidly within hours and exacerbated by delayed choke vessel recruitment and non-occlusive flow disturbances. Both ischaemia and congestion initiate a cascade of events that compromise flap viability, beginning at the microvascular level. - **Initial Vascular Obstruction:** Leads to tissue hypoxia and, in venous congestion, early stasis. - **Capillary Leak and Cellular Injury:** Hypoxia-induced endothelial damage results in fluid extravasation, edema, and cellular breakdown. - **Microvascular Thrombosis:** Particularly critical after 6–8 hours, this exacerbates hypoxia and reduces chances of flap salvage ([Chen](https://pubmed.ncbi.nlm.nih.gov/17572562/?ref=theplasticsfella.com), 2007). - **Inflammatory Cascade:** Drives further edema, elevates interstitial pressure, and compresses microcirculation. - **Choke Vessel Recruitment:** Occurs later as a compensatory mechanism to redistribute flow between angiosomes, mainly relevant in delayed congestion. - **Non-Occlusive Factors:** Flow turbulence, altered shear stress, and rheological changes can mimic thrombosis, complicating diagnosis and management. 😎 ****Fun Fact:** Not all venous congestion is true thrombosis. Phenomena such as flow redistribution, choke vessel opening, and transient turbulence can mimic congestion without actual vessel occlusion. --- ## Classification of Flap Compromise ****Key Point** Although no single, universally accepted system exists, grouping flap compromise by timing, type of vascular insufficiency, and extent of tissue involvement provides a practical framework for diagnosis and management. While arterial and venous classifications are commonly used to describe flap failure, other classification methods also exist—though they are not universally adopted. A more practical approach categorizes flap compromise based on three factors: **timing** (when it occurs), and **extent** (how much of the flap is affected). ### Timing of Compromise Timing influences both the cause and urgency of treatment, with early recognition offering the highest chance of flap salvage. - **Immediate (Intra-operative):** Usually **technical errors** such as kinking or misalignment. High salvage potential if corrected during surgery. - **Early (0–72 hours Post-op): Most common window** for vascular compromise. Rapid onset events like thrombosis or twisting occur here. Prompt re-intervention can result in up to 70% salvage success. - **Delayed (>72 hours Post-op):** Often secondary to **infection, compression,** or **late thrombosis**. Salvage rates decline significantly due to compounded tissue damage. ### Extent of Tissue Involvement Describing the distribution of compromise — whether global or segmental — helps assess severity and salvage potential. - **Global Compromise: Entire flap is ischaemic or congested.** Typically occurs from major vessel thrombosis and is seen early post-op. - **Distal or Segmental Compromise: Affects flap tip or isolated zone.** More common in late or partial venous issues and may mimic low-grade congestion. ### Special Consideration: Early vs. Late Congestion - **Early Congestion:** Often due to **large vessel thrombosis**, leading to rapid onset global flap congestion. - **Late Congestion:** Typically **microvascular in nature**, involving distal zones. Presents subtly and can be mistaken for non-occlusive or inflammatory congestion. 😎 ****Fun Fact:** What looks like venous congestion in the first 24 hours might just be ****transient hyperaemia or pseudo-congestion**. This self-limiting state results from flow turbulence or early vasodilatation. Serial assessments help avoid unnecessary re-exploration. --- ## Clinical Assessment for Flap Compromise ****Key Point** Early, structured clinical assessment including history, examination, and adjunct monitoring remains the cornerstone of detecting vascular compromise and maximising flap salvage. ### History Careful history-taking pinpoints the onset and context of flap issues. - **Timing:** Most complications arise within 72 hours post-surgery ([Shen](https://pubmed.ncbi.nlm.nih.gov/33395711/?ref=theplasticsfella.com), 2021). - **Symptoms (Sensate Flaps):** Increased pain or pressure reported by patients. - **Operative Factors:** Flap type (e.g., free vs. pedicled), tunneling, prior revisions, anticoagulation use. - **Systemic Risks:** Hypotension, vasopressor exposure, coagulopathy, smoking, or diabetes. ### Examination A structured examination is performed hourly for the first 24 h, then tapered. **Venous Congestion Signs** - **Color:** Dusky or purplish hue - **Capillary Refill:** Brisk (<3 seconds) - **Bleeding:** Dark, deoxygenated blood on pinprick - **Turgor:** Swollen, tense flap - **Temperature:** Warm (may mislead if isolated) **Arterial Ischemia Signs** - **Color:** Pale or mottled appearance - **Capillary Refill:** Delayed (>3 seconds) - **Bleeding:** Absent or minimal bright red blood - **Turgor:** Flaccid, soft flap - **Temperature:** Cool or cold to touch **Adjuncts** - **Handheld Doppler:** Assesses pedicle patency. - **Implantable Doppler:** Monitors arterial and venous flow. - **Near-infrared spectroscopy (NIRS):** Tracks oxygenation continuously. ### Risk Factors Certain conditions increase the likelihood of flap failure. - **Smoking and Diabetes:** Impair microvascular function. - **Previous Radiotherapy:** Causes vessel fibrosis and delayed healing. - **Hypercoagulable States:** Elevate thrombosis risk (e.g., Factor V Leiden). - **Obesity or Large Flaps (e.g., TRAM, DIEP):** Prone to congestion. - **Long Pedicles or Multiple Anastomoses**: Raise technical failure odds. ### Differential Diagnosis Not all flap changes indicate vascular issues. Differential diagnosis considers, - **Hematoma:** Compresses pedicle, mimics congestion. - **Seroma:** Fluid collection in loose tissue beds. - **Flap Edema:** Normal post-op, lacks rapid progression. - **Infection:** Onset >48–72 hours, with fever or systemic signs. - **Pseudo-Congestion:** Capillary hyperemia or turbulence (no thrombosis). 💡 ****Tip:** Early post‑op flaps may appear compromised. Correlate findings with serial exams and timing to avoid unnecessary re‑exploration. --- ## Investigations for Flap Compromise ****Key Point** Clinical assessment is key to flap monitoring, but real-time modalities such as Doppler and NIRS can detect early compromise. Blood tests and imaging play supportive roles in select cases, and should never delay surgical re-exploration if acute compromise is strongly suspected. **Clinical examination is the gold standard**. Imaging tools and monitoring devices can provide additional insights, especially when the diagnosis is unclear or the flap is buried. ### Blood Tests Routine labs uncover contributing factors. - **Full Blood Count:** Screens for anemia or infection. - **Coagulation Profile:** Rules out clotting disorders. - **CRP & ESR:** Tracks inflammation or infection in delayed cases. - **Thrombophilia Screen:** Probes unexplained thrombosis (e.g., in young patients). 💡 ****Tip:** Order a thrombophilia workup if flaps fail despite sound technique and anticoagulation. ### Imaging Used selectively when clinical findings are ambiguous. - **Doppler Ultrasound (Handheld/Duplex):** Checks arterial and venous signals. - **CT Angiography:** Evaluates late failure, especially in buried flaps. - **MRI with Contrast:** Assesses deep infections or complex reconstructions. ❗ Don’t delay surgical exploration for imaging if acute compromise is evident. ### Other Monitoring Tools Common tools for flap surveillance. - **Handheld Doppler:** Quick bedside patency check. - **Implantable Doppler:** Continuous arterial/venous monitoring. - **Near-Infrared Spectroscopy (NIRS):** Non-invasive oxygenation tracking. - **Pinprick Test:** Assesses bleeding quality and perfusion. ### Monitoring Pearls - Use multiple tools to avoid false negatives. - NIRS excels at detecting venous congestion early. 😎 ****Fun Fact:** Serial pinprick tests can outperform Doppler for venous congestion assessment. Doppler flow may sound acceptable while actual perfusion is still insufficient! --- ## Management of Flap Compromise ****Key Point** Flap salvage depends on early recognition and prompt action. Surgical re-exploration remains the mainstay for mechanical causes, while non-surgical strategies may support venous drainage when revision is not feasible or no structural issue is found. Management of flap vascular compromise hinges on understanding the cause (arterial, venous, or both), identifying mechanical versus microvascular problems, and acting swiftly. Time is tissue: early intervention is critical to improve salvage rates, particularly in free flaps. ### At the Bedside Before rushing to theatre, a systematic bedside assessment can yield crucial information and sometimes resolve reversible issues. - **Check Patient Vitals:** Hypotension or hypoxia can exacerbate ischaemia. Address any systemic instability that might impact perfusion. Assess Urine Output as a practical measure of systemic perfusion and volume status. - **Remove Tight Dressings or Sutures:** Loosen any compressive garments or sutures that may restrict venous outflow. - **Maintain Optimal Positioning:** Keep the flap **dependent and uncovered** to encourage venous drainage. Avoid kinking or flexion near pedicles. - **Stop Cooling and Keep Warm:** Vasospasm can be aggravated by cold. Apply gentle warming and maintain a neutral thermal environment. - **Communicate and Consent:** Alert the surgical team early. If re-exploration is likely, obtain **informed consent** and prepare for theatre. ### Surgical Management If flap compromise is suspected, surgical re-exploration is the first-line treatment. **Emergency Re-Exploration** - **Hematoma** or **tight inset** compressing the pedicle - **Twisting, kinking, or vasospasm** - **Thrombosis at the anastomosis** **Pedicled Flaps** - Reposition or **untwist the pedicle** (common in propeller flaps) - Reopen inset or **add venous supercharging** to improve drainage **Free Flaps** - **Revise anastomoses**, checking for thrombus or vasospasm - Perform **thrombectomy** using Dumont forceps or a Fogarty catheter - Consider **thrombolysis** (e.g., intra-arterial Actilyse 2 mg with venous outflow open) - Use **vein grafting** or alternate recipient vessels if structural damage is severe 💡 ****Tip:** Most flap salvages occur in the operating room. Early surgical take-back offers the best chance of success and delays beyond 6 hours significantly reduce flap survival. ### Non-Surgical Management Used primarily for venous congestion when mechanical issues are excluded or surgical re-exploration is not feasible. **Leech Therapy (Hirudotherapy)** Gold standard for passive drainage and anticoagulation. - **Effectiveness:** \~70% success; lower (\~30%) in bulky flaps like TRAM/DIEP ([Slijepcevic](https://pubmed.ncbi.nlm.nih.gov/36776810/?ref=theplasticsfella.com), 2022). - **Risks:** Bleeding, **Aeromonas** infection (prophylactic ciprofloxacin recommended). ![Leech therapy for venous congestion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-10T014937.932.png) Leech therapy for venous congestion **Chemical Leeching** Subcutaneous LMWH with **scarification** (superficial dermal cuts). - Useful for **small flaps**. - Requires intensive nursing; risk of bleeding. **Venocutaneous Catheterization** Cannulates superficial flap vein for **controlled drainage**. - Near 100% success in small series ([Okazaki](https://pubmed.ncbi.nlm.nih.gov/17496594/?ref=theplasticsfella.com), 2007). - Safer and more controlled than leeches but needs pre-planning. **Negative Pressure Therapy (NPT)** Enhances **venous return** and reduces flap edema. - Particularly useful in trauma-related flaps. - Use **intermittent suction** to avoid compromising arterial inflow. **Hyperbaric Oxygen Therapy (HBOT)** Experimental; **not routinely recommended** for flap salvage. - Limited evidence of benefit in venous congestion. --- ## Prognosis of Flap Compromise ****Key Point** Flap salvage is time-dependent. Early recognition and revision within 6 hours offer the best chance of success, while delayed intervention or repeated compromise significantly lowers survival. ### Outcomes Flap viability is closely tied to the timing of diagnosis and management. - **Early Revision (within 6 hours):** 60–70% salvage success rate ([Chen](https://pubmed.ncbi.nlm.nih.gov/17572562/?ref=theplasticsfella.com), 2007). - **Delayed Recognition (>6–8 hours):** Causes irreversible microvascular damage ([Chen](https://pubmed.ncbi.nlm.nih.gov/17572562/?ref=theplasticsfella.com),2007). - **Venous vs. Arterial:** Venous congestion has a poorer prognosis due to insidious onset and microcirculatory failure. - **Recurrence Impact:** First episode salvage \~60–70%, second \~30%, third rarely salvageable ([Odorico](https://pubmed.ncbi.nlm.nih.gov/35611652/?ref=theplasticsfella.com), 2023). - **Context:** Free flaps succeed in \~95% of cases, but 10% need revision—most salvageable if acted on quickly. ### Complications Even with flap survival, complications can develop locally or systemically. - **Local Complications** - **Partial or Total Flap Loss:** Often linked to delayed revision. - **Flap Necrosis:** May require further debridement and secondary reconstruction. - **Infection:** Especially *Aeromonas* infections after leech therapy. - **Wound Breakdown:** Common in irradiated tissue or high-tension closures. - **Edema or Hematoma:** Can trigger further vascular compromise if not addressed. - **Systemic Complications** - **Blood Loss:** Seen with extensive leeching or chemical scarification. - **Sepsis:** Rare, but possible if infections are missed or untreated. - **Thromboembolic Events:** Associated with aggressive anticoagulation protocols. 💡 ****Tip:** Flap failures occurring after discharge (typically after day 7) are rarely salvageable. Causes include infection, pressure during sleep, or late thrombosis, not purely vascular issues. Patients should be clearly counselled on warning signs before leaving hospital. --- ## Conclusion Upon completing this article, you will have accomplished the following: 1\. ****Overview:** Flap vascular compromise refers to impaired blood flow within a flap, typically due to arterial ischaemia or venous congestion, and most commonly occurs within the first 72 hours post-op. 2\. ****Aetiology & Pathophysiology:** Causes include pedicle kinking, thrombosis, or compression, leading to hypoxia, edema, and microvascular clotting. Venous congestion is more frequent and harder to manage than arterial insufficiency. 3\. ****Clinical Assessment:** Diagnosis relies on flap colour, capillary refill, and pinprick testing, supported by Doppler or NIRS. Risk factors include smoking, radiotherapy, large flap volume, and coagulopathies. 4\. ****Investigations:** While clinical signs are primary, adjuncts like implantable Dopplers, coagulation screens, and venous imaging may aid in complex or delayed presentations. 5\. ****Management & Prognosis:** Surgical revision remains the mainstay for mechanical causes; medical salvage (e.g. leeches, heparin injections) is used when revision is not feasible. Salvage rates drop significantly after 6–8 hours or with recurrent compromise. --- ## Further Reading 1. Chen KT, Mardini S, Chuang DC, et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. *Plast Reconstr Surg*. 2007;120(1):187-195\. doi:10.1097/01.prs.0000264077.07779.50 2. Khansa I, Chao AH, Taghizadeh M, Nagel T, Wang D, Tiwari P. A systematic approach to emergent breast free flap takeback: clinical outcomes, algorithm, and review of the literature. *Microsurgery*. 2013;33(7):505-513\. doi:10.1002/micr.22151 3. Chang EI, Chang EI, Soto-Miranda MA, et al. Comprehensive evaluation of risk factors and management of impending flap loss in 2138 breast free flaps. *Ann Plast Surg*. 2016;77(1):67-71\. doi:10.1097/SAP.0000000000000263 4. Shen AY, Lonie S, Lim K, Farthing H, Hunter-Smith DJ, Rozen WM. Free flap monitoring, salvage, and failure timing: a systematic review. *J Reconstr Microsurg*. 2021;37(4):300-308\. doi:10.1055/s-0040-1717141 5. Slijepcevic AA, Yang S, Petrisor D, Chandra SR, Wax MK. Management of the failing flap. *Semin Plast Surg*. 2023;37(1):19-25\. doi:10.1055/s-0042-1759563 6. Hara H, Mihara M, Narushima M, et al. Predictors, management and prognosis of initial hyperemia of free flap. *Sci Rep*. 2024;14(1):3678\. doi:10.1038/s41598-024-54321-5 7. Odorico SK, Reuter Muñoz K, Nicksic PJ, et al. Surgical and demographic predictors of free flap salvage after takeback: a systematic review. *Microsurgery*. 2023;43(1):78-88\. doi:10.1002/micr.30921 8. Coriddi M, Myers P, Mehrara B, et al. Management of postoperative microvascular compromise and ischemia reperfusion injury in breast reconstruction using autologous tissue transfer: retrospective review of 2103 flaps. *Microsurgery*. 2022;42(2):109-116\. doi:10.1002/micr.30845 9. Largo RD, Selber JC, Garvey PB, et al. Outcome analysis of free flap salvage in outpatients presenting with microvascular compromise. *Plast Reconstr Surg*. 2018;141(1):20e-27e. doi:10.1097/PRS.0000000000003917 10. Okazaki M, Asato H, Takushima A, et al. Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer. *Plast Reconstr Surg*. 2007;119(4):1223-1232\. doi:10.1097/01.prs.0000254400.43453.c7 ### Tariffs on Toxins,3 Extensor Tendon Truths, & Your Next Journal Club Pick URL: https://www.theplasticsfella.com/april-13th/ Last updated: 2025-04-11T18:58:25.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/april-13th/#a-letter-from-pfella) Trump’s tariffs are coming for your forehead lines! 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/april-13th/#the-sunday-quiz) How well do you know **extensor tendon injuries*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/april-13th/#image-of-the-week) Zone VI extensor tendon injury. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/april-13th/#technique-tip) Kessler tendon repair in action. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-13th/#upcoming-events) New event added! 6. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/april-13th/#jpras-journal-club) Make your call on the next article! 7. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/april-13th/#what-does-the-evidence-say) What's the best repair technique for extensor tendons? 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/april-13th/#articles-of-the-week) Managing open extensor tendon injuries, repair for partial extensor tendon lacerations, & post extensor tendon repair protocols: with 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/april-13th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Trump’s Tariffs Are Coming for Your Forehead Lines!* 👋 ****Hey Team!** **Botox might be Irish, but it’s not immune to American politics.* President Trump’s latest tariff blitz could hit closer to the face than you'd think. A 10–26% hike on imports from Europe and Asia? That’s not just bad news for iPhones — it’s coming for your neuromodulators and fillers. **Yes, your Botox might soon cost more.** ### The Hidden Geography of Injectables Let’s map it out. - **Botox:** Made in *Westport, Ireland* (yep, population 5,000). - **Xeomin:** Straight out of *Germany*. - **Jeuveau & Letybo:** Born in *South Korea*. - **Sculptra & Restylane:** Shipped from *Sweden*. - **U.S.-made** options? Just a few: **Daxxify** (*California*), **Radiesse** (*Wisconsin*). Bottom line? Injectables run on a global supply chain — and tariffs are about to poke that pipeline. ### The Price Is Not Right (Yet) “It becomes an issue if, because of tariffs, they increase my wholesale pricing, which means I have to charge patients more money.” — **Dr. Roy Kim**, Plastic Surgeon, San Francisco ([Allure](https://www.allure.com/story/will-tariffs-make-botox-filler-more-expensive?ref=theplasticsfella.com)) So far, many injectables are protected by a pharmaceutical exemption — but that’s just policy, not law. If that changes, prices won’t just rise — they’ll spike. Fillers and other injectables classified as *devices* aren’t protected. Evolus has already flagged that its upcoming **Evolysse** range may take a tariff hit. That uncertainty? It’s already inflating forecasts. ### The Real Takeaway This isn’t just about Botox — it’s about a specialty built on global supply chains. When one country imposes a tariff, every aesthetic practice downstream feels it. If exemptions tighten and prices rise, clinics may have to: - Pass the cost to patients - Absorb the margin loss - Or finally give Daxxify the moment it’s been waiting for But this isn’t just a pricing issue — it’s a reminder that our beauty economy is more global than we like to admit. With Love (and tariffs), P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Extensor Tendon Injuries?* ****Are you ready to make it to the leaderboard?** Welcome to the ****next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. --- ## Image of the Week **Zone VI Extensor Tendon Injury* 🖼️ ****Image of the Week** This week’s image illustrates a Zone VI extensor tendon injury. This AI-generated image depicts a laceration over the ****dorsum of the hand** — a common site for open tendon injuries following sharp trauma. Zone VI contains the ****extensor digitorum communis tendons** and lies ****superficial to the dorsal interosseous muscles**. Surgical repair in this zone often requires precise tendon reapproximation and careful handling of surrounding soft tissue. ![An AI-generated image of a zone VI extensor tendon injury.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-10T191038.702-1-1.png) An AI-generated image of a zone VI extensor tendon injury. ## Technique Tip **Kessler Tendon Repair in Action* 🚑 ****Technique Tip of the Week** This week’s tip highlights the Kessler repair, a core suture technique used in ****flexor and extensor tendon repair**. It provides strong ****central fixation** with minimal bulk, which is ideal for early mobilisation protocols. The method uses a modified ****grasping loop configuration** to reapproximate tendon ends under tension. ▶️ Watch the repair in action below. ## Upcoming Events **New Event Added!* 📅 ****P’Fella’s event calendar** highlights the most impactful conferences, high-yield webinars, and carefully curated courses for you. You can also ****submit your event** and get it featured! We've just added the ****35th Annual Meeting of EURAPS** to our calendar; sign up below👇 ## JPRAS Journal Club **Make Your Call on the Next Article* 🗞️ We’re handing the mic to you. Help us decide which paper to feature in next month’s Journal Club. Two super insightful articles, one winner, and a full breakdown coming your way. Cast your vote below 👇 ## What Does the Evidence Say? **Optimal Techniques for Extensor Tendon Repair* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Extensor tendon injuries are common and require proper repair techniques for optimal outcomes. Various methods have been described, including ****figure-of-8 sutures** for zones I-II and ****core sutures with running sutures** for zones III-VII (Arvind et al., 2024). The ****mattress suture** technique is simpler and quicker for multiple small flat tendons, while augmented ****Kessler and cruciate techniques** are stronger for thicker tendons (Al-Asadi, 2024). The ****roll stitch** technique showed superior outcomes compared to core sutures at the metacarpophalangeal joint level (Namazi et al., 2016). ****Four-strand repair** techniques demonstrated better results than two-strand techniques (Abdella et al., 2019). The running interlocking horizontal mattress (****RIHM**) suture technique yielded superior results compared to the modified Kessler technique (Shaju et al., 2021). Repair outcomes may vary based on the zone of injury, with ****zones 5-8** showing ****better final flexion** than zones 1-4 (Dalton et al., 2023). Early controlled motion protocols can improve tendon gliding after repair (Abdella et al., 2019). ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Concepts in the Management of Open Extensor Tendon Injuries** ([Amirtharajah & Lattanza](https://www.jhandsurg.org/article/S0363-5023%2814%2900986-1/abstract?ref=theplasticsfella.com), 2015) Despite their superficial location, extensor tendon injuries demand precise zone-based management and adherence to evolving repair and rehabilitation strategies to optimise functional recovery. ✅ ****Is Repair Always Necessary for Partial Extensor Tendon Lacerations?** ([Dickson](https://www.jprasurg.com/article/S1748-6815%2823%2900330-3/abstract?ref=theplasticsfella.com), 2023) Contrary to common practice, evidence suggests partial extensor tendon lacerations may heal just as well without surgical repair, raising questions about the necessity of routine intervention. ✅ ****Early Motion & Relative Motion Splints in Extensor Tendon Repair** ([Merritt](https://journals.lww.com/plasreconsurg/abstract/2020/03000/recent%5Fdevelopments%5Fare%5Fchanging%5Fextensor%5Ftendon.44.aspx?ref=theplasticsfella.com), 2020) Early protected mobilization using relative motion splinting, combined with WALANT techniques is reshaping extensor tendon management, enabling functional recovery to begin as early as day 3 post-repair. ## Feedback ### I hope you enjoyed it 😄 --- ### Extensor Tendon Injuries: Anatomy, Clinical Assessment, & Management URL: https://www.theplasticsfella.com/extensor-tendon-injuries/ Last updated: 2025-04-10T13:51:59.000Z #### Summary Card [****Extensor Tendon Anatomy**](https://www.theplasticsfella.com/extensor-tendon-injuries/#anatomy-of-extensor-tendon-injuries) The extensor tendons form a complex system for coordinated finger, wrist, and thumb movement, divided into extrinsic (originating from the forearm) and intrinsic (within the hand) components. [****Zones of Injury**](https://www.theplasticsfella.com/extensor-tendon-injuries/#zones-of-extensor-tendon-injury) The Kleinert and Verdan Classification divides extensor tendon injuries into seven zones based on anatomical location, later expanded to nine zones. The thumb has its own five-zone system. [****Clinical Assessment**](https://www.theplasticsfella.com/extensor-tendon-injuries/#clinical-assessment-of-extensor-tendon-injuries) Assessing extensor tendon injuries involves a stepwise approach: evaluating the wound, function, and neurovascular status, complemented by specific tests such as Elson’s test. [****Management**](https://www.theplasticsfella.com/extensor-tendon-injuries/#management-of-extensor-tendon-injuries) Extensor tendon injuries are managed nonoperatively or operatively, depending on severity, chronicity, and functional impairment. Local protocols may vary, and institutional guidelines should be consulted. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Anatomy of Extensor Tendon Injuries ****Key Point** The extensor tendons form a complex system for coordinated finger, wrist, and thumb movement, divided into extrinsic (originating from the forearm) and intrinsic (within the hand) components. The extensor tendons form a complex system that allows for coordinated movement of the fingers, wrist, and thumb. They are divided into **extrinsic** and **intrinsic** and **terminal** components ([von Schroeder](https://www.sciencedirect.com/science/article/abs/pii/S0749071221000809?ref=theplasticsfella.com), 1997). ### Extrinsic Extensor Tendons The extrinsic extensor tendons begin in the **posterior forearm**, primarily at the **lateral epicondyle of the humerus**, and extend into the hand to control wrist and finger movements. - **Innervation:** radial nerve, with most receiving their supply from its deep branch, the posterior interosseous nerve (PIN). - **Pathway:** six dorsal compartments, each housed within a synovial sheath and secured by the extensor retinaculum—a fibrous band that prevents tendon bowstringing during movement ([von Schroeder](https://www.sciencedirect.com/science/article/abs/pii/S0749071221000809?ref=theplasticsfella.com), 1997). The layout of these six compartments is outlined below, each containing specific tendons that contribute to precise and coordinated hand function. ![Six dorsal compartments of the wrist and passing tendons](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-26T030742.172.png) Six dorsal compartments of the wrist and passing tendons 💡 ****Tip:** The EPL tendon winds around Lister’s tubercle, changing direction before inserting into the thumb’s distal phalanx. Ruptures often occur at this point due to attrition. ### Intrinsic Extensor Mechanism Intrinsic tendons originate entirely within the hand, while extrinsic tendons come from the forearm. Intrinsic and extrinsic tendons can insert into the **extensor hood**. Intrinsic tendons typically flex the **MCP joints** and extend the **IP joints**. **Lumbricals** - **Function:** Flex the MCP joints, extending the PIPJ and DIPJ - **Origin:** From the tendons of **flexor digitorum profundus**. - **Insertion:** Into the **radial side of the extensor expansion** on fingers 2–5. **Palmar and Dorsal Interossei** - **Function:** IP joint extension; **dorsal interossei** abduct & **palmar interossei** adduct fingers. - **Origin:** From the **metacarpal bones**. - **Insertion:** Into the **lateral bands** of the extensor expansion on fingers 2–5. **Thenar Muscles** Some intrinsic thumb muscles such as **abductor pollicis brevis** and **adductor pollicis,** partially insert into the extensor mechanism of the thumb. These attachments help fine-tune and stabilize thumb movements through the dorsal apparatus. The extensor expansion is highlighted in the image below. ![The extensor expansion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-10T185459.451.png) The extensor expansion 😎 ****Fun Fact:** This common insertion site known as the extensor hood or extensor expansion, is a specialized connective tissue that allows multiple tendons to attach to the phalanges. It is stabilized by sagittal bands. ### Terminal Extensor Tendons Once both intrinsic and extrinsic tendons insert into the extensor hood, the extensor mechanism continues distally and divides into structures responsible for extending the finger joints. - **Central Slip:** Passes over the middle phalanx and inserts at its base, extending the **proximal interphalangeal (PIP)** joint. - **Lateral Bands:** Two bands run along either side of the finger and converge to insert at the base of the distal phalanx, enabling extension of the **distal interphalangeal (DIP)** joint. - **Oblique Retinacular Ligament:** Runs from the proximal phalanx and flexor sheath to the lateral bands, linking PIP and DIP joint extension ([Shrewsbury](https://www.sciencedirect.com/science/article/abs/pii/S0363502377800695?ref=theplasticsfella.com), 1977). 💡 ****Tip:** Juncturae Tendinum are fibrous links between extensor digitorum tendons that coordinate finger extension and prevent tendon retraction ([Hirai](https://www.sciencedirect.com/science/article/abs/pii/S0363502301700457?ref=theplasticsfella.com), 2001). --- ## Zones of Extensor Tendon Injury ****Key Point** The Kleinert and Verdan Classification divides extensor tendon injuries into seven zones based on anatomical location, later expanded to nine zones. The thumb has its own five-zone system. The **Kleinert and Verdan Classification** divided extensor tendon injuries into **7 zones** based on anatomical location, with 2 further zones added in later modifications ([Kleinert](https://www.sciencedirect.com/science/article/abs/pii/0363502389901184?ref=theplasticsfella.com), 1989). The thumb is divided into 5 zones in a similar manner. The most commonly injured structures in each zone of the hand are summarised below. - **Zone I (DIP Joint):** Mallet Finger. - **Zone II (Middle Phalanx):** Tendon laceration or avulsion. - **Zone III (PIP Joint):** Boutonnière Deformity. - **Zone IV (Proximal Phalanx):** Extensor tendon rupture. - **Zone V (MCP Joint):** "Fight bite," Sagittal Band Rupture. - **Zone VI (Metacarpals):** Lacerations, EDC injuries. - **Zone VII (Wrist):** Retinaculum injury, tendon bowstringing. - **Zone VIII (Distal Forearm):** Muscle belly injuries. - **Zone IX (Proximal Forearm):** Neuromuscular injuries. These hand zones are illustrated below. ![Extensor zones of the hand, Kleinert and Verdan classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-26T030914.671.png) Extensor zones of the hand 😎 ****Fun Fact:** Odd numbered zones correspond to joints while even numbered zones correspond to bones starting from distal to proximal. --- ## Clinical Assessment of Extensor Tendon Injuries ****Key Point** A systematic evaluation focusing on the wound, tendon function, and neurovascular integrity is critical in diagnosing extensor tendon injuries, with Elson’s test serving as a pivotal diagnostic tool for central slip injuries Extensor tendon injuries, though often less complex than flexor tendon injuries, require careful assessment due to their intricate anatomy and potential for functional compromise. ### History ### Extensor tendon injuries occur through diverse mechanisms, from sharp trauma to underlying pathological conditions ([Hanz](https://journals.lww.com/plasreconsurg/abstract/2008/03000/extensor%5Ftendon%5Finjuries%5F%5Facute%5Fmanagement%5Fand.46.aspx?ref=theplasticsfella.com), 2008; [Matzon](https://www.sciencedirect.com/science/article/abs/pii/S0363502310002649?ref=theplasticsfella.com), 2010). - **Sharp Lacerations:** Commonly caused by glass, knives, or industrial machinery, these clean-cut injuries may clearly transect tendons. - **Crush Injuries:** Often resulting from door entrapment or machinery, these can involve deeper soft tissues including tendons and joints. - **Mallet Finger (Zone I):** Results from forced flexion of an extended distal interphalangeal (DIP) joint, typically seen in sports. - **Sagittal Band Rupture (Zone V):** Often results from forced extension of a flexed finger, which is common in contact sports. Suspect it if the MCP joint stays flexed with no active extension. Diagnosis is confirmed when the patient can’t initiate MCP extension but can hold it once passively extended. - **Closed Ruptures:** Often seen in patients with rheumatoid arthritis or following attrition over implants, particularly the extensor pollicis longus (EPL) near Lister’s tubercle. - **"Fight Bite" Injuries (Zone V):** Occur during clenched-fist impacts against teeth; high risk for infection and deep structural damage. An extensor tendon injury of zone VI is illustrated in the image below. ![Extensor tendon injury of zone VI ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Main-Article-Images---2025-04-10T191038.702.png) Extensor tendon injury of zone VI ### Examination A structured approach is essential in evaluating extensor tendon injuries to prevent misdiagnosis, especially in cases masked by compensatory mechanisms. - **Wound Assessment:** Determines the affected tendon zone, as described below, and possible involvement of joint capsules or bones. - **Functional Testing:** Assess each joint individually—look for extensor lag or inability to extend joints. Resisted Movement can uncover partial tendon injuries or imbalances. - **Palpation:** A palpable defect or tenderness along the tendon path may indicate rupture or laceration. - **Neurovascular Examination:** Full Sensory and Vascular Evaluation: To identify associated digital nerve or vessel injuries. - **Elson’s Test:** Used to identify central slip injuries (distal to Zone III); a positive result is when the PIP joint cannot extend against resistance while the DIP remains rigid, indicating a central slip rupture (Hart, 1993). This is visualised below 💡 ****Tip:** Juncturae Tendinum allow compensation by adjacent tendons, potentially masking proximal injuries. Always test each finger in isolation ([von Schroeder](https://www.sciencedirect.com/science/article/abs/pii/S0749071221000809?ref=theplasticsfella.com), 1997). ### Investigations While clinical examination is paramount, imaging complements the assessment, particularly in uncertain or chronic cases. - **X-rays:** Avulsion Fractures and joint involvement, especially helpful in suspected bony mallet finger or joint misalignment. - **Ultrasound (US):** Tendon integrity and fluid collections can visualize partial or complete ruptures and associated effusions. - **MRI:** Detailed soft tissue evaluation, which is reserved for complex or delayed presentations; ideal for assessing retraction or chronic injuries ([Colzani](https://pubmed.ncbi.nlm.nih.gov/27616821/?ref=theplasticsfella.com), 2016). --- ## Management of Extensor Tendon Injuries ****Key Point** Extensor tendon injuries are managed either conservatively or surgically depending on the extent of damage, chronicity, and functional impairment, with local protocols guiding specific treatment decisions. Management strategies for extensor tendon injuries hinge on several factors, including the zone of injury, tendon integrity, timing of presentation, and institutional protocols. While some injuries heal well with splinting alone, others require surgical intervention to restore function and prevent deformity ([Griffin](https://pmc.ncbi.nlm.nih.gov/articles/PMC3293224/?ref=theplasticsfella.com), 2012). ### Non-operative Management Conservative treatment remains effective for select extensor tendon injuries, particularly partial lacerations or stable closed injuries. **Immobilization with Early Protected Motion** - **Indication:** Lacerations involving <50% of tendon width in any zone. - **Rationale:** Allows tendon healing while preserving joint motion when active extension is intact. **DIP Extension Splinting** - **Indications:** Acute Zone I injuries (mallet finger), nondisplaced bony mallet injuries, and chronic mallet fingers with a congruent joint. - **Protocol:** Full-time splinting for 6 weeks or part-time for 4–6 weeks; maintain PIP motion to avoid stiffness ([Lutz](https://www.hand.theclinics.com/article/S0749-0712%2814%2900141-3/abstract?ref=theplasticsfella.com), 2015). **PIP Extension Splinting** - **Indications:** Closed central slip injuries (Zone III). - **Protocol:** Full-time for 6 weeks or part-time for 4–6 weeks; ensure DIP flexion is maintained ([Lutz](https://www.hand.theclinics.com/article/S0749-0712%2814%2900141-3/abstract?ref=theplasticsfella.com), 2015). **MCP Extension Splinting** - **Indications:** Closed sagittal band ruptures (Zone V). - **Protocol:** Full-time splinting for 4–6 weeks ([Lutz](https://www.hand.theclinics.com/article/S0749-0712%2814%2900141-3/abstract?ref=theplasticsfella.com), 2015). ### Operative Management Surgical repair is indicated for extensive tendon lacerations, unstable avulsion fractures, and chronic injuries that compromise function. **Tendon Repair** - **Indication:** Lacerations >50% of tendon width in any zone. - **Approach:** Use existing wound or extend via longitudinal dorsal incision. - **Suture Technique** - Increased number of strands improves repair strength. - Use locking stitches and thicker suture material ([Yoon](https://europepmc.org/article/med/31103083?ref=theplasticsfella.com), 2019). - Optional circumferential epitendinous suture for added strength. **Fixation of Bony Avulsion Injuries** - **Indications:** Bony mallet finger with volar subluxation of the distal phalanx. - **Techniques** - Closed reduction with percutaneous pinning - Extension block pinning - Open reduction and internal fixation (ORIF) **Tendon Reconstruction** - **Indications:** Chronic ruptures or irreparable injuries (Hanz, 2008). - **Options** - Tendon grafting or extensor turndown - Lateral band mobilization - Transverse retinacular ligament reconstruction - FDS slip transfer **Staged Reconstruction (Hunter Technique)** - **Stage 1:** Silicone rod placement to maintain sheath integrity in scarred or deficient beds. - **Stage 2:** Tendon graft insertion after 3–6 months ([Colzani](https://pubmed.ncbi.nlm.nih.gov/27616821/?ref=theplasticsfella.com), 2016) 💡 ****Tip:** Immediate irrigation and debridement (I&D) is required for fight bite injuries to the MCP joint, with the wound closed loosely or in a delayed fashion and treated with culture-specific antibiotics, particularly targeting **Eikenella* **corrodens*, a common mouth flora pathogen. ### Outcomes With early repair and rehabilitation, extensor tendon injuries typically have a good prognosis ([Colzani](https://pubmed.ncbi.nlm.nih.gov/27616821/?ref=theplasticsfella.com), 2016). Poor outcomes often correlate with **delayed presentation**, **poor compliance**, or **joint stiffness** at the time of treatment. Extensor tendon injuries can lead to various complications ([Lutz](https://www.hand.theclinics.com/article/S0749-0712%2814%2900141-3/abstract?ref=theplasticsfella.com), 2015). - **Adhesion Formation:** Causes loss of finger flexion, commonly seen in Zone IV and VII and in older patients. Early protected ROM and dynamic splinting (especially in Zone IV) may prevent this. - **Tendon Rupture:** Caused by poor suture material or technique, aggressive therapy, or patient noncompliance. - **Swan Neck Deformity:** Caused by prolonged DIP flexion, leading to dorsal subluxation of lateral bands and PIP hyperextension. - **Boutonnière Deformity:** Caused by central slip disruption and volar subluxation of the lateral bands leading to DIP hyperextension. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Anatomy:** Extensor tendons enable finger and wrist movement, divided into extrinsic (forearm origin) and intrinsic (hand-based) systems. ****2\. Extensor Mechanism:** The extensor hood stabilizes the MCP joint; central slip and lateral bands insert into middle and distal phalanges. These injuries are caused by sharp trauma, hyperflexion, or attrition. ****3\. Assessment:** Evaluate wound, tendon function, and neurovascular status; use Elson’s test for central slip injuries. X-ray rules out fractures, US confirms tendon integrity, and MRI helps in chronic or complex cases. ****4\. Mallet Finger:** Zone I injury from forced DIP flexion; presents with DIP droop and is treated with extension splinting. ****5\. Management:** Partial tendon injuries or closed injuries in Zones I, III, and V often managed with splinting. Operative management is indicated for complete lacerations, bony avulsions, or chronic tendon defects. ****6\. Complications:** Include adhesions, tendon rupture, boutonnière or swan-neck deformity; early motion helps prevent stiffness. --- ## Further Reading 1. von Schroeder, Herbert P., and Michael J. Botte. "[Anatomy of the extensor tendons of the fingers: variations and multiplicity](https://www.sciencedirect.com/science/article/abs/pii/S0749071221000809?ref=theplasticsfella.com)." *The Journal of hand surgery* 20.1 (1995): 27-34. 2. Hirai, Yoshimasa, et al. "[An anatomic study of the extensor tendons of the human hand](https://www.sciencedirect.com/science/article/abs/pii/S0363502301700457?ref=theplasticsfella.com)." *The Journal of hand surgery* 26.6 (2001): 1009-1015. 3. Shrewsbury, Marvin M., and Richard K. Johnson. "[A systematic study of the oblique retinacular ligament of the human finger: its structure and function](https://www.sciencedirect.com/science/article/abs/pii/S0363502377800695?ref=theplasticsfella.com)." *The Journal of Hand Surgery* 2.3 (1977): 194-199. 4. Kleinert, Harold E. "[Report of the committee on tendon injuries.](https://www.sciencedirect.com/science/article/abs/pii/0363502389901184?ref=theplasticsfella.com)" *The Journal of Hand Surgery* 14.2 (1989): 381-385. 5. Hanz, Kevin R., et al. "[Extensor tendon injuries: acute management and secondary reconstruction.](https://journals.lww.com/plasreconsurg/abstract/2008/03000/extensor%5Ftendon%5Finjuries%5F%5Facute%5Fmanagement%5Fand.46.aspx?ref=theplasticsfella.com)" *Plastic and Reconstructive Surgery* 121.3 (2008): 109e-120e. 6. Matzon, Jonas L., and David J. Bozentka. "[Extensor tendon injuries](https://www.sciencedirect.com/science/article/abs/pii/S0363502310002649?ref=theplasticsfella.com)." *The Journal of hand surgery* 35.5 (2010): 854-861. 7. Hart, Raymond G., Dennis T. Uehara, and Joseph E. Kutz. "[Extensor tendon injuries of the hand](https://www.sciencedirect.com/science/article/abs/pii/S0733862720304715?ref=theplasticsfella.com)." *Emergency medicine clinics of north america* 11.3 (1993): 637-649. 8. Colzani, Giulia, et al. "[Traumatic extensor tendon injuries to the hand: clinical anatomy, biomechanics, and surgical procedure review](https://pubmed.ncbi.nlm.nih.gov/27616821/?ref=theplasticsfella.com)." *Journal of hand and microsurgery* 8.01 (2016): 002-012. 9. Bendre, Anup A., Brian J. Hartigan, and David M. Kalainov. "[Mallet finger](https://journals.lww.com/jaaos/abstract/2005/09000/mallet%5Ffinger.7.aspx?ref=theplasticsfella.com)." *JAAOS-Journal of the American Academy of Orthopaedic Surgeons* 13.5 (2005): 336-344. 10. Griffin, M., Hindocha, S., Jordan, D., Saleh, M., & Khan, W. (2012). [Management of extensor tendon injuries](https://pmc.ncbi.nlm.nih.gov/articles/PMC3293224/?ref=theplasticsfella.com). *The Open Orthopaedics Journal*, *6*, 36. 11. Lutz, Kristina, Joey Pipicelli, and Ruby Grewal. "Management of complications of extensor tendon injuries." *Hand Clinics* 31.2 (2015): 301-310. 12. Yoon, Alfred P., and Kevin C. Chung. "[Management of acute extensor tendon injuries.](https://europepmc.org/article/med/31103083?ref=theplasticsfella.com)" Clinics in plastic surgery 46.3 (2019): 383-391. ### Bilobed Flaps: Indications, Flap Design, & Complications URL: https://www.theplasticsfella.com/bilobed-flaps/ Last updated: 2025-05-15T09:45:27.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/bilobed-flaps/#overview-of-bilobed-flaps) The bilobed flap is a reliable reconstructive option for nasal and facial cutaneous defects, using a double transposition design to redirect tension and preserve aesthetic contours. [****Indications**](https://www.theplasticsfella.com/bilobed-flaps/#indications-for-bilobed-flaps) The bilobed flap is especially useful for small to moderate-sized nasal and facial defects, offering excellent colour/texture match, minimized tension, and improved aesthetic outcomes compared to simple grafts. [****Flap Design**](https://www.theplasticsfella.com/bilobed-flaps/#bilobed-flap-design) The bilobed flap is a double transposition design comprising two lobes rotating around a single pivot point, effectively distributing tension and preserving aesthetic contours for facial reconstruction. [****Complications**](https://www.theplasticsfella.com/bilobed-flaps/#complications-of-bilobed-flaps) Although bilobed flaps generally yield excellent reconstructive outcomes, complications often stem from poor planning, flap design errors, or surgical technique. ****Updated by:** Dr Kurt Lee Chircop, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview of Bilobed Flaps ****Key Point** The bilobed flap is a time-tested, reliable reconstructive option for nasal and facial cutaneous defects, using a double transposition design to redirect tension and preserve aesthetic contours. The bilobed flap is a classic yet continually refined technique for closing cutaneous defects, especially on the nose. Its unique design permits redistribution of wound closure tension away from critical aesthetic landmarks, ensuring both functional and cosmetic success. This flap combines principles of **rotation** and **transposition** to achieve tension-free closure using adjacent tissue. - **Double Transposition Design:** The flap consists of two lobes rotating around a single pivot point. This design allows redistribution of tension vectors over a broader area, reducing stress on any single region ([Grieco](https://pubmed.ncbi.nlm.nih.gov/29564875/?ref=theplasticsfella.com), 2018), - **Random Pattern Flap:** It does not rely on a named vascular pedicle but rather uses the subdermal plexus for perfusion, increasing its versatility in different anatomical regions. - **Primary and Secondary Defect Closure:** It simultaneously addresses the main defect and the donor site, reducing the need for distant grafts or flaps. The shared pivot point allows each lobe to recruit skin from regions with more laxity, optimizing flap mobility and minimizing dog-ears or buckling ([Cook](https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1524-4725.2005.31827?saml%5Freferrer&ref=theplasticsfella.com), 2006). The flap has evolved from a simple concept to a precisely executed modern surgical tool. - **Esser (1918):** First described the bilobed flap for nasal defects, focusing on using local tissue for facial reconstruction. Thisoriginal design included two lobes of equal size, each rotating **90°**. ![Esser's first description of a bilobed flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-15T151642.467.png) Esser's first description of a bilobed flap - **Zitelli (1989):** Refined the design by modifying angles and dimensions, leading to improved contour and decreased distortion, particularly in the nasal tip and ala. First and second lobes rotate **45-50°** each, for a total arc of **90-100°**. 💡 ****Tip:** If designed correctly, the bilobed flap minimizes upward pull and prevents distortion of the alar margin — key for preserving the natural nasal contour. --- ## Indications for Bilobed Flaps ****Key Point** The bilobed flap is especially useful for small to moderate-sized nasal and facial defects, offering excellent color/texture match, minimized tension, and improved aesthetic outcomes compared to simple grafts. The bilobed flap is most commonly used in nasal reconstruction, particularly the distal nasal tip and ala, where aesthetics and contour preservation are critical. - **Size Suitability:** Best for defects <1.5 cm on the nasal tip, where sebaceous skin thickness requires a robust, shape-preserving technique (Steiger, 2011). - **Avoidance of Graft Limitations:** Provides superior contour and texture compared to skin grafts, which may contract or appear mismatched ([Cook](https://journals.lww.com/dermatologicsurgery/abstract/2000/04000/a%5Freview%5Fof%5Fthe%5Fbilobed%5Fflap%5Fs%5Fdesign%5Fwith.13.aspx?ref=theplasticsfella.com), 2000) - **Local Tissue Match:** Uses adjacent, color- and texture-matched tissue for a natural appearance, essential in high-visibility regions ([Salgarelli](https://www.sciencedirect.com/science/article/abs/pii/S101051820900198X?ref=theplasticsfella.com), 2010). The illustration below shows common sites on the distal nose where a bilobed flap is suitable for reconstruction. ![Indications for Bilobed Flap Reconstruction on the Nasal Tip and Nasal Defect Size, medial canthus](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-04-01T005559.469.png) Sites on the distal nose that are suitable for bilobed flap reconstruction While classically nasal in application, bilobed flap principles have been successfully adapted to several other anatomical regions. - **Cheek, Periorbital, and Perioral Areas:** Suitable for concave or mobile facial zones, offering predictable healing and contour adaptation. - **Temporal Forehead Defects:** Allows large post-oncologic defects to be closed in one stage with excellent contour restoration using medially/laterally based bilobed designs ([Sutton](https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/620991?ref=theplasticsfella.com), 1992). - **Forearm Flap Donor Sites:** A perforator-based bilobed flap (ulnar artery) allows primary closure of small to medium radial forearm flap donor sites, reducing morbidity and supporting early rehabilitation ([Hsieh](https://journals.lww.com/plasreconsurg/abstract/2004/04150/primary%5Fclosure%5Fof%5Fradial%5Fforearm%5Fflap%5Fdonor.6.aspx?ref=theplasticsfella.com), 2004). - **DIP Joint (DIPJ) Wound Coverage:** A refined bilobed flap technique provides aesthetic and functional coverage after mucous cyst excision at the distal interphalangeal joint ([Jimenez](https://www.sciencedirect.com/science/article/abs/pii/S0363502317304306?ref=theplasticsfella.com#:~:text=The%20Zitelli%20bilobed%20flap%20after,risk%20to%20the%20nail%20matrix.), 2017). 💡 ****Tip:** ****Position alar defects at least 1 cm from the alar margin** to prevent margin distortion and ensure a smooth, natural alar contour during healing. --- ## Bilobed Flap Design ****Key Point** The bilobed flap uses two rotating lobes around a single pivot point. This double transposition design helps spread tension evenly and maintain natural facial contours, especially on the nose. ### Key Principles The bilobed flap uses geometric planning and tissue movement to achieve reliable, aesthetic reconstruction. Its success depends on maintaining key proportions: - **Lobe Sizes:** The first lobe should match the width of the defect. The second lobe should be slightly smaller to minimize tension and avoid dog-ear formation. - **Angles:** The first lobe is set at a 45° angle from the defect, and the second lobe at 90° from the pivot point. - **Pivot Point:** Located one defect-width away from the edge of the original defect. Originally developed by **Esser in 1918**, the first bilobed flap used two equal-sized lobes, each rotating 90°. This created a 180° arc. **Zitelli later refined the design**, reducing the rotation to 45–50° per lobe. This is visualised in the image below. ![Comparison of the Esser (Left) and Zitelli (Right) bilobed flap designs](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-04-01T010111.205.png) Comparison of Esser and Zitelli bilobed flap designs ### 😎 ****Fun Fact:** [Cho](https://www.liebertpub.com/abs/doi/10.1001/archfaci.8.6.404?ref=theplasticsfella.com) (2006) suggests extending the primary lobe by 10% to prevent alar retraction and wound distortion, while [Wang](https://f.oaes.cc/xmlpdf/100f13d1-236c-4cab-a3dc-ec3046ffe80e/26.pdf?ref=theplasticsfella.com) (2014) recommends using nasal and cheek skin in younger patients to better conceal scars. ### Steps to Bilobed Flap Understanding the geometry of each element ensures successful planning, rotation, and inset of the flap. The key steps are as follows. **Flap Design** 1. **Measure the Defect:** Use the diameter as your base for all further measurements. 2. **Mark the Pivot Point:** Place it one defect-width away from the defect's edge. 3. **Draw Lobe A (Primary):** At a 45° angle from the pivot point, matching the defect’s width. 4. **Draw Lobe B (Secondary):** At a 90° angle, slightly smaller and often triangular (Steiger, 2011). 5. **Excise a Standing Cutaneous Defect (SCD):** Remove a small triangle of tissue between the defect and pivot to allow flap rotation without bunching. ![Steps of designing a bilobed flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Main-Article-Images---2025-05-15T151312.980.png) Steps of designing a bilobed flap 💡 ****Tip:** The 3-2-1 mnemonic simplifies geometric flap planning with 1 pivot point (one defect away), 2 lobes angled at 45°, and 3 incisions (defect, primary, and secondary lobes). **Flap Raising** - **Dissection Plane:** Can be subcutaneous, submuscular, or periosteal—depending on the defect depth. - **Undermining:** Widely undermine to allow smooth rotation and reduce tension. - **Instruments:** Use **skin hooks**, not forceps, to avoid trauma. - **Thinning:** Carefully thin the flap to match nasal contour, but preserve subdermal vascularity **Suturing** - **Tension Check:** Ensure the flap rotates freely before suturing. - **Step 1:** Close **Lobule B donor site** first to anchor the flap. - **Step 2:** Rotate the primary lobe into the defect. - **Step 3:** Use **layered closure** with deep sutures to minimize dead space and avoid pincushioning. - **Step 4:** Complete with fine skin sutures, respecting skin tension lines (Wang, 2014). ([Wang](https://f.oaes.cc/xmlpdf/100f13d1-236c-4cab-a3dc-ec3046ffe80e/26.pdf?ref=theplasticsfella.com), 2014). 💡 ****Tip:** ****Superiorly based bilobed flaps** reduce nasal tip distortion more effectively than lateral flaps. They are especially useful for larger or cephalic defects, offering better contour control and lower complication rates ([Kelly-sell](https://pubmed.ncbi.nlm.nih.gov/29056236/?ref=theplasticsfella.com), 2018). --- ## Complications of Bilobed Flaps ****Key Point** While bilobed flaps are highly effective for facial reconstruction, complications typically arise from poor planning, incorrect flap dimensions, or suboptimal surgical technique. ### Advantages of Bilobed Flaps Bilobed flaps are designed as random pattern flaps, meaning they rely on the subdermal plexus for blood supply. This gives them several advantages over other local flaps: - **Strong Vascularity:** Excellent perfusion reduces the risk of flap loss ([Cook](https://journals.lww.com/dermatologicsurgery/abstract/2000/04000/a%5Freview%5Fof%5Fthe%5Fbilobed%5Fflap%5Fs%5Fdesign%5Fwith.13.aspx?ref=theplasticsfella.com), 2000). - **Tension Redistribution:** Using two lobes spreads tension more evenly than a single flap, reducing stress on any one point ([Steiger](https://www.facialplastic.theclinics.com/article/S1064-7406%2810%2900163-X/abstract?ref=theplasticsfella.com), 2011). - **Extended Reach:** They allow movement of more skin over a greater distance than single transposition flaps like the rhomboid flap. - **One-Stage Repair:** Enables reconstruction using local tissue with matching texture and color ([Salgarelli](https://www.sciencedirect.com/science/article/abs/pii/S101051820900198X?ref=theplasticsfella.com), 2010). Despite these strengths, outcomes depend heavily on meticulous design and execution. ### Complications of Bilobed Flaps - **Alar Retraction:** The alar rim pulls upward or distorts, affecting nasal contour. Commonly due to undersized primary lobes or improper placement of the secondary defect. Reported in up to **5% of cases** ([Cho](https://www.liebertpub.com/abs/doi/10.1001/archfaci.8.6.404?ref=theplasticsfella.com), 2006). Minimisation strategy should include: - Ensure the **primary lobe equals or slightly exceeds the defect size** ([Cook](https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1524-4725.2005.31827?saml%5Freferrer&ref=theplasticsfella.com), 2006). - Use **vertical closure** of the secondary lobe to reduce distortion ([Zitelli](https://www.liebertpub.com/abs/doi/10.1001/archfaci.10.3.186?ref=theplasticsfella.com), 2008). - **Wide undermining** helps release tension and prevents retraction ([Cho](https://www.liebertpub.com/abs/doi/10.1001/archfaci.8.6.404?ref=theplasticsfella.com), 2006). - **Standing Cone and Dog-Ears:** Raised puckers of skin at closure points, or tissue bunching at lobe junctions. Often from failing to account for excess skin or improper arc design. Minimisation strategy should include: - Excise a **triangular wedge (standing cutaneous deformity)** between the defect and pivot point to create space for flap rotation. - Properly size the second lobe — **slightly smaller than the first** — to reduce redundancy. - **Trapdoor Effect (Pincushioning):** The central area of the flap bulges above the skin surface. Due to excessive bulk or inadequate tissue thinning. Minimisation strategy should include: - Carefully **thin the lobes** to match the surrounding nasal contour. - Use **layered suturing** to flatten the flap and avoid central elevation ([Cook](https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1524-4725.2005.31827?saml%5Freferrer&ref=theplasticsfella.com), 2006). - **Flap Necrosis (Rare):** Partial or full flap loss from poor blood flow caused by aggressive thinning or tension that compromises vascularity. Minimisation strategy should include: - Avoid over-thinning, especially in distal lobe tips. - Handle tissues gently — **use skin hooks instead of forceps** — and elevate flaps on a reliable vascular plane. - Confirm **tension-free rotation** intraoperatively before suturing. - **Donor Site Scarring:** Visible or asymmetric scars at the flap harvest site. Misaligned incisions or excessive tension during closure. Minimisation strategy should include: - Align incisions with **relaxed skin tension lines** for better healing ([Cook](https://journals.lww.com/dermatologicsurgery/abstract/2000/04000/a%5Freview%5Fof%5Fthe%5Fbilobed%5Fflap%5Fs%5Fdesign%5Fwith.13.aspx?ref=theplasticsfella.com), 2000). - Choose **mobile, less sebaceous skin** (like nasal dorsum or sidewall) for the second lobe to allow smoother closure. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** The bilobed flap is a double transposition flap ideal for small to moderate nasal and facial cutaneous defects, redirecting tension to preserve contours. ****2\. Indications:** It’s best used for nasal tip or ala defects <1.5 cm, offering excellent vascularity, contour match, and reduced distortion versus grafts. ****4\. Design:** The Zitelli modification rotates two lobes 45–50° around a pivot, distributing tension and minimizing dog-ears or standing cones. ****5\. Flap Geometry:** Use the “3-2-1” mnemonic: 3 radii, 2 angles (45°), 1 pivot point — key to consistent design and easy intraoperative planning. ****6\. Complications:** Issues like alar retraction, dog-ears, trapdoor deformity, or necrosis stem from poor flap planning, tension, or excess thinning. --- ## Further Reading 1. Cook, Jonathan L. "[Reconstructive utility of the bilobed flap: lessons from flap successes and failures](https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1524-4725.2005.31827?saml%5Freferrer&ref=theplasticsfella.com)." *Dermatologic surgery* 31 (2005): 1024-1033\. 2. Grieco MP, Bertozzi N, Grignaffini E, Raposio E. [Nose defects reconstruction with the Zitelli bilobed flap.](https://pubmed.ncbi.nlm.nih.gov/29564875/?ref=theplasticsfella.com) G Ital Dermatol Venereol. 2018 Apr;153(2):278-282\. 3. Cook, Jonathan L. "[A review of the bilobed flap's design with particular emphasis on the minimization of alar displacement.](https://journals.lww.com/dermatologicsurgery/abstract/2000/04000/a%5Freview%5Fof%5Fthe%5Fbilobed%5Fflap%5Fs%5Fdesign%5Fwith.13.aspx?ref=theplasticsfella.com)" *Dermatologic surgery* 26.4 (2000): 354-362. 4. Salgarelli, Attilio Carlo, et al. "[The bilobed flap in skin cancer of the face: our experience on 285 cases](https://www.sciencedirect.com/science/article/abs/pii/S101051820900198X?ref=theplasticsfella.com)." *Journal of Cranio-Maxillofacial Surgery* 38.6 (2010): 460-464. 5. Steiger, Jacob D. "[Bilobed flaps in nasal reconstruction.](https://www.facialplastic.theclinics.com/article/S1064-7406%2810%2900163-X/abstract?ref=theplasticsfella.com)" *Facial Plastic Surgery Clinics* 19.1 (2011): 107-111. 6. Zitelli, John A. "[Design aspect of the bilobed flap.](https://www.liebertpub.com/abs/doi/10.1001/archfaci.10.3.186?ref=theplasticsfella.com)" *Archives of Facial Plastic Surgery* (2008). 7. Wang, Zhi-Guo, Xiu-Juan Chen, and Zhen-Yu Chen. "[A modified bilobed flap design for nasal tip defects.](https://f.oaes.cc/xmlpdf/100f13d1-236c-4cab-a3dc-ec3046ffe80e/26.pdf?ref=theplasticsfella.com)" *Plastic and Aesthetic Research* 1 (2014): 16-20. 8. Kelly-Sell M, Hollmig ST, Cook J. [The superiorly based bilobed flap for nasal reconstruction](https://pubmed.ncbi.nlm.nih.gov/29056236/?ref=theplasticsfella.com). J Am Acad Dermatol. 2018 Feb;78(2):370-376. 9. Cho, Michael, and David W. Kim. "[Modification of the Zitelli bilobed flap.](https://www.liebertpub.com/abs/doi/10.1001/archfaci.8.6.404?ref=theplasticsfella.com)" *Archives of Facial Plastic Surgery* (2006). 10. Sutton, Andrew E., and Vito C. Quatela. "[Bilobed flap reconstruction of the temporal forehead.](https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/620991?ref=theplasticsfella.com)" *Archives of Otolaryngology–Head & Neck Surgery* 118.9 (1992): 978-982. 11. Hsieh, Ching-Hua, et al. "[Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery.](https://journals.lww.com/plasreconsurg/abstract/2004/04150/primary%5Fclosure%5Fof%5Fradial%5Fforearm%5Fflap%5Fdonor.6.aspx?ref=theplasticsfella.com)" *Plastic and reconstructive surgery* 113.5 (2004): 1355-1360. 12. Jiménez, Isidro, Pedro J. Delgado, and Ricardo Kaempf de Oliveira. "[The Zitelli bilobed flap on skin coverage after mucous cyst excision: a retrospective cohort of 33 cases.](https://www.sciencedirect.com/science/article/abs/pii/S0363502317304306?ref=theplasticsfella.com#:~:text=The%20Zitelli%20bilobed%20flap%20after,risk%20to%20the%20nail%20matrix.)" *The Journal of Hand Surgery* 42.7 (2017): 506-510. ### We’re Growing, 3 Flap Classifications, & Sub-I Inequity URL: https://www.theplasticsfella.com/april-6th/ Last updated: 2025-04-11T15:14:42.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/april-6th/#a-letter-from-pfella) Trust us, we’re growing. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/april-6th/#the-sunday-quiz) How well do you know f**asciocutaneous flaps*? 3. 🖼️ [****Image of the Week**](https://www.theplasticsfella.com/april-6th/#image-of-the-week) Mathes and Nahai muscle flap classification. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/april-6th/#technique-tip) Keystone design perforator island flap. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-6th/#upcoming-events) Your events deserve a spot here too! 6. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/april-6th/#the-fellows-corner) Visual guide to fat grafting. 7. 📖 [****JPRAS Journal Club**](https://www.theplasticsfella.com/april-6th/#jpras-journal-club) Sub-internship cost: The numbers speak for themselves 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/april-6th/#articles-of-the-week) Original Mathes and Nahai, Cormack & Lamberty foundational system for fasciocutaneous flaps, & original angiosomes publication: with 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/april-6th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Trust Us, We’re Growing* 👋 ****Hey Team!** We came in second. Just saw the results from this week’s PlasticsPaper poll — rank your most trusted sources for plastic surgery. And to be totally honest? I was surprised. Because four years ago, this platform didn’t really exist. There was no reason to trust us. No reason to even notice us. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/White-and-Green-Minimalist-Table-Comparison-Chart--1-.png) Your Most Trusted Source **We Didn’t Set Out to Be Trusted — We Just Wanted Less Noise** Let’s be real. Most plastic surgery education feels like a bad algorithm: Paywalls, recycled abstracts, and PDFs so dense they make you feel dumber. That’s why we started this — to cut through the noise. It wasn’t about being “the best.” It was about being **useful**. Something you could read between cases. Listen to on the commute. Share with your team. And slowly, it turns out… that builds trust. Not because we asked for it — but because we showed up. Every week. No clickbait. No sponsorships. No fluff. **So What Now?** This poll isn’t a victory lap. It’s a mirror. If people trust us, it means we’ve got a responsibility to **keep earning it**. And if we're not at the top? That’s fair too. There’s still room to grow — and a lot of ground left to cover. That’s why over the next 12 months, *The Plastics Fella* will be investing **over $100,000** into plastic surgery education. We’re here for the long game. But first — I want to hear from you. No trophies. Just trust. P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Fasciocutaneous Flaps?* ****Are you ready to make it to the leaderboard?** Welcome to the ****next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ❗You asked, we listened: The quiz now runs on a fixed time limit, not a countdown. --- ## Image of the Week **Mathes and Nahai Muscle Flap Classification* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week’s image illustrates the ****five types of muscle vascular supply**, as described in the original 1981 classification by ****Mathes and Nahai**. A foundational concept in flap planning, this system categorises muscles based on the ****number & dominance of vascular pedicles**, which is critical when selecting flaps for reconstruction. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/image.png) Mathes and Nahai Muscle Flap Classification ## Technique Tip **Keystone Design Perforator Island Flap* 🚑 ****Technique Tip of the Week** This week’s tip highlights the original ****Keystone Design Perforator Island Flap**. The flap is trapezoidal, based on perforators, and positioned adjacent to an elliptical defect. The key features include, \- A 1:1 flap-to-defect width ratio \- 90° angled lateral borders \- V–Y advancement at each end for tension redistribution This simple yet effective design allows great coverage without the need for grafts in most cases. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/Screenshot-2025-04-03-at-13-56-23.png) [Source](https://pubmed.ncbi.nlm.nih.gov/12608972/?ref=theplasticsfella.com) ## Upcoming Events **Your Events Deserve a Spot Here Too!* 📅 ****P’Fella’s event calendar** highlights the most impactful conferences, high-yield webinars, and carefully curated courses for you. Got something worth sharing? ****Submit your event and get it featured on our events page!** ## the Fellows' Corner **Visual Guide to Fat grafting* 📹 This week in the Fellows’ Corner, we’re featuring ****a visual breakdown of fat grafting** by our educational fellow, Benedetta Agnelli. The video walks through the key steps in ****harvesting**, ****processing**, and ****injecting** ****fat** for optimal graft survival. Watch below for a quick reference for anyone in theatre ▶️ 0:00 /1:33 1× Fat Grafting - Video Guide ## JPRAS Journal Club **Sub-Internship Cost in the US: The Numbers Speak for Themselves* 🩹 **In Case You Missed It:* **How Much Does a Sub-Internship Actually Cost?** P’Fella’s educational fellow, Hatan Mortada breaks down a powerful JPRAS study that exposes the stark financial disparities in plastic surgery sub-internships. The Numbers Speak: \- IMGs face ****17x higher costs** than US peers. \- Median cost for \~4.5 away rotations: ****$9,114 for IMGs** vs ****$410 for US students.** \- IMGs also have ****80% fewer programs** available to them. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/How-much-does-a-sub-internship-actually-cost---Journal-Club--1-.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/How-much-does-a-sub-internship-actually-cost---Journal-Club.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/04/How-much-does-a-sub-internship-actually-cost---Journal-Club--2-.png) [Read the Article](https://www.theplasticsfella.com/journal-sub-internships/) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Muscle Vascular Classification and Its Role in Flap Design** ([Mathes & Nahai](https://pubmed.ncbi.nlm.nih.gov/7465666/?ref=theplasticsfella.com), 1981) Mathes and Nahai propose a five-type classification of muscle blood supply, linking vascular anatomy with surgical flap design. ✅ ****A Vascular Classification System for Fasciocutaneous Flaps** ([Cormack & Lamberty](https://pubmed.ncbi.nlm.nih.gov/6692066/?ref=theplasticsfella.com), 1984) This study defines four distinct vascular patterns in fasciocutaneous flaps, laying the anatomical and conceptual foundation for designing reliable and versatile flaps in reconstructive surgery. ✅ ****Original Angiosomes Publication: Vascular Guidelines for Flap Design** ([Taylor & Palmer](https://pubmed.ncbi.nlm.nih.gov/3567445/?ref=theplasticsfella.com), 1987) This foundational work introduces angiosomes through cadaveric dissection and radiographic analysis, defining the 3D vascular territories of source arteries and setting the stage for flap planning. ## Feedback ### I hope you enjoyed it 😄 --- ### Fasciocutaneous Flaps: Anatomy, Classification, & Clinical Applications URL: https://www.theplasticsfella.com/fasciocutaneous-flaps/ Last updated: 2025-04-03T12:48:28.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/fasciocutaneous-flaps/#overview-of-fasciocutaneous-flaps) Fasciocutaneous flaps — comprising skin, subcutaneous tissue, and deep fascia — offer thin, well-vascularised coverage ideal for reconstructing exposed structures while preserving contour. [****Anatomy**](https://www.theplasticsfella.com/fasciocutaneous-flaps/#anatomy-of-fasciocutaneous-flaps) Fasciocutaneous flaps use perforator-fed plexuses for reliable perfusion and flexible design — key principles include vascular planning, pattern type, and low donor morbidity [****Classification**](https://www.theplasticsfella.com/fasciocutaneous-flaps/#classification-of-fasciocutaneous-flaps) Cormack & Lamberty classify fasciocutaneous flaps by vascular entry, while Mathes & Nahai focus on pedicle type. Both systems enhance surgical precision and flap survival by defining vascular anatomy. [****Clinical Indications**](https://www.theplasticsfella.com/fasciocutaneous-flaps/#clinical-indications-for-fasciocutaneous-flaps) Fasciocutaneous flaps are ideal for covering soft tissue defects where thin, vascularised, and contour-preserving tissue is required — especially in trauma, oncologic, and revision settings. [****Fasciocutaneous vs Muscle Flaps**](https://www.theplasticsfella.com/fasciocutaneous-flaps/#fasciocutaneous-flaps-vs-muscle-flaps) The choice between fasciocutaneous and muscle flaps hinges on wound depth, vascular needs, and functional preservation — fasciocutaneous flaps excel in contour-sensitive areas, while muscle flaps dominate in infection-prone and volumetric reconstructions. [****Surgical Technique**](https://www.theplasticsfella.com/fasciocutaneous-flaps/#surgical-technique-of-fasciocutaneous-flaps) Successful fasciocutaneous flap reconstruction depends on meticulous preoperative planning, subfascial dissection preserving perforators, and tension-free inset — followed by diligent vascular monitoring postoperatively. [****Complications**](https://www.theplasticsfella.com/fasciocutaneous-flaps/#complications-of-fasciocutaneous-flaps) Fasciocutaneous flaps are generally safe and effective, but complications such as necrosis, venous congestion, and donor site issues can occur — most often due to vascular compromise, tension, or poor intraoperative handling. ****Updated by:** Dr Hatan Mortada, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview of Fasciocutaneous Flaps ****Key Point** Fasciocutaneous flaps — comprising skin, subcutaneous tissue, and deep fascia — offer thin, well-vascularised coverage ideal for reconstructing exposed structures while preserving contour. Fasciocutaneous flaps, also called axial flaps, exclude muscle but include skin, fat, and fascia, providing structural and vascular benefits. These flaps have become increasingly valuable in reconstructive surgery due to their versatility, pliability, and dependable perfusion. The concept and utility of fasciocutaneous flaps have evolved through landmark contributions that advanced both design principles and vascular understanding. - [Pontén](https://pubmed.ncbi.nlm.nih.gov/7236984/?ref=theplasticsfella.com) **(1981):** First described fasciocutaneous flaps for lower limb reconstruction. His inclusion of deep fascia extended safe flap dimensions (length-to-width ratio up to 3:1), improving survival. - [Haertsch](https://pubmed.ncbi.nlm.nih.gov/7296153/?ref=theplasticsfella.com) & [Barcla](https://pubmed.ncbi.nlm.nih.gov/7044458/?ref=theplasticsfella.com)y **(1981–1982):** Demonstrated that fascia preserves longitudinal anastomotic vascular pathways, especially the suprafascial plexus, enhancing perfusion across flap length. - [Cormack](https://pubmed.ncbi.nlm.nih.gov/6692066/?ref=theplasticsfella.com) & [Lamberty](https://pubmed.ncbi.nlm.nih.gov/6692066/?ref=theplasticsfella.com) **(1984):** Developed a classification system based on vascular anatomy—random, axial, septocutaneous, and musculocutaneous perforator flaps—standardising flap selection and improving planning. 😎 ****Fun Fact:** Pontén’s 1981 fasciocutaneous flap revolutionised reconstruction — offering better contour, less donor-site morbidity, and no muscle sacrifice. --- ## Anatomy of Fasciocutaneous Flaps ****Key Point** Fasciocutaneous flaps use perforator-fed plexuses for reliable perfusion and flexible design — key principles include vascular planning, pattern type, and low donor morbidity Fasciocutaneous flaps provide consistent soft tissue coverage without compromising muscle, making them valuable in reconstructive surgery. Their effectiveness is rooted in a detailed understanding of vascular anatomy and the strategic use of perforator vessels. ### Vascular Plexuses The vascular anatomy of fasciocutaneous flaps is centered around interconnected plexuses fed by perforator arteries that guide flap design and survival. - **Suprafascial Plexus:** The primary vascular network that runs above the deep fascia, ensuring robust skin and fascial perfusion. - **Subfascial Plexus:** Located between deep fascia and underlying muscle, this layer supports flap viability and links to deeper arterial sources. - **Subdermal & Dermal Plexi:** These smaller vessels form a collateral network that further stabilises perfusion, especially in distal or narrow flaps. - **Source Vessels:** All plexuses are ultimately fed by perforators branching from main axial arteries, such as the profunda femoris or radial artery, depending on flap location. The anatomy of fasciocutaneous flaps is illustrated below. ![Anatomy of fasciocutaneous flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template--6-.png) Anatomy of fasciocutaneous flaps ### ### Perforators The route and origin of perforators influence flap selection, reliability, and dissection complexity. - **Musculocutaneous Perforators:** Traverse muscle tissue to reach the fascia and skin, often requiring intramuscular dissection (e.g., thoracodorsal perforator flap). - **Septocutaneous Perforators:** Run in intermuscular septa and are easier to dissect; commonly found in limbs (e.g., fibular flap). - **Direct Cutaneous Branches:** Arise directly from source arteries without passing through muscle or septa, offering straightforward flap elevation. The type and consistency of perforators vary by anatomical region, influencing flap reliability and planning. - **Extremities:** Dominated by septocutaneous perforators, offering consistent and easy-to-harvest vascular pedicles. - **Trunk:** More variable and reliant on musculocutaneous perforators, requiring deeper dissection and more meticulous planning. - **Scalp and Face:** Rich in direct cutaneous branches due to superficial arterial networks, allowing thin and mobile flaps. 😎 ****Fun Fact:** The fibular flap is a classic example of a fasciocutaneous flap with septocutaneous perforators — surgeons often prefer it for mandibular reconstruction due to its consistent anatomy and dual utility (bone + skin). ### --- ## Classification of Fasciocutaneous Flaps ****Key Point** Cormack & Lamberty classify fasciocutaneous flaps by vascular entry, while Mathes & Nahai focus on pedicle type. Both systems enhance surgical precision and flap survival by defining vascular anatomy. Understanding the classification of fasciocutaneous flaps allows surgeons to better predict perfusion patterns, plan dissections, and minimise complications. Two foundational systems — **Cormack & Lamberty** and **Mathes & Nahai** — categorise flaps by vascular design, providing critical frameworks for clinical decision-making. ### Cormack & Lamberty Classification This system organises flaps into four types based on how vascular perforators enter and supply the flap, focusing on anatomical blood supply routes ([Cormack & Lamberty](https://pubmed.ncbi.nlm.nih.gov/6692066/?ref=theplasticsfella.com), 1984). - **Type A – Multiple Perforators at Base** - Supplied by several fasciocutaneous perforators entering the flap base. Allows for both proximal and distal orientation. - *Example:* Most lower limb flaps. - **Type B – Single Perforator** - Perfused by one dominant perforator, suitable for island or free flap design. - *Example:* Scapular flap. - **Type C – Septal-Based with Main Artery** - Vessels enter through a fascial septum; the main artery is included in the flap. - *Example:* Radial forearm flap. - **Type D – Composite Flap** - Includes additional components such as bone or muscle with a fasciocutaneous element. - *Example:* Osteocutaneous radial forearm flap.Mathes & Nahai Classification (Based on Pedicle Type) Cormack & Lamberty classification guides where to dissect and whether the main artery must be included. ### Mathes & Nahai Classification This classification categorises flaps based on the type of vascular pedicle that supplies the skin and fascia, useful in determining free vs. pedicled flap design ([Mathes & Nahai](https://pubmed.ncbi.nlm.nih.gov/7465666/?ref=theplasticsfella.com), 1981). - **Type A – Direct Cutaneous Pedicles** - Supplied directly by branches from an artery to the skin. - *Example:* Groin flap, Foucher flap. - **Type B – Septocutaneous Pedicle** - Blood supply reaches the flap via perforators through intermuscular septa. - *Example:* Scapular flap, Posterior Interosseous Artery flap. - **Type C – Musculocutaneous Pedicle** - Vascularised by perforators passing through underlying muscle. - *Example:* Anterolateral Thigh (ALT) flap. Mathes & Nahai help determine the vascular reliability, especially for free tissue transfer. ⚠️ ****Important**: Do not confuse this with the Mathes and Nahai [Muscle Flap Classification](https://www.theplasticsfella.com/mathes-and-nahai-classification/). These fasciocutaneous flap classification systems are summarised in the table below. ![Classification of fasciocutaneous flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template---Textbook-Images--9-.png) Classification of fasciocutaneous flaps 💡 ****Tip:** Use Cormack & Lamberty to understand how vessels enter the flap, and Mathes & Nahai to assess pedicle quality for safe elevation and transfer. --- ## Clinical Indications for Fasciocutaneous Flaps ****Key Point** Fasciocutaneous flaps are ideal for covering soft tissue defects where thin, vascularised, and contour-preserving tissue is required — especially in trauma, oncologic, and revision settings. Fasciocutaneous flaps offer tailored solutions across trauma, oncologic, and salvage scenarios, with demonstrated reliability and versatility. **Trauma Reconstruction** - Covers open fractures, degloving injuries, and burns with tissue that conforms well and preserves joint mobility. - Useful in both acute trauma and subacute reconstruction stages. **Oncologic Defects** - Effective following tumor excision, particularly in head and neck or extremity cancers ([Hanasono](https://pmc.ncbi.nlm.nih.gov/articles/PMC4590972/?ref=theplasticsfella.com), 2014). - Offers good aesthetic outcomes with minimal donor morbidity. **Chronic Wounds and Pressure Sores** - Preferred for wounds in thin-skinned or high-risk areas like the lower leg and dorsum of the hand ([Chiu](https://pubmed.ncbi.nlm.nih.gov/28552279/?ref=theplasticsfella.com), 2017). - Durable yet non-bulky coverage supports long-term healing. **Head, Neck, and Trunk Reconstruction** - Flaps like the forehead or supraclavicular fasciocutaneous flap are ideal for nasal lining or oropharyngeal repair. - Chosen over muscle flaps where bulk could distort anatomy. **Revision and Salvage Surgery** - Valuable in covering exposed hardware, revising failed flaps, or minimising the need for additional grafts ([AlMugaren et al.](https://pubmed.ncbi.nlm.nih.gov/32440438/?ref=theplasticsfella.com), 2020). - Their dependable perfusion supports healing in compromised fields The image below illustrates a forehead fasciocutaneous flap used for nasal reconstruction. ![Forehead fasciocutaneous flap used for nasal reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template--7-.png) Forehead fasciocutaneous flap used for nasal reconstruction 💡 ****Tip:** Consider fasciocutaneous flaps for thin-skinned areas. Ideal for lower limb, hand dorsum, nasal lining, and oropharynx, where muscle flaps would be too bulky. --- ## Fasciocutaneous Flaps vs Muscle Flaps ****Key Point** The choice between fasciocutaneous and muscle flaps hinges on wound depth, vascular needs, and functional preservation — fasciocutaneous flaps excel in contour-sensitive areas, while muscle flaps dominate in infection-prone and volumetric reconstructions. Fasciocutaneous and muscle flaps serve distinct purposes, each tailored to specific clinical demands based on anatomy, perfusion, and the complexity of the defect. ### Fasciocutaneous Flaps Fasciocutaneous flaps provide thin, well-vascularised tissue suitable for restoring contour and function with minimal disruption to underlying musculature. - **Thin and Pliable Coverage Is Required:** Ideal for the lower limb, hand dorsum, and facial regions where excessive bulk can impair aesthetics and mobility. - **Muscle Function Must Be Preserved:** Useful in the upper and lower limbs where sacrificing muscle would compromise movement or strength. - **Contour Restoration Is a Priority:** Their natural conformity makes them the flap of choice in head, neck, and extremity reconstructions. - **Single-Stage Reconstruction Is Preferred:** Reduces the need for multiple operations or secondary grafting, accelerating recovery. ### Muscle Flaps Muscle flaps offer robust vascularity and volume, making them effective for complex or infected wounds and for obliterating deep spaces. - **Deep or Irregular Wounds Require Filling:** Muscle bulk fills cavities and irregular defects that fasciocutaneous flaps may not adequately address. - **Infection Control Is Crucial:** The high perfusion rate in muscle flaps aids in delivering immune cells and antibiotics to contaminated fields. - **Bulk Is Beneficial:** Indicated in cases like pressure sores, traumatic tissue loss, or post-oncologic defects where volume restoration is needed. The key differences between fasciocutaneous and muscle flaps are summarised below. ![Key differences between fasciocutaneous and muscle flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template---Textbook-Images--7-.png) Key differences between fasciocutaneous and muscle flaps 😎 ****Fun Fact:** Fasciocutaneous flaps were once considered inferior to muscle flaps for infected wounds due to presumed lower vascularity, but recent evidence shows they offer comparable outcomes (Lee, 2019) --- ## Surgical Technique of Fasciocutaneous Flaps ****Key Point** Successful fasciocutaneous flap reconstruction depends on meticulous preoperative planning, subfascial dissection preserving perforators, and tension-free inset — followed by diligent vascular monitoring postoperatively. Fasciocutaneous flaps are based on the rich vascular plexuses located above and below the deep fascia, which allow for thin, pliable tissue transfer with reliable perfusion. They remain a **reliable** and **versatile** option, particularly for **salvage reconstructions** where simpler techniques are preferred ([Kovar](https://pubmed.ncbi.nlm.nih.gov/31590192/?ref=theplasticsfella.com), 2020). ### Fasciocutaneous Flap Design Flap success begins before the incision. Detailed design, proper patient positioning, and vascular assessment are essential to avoid intraoperative surprises. Key principles of fasciocutaneous flap design includes, 1. **Deep Fascia Inclusion:** Incorporating deep fascia strengthens vascularity and increases the safe length-to-width ratio. 2. **Perforator-Based Planning:** Doppler identification of dominant perforators enhances design precision and outcomes. 3. **Flap Sizing and Design:** Precisely match the defect while accounting for length lost during rotation. Use these approximations for rotational loss: 45° = 5% loss, 90° = 15% loss, 180° = 40% loss 4. **Flap Delay Technique:** Pre-elevation of the flap can increase vascular territory before transfer. 💡 ****Tip:** ****“The Doppler doesn’t lie!”** Preoperative Doppler mapping significantly reduces intraoperative uncertainty and flap failure. ### Fasciocutaneous Flap Elevation The surgical steps for harvesting and insetting a fasciocutaneous flap emphasise vascular preservation and a tension-free closure. **Step 1: Incision and Flap Elevation** - **Incise** through the skin, subcutaneous fat, and deep fascia. - **Elevate** the flap in a subfascial plane to protect the underlying perforators. **Step 2: Pedicle Management** - **Avoid skeletonising** vessels unnecessarily; maintain surrounding tissues to preserve flow. - **Maintain pedicle length** to allow tension-free movement to the defect. **Step 3: Flap Transfer and Inset** - **Prepare the recipient** site by excising nonviable tissue and undermining wound edges. - **Rotate or advance** the flap into position without kinking the pedicle. - **Suture fascia to fascia** for structural stability, using minimal tacking sutures on the skin. The following video is an example of a PIA fasciocutaneous flap. PIA Fasciocutaneous Flap ### Postoperative Care and Monitoring Immediate postoperative care focuses on early detection of vascular compromise and ensuring optimal perfusion to the transferred tissue. **Flap Monitoring** - Check for color, capillary refill, turgor, and Doppler signals regularly in the first 48–72 hours. - Any signs of congestion or pallor should prompt rapid intervention. **Positioning and Support** - Elevate extremities to reduce edema. - Avoid compression over the flap or pedicle to prevent venous outflow obstruction. **Reassessment for Secondary Grafting** - In thinner flaps with volume loss, skin grafting may be required for final contouring. 💡 ****Tip:** Fascial and adipofascial flaps are skinless variants, relying on fascia alone or fascia with fat for vascularised reconstruction. --- ## Complications of Fasciocutaneous Flaps ****Key Point** Fasciocutaneous flaps are generally safe and effective, but complications such as necrosis, venous congestion, and donor site issues can occur — most often due to vascular compromise, tension, or poor intraoperative handling. The viability of fasciocutaneous flaps hinges on perfusion through delicate perforator networks. Disruption to either arterial inflow or venous outflow can threaten flap survival. **Flap Necrosis (Partial or Total)** - **Cause:** Inadequate vascular supply, excessive tension, or pedicle compromise. - **Clinical Signs:** Dusky color, reduced capillary refill, distal tip ischemia. - **Tip:** Always include the **deep fascia** in flap elevation and avoid over-tightening sutures—these can compress perforators and lead to distal necrosis *(Tolhurst, 1986)*. **Venous Congestion** - **Cause:** Twisted pedicle, excessive flap rotation, or tight closure restricting venous drainage. - **Signs:** Flap appears bluish or congested with rapid capillary refill and increased turgor. - **Tip:** Limit rotation angles and avoid kinking the pedicle. Elevate the limb postoperatively to promote venous return. **Arterial Insufficiency** - **Cause:** Pedicle tension, inadequate perforator inclusion, or compression. - **Signs:** Pale, cool flap with delayed capillary refill and absent Doppler signal. - **Tip:** Map perforators with a handheld Doppler during planning and preserve pedicle soft tissue during elevation. **Hematoma and Seroma Formation** - **Cause:** Incomplete hemostasis or failure to place suction drains. - **Complications:** Flap elevation, wound tension, delayed healing, secondary infection. - **Tip:** Perform meticulous hemostasis and always use drains for large or high-risk flaps. Avoid early removal if drainage persists. **Infection and Wound Breakdown** - **Cause:** Hematoma, poor flap perfusion, or contaminated wounds. - **Risk Factors:** Diabetes, smoking, peripheral vascular disease, or late presentation. - **Signs:** Erythema, discharge, wound dehiscence, or flap edge necrosis. - **Tip:** Minimise dead space, ensure tension-free closure, and avoid using compromised tissue for inset. **Donor Site Dehiscence or Graft Loss (if used)** - **Cause:** Closure under tension or poor vascularity at the donor site, poor bed preparation, shearing forces, or infection. - **Tip:** If tension is unavoidable, opt for split-thickness skin grafts (STSGs) over forced primary closure to prevent breakdown. Reinforce with bolster dressings and delay grafting if bed viability is questionable. **Contour Defects & Aesthetic Concerns** - **Cause:** Loss of subcutaneous bulk or irregular wound bed topography. - **Outcome:** Visible depressions or asymmetry, especially in cosmetic zones. - **Tip:** Choose donor sites with good tissue match and anticipate visible defects in thin-skinned areas like the forearm. The complications of fasciocutaneous flaps are summarised below. ![Common complications of fasciocutaneous flaps, their causes, and management strategies](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template---Textbook-Images--8-.png) Common complications of fasciocutaneous flaps, their causes, and management strategies ### 💡 ****Tip:** Avoid excessive tension at closure as over-tightened sutures can restrict microcirculation, leading to ischemia and distal necrosis. ### Advantages and Limitations of Fasciocutaneous Flaps Fasciocutaneous flaps offer distinct benefits but also come with specific structural and practical limitations. Their use must be carefully tailored to the clinical scenario. **Advantages** - **Muscle Function Preservation:** These flaps spare muscle tissue, preserving strength and mobility — particularly valuable in functional areas such as the lower limb. This also reduces donor site morbidity compared to muscle-based flaps. - **Thin and Pliable Tissue:** Their soft, flexible nature makes them ideal for reconstructing contour-sensitive areas like the hand, face, and distal lower limb. Unlike bulkier muscle flaps, they provide superior aesthetic outcomes. - **Potential for Sensory Restoration:** When incorporating cutaneous nerves, fasciocutaneous flaps can restore sensation — especially beneficial in the hand and foot where tactile feedback is crucial. **Limitations** - **Limited Reach in Pedicled Designs:** Pedicle length and arc of rotation restrict the flap’s reach, particularly in pedicled designs. - *Tip:* Consider converting to a free flap if the arc is insufficient or there's a risk of vascular compromise due to tension. - **Unsuitable for Deep or Voluminous Defects:** These flaps lack bulk, making them less effective for filling large cavities or obliterating dead space. - *Alternative:* Muscle flaps provide superior volume and are more effective in managing deep infections. - **May Require Delayed Flap Technique:** In areas with marginal vascularity — such as distal limbs — a staged delay procedure may be necessary to improve perfusion before full elevation. - *Guidance:* Plan delays proactively when vascular supply is uncertain. - **Donor Site Morbidity:** Large flaps can lead to delayed healing or contour irregularities at the donor site. Closure may require additional interventions like skin grafting. - **Frequent Need for Skin Grafting:** When primary closure isn’t possible, split-thickness skin grafts (STSGs) are often required. This can result in color or texture mismatch between donor and recipient sites. - **Historically Considered Less Infection-Resistant:** While once thought to be less vascularised than muscle flaps, newer evidence suggests fasciocutaneous flaps can perform comparably in managing infections in selected cases. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Fasciocutaneous flaps consist of skin, subcutaneous fat, and deep fascia, providing thin, pliable coverage while preserving muscle function. Used in trauma, oncologic reconstruction, and pressure sores. ****2\. Anatomy & Physiology:** Perfusion relies on fasciocutaneous perforators (musculocutaneous, septocutaneous, and direct cutaneous) and suprafascial/subfascial plexuses, ensuring vascular reliability. ****3\. Classification & Design:** Cormack & Lamberty (Types A–D) categorises fasciocutaneous flaps by vascular supply patterns. Mathes & Nahai (Types A–C) is based on pedicle type and blood supply source. ****4\. Comparison:** Fasciocutaneous flaps for contour-sensitive coverage, muscle flaps for bulk & deep defects. ****5\. Surgical Technique & Post-op:** Pre-op: Precise flap planning to match the defect and minimise tension. Intra-op: Subfascial dissection to preserve perforators and avoid vascular compromise. Post-op: Monitor for vascular integrity, edema control, and donor site healing. ****6\. Complications & Management:** Common risks: Necrosis, venous congestion, hematoma, infection, and donor site morbidity. Prevention: Proper flap design, tension-free inset, and vascular monitoring. --- ## Further Reading 1. Pontén B. [The fasciocutaneous flap: its use in soft tissue defects of the lower leg](https://pubmed.ncbi.nlm.nih.gov/7236984/?ref=theplasticsfella.com). *Br J Plast Surg*. 1981;34(2):215-220\. doi:10.1016/s0007-1226(81)80097-5 2. Cormack GC, Lamberty BG. [Fasciocutaneous vessels: their distribution on the trunk and limbs, and their clinical application in tissue transfer](https://pubmed.ncbi.nlm.nih.gov/6388596/?ref=theplasticsfella.com). *Anat Clin*. 1984;6(2):121-131\. doi:10.1007/BF01773164 3. Hallock GG. Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds. *J Trauma*. 1989;29(9):1240-1244\. doi:10.1097/00005373-198909000-00010 4. Fix RJ, Vasconez LO. [Fasciocutaneous flaps in reconstruction of the lower extremity](https://pubmed.ncbi.nlm.nih.gov/1889167/?ref=theplasticsfella.com). *Clin Plast Surg*. 1991;18(3):571-582\. PMID:1889167 5. Losco L, Sereni S, Aksoyler D, et al. [Perforator-based adipofascial flaps and ADM: a novel combined approach to distal lower extremity defects](https://pubmed.ncbi.nlm.nih.gov/35198355/?ref=theplasticsfella.com). *Plast Reconstr Surg Glob Open*. 2022;10(2):e4131\. doi:10.1097/GOX.0000000000004131 6. AlMugaren FM, Pak CJ, Suh HP, Hong JP. [Best local flaps for lower extremity reconstruction](https://pubmed.ncbi.nlm.nih.gov/32440438/?ref=theplasticsfella.com). *Plast Reconstr Surg Glob Open*. 2020;8(4):e2774\. doi:10.1097/GOX.0000000000002774 7. Gupta S, Gupta P, Khichar P, Mohammad A, Escandón JM, Kalra S. [Perforator propeller flaps for lower extremity soft-tissue defect reconstruction: shortening the learning curve](https://pmc.ncbi.nlm.nih.gov/articles/PMC8919289/?ref=theplasticsfella.com). *J Clin Orthop Trauma*. 2022;27:101831\. doi:10.1016/j.jcot.2022.101831 8. Vogt PM, Limbourg FP. A new fasciocutaneous flap model identifies a critical role for endothelial Notch signaling in wound healing and flap survival. *Sci Rep*. 2023;13(1):12542\. doi:10.1038/s41598-023-39561-9 9. Boretto J, Morgan B. [Fasciocutaneous flaps](https://www.ncbi.nlm.nih.gov/books/NBK562280/?ref=theplasticsfella.com). In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024\. PMID:32965937 10. Tolhurst DE. [Clinical experience and complications with fasciocutaneous flaps](https://colab.ws/articles/10.3109%2F02844318609006296?ref=theplasticsfella.com). *Scand J Plast Reconstr Surg*. 1986;20(1):75-78\. doi:10.3109/02844318609006296 ### Good Journals Making a Comeback, 3 Classic Hand Flaps, & Sub-I Accessibility URL: https://www.theplasticsfella.com/march-30th/ Last updated: 2025-03-29T22:44:55.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/march-30th/#a-letter-from-pfella) Are plastic surgery journals about to get good again? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/march-30th/#the-sunday-quiz) How well do you know **local flaps*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/march-30th/#image-of-the-week) A raised PIA flap illustration. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-30th/#technique-tip) The original description of the Quaba flap. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/march-30th/#upcoming-events) A curated list of webinars, courses, & conferences. 6. ****🚀**[ **New Features**](https://www.theplasticsfella.com/march-30th/#new-features) AI surgical studio update! 7. 🎓 [****JPRAS Journal Club**](https://www.theplasticsfella.com/march-30th/#jpras-journal-club) Accessibility and cost of plastic surgery sub-internships. 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-30th/#articles-of-the-week) Foucher flap, PIA flap, & Moberg's original on upper limb sensations: with 1-sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/march-30th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Are Plastic Surgery Journals About to Get Good Again?* 👋 ****Hey Team!** PRS just released a bold new mission and vision: to publish the most impactful, innovative, and clinically relevant advances in plastic surgery. And honestly? It feels like the journal world might finally be waking up. Because here’s the truth — we’ve been drowning in data. Hundreds of papers every month. But how many actually change what we do in the OR? This could be the moment things turn. **Why This Actually Matters** Plastic surgery is built on creativity, evidence, and precision. But our literature hasn’t always reflected that. We've seen: - Paywalls blocking essential knowledge. - Industry influence shaping conclusions. - Copy-paste citations creating a broken game of academic telephone​. - And entire papers written to tick career boxes instead of solve problems. PRS says it’s time to reset. Focus on breakthroughs. Elevate peer review. Embrace new media. If they mean it — and stick to it — it could raise the bar for every journal in the field. **Who’s Doing What?** Let’s give credit where it’s due: - **PRS** is leaning into innovation with a clearer purpose and higher ambition. - **JPRAS** continues to quietly deliver the clinical content people actually use. - **Open-access journals** is still not sure about these, to be honest. - **The Plastics Fella** (yeah, us) is making content actually readable and useful — especially for trainees who need clarity, not clutter. The journal world is finally diversifying. Each one has a lane. And that’s a *good* thing. P’Fella ❤️ ## The Sunday Quiz **How Well Do You Know Local Flaps?* ****Are you ready to make it to the leaderboard?** Welcome to the ****next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. --- ## Image of the Week **Posterior Interosseous Artery (PIA) Flap* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week’s image shows a raised PIA flap, a fasciocutaneous flap based on ****septocutaneous perforator**s from the ****posterior interosseous artery**. It’s commonly used for ****dorsal hand and wrist** ****reconstruction**, preserving major vessels and minimising donor site morbidity. ![a raised PIA flap for dorsal hand and wrist reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/image-7.png) [Source](https://journals.sagepub.com/cms/10.1177/15589447211028925/asset/af8f7c03-8c94-480b-bbd7-975907c718dd/assets/images/large/10.1177%5F15589447211028925-fig1.jpg?ref=theplasticsfella.com) ## Technique Tip **Original Description of the Quaba Flap* 🚑 ****Technique Tip of the Week** This week’s tip highlights the original Quaba flap operative technique, described for post-electric burn contracture of the dorsal hand. \- The flap is elliptical, raised at the ****radial border to the paratenon**. \- Dissection continues ****proximal to intertendinous** connections; some serpiginous vessels may be sacrificed. \- Once the ****pedicle** is identified, the flap is islanded and inset. ![Quaba flap operative technique](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Screenshot-2025-03-26-at-08-05-45.png) [Source](https://www.jprasurg.com/article/0007-1226%2890%2990042-X/fulltext?ref=theplasticsfella.com) ## Upcoming Events **A Curated List of Webinars, Courses, & Conferences* 📣 P’Fella spotlights impactful events, high-yield webinars, and hand-picked courses we know you'll love. If there’s a new feature or update, you’ll hear about it here first. We continuously update our event page with fresh additions — both hand-picked by our team and suggested by you. ## New Features **AI Surgical Studio Update* 🩹 **In Case You Missed It:* Our ****AI Surgical Studio** is now live — an interactive, AI-powered tool designed to help surgeons visualise, plan, and refine operative techniques. ****C**heck out the new elements! ****Join the waitlist** to get early access to ****Guide Mode** and ****Exam Mode** before the full release. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/sutdiooo.png) ## JPRAS Journal Club **We have partnered with JPRAS to improve access to evidence-based information.* 📽️ ****How Much Does a Sub-Internship Actually Cost?** P'fella's educational fellow, Dr. Hatan Mortada explores the ****disparities in plastic surgery sub-internships** using 2024–2025 VSLO and program data. [Differences in Accessibility and Cost of Plastic Surgery Sub-Internships and Away Rotations for International and US Medical StudentsThis study highlights large cost disparities for IMGs in plastic surgery sub-internships: fewer program acceptances and fees 17x higher. IMGs’ median cost for \~4.5 away rotations is \~$9K vs. \~$500 for US peers, emphasizing the need for standardized fees and scholarships.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/Logo-Small-2-7.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/Lunchtime-Lessons-2.png)](https://www.theplasticsfella.com/journal-sub-internships/) ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****First Dorsal Metacarpal Artery Flap for Thumb Reconstruction** ([Foucher & Braun](https://pubmed.ncbi.nlm.nih.gov/368837/?ref=theplasticsfella.com), 1979) The Foucher flap, based on the first dorsal metacarpal artery and including veins and sensory nerves, offers reliable one-stage sensate thumb reconstruction using a dorsal index flap without a skin pedicle. ✅ ****Posterior Interosseous Artery Flap for Hand and Wrist Reconstruction** ([Zancolli & Angrigiani](https://pubmed.ncbi.nlm.nih.gov/3385286/?ref=theplasticsfella.com), 1988) The posterior interosseous artery flap provides a thin, reliable island flap from the dorsal forearm for hand and wrist defects, based on distal anastomoses of the interosseous arteries, with primary closure possible if flap width is ≤4 cm. ✅ ****Moberg’s Foundational Work on Sensation in Upper Limb Reconstruction** ([Moberg](https://pubmed.ncbi.nlm.nih.gov/14161094/?ref=theplasticsfella.com), 1964) Moberg's original paper highlights the critical importance of preserving and restoring sensibility in upper extremity reconstruction, emphasizing its central role in functional hand recovery. ## Feedback ### I hope you enjoyed it 😄 --- ### How much does a sub-internship actually cost? JPRAS Journal Club. URL: https://www.theplasticsfella.com/journal-sub-internships/ Last updated: 2025-03-29T17:18:10.000Z ****Journal Article:** Differences in Accessibility and Cost of Plastic Surgery Sub-Internships and Away Rotations for International and US Medical Students **Rodríguez-Silva et al. JPRAS 2025 Feb PMID: 39970748.* #### In this Journal Club [****5-Point Summary**](https://www.theplasticsfella.com/journal-sub-internships/#5-point-summary) Disparities in plastic surgery sub-internships have been highlighted using 2024–2025 VSLO and program data, focusing on IMGs, uUS-MSs, and hpUS-MSs. [****4-Key Findings**](https://www.theplasticsfella.com/journal-sub-internships/#4-key-findings) IMGs have 80% fewer sub-internship opportunities and pay 17 times more on average. Median 4.5-rotation costs are $9,114 for IMGs vs. $410 for hpUS-MSs, with statistically significant disparities (p < 0.001). [****3-Critiques**](https://www.theplasticsfella.com/journal-sub-internships/#3-critiques) Program listings may be incomplete or outdated, and excluding travel/visa costs understates true expenses. Findings rely on a single application cycle, limiting their broader applicability. [****2-Practical Takeaways** ](https://www.theplasticsfella.com/journal-sub-internships/#2-practical-takeaways) Capping or standardizing sub-internship fees could reduce financial barriers. Targeted financial aid would foster more equitable access for IMGs and uUS-MSs. [****1-Recommended Reading**](https://www.theplasticsfella.com/journal-sub-internships/#1-recommended-reading) Sergesketter et al. (2021) explores how sub-internships influence match success. This highlights the pressing need for improved and equitable sub-internship access. [Read the Full Article](https://bit.ly/jpras?ref=theplasticsfella.com) ✍️ ****Note from the Editor** Rodríguez-Silva **et al* effectively identify systemic challenges to plastic surgery pre-residency training programmes in the United States. They demonstrate the differences in accessibility for International Medical Graduates through the reduced number of available schemes and very high cost of these opportunities. The authors should be congratulated for shining a light on the inequities which are likely to hinder the best candidates from pursuing careers in plastic & reconstructive surgery in the US. Mr Adam Reid, Editor JPRAS --- ## 5 Point Summary This study explores disparities in access and financial burden of plastic surgery sub-internships for IMGs, uUS-MSs, and US medical students with home programs (hpUS-MSs). 1️⃣ ****Hypothesis** IMGs and uUS-MSs face greater barriers to sub-internships due to limited access and higher costs compared to hpUS-MSs. 2️⃣ ****Method** Data from the Visiting Student Learning Opportunities (VSLO) platform and institutional websites for the 2024-2025 academic year were analyzed to assess sub-internship availability and costs. Monte Carlo simulations estimated total expenses for an average of 4.5 rotations, with statistical tests (ANOVA and Tukey’s HSD) comparing groups. 3️⃣ ****Results** IMGs have access to only 20 programs (vs. 100 for US-MSs) and face average costs of $2062.05 per rotation (vs. $121.49 for US-MSs). Median total costs for 4.5 rotations are $9114 for IMGs, $530 for uUS-MSs, and $410 for hpUS-MSs. 4️⃣ ****Conclusion** Significant financial and systemic inequities disadvantage IMGs and uUS-MSs, potentially reducing their chances of matching into plastic surgery residency. 5️⃣ ****Implication** Addressing these disparities is vital to ensure equitable access to training and enhance diversity in the plastic surgery workforce. ## 4 Key Findings The study uncovers pronounced inequities in access and cost, with IMGs disproportionately affected. 1️⃣ ****Numbers** Only 20 programs offer sub-internships to IMGs, compared to 100 for US-MSs, an 80% reduction in opportunities. ![Number of programs offering PRS sub-internships](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Journal-Club-Images--4-.png) Number of programs offering PRS sub-internships 2️⃣ ****Cost** IMGs incur an average cost of $2062.05 per sub-internship, over 17 times higher than the $121.49 for US-MSs. ![Cost difference between groups](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Journal-Club-Images--9-.png) Cost difference between groups 3️⃣ ****Cost Estimations** Monte Carlo simulations estimate median total costs for 4.5 rotations at $9114 for IMGs (IQR: $6490–$11,997), $530 for uUS-MSs (IQR: $395–$681), and $410 for hpUS-MSs (IQR: $285–$544). ![Average cost of one PRS sub-internship](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Journal-Club-Images--6--1.png) Average cost of one PRS sub-internship 4️⃣ ****Burden** ANOVA and Tukey’s HSD tests confirm significant cost differences (p < 0.001), with IMGs facing the highest burden ($8812.51 more than hpUS-MSs; $8688.89 more than uUS-MSs). ![Simulated total cost of completing 4.5 plastic surgery sub-internships](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Journal-Club-Images--5--1.png) Simulated total cost of completing 4.5 plastic surgery sub-internships --- ## 3 Critiques While insightful, the study has limitations that warrant consideration. 1️⃣ ****Data Set** Reliance on VSLO and institutional websites may overlook some sub-internship opportunities not listed or updated. 2️⃣ ****Scholarships** Standardizing fees and expanding scholarships may reduce the $2062.05 vs. $121.49 cost disparity and improve equity for IMGs and uUS-MSs. 3️⃣ ****Expenses** Exclusion of personal expenses (e.g., travel, housing) and additional IMG-specific costs (e.g., visas, TOEFL, USMLE fees) underestimates the true financial burden. ![Key limitations of the study](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Journal-Club-Images--10-.png) Key limitations of the study --- ## 2 Practical Takeaways The findings highlight actionable steps to reduce barriers for IMGs and uUS-MSs. 1️⃣ ****Cap Costs** Institutions could cap or standardize costs to narrow the $2062.05 vs. $121.49 gap between IMGs and US-MSs. 2️⃣ ****Grants** Scholarships or grants specifically targeting IMGs and uUS-MSs could help offset the $9114 median cost, enhancing access. ![Simulated total cost of 4.5 PRS sub-internships](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Journal-Club-Images--7-.png) Simulated total cost of 4.5 PRS sub-internships ## 1 Recommended Reading Sergesketter et al.’s "The Association Between Away Rotations and Rank Order in the Integrated Plastic Surgery Match" (Plast Reconstr Surg, 2021) complements this study by demonstrating the critical role of sub-internships in residency matching, reinforcing the need to address access disparities. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/33973940/?ref=theplasticsfella.com) ### Total Body Surface Area Calculations in Burns URL: https://www.theplasticsfella.com/total-body-surface-area-in-burns/ Last updated: 2025-03-27T18:24:20.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#overview-of-tbsa-burn-calculations) Burn size, expressed as total body surface area (TBSA%), is a cornerstone of burn assessment — influencing decisions from triage to rehabilitation [****Lund and Browder Burn Chart**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#lund-and-browder-burn-chart) The Lund and Browder Chart is the gold standard for calculating burn surface area. It accounts for anatomical differences across age groups and provides the most accurate TBSA% estimate. [****Wallace Rule of Nines**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#wallace-rule-of-nines) The Wallace Rule of Nines estimates burn surface area by dividing the body into regions of 9%. While efficient and widely used, it lacks precision in pediatric and obese populations. [****Palmar Method**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#palmar-method) The Palmar Method estimates burn size using the patient’s palm as a reference point, making it a practical tool for assessing small or scattered burns. [****Mortality Score**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#mortality-score-in-burns-patients) Several scoring systems exist to predict burn mortality, but the revised Baux score is the most clinically reliable — incorporating age, TBSA%, and inhalation injury to assess prognosis. [****Special Considerations**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#special-considerations) While TBSA estimation methods are widely used, specific populations and burn types require individualized clinical consideration to ensure accurate assessment and appropriate management. ****Updated by:** Dr Waruguru Wanjau, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview of TBSA Burn Calculations ****Key Point** Burn size, expressed as total body surface area (TBSA%), is a cornerstone of burn assessment — influencing decisions from triage to rehabilitation The extent of a burn (particularly its size) directly impacts mortality, functional outcomes, and treatment strategy ([Pham](https://pubmed.ncbi.nlm.nih.gov/30247559/?ref=theplasticsfella.com), 2019). Three primary methods are used to estimate burn surface area. - **Lund & Browder Chart:** Age-adjusted for proportional differences in body surface area. - **Rule of Nines:** Simplified method of dividing the body into 9% regions. - **Palmar Method:** The patient's palm (including fingers) ≈ 1% TBSA, useful for small or patchy burns. Accurate estimation of burn TBSA is essential in modern burn care. However, variability between assessors can lead to overestimation and significant differences in measurements ([Chan](https://pubmed.ncbi.nlm.nih.gov/22487668/?ref=theplasticsfella.com), 2011). - **Fluid Resuscitation:** Guides volume calculations in the acute phase. - **Triage & Transfers:** Determines need for burn center referral. - **Nutritional and Metabolic Support:** Correlates with hypermetabolic demand. - **Length of Stay & Rehabilitation Planning:** Predicts care trajectory and intensity. This table provides an overview of the different methods for TBSA calculation. ![Different methods for TBSA calculation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template--9-.png) Different methods for TBSA calculation Modern tools like 3D imaging, mobile apps, and AI offer improved precision, but adoption is limited by cost, training gaps, and workflow integration ([Chong](https://pubmed.ncbi.nlm.nih.gov/31561927/?ref=theplasticsfella.com), 2020). As a result, most clinical settings still rely on manual methods, particularly in acute care. 💡 ****Tip:** Common burn assessment methods should be used cautiously in obese adult patients, with clinical parameters monitored even more closely ([Borhani- Khomani](https://pubmed.ncbi.nlm.nih.gov/28417654/?ref=theplasticsfella.com), 2017). --- ## Lund and Browder Burn Chart ****Key Point** The Lund and Browder Chart is the gold standard for calculating burn surface area. It accounts for anatomical differences across age groups and provides the most accurate TBSA% estimates for both adults and children. First introduced by Lund and Browder in 1944, this chart revolutionized burn assessment by dividing the body into 12 anatomical regions and incorporating an age-correction factor for pediatric patients ([Lund & Browder](https://scholar.google.com/scholar?cluster=4671664022958447735&hl=en&as%5Fsdt=0,5.&ref=theplasticsfella.com), 1994). Building on Samuel Berkow’s earlier formula and [Boyd’s](https://scholar.google.com/scholar%5Flookup?title=History%20of%20burns%3A%20the%20past%2C%20present%2C%20and%20the%20future&publication%5Fyear=2014&author=K.C.%20Lee&author=K.%20Joory&author=N.S.%20Moiemen&ref=theplasticsfella.com) 1935 data, it remains one of the most historically significant yet clinically relevant burn assessment tools. Today's updated version has expanded to 19 regions, providing greater precision ([Hampe](https://scholar.google.com/scholar%5Flookup?title=Impacting%20care%20and%20treatment%20of%20the%20burn%20patient%20conversion%20to%20electronic%20documentation&publication%5Fyear=2017&author=H.%20Hampe&author=T.%20Keeling&author=M.%20Fontana&author=D.%20Balcik&ref=theplasticsfella.com), 2017), and can be used in the following manner. - **Visual Mapping:** Providers outline burned areas on a printed diagram. - **Age-Based Reference:** Each region’s TBSA% is adjusted according to patient age, particularly in the **head, thighs, and legs** — the only regions that change with growth ([Hampe, ](https://scholar.google.com/scholar%5Flookup?title=Impacting%20care%20and%20treatment%20of%20the%20burn%20patient%20conversion%20to%20electronic%20documentation&publication%5Fyear=2017&author=H.%20Hampe&author=T.%20Keeling&author=M.%20Fontana&author=D.%20Balcik&ref=theplasticsfella.com)2017). - **Burn Depth Inclusion:** The chart distinguishes between **partial-thickness** and **full-thickness** burns. Superficial burns are excluded from TBSA% calculations. The image below illustrates the Lund and Browder chart used for calculating TBSA% in burns. ![Lund and Browder chart](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template--13-.png) Lund and Browder chart **Advantages** - **High Accuracy:** Considered more precise than Rule of Nines, especially in pediatric patients ([Wallace](https://scholar.google.com/scholar?q=Wallace%20AB.%20The%20exposure%20treatment%20of%20burns.%20Lancet.%201951%3BMar%203%3B1%286653%29%3A501-504.%20doi%3A10.1016%2Fs0140-6736%2851%2991975-7.&ref=theplasticsfella.com), 1951). - **Pediatric Adaptability:** Head is a larger percentage in infants; leg regions compensate proportionally. - **Standard in Practice:** Widely used in emergency departments and burn centers ([American Burn Association](https://ameriburn.org/education/advanced-burn-life-support-abls/?ref=theplasticsfella.com), 2020). - **Evidence-Based:** Based on BSA data applicable to 99.9% of the population ([Boyd](https://scholar.google.com/scholar%5Flookup?title=History%20of%20burns%3A%20the%20past%2C%20present%2C%20and%20the%20future&publication%5Fyear=2014&author=K.C.%20Lee&author=K.%20Joory&author=N.S.%20Moiemen&ref=theplasticsfella.com), 1935). **Limitations** - **Time-Intensive:** Slower to apply than simplified methods. - **Reference Dependent:** Requires printed chart and familiarity with scoring technique. - **Obesity Considerations:** Not designed to account for variations in body habitus seen in obese patients ([Tapking](https://scholar.google.com/scholar?q=Houschyar%20M%2C%20M.R.%20B%2C%20Tapking%20C%2C%20et%20al.%20Burns%3A%20modified%20metabolism%20and%20the%20nuances%20of%20nutrition%20therapy.%20J%20Wound%20Care.%202020%3B29%283%29doi%3Ahttps%3A%2F%2Fdoi.org%2F10.12968%2Fjowc.2020.29.3.184.&ref=theplasticsfella.com), 2019; [Neaman](https://scholar.google.com/scholar%5Flookup?title=A%20new%20method%20for%20estimation%20of%20involved%20BSAs%20for%20obese%20and%20normal-weight%20patients%20with%20burn%20injury&publication%5Fyear=2011&author=K.C.%20Neaman&author=L.A.%20Andres&author=A.M.%20McClure&author=M.E.%20Burton&author=P.R.%20Kemmeter&author=R.D.%20Ford&ref=theplasticsfella.com), 2011). - **Landmark Challenges:** Lateral burns are harder to assess due to a lack of anatomical guidance. - **Depth Judgement Required:** Accurate scoring depends on clinical expertise in assessing burn depth. 💡 ****Tip:** The Lund-Browder chart has recently been validated in the modern, more obese pediatric population ([Rumpf](https://pubmed.ncbi.nlm.nih.gov/29229139/?ref=theplasticsfella.com), 2018). --- ## Wallace Rule of Nines ****Key Point** The Wallace Rule of Nines estimates burn surface area by dividing the body into regions of 9%. While efficient and widely used, it lacks precision in pediatric and obese populations. The Rule of Nines, first described by Pulaski and Tennison in 1947 and popularized by [Wallace](https://pubmed.ncbi.nlm.nih.gov/14805109/?ref=theplasticsfella.com) in 1951, remains widely used for emergency burn assessment due to its speed, simplicity, and accuracy ([Tocco-Tussardi](https://pubmed.ncbi.nlm.nih.gov/28877135/?ref=theplasticsfella.com), 2018; [Cheah](https://pubmed.ncbi.nlm.nih.gov/29497619/?ref=theplasticsfella.com), 2018). It primarily functions as a rapid screening tool to estimate the extent of partial- and full-thickness burns quickly for initial treatment guidance. Key points include, - **Not Definitive:** After initial stabilization, clinicians should use more detailed methods, such as the Lund and Browder Chart, for comprehensive burn care planning ([Giretzlehner](https://scholar.google.com/scholar%5Flookup?title=The%20use%20of%20telemedicine%20in%20burn%20care%3A%20development%20of%20a%20mobile%20system%20for%20TBSA%20documentation%20and%20remote%20assessment&publication%5Fyear=2014&author=D.%20Parvizi&author=M.%20Giretzlehner&author=J.%20Dirnberger&ref=theplasticsfella.com), 2025). - **Effective in Mass Casualties and Prehospital Settings:** Valuable for rapid triage because it is easy to memorize and apply quickly ([Giretzlehner](https://scholar.google.com/scholar%5Flookup?title=The%20use%20of%20telemedicine%20in%20burn%20care%3A%20development%20of%20a%20mobile%20system%20for%20TBSA%20documentation%20and%20remote%20assessment&publication%5Fyear=2014&author=D.%20Parvizi&author=M.%20Giretzlehner&author=J.%20Dirnberger&ref=theplasticsfella.com), 2025). - **Excludes Superficial Burns:** Includes only partial- and full-thickness injuries, enhancing clinical accuracy and decision-making. The correct calculation of the Rule of 9's is visualised below. ![Calculating the total body surface area of a burn with Wallace Rule of Nines](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template--12-.png) Calculating TBSA with Wallace rule of nines **Advantages** - **Efficient:** Ideal for rapid estimation in high-pressure settings like field triage or emergency departments ([Wallace](https://pubmed.ncbi.nlm.nih.gov/14805109/?ref=theplasticsfella.com), 1951). - **Reduces Underestimation:** Tends to overestimate slightly, which is safer when calculating initial resuscitation needs ([Watchel](https://pubmed.ncbi.nlm.nih.gov/10716359/?ref=theplasticsfella.com), 2000). - **Minimal Training Required:** Quickly understood and applied by most healthcare providers. **Limitations** - **Lacks Precision in Key Populations:** Not recommended for children under 12 years due to inaccurate body proportion representation (Lee, 2025). - **Not Obesity-Adjusted:** Poorly reflects surface area distribution in obese or very muscular patients ([Tapking](https://scholar.google.com/scholar%5Flookup?title=A%20new%20method%20for%20estimation%20of%20involved%20BSAs%20for%20obese%20and%20normal-weight%20patients%20with%20burn%20injury&publication%5Fyear=2011&author=K.C.%20Neaman&author=L.A.%20Andres&author=A.M.%20McClure&author=M.E.%20Burton&author=P.R.%20Kemmeter&author=R.D.%20Ford&ref=theplasticsfella.com), 2019). - **Overestimation Risk:** Especially for smaller burns or when used by less experienced providers (Wachtel, 2000). 💡 ****Tip:** The "Rule of Eights" provides a more accurate TBSA burn estimation for infants weighing less than 10 kg, assigning approximately 32% to the trunk, 20% to the head, 16% to each leg, and 8% to each arm ([Moore](https://www.ncbi.nlm.nih.gov/books/NBK513287/?ref=theplasticsfella.com), 2024). --- ## Palmar Method ****Key Point** The Palmar Method estimates burn size using the patient’s palm as a reference point, making it a practical tool for assessing small or scattered burns. The Palmar Method is the **simplest and most accessible** way to estimate Total Body Surface Area (TBSA) in burn patients. It relies on the patient’s **own palm**, including digits, as a reference — typically representing about **1% of their TBSA**. This method is especially useful when burns are **irregularly distributed** or when other tools are unavailable. [NICE](http://cks.nice.org. uk/burns-and-scalds) guidelines recommend using the **palm, including digits** for estimating **small or patchy burns**. However, the exact percentage can vary based on body habitus, age, and whether digits are included. - **Palm + Digits ≈** 1% TBSA - **Palm only (no fingers) ≈** 0.5% TBSA **Advantages** - **Quick and Requires No Tools:** Useful in prehospital settings or when resources are limited ([Carrougher](https://www.sciencedirect.com/science/article/pii/S2468912224000014?ref=theplasticsfella.com), 2024). - **Ideal for Scattered or Localized Burns:** Offers flexibility when assessing non-contiguous burn areas. - **Simple for Patient Involvement:** Easy to explain and demonstrate for patient education. **Limitations** - **Not Accurate for Large Burns:** Accumulated errors increase as burn size increases. - **Subject to Variability:** Palm size differs between individuals, especially in children, making estimates less reliable ([Pham](https://pubmed.ncbi.nlm.nih.gov/30247559/?ref=theplasticsfella.com), 2019). - **No Burn Depth Consideration:** This method doesn’t distinguish between burn types (e.g., superficial vs full-thickness). --- ## Mortality Score in Burns Patients ****Key Point** Several scoring systems exist to predict burn mortality, but the revised Baux score is the most clinically reliable — incorporating age, TBSA%, and inhalation injury to assess prognosis. Mortality prediction tools help assess burn severity, guide treatment, and inform prognosis. Among various models (ABSI, Ryan, Smith, McGwin, BOBI, FLAMES, APACHE II), the Revised Baux Score and ABSI are most commonly used. Studies suggest the Revised Baux Score is more accurate and practical in contemporary burn care ([Halgas](https://pmc.ncbi.nlm.nih.gov/articles/PMC6199008/?ref=theplasticsfella.com), 2018; [Edgar](https://pubmed.ncbi.nlm.nih.gov/37220881/?ref=theplasticsfella.com), 2023; [Lip](https://pubmed.ncbi.nlm.nih.gov/31699024/?ref=theplasticsfella.com), 2018). **Revised Baux Score** Revised Baux Score = Age + TBSA (%) + 17 (if inhalation injury is present). This scoring system provides a rapid severity assessment, predicts mortality risk, and supports clinical decision-making. It uses three key clinical factors. - **Age:** Mortality risk increases with patient age. - **TBSA (%):** Greater burn surface area correlates with poorer outcomes. - **Inhalation Injury:** Airway involvement significantly elevates the mortality risk. Revised Baux score is summarised in the image below. ![Revised Baux score for TBSA](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template--8-.png) Revised Baux score for TBSA **Limitations** - **Oversimplified:** Does not account for comorbidities, frailty, or modern care improvements. - **Overestimation Risk:** May overpredict mortality in centers with advanced burn care. - **Less Accurate at Extremes:** Performance decreases in very young or very old patients ([Edgar](https://pubmed.ncbi.nlm.nih.gov/37220881/?ref=theplasticsfella.com), 2023). 💡 ****Tip:** The Baux equation has a diminished ability to predict mortality risk when applied to patients at both extremes of age ([Edgar](https://pubmed.ncbi.nlm.nih.gov/37220881/?ref=theplasticsfella.com), 2023). --- ## Special Considerations ****Key Point** While TBSA estimation methods are widely used, specific populations and burn types — such as pediatric, obese, circumferential, electrical, and chemical burns — require individualized clinical consideration to ensure accurate assessment and appropriate management. Standard burn estimation techniques like the Rule of Nines, Lund-Browder Chart, and Palmar Method are based on assumptions of average body proportions. However, factors such as **age, BMI, burn depth, and distribution** can significantly impact accuracy. ### Pediatric Patients - **Proportional Differences:** Children have proportionally **larger heads** and **smaller limbs**, impacting TBSA estimates ([Lund & Browder](https://scholar.google.com/scholar%5Flookup?title=The%20estimation%20of%20areas%20of%20burns&publication%5Fyear=1944&author=C.C.%20Lund&author=N.C.%20Browder&ref=theplasticsfella.com), 1944; [Meeh](https://scholar.google.com/scholar%5Flookup?title=Clinical%20calorimetry%3A%20the%20measurements%20of%20the%20surface%20of%20area%20of%20a%20man&publication%5Fyear=1915&author=D.%20DuBois&author=E.F.%20DuBois&ref=theplasticsfella.com), 1879; [Rumpf](https://scholar.google.com/scholar%5Flookup?title=Comparison%20of%20the%20Lund%20and%20Browder%20table%20to%20computed%20tomography%20scan%20three-dimmensional%20surface%20area%20measurement%20for%20a%20pediatric%20cohort&publication%5Fyear=2018&author=R.W.%20Rumpf&author=W.C.L.%20Stewart&author=S.K.%20Martinez&ref=theplasticsfella.com), 2018). - **Preferred Tools:** Use the **Lund-Browder chart** or **Pediatric Rule of Nines** — the latter assigns 18% to the head and 14% to each leg in infants ([American Burn Association](https://ameriburn.org/education/advanced-burn-life-support-abls/?ref=theplasticsfella.com), 2023). - **Common Pitfall:** Errors are often due to **incorrect application**, not the reference values themselves ([Rumpf](https://scholar.google.com/scholar%5Flookup?title=Comparison%20of%20the%20Lund%20and%20Browder%20table%20to%20computed%20tomography%20scan%20three-dimmensional%20surface%20area%20measurement%20for%20a%20pediatric%20cohort&publication%5Fyear=2018&author=R.W.%20Rumpf&author=W.C.L.%20Stewart&author=S.K.%20Martinez&ref=theplasticsfella.com), 2018). - **Educational Support:** Pediatric burn estimation is emphasized in global training programs like **ABLS**, **Interburns**, and **EMSB** ([Interburns](https://scholar.google.com/scholar?q=Interburns.%20Essential%20Burn%20Care%20%28EBC%29.%20Interburns.%20Accessed%2010-30-2023%2C%20https%3A%2F%2Finterburns.org%2Ftraining%2F%23training-education-banner.&ref=theplasticsfella.com), 2025; [ANZBA](https://scholar.google.com/scholar?q=Australian-and-New-Zealand-Burn-Association.%20Emergency%20Management%20of%20Severe%20Burns%20course%20manual%20%28v.%2019%29%20%28c%29.%202023.&ref=theplasticsfella.com), 2023). ### Obese and Morbidly Obese Patients - **Inaccurate Surface Area Distribution:** Higher BMI alters skin surface proportions — typically **underestimating trunk** and **overestimating limbs** ([Borhani- Khomani 2017](https://pubmed.ncbi.nlm.nih.gov/28417654/?ref=theplasticsfella.com); [Neaman](https://scholar.google.com/scholar%5Flookup?title=A%20new%20method%20for%20estimation%20of%20involved%20BSAs%20for%20obese%20and%20normal-weight%20patients%20with%20burn%20injury&publication%5Fyear=2011&author=K.C.%20Neaman&author=L.A.%20Andres&author=A.M.%20McClure&author=M.E.%20Burton&author=P.R.%20Kemmeter&author=R.D.%20Ford&ref=theplasticsfella.com), 2011). - **Proposed Adjustments:** Head: 5%, Arms: 15%, with trunk and leg proportions adjusted by BMI category ([Neaman](https://scholar.google.com/scholar%5Flookup?title=A%20new%20method%20for%20estimation%20of%20involved%20BSAs%20for%20obese%20and%20normal-weight%20patients%20with%20burn%20injury&publication%5Fyear=2011&author=K.C.%20Neaman&author=L.A.%20Andres&author=A.M.%20McClure&author=M.E.%20Burton&author=P.R.%20Kemmeter&author=R.D.%20Ford&ref=theplasticsfella.com), 2011). - **Alternate Systems:** The **Rule of Sevens**, developed by Williams and Wohlgemuth, proposes more accurate TBSA percentages for obese patients ([Williams](https://scholar.google.com/scholar%5Flookup?title=Risk%20factors%20for%20healthcare-associated%20infections%20in%20adult%20burn%20patients&publication%5Fyear=2017&author=P.D.%20Strassle&author=F.N.%20Williams&author=D.J.%20Weber&ref=theplasticsfella.com), 2013). - **Gender Considerations:** Burn size involving the **breasts** in women can be underestimated; bra cup size may need to be factored into anterior trunk TBSA estimates ([Hidvegi](https://scholar.google.com/scholar%5Flookup?title=Estimation%20of%20breast%20burn%20size&publication%5Fyear=2004&author=N.%20Hidvegi&author=C.%20Nduka&author=S.%20Myers&author=P.%20Dziewulski&ref=theplasticsfella.com), 2004). ### Circumferential Burns - **Extremities:** Risk of **compartment syndrome**, potentially requiring **escharotomy** to restore perfusion. - **Chest Involvement:** Can restrict ventilation, necessitating early airway management or chest wall escharotomy. - **Abdominal Burns:** May increase **intra-abdominal pressure**, leading to abdominal compartment syndrome and systemic compromise. ### Electrical Burns - **Injury Beyond the Surface:** Electrical injuries often cause **deep muscle and tissue necrosis**, not reflected in TBSA%. - **TBSA Misleading:** Surface appearance underestimates true injury severity — advanced imaging and cardiac monitoring are essential. - **Clinical Priority:** Early surgical evaluation and compartment pressure monitoring are often warranted. ### Chemical Burns - **Severity ≠ Size:** Unlike thermal burns, TBSA does **not correlate with severity** in chemical injuries. - **Assessment Factors:** Severity depends on **chemical type**, **concentration**, **contact time**, and **penetration depth**. - **Immediate Care Focus:** Rapid **decontamination** and **pH neutralization** take precedence over TBSA measurement. 😎 ****Fun Fact:** For extensive burns, calculating unburned areas and subtracting from 100% can improve accuracy — a technique taught in Interburns and EMSB courses ([Interburns](https://scholar.google.com/scholar?q=Interburns.%20Essential%20Burn%20Care%20%28EBC%29.%20Interburns.%20Accessed%2010-30-2023%2C%20https%3A%2F%2Finterburns.org%2Ftraining%2F%23training-education-banner.&ref=theplasticsfella.com), 2025; [ANZBA](https://scholar.google.com/scholar?q=Australian-and-New-Zealand-Burn-Association.%20Emergency%20Management%20of%20Severe%20Burns%20course%20manual%20%28v.%2019%29%20%28c%29.%202023.&ref=theplasticsfella.com), 2023). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** TBSA% is critical in burn care — influencing resuscitation, referrals, nutrition, and rehab planning. ****2\. Lund and Browder Chart:** Gold standard TBSA tool; adjusts for age-based anatomical differences, offering high accuracy. ****3\. Rule of Nines:** Quick and easy; divides the body into 9% segments but lacks precision in kids and obese patients. ****4.** ****Palmar Method:** Uses the patient’s palm (≈1% TBSA) for small, scattered burns — ideal when tools aren’t available. ****5\. Mortality Score (Revised Baux):** Adds age + TBSA + 17 (if inhalation injury) to predict burn mortality; simple but less accurate in extremes. ****6\. Special Considerations:** Children, obese patients, and electrical or chemical burns require tailored TBSA assessment strategies. --- ## Further Reading 1. Miller S, Bessey P, Schurr M, et al. National Burn Repository 2005: a ten-year review. *J Burn Care Res*. 2006;27(4):411-436\. doi:[10.1097/01.BCR.0000226260.17523.22](https://doi.org/10.1097/01.BCR.0000226260.17523.22?ref=theplasticsfella.com) 2. Chan QE, Barzi F, Cheney L, Harvey JG, Holland AJ. Burn size estimation in children: Still a problem. *Emergency Medicine Australasia*. November 2011:181-186\. doi:[10.1111/j.1742-6723.2011.01511.x](https://doi.org/10.1111/j.1742-6723.2011.01511.x?ref=theplasticsfella.com) 3. Lund C, Browder NC. The estimation of areas of burns. *Surg Gynecol Obstet* . 1944:79:352–8\. [https://scholar.google.com/scholar?cluster=4671664022958447735&hl=en&as\_sdt=0,5](https://scholar.google.com/scholar?cluster=4671664022958447735&hl=en&as%5Fsdt=0,5&ref=theplasticsfella.com). 4. Wachtel TL, Berry CC, Wachtel EE, Frank HA. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. *Burns*. March 2000:156-170\. doi:[10.1016/s0305-4179(99)00047-9](https://doi.org/10.1016/s0305-4179%2899%2900047-9?ref=theplasticsfella.com) 5. WALLACE A. The exposure treatment of burns. *Lancet*. 1951;1(6653):501-504\. doi:[10.1016/s0140-6736(51)91975-7](https://doi.org/10.1016/s0140-6736%2851%2991975-7?ref=theplasticsfella.com) 6. Tocco-Tussardi I, Presman B, Huss F. Want Correct Percentage of TBSA Burned? Let a Layman Do the Assessment. *J Burn Care Res*. 2018;39(2):295-301\. doi:[10.1097/BCR.0000000000000613](https://doi.org/10.1097/BCR.0000000000000613?ref=theplasticsfella.com) 7. Cheah A, Kangkorn T, Tan E, Loo M, Chong S. The validation study on a three-dimensional burn estimation smart-phone application: accurate, free and fast? *Burns Trauma*. 2018;6:7\. doi:[10.1186/s41038-018-0109-0](https://doi.org/10.1186/s41038-018-0109-0?ref=theplasticsfella.com) 8. Moore R, Waheed A, Burns B. statpearls. February 2024\. [http://www.ncbi.nlm.nih.gov/books/NBK513287/](http://www.ncbi.nlm.nih.gov/books/NBK513287/?ref=theplasticsfella.com). 9. Jose RM, Roy DK, Vidyadharan R, Erdmann M. Burns area estimation—an error perpetuated. *Burns*. August 2004:481-482\. doi:[10.1016/j.burns.2004.01.019](https://doi.org/10.1016/j.burns.2004.01.019?ref=theplasticsfella.com) 10. Kamolz L, Lumenta D, Parvizi D, et al. Smartphones and burn size estimation: “Rapid Burn Assessor”. *Ann Burns Fire Disasters*. 2014;27(2):101-104\. [https://www.ncbi.nlm.nih.gov/pubmed/26170784](https://www.ncbi.nlm.nih.gov/pubmed/26170784?ref=theplasticsfella.com). 11. [Pham C,](https://pubmed.ncbi.nlm.nih.gov/30247559/?ref=theplasticsfella.com) Collier Z, Gillenwater J. Changing the Way We Think About Burn Size Estimation. J Burn Care Res. 2019 Jan 1;40(1):1-11\. doi: 10.1093/jbcr/iry050\. PMID: 30247559. 12. [Rumpf RW](https://pubmed.ncbi.nlm.nih.gov/29229139/?ref=theplasticsfella.com), Stewart WCL, Martinez SK, Gerrard CY, Adolphi NL, Thakkar R, Coleman A, Rajab A, Ray WC, Fabia R. Comparison of the Lund and Browder table to computed tomography scan three-dimensional surface area measurement for a pediatric cohort. J Surg Res. 2018 Jan;221:275-284\. doi: 10.1016/j.jss.2017.08.019\. Epub 2017 Oct 5\. PMID: 29229139. 13. [Borhani-Khomani K](https://pubmed.ncbi.nlm.nih.gov/28417654/?ref=theplasticsfella.com), Partoft S, Holmgaard R. Assessment of burn size in obese adults; a literature review. J Plast Surg Hand Surg. 2017 Dec;51(6):375-380\. doi: 10.1080/2000656X.2017.1310732\. Epub 2017 Apr 18\. PMID: 28417654. 14. [Chong HP](https://pubmed.ncbi.nlm.nih.gov/31561927/?ref=theplasticsfella.com), Quinn L, Jeeves A, Cooksey R, Lodge M, Carney B, Molony D. A comparison study of methods for estimation of a burn surface area: Lund and Browder, e-burn and Mersey Burns. Burns. 2020 Mar;46(2):483-489\. doi: 10.1016/j.burns.2019.08.014\. Epub 2019 Sep 24\. PMID: 31561927. 15. [Edgar MC](https://pubmed.ncbi.nlm.nih.gov/37220881/?ref=theplasticsfella.com), Bond SM, Jiang SH, Scharf IM, Bejarano G, Vrouwe SQ. The Revised Baux Score as a Predictor of Burn Mortality: A Systematic Review and Meta-Analysis. J Burn Care Res. 2023 Nov 2;44(6):1278-1288\. doi: 10.1093/jbcr/irad075\. PMID: 37220881. 16. [Halgas B](https://pmc.ncbi.nlm.nih.gov/articles/PMC6199008/?ref=theplasticsfella.com), Bay C, Foster K. A comparison of injury scoring systems in predicting burn mortality. Ann Burns Fire Disasters. 2018 Jun 30;31(2):89-93\. PMID: 30374258; PMCID: PMC6199008. 17. [Lip](https://pubmed.ncbi.nlm.nih.gov/31699024/?ref=theplasticsfella.com) HTC, Idris MAM, Imran FH, Azmah TN, Huei TJ, Thomas M. Predictors of mortality and validation of burn mortality prognostic scores in a Malaysian burns intensive care unit. BMC Emerg Med. 2019 Nov 7;19(1):66\. doi: 10.1186/s12873-019-0284-8\. PMID: 31699024; PMCID: PMC6839226. 18. [Carrougher](https://www.sciencedirect.com/science/article/pii/S2468912224000014?ref=theplasticsfella.com), G.J. and Pham, T.N., 2024\. Burn size estimation: A remarkable history with clinical practice implications. *Burns Open*, *8*(2), pp.47-52. ### "The Match", 6 Fat Grafting Tips, & New Events Database URL: https://www.theplasticsfella.com/march-23rd/ Last updated: 2025-03-24T12:24:35.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/march-23rd/#a-letter-from-pfella) The match reality: When great candidates go unmatched. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/march-23rd/#the-sunday-quiz) New rules this round! 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/march-23rd/#image-of-the-week) Dupuytren's disease: Clinical image. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-23rd/#technique-tip) How to optimise fat graft retention. 5. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/march-23rd/#upcoming-events) A curated list of webinars, courses, & conferences 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/march-23rd/#what-does-the-evidence-say) What is the true retention rate of fat grafts? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-23rd/#articles-of-the-week) Trends in plastic surgery match, how many publications do you need to match?, & is plastic surgery the most competitive specialty?: with 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/march-23rd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Match Reality: When Great Candidates Go Unmatched* 👋 ****Hey Team!** Let’s be clear — the residency 'Match' isn't perfect. Every year, genuinely talented medical graduates face the harsh reality: "You did not match." It's brutal, heartbreaking, and damaging to plastic surgery. **The Ugly Truth** We've unintentionally created an arms race — students padding CVs with abstracts, posters, and superficial metrics. Nearly half (**46.9%**) match within their medical school’s geographic region, underscoring the powerful role of networking over objective metrics. The independent plastic surgery match is even tougher. Between 2019 and 2022, match rates fell dramatically — from **82% to 56%** — while the number of applicants soared (**up 42.3%**). Even strong applicants face harsh odds, with successful matches linked to having more than eight interviews, USMLE scores above 230, and exceptional ABSITE scores. **Collateral Damage** Missing the Match isn't just disappointing — it's devastating. Careers stall, confidence crumbles, and talented future surgeons are left questioning their worth, simply because they didn't navigate an inherently challenging system. **Turning the Tables** We must do better. Unmatched candidates deserve meaningful clinical fellowships, structured mentorship, and honest feedback. It's time to prioritize true clinical potential over arbitrary metrics. If you have opportunities or programs specifically for unmatched candidates, please connect with us below 👇 Let's support our community, P’Fella ❤️ ## The Sunday Quiz **New Rules This Week!* ****Are you ready to make it to the leaderboard?** Welcome to ****a fresh round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. --- ## Image of the Week **Clinical Presentation of Dupuytren's Disease* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week’s image showcases ****Dupuytren’s disease**, a fibroproliferative disorder of the palmar fascia leading to progressive digital contractures. Characterized by nodular thickening and cord formation, it most commonly affects the ****ring and little fingers**. Advanced stages may limit hand function, necessitating surgical intervention. Learn more about [Dupuytren’s disease](https://www.theplasticsfella.com/dupuytrens-disease/) and its treatment options. ![Presentation of Dupuytren’s disease](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/AI-generated-image--19--1.png) Presentation of Dupuytren’s disease ## Technique Tip **How to Optimise Fat Graft Retention* 🚑 ****Technique Tip of the Week** This week, we’re focusing on maximising fat graft viability during harvesting. Here are some key considerations for optimal graft survival. ****\- Donor Site:** No significant difference across common donor areas. ****\- Infiltration:** **Wet* technique improves adipocyte viability. ****\- Local Anesthetic:** **Bupivacaine* has the highest cell viability. ****\- Harvesting Technique:** **Coleman technique* ensures better adipocyte retention. \- ****Cannula Selection:** **Large bore cannulas* reduce cellular damage. \- ****Suction Speed:** **Constant and slow* suction minimizes trauma. Find detailed insights on fat grafting techniques in the table below. ![Tips on how to maximise fat graft retention and viability during the harvesting process](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/image-6.png) Tips on how to maximise fat graft retention and viability during the harvesting process ## Upcoming Events **A Curated List of Webinars, Courses, & Conferences* 📣 P’Fella spotlights impactful events, high-yield webinars, and hand-picked courses we know you'll love. If there’s a new feature or update, you’ll hear about it here first. We continuously update our event page with fresh additions — both hand-picked by our team and suggested by you. --- ## What Does the Evidence Say? **What Is the True Retention Rate of Fat Grafts?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Autologous fat grafting** is widely used for soft tissue augmentation, but its main drawback is the ****variable resorption rate**, ranging from ****20% to 90%** (Sforza et al., 2016; Ho Quoc et al., 2015; Kim et al., 2014). Studies have reported average resorption rates of 27.5% (Sforza et al., 2016), 21.5% (Ho Quoc et al., 2015), and 32.9% (Kim et al., 2014). To improve fat graft survival, ****cell-assisted lipotransfer (CAL)** was developed, which involves injecting fat along with adipose-derived stromal cells (Laloze et al., 2018). Meta-analyses have shown that CAL significantly ****improves fat graft survival** rates compared to conventional fat grafting (64% vs. 44%) (Laloze et al., 2018; Zhou et al., 2016). However, CAL is associated with a higher incidence of ****complications** (8.4% vs. 1.5%) (Laloze et al., 2018). Factors affecting fat graft survival include ****obesity phenotypes**, ****low-grade inflammation markers**, and ****injection volume** (Gentile et al., 2016; Laloze et al., 2018). Further research is needed to establish standardized protocols (Doornaert et al., 2018). ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Independent Plastic Surgery Match Trends and Predictors** ([Amro](https://journals.lww.com/prsgo/fulltext/2024/08000/an%5Fupdate%5Fon%5Fthe%5Findependent%5Fplastic%5Fsurgery%5Fmatch.13.aspx?ref=theplasticsfella.com), 2024) From 2019–2022, independent plastic surgery match success correlated with ≥8 interviews, US allopathic degrees, university-based training, Step 1 >230, and high PGY1–3 ABSITE scores, despite fewer programs and rising applicants. ✅ ****Manuscript Counts as a Research Output Measure in the Integrated Plastics Match** ([Ward](https://www.jprasurg.com/article/S1748-6815%2820%2930020-6/abstract?ref=theplasticsfella.com), 2020) Since manuscript publications may hold more weight than total research items in the integrated plastics match, actual publication counts offer a more meaningful metric of applicant competitiveness. ✅ ****Is Integrated Plastics Really the Most Competitive Match?** ([Asserson](https://www.journalofsurgicalresearch.com/article/S0022-4804%2822%2900205-0/abstract?ref=theplasticsfella.com), 2022) From 2016–2020, integrated plastic surgery had the highest USMLE scores and among the highest research outputs, yet offered limited residency positions, confirming its status as one of the most competitive specialties. ## Feedback ### I hope you enjoyed it 😄 --- ### Burns: Initial Assessment and Management URL: https://www.theplasticsfella.com/burns-initial-assessment-and-management/ Last updated: 2025-03-20T20:27:25.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/burns-initial-assessment-and-management/#overview-of-initial-burn-management) Burn management requires systematic assessment, timely intervention, and specialized care to prevent complications and optimize recovery. [****Pathophysiology**](https://www.theplasticsfella.com/burns-initial-assessment-and-management/#pathophysiology-of-burns) Burn injuries trigger a cascade of physiological responses that unfold in a predictable timeline, progressing from acute inflammatory changes to hypermetabolism, multi-organ dysfunction, and long-term systemic effects. [****Clinical Assessment**](https://www.theplasticsfella.com/burns-initial-assessment-and-management/#clinical-assessment-of-burns) The clinical presentation of a burn is determined by its depth, which affects skin color, blister formation, capillary refill, and sensation. [****Initial ABCDE Trauma Assessment**](https://www.theplasticsfella.com/burns-initial-assessment-and-management/#initial-abcde-trauma-assessment-for-burns) The initial management of burns focuses on early trauma assessment, wound care, supportive measures, and identifying cases requiring surgical intervention or burn center referral. [****Surgery**](https://www.theplasticsfella.com/burns-initial-assessment-and-management/#surgery-for-burns-management) Surgical intervention in burns is essential to remove necrotic tissue, restore skin integrity, and prevent complications such as ischaemia, contractures, and compartment syndrome. [****Referral to a Burn Centre**](https://www.theplasticsfella.com/burns-initial-assessment-and-management/#referral-to-a-burn-centre) Patients with large burns, specialized area involvement, inhalation injuries, or co-morbid conditions require specialized burn care for better outcomes. [****Management of Burn Types**](https://www.theplasticsfella.com/burns-initial-assessment-and-management/#management-of-burn-types) Certain burn types — chemical, electrical, and inhalation burns — have unique pathophysiological effects and require specialized management beyond standard thermal burn care. [****Complications**](https://www.theplasticsfella.com/burns-initial-assessment-and-management/#complications-of-burns) Burn complications can be acute (life-threatening) or chronic (long-term functional and psychological impacts). ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview of Initial Burn Management ****Key Point** Burn management requires systematic assessment, timely intervention, and specialized care to prevent complications and optimize recovery. Effective burn care follows a structured approach that includes trauma assessment, wound evaluation, surgical intervention, and long-term rehabilitation. The severity of a burn is determined by depth, total body surface area (TBSA), and associated injuries, guiding treatment decisions. **Initial Assessment & Management** - **ABCDE Approach:** Airway protection, fluid resuscitation, and hypothermia prevention are priorities in early burn care. - **TBSA & Depth Classification:** Burn severity dictates resuscitation needs and determines the necessity for surgical management. - **Early Cooling & Wound Care:** Cooling the burn (without ice) within the first 3 hours minimizes tissue damage, while early dressing and tetanus prophylaxis prevent infection. **Specialized Burns & Surgical Considerations** - **Chemical, Electrical, & Inhalation Burns:** Each requires a tailored approach, including irrigation, cardiac monitoring, or airway protection. - **Surgical Management:** Early excision, grafting, and escharotomy prevent infection, restore function, and relieve compartment pressure in severe burn --- ## Pathophysiology of Burns ****Key Point** Burn injuries trigger a cascade of physiological responses that unfold in a predictable timeline, progressing from acute inflammatory changes to hypermetabolism, multi-organ dysfunction, and long-term systemic effects. Burn injuries trigger complex immune, metabolic, and circulatory responses driven by inflammation and hormonal shifts, causing burn shock, hypermetabolism, and multi-organ dysfunction through **immediate**, **acute**, and **long-term** phases. ### Immediate Phase The **first 24 hours** after a burn are critical, as they set the stage for fluid shifts, inflammatory activation, and circulatory instability. **Inflammatory Response** This response begins immediately after injury, peaks within the first 24 hours, and can persist for months. Initial cytokine release (TNF-α, IL-1, IL-6) increases vessel permeability, reduces T-cell activation, and induces hypermetabolism ([Chung](https://shop.lww.com/Grabb-and-Smith-s-Plastic-Surgery--Print---eBook-with-Multimedia/p/9781975214265?ref=theplasticsfella.com), 2024). - **Increased Vascular Permeability:** Fluid shifts, oedema, & hypovolaemia. - **Reduced T-cell Activation:** Immune suppression - **Hypermetabolic State:** Increased energy demands and tissue breakdown​. **Burn Shock & Circulatory Changes** Burn shock is due to capillary leak syndrome, resulting in hypovolemia, tissue hypoxia, and cardiac dysfunction. - **Increased Vascular Permeability:** Plasma leakage, leading to third spacing - **Loss of Oncotic Pressure:** Decreased intravascular volume - **Myocardial Depression:** Decreased cardiac output despite normal or increased preload 💡 ****Tip:** ****Fluid resuscitation** is essential to restore ****vascular volume** and prevent ****multi-organ failure**. ### Acute Phase This phase is dominated by hypermetabolism and immune suppression, with continued tissue injury progression, and occurs \~24 Hours – 7 days post-burn. **Hypermetabolic Response** The hypermetabolic response peaks around 5–7 days post-burn, following an initial decrease in metabolic rate during the first 48 hours. It plateaus around day 5 and can persist from one to three years in severe cases([Jeshke](https://pubmed.ncbi.nlm.nih.gov/18791359/?ref=theplasticsfella.com), 2008). - **Increased Basal Metabolic Rate (BMR):** 2-3× normal energy expenditure. - **Hyperdynamic Circulation:** Increased heart rate, cardiac output, and oxygen consumption. - **Protein Catabolism:** Muscle wasting. - **Fat lipolysis and Glycogenolysis:** Insulin resistance and hyperglycemia. **Multi-Organ Dysfunction (MODS)** If inflammatory mediators persist, burn patients may develop organ failure ([Haruta](https://pubmed.ncbi.nlm.nih.gov/37806692/?ref=theplasticsfella.com), 2023). - **Heart:** Burn-induced myocardial depression, hypovolemia, and tachycardia. - **Lungs:** Acute lung injury & acute respiratory distress syndrome from cytokine-mediated inflammation. - **Renal:** Acute kidney injury due to hypoperfusion and myoglobinuria (in electrical burns). - **GI:** Ileus and stress ulcers (Curling’s ulcers) due to ischemia and inflammation. - **Immune**: Increased susceptibility to sepsis due to T-cell suppression and compromised barrier function​. 💡 ****Tip:** Aggressive nutritional support with high-protein, high-calorie feeding is critical to prevent muscle wasting and immune dysfunction. ### Chronic Phase Over time, the focus shifts to healing and managing long-term complications, notably chronic hypermetabolism and muscle wasting, which can persist for months to years. More specifically, - **Severe catabolism** continues, requiring ongoing **rehabilitation** and **nutrition** support. - **Scarring & contractures** develop, affecting mobility. - Persistent **insulin resistance** increases the risk of **diabetes & metabolic dysfunction**. 💡 ****Tip:** Long-term rehabilitation & physical therapy to restore function and prevent complications. --- ## Clinical Assessment of Burns ****Key Point** The clinical presentation of a burn is determined by its ****depth**, which affects skin color, blister formation, capillary refill, and sensation. ### History A structured history is essential for evaluating burn severity, systemic impact, and complications. The following **five** key questions help guide assessment. 1. **Time of Burn** Time elapsed since injury influences treatment urgency—delayed presentation increases the risk of infection and complications. 1. **Duration of Exposure** Longer exposure = deeper burns, particularly for flame, electrical, and chemical burns. 1. **First Aid & Initial Management at Scene** Running cool water (not ice) within 20 minutes of injury reduces burn severity. If transferred from another hospital, clearly note when fluid resuscitation started. 1. **Type of Burn** Different burn types have unique characteristics that influence depth and complications. For example, - **Scald Burns:** Temperature, viscosity (e.g., milk retains heat longer), and solutes (e.g., sugar/salt raise boiling point). - **Flame Burns:** Longer exposure & enclosed spaces (inhalation injury risk). - **Chemical Burns:** Acids cause coagulative necrosis (protective eschar limits penetration); alkalis cause deeper liquefactive necrosis. - **Electrical Burns:** Voltage (high-voltage penetrates deeper, risk of arrhythmias), contact duration (increases muscle necrosis). - **Contact Burns:** Prolonged contact typically leads to full-thickness burns. 1. **Additional Medical Considerations** Other important factors, as per the AMPLE approach, include ([Schafer](https://www.ncbi.nlm.nih.gov/books/NBK430795/?ref=theplasticsfella.com), 2023), - **A**llergies: Identify reactions to medications or dressings. - **M**edications: Consider drugs that impair healing (e.g., steroids, anticoagulants, immunosuppressants). - **P**ast Medical history: Diabetes, vascular disease, or immunosuppression delay healing. - **L**ast Oral Intake: Relevant for fluid resuscitation and surgical planning. - **E**vents: As discussed above. 💡 ****Tip:** Voice changes may indicate inhalation injury, confusion suggests secondary trauma, and delayed presentation raises suspicion of non-accidental injury. ### Examination A thorough **clinical examination** focuses on **burn depth, total body surface area (TBSA) estimation,** and **associated injuries** to guide management. **Burn Depth Assessment** Burns are classified based on **appearance, sensation,** and **capillary refill**. - [**Superficial**](https://www.theplasticsfella.com/burn-depth/#superficial-burn-depth-1st-degree-burns)**:** Red, painful, blanches, no blisters. - [**Superficial Partial-Thickness**](https://www.theplasticsfella.com/burn-depth/#partial-thickness-burn-depth-2nd-degree-burns)**:** Pink, moist, blisters, brisk capillary refill. - [**Deep Partial-Thickness**](https://www.theplasticsfella.com/burn-depth/#partial-thickness-burn-depth-2nd-degree-burns)**:** Pale, sluggish refill, reduced sensation. - [**Full-Thickness**](https://www.theplasticsfella.com/burn-depth/#full-thickness-burn-depth-3rd-degree-burns)**:** White/leathery, no pain, no capillary refill. The table below highlights key burn depth characteristics ([RCHM](https://www.rch.org.au/clinicalguide/guideline%5Findex/burns/?ref=theplasticsfella.com), 2020). For detailed guidance, refer to our article on [Burn Depth Assessment](https://www.theplasticsfella.com/burn-depth/). ![Key characteristics of different burn depths, managing burns](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T214903.459.png) Key characteristics of different burn depths **TBSA Estimation** Accurate **TBSA calculation** determines **fluid resuscitation needs**. - [**Rule of Nines**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#wallace-rule-of-nines) – Quick adult estimation. - [**Lund & Browder Chart**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#lund-and-browder-chart) – More precise, especially for children. - [**Palm Method**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/#palmar-method) – Patient’s palm = \~1% TBSA, useful for small burns. For comprehensive guidance on calculating Total Body Surface Area (TBSA), see our detailed article on [**TBSA Calculation**](https://www.theplasticsfella.com/total-body-surface-area-in-burns/). ![Rule of nines for estimating TBSA, burn management](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template--3--1.png) Rule of nines for estimating TBSA **Associated Injuries** - [**Smoke Inhalation**](https://www.theplasticsfella.com/inhalation-injury/)**:** Signs include singed nasal hair, soot around the mouth, voice changes, or respiratory distress, indicating high risk of airway injury. - **Associated Trauma:** Look for blunt or blast injuries, such as fractures, traumatic brain injury, or internal bleeding, common in explosions, falls, or motor vehicle accidents. - **Non-Accidental Injury (NAI):** Suspect abuse with glove-and-stocking burn patterns (clear immersion lines), delayed presentation, or inconsistent injury history. 💡 ****Tip:** Patients’ smoking habits should be documented, as they may affect blood gas analysis and increase the risk of inhalation injury ([Hettiaratchy](https://pmc.ncbi.nlm.nih.gov/articles/PMC437156/?ref=theplasticsfella.com), 2004). ### Investigations Investigations are guided by burn type, severity, and systemic involvement, helping to detect shock, inhalation injury, organ dysfunction, or associated trauma. **Routine Blood Tests** - **Full Blood Count:** Monitors hemoconcentration (early) and infection risk (later). - **Urea & Electrolytes (U&Es):** Assesses fluid balance, renal function, and electrolyte disturbances. - **Coagulation Screen & Lactate:** Important in severe burns and shock states. - **Arterial Blood Gas (ABG) & Carboxyhemoglobin:** Essential for inhalation injury, carbon monoxide poisoning, and metabolic acidosis. **Specialised Tests** - **Inhalation Injury:** Carboxyhemoglobin, ABG, Chest X-ray (CXR). - **Electrical Burns:** ECG, Creatine Kinase (CK), Myoglobin (rhabdomyolysis risk). - **Chemical Burns:** Serum pH, toxin screening for systemic absorption. **Imaging** Additional imaging is required if **associated injuries** are suspected. - **Chest X-Ray (CXR):** If **inhalation injury or blast trauma** is suspected. - **Pelvic X-Ray:** For **falls, blast injuries, or suspected fractures**. These investigations for burns patients are summarised below. ![Specific investigations for each burn type](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T215223.229.png) Specific investigations for each burn type --- ## Initial ABCDE Trauma Assessment for Burns ****Key Point** The initial management of burns focuses on early trauma assessment, wound care, supportive measures, and identifying cases requiring surgical intervention or burn center referral. Burn patients should be assessed systematically using the ABCDE framework, as many have airway compromise, inhalation injuries, or associated trauma. ### A. Airway Early airway management is **critical** as inhalation injuries can cause rapid airway swelling. - **Assess for voice changes, soot in the mouth, or singed nasal hair**, which suggest inhalation injury. - Secure the airway early with **endotracheal intubation** or **tracheostomy** if needed. ### B. Breathing Circumferential burns of the chest and inhalation injuries can cause **respiratory distress**. - **Assess breath sounds, respiratory rate, and effort** to detect restrictive burns or inhalation injury. - **Administer 100% oxygen** if carbon monoxide poisoning is suspected (carboxyhemoglobin >10%). ### C. Circulation Burns cause **fluid loss and systemic shock**, requiring early IV fluid resuscitation. - **Check Peripheral Circulation:** Deep/full-thickness circumferential extremity burns can act as tourniquets, worsening edema and impairing perfusion ([Hettiaratchy](https://pmc.ncbi.nlm.nih.gov/articles/PMC437156/?ref=theplasticsfella.com), 2004). - **Establish Two Large-Bore IV Lines** Start goal-directed resuscitation ([Parkland Formula](https://www.theplasticsfella.com/burns-fluid-resuscitation/#formulas-for-burn-resuscitation): 2–4 mL/kg/%TBSA in 24 hrs—half within first 8 hrs, remainder over next 16 hrs); use warmed IV fluids and maintain a warm environment. - **Monitor Urine Output** via urinary catheter: **Target:** adults 0.5–1 mL/kg/hr, children 1–2 mL/kg/hr, electrical burns 1.5–2 mL/kg/hr; adjust fluids by ±10–20% to maintain targets (RCHM, 2020). ([RCHM](https://www.rch.org.au/clinicalguide/guideline%5Findex/burns/?ref=theplasticsfella.com), 2020). The image below breaks down the Parkland and modified Brooke formula for burns. ![Parkland formula and modified Brooke formula for burns](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Template--4-.png) Parkland formula and modified Brooke formula for burns ### D. Disability Assess neurological status promptly to identify potential secondary complications or underlying conditions: - **Glasgow Coma Scale (GCS):** Low scores may indicate traumatic brain injury (TBI), hypoxia, intoxication, or pre-existing neurological conditions. - **Early Shock Considerations:** Severe hypovolemia is unusual immediately after burns; consider alternative causes such as hemorrhage or cardiogenic dysfunction ([Hettiaratchy](https://pmc.ncbi.nlm.nih.gov/articles/PMC437156/?ref=theplasticsfella.com), 2004). 💡 ****Tip:** Burn patients normally exhibit a hyperadrenergic state (HR 100–120 bpm); higher rates suggest hypovolemia, inadequate analgesia, or additional trauma ([ISBI](https://pubmed.ncbi.nlm.nih.gov/27542292/?ref=theplasticsfella.com) 2016). ### E. Exposure & Hypothermia Prevention Fully expose and carefully log-roll the patient to inspect all injuries thoroughly. After examination, prevent hypothermia by promptly, - **Total Body Surface Area (TBSA) Estimation:** Expose the whole body and log-roll the patient to assess the posterior surfaces. Superficial burns should not be included in the TBSA calculation. - **Cooling** **Burns:** Running cool water (20 minutes, ideally within 3 hours post-burn - [RCHM](https://www.rch.org.au/clinicalguide/guideline%5Findex/burns/?ref=theplasticsfella.com), 2020), removing wet clothing and dressings immediately afterward. - **Initial Wound Care:** Cleaning, removal of nonviable tissue, and appropriate dressings to optimize healing.Remove loose, necrotic skin through mechanical debridement (tangential excision), gentle scrubbing, or intraoperative irrigation - **Dressings:** For superficial partial-thickness burns, occlusive dressings are preferred to maintain moisture. For deeper burns, closed dressings are standard; if early excision is delayed, use open dressings, or moist dressings if heat-preserving options are unavailable (ISBI, 2016). ### Additional Early Treatments - **Feeding:** Start early enteral feeding promptly (oral or nasogastric) to reduce ulcers and muscle loss; nasogastric feeding is preferred if gastrointestinal function is intact ([Schafer](https://www.ncbi.nlm.nih.gov/books/NBK430741/?ref=theplasticsfella.com), 2023). - **Tetanus Prophylaxis:** Burn wounds are tetanus-prone. If vaccination status is uncertain or incomplete, administer **Tetanus toxoid** if the patient is inadequately vaccinated.**Tetanus immunoglobulin** in non-immunized individuals ([ISBI](https://pubmed.ncbi.nlm.nih.gov/27542292/?ref=theplasticsfella.com) 2016). - **Medication:** Medication to address analgesia, pruritus, and burn supplementation should be prescribed for burn patients. See the table below for examples of drugs. ![Medication to address analgesia, pruritus, and burn supplementation in burn care](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T215813.437.png) Medication to address analgesia, pruritus, and burn supplementation in burn care --- ## Surgery for Burns Management ****Key Point** Surgical intervention in burns is essential to remove necrotic tissue, restore skin integrity, and prevent complications such as ischaemia, contractures, and compartment syndrome. The need for burn surgery is guided by extent, depth, location of burns, and patient condition. The goal is to remove non-viable tissue, promote healing, and prevent complications. The approach includes early excision, grafting, and escharotomy when indicated. ### Timing of Excision Surgical excision of necrotic tissue is performed based on patient status and wound progression. - **Early Excision (≤10 days):** The standard of care when feasible, removing eschar before infection or spontaneous sloughing ([ISBI](https://pubmed.ncbi.nlm.nih.gov/27542292/?ref=theplasticsfella.com), 2016). - **Delayed Excision (10–21 days):** Used when partial spontaneous healing is expected, with eventual removal of necrotic tissue. - **Late Grafting:** Performed after granulation tissue formation, requiring debridement of slough before coverage. - **Staged** **Burn Excision:** Manage option for extensive injuries in multiple sessions. ### Depth of Excision Excision strategies vary depending on burn severity and location. - **Tangential Excision:** Sequential removal of necrotic layers, preserving viable tissue; ideal for high-voltage electrical burns or deep burns. - **Fascial Excision:** Full-thickness removal down to deep fascia, used for extensive burns requiring rapid debridement. ### Grafting Techniques Following excision, **wound coverage is essential** to restore function and prevent excessive scarring. - **Early Autografting:** Preferred whenever possible for **faster wound closure and lower infection risk**. - **Skin Substitutes:** Used when autografts are unavailable, providing **temporary or permanent coverage**. 💡 ****Tip:** Hemostasis during burn excision involves epinephrine infiltration, tourniquets, electrocautery, topical agents, hypothermia prevention, compression dressings, and staged procedures. ### Escharotomy Escharotomy involves making incisions from healthy skin to healthy skin (or joint-to-joint, if needed) to fully relieve constriction without damaging deeper structures ([ISBI](https://pubmed.ncbi.nlm.nih.gov/27542292/?ref=theplasticsfella.com), 2016). It's indicated in, - **Limb Ischemia:** Circumferential burns constricting circulation and causing impaired perfusion. - **Chest Burns:** Restrictive burns limit chest expansion, causing respiratory distress. - **Abdominal Compartment Syndrome:** Elevated intra-abdominal pressure compromising organ function. ### Fasciotomy Compartment syndrome, more common in electrical burns, occurs when increased pressure within muscle compartments leads to ischemia and necrosis. Key principles include, - **Fasciotomy** is required for pressure relief and tissue perfusion. - Monitor for **rhabdomyolysis** (myoglobinuria) and prevent acute kidney injury with aggressive IV fluids. --- ## Referral to a Burn Centre ****Key Point** Patients with large burns, specialized area involvement, inhalation injuries, or co-morbid conditions require specialized burn care for better outcomes Burn center referral criteria vary internationally, but generally include the following. - **Extent & Depth:** Partial-thickness burns >10% TBSA, full-thickness burns, or circumferential burns. - **Specialized Areas:** Burns involving the face, eyes, neck, hands, feet, joints, genitalia, or perineum. - **High-Risk Burns:** Chemical, electrical, lightning strike, and inhalation injuries. - **Vulnerable Populations:** Infants (<1 year), elderly (>50 years), or patients with co-morbidities (e.g., diabetes, cardiovascular disease). - **Associated Trauma:** Burns with fractures, spinal cord injuries, or multi-system trauma. --- ## Management of Burn Types ****Key Point** Certain burn types — chemical, electrical, and inhalation burns — have unique pathophysiological effects and require specialized management beyond standard thermal burn care. ### Chemical Burns [Chemical burn](https://www.theplasticsfella.com/chemical-burns/) vary in severity based on the **type of chemical and duration of exposure**. **Alkali burns** cause **liquefactive necrosis**, allowing deep penetration, while **acid burns** cause **coagulative necrosis**, forming a protective eschar that limits tissue damage [Schafer](https://www.ncbi.nlm.nih.gov/books/NBK430741/?ref=theplasticsfella.com), 2023). **Immediate Management** - **Decontamination:** Remove the chemical promptly to prevent further penetration. - **PPE Use:** Prevent secondary contamination by wearing gloves and protective equipment. - **Clothing & Residue Removal:** Brush off dry powders before irrigation ([Haruta](https://pubmed.ncbi.nlm.nih.gov/37806692/?ref=theplasticsfella.com), 2023) - **Irrigation:** Flush with warm water for **20–30 minutes** (extend to **60 minutes** for alkali burns), ensuring proper drainage to avoid further exposure Special Considerations include, - **Hydrofluoric Acid Burns:** Cause hypocalcemia, treated with topical and IV calcium gluconate; severe cases may require emergent excision for refractory hypocalcemia. - **Tar Burns:** Cool to solidify tar and dissipate heat, then remove with a solvent (e.g., Neosporin ointment) to dissolve it and minimize skin trauma ([Haruta](https://pubmed.ncbi.nlm.nih.gov/37806692/?ref=theplasticsfella.com), 2023). ### Electrical Burns [Electrical burns](https://www.theplasticsfella.com/electrical-burns/) cause deep tissue damage despite minimal surface injury. High-voltage (>1000V) burns can lead to severe internal injuries, including cardiac arrhythmias, muscle necrosis, and compartment syndrome. **Immediate Management** Patients require systemic monitoring, fluid resuscitation, and evaluation for deep tissue injury. - Assess for associated trauma (falls, fractures, spinal injuries). - Monitor for dysrhythmias — perform ECG and 24-hour cardiac monitoring if needed. - Monitor for rhabdomyolysis — check CK, urine myoglobin, and hemoglobin. - Aggressive fluid resuscitation with target urine output of 1.5–2 mL/kg/hr. - Alkalinize urine with sodium bicarbonate to prevent renal injury from myoglobinuria. **Surgical Considerations** Early fasciotomy is required if compartment syndrome is diagnosed, and urgent debridement may be necessary for severe high-voltage injuries to improve limb salvage. 💡 ****Tip:** Inspect oral commissures for electrical cord burns. Watch for ****labial artery bleeding** (7–10 days post-burn), managed with direct pressure inside the cheek ([Haruta](https://pubmed.ncbi.nlm.nih.gov/37806692/?ref=theplasticsfella.com), 2023). ### Inhalation Burns [Inhalation](https://www.theplasticsfella.com/inhalation-injury/) [injuries](https://www.theplasticsfella.com/inhalation-injury/) occur due to smoke, heat, and toxic gas exposure and can affect the upper airway, lower respiratory tract, or cause systemic poisoning (CO or cyanide toxicity). **Early recognition is critical for preventing airway obstruction and respiratory failure.** - Singed facial hair, soot in or around the mouth, carbonaceous sputum. - Hoarseness, stridor, increased work of breathing. - Inability to tolerate secretions and signs of upper airway edema. Treatment depends on the severity of the injury and risk of airway obstruction. - Observe and monitor closely for delayed airway edema. - Elevate the head of the bed to reduce swelling and support breathing. - Secure the airway early if airway compromise is suspected (jaw-thrust, intubation, or surgical airway if needed). - For CO poisoning, administer 100% high-flow oxygen for at least 6 hours ([ISBI](https://pubmed.ncbi.nlm.nih.gov/27542292/?ref=theplasticsfella.com), 2016). - Lung-protective ventilation strategies should be used in patients requiring mechanical ventilation. 💡 ****Tip:** A normal oxygen saturation or clear chest X-ray does not exclude inhalation injury — clinical suspicion is key. --- ## Complications of Burns ****Key Point** Burn complications can be acute (life-threatening) or chronic (long-term functional and psychological impacts). ### Acute Complications Immediate risks include breathing disturbances, infection, and hypovolemia, while long-term effects involve scarring, hypermetabolism, and psychological distress. **Systemic Instability** Severe burns disrupt fluid balance, thermoregulation, and immune response, leading to multi-organ dysfunction if not managed promptly. - **Breathing Problems:** Inhalation injuries can cause airway swelling, carbon monoxide poisoning, or lung injury from toxic fumes. - **Hypovolemia and Shock:** Severe burns result in fluid loss and circulatory collapse if resuscitation is inadequate. - **Hypothermia:** Skin loss impairs temperature regulation, worsening metabolic stress. **Infection and Wound-Related Risks** Burn wounds create an ideal environment for bacterial invasion, making infection a leading cause of sepsis and delayed healing. - **Sepsis Risk:** Major burns compromise the immune barrier, increasing the likelihood of systemic infection. - **Tetanus:** Burn wounds are particularly susceptible to tetanus, requiring vaccination if the status is uncertain. **Blood and Muscular Complications** - **Anemia:** Burns exceeding 10% TBSA (full-thickness) often lead to significant red blood cell loss. - **Deep Vein Thrombosis (DVT):** Prolonged immobilization increases clotting risks, predisposing patients to DVT or pulmonary embolism (PE). - **Electrical Burns:** High-voltage injuries can cause compartment syndrome, rhabdomyolysis, and cardiac arrhythmias, requiring close monitoring. ### Chronic Complications **Metabolic and Musculoskeletal Effects** Large burns trigger a prolonged hypermetabolic state, leading to muscle loss, bone density reduction, and growth impairment in children. - **Hypermetabolism:** Increases nutritional demands, requiring long-term dietary management. - **Bone and Muscle Wasting:** Persistent catabolism reduces muscle mass and weakens bones, increasing the risk of fractures. **Scarring and Functional Impairment** Burn scars can significantly affect movement and quality of life, particularly in joint or facial burns. - **Keloids and Contractures:** Thick, raised scars can restrict mobility, especially if burns involve joints, hands, or the face. - **Chronic Pain:** Some patients experience neuropathic pain or hypersensitivity in healed burn areas. **Psychosocial and Economic Impact** Burn injuries often lead to **emotional trauma and social difficulties**, especially in cases of **visible scarring**. - **Post-Traumatic Stress Disorder (PTSD):** Anxiety, depression, and flashbacks are common in burn survivors. - **Body Image Concerns:** Visible scarring can result in **low self-esteem and social withdrawal**. - **Economic and Social Hardship:** In low-resource settings, severe burns may lead to **poverty, social exclusion, or child abandonment** due to disability. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Burn management depends on type, depth, extent, location, and patient factors like age and comorbidities. ****2\. Pathophysiology:** Burns trigger hypermetabolism, inflammation, hormonal shifts, and organ dysfunction, with Jackson’s Zones defining tissue damage. ****3\. Clinical Assessment:** Burn depth determines skin appearance, blistering, capillary refill, and sensation, while AMPLE history aids evaluation. ****4\. Initial Management:** Cool burns (20 min, running water), prevent hypothermia, follow ABCDE approach, ensure fluid resuscitation, and perform escharotomies if needed. ****5\. Wound Care:** Debride necrotic tissue, apply occlusive dressings for superficial burns, and consider early excision and grafting for deeper burns. ****6\. Medications & Supportive Care:** Manage pain with multimodal analgesia, treat pruritus with antihistamines, and start early enteral feeding. Burn center referral is required for burns >10% TBSA, full-thickness burns, inhalation injuries, and burns in critical areas. ****7\. Managing Special Burn Types:** Chemical burns require immediate irrigation, electrical burns risk cardiac arrhythmias, inhalation burns need 100% O₂, and minor burns require basic wound care. ****8\. Complications:** Acute risks include airway obstruction, sepsis, and hypothermia, while chronic issues involve scarring, PTSD, and long-term hypermetabolism. --- ## Further Reading 1. [Hettiaratchy S](https://pmc.ncbi.nlm.nih.gov/articles/PMC437156/?ref=theplasticsfella.com), Papini R. Initial management of a major burn: I--overview. BMJ. 2004 Jun 26;328(7455):1555-7\. doi: 10.1136/bmj.328.7455.1555\. PMID: 15217876; PMCID: PMC437156. 2. [Schaefer TJ](https://www.ncbi.nlm.nih.gov/books/NBK430741/?ref=theplasticsfella.com), Szymanski KD. Burn Evaluation and Management. \[Updated 2023 Aug 8\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430741/ 3. [Schaefer TJ](https://www.ncbi.nlm.nih.gov/books/NBK430795/?ref=theplasticsfella.com), Nunez Lopez O. Burn Resuscitation and Management. \[Updated 2023 Jan 23\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430795/ 4. [Haruta A](https://pubmed.ncbi.nlm.nih.gov/37806692/?ref=theplasticsfella.com), Mandell SP. Assessment and Management of Acute Burn Injuries. Phys Med Rehabil Clin N Am. 2023 Nov;34(4):701-716\. doi: 10.1016/j.pmr.2023.06.019\. Epub 2023 Jul 27\. PMID: 37806692. 5. [ISBI Practice Guidelines Committee](https://pubmed.ncbi.nlm.nih.gov/27542292/?ref=theplasticsfella.com); Steering Subcommittee; Advisory Subcommittee. ISBI Practice Guidelines for Burn Care. Burns. 2016 Aug;42(5):953-1021\. doi: 10.1016/j.burns.2016.05.013\. PMID: 27542292. 6. [Jeschke MG](https://pubmed.ncbi.nlm.nih.gov/18791359/?ref=theplasticsfella.com), Chinkes DL, Finnerty CC, Kulp G, Suman OE, Norbury WB, Branski LK, Gauglitz GG, Mlcak RP, Herndon DN. Pathophysiologic response to severe burn injury. Ann Surg. 2008 Sep;248(3):387-401\. doi: 10.1097/SLA.0b013e3181856241\. PMID: 18791359; PMCID: PMC3905467. 7. [The Royal Children’s Hopsital Melbourne](https://www.rch.org.au/clinicalguide/guideline%5Findex/burns/?ref=theplasticsfella.com) Acute burns June 2020 [https://www.rch.org.au/clinicalguide/guideline\_index/burns/](https://www.rch.org.au/clinicalguide/guideline%5Findex/burns/?ref=theplasticsfella.com) Accessed on 5th March 2025 8. [Chung 2024](https://shop.lww.com/Grabb-and-Smith-s-Plastic-Surgery--Print---eBook-with-Multimedia/p/9781975214265?ref=theplasticsfella.com) Grabb and Smith's Plastic Surgery: 9th Edition September 2024 page 147-148 ### Fat Grafting: Basic Science, Techniques, & Patient Management URL: https://www.theplasticsfella.com/fat-grafting/ Last updated: 2025-03-24T21:35:01.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/fat-grafting/#overview-of-fat-grafting) Autologous fat grafting is the transfer of adipose tissue to correct volume and contour abnormalities in reconstructive and aesthetic surgery, leveraging its biocompatibility and regenerative potential. [****Basic Principles**](https://www.theplasticsfella.com/fat-grafting/#basic-principles-of-fat-grafting) Fat grafting transfers adipocytes, preadipocytes, and stromal tissue. Preadipocytes play a crucial role in graft survival and regeneration. Optimal outcomes depend on atraumatic surgical technique, processing, and controlled reinjection. [****Indications**](https://www.theplasticsfella.com/fat-grafting/#indications-for-fat-grafting) Fat grafting is used across multiple anatomical areas for volume restoration, contour correction, and tissue repair. It plays a key role in breast reconstruction, facial rejuvenation, and orthopedic applications. [****Surgical Technique**](https://www.theplasticsfella.com/fat-grafting/#surgical-technique-of-fat-grafting) The technique involves fat harvesting (syringe or suction), processing (sedimentation, filtration, or centrifugation), and injection into the recipient site. [****Complications**](https://www.theplasticsfella.com/fat-grafting/#complications-of-fat-grafting) Fat grafting complications can occur at both the recipient and donor sites. Issues include fat resorption, necrosis, embolism, infection, and aesthetic deformities. ****Primary Contributor:** Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Fat Grafting ****Key Point** Autologous fat grafting is the transfer of adipose tissue to correct volume and contour abnormalities in reconstructive and aesthetic surgery, leveraging its biocompatibility and regenerative potential. Fat grafting, also known as **lipofilling**, is the free, non-vascularized transplantation of adipose tissue. It is widely used in **reconstructive** and **aesthetic** surgery due to it's favourable characteristics: - **Biocompatibility:** Uses the patient’s own tissue, eliminating rejection risk. - **Low Immunogenicity:** Reduce inflammatory response & foreign body reactions. - **Cost-Effectiveness:** Avoids synthetic fillers and implant-related complications. - **Accessibility and Versatility:** Adaptable to multiple anatomical regions. The primary goal of fat grafting is **long-term volume maintenance**, though its main limitation remains the unpredictable resorption of the graft over time. 😎 ****Fun Fact:** The first adipose tissue transfer was reported by Neuber et al. in 1893, using forearm fat to correct a facial scar, achieving excellent aesthetic results. --- ## Basic Principles of Fat Grafting ****Key Point** Fat grafting involves the transfer of adipocytes, preadipocytes, and stromal tissue. Preadipocytes play a critical role in graft survival and regeneration. Optimal outcomes depend on an atraumatic surgical technique, proper fat processing, and controlled reinjection. ### **Biology of Adipose Tissue** Fat grafting transfers a mixture of adipocytes, preadipocytes, and surrounding stromal tissue. The biological components of fat grafting contribute significantly to graft survival and tissue regeneration. - **Adipocytes (Mature Fat Cells):** These cells provide volume but are highly susceptible to ischemia, leading to potential cell loss after transplantation. - **Preadipocytes (Adipogenic Precursor Cells):** These adipose-derived stem cells tolerate ischemia better than mature adipocytes, enabling: - Survival and differentiation into new adipocytes. - Stimulation of angiogenesis. - Enhanced long-term graft retention. - **Stromal Vascular Fraction (SVF):** This fraction contains mesenchymal stem cells (MSCs) and other regenerative cells that promote: - **Tissue repair** by differentiating into adipocytes or other supportive cells. - **Angiogenesis** by releasing vascular growth factors. - **Improved graft integration** by interacting with local tissue. 💡 ****Tip:** The use of SVF and MSCs in fat grafting remains under research and is not yet FDA-approved for routine clinical use. ### **Factors Affecting Graft Retention** Fat graft survival is dependent on proper revascularization. Initially, fat grafts rely on plasmatic diffusion for nourishment before new vascular networks form. [**Eto**](https://pubmed.ncbi.nlm.nih.gov/22261562/?ref=theplasticsfella.com)**'s Three-Zone Survival Theory (2012)** Fat grafts follow a predictable survival pattern based on oxygenation levels: - **Survival Zone (Outer Layer):** Well-oxygenated; adipocytes and adipose-derived stem cells (ASCs) survive. - **Regenerative Zone (Intermediate Layer):** Adipocytes undergo ischemic death, but ASCs survive, differentiate, and promote angiogenesis. - **Necrotic Zone (Central Core):** Poorly vascularized; cells undergo resorption or fibrosis. **Revascularization Process:** - Starts within **48 hours**, progressing from the periphery inward. - **ASCs resist ischemia better than adipocytes**, playing a key role in regeneration. - **Adipogenesis (fat cell formation) continues for up to 3 months**, while **phagocytosis of dead adipocytes lasts for weeks**. The image below illustrates the three-zone survival for fat grafts. ![3 zones of perfusion for grafted adipose tissue](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Fat-Grafting--3--1.png) 3 zones of perfusion for grafted adipose tissue 😎 ****Fun Fact:** Adipose-derived stem cells (ASCs) can survive up to ****three days in severe ischemic conditions** ([Shih](https://pubmed.ncbi.nlm.nih.gov/32071573/?ref=theplasticsfella.com), 2020). ### **Enhancing Graft Retention** Three primary steps can significantly improve fat graft survival: 1. **Atraumatic Harvesting:** Gentle liposuction techniques minimize damage to adipocytes and maintain donor site integrity. 2. **Proper Processing:** Purification methods (e.g., centrifugation or filtration) remove contaminants like blood and oil, improving graft viability. 3. **Optimized Reinjection:** Controlled injection techniques in small aliquots enhance vascular integration and prevent necrotic cyst formation. The image below shows properly processed fat grafts prepared for injection. ![Processed fat grafts prepared for injection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Fat-Grafting--1--1.png) Processed fat grafts prepared for injection 💡 ****Tip:** Larger volumes injected at once may lead to central necrosis, reducing the effectiveness of the graft. --- ## Indications for Fat Grafting ****Key Point** Fat grafting is used across multiple anatomical areas for volume restoration, contour correction, and tissue repair. It plays a key role in breast reconstruction, facial rejuvenation, and emerging orthopedic applications. Fat grafting is widely utilised across multiple anatomical regions for both reconstructive and aesthetic purposes. It is commonly used in three main domains: 1. **Aesthetic Enhancement** (Breast, Buttocks, Face, Hands, Genitalia) 2. **Reconstructive Applications** (Post-surgical corrections, trauma, and congenital conditions) 3. **Regenerative & Emerging Applications** (Orthopedics, scar therapy, radiation damage) ### Aesthetic Enhancement Fat grafting is a preferred method for natural soft tissue augmentation due to its **biocompatibility** and **lifelong integration**. - **Breast Augmentation:** Enhances volume naturally without implants. - **Brazilian Butt Lift (BBL):** Augments the buttocks for improved shape and contour. - **Facial Volume Restoration:** Treats age-related volume loss, hollowed eyes, and sunken cheeks. - **Lip & Malar Augmentation:** Subtly enhances lip fullness and cheek projection. - **Hand Rejuvenation:** Improves skin texture and volume, reducing visibility of veins and tendons. - **Genital Enhancement:** Used for penile enlargement and labial augmentation. ### **Reconstructive Applications** Fat grafting plays a critical role in **correcting defects and restoring soft tissue integrity** in reconstructive surgery. - **Post-Mastectomy & Lumpectomy Corrections:** Fills contour irregularities in breast reconstruction. - **Nipple Reconstruction:** Enhances soft tissue volume post-mastectomy. - **Congenital Breast Deformities:** Corrects conditions such as micromastia, tuberous breast, and Poland’s syndrome. - **Post-Traumatic & Surgical Defect Repair:** Restores facial and body contours after accidents or surgeries. - **Correction of Liposuction Irregularities:** Treats asymmetries and indentations from body contouring procedures. ### **Regenerative & Emerging Applications** Fat grafting is increasingly studied for **its regenerative potential**, particularly in **scar treatment, orthopedic medicine, and radiation damage repair**. - **Scar Therapy:** Improves elasticity and softens hypertrophic or retracting scars. - **Radiation-Induced Skin Damage:** Enhances tissue quality and hydration. - **Cartilage & Tendon Regeneration:** Investigated for orthopedic conditions such as osteoarthritis and joint repair. ### **Contraindications for Fat Grafting** **Absolute Contraindications** - **Active Infection or Inflammation:** Increases risk of fat necrosis and poor healing. - **Severe Vascular Compromise**: conditions like **peripheral artery disease** may lead to graft failure. **Relative Contraindications** - **Uncontrolled Systemic Diseases:** Diabetes, cardiovascular disease, or autoimmune disorders may impair healing. - **History of Extensive Radiation Therapy:** Compromised blood supply can reduce fat graft viability. - **Psychological Considerations:** Unrealistic expectations or body dysmorphia should be carefully evaluated. - **Insufficient Donor Fat:** Patients with low body fat may require alternative augmentation options. 💡 ****Tip:** Combining fat grafting with ****platelet-rich plasma (PRP)** or ****stem cell-enriched fat** is an emerging technique that may improve graft survival and integration. --- ## Surgical Technique of Fat Grafting ****Key Point** Fat grafting involves three main steps: ****fat harvesting** (via suction, syringe aspiration, or excision), ****processing** (sedimentation, filtration, or centrifugation), and ****injection** into the recipient site using precise volumetric techniques. ### **Step 1: Fat Harvesting** The goal of fat harvesting is to **extract adipocytes while minimizing trauma** to maximize graft survival. The deep subcutaneous fat layer is the ideal donor site due to its **high adipocyte concentration and minimal contamination** with blood, debris, and dermal appendages ([Sommer](https://pubmed.ncbi.nlm.nih.gov/11134994/?ref=theplasticsfella.com), 2000). **Suction-Assisted Fat Harvest (**[**Liposuction**](https://www.theplasticsfella.com/liposuction/)**\-Based)** - **Negative-pressure liposuction** enables large-volume fat harvesting. - **Fast and efficient**, but **excess suction pressure** may damage adipocytes, reducing viability. **Syringe Aspiration (Coleman Technique)** - **17G blunt cannula** minimizes cellular trauma. - **10-mL Luer-Lok syringe** enables controlled low-pressure aspiration. - **Crosshatch technique** ensures uniform fat retrieval. - **Ideal for small-volume grafting** (e.g., facial fat grafting) ([Coleman](https://pubmed.ncbi.nlm.nih.gov/11248861/?ref=theplasticsfella.com), 2001). **Surgical Excision** - **Precision harvesting** for small areas. - **Ideal for autologous fat banking** or when liposuction is unsuitable. ### **Tumescent Infiltration Techniques** Tumescent solutions reduce **bleeding, bruising, and tissue trauma**, facilitating **fat extraction**. Options include: - **Dry Technique:** No infiltration; higher bleeding risk. - **Wet Technique:** Minimal fluid infiltration. - **Super-Wet Technique:** Fluid volume approximates aspirated fat volume. - **Tumescent Technique:** Large volumes of fluid with **epinephrine and lidocaine** for pain control and vasoconstriction. The table below summarises the surgical technique of fat grafting. ![Tips on how to maximise fat graft retention and viability during the harvesting process of fat grafting](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Fat-Grafting--5-.png) Tips on how to maximise fat graft retention and viability during the harvesting process 💡 ****Tip:** Maintain continuous negative pressure in the harvesting syringe, keeping the plunger at the 2–3 cc mark to avoid excessive force. ### Step Two: Processing After fat harvesting, processing is essential to **remove impurities** such as oil, blood, and inflammatory byproducts, ensuring **optimal graft survival**. This is achieved through three primary methods: **Sedimentation, Filtration, and Centrifugation**. **Sedimentation** Thisis the the least traumatic method and has features of: - **Gravity separation** or decantation (layers based on density over time). - Retains fewer stromal and stem cell components - Less effective at eliminating pro-inflammatory substrates **Filtration** Effectively removes contaminants and inflammation and has features of: - Preservation of viable adipocytes and adipose-derived MSCs. - Can be manual or automated. - Can be integrated with **washing** (normal saline or lactated Ringer’s solution). **Centrifugation** Involves loading lipoaspirate into 10-mL Luer-Lok syringes and centrifuging at 3000 rpm for 3 minutes. It is widely regarded as the gold standard because: - Precise separation of graft components based on density. - Optimisation of the concentration of adipocytes and MSCs. This process yields **four distinct layers,** - **Upper Oil Layer:** Oil (ruptured fat cells) – **discarded**. - **Middle Fat Layer:** Viable adipocytes – **used for grafting**. - **Lower Aqueous Layer:** Blood, residual anesthetic, and water – **discarded**. - **SVF (Stromal Vascular Fraction) Pellet:** Rich in **stem cells**, retained in specific protocols. ![Components of centrifuged fat graft](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Fat-Grafting--2--1.png) Components of centrifuged fat graft 😎 ****Fun Fact:** ****Microfat** (≥0.7 mm cannulas) allows precise fat placement in delicate areas, while ****Nanofat** (filtered into a liquid suspension) is rich in ****stem cells** and ideal for ****skin rejuvenation**, not volumization! ([Tonnard](https://pubmed.ncbi.nlm.nih.gov/23783059/?ref=theplasticsfella.com), 2013). ### Step 3: Engraftment (Injection & Placement) The final step involves **precise injection** of purified fat into the recipient site. **Injection Technique** - A **small incision** is made to match the cannula diameter. - Fat is injected in **small aliquots** (droplets) upon withdrawal to maximize **oxygenation and perfusion**. - Fat is distributed in a **crosshatch pattern** with **long radial passes from multiple angles**. - **Digital manipulation** is used to smooth out **clumps or minor irregularities**. For **large-volume fat transfer**, **10–60 mL syringes** improve efficiency, **radial injections** ensure even distribution, and **intramuscular placement** enhances graft survival. **Cannula Selection** - **Small-gauge cannulas (e.g., 18G–22G)** minimize **trauma to the recipient site**. - **Larger cannulas (e.g., 14G–16G)** may improve **adipocyte survival** by reducing shear forces. - Cannula choice depends on **recipient site anatomy, fat viscosity, and injection depth**. 💡 ****Tip:** ****Overcorrect (by \~20%)** to account for postoperative resorption of ****tumescent fluid and partial graft loss**. --- ## Complications of Fat Grafting ****Key Point** Fat grafting complications can occur at both the ****recipient and donor sites**, including ****fat resorption, necrosis, embolism, infection, and aesthetic deformities**. ### Recipient Site Complications - **Fat Resorption & Volume Fluctuation:** Graft volume may change over time, requiring at least 6 months before assessing permanent results or considering additional grafting. - **Aesthetic Deformities:** Uneven fat distribution can occur due to poor technique or over-injection in one area. - **Fat Necrosis & Calcifications:** Common in breast reconstruction, sometimes leading to microcalcifications that mimic malignancy on mammograms; an experienced radiologist can differentiate them. - **Pseudocyst Formation:** Breakdown of grafted fat may cause cystic fluid collections, which may require aspiration or excision if symptomatic. - **Fat Embolism & Vascular Complications:** Arterial occlusion can lead to blindness, stroke, or skin necrosis in rare cases. - **Lipoid Meningitis:** A rare condition where fat unintentionally migrates into the cerebrospinal fluid (CSF). ### Donor Site Complications - **Aesthetic Deformities:** Uneven fat removal may result in **contour irregularities**. - **Hematoma & Seroma Formation:** Fluid or blood accumulation may require **drainage**. - **Infection & Poor Healing:** Improper wound care or preexisting conditions can increase **infection risk**. 😎 ****Fun Fact:** Fat graft volume ****fluctuates with weight changes**! Since grafted fat cells ****retain metabolic function**, weight gain or loss can affect the ****final contour**. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Autologous fat grafting transfers adipose tissue to correct volume and contour abnormalities in reconstructive and aesthetic surgery. It is biocompatible, low-risk, and widely used for soft tissue augmentation. ****2\. Basic Principles:** Fat grafting transfers adipocytes, preadipocytes, and stromal vascular fractions (SVF), with preadipocytes promoting angiogenesis and tissue regeneration. ****3\. Indications:** Used for volume restoration and contour correction in breast reconstruction, facial rejuvenation, gluteal augmentation, hand rejuvenation, scar treatment, and emerging orthopedic applications. ****4\. Surgical Technique:** The procedure involves harvesting (syringe aspiration or suction-assisted liposuction), processing (sedimentation, filtration, or centrifugation), and reinjection (small aliquots, multiplanar technique, controlled deposition). ****5\. Complications:** Risks include fat resorption, necrosis, pseudocyst formation, embolism (potentially causing blindness or stroke), donor site contour irregularities, and infections. ****6\. Outcomes:** Fat survival varies; resorption occurs over months. Permanent volume is assessed after \~6 months, with overcorrection (\~20%) recommended to account for initial loss. --- ## Further Reading 1. Shauly O, Gould DJ, Ghavami A. Fat Grafting: Basic Science, Techniques, and Patient Management. Plast Reconstr Surg Glob Open. 2022 Mar 18;10(3):e3987\. doi: 10.1097/GOX.0000000000003987\. PMID: 35317456; PMCID: PMC8932485. 2. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg. 2001 Jan;28(1):111-9\. PMID: 11248861. 3. Coleman SR, Katzel EB. Fat Grafting for Facial Filling and Regeneration. Clin Plast Surg. 2015 Jul;42(3):289-300, vii. doi: 10.1016/j.cps.2015.04.001\. PMID: 26116934. 4. Sommer B, Sattler G. Current concepts of fat graft survival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg. 2000 Dec;26(12):1159-66\. PMID: 11134994. 5. Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declercq H. Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg. 2013 Oct;132(4):1017-1026\. doi: 10.1097/PRS.0b013e31829fe1b0\. PMID: 23783059. 6. Trepsat F. Lipostructure du tiers moyen du visage \[Midface reshaping with micro-fat grafting\]. Ann Chir Plast Esthet. 2009 Oct;54(5):435-43\. French. doi: 10.1016/j.anplas.2009.03.008\. Epub 2009 May 15\. PMID: 19446945. 7. Mashiko T, Yoshimura K. How does fat survive and remodel after grafting? Clin Plast Surg. 2015 Apr;42(2):181-90\. doi: 10.1016/j.cps.2014.12.008\. Epub 2015 Jan 29\. PMID: 25827562. 8. Eto H, Kato H, Suga H, Aoi N, Doi K, Kuno S, Yoshimura K. The fate of adipocytes after nonvascularized fat grafting: evidence of early death and replacement of adipocytes. Plast Reconstr Surg. 2012 May;129(5):1081-1092\. doi: 10.1097/PRS.0b013e31824a2b19\. PMID: 22261562. 9. Shih L, Davis MJ, Winocour SJ. The Science of Fat Grafting. Semin Plast Surg. 2020 Feb;34(1):5-10\. doi: 10.1055/s-0039-3402073\. Epub 2020 Feb 15\. PMID: 32071573; PMCID: PMC7023968. 10. Schiraldi L, Sapino G, Meuli J, Maruccia M, Cherubino M, Raffoul W, di Summa PG. Facial Fat Grafting (FFG): Worth the Risk? A Systematic Review of Complications and Critical Appraisal. J Clin Med. 2022 Aug 11;11(16):4708\. doi: 10.3390/jcm11164708\. PMID: 36012947; PMCID: PMC9410081. 11. Ørholt M, Larsen A, Hemmingsen MN, Mirian C, Zocchi ML, Vester-Glowinski PV, Herly M. Complications after Breast Augmentation with Fat Grafting: A Systematic Review. Plast Reconstr Surg. 2020 Mar;145(3):530e-537e. doi: 10.1097/PRS.0000000000006569\. PMID: 32097306. 12. Liao X, Zhou H, Deng T. The composition, function, and regulation of adipose stem and progenitor cells. J Genet Genomics. 2022 Apr;49(4):308-315\. doi: 10.1016/j.jgg.2022.02.014\. Epub 2022 Feb 28\. PMID: 35240306. 13. Duhoux A, Chennoufi M, Lantieri L, Hivelin M. Complications of fat grafts growth after weight gain: report of a severe diplopia. J Plast Reconstr Aesthet Surg. 2013 Jul;66(7):987-90\. doi: 10.1016/j.bjps.2012.11.038\. Epub 2012 Dec 24\. PMID: 23270665. ### Upper Limb Cellulitis: Diagnosis, Management, & Complications URL: https://www.theplasticsfella.com/upper-limb-cellulitis/ Last updated: 2025-03-24T18:53:08.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/upper-limb-cellulitis/#overview-of-upper-limb-cellulitis) An acute bacterial infection of the dermis and subcutaneous tissue, characterized by erythema, warmth, edema, and tenderness. [****Pathogenesis**](https://www.theplasticsfella.com/upper-limb-cellulitis/#pathogenesis-of-upper-limb-cellulitis) Bacteria breach the skin barrier, triggering an inflammatory cascade, with high-risk groups including IV drug users, diabetics, and immunocompromised patients. [****Clinical Assessment**](https://www.theplasticsfella.com/upper-limb-cellulitis/#clinical-assessment-of-upper-limb-cellulitis) Poorly demarcated erythema, warmth, swelling, and tenderness. Systemic signs such as fever and lymphangitis indicate more severe infection. [****Investigations**](https://www.theplasticsfella.com/upper-limb-cellulitis/#investigations-for-upper-limb-cellulitis) Diagnosed clinically, but imaging and laboratory tests may be required to detect abscesses, systemic toxicity, or deep infections. [****Management**](https://www.theplasticsfella.com/upper-limb-cellulitis/#management-of-upper-limb-cellulitis) Management depends on severity and risk factors. Cephalexin is first-line for mild to moderate cases. Abscesses require incision & drainage, while severe cases may need IV antibiotics or surgical debridement. [****Complications**](https://www.theplasticsfella.com/upper-limb-cellulitis/#complications-of-upper-limb-cellulitis) Early complications include bacteremia, sepsis, and abscess formation, while late complications involve osteomyelitis. ****Primary Contributor:** Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Upper Limb Cellulitis ****Key Point** Upper limb cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue, characterized by erythema, warmth, edema, and tenderness. Prompt antibiotic therapy is essential. Cellulitis is an **acute bacterial skin infection** affecting the **deep dermis and subcutaneous tissue.** It is primarily caused by **beta-hemolytic streptococci* (Group A Streptococcus),* followed by ***Staphylococcus aureus***. Classic features of upper limb cellulitis include ([Stevens](https://academic.oup.com/cid/article/59/2/e10/2895845?ref=theplasticsfella.com), 2014): - **Early:** Erythemal, Warmth, Oedema, Tenderness (without abscess formation) - **Late:** Abscess formation, Necrotizing fasciitis, Systemic sepsis Annually, the U.S. sees 14 million cases resulting in 650,000 hospitalizations ([Raff](https://pubmed.ncbi.nlm.nih.gov/27434444/?ref=theplasticsfella.com), 2016). In the U.K, the median hospital stay is three days ([Sullivan](https://pmc.ncbi.nlm.nih.gov/articles/PMC6303460/?ref=theplasticsfella.com#R1), 2018). ![Presentation of upper limb cellulitis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T155635.342.png) Presentation of upper limb cellulitis 😎 ****Fun Fact:** Historically, red streaks (lymphangitis) were feared as “blood poisoning”, a term still used by some patients today. --- ## Pathogenesis of Upper Limb Cellulitis ****Key Point** Upper limb cellulitis develops when bacteria breach the skin barrier, triggering an inflammatory cascade, with high-risk groups including IV drug users, diabetics, and immunocompromised patients. Upper limb cellulitis is most commonly caused by *Streptococcus pyogenes* (Group A beta-hemolytic streptococcus), followed by methicillin-sensitive *Staphylococcus aureus* (MSSA) ([Swartz](https://cir.nii.ac.jp/crid/1573950401011002496?ref=theplasticsfella.com), 2020). The **pathophysiology** of upper limb cellulitis is explained below. 1. **Mechanism** Bacteria penetrate the dermis and subcutaneous tissue via a disrupted skin barrier, bypassing the protective role of the epidermis. 1. **Inflammatory Response** The infection triggers an acute inflammatory cascade with cytokine release, leading to vasodilation, edema, and neutrophil infiltration in the deep dermis and subcutaneous layers. 1. **Spread** In the upper limb, unchecked infection may extend along subcutaneous planes or lymphatics, potentially causing lymphangitis (visible red streaks) ([Cruciani & De Lalla](https://link.springer.com/chapter/10.1007/978-94-011-5482-6%5F37?ref=theplasticsfella.com#citeas), 1998). Severe cases may progress to **bacteremia** or **sepsis**. The table below summarises common pathogens and associated risk factors for upper limb cellulitis, highlighting key clinical notes for rapid identification and management. ![Common pathogens and associated risk factors for upper limb cellulitis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T161706.033.png) Common pathogens and associated risk factors for upper limb cellulitis 💡 ****Tip:** Animal bites on the hand can introduce Pasteurella multocida, causing rapid-onset cellulitis. Recurrent cellulitis in the upper limb should raise suspicion for chronic lymphedema. --- ## Clinical Assessment of Upper Limb Cellulitis ****Key Point** Upper limb cellulitis is characterized by poorly demarcated erythema, warmth, swelling, and tenderness. Systemic signs such as fever and lymphangitis indicate more severe infection. Clinical assessment of upper limb cellulitis includes taking detailed history, physical examination, and special tests. ### History - **Onset & Progression:** Sudden or gradual spread of erythema, warmth, and swelling. - **Associated Symptoms:** Malaise, fatigue, fever, and chills. - **Precipitating Factors:** Recent trauma, insect/animal bites, IV drug use, or prior skin infections. - **Medical History:** Diabetes, venous insufficiency, lymphedema, or prior cellulitis episodes are risk factors. - **Travel & Exposure:** History of immersion injuries, bites, or recent surgery. Certain anatomical regions of cellulitis have been associated with specific triggers. - **Lower Limbs** (most common): Venous insufficiency, lymphedema, trauma. - **Upper Limbs:** IV drug use, post-surgical wounds, bites. - **Face & Periorbital Region:** Dental infections, sinusitis, preseptal cellulitis. - **Trunk & Abdomen:** Post-surgical infections, obesity-related skin folds. - **Breast:** Mastitis in lactating women, post-surgical infections. ### Examination - **Local Signs:** Poorly demarcated erythema, warmth, swelling, and tenderness. - **Systemic Signs:** Fever, tachycardia, and lymphadenopathy (suggesting systemic involvement). - **Skin Breakdown:** Look for wounds, fissures, ulcers, or surgical sites. - **Complications:** Presence of bullae, vesicles, or peau d’orange may indicate severe infection. ### Special Tests - **Marking Borders:** Use a skin marker to outline the erythema’s edge — monitor spread and treatment response. - **Two-of-Four Criteria:** Confirm diagnosis with at least two of: warmth, erythema, edema, or tenderness (per clinical guidelines). - **Lymph Node Palpation:** Gently palpate axillary lymph nodes for enlargement or tenderness, indicating lymphatic involvement. - **Abscess Exclusion:** Apply gentle pressure to detect fluctuance; if present, consider ultrasound to differentiate from simple cellulitis. The image below illustrates the clinical presentation of upper limb cellulitis. ![Clinical presentation of upper limb cellulitis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T155446.111.png) Clinical presentation of upper limb cellulitis ### Differential Diagnosis - **Erysipelas:** Superficial *Streptococcus pyogenes* infection with bright red, well-demarcated erythema; may show lymphatic streaking. Less common in the upper limb but possible post-trauma. - **Venous Stasis Dermatitis:** Chronic venous insufficiency causing bilateral erythema, scaling, edema, and hyperpigmentation. Unlike cellulitis, it lacks acute tenderness and warmth. - **Necrotizing Fasciitis:** Rapidly spreading deep soft tissue infection with severe pain disproportionate to findings, crepitus, and systemic toxicity. CT may show subcutaneous gas. Surgical emergency. - **Septic Arthritis:** Joint infection (e.g., elbow, wrist) with localized swelling, warmth, pain, and reduced mobility. Unlike cellulitis, it remains joint-specific. Confirmed by joint aspiration. - **Deep Vein Thrombosis (DVT):** Upper limb venous thrombus presenting with unilateral swelling, erythema, warmth, and tenderness. No fever or leukocytosis. Confirmed via ultrasound. The table below summarises these conditions, their features, and their distinct qualities. ![Differential diagnosis of upper limb cellulitis and key distinguishing features](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T162227.373.png) Differential diagnosis of upper limb cellulitis and key distinguishing features 💡 ****Tip:** Bilateral cellulitis is uncommon → Consider venous stasis dermatitis or contact dermatitis instead. --- ## Investigations for Upper Limb Cellulitis ****Key Point** Upper limb cellulitis is diagnosed clinically, but imaging and laboratory tests may be required to detect abscesses, systemic toxicity, or deep infections. Investigations including bloods and imaging for upper limb cellulitis are as follows. ### Blood Work - **Inflammatory Markers:** Elevated WBC, CRP, and ESR suggest infection but are nonspecific. - **Blood Cultures:** Only indicated in immunocompromised patients, systemic toxicity, or extensive disease (positive in <5% of cases) ([Torres](https://pubmed.ncbi.nlm.nih.gov/28592371/?ref=theplasticsfella.com), 2017). - **Serologic Tests*:* *Antistreptolysin O (ASO)*** and *anti-DNase B titers* can confirm recent streptococcal infection in recurrent cellulitis. ### Imaging - **Ultrasound:** Differentiates cellulitis vs. abscess → Abscess appears as a hypoechoic fluid collection requiring drainage. - **X-ray:** Rules out foreign bodies or gas-forming infections (e.g., necrotizing fasciitis). - **CT Scan:** Indicated for deep infections, extensive soft tissue involvement, or suspected necrotizing fasciitis (findings: fascial thickening, gas formation). - **MRI:** Best for detecting deep tissue involvement (e.g., osteomyelitis or fasciitis) but reserved for unclear cases. ### Other Tests - **Wound Cultures:** Only needed if purulent drainage or unusual infection is suspected (e.g., animal bites, immunosuppression). - **Biopsy:** Rarely performed but may be indicated for chronic, non-resolving cellulitis to rule out vasculitis or malignancy. 💡 ****Tip:** Ultrasound is the first-line imaging for suspected abscess, while CT is preferred for deep infections or necrotizing fasciitis. --- ## Management of Upper Limb Cellulitis ****Key Point** Management depends on severity and risk factors. Cephalexin is first-line for mild to moderate cases. Abscesses require incision and drainage, while severe cases may need IV antibiotics or surgical debridement. Treatment depends on severity and risk factors. First-line is cephalexin 500 mg every 6 hours for 5 days is first-line for mild to moderate cases. Clindamycin is used in penicillin-allergic patients, and trimethoprim-sulfamethoxazole is added for MRSA risk. Abscesses require incision and drainage, while severe cases may need IV antibiotics or surgical debridement. ### Outpatient (Mild to Moderate Cellulitis) - **First-Line** (Non-Purulent Cellulitis):*Cephalexin* 500 mg every 6 hours for 5 days (longer if slow improvement) ([Gibbons](https://pubmed.ncbi.nlm.nih.gov/28732743/?ref=theplasticsfella.com), 2017). - **Beta-Lactam Allergy:** *Clindamycin* 300–450 mg every 6 hours ([Gibbons](https://pubmed.ncbi.nlm.nih.gov/28732743/?ref=theplasticsfella.com), 2017). - **MRSA Risk Factors** (IV drug use, abscess, puncture wounds): *Trimethoprim-Sulfamethoxazole (TMP-SMX)* 800/160 mg twice daily + *Cephalexin* ([Gibbons](https://pubmed.ncbi.nlm.nih.gov/28732743/?ref=theplasticsfella.com), 2017). - **Supportive Care:** Limb elevation, hydration, and analgesia. ### Inpatient (Severe or Complicated Cases) Indications for hospitalisation include, - Systemic signs of infection (fever >38°C, tachycardia, hypotension). - Rapidly spreading erythema or failure of outpatient therapy. - Immunocompromised patients (diabetes, chemotherapy, chronic illness). - Cellulitis near an indwelling medical device (e.g., prosthetic joints, vascular catheters). ### IV Antibiotics It is important to consult your local hospital guidelines. Suggestions include, - **No MRSA Risk:** *Cefazolin IV*, then switch to *Cephalexin PO* once stable. - **MRSA Risk:** *Vancomycin IV*, then step down to *TMP-SMX PO*. - **Immunocompromised/Broad-Spectrum Needed:** *Vancomycin + Piperacillin-Tazobactam IV*. ### Special Considerations - **Abscess or Purulent Lesions:** Incision & drainage, with culture-guided antibiotics. - **Animal Bites**: Cover *Pasteurella multocida* (*Amoxicillin-Clavulanate*). - **Water-Related Injuries:** Cover *Vibrio vulnificus* (doxycycline + ceftazidime). - **Diabetic Hand Infections:** Consider *Pseudomonas aeruginosa* coverage. The table below summarises antibiotic regimens for upper limb cellulitis, stratified by clinical scenario, pathogen coverage, and treatment duration. ![Antibiotic regimens for upper limb cellulitis management](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T163602.369.png) Antibiotic regimens for upper limb cellulitis management 💡 ****Tip:** If cellulitis fails to improve within 48–72 hours, reassess for abscess, resistant organisms, or alternative diagnoses (DVT, necrotizing fasciitis, etc.). --- ## Complications of Upper Limb Cellulitis ****Key Point** Early complications include bacteremia, sepsis, and abscess formation, while late complications involve osteomyelitis and chronic lymphedema. Symptoms improve within 48 hours with treatment, with full recovery in 5–7 days. Early complications include bacteremia, sepsis, and abscess formation, while late complications include osteomyelitis and chronic lymphedema. With appropriate treatment, symptoms improve within 48 hours, and full recovery occurs within 5-7 days. Recurrence rates range from 8–20% annually if risk factors persist. ### Expected Prognosis **Recovery Time** With prompt diagnosis and correct antibiotics, signs (erythema, tenderness) typically improve within 48 hours; full resolution often occurs within 5–7 days for uncomplicated cases ([Raff](https://pubmed.ncbi.nlm.nih.gov/27434444/?ref=theplasticsfella.com), 2016). **Recurrence Rates** Annual recurrence affects 8–20% of patients, with lifetime rates up to 49%, especially if risk factors (e.g., lymphedema, IV drug use) persist; preventable with wound care and hygiene ([Richmond](https://pubmed.ncbi.nlm.nih.gov/25452424/?ref=theplasticsfella.com), 2014) ([Raff](https://pubmed.ncbi.nlm.nih.gov/27434444/?ref=theplasticsfella.com), 2016). **Treatment Success** Initial antibiotic failure occurs in \~18% of cases, but the overall prognosis remains good with timely management ([Obaitan](https://pubmed.ncbi.nlm.nih.gov/27344098/?ref=theplasticsfella.com), 2016). ### Complications **Early** - **Bacteremia:** Bacteria enter the bloodstream (diagnosed via blood cultures in systemic cases), risking systemic spread if untreated. - **Sepsis:** Occurs with two or more SIRS criteria (fever >38°C, tachycardia >90 bpm, tachypnea >20 breaths/min, abnormal WBC); requires urgent IV antibiotics. - **Abscess Formation:** Progression to purulent collections needing drainage, more common with MRSA or delayed treatment. **Late** - **Osteomyelitis:** Infection spreads to the bone (e.g., radius/ulna in upper limb), necessitating prolonged antibiotics and possible surgery. - **Endocarditis:** Rare but severe; bacteremia infects the heart’s endocardium, requiring extended treatment. - **Lymphatic Damage:** Recurrent episodes or severe infection may cause chronic lymphedema, impairing arm function ([Brandon](https://www.ncbi.nlm.nih.gov/books/NBK549770/?ref=theplasticsfella.com), 2023). The table below summarises complications of upper limb cellulitis and their management. ![ Upper limb cellulitis complications and management strategies](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-13T164742.093.png) Upper limb cellulitis complications and management strategies 💡 ****Tip:** Lymphatic damage = Chronic swelling → Repeated cellulitis episodes increase the risk of permanent lymphedema, making future infections more frequent and severe. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Upper limb cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue, presenting with erythema, warmth, edema, and tenderness. Prompt antibiotic therapy prevents complications. ****2\. Aetiology & Pathophysiology:** Most cases are caused by Streptococcus pyogenes or Staphylococcus aureus, often entering through skin breaks (e.g., trauma, IV drug use, bites). Bacterial invasion triggers an inflammatory response, leading to vasodilation, edema, and neutrophil infiltration. ****3\. Clinical Features & Differential:** Patients present with poorly demarcated erythema, warmth, swelling, and tenderness. Fever and lymphangitis indicate severe infection. Differentials include erysipelas, necrotizing fasciitis, septic arthritis, and DVT. ****4\. Diagnosis & Investigations:** Clinical diagnosis is key. Ultrasound helps differentiate cellulitis from abscesses. Blood cultures are reserved for systemic signs, while CT scans assess deep infections or necrotizing fasciitis. ****5\. Management:** Cephalexin (500 mg q6h for 5 days) is first-line; clindamycin is an alternative for penicillin allergies. Add trimethoprim-sulfamethoxazole for MRSA risk. Abscesses require incision and drainage, while severe cases need IV antibiotics and possible debridement. ****6\. Complications & Prognosis:** Early risks include bacteremia, sepsis, and abscess formation; late risks include osteomyelitis and chronic lymphedema. Symptoms improve within 48 hours, with full recovery in 5–7 days. Recurrence rates range from 8–20% annually in high-risk patients. --- ## Further Reading 1. Brown BD, Hood Watson KL. Cellulitis. \[Updated 2023 Aug 7\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549770/ 2. Parikh RP, Pappas-Politis E. Soft tissue infection of the upper extremity. Eplasty. 2011;11:ic6\. Published 2011 Apr 11. 3. Sullivan T, de Barra E. Diagnosis and management of cellulitis. Clin Med (Lond). 2018;18(2):160-163\. doi:10.7861/clinmedicine.18-2-160 4. Spelman D, Baddour LM, Nelson S, Hall KK. Acute cellulitis and erysipelas in adults: Treatment. UpToDate. Updated December 12, 2024\. Accessed March 4, 2025\. https://www.uptodate.com/contents/acute-cellulitis-and-erysipelas-in-adults-treatment 5. Burian, E.A., Franks, P.J., Borman, P. et al. Factors associated with cellulitis in lymphoedema of the arm – an international cross-sectional study (LIMPRINT). BMC Infect Dis 24, 102 (2024). https://doi.org/10.1186/s12879-023-08839-z 6. Ortiz-Lazo E, Arriagada-Egnen C, Poehls C, Concha-Rogazy M. An update on the treatment and management of cellulitis. Actas Dermo-Sifiliogr (Engl Ed). 2019;110(2):124-130\. doi:10.1016/j.adengl.2019.01.011 7. Lim SH, Tunku Ahmad TS, Devarajooh C, Gunasagaran J. Upper limb infections: A comparison between diabetic and non-diabetic patients. Journal of Orthopaedic Surgery. 2022;30(1). doi:10.1177/23094990221075376 8. Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016;316(3):325-337\. doi:10.1001/jama.2016.8825 ### Cash Influences Research, 1 Important Podcast Guest, & All Things Vascular Anomalies URL: https://www.theplasticsfella.com/march-16th/ Last updated: 2025-03-15T21:44:37.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/march-16th/#a-letter-from-pfella) Research or marketing? The industry cash behind nerve allografts. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/march-16th/#the-sunday-quiz) New winners top the leaderboard! 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/march-16th/#image-of-the-week) Clinical insights on vascular tumours. 4. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/march-16th/#foundations-textbook) Calling plastic surgery experts to contribute! 5. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/march-16th/#behind-the-fella) What should we ask Rod Rohrich? 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/march-16th/#what-does-the-evidence-say) What is the optimal dose of oral propranolol? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-16th/#articles-of-the-week) Vascular malformations, ISSVA classification, & The original 1982 classification of hemangiomas: with 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/march-16th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Research or Marketing? The Industry Cash Behind Nerve Allografts* 👋 ****Hey Team!** Let's call it what it is: ****Nerve allograft researc**h is a tangled web of academia and industry cash. It’s a snapshot of a bigger struggle — clinical integrity versus commercial pressure. **The Dirty Truth** A recent [publication](https://journals.lww.com/plasreconsurg/fulltext/2025/03000/academic%5Finfluence%5Fand%5Findustry%5Ffunding%5Fin%5Fnerve.44.aspx?ref=theplasticsfella.com) in the PRS journal caught my eye. Nearly **80%** of the top **nerve allograft researchers** have pocketed industry cash, totaling over **$14 million** in the past decade. We're not just talking lunch money — some pulled in hundreds of thousands. If that doesn’t raise your eyebrows, you’re not paying attention. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/image-4.png) [Source](https://x.com/prsjournal/status/1899445516120760830?ref=theplasticsfella.com) Yes, industry dollars can drive innovation, but when **funding dictates research outcomes**, the integrity of the science takes a hit. Positive spin often overshadows solid, comparative evidence — leaving clinicians and patients to wonder what’s real innovation and what's just clever marketing. **Real Winners or Real Risks?** Sure, nerve allografts offer appealing perks — shorter operations and no donor-site complications. But without robust, comparative evidence, we're left wondering: Are we truly advancing care, or simply buying into flashy marketing? **Beyond the Allograft** This isn't just about nerve grafts — it's a microcosm of medicine’s broader conflict-of-interest dilemma. Without clear, standardized disclosures, clinicians risk confusing genuine breakthroughs with industry sales pitches. **Transparency isn’t optional — it’s essential.** With love, P’Fella ❤️ ## The Sunday Quiz **\*Drumroll*🥁**\* New Winners Top the Leaderboard!* ****Congratulations to the Winners** of The Weekly Quiz! We're thrilled to announce the winners of this edition's quiz. After six rounds of questions on plastic surgery, our top scorers are ****Cher**, ****AL**, ****Manolo**, and ****Alexander L**. Winners, please reply to this newsletter or reach out to us! Thank you to everyone who participated and stay tuned for more fun quizzes in future editions! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Leaderboard-Team-Post-Template--5-.png) Leaderboard - March Here's the rest of the leaderboard ## Image of the Week **Clinical Insights on Vascular Tumours* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week’s image shows a ****rapidly growing vascular lesion** on the ****left cheek**. Infantile hemangiomas are common benign tumors, often self-resolving but sometimes requiring treatment, such as ****oral propranolol**, based on size, location, and complications. You can explore vascular tumours in detail in our [clinical case](https://www.theplasticsfella.com/vascular-tumour-clinical-case/). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/image-2-1-1-1.png) #### Vascular Tumour - Clinical Case 1. Clinical diagnosis of a vascular malformation. 2. Create and justify a differential diagnosis. 3. Describe the natural history and aetiology of this condition. 4. Identify and treat complications and associated conditions. 5. Order relevant investigations. 6. Treat this condition in the short and long term. 7. Learn novel techniques and indications for surgery. [Read the Article](https://www.theplasticsfella.com/vascular-tumour-clinical-case/) ## Foundations Textbook **Calling Plastic Surgery Experts!* 📙 ****Plastic Surgery Student Guide Contributors** We're seeking ****plastic surgery experts** to contribute to the final review of our Plastic Surgery Student Guide. If you're interested in joining us, sign up below! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Textbook-Design.png) Mock Template of the Textbook ## Behind the 'Fella **What Should We Ask Rod Rohrich?* 🎧 ****Releasing Soon: Behind the 'Fella Season Two** To kick off season two of our podcast, we've invited ****Rod Rohrich** as a guest for our first episode. Got a question for him? ****Submit yours** below. ## What Does the Evidence Say? **What Is the Optimal Dose of Oral Propranolol?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Oral propranolol has emerged as an effective ****first-line** treatment for ****infantile hemangiomas** (IH). Multiple studies have demonstrated its superiority over corticosteroids, with success rates of ****60-96%** (Léauté-Labrèze et al., 2015; Andersen et al., 2014; Price et al., 2011). The recommended dosage is ****2-3 mg/kg/day**, typically administered for 6-12 months (Léauté-Labrèze et al., 2015; Solman et al., 2014). Early initiation of treatment, preferably before 5 months of age, has been associated with better outcomes (Andersen et al., 2014). Propranolol effectively ****stops IH growth**, ****reduces volume**, and ****improves color and elevation** (Hogeling et al., 2011; Sans et al., 2009). It has shown efficacy in treating various ****IH complications**, including ****vision compromise**, ****ulceration**, and ****airway obstruction** (Solman et al., 2014; Haider et al., 2010). Adverse effects are generally mild and infrequent, with no significant differences compared to placebo (Léauté-Labrèze et al., 2015; Price et al., 2011). However, ****careful monitoring** is recommended, especially during treatment initiation. ## Articles of the Week **3 Interesting Articles with One-Sentence Summaries* ✅ ****Classification, Evaluation, and Treatment of Vascular Malformations** ([Arneja](https://pubmed.ncbi.nlm.nih.gov/18349599/?ref=theplasticsfella.com), 2008) Vascular malformations differ from hemangiomas in their endothelial characteristics and require a multidisciplinary approach, with treatment strategies varying based on whether the lesion is capillary, venous, lymphatic, or arteriovenous. ✅ ****ISSVA Classification for Vascular Anomalies** ([ISSVA](https://www.issva.org/UserFiles/file/ISSVA-Classification-2018.pdf?ref=theplasticsfella.com), 2014) The ISSVA classification distinguishes vascular anomalies into vascular tumors and vascular malformations, categorizing malformations as simple (capillary, lymphatic, venous, arteriovenous), combined, of major named vessels, or associated with other anomalies. ✅ ****Mulliken and Glowacki’s Landmark Classification of Hemangiomas and Vascular Malformations** ([Mulliken](https://pubmed.ncbi.nlm.nih.gov/7063565/?ref=theplasticsfella.com), 1982) Mulliken and Glowacki's 1982 classification distinguishes hemangiomas, which exhibit endothelial proliferation and spontaneous regression, from vascular malformations, which are present at birth, grow proportionally, and lack proliferative endothelial activity. ## Feedback ### I hope you enjoyed it 😄 --- ### Carpal Tunnel Syndrome URL: https://www.theplasticsfella.com/carpal-tunnel-syndrome-interview/ Last updated: 2025-03-14T19:10:43.000Z The aim of this section is to improve your diagnostic skills in treating a common plastic surgery condition. A good candidate is competent in the management of these patients from diagnosis to discharge. In this section, you'll find a [clinical scenario](https://www.theplasticsfella.com/theplasticsinterview/finger-replant-interview/#clinical-scenario), [consent](https://www.theplasticsfella.com/theplasticsinterview/finger-replant-interview/#consent), [call the boss,](https://www.theplasticsfella.com/theplasticsinterview/finger-replant-interview/#call-the-boss) [Read up on Carpal Tunnel Syndrome](https://www.theplasticsfella.com/my-creator-reward-monthlyhttps://www.theplasticsfella.com/carpal-tunnel-syndrome/) --- ## Clinical Scenario Review the clinical information before answering the following questions. A 47-year-old landscaper is referred to your clinic with potential carpal tunnel syndrome. The referral letter is relatively non-specific and lacks important clinical details. His main symptom is "tingling in the hands". You invite him into the consultation room to take a detailed history and examine his hand (pictured below) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/For-Interviews-10.png) #### 1\. What would you ask in your history? The aim of my history would be to determine if the patient does indeed have carpal tunnel syndrome, the degree/severity, and patient expectations. ****History of Presenting Complaint** - What exactly are his symptoms? Pins and needles in median nerve distribution or the entire hand. - When did the symptoms begin and have they progressed - Any exacerbating factors such as sleeping at night, manual work - Any relieving factors such as "flicking of the hand". ****Past Medical/Surgical History** ****Patient** 1. Social History: dexterity, occupation 2. Medical History including smoking status 3. Patient Expectations ****Current Management** 1. Storage of Finger 2. Imaging 3. Medications: Antibiotics, Tetanus, Analgesia 4. Fasting Status #### 2\. How would you transport the finger? I would urgently transport the finger with the patient. The finger should be stored as follows: 1. Wrapped in moist gauze and placed in a secure plastic bag 2. The bag is then placed in another bag container, which contains icy water I would definitively point out that the finger tip should never be in direct contact with the ice. I would ask them to record the time the finger was placed in this cooling transport container. #### 3\. What are the indications for replantation? 1. Thumb 2. Multiple digits 3. Paediatric 4. Single-digit **distal* to FDS\* 5. Mid-palm/hand These are ****relative indications** and other factors should be considered – such as patient preferences, patient motivations & expectations, and overall health. \*As a side note, this may seem strange and is controversial - why **distal* to FDS insertion? Evidence suggests that a replanted finger with limited function has an overall negative effect on dexterity​, especially with a poorly-functioning PIPJ. When the injury is distal to FDS, the PIPJ and FDS are presented. #### 4\. What are the indications for replantation? 1. Thumb 2. Multiple digits 3. Paediatric 4. Single-digit **distal* to FDS\* 5. Mid-palm/hand These are ****relative indications** and other factors should be considered – such as patient preferences, patient motivations & expectations, and overall health. \*As a side note, this may seem strange and is controversial - why **distal* to FDS insertion? Evidence suggests that a replanted finger with limited function has an overall negative effect on dexterity​, especially with a poorly-functioning PIPJ. When the injury is distal to FDS, the PIPJ and FDS are presented. #### 5\. What are the key steps during a finger replant operation? 1. ****Equipment**: Microscope, microsurgical instruments, radiography 2. ****Teams**: ideally two teams each preparing the 2 segments 3. ****Bone:** ORIF ± shortening with K-wires 4. ****Tendons**: Flexor and Extensor Tendon repair 5. ****Nerves**: epineural repair 6. ****Artery** Anastomosis +/- Vein Graft 7. ****Vein** ****Anastomosis**: A strong predictor of survival 8. ****Skin**: also has a role in venous drainage \*There is no "perfect order". There is a general agreement for bone and tendons first. Some may prefer to do artery/veins before the nerve to reduce the ischemia time. --- ## Consent Please consent a patient on the information provided below. Following clinical examination and review of the imaging, you decide the patient is a good candidate for finger replantation. He is alert and orientated. Please consent him. ****An example answer** Good evening, my name is P'Fella and I am here to consent you for this operation. I am going to explain what will happen before, during, and after the surgery. At any stage feel free to ask questions. But first, I just need to confirm your name and understanding of the procedure. Before the operation, you will be meeting different health care staff. They are all here for your treatment and will be involved in performing your surgery or the anesthetic. To start off, there will be a surgical checklist to confirm your details. Then you will receive the anesthetic. This will involve a mask being gently placed over your face as you fall asleep. During the operation, our goal is to replant your finger. This involves several steps, techniques, and potentially further skin incisions. You will be asleep for several hours as we fix your bones, tendon, nerves, arteries, veins, and skin. This operation may be prolonged so a urinary catheter will be placed. There is no guarantee we can save your finger. After the operation, you will have dressings on the arm. You and your finger will be monitored closely by the Plastics team and nursing staff. This is to ensure blood is entering and leaving your finger. Further treatments might be necessary on the ward. This includes warming blankets and leeches. You may need to be brought back to the theatre and you may require multiple operations. If successful, the rehabilitation process does take time and patience. With any operation, there are risks and complications you need to be aware of. These may be related to the surgery or the anesthetic or the necrotizing fasciitis. • Bone: osteomyelitis, non- or mal-union, graft • Tendon: rupture, stiff finger, tenolysis • Nerve: delayed sensation return, neuroma, CRPS, conduits, grafts • Artery: thrombus, embolus, ischaemia, vein grafts • Vein: congestion, leeches, • Skin: scarring, hypersensitivity, poor wound healing • Anaesthetic complications • Multiple operations • Blood transfusion • DVT/PE • Urinary Catheter complications Without this operation, there is a risk it will not be successful. If this is, unfortunately, the case, you will need to return to the theatre for a revision terminalisation. I understand this is a lot of information to take on. Before I get you to sign the consent form, do you have any questions for me? #### 5 Follow-Up Questions from the Patient 1. "How long will this operation take?" 2. "Promise me you'll save my finger" 3. "Will I be able to feel and move my finger again?" 4. "You mentioned bone graft, where do you get the from?" 5. "Will you be doing the operation?" --- ## Call the Boss ****Read the following scenario and perform the requested tasks.** ****History** \- 37-year-old male is transferred to your emergency department. \- A 2mm circular saw cut his right index finger 2 hours prior \- He is right hand dominant and works as a plasterer \- Fit & healthy, non-smoker, no previous surgeries. \- He last ate and drank \~9 hours ago. \- He is very keen for the finger to be saved. ****Examination:** \- ATLS assessment performed by Emergency Physicians. \- Finger amputation has been transported appropriately. \- Total amputation just distal to the FDS insertion \- It appears to be a clean-cut with no crush. \- The stump is clean. ****Investigations** \- ****Bloods**: Normal \- ****Vitals**: Normal \- ****Xray of Stump and Amputation**: Amputation at the shaft of the middle phalanx with no intra-articular extension. Appears to be small bone loss. ****Task:** Call your Boss and outline the patient's ****clinical history**, ****examination**, ****working diagnosis**, and ****management plan**. #### Show Example Answer Good afternoon, this is P'Fella, the Plastic Surgery Trainee. Am I speaking to Prof. P'Fella? **Yes* I am calling you in relation to a finger amputation that is suitable for replantation. I plan to bring him to the theatre urgently and would like you to help me with the surgery, please. In terms of his ****history**, he is a 37-year-old male transferred to our emergency department 2-hours after a 2mm circular saw caused a total amputation of his right index finger. He is a fit and healthy non-smoker with a 9-hour fasting status. He is very keen for surgery. On ****examination**, his right index finger is a total amputation distal to the FDS insertion. It is clean-cut with no crush appearance. The proximal stump is viable and the amputated finger was transported appropriately. In terms of ****investigations**, the x-ray shows the amputation to be at the shaft of the middle phalanx. There is no secondary fracture but there is some bone loss. His vital signs and blood results are all within normal limits. My ****management** so far has included: \- ATLS Assessment \- Anaesthetics have pre-operatively reviewed \- Consented and marked the patient \- Informed theatre \- Microsurgical equipment and warming blankets requested \- Leeches are available if needed So, in ****summary**, this 37-year-old male is a good candidate for finger replantation. Anesthetics have been informed and will send for the patient shortly. The patient has been marked, consented, and next-of-kin contacted. I would really appreciate your help intra-operatively. Is there anything else you would like to know or want me to do? #### 5 Follow-Up Questions from your Boss 1. What makes this patient a good candidate for finger replantation? 2. What are the key steps to the operation? 3. What instruments would you like theatre to have ready for you? 4. What are the contraindications for finger replant? 5. Post-operatively, what are the signs of venous congestion? [Read up on Finger Replants](https://www.theplasticsfella.com/finger-replant) ### New AI Surgical Studio, 3 Local Flap Techniques, & Design the Rotation Flap (properly) URL: https://www.theplasticsfella.com/march-9th/ Last updated: 2025-03-08T21:01:14.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/march-9th/#a-letter-from-pfella) Stay tuned for: AI surgical studio. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/march-9th/#the-sunday-quiz) How well do you know **rotation flaps*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/march-9th/#image-of-the-week) Featured: Keystone flap for defect reconstruction. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-9th/#technique-tip) Principles of effective design for a rotation flap. 5. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/march-9th/#the-fellows-corner) The role of TXA in plastic and reconstructive surgery. 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/march-9th/#what-does-the-evidence-say) Why does pincushioning occur in local flaps? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-9th/#articles-of-the-week) Zitelli's original bilobed flap, original keystone flap publication & an overview of local flaps: with 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/march-9th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Stay Tuned for: AI Surgical Studio!* 👋 ****Hey Team!** Surgical planning just got a major upgrade. ****AI Surgical Studio** is live, and it’s built for the way surgeons think, plan, and refine their techniques. This isn’t just a drawing tool—it’s a **surgical studio** with precision controls, AI-powered feedback, and seamless workflow integration. Whether you’re mapping incisions, planning complex reconstructions, or prepping for exams, this changes the game. We’ve combined **pro-grade drawing tools** with **AI-driven analysis** to bring surgical planning into the future: - **Flawless Freehand & Incision Planning** – Draw, erase, and refine with pixel-perfect accuracy. - **Real-Time Measurements** – **Ruler & angle tools** ensure precision at every step. - **AI-Powered Second Opinion** – Get instant feedback on incision placement, symmetry, and design. - **Smart Layer Management** – Organize complex surgical plans effortlessly. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/image-1.png) Right now, **Freestyle Mode** is fully functional—giving you complete control to map out all the key **flaps, incisions, and surgical plans** you need to prepare for. But we’re not stopping here - coming soon: - **Guide Mode** – Assisted drawing with structured overlays and real-time AI adjustments to refine every step. - **Exam Mode** – A challenge-based system to **test your decision-making and technique under pressure**, perfect for trainees and board prep. ### **Want Early Access? Join the Waitlist** We’re building this for **surgeons, not just artists.** **Sign up for the waiting list now** to be the first to access **Guide Mode & Exam Mode** before the full release. **P’Fella ❤️** ## The Sunday Quiz **How Well Do You Know* ***Rotation Flaps?** ****Are you ready to make it to the leaderboard?** Welcome to the ****final** round of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![Overview of rotation flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-07T233232.416.png) Overview of rotation flaps ## Image of the Week **Keystone Flap* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week’s image highlights the ****keystone flap**, a reliable local flap for defect reconstruction. ![Keystone Flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Keystone-Flap.png) Keystone flap ## Technique Tip **How to Design a Rotation Flap* 🚑 ****Technique Tip of the Week** This week, we’re focusing on rotation flaps, a fundamental technique for closing circular defects with minimal tension. 🔹 ****Key principle:** The flap should be ****at least 4x the defect radius** to allow adequate mobilization. 🔹 ****Pivot point:** Strategically placed to maximize tissue movement while preserving vascularity. 🔹 ****Back-cut:** Used sparingly to gain additional length but should be avoided if possible to maintain perfusion. Effective rotation flap design ensures optimal contour and tension-free closure. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/image.png) Rotation flap design ## the Fellows' Corner **The Role of TXA in Plastic and Reconstructive Surgery* 📽️ ****Role of Tranexamic Acid (TXA) in Plastic and Reconstructive Surgery: A National Perspective** **In case you missed it:* Dr. Hatan Mortada explores the role of ****TXA in plastic surgery** in our latest ****JPRAS**\-partnered journal article. Read it here👇 [Role of Tranexamic Acid (TXA) in Plastic and Reconstructive Surgery: A National PerspectiveTXA is widely used in plastic surgery, especially in facelifts (83.6%) and rhinoplasty (55.0%), reducing bleeding (61.8%) and bruising (63.2%). Common methods include 1 g IV bolus or 3% topical solution, with 92.4% reporting no complications. Despite benefits, standardization is needed.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/Logo-Small-2-3.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/Lunchtime-Lessons-1.png)](https://www.theplasticsfella.com/journal-tranexamic-acid/) ## What Does the Evidence Say? **Why Does Pincushioning Occur in Local Flaps?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Pincushioning**, or the ****trapdoor effect**, is a common complication in ****transposition flaps**, particularly in nasal reconstruction. It occurs due to ****contraction of the flap** over the wound bed, leading to poor aesthetic outcomes (Kaufman et al., 1993; Okland et al., 2020). Several factors contribute to pincushioning, including ****lack of tissue undermining**, ****scar contracture**, and ****biomechanical factors** specific to the nasal region (Kaufman et al., 1993; Amici, 2014). Prevention techniques include ****wide tissue undermining**, ****thinning of excess subcutaneous tissue**, and ****primary lobe pexing sutures** (Kaufman et al., 1993; Okland et al., 2020; Boylan et al., 2021). Intraoperative triamcinolone injections have shown limited effectiveness (Boylan et al., 2021). Early ****corticosteroid injections** at the first signs of ****hypertrophy** can be an effective treatment (Amici, 2014). Proper flap design, delicate tissue handling, and tension-free closure are crucial in reducing complications (Woodard, 2013; Zitelli, 1989; Hom & Ostrander, 2023). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Zitelli’s Original Publication on Bilobed Flaps for Nasal Recon** ([Zitelli](https://jamanetwork.com/journals/jamadermatology/article-abstract/550671?ref=theplasticsfella.com), 1989) The bilobed flap is a versatile technique for reconstructing defects in the lower third of the nose, reducing pincushioning and optimizing contour by refining transposition angles. ✅ ****Original Publication on the Keystone Design Perforator Island Flap** ([Behan](https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1445-2197.2003.02638.x?sid=nlm%3Apubmed&ref=theplasticsfella.com), 2003) The Keystone Design Perforator Island Flap (KDPIF) is a versatile, vascularized local flap that minimizes skin grafting and achieves high primary wound healing rates, making it a reliable option for reconstructing skin defects. ✅ ****Techniques and Applications of Local Flaps and Pedicled Perforator Flaps** ([Miranda](https://journals.lww.com/plasreconsurg/abstract/2013/06000/local%5Fflaps,%5Fincluding%5Fpedicled%5Fperforator%5Fflaps%5F.27.aspx?ref=theplasticsfella.com), 2013) Local perforator flaps offer a versatile reconstructive option by preserving vascular perforators, enabling tissue transfer with minimal donor-site morbidity, superior color and texture match, and primary closure. ## Feedback ### I hope you enjoyed it 😄 --- ### Rotation Flap: Design Principles, Complications, & Flap Modifications URL: https://www.theplasticsfella.com/rotation-flap/ Last updated: 2025-03-07T18:05:43.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/rotation-flap/#overview-of-rotation-flap-design) Rotation flaps are curvilinear pivotal flaps that incorporate both pivotal and advancement movements, making them ideal for triangular defect repair. [****Indications & Contraindications**](https://www.theplasticsfella.com/rotation-flap/#indications-contraindications-of-rotation-flap) Rotation flaps are indicated for lateral facial, cheek, chin, and scalp reconstruction and can be contraindicated in cases of residual malignancy, and high hemorrhage risk. [****Design & Execution**](https://www.theplasticsfella.com/rotation-flap/#design-execution-of-a-rotation-flap) The success of a rotation flap depends on precise defect triangulation, appropriate flap circumference, and optimal pivot point positioning to ensure proper tension distribution and closure. [****Design Variations**](https://www.theplasticsfella.com/rotation-flap/#variations-of-rotation-flap-design) Ahuja’s and Sandhir’s flaps adjust the pivot point to improve reach and tension distribution, allowing for shorter flaps in lax skin while ensuring optimal scar placement along aesthetic subunits. [****Complications**](https://www.theplasticsfella.com/rotation-flap/#complications-of-rotation-flaps) Postoperative care should focus on hematoma prevention, tension distribution, and vascular monitoring to ensure optimal healing. Limited movement and sun protection can reduce complication ****Updated by:** Dr Waruguru Wanjau, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview of Rotation Flap Design ****Key Point** Rotation flaps are curvilinear pivotal flaps that incorporate both pivotal and advancement movements, making them ideal for triangular defect repair. Rotation flaps are **curvilinear pivotal flaps** commonly used to reconstruct defects without creating a secondary donor site. Their design prioritizes **tension distribution, flap geometry, and pivot positioning** to optimize defect coverage ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2022). **Principles of Rotation Flap Design** - Curvilinear pivotal flap that moves around a fixed pivot point. - Best suited for triangular defects ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2022). - Reduces tension by redistributing forces along a curved arc. - Particularly useful for areas at risk of distortion, such as the eyelid and lips. Rotation flap design is illustrated below. ![Rotation flap design](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-07T233232.416-1.png) Rotation flap design 💡 ****Tip:** Rotation flaps redirect tension around free margins, minimizing distortion in delicate areas like the eyebrow and lips ([Prohaska](https://www.ncbi.nlm.nih.gov/books/NBK482371/?ref=theplasticsfella.com), 2023). --- ## Indications & Contraindications of Rotation Flap ****Key Point** Rotation flaps are primarily used for reconstructing defects on the lateral face, cheeks, chin, and scalp. They are relatively contraindicated in cases of residual malignancy, high hemorrhage risk, and active smoking. Rotation flaps are ideal when primary closure is not possible due to excessive tension or risk of distortion. They are commonly used for, - **Scalp** - **Lateral Face** - **Cheeks** - **Chin** These flaps are particularly useful for redirecting tension around free margins, preventing distortion in areas such as the **eyebrows and lips**. The areas and their dimensions are summarized in the table below. ![Rotation flap areas and their dimensions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-25T200241.462.png) Rotation flap areas and their dimensions ### Contraindications Rotation flaps are contraindicated if a malignancy is not completely cleared and relatively contraindicated in an increased risk of hemorrhage and active smoking. - **Absolute Contraindications:** Residual malignancy (requires complete excision, such as Mohs micrographic surgery). - **Relative Contraindications:** an increased risk of hemorrhage, particularly in anticoagulated patients, and active smoking, which can compromise vascular supply and healing. Proper rotation flap geometry and tension management are essential to ensure optimal outcomes and minimize complications. 💡 ****Tip:** Several named rotation flaps, such as ****Tenzel** and ****Mustardé** flaps, are designed for specific locations and indications. --- ## Design & Execution of a Rotation Flap ****Key Point** The success of a rotation flap depends on precise defect triangulation, appropriate flap circumference, and optimal pivot point positioning to ensure proper tension distribution and closure. A rotation flap follows a structured design to ensure optimal reach, minimal tension, and reliable closure by **triangulating** the defect, determining the **pivot point**, drawing an **arc**, and making strategic **adjustments**. A rotation flap design is illustrated below. ![Rotation flap design](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-07T233358.670.png) Rotation flap design ### Step 1: Triangulate the Defect Isosceles triangle is more symmetrical and aligns better with semicircular flaps than a right-angled triangle ([Lo](https://pubmed.ncbi.nlm.nih.gov/18448409/?ref=theplasticsfella.com), 2008). Key factors include: - **Base of Triangle:** Slightly wider than the defect, this is **𝑥.** - **Sides of Triangle:** Sides \~2× defect width, this is **2𝑥**. ### Step 2: Identify Pivot Point The **geometrical pivot point** is the **center of the semicircular flap**, ideally aligned with the apex of the triangulated defect. There is often confusion about pivot points, as there are two additional types. - **Functional Pivot Point:** Origin of the line of tension, determining how the flap moves. - **Anteriorly Displaced Pivot Point:** Increases closing tension, making flap advancement more difficult. 💡 ****Tip**: Increasing triangle length reduces defect width and angle, increasing flap radius and facilitating closure. ### Step 3: Draw An Arc There is no fixed flap size, but classical references ([McGregor](https://www.elsevier.com/books/fundamental-techniques-of-plastic-surgery/mcgregor/978-0-443-06372-5?ref=theplasticsfella.com), 2000 & [Smith](https://scholar.google.com/scholar%5Flookup?title=Grabb+and+Smith%E2%80%99s+Plastic+Surgery&author=S+Jankauskas&author=IK+Cohen&author=WC+Grabb&publication%5Fyear=1991&&ref=theplasticsfella.com), 1979) suggest a flap circumference of 5–8× the defect width or 4–5× the defect base length. This “5× rule” comes from π, since the flap follows a semicircular path when it rotates. - **Arc Length =** π×radius (where radius = 2𝑥 and π ≈3) - Therefore, **Arc Length** \= 3 x 2𝑥 = 6𝑥 However, **some tissue is lost at the base**, reducing the **effective arc length to \~5**𝑥. Rotation arcs beyond **90°** provide diminishing tension relief. 💡 ****Tip:** As flap circumference increases, the benefit of tension reduction decreases. ### Step 4: Incision & Elevation Incising and elevating the flap properly ensures **vascular preservation and mobility**. Key factors include, - **Incision Path:** Follow the **semicircular design**, ensuring smooth rotation. - **Elevation Plane:** Elevate the flap in the **subdermal or subgaleal plane** to preserve vascularity. - **Undermining:** Improves flap movement but should be **wide yet controlled** to avoid disrupting blood supply. - **Rotate:** Gently rotate the flap into the defect, ensuring even tension distribution. 💡 ****Tip:** Inferiorly-based flaps are preferred as they promote lymphatic drainage and reduce post-op edema. ### Step 5: Alterations to Reduce Tension Reducing tension improves **flap mobility and closure**. Key techniques include, - **Back-Cut:** Moves pivot point closer, increases reach; use cautiously in vascularly compromised areas. - **Burow’s Triangle Excision:** Small triangular excision near pivot; modestly improves mobility. - **Z-Plasty:** Placed at flap base to increase mobility; may replace Burow’s triangle excision ([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2022). - **Undermining:** Enhances movement; must balance range of motion with vascular preservation. ### --- ## Variations of Rotation Flap Design ****Key Point** Ahuja’s and Sandhir’s flaps adjust the pivot point to improve reach and tension distribution, allowing for shorter flaps in lax skin while ensuring optimal scar placement along aesthetic subunits. Variations of the classical rotation flap improve mobility, tension distribution, and adaptability, making them ideal for complex reconstructions. **Ahuja’s** and **Sandhir’s** modifications are designed to enhance reach, flexibility, and closure reliability, optimizing defect coverage with minimal tension. ### Ahuja’s Modified Rotation Flap (1988) This technique shifts the center of rotation forward, creating a larger arc and a more adaptable flap for large defects. Key Differences from a classic rotation flap are, - **Pivot Point Modification:** The triangular defect is mirrored, establishing a new pivot point further from the defect. This allows for a longer, more mobile flap with less tension, making it ideal for large defects. - **Flap Length & Flexibility:** The extended arc increases reach, ensuring better defect coverage. The flap end remains adjustable intraoperatively, allowing a cut-as-you-go approach for optimal closure. This flap design is illustrated below. ![Ahuja’s modified rotation flap design](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-03T194224.412.png) Ahuja’s modified rotation flap design ### Sandhir’s Divine Rotation Flap (1997) This modification **enhances control and flexibility** by incorporating geometric shapes into the flap design. - **Geometric Pivot Adjustment:** A **rectangle and square** are added around the defect, with the **pivot point recalculated** by bisecting these shapes, rather than using the standard fixed pivot. - **Improved Reach & Tension Distribution:** The flap rotates from a **new pivot point**, reducing tension and allowing **intraoperative extension** if needed. - **Greater Flexibility:** The geometric design enhances **movement precision**, enabling flap **length adjustments** during surgery for a better fit. ### Other Modifications Several other minor modifications enhance **closure, tension distribution, and adaptability** for specific anatomical regions. - **Double Rotation Flap:** Two opposing arcs extend from the same point, used when a single flap is insufficient; ideal for **forehead, lip, and chin defects** ([Albom](https://doi.org/10.1111/j.1524-4725.1978.tb00578.x?ref=theplasticsfella.com), 1978). - **O-Z Rotation Flap:** Two counter-rotating flaps create a **Z-shaped scar**, preferred for **scalp defects**; not to be confused with Z-plasty. - **Modified Peng Flap:** A **double rotation flap for nasal defects**, pivoting from the **nasal root**; avoids forehead flaps but may distort nasal symmetry ([Prohaska](https://www.ncbi.nlm.nih.gov/books/NBK482371/?ref=theplasticsfella.com), 2023). - **Tenzel Flap:** A semicircular flap involves rotation of skin and orbicularis muscle from the area superior to the lateral canthus to fill defects of the lower lid and incorporates lysis of the lateral canthal tendon to increase tissue mobility → [Lower eyelid](https://www.theplasticsfella.com/lower-eyelid-anatomy/) defects ([Tenzel](https://doi.org/10.1016/s0161-6420%2878%2935578-0?ref=theplasticsfella.com), 1978). - **Mustardé Flap:** A similar design in which a broad sweeping rotation is arched superiorly from the lateral canthus, through the temple, and ending in the preauricular sulcus → Large cheek/lower eyelid defects ([Mustarde](https://www.ncbi.nlm.nih.gov/pubmed/5411895?ref=theplasticsfella.com), 1970). --- ## Complications of Rotation Flaps ****Key Point** Postoperative care should focus on hematoma prevention, tension distribution, and vascular monitoring (if needed) to ensure optimal healing. Limited movement and sun protection can reduce complication Proper **tension distribution, vascular monitoring, and postoperative care** are essential to prevent complications. **Early intervention** minimizes the risk of functional and aesthetic issues Complications are uncommon but include, - **Haematoma** formation, usually in the first 24 hours. - **Ectropion/Eclabium:** Caused by poor tension vector distribution; managed with revision surgery. - **Trapdoor Deformity:** Results from insufficient flap thinning; treated with triamcinolone injection.([Baker](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com), 2022). - **Pincushioning:** Excess flap thickness; corrected with flap debulking. Complications, their causes, and management are detailed in the table below. ![Rotation flap complications, their causes, and management ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/03/Main-Article-Images---2025-03-07T233440.791.png) Rotation flap complications, their causes, and management --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Rotation flaps are pivotal, curvilinear flaps designed to repair triangular defects while minimizing tension and distortion, particularly in delicate areas like the eyelids and lips. ****2\. Indications & Contraindications:** Used for lateral facial, cheek, chin, and scalp defects. Contraindications include incomplete tumor excision, high hemorrhage risk, and active smoking. ****3\. Flap Design & Tension Management:** Proper triangulation, adequate flap circumference, and optimal pivot point positioning reduce closure stress. Tension is managed through back-cuts, Burow’s triangles, Z-plasty, and wide-undermining. ****4\. Postoperative Care & Complications:** Hematoma prevention, activity restriction, and sun protection are key for healing. Common issues include trapdoor deformity and excessive tension. ****5\. Flap Modifications:** Variants like double rotation flaps, O-Z plasty, and Peng/Mustardé/Tenzel flaps improve outcomes based on defect location and complexity. --- ## Further Reading 1. Lo CH, Kimble FW. The ideal rotation flap: an experimental study. *Journal of Plastic, Reconstructive & Aesthetic Surgery*. July 2008:754-759\. doi:[10.1016/j.bjps.2007.12.032](https://doi.org/10.1016/j.bjps.2007.12.032?ref=theplasticsfella.com) 2. Ahuja R. Geometric considerations in the design of rotation flaps in the scalp and forehead region. *Plast Reconstr Surg*. 1988;81(6):900-906\. doi:[10.1097/00006534-198806000-00012](https://doi.org/10.1097/00006534-198806000-00012?ref=theplasticsfella.com) 3. Albom M. Repair of large scalp defects by bilateral rotation flaps. *J Dermatol Surg Oncol*. 1978;4(12):906-907\. doi:[10.1111/j.1524-4725.1978.tb00578.x](https://doi.org/10.1111/j.1524-4725.1978.tb00578.x?ref=theplasticsfella.com) 4. Tenzel R, Stewart W. Eyelid reconstruction by the semicircle flap technique. *Ophthalmology*. 1978;85(11):1164-1169\. doi:[10.1016/s0161-6420(78)35578-0](https://doi.org/10.1016/s0161-6420%2878%2935578-0?ref=theplasticsfella.com) 5. Mustardé J. The use of flaps in the orbital region. *Plast Reconstr Surg*. 1970;45(2):146-150\. [https://www.ncbi.nlm.nih.gov/pubmed/5411895](https://www.ncbi.nlm.nih.gov/pubmed/5411895?ref=theplasticsfella.com). 6. [Starkman SJ](https://pubmed.ncbi.nlm.nih.gov/28676159/?ref=theplasticsfella.com), Williams CT, Sherris DA. Flap Basics I: Rotation and Transposition Flaps. Facial Plast Surg Clin North Am. 2017 Aug;25(3):313-321\. doi: 10.1016/j.fsc.2017.03.004\. Epub 2017 May 30\. PMID: 28676159 7. [Baker, S.R](https://www.sciencedirect.com/book/9780323036849/local-flaps-in-facial-reconstruction?ref=theplasticsfella.com)., 2021\. Rotation Flaps Chapter 7, 100-123.e1 Local flaps in facial reconstruction E-book. 8. [Prohaska J](https://www.ncbi.nlm.nih.gov/books/NBK482371/?ref=theplasticsfella.com), Sequeira Campos MB, Cook C. Rotation Flaps. \[Updated 2023 Aug 16\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482371/ ### New JPRAS Partnership, 2 Tips on Eyelid Recon, & Textbook Updates URL: https://www.theplasticsfella.com/march-2nd/ Last updated: 2025-03-03T18:36:25.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/march-2nd/#a-letter-from-pfella) The Plastics Fella x JPRAS: Our new partnership! 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/march-2nd/#the-sunday-quiz) How well do you know **upper eyelid recon*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/march-2nd/#image-of-the-week) Featured: Original Mustardé publication from 1974. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/march-2nd/#technique-tip) Optimal Mustardé cheek flap. 5. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/march-2nd/#the-fellows-corner) SMAS lift Botox: Is there science behind the hype? 6. ****📙** [****Foundations Textbook**](https://www.theplasticsfella.com/march-2nd/#foundations-textbook) Progress update: March. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/march-2nd/#articles-of-the-week) Guidelines for reconstructing eyelids & paediatric eyelid burns: with 1-sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/march-2nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Plastics Fella x JPRAS: Our New Partnership* 👋 ****Hey Team!** We’ve got something big to share — ****The Plastics Fella is partnering with JPRAS** to make top-tier plastic surgery research ****more accessible than ever!** ![The Plastics Fella x JPRAS: Our New Partnership](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/JPRAS-Parternship--1-.png) The Plastics Fella x JPRAS: Our New Partnership Every month, we’ll get **early access** to a standout article, and — here’s the real win — **JPRAS is taking down the paywall** for a limited time so you can read it in full. No barriers or restrictions; just open access to knowledge that actually matters. ### Big Thanks to JPRAS JPRAS has been leading the way in plastic surgery research for years, publishing the studies that shape how we practice. Their decision to team up with us and **make these key papers free** speaks volumes about their commitment to education and the plastic surgery community. We’re honored to work with them and grateful for their support. ### What’s in It for You? - **First Dibs:** Get access to key research before it hits the mainstream - **No-Fluff Breakdowns:** We’ll cut through the complexity and deliver **practical takeaways you can actually use.** - **Paywall-Free Access:** Thanks to JPRAS, you’ll get full access to the article — for free, for a limited time. ### Why This Matters At **The Plastics Fella**, we’re here to **break down barriers to education** and bring you **high-yield, real-world insights** without the usual restrictions. This partnership is another step in that direction, making sure you **get the best research without the hassle.** ### What’s Next? Our first article explored [TXA](https://www.google.com/url?q=https://www.jprasurg.com/article/S1748-6815%2824%2900639-9/fulltext&source=gmail&ust=1741109073619000&usg=AOvVaw0D-ktbgdmG12ipl8h9tIEy), widely used especially in facelifts and rhinoplasty to reduce bleeding and bruising. Read more here 👇 [Role of Tranexamic Acid (TXA) in Plastic and Reconstructive Surgery: A National PerspectiveTXA is widely used in plastic surgery, especially in facelifts (83.6%) and rhinoplasty (55.0%), reducing bleeding (61.8%) and bruising (63.2%). Common methods include 1 g IV bolus or 3% topical solution, with 92.4% reporting no complications. Despite benefits, standardization is needed.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/Logo-Small-2-1.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/Lunchtime-Lessons.png)](https://www.theplasticsfella.com/journal-tranexamic-acid/) To the Editor at JPRAS, Mr Adam Reid, and his team — **huge thanks** for making this happen and for pushing the specialty forward. Let’s keep making plastic surgery education **bigger, better, and more open.** P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Upper Eyelid Recon?** ****Are you ready to make it to the leaderboard?** Welcome to the next round of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-10.png) ## Image of the Week **Original Mustardé Publication from 1974* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week’s image highlights the ****pentagon-shaped resection** for eyelid defect closure — from Mustardé's original publication. Here's how it illustrates maintaining lid contour and function👇 ![Pentagon-shaped resection for eyelid defect closure](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-11.png) Pentagon-shaped resection for eyelid defect closure ## Technique Tip **Mustardé Cheek Flap* 🚑 ****Technique Tip of the Week** This week, we’re focusing on how to get an optimal Mustardé flap. ****Medial Incision:** Perpendicular and shorter than the lateral incision. ****Flap Apex:** Positioned ****above the lateral canthus**, as per Mustardé’s original 1974 description. ****Back-Cut:** Used only if additional length is required. Precision in flap design minimizes tension and optimizes contour. ![Mustardé flap technique](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Mustarde-Flap.png) Mustardé flap technique ## the Fellows' Corner **SMAS Lift Botox: Is There Science Behind the Hype?* 📽️ ****Is SMAS Lift Botox supported by principles of botox or evidence?** Dr. Benedetta Agnelli breaks down the trending SMAS Lift Botox — does it align with Botox principles and evidence? 0:00 /2:01 1× SMAS Lift Botox For further details on Botox, check out the article below👇 [Botulinum Toxin: Mechanisms, Clinical Applications, & Injection TechniquesBotulinum toxin is a versatile neurotoxin that inhibits acetylcholine release, causing temporary muscle paralysis. FDA-approved for migraines, hyperhidrosis, and bladder issues, it’s also used off-label for facial aesthetics and pain. Proper technique and anatomy knowledge ensure effective outcomes.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/Logo-Small-2-2.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/Feature-Images--40-.png)](https://www.theplasticsfella.com/botulinum-toxin/) ## Foundations Textbook **March Update* 📙 ****Plastic Surgery Student Guide Update** In line with our "Building in Public" approach, we’re keeping you in the loop on the latest developments in the Plastic Surgery Student Guide. ![Subject pipeline of the student guide](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Student-Guide-Progress-Update.png) Subject pipeline of the student guide ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Optimal Aesthetic and Functional Outcomes for Eyelid and Canthal Reconstruction** ([Mathijssen](https://pubmed.ncbi.nlm.nih.gov/19559662/?ref=theplasticsfella.com), 2010) Eyelid and canthal reconstruction requires precise technique selection based on defect depth, size, and location to ensure functional and stable outcomes. ✅ ****A Step-by-Step Eyelid Recon Guide to Restoring Form and Function** ([Chang](https://journals.lww.com/plasreconsurg/abstract/2017/11000/eyelid%5Freconstruction.29.aspx?ref=theplasticsfella.com), 2017) Eyelid reconstruction requires precise anatomical knowledge, defect analysis, a structured reconstructive algorithm, and effective complication management to restore form and function. ✅ ****Surgical Outcomes in Pediatric Eyelid Burns: Timing, Techniques, & Long-Term Considerations** ([Lixin](https://journals.lww.com/op-rs/abstract/9900/surgical%5Ftechniques%5Fand%5Foutcomes%5Fin%5Fthe%5Fmanagement.559.aspx?ref=theplasticsfella.com), 2025) Early surgical release in pediatric eyelid burns optimizes ocular protection and recovery, while techniques like antegrade foreheadplasty and Double Frost Suture enhance the outcomes. ## Feedback ### I hope you enjoyed it 😄 --- ### Role of Tranexamic Acid (TXA) in Plastic and Reconstructive Surgery: A National Perspective URL: https://www.theplasticsfella.com/journal-tranexamic-acid/ Last updated: 2025-03-03T18:36:59.000Z #### In this Journal Club [****5-Point Summary**](https://www.theplasticsfella.com/journal-tranexamic-acid/#5-point-summary) TXA is widely used among ASPS members, especially in aesthetic (90.3%) and craniofacial surgery (78.2%), with 92.4% reporting no complications. [****4-Key Findings**](https://www.theplasticsfella.com/journal-tranexamic-acid/#4-key-findings) TXA is common in facelifts (83.6%) and rhinoplasty (55.0%), with 61.8% reporting less bleeding and 63.2% less bruising. Popular methods include 1 g IV bolus (43.2%) and 3% topical solution (36.0%). [****3-Critiques**](https://www.theplasticsfella.com/journal-tranexamic-acid/#3-critiques) A 21% response rate risks selection bias, potentially overrepresenting TXA users. Detailed outcomes are lacking data for specific procedures. Self-reported complications may be skewed by recall bias. [****2-Practical Takeaways** ](https://www.theplasticsfella.com/journal-tranexamic-acid/#2-practical-takeaways) TXA (1 g IV or 3% topical) reduces bleeding and bruising in facelifts and rhinoplasty. Topical TXA offers a safe, localized option for high-bleed surgeries. [****1-Recommended Reading**](https://www.theplasticsfella.com/journal-tranexamic-acid/#1-recommended-reading) Brown et al.’s meta-analysis (45 studies, 4,361 patients) confirms that TXA reduces blood loss in rhinoplasty and craniofacial surgery, supporting standardized protocols. ****Primary Contributor:** Hatan Mortada, Educational Fellow ****Verified by JPRAS✅** [Full Article](https://www.google.com/url?q=https://www.jprasurg.com/article/S1748-6815%2824%2900639-9/fulltext&source=gmail&ust=1741109073619000&usg=AOvVaw0D-ktbgdmG12ipl8h9tIEy) ✍️ ****Note from the Editor** [Rohrich et al](https://www.jprasurg.com/article/S1748-6815%2824%2900639-9/fulltext?ref=theplasticsfella.com) report widespread use of TXA among ASPS members with very low numbers reporting complications. There is good evidence for TXA use in trauma; however, elective breast and aesthetic surgery data is developing and will require further focussed research with validated outcome measures to enable standardised approaches to dosage, delivery route and timing. Congratulations to Rohrich and co-authors for publishing this work and raising awareness of the current trends in TXA use. Adam Reid, JPRAS Editor --- ## 5 Point Summary This study explores the use of tranexamic acid (TXA) among American Society of Plastic Surgeons (ASPS) members, highlighting its widespread adoption, preferred administration methods, and safety profile in plastic surgery. 1️⃣ ****Hypothesis:** TXA is increasingly utilized in plastic surgery with varying practices, but standardized guidelines are lacking. 2️⃣ ****Method:** A survey of 502 ASPS members assessed TXA use across procedures, administration protocols, and perceived benefits. 3️⃣ ****Results:** TXA is most common in aesthetic (90.3%) and craniofacial surgery (78.2%), with 92.4% reporting no complications. 4️⃣ ****Conclusion:** TXA is effective and safe, but administration varies widely, necessitating standardized protocols. 5️⃣ ****Implication:** Evidence supports broader TXA adoption, though further research is needed for specific procedures. ## 4 Key Findings The survey reveals TXA’s prominence in specific fields, its benefits in reducing bleeding, and a reassuring safety profile. ![TXA Injection: Dosage, Administration, and Clinical Use](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Journal-Club-Article-Title-Role-of-Tranexamic-Acid--TXA--in-Plastic-and-Reconstructive-Surgery-A-National-Perspective-TXA-Injection-Dosage--Administration--and-Clinical-Use--1-.png) TXA Injection: Dosage, Administration, and Clinical Use 1️⃣ Aesthetic surgery leads TXA use (90.3%), especially in facelifts (83.6%) and rhinoplasty (55.0%). ![Distribution of TXA Adoption Among ASPS Members](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Journal-Club-Article-Title-Role-of-Tranexamic-Acid--TXA--in-Plastic-and-Reconstructive-Surgery-A-National-Perspective-TXA-Injection-Dosage--Administration--and-Clinical-Use--3-.png) Distribution of TXA Adoption Among ASPS Members 2️⃣ Respondents report reduced blood loss (61.8%) and bruising (63.2%), improving surgical outcomes. ![TXA Advantages for Surgical and Nonsurgical Procedures Among ASPS Members](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Journal-Club-Images-1.png) TXA Advantages for Surgical and Nonsurgical Procedures Among ASPS Members 3️⃣ IV bolus (1 g, 43.2%) and topical 3% solution (36.0%) are the most common administration methods. ![TXA Advantages for Surgical and Nonsurgical Procedures Among ASPS Members](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Journal-Club-Images--1-.png) TXA Advantages for Surgical and Nonsurgical Procedures Among ASPS Members 4️⃣ Only 3.4% observed thrombotic events, with 92.4% noting no complications, suggesting a favorable safety profile. ![Observed TXA-Related Complications/Side Effects](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Journal-Club-Images--2-.png) Observed TXA-Related Complications/Side Effects --- ## 3 Critiques While comprehensive, the study has limitations in scope, depth, and generalizability. 1️⃣ ****Response Rate:** The 21% response rate (502/2,390 members) may introduce selection bias, potentially overrepresenting TXA users. 2️⃣ ****Outcomes:** Lack of procedure-specific outcome data limits insights into TXA’s efficacy for individual surgeries like abdominoplasty. 3️⃣ ****Self-reporting:** Self-reported complication rates may underreport adverse events due to recall bias or reluctance to disclose. ![Reported Concerns About TXA Usage](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Journal-Club-Images--3--1.png) Reported Concerns About TXA Usage --- ## 2 Practical Takeaways TXA offers actionable benefits for surgeons, particularly in aesthetic and craniofacial fields. 1️⃣ ****Efficacy**: Surgeons can confidently use TXA (e.g., 1 g IV or 3% topical) in facelifts or rhinoplasty to reduce bleeding and bruising. 2️⃣ ****Safety**: Topical TXA’s low systemic absorption makes it a safe option for localized effects, minimizing risks in high-bleed procedures. ## 1 Recommended Reading Brown et al.’s meta-analysis (45 studies, 4,361 patients) confirms that TXA reduces blood loss in rhinoplasty (high certainty) and craniofacial/burn surgery (moderate certainty), urging standardized outcome measures. [Read the Article](https://journals.lww.com/plasreconsurg/pages/articleviewer.aspx?year=2024&issue=12000&article=00047&type=Fulltextcle&ref=theplasticsfella.com) ### Finger Replantation: Indications, Surgical Technique, & Complications URL: https://www.theplasticsfella.com/finger-replant/ Last updated: 2025-02-28T14:06:26.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/finger-replant/#overview-of-finger-replantation) Finger amputation refers to the loss of a digit due to trauma or surgery, with thumb injuries being the most functionally significant. Replantation aims to restore function, sensation, and aesthetics. [****Indications**](https://www.theplasticsfella.com/finger-replant/#indications-for-finger-replantation) Replantation is preferred for thumb, multiple-digit, and distal injuries. Contraindications include severe crush injuries, prolonged ischemia (>12 hours warm, >3 days cold), and multilevel amputations. [****Clinical Assessment**](https://www.theplasticsfella.com/finger-replant/#clinical-assessment-for-finger-replantation) Preoperative preparation involves assessing ischemia time, injury mechanism, and comorbidities, conducting X-rays and vascular studies, starting antibiotics and anticoagulation, and preserving the amputated part in a cold water bath. [****Decision-Making Factors**](https://www.theplasticsfella.com/finger-replant/#decision-making-factors-for-finger-replantation) Injury type impacts survival — sharp injuries (\~90%) have the best prognosis, while avulsions (\~60%) often require vein grafts. Fingers tolerate ischemia better than muscle-containing tissues. [****Surgical Procedure**](https://www.theplasticsfella.com/finger-replant/#surgical-procedure-for-finger-replantation) The replantation process follows a stepwise approach: bone fixation, tendon and nerve repair, arterial and venous anastomosis, and skin closure. Postoperatively, vascular monitoring and early mobilization. [****Post-Operative Care**](https://www.theplasticsfella.com/finger-replant/#post-operative-care-of-a-finger-replant) Optimal recovery requires vascular monitoring, anticoagulation, immobilization, and early rehabilitation. [****Complications**](https://www.theplasticsfella.com/finger-replant/#complications-of-finger-replantation) Key complications include venous insufficiency (blue, swollen) and arterial thrombosis (pale, cold), managed through elevation, leech therapy, or surgical revision. ****Updated by:** Dr Hatan Mortada, Educational Fellow. ****Verified by thePlasticsFella ✅** --- ## Overview ofFinger Replantation ## ****Key Point** Finger amputation refers to the loss of a digit due to trauma or surgery, with thumb injuries being the most functionally significant. Replantation aims to restore function, sensation, and aesthetics. Finger amputation, also referred to as **re-implantation** or **re-attachment surgery**, involves the loss of a digit, ranging from distal fingertip injuries to proximal hand amputations. Understanding the distinction between replantation and revascularization is crucial in determining the appropriate surgical approach. - **Replantation** refers to the reattachment of a completely amputated part with the goal of restoring function, sensation, and aesthetics. - **Revascularization**, in contrast, is the restoration of blood flow to an incompletely amputated digit where some soft tissue connections remain intact. A successful outcome depends on careful patient selection, precise microsurgical technique, and structured post-operative rehabilitation ([Bregman](https://pmc.ncbi.nlm.nih.gov/articles/PMC11490447/?ref=theplasticsfella.com), 2023). 😎 ****Fun Fact:** The first successful digital replantation was performed in 1965, marking a major milestone in microsurgery. --- ## Indications for Finger Replantation ****Key Point** Replantation is prioritized for thumb and multiple-digit amputations, especially in children due to superior nerve regeneration. Severe crush injuries, prolonged ischemia (>12h warm, >3d cold), and multilevel amputations are relative contraindications due to poor outcomes. The decision to replant depends on **viability, functional recovery, and patient factors** ([Peterson](https://www.sciencedirect.com/science/article/pii/S0363502314005012?casa%5Ftoken=Z4OdgFocwOcAAAAA:3BQU-RzOWauE9bqP8OMWP5X3WJSwptV-JjOcL1MsRVMzFTL4O8QVVj2rJoveaZ9NfMHM3YTx&ref=theplasticsfella.com), 2018). The focus of replanting any part of the upper extremity is maximizing functional outcomes rather than simply ensuring the survival of the amputated part. Functional success depends on, - Level of amputation. - Arterial intima damage - Soft tissue condition. - Patient factors such as age, occupation, and cultural significance. ### Indications for Finger Replantation Replantation is considered when it significantly improves function([Barbary](https://www.sciencedirect.com/science/article/abs/pii/S1297320313001108?ref=theplasticsfella.com#:~:text=The%20absolute%20indications%20for%20replantation,are%20also%20a%20good%20indication.), 2013). Key indications include, - **Thumb Amputation:** essential for 40-50% of hand function; salvageable thumb is better than a prosthetic. - **Multiple-Digit Amputation:** particularly when the thumb or middle finger is involved. - **Zone 1 (Distal to FDS Insertion):** improve function despite potential DIP stiffness. - **Mid-Palm/Hand Amputation**: preferrable to prosthetics when function can be restored. - **Pediatric Cases:** superior nerve regeneration and adaptability enhance outcomes. ❗ ****Important**: ****Zone 2 (Proximal to FDS Insertion)** is controversial due to high risk of PIP stiffness ([Zhu](https://www.sciencedirect.com/science/article/pii/S1743919121002995?ref=theplasticsfella.com), 2021). Indications for finger replantation are summarised in the image below. ![Indications for Finger Replant after amputation in adult and child or paediatric patient. Thumb, fingers and palms](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-28T190507.907.png) Indications for finger replantation ### Contraindications for Replantation Replantation is unlikely to succeed in cases with: - **Severe Crush Injuries:** High risk of thrombosis and poor recovery. - **Multilevel Amputations:** Complex reconstruction with low success rates. - **Prolonged Ischemia:** \>12h warm ischemia has poorer outcomes, >3d cold ischemia may be viable but remains controversial. - **Life-Threatening Injuries:** Patient stabilization takes priority. The general indications and contraindications for replantation are summarized in the table below. ![General indications and contraindications for finger replantation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Template---Textbook-Images--1--1.png) General indications and contraindications for finger replantation 💡 ****Tip:** Thumb and index finger amputations should be prioritized, as they are the most functionally important digits. --- ## Clinical Assessment for Finger Replantation ****Key Point** Preoperative preparation for replantation involves assessing ischemia time, injury mechanism, and comorbidities, conducting X-rays and vascular studies, starting antibiotics and anticoagulation, and preserving the amputated part in a cold water bath to minimize tissue degradation. ### Preoperative Preparation A thorough preoperative evaluation is essential to improve replantation success rates and minimize complications. The key steps include: - **Clinical Assessment:** Evaluate ischemia time, injury mechanism, and patient comorbidities. - **Imaging:** X-rays to assess fractures and vascular studies if perfusion is unclear. - **Antibiotics & Anticoagulation:** These are initiated to prevent infection and thrombosis. - **Digit Preservation:** The amputated part should be **wrapped in sterile gauze, placed in a waterproof container, and stored in a cold water bath** (not frozen) to slow tissue degradation. --- ## Decision-Making Factors for Finger Replantation ****Key Point** Injury type impacts survival — sharp injuries (\~90%) have the best prognosis, while avulsions (\~60%) often require vein grafts. Fingers tolerate ischemia better than muscle-containing tissues, but survival rates drop beyond 24 hours. Replantation success depends on **4 important factors**: injury mechanism, ischaemia time, anatomical location, and patient factors. ### Mechanism of Injury & Survival Rates Finger amputations are classified into three major types, each with varying success rates. - **Sharp Injuries** (\~90% survival): Best prognosis due to clean-cut tissue planes. - **Crush Injuries:** Poor prognosis due to extensive soft tissue damage. - **Avulsion Injuries** (\~60% survival): Often require vein grafts due to vessel retraction. The injury mechanisms and their survival rates are summarized in the table below. ![Finger amputation injury mechanisms and corresponding survival rates](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Template---Textbook-Images--2-.png) Finger amputation injury mechanisms and corresponding survival rates ### Ischemia Time Considerations Fingers have a higher tolerance for ischemia compared to muscle-containing tissues ([Chang](https://pmc.ncbi.nlm.nih.gov/articles/PMC11304438/?ref=theplasticsfella.com), 2024): - **<12 hours:** 93% survival, optimal function. - **12–24 hours:** 87% survival, risk of stiffness and sensory loss. - **\>24 hours:** 65% survival, often requires secondary procedures. - **Cold ischemia >3 days:** Possible, but with diminished function. 😎 ****Fun Fact:** Fingers tolerate ischemia longer than other tissues because they lack muscle, allowing replantation success even after prolonged ischemia ### Anatomical Zones & Functional Outcomes: The **FDS insertion** defines key anatomical zones. - **Distal Zone (beyond FDS insertion):** Better DIP joint motion, protective sensation. - **Proximal Zone (proximal to FDS insertion)**: Higher risk of PIP joint stiffness. Anatomical zones and their functional outcomes are summarised below. ![Anatomical zones and their functional outcomes for finger replantation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Template---Textbook-Images--3-.png) Anatomical zones and their functional outcomes for finger replantation 😎 ****Fun Fact:** Studies using Tamai and Ishikawa classifications suggest that distal tip replantation preserves length, sensation, and motion without significantly affecting grip strength or cold intolerance (Sebastin, 2012). ### Patient-Related Factor Certain patient characteristics influence replantation success. - **Age:** Children have superior nerve regeneration and better outcomes. - **Smoking:** Conflicting evidence, but potential microvascular impact. - **Comorbidities:** Diabetes may impair microvascular healing. 😎 ****Fun Fact:** Children have the highest replantation success rates due to their exceptional nerve regeneration ability. --- ## Surgical Procedure for Finger Replantation ****Key Point** The replantation process follows a stepwise approach: bone fixation, tendon and nerve repair, arterial and venous anastomosis, and skin closure. Postoperatively, vascular monitoring and early mobilization. Finger replantation prioritizes **survival and function**, following the **"Macro Before Micro"** principle — stabilizing bone before soft tissue repair. Beyond reattachment, the goal is to restore **hand stability, movement, and sensation**. Key considerations include. - **Bone Shortening:** Facilitates tension-free closure and vascular anastomosis. - **Tendon Length Preservation:** Reduces adhesions and maintains mobility. - **Vein Grafting:** Necessary when direct anastomosis is not feasible. - **Replantation Priority:** Thumb > Long > Ring > Small > Index - **Multiple Amputations:** Structure-first repair is more efficient than digit-by-digit reconstruction ([Ono](https://pmc.ncbi.nlm.nih.gov/articles/PMC6527348/?ref=theplasticsfella.com), 2020). These steps of finger replanting are illustrated below. ![How to replant a finger amputation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-28T191521.212.png) How to replant a finger amputation ### **Bone Fixation** - The first step in replantation is stabilising the skeletal framework to allow precise soft tissue repair. - **Methods:** K-wires, interosseous wires, mini-plates, or screws. - **Bone Shortening:** Typically required to prevent excessive tension on vessels and nerves. **Extensor & Flexor Tendon Repair** - Tendon repair is essential for functional movement and grip strength. - **Techniques:** Core and epitendinous sutures for durability and minimal gap formation. - **Priority:** Spend time on a good flexor tendons repair 💡 ****Tip:** Two surgical teams working simultaneously can significantly reduce operative time. **Nerve Repair** - Nerve coaptation is crucial in proximal amputations to restore sensory and motor function. - **Preferred Method:** Direct coaptation whenever possible. - **Nerve Grafting:** Required when there is significant nerve loss. Common donor nerves: posterior interosseous nerve, sural nerve **Arterial Anastomosis** - Adequate arterial supply is critical for digit survival. - **At Least One Artery Must Be Repaired:** Preferably tension-free. - **Vein Grafting:** Used when direct arterial repair is not possible due to vessel damage or retraction. **Venous Repair** - Venous outflow is equally important as arterial inflow; inadequate venous drainage leads to venous congestion and failure. - **Two or More Veins Should Be Repaired:** If possible, to improve drainage. - **Preferred Veins:** Dorsal veins are larger, more accessible, and preferred for anastomosis. Volar veinsare an alternative if dorsal veins are unavailable. - **Salvage Techniques:** If venous repair is inadequate, leech therapy or controlled external bleeding can be used to manage congestion. 😎 ****Fun Fact:** The survival rate of replantation increases significantly with successful venous repair, reducing the risk of congestion. **Skin Closure** - Skin coverage ensures wound healing and prevents infection while also supporting venous drainage. - **Options:** Direct closure, local flaps, or skin grafting depending on tissue loss. - **Delayed Closure:** Considered in cases with excessive swelling or questionable perfusion. --- ## Post-Operative Care of a Finger Replant ****Key Point** Optimal recovery requires vascular monitoring, anticoagulation, immobilization, and early rehabilitation. There is no universal postoperative protocol for replantation. **Early vascular monitoring, tailored anticoagulation, structured rehabilitation,** and **patient involvement** are critical to achieving the best functional outcomes. **Vascular Monitoring** - Frequent checks are essential to identify arterial insufficiency or venous congestion. - Assess **capillary refill, skin color, and temperature** regularly. - Maintain a **warm environment** to promote vasodilation and circulation. - **Avoid vasoconstrictors** such as caffeine, nicotine, and chocolate. **Anticoagulation** - There is **no consensus** on anticoagulation in finger replantation, and practices vary widely ([Retrouvey](https://pubmed.ncbi.nlm.nih.gov/31192869/?ref=theplasticsfella.com), 2019). Common approaches include, - **Systemic:** Aspirin, intravenous heparin, LMWH, dextran. - **Local:** Heparin ("chemical leech") applied at the surgical site. - **No Thromboprophylaxis:** Some surgeons avoid anticoagulation due to lack of strong evidence. **Hand Therapy** - Strict movement protocols prevent stress on vascular anastomoses and avoid adhesions. - **Positioning** should maintain alignment while avoiding excessive tension on repaired structures. - Start **motion exercises** within 2-3 weeks, balancing mobility with repair protection. **Secondary Procedures** - Delayed rehabilitation may necessitate additional surgery to improve function: - **Flexor Tenolysis:** Releases adhesions to restore tendon movement. - **DIP Joint Arthrodesis:** Performed when joint mobility remains severely restricted. 💡 ****Tip:** Rehabilitation should begin ****as early as possible** but must be ****individualized** based on injury and repair stability. --- ## Complications of Finger Replantation ****Key Point** Replantation has a high survival rate (80-90%) in ideal candidates. Early complications, such as arterial thrombosis and venous congestion, require urgent management. Long-term issues, including joint stiffness and cold intolerance, affect functional recovery. Successful replantation depends on **early vascular monitoring, infection control,** and **structured rehabilitation** to prevent complications and optimize function. In cases of severe injury, amputation may be a more practical option to avoid prolonged recovery with uncertain functional gains. ### Early Complications The first **72 hours** are critical for **vascular monitoring and infection control**. **Venous insufficiency** and **arterial thrombosis** are the two most common complications in finger replantation surgery. **Arterial Thrombosis** - **Signs:** Pale, cold, dusky digit. - **Management:** Immediate revision surgery, loosening of dressings, and nerve block to restore perfusion. **Venous Congestion** - **Signs:** Blue, swollen, congested digit. - **Management:** Leech therapy, vein grafts, or surgical re-exploration to relieve venous obstruction. **Infection** - **Signs:** Redness, swelling, pus formation. - **Management:** Aggressive IV antibiotics, wound care, and surgical drainage if needed. The table below compares the arterial and venous complications. ![Comparison of venous insufficiency and arterial thrombosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Template---Textbook-Images--4-.png) Comparison of venous insufficiency and arterial thrombosis 💡 ****Tip:** 90% of vascular complications occur within the first 24-72 hours — early detection and intervention are critical to prevent digit loss ### Late Complications Delayed complications impact **movement, sensation, and circulation**, often requiring secondary interventions. While replantation can restore function, long-term success depends on injury severity, surgical precision, and rehabilitation commitment. **Joint Stiffness** - **Cause:** Prolonged immobilization, tendon adhesions, or capsular contracture. - **Management:** Early rehabilitation, secondary tenolysis, or capsulotomy. **Cold Intolerance** - **Signs:** Pain and discomfort in cold exposure. - **Management:** Conservative treatment with patient education and protective gloves. **Neuroma Formation** - **Signs:** Localized pain, hypersensitivity at the nerve injury site. - **Management:** Excision or nerve grafting if symptomatic. Common complications and their management options are summarised in the table below. ![Common complications of finger replantation and their management](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Template---Textbook-Images--5-.png) Common complications of finger replantation and their management 😎 ****Fun Fact:** Cold intolerance is one of the most common long-term complications, significantly impacting daily activities and patient satisfaction. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Understanding the causes and classification of finger amputation and replantation, along with the importance of functional restoration. ****2\. Indications & Contraindications:** Recognizing the key factors influencing the decision for replantation versus revision amputation. ****3\. Principles:** Identifying the mechanism of injury, ischemia time considerations, and anatomical factors that impact surgical outcomes. ****4\. Procedure:** Learning the stepwise surgical approach, including bone fixation, tendon and nerve repair, and vascular anastomosis. ****5\. Complications:** Familiarising with common post-operative issues such as arterial thrombosis, venous insufficiency, infection, and stiffness. ****6\. Discussion:** Comparing the benefits and drawbacks of replantation versus amputation for optimal patient outcomes. --- ## Further Reading 1. Rebowe RE, Tannan SC. Digit Replantation. \[Updated 2022 Sep 12\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448187/ 2. Pet MA, Ko JH. Indications for Replantation and Revascularization in the Hand. Hand Clin. 2019;35(2):119-130\. doi:10.1016/j.hcl.2018.12.003 3. Chang MK, Lim JX, Sebastin SJ. Current trends in digital replantation—a narrative review. Annals of Translational Medicine. 2024 Feb 26. 4. Maricevich M, Carlsen B, Mardini S, Moran S. Upper extremity and digital replantation. Hand (N Y). 2011;6(4):356-363\. doi:10.1007/s11552-011-9353-5 5. Kleinert HE, Juhala CA, Tsai TM, Van Beek A. Digital replantation—selection, technique, and results. Orthopedic Clinics of North America. 1977 Apr 1;8(2):309-18. 6. Sears ED, Chung KC. Replantation of finger avulsion injuries: a systematic review of survival and functional outcomes. J Hand Surg Am. 2011;36(4):686-694\. doi:10.1016/j.jhsa.2010.12.023 7. Scheker LR, Becker GW. Distal finger replantation. The Journal of hand surgery. 2011 Mar 1;36(3):521-8. 8. Hayashi, Kota MD1; Hattori, Yasunori MD, PhD1; Chia, Dawn Sinn Yii MBBS2; Sakamoto, Sotetsu MD1; Sonezaki, Shicho MD1; Doi, Kazuteru MD, PhD1\. Fingertip Replantation: Surgical Technique, Tips, and Tricks. Plastic and Reconstructive Surgery 153(1):p 168-171, January 2024\. | DOI: 10.1097/PRS.0000000000010521 ### Designer Nipple Filler, 3 Facial Nerve Landmarks, & Tips for Clinical Examination. URL: https://www.theplasticsfella.com/february-23rd/ Last updated: 2025-02-22T18:53:10.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/february-23rd/#a-letter-from-pfella) Designer Nipples... 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-23rd/#the-sunday-quiz) How well do you know **the facial nerve*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/february-23rd/#image-of-the-week) Signs of facial nerve palsy. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-23rd/#technique-tip) Sural nerve graft location for nerve recon. 5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/february-23rd/#what-does-the-evidence-say) Facial nerve branch localization. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-23rd/#articles-of-the-week) Facial nerve danger zones, parotidectomy, & assessing the facial nerve: with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/february-23rd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Designer Nipples....* 👋 ****Hey Team!** Nothing is currently off limits—even our most unexpected features. We have evolved from cheek and lip fillers to a trend that now offers a quick shot of hyaluronic acid to enhance nipple appearance. Priced \~$5K and promising results from six months to two years, this development is a perky twist... Before you raise an eyebrow, consider this: a 2017 Independent article already spotlighted “designer nipples” as a controversial trend, highlighting how the quest for perfection isn’t just about major features. Scientific [literature](https://pubmed.ncbi.nlm.nih.gov/32158901/?ref=theplasticsfella.com) has documented the evolution of nipple reconstruction and augmentation techniques. So, are we truly witnessing innovation, or is this just an old idea repackaged for today’s market? **The Big Question** Here’s where it gets controversial: Is this a genuine step toward personal empowerment, or are we just enabling an industry that thrives on our insecurities? This isn’t about passing judgment on anyone’s body— the literature shows all genders have reported outcomes - it’s about the fine line between self-expression and a market-driven obsession with perfection. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Screenshot-2025-02-22-at-18.51.15.png) [Source](https://link.springer.com/article/10.1007/s00266-004-0145-y?ref=theplasticsfella.com) **Downstream Effects** I'm particularly interested in the second-order effects. Redesigning every detail creates ripple effects throughout our practice. For example, altering nipple anatomy may complicate breast screening and imaging, while changes in tissue contours and projections can obscure subtle signs on [mammograms or ultrasounds](https://academic.oup.com/jbi/article-abstract/6/2/223/7638511?redirectedFrom=fulltext&ref=theplasticsfella.com), potentially leading to diagnostic challenges later. Even minor cosmetic procedures can have significant consequences for patient care. With love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know the* ***Facial Nerve?** ****Are you ready to make it to the leaderboard?** Welcome to the next round of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-9.png) ## Image of the Week **Signs of Facial Nerve Palsy* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week’s image highlights left-sided lower motor neuron facial nerve palsy. ****(A)** Generalized muscle weakness affecting the forehead, cheek, and mouth. ****(B)** ****Positive Bell’s phenomenon** — upward eye movement when attempting to close the left eye. ![Left-sided lower motor neurone facial nerve palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-7.png) Left-sided lower motor neurone facial nerve palsy - [Source](https://entokey.com/facial-palsy/?ref=theplasticsfella.com) ## Technique Tip **Sural Nerve Graft Location* 🚑 ****Technique Tip of the Week** This week, we’re focusing on optimal sural nerve graft location for nerve reconstruction. ****Landmarks:** Found beneath superficial fascia, adjacent to the saphenous vein. ****Technique:** Incise over the posterolateral ankle, dissect carefully to expose the nerve. ****Tip:** Preserve the saphenous vein to minimize trauma. Efficient dissection ensures a viable graft for reconstruction. ![Sural nerve graft location for nerve reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-8.png) Sural nerve graft location for nerve reconstruction - [Source](https://www.cns.org/nexus/spine/case/sural-nerve-harvesting?ref=theplasticsfella.com) ## What Does the Evidence Say? **Facial Nerve Branch Localization* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The **temporal branch** of the facial nerve (CN VII) is a critical structure in the frontotemporal region. It typically pierces the ****parotidomasseteric fascia** below the ****zygomatic arch**, travels in the ****subcutaneous tissue**, and then enters the ****subgaleal space** above the arch (Ammirati et al., 1993). The nerve's course is variable, with ****twigs** sometimes extending ****posterior** to the ****anterior quarter** of the ****temporalis muscle** (Ammirati et al., 1993). Several landmarks have been proposed to locate the nerve, including the ****frontal branch** of the ****superficial temporal artery** (Lei et al., 2005) and a point ****3.21 cm from the tragus** along the ****zygomatic arch** (Sanderson et al., 2020). The nerve is generally found within ****2.5-3 cm** of the ****lateral orbital rim** and ****2.85 cm superior** and ****2.54 cm lateral** to the ****lateral canthus** (Hashmi et al., 2021). Various surgical techniques have been developed to protect the nerve during procedures, including ****interfascial dissection** and combined ****frontotemporal scalp**/****superficial temporal fascia dissection** (Pekár et al., 2004). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Facial Nerve Danger Zones: Anatomical Insights for Facelift Surgery** ([Stuzin](https://journals.lww.com/plasreconsurg/abstract/2020/01000/facial%5Fnerve%5Fdanger%5Fzones.21.aspx?ref=theplasticsfella.com), 2020) Understanding the three-dimensional anatomy and danger zones of the facial nerve is crucial for preventing iatrogenic injury during facial rejuvenation surgery. ✅ ****How to Optimize Facial Nerve Outcomes in Parotidectomy** ([Brenner](https://www.jprasurg.com/article/S1748-6815%2824%2900622-3/abstract?ref=theplasticsfella.com), 2025) Malignant parotid tumors often necessitate facial nerve sacrifice due to locoregional invasion, increasing the need for microsurgical reconstruction, nerve grafting, or reinnervation to optimize outcomes. ✅ ****Facial Nerve Trauma: Assessing, Predicting, & Restoring Function After Injury** ([Brown](https://journals.lww.com/plasreconsurg/abstract/2019/05000/facial%5Fnerve%5Ftrauma%5F%5Fclinical%5Fevaluation%5Fand.41.aspx?ref=theplasticsfella.com), 2019) Facial nerve palsy management depends on duration, location, and mechanism of injury. Early cases may allow direct repair, grafting, or nerve transfer, while prolonged palsy requires free functional muscle transfer for reanimation. ## Feedback ### I hope you enjoyed it 😄 --- ### Facial Nerve Palsy: Clinical Assessment, Grading, & Management URL: https://www.theplasticsfella.com/facial-nerve-palsy/ Last updated: 2025-02-17T19:54:01.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/facial-nerve-palsy/#overview-of-facial-nerve-palsy) Facial nerve palsy is characterized by weakness or paralysis of the facial muscles, affecting not only motor control but also sensory and autonomic functions of the face. [****Anatomy of the Facial Nerve**](https://www.theplasticsfella.com/facial-nerve-palsy/#anatomy-of-the-facial-nerve) The facial nerve originates in the pons and travels through the internal auditory and facial canals to exit via the stylomastoid foramen, where it branches into five divisions that control facial expression, taste, and gland secretion. [****Causes**](https://www.theplasticsfella.com/facial-nerve-palsy/#causes-of-facial-nerve-palsy) Causes are categorized as intracranial (e.g., stroke, tumors), intratemporal (e.g., Bell’s palsy, infections), or extratemporal (e.g., trauma, neoplasms). [****Clinical Assessment**](https://www.theplasticsfella.com/facial-nerve-palsy/#clinical-assessment-of-facial-nerve-palsy) Assessment of the facial nerve includes a detailed history, a targeted focal and systemic examination, and investigations, including blood tests, electrophysiological studies such as EMG, and imaging. [****Grading**](https://www.theplasticsfella.com/facial-nerve-palsy/#grading-of-facial-nerve-palsy) Facial nerve palsy is most commonly graded using the House-Brackmann scale, but additional grading systems are also used, particularly for reconstructive and functional assessments. [****Management**](https://www.theplasticsfella.com/facial-nerve-palsy/#management-of-facial-nerve-palsy) Management of facial nerve palsy includes non-operative treatments, static procedures, and dynamic reanimation techniques, all tailored to the aetiology, degree of nerve damage, and duration of paralysis. [****Complications**](https://www.theplasticsfella.com/facial-nerve-palsy/#complications-of-facial-nerve-palsy) Facial nerve palsy can lead to a range of complications that impact vision, facial symmetry, and overall function. Prognosis varies based on factors such as severity, patient age, and treatment response. ****Primary Contributor:** Dr Waruguru Wanjau, Kurt Lee Chircop Educational Fellows. ****Verified by thePlasticsFella ✅** --- ## Overview of Facial Nerve Palsy ****Key Point** Facial nerve palsy is characterized by weakness or paralysis of the facial muscles, affecting not only motor control but also sensory and autonomic functions of the face. Facial nerve palsy is a condition characterized by weakness or paralysis of the muscles responsible for facial expression. It presents with a wide range of effects, from motor deficits that impair essential functions such as smiling and blinking to sensory and autonomic disturbances affecting tear and saliva production. The image below shows right-sided facial palsy. ![Right-sided facial palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-17T233915.437.png) Right-sided facial palsy A critical component of understanding facial nerve palsy is distinguishing between central and peripheral lesions. This differentiation not only aids in diagnosis but also directs appropriate treatment strategies. --- ## Anatomy of the Facial Nerve ****Key Point** The facial nerve originates in the pons, travels through the internal auditory and facial canals to exit via the stylomastoid foramen, where it branches into five divisions that control facial expression, taste, and gland secretion. [Facial nerve anatomy](https://www.theplasticsfella.com/facial-nerve/) begins its journey in the brainstem, specifically in the pons, and follows a complex path before reaching the face. It travels through several key regions. - [**Intracranial**](https://www.theplasticsfella.com/facial-nerve/#intracranial-facial-nerve-anatomy) **Segment:** Originates in the pons. - [**Intratemporal**](https://www.theplasticsfella.com/facial-nerve/#intratemporal-facial-nerve-anatomy) **Segment:** Passes through the internal auditory canal and the facial canal within the temporal bone. - [**Extratemporal**](https://www.theplasticsfella.com/facial-nerve/#extracranial-facial-nerve-anatomy) **Segment:** Exits the skull via the stylomastoid foramen, enters the parotid gland, and divides into its five terminal branches. Facial nerve anatomy is illustrated below. ![Facial nerve anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-17T235118.023.png) Facial nerve anatomy These terminal branches are the [temporal](https://www.theplasticsfella.com/temporal-or-frontal-branch-of-facial-nerve/), zygomatic, buccal, marginal mandibular, and cervical divisions. The nerve has three main functional components. - **Motor:** Controls the muscles for facial expression. - **Sensory:** Provides taste sensation to the anterior two-thirds of the tongue and tactile sensation to the skin of the concha. - **Parasympathetic:** Supplies secretomotor fibers to the lacrimal, submandibular, and sublingual glands. --- ## Causes of Facial Nerve Palsy ****Key Point** Causes are categorized as intracranial (e.g., stroke, tumors), intratemporal (e.g., Bell’s palsy, infections), or extratemporal (e.g., trauma, neoplasms). Facial nerve palsy covers a wide range of conditions and is traditionally categorized into upper and lower motor neuron lesions. **Lower** motor neuron lesions include **Bell’s palsy** and **Ramsay Hunt syndrome**, while **upper** motor neuron lesions encompass conditions such as **stroke**, **multiple sclerosis**, **subdural hemorrhage**, and **intracranial neoplasia**. ### Bell's Palsy Bell’s palsy accounts for the majority of acute unilateral facial nerve palsy cases, with over 90% recovering fully ([Flifel](https://link.springer.com/article/10.1186/s41983-020-00171-6?ref=theplasticsfella.com), 2020). Key points in relation to Bell's Palsy include, - Idiopathic lower motor neuron disorder typically after a viral prodrome. - Complete unilateral facial paralysis, recurrence in 10%, recovery up to one year (with 13% incomplete) ([Walker](https://www.ncbi.nlm.nih.gov/books/NBK549815/?ref=theplasticsfella.com), 2023). ### Other Causes Other Causes of facial nerve palsy can be classified according to the location where the pathology or injury has occurred ([Spencer](https://www.magonlinelibrary.com/doi/abs/10.12968/hmed.2016.77.12.686?ref=theplasticsfella.com), 2016). **Intracranial Causes** - **Vascular:** Stroke, TIA, aneurysms. - **Neoplasms:** Primary or secondary intracranial tumors. - **Trauma:** Brainstem or intracranial injuries. - **Congenital:** Conditions like Möbius syndrome or Goldenhar syndrome. **Intratemporal Causes** - **Idiopathic**: Bell's Palsy. - **Infections:** Viral (herpes simplex, varicella-zoster); bacterial (otitis media), Lyme Disease ([Hohman](https://www.ncbi.nlm.nih.gov/books/NBK560623/?ref=theplasticsfella.com), 2023). - **Trauma:** Temporal bone fractures. - **Neoplasms:** Acoustic neuroma compressing CN VII. **Extratemporal Causes** - **Neoplastic:** Parotid gland malignancies, facial nerve tumors. - **Trauma:** Penetrating trauma, birth trauma. - **Iatrogenic**: Parotid, Acoustic Neuroma surgery - **Congenital:** Hemifacial microsomia. 😎 ****Fun Fact:** Melkersson-Rosenthal Syndrome is a rare idiopathic condition marked by non-inflammatory facial edema, congenital tongue fissures (lingua plicata), and facial palsy ([Fagan](https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Surgical%20reanimation%20techniques%20for%20facial%20palsy%20%5Fparalysis%5F.pdf?ref=theplasticsfella.com), 2014). --- ## Clinical Assessment of Facial Nerve Palsy ****Key Point** Assessment of the facial nerve includes a detailed history, a targeted focal and systemic examination, and investigations, including blood tests, electrophysiological studies such as EMG, and imaging. Clinical assessment of facial nerve palsy relies on history, examination, and distinguishing central from peripheral causes using features such as symmetry, muscle movements, and special sensory changes. ### History A thorough history is essential to determine the underlying cause, severity, and progression of facial nerve palsy. Once **aetiology** is established, the next step is to ascertain the **time** elapsed since onset, as this will directly affect the surgical strategy employed. **Onset and Progression** - Sudden onset (e.g., Bell’s palsy) versus gradual progression (e.g., tumors). - Evaluate the duration, rate of worsening, and any fluctuations in severity. - Any head or neck trauma that could suggest a temporal bone fracture or iatrogenic injury. **Associated Symptoms** - **Otological:** Otalgia (ear pain), otorrhoea (ear discharge), hearing loss, ear fullness, tinnitus, and dizziness, which may indicate conditions like otitis externa, otitis media, or temporal bone pathology. - **Vesicular Eruptions/Rash:** Suggestive of Ramsay Hunt syndrome or herpes zoster. - **Brow Ptosis:** Can obstruct vision and cause chronic eye irritation. - **Systemic Symptoms:** May point to underlying conditions such as sarcoidosis or Lyme disease. ![Presentation of facial nerve palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-31T193327.001.png) Presentation of facial nerve palsy ### Examination The goal of examination is to determine the location of the facial nerve palsy and potential aetiology. This should be done in a systematic fashion to assess both focal deficits and systemic signs. **Terminal Branches** Begin by evaluating each branch of the facial nerve (temporal, zygomatic, buccal, mandibular, and cervical). - [**Temporal**](https://www.theplasticsfella.com/temporal-or-frontal-branch-of-facial-nerve/)**:** Test eyebrow elevation, forehead wrinkling degree of brow ptosis. This branch innervates the frontalis, orbicularis oculi, and corrugator supercilii. - **Zygomatic:** Evaluate complete eye closure, ectropion, Bell’s phenomenon and Snap Test. This branch controls the lower orbicularis oculi, essential for corneal protection. - **Buccal:** Ask the patient to smile and puff out their cheeks. Innervates the buccinator and orbicularis oris; dysfunction allows air to escape from the affected side ([Masterson](https://www.bmj.com/content/351/bmj.h3725.full?ref=theplasticsfella.com), 2015). - **Mandibular Branch:** Assess for commissure droop or philtrum deviation, and observe lip movement during smiling. This branch innervates the depressor anguli oris and depressor labii inferioris; dysfunction results in a flattened nasolabial fold and asymmetry. - **Cervical:** Check neck and lower facial expressions. The cervical branch innervates the platysma, which tenses neck skin and aids lower facial movement. The below table breaks down the clinical examination of facial nerve palsy. ![Clinical assessment of facial nerve palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-17T235919.963.png) Clinical assessment of facial nerve palsy 😎 ****Fun Fact:** Using the "Look & Move ± Feel" approach, differentiate between UMN lesions (forehead sparing due to bilateral cortical innervation) and LMN lesions (causing complete facial paralysis). **Specific Competence Examinations** - **Oral Competence:** Facial weakness can impair speech (due to lower lip depressor dysfunction), complicate eating/drinking (with risk of food spillage in bilateral palsy), increase dental caries (from reduced saliva), and alter taste sensation (from chorda tympani involvement) ([Pineckwitz](https://pmc.ncbi.nlm.nih.gov/articles/PMC9143601/?ref=theplasticsfella.com#B76-jcm-11-02890), 2022). - **Ocular Competence:** Denervation of the orbicularis oculi can lead to dryness, irritation, excessive tearing, exposure keratitis, corneal ulceration/infections, and long-term vision risk ([Crawford](https://pubmed.ncbi.nlm.nih.gov/32628417/?ref=theplasticsfella.com), 2020). - **Otologic Evaluation:** Perform otoscopy to assess for ear pain, discharge, hearing loss, tinnitus (suggestive of infection), or vesicular eruptions (indicative of Ramsay Hunt syndrome). - **Airway Competence:** Assess airway patency and protective reflexes, and perform Cottle's Maneuver—which involves gently pulling the cheek laterally to widen the nasal valve—to specifically evaluate for nasal valve collapse and confirm adequate nasal airflow. These examinations are explained in the video below. **Sensory Testing** - **Taste Sensation:** Apply various taste stimuli to the anterior two-thirds of the tongue to evaluate chorda tympani function; decreased or altered taste indicates its involvement. - **Hearing and Hyperacusis:** Assess for sensitivity to loud sounds and check the stapedius reflex. - **Lacrimation:** Use Schirmer’s test to measure tear production and assess greater superficial petrosal nerve involvement. - **Other Cranial Nerves:** Evaluate CN V (facial sensation) and CN VIII (hearing) to detect additional deficits that may aid in diagnosis. 💡 ****Tip:** Bilateral facial nerve palsy is rare (\~2% of cases); consider Lyme disease, Guillain-Barré, diabetes, sarcoidosis, and neurological causes like Parkinson’s, multiple sclerosis, or pseudobulbar/bulbar palsy. ### Investigations A comprehensive workup — including blood tests, special functional assessments, and imaging studies — is essential for determining the underlying cause of facial nerve palsy. **Blood Tests** - **Full Blood Count (FBC):** Detects infections or hematologic abnormalities. - **Urea & Electrolytes (U&E):** Evaluates metabolic causes. - **C-reactive Protein (CRP):** Serves as an inflammatory marker. - **Varicella-Zoster Virus (VZV) Antibody Titers:** Elevated in Ramsay Hunt syndrome. - **Borrelia Burgdorferi IgG/IgM:** Indicates Lyme disease. **Special Tests** - **Audiogram:** Assesses hearing loss, helping to differentiate Bell’s palsy from cerebellopontine angle tumors. - **Nerve Excitability Test (NET):** Measures the minimal stimulus required for facial muscle contraction; a side-to-side difference >3.0 mA is abnormal. - **Maximal Stimulation Test (MST):** Evaluates the muscle response to maximal stimulus and often becomes positive earlier than NET in nerve injuries. - **Electroneurography (ENoG):** Compares muscle action potentials between affected and normal sides; >75% degeneration indicates a poor prognosis and guides early surgical planning. - **Electromyography (EMG):** Detects fibrillation potentials after 14–21 days, useful for late prognostic evaluation in cases of total paralysis. **Imaging** - **CT Scan:** Indicated for suspected necrotizing otitis externa, middle ear infections, head trauma (to assess temporal bone fractures), or malignancy evaluation. - **MRI Scan:** Used for intratemporal and intracranial pathology, particularly when suspecting facial nerve compression (e.g., at the cerebellopontine angle) or enhancement around the geniculate ganglion. 💡 ****Tip:** Always rule out stroke and other serious underlying conditions when evaluating facial nerve palsy. In Bell's palsy, brain MRI should be negative. --- ## Grading of Facial Nerve Palsy ****Key Point** Facial nerve palsy is most commonly graded using the House-Brackmann scale, but additional grading systems are also used, particularly for reconstructive and functional assessments. Facial nerve palsy is evaluated using standardized grading systems that help quantify severity, track recovery, and guide treatment decisions. The most common is the House-Brackmann grading system. ### House-Brackmann Grading System The H-B scale is the most widely used system, categorizing facial function from Grade I (normal) to Grade VI (total paralysis) ([Samsudin](https://telkomnika.uad.ac.id/index.php/TELKOMNIKA/article/view/6128?ref=theplasticsfella.com), 2017). Its simplicity makes it popular for clinical use, though it may lack granularity when monitoring subtle, regional changes. The gradings and their features are shown in the table below. ![House-Brackmann grading system of facial nerve palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-13T011150.760.png) House-Brackmann grading system of facial nerve palsy ❗ ****Important**: The key difference between Grades III and IV is eye closure — Grade III allows complete closure, whereas Grade IV does not. ### Other Grading Systems Other facial nerve palsy reading systems also exist and may be more useful to assess for reconstruction ([Fagan](https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Surgical%20reanimation%20techniques%20for%20facial%20palsy%20%5Fparalysis%5F.pdf?ref=theplasticsfella.com), 2014). **Sunnybrook Facial Grading System** The Sunnybrook system uses a composite score (0–100) to assess regional function, including synkinesis, making it highly reproducible and sensitive for longitudinal monitoring and research. It evaluates three key components, - **Resting Symmetry:** symmetry of the eye, cheek, and mouth. - **Voluntary Movement:** forehead wrinkling, gentle eye closure, and an open-mouth smile. - **Synkinesis:** degree of involuntary muscle movements during voluntary actions. **FaCE (Facial Clinimetric Evaluation) Scale** A 51-item assessment tool used to measure patient-reported outcomes. This scale is particularly valuable in reconstructive and rehabilitation settings where patient feedback on functional outcomes is crucial. It comprises of: - **7 Visual Analogue Scale (VAS) Items:** Quantify subjective measures of facial function. - **44 Likert Scale Items:** Rated from 1 (worst) to 5 (best), they assess the patient’s perception of facial impairment and disability. --- ## Management of Facial Nerve Palsy ****Key Point** Management of facial nerve palsy includes non-operative treatments (eye protection, physiotherapy, and monitoring), static procedures for symmetry, and dynamic reanimation techniques to restore movement, all tailored to the aetiology, degree of nerve damage, and duration of paralysis. Management strategies for facial nerve palsy are guided by the underlying **aetiology**, degree of **nerve degeneration**, and **duration of paralysis**. Approaches can be broadly classified into three categories. - **Non-Operative:** Eye Protection, Physiotherapy, Monitoring - **Static Procedures:** Eyelids, Forehead, Neck - **Dynamic Procedures:** Nerve and Muscle Procedures ### Decision-Making Process Facial nerve injury management depends on nerve function, muscle viability, and proximal stump presence — early injuries with a stump allow for direct repair or grafting, while those without (and late injuries) require cross-face nerve grafts, cranial nerve transfers, or free muscle transfers. The streamlined approach involves, **Assess Nerve Function** - **Adequate Function:** Improve symmetry by weakening the unaffected side. - **Inadequate Function:** Augment the affected side using a cross-face nerve graft or cranial nerve transfer. **For Early Injuries (Viable Facial Muscle)** - **Proximal Nerve Stump Present:** Proceed with direct repair or ipsilateral nerve grafting. - **No Proximal Nerve Stump:** Opt for a cross-face nerve graft or cranial nerve transfer. **For Late Injuries (Nonviable Facial Muscle)** - **Proximal Nerve Stump Present:** Use free muscle transfer to the ipsilateral facial nerve (VII). - **No Proximal Nerve Stump:** Combine free muscle transfer with a cross-face nerve graft or cranial nerve transfer. This approach helps determine the optimal management strategy based on injury timing and anatomical viability. ### Non-Operative Management While Bell’s palsy is a common cause of facial nerve palsy, non-operative management applies to a range of etiologies — including traumatic, infectious, and neoplastic causes. - **Medical Management:** For inflammatory or viral-related palsies (e.g., Ramsay Hunt syndrome), early intervention with high-dose corticosteroids (ideally within 72 hours) is beneficial, and adjunct antiviral therapy may be warranted ([Gilden](https://pubmed.ncbi.nlm.nih.gov/21342215/?ref=theplasticsfella.com), 2011). - **Eye Protection:** For patients with incomplete eyelid closure, aggressive ocular management is critical. This includes lubricating drops, moisture chambers, and, in severe cases, temporary tarsorrhaphy to prevent exposure keratitis ([Baugh](https://pubmed.ncbi.nlm.nih.gov/24190889/?ref=theplasticsfella.com), 2013). - **Facial Physiotherapy:** Neuromuscular retraining and biofeedback can enhance recovery by promoting synkinetic movement and facilitating re-education of facial muscles. - **Monitoring and Prognostication:** Electrophysiological studies (ENoG and EMG) are essential for prognosis: ENoG measures axonal degeneration (over 75% suggests poor outcome), while EMG (14–21 days post-onset) detects denervation via fibrillation potentials. ### Static Procedures for Treating Facial Nerve Palsy Static procedures aim to re-establish resting facial symmetry and improve functional deficits — such as protecting the cornea, enhancing nasal airflow, and reducing drooling — **but do not restore dynamic facial movement.** These interventions are particularly indicated in, - **Patient Cohort:** Elderly patients, medically unfit to undergo long surgery. - **Timing:** established paralysis with nonviable facial musculature, temporary solutions for large facial defects (eg. oncological resection) ([Fagan](https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Surgical%20reanimation%20techniques%20for%20facial%20palsy%20%5Fparalysis%5F.pdf?ref=theplasticsfella.com), 2014). **Non-Operative Static Treatment** - **Botulinum Toxin Injections:** Help manage synkinesis and improve facial asymmetry. - **Facial Fillers:** Provide temporary volume correction for asymmetry. - **Physical Therapy:** Rehabilitative exercises and neuromuscular retraining can improve static symmetry ([Garcia](https://pubmed.ncbi.nlm.nih.gov/26017609/?ref=theplasticsfella.com), 2015). **Eyelid Procedures** - **Tarsorrhaphy:** Temporary or permanent eyelid closure to protect the cornea. - **Upper Eyelid Weight Implantation:** Gold or platinum weights assist with passive eyelid closure, reducing corneal risk (Chen et al., 2010). - **Palpebral Springs/Lid Magnets:** Alternative methods to improve eyelid function. **Brow and Forehead Procedures** - **Müllerectomy:** Corrects ptosis. - **Brow Lift/Suspension:** Elevates a drooping brow. - **Forehead Skin Excision:** Enhances brow elevation and reshapes the forehead. **Facial and Neck Procedures** - **Unilateral Facelift-Type Procedures:** Improve lower face symmetry. - **Static Slings/Fascial Suspension:** Reposition drooping soft tissues to restore static balance. - **Platysmectomy:** Addresses cervical synkinesis. 😎 ****Fun Fact:** Müller’s muscle, an involuntary, sympathetically innervated muscle located below the levator aponeurosis and attached to the cephalad tarsal border, contributes 2–3 mm of eyelid elevation ([Fagan](https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Surgical%20reanimation%20techniques%20for%20facial%20palsy%20%5Fparalysis%5F.pdf?ref=theplasticsfella.com), 2014). ### Dynamic Procedures for Treating Facial Nerve Palsy [Dynamic reanimation](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/) seeks to restore voluntary, spontaneous facial movement and improve overall function by addressing both **nerve** continuity and **muscle** function. The goal of these techniques is to, - Re-establish a coordinated, symmetrical smile and improve facial tone for speech and eating ([Coyle](https://pubmed.ncbi.nlm.nih.gov/23385066/?ref=theplasticsfella.com), 2013). - Improve cheek tone, which enhances speech and the ability to eat. **Nerve-Related Procedures** - [**Primary Repair**](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#primary-facial-nerve-repair)**:** Immediate direct repair in cases of acute transection or iatrogenic injury—ideally within 48–72 hours—to restore nerve continuity. - [**Interposition Nerve Grafting**](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#ipsilateral-nerve-grafting)**:** When direct repair is not possible, nerve grafts (e.g., sural nerve grafts) are used to bridge the gap, with early intervention optimizing outcomes - [**CFNG**](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#cross-facial-nerve-graft)**:** Cross facial nerve graft transfers motor axons from the unaffected side to reinnervate paralyzed muscles, serving as the first stage in two-stage reanimation. - [**Nerve Transfers**](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#nerve-transfers)**:** Nerve transfers (e.g., masseter-to-facial) provide motor input when proximal regeneration is unlikely, while the babysitter procedure (using the hypoglossal nerve) maintains muscle tone during axonal migration ([Fagan](https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Surgical%20reanimation%20techniques%20for%20facial%20palsy%20%5Fparalysis%5F.pdf?ref=theplasticsfella.com), 2014) in the CFNG. The babysitter procedure for treating facial nerve palsy is illustrated below. ![The babysitter procedure for treating facial nerve palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-17T225458.507.png) The babysitter procedure for treating facial nerve palsy 💡 ****Tip:** Nerve transfers options for facial reinnervation include the glossopharyngeal, spinal accessory, hypoglossal, and masseteric nerves. **Muscle Transfer** Longstanding facial nerve paralysis (>2 years) causing irreversible atrophy requires dynamic reanimation via regional or free muscle transfer. - [**Free Muscle Transfer**](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#free-muscle-transfer)**:** In long-standing or complete paralysis, a free muscle transfer—commonly using the gracilis—reinnervated by a cross-facial nerve graft or nerve transfer restores dynamic movement, including smile and eye closure. - [**Regional Muscle Transfer**](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#regional-muscle-transfer)**:** For paralysis exceeding two years with irreversible muscle atrophy, regional muscle transfers or local flaps (e.g., masseter, temporalis) provide substitute musculature, sometimes combined with CFNG. Used when there is no functional mimetic muscle left for reinnervation. 💡 ****Tip:** Other muscles used for facial reanimation include the latissimus dorsi, rectus femoris, extensor digitorum brevis, serratus anterior, rectus abdominis, and platysma. --- ## Complications of Facial Nerve Palsy ****Key Point** Facial nerve palsy can lead to a range of complications that impact vision, facial symmetry, and overall function. Prognosis varies based on factors such as the severity of the palsy, patient age, and treatment response. Facial nerve palsy may result in a variety of complications that not only impair facial appearance but also compromise ocular health and overall facial function ([Walker](https://www.ncbi.nlm.nih.gov/books/NBK549815/?ref=theplasticsfella.com), 2023). Important **complications** to be aware of include, - **Exposure Keratitis:** Inadequate eyelid closure dries the cornea, increasing the risk of ulceration and infection. - **Hemifacial Spasm:** Involuntary muscle contractions on one side of the face due to axonal degeneration. - **Synkinesis:** involuntary facial movements during voluntary actions—for example, ocular-oral synkinesis (eye closure triggers mouth movement) and gustatory lacrimation ("Crocodile Tear Syndrome) ([Ziahosseni](https://pubmed.ncbi.nlm.nih.gov/25563764/?ref=theplasticsfella.com), 2015). ### Prognosis Poor prognostic indicators include complete palsy, loss of the stapedial reflex, absence of recovery signs within three weeks, age over 50, Ramsay Hunt syndrome, and a poor response to electrophysiological testing ([Walker](https://www.ncbi.nlm.nih.gov/books/NBK549815/?ref=theplasticsfella.com), 2023). Facial nerve function can continue improving for up to one year. Literature suggests the following timeline, - **Incomplete** **Bell’s Palsy:** \~ 94% achieve full recovery ([Finsterer](https://pubmed.ncbi.nlm.nih.gov/18368417/?ref=theplasticsfella.com), 2008). - **Complete** **Bell’s Palsy:** \~20–30% may experience permanent disability without treatment. 😎 ****Fun Fact:** When treated with corticosteroids — alone or combined with acyclovir — 94% of Bell’s palsy patients recover fully within 9 months ([Finsterer](https://pubmed.ncbi.nlm.nih.gov/18368417/?ref=theplasticsfella.com), 2008). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Facial nerve palsy affects individuals aged 15-45, with Bell’s palsy being the most common cause. Other causes include trauma, infections, neoplasms, congenital conditions, and neurological disorders. ****2\. Clinical Assessment:** Diagnosis involves history, examination of facial nerve function, and distinguishing neuron lesions. Investigations include blood tests, audiograms, EMG, and imaging. The House-Brackmann scale is used for grading. ****3\. Treatment Approaches:** Static procedures improve symmetry at rest while dynamic procedures restore movement using nerve grafts, transfers, and free muscle flaps. Non-surgical options include physiotherapy, botulinum toxin, and corneal protection. ****4\. Complications & Prognosis:** Risks include exposure keratitis, synkinesis, and facial asymmetry. Recovery depends on severity, age, and cause. --- ## Further Reading 1. Heckmann JG, Urban PP, Pitz S, Guntinas-Lichius O, Gágyor I. [The Diagnosis and Treatment of Idiopathic Facial Paresis (Bell's Palsy)](https://pmc.ncbi.nlm.nih.gov/articles/PMC9143601/?ref=theplasticsfella.com#sec4-jcm-11-02890). Dtsch Arztebl Int. 2019 Oct 11;116(41):692-702\. doi: 10.3238/arztebl.2019.0692\. PMID: 31709978; PMCID: PMC6865187. 2. Hohman MH, De Jesus O. [Facial Nerve Repair](https://www.ncbi.nlm.nih.gov/books/NBK560623/?ref=theplasticsfella.com). \[Updated 2023 Aug 23\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. 3. Walker NR, Mistry RK, Mazzoni T. [Facial Nerve Palsy](https://www.ncbi.nlm.nih.gov/books/NBK549815/?ref=theplasticsfella.com). \[Updated 2023 Jul 4\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. 4. Pinkiewicz M, Dorobisz K, Zatoński T. [A Comprehensive Approach to Facial Reanimation: A Systematic Review](https://pmc.ncbi.nlm.nih.gov/articles/PMC9143601/?ref=theplasticsfella.com#sec1-jcm-11-02890). J Clin Med. 2022 May 20;11(10):2890\. doi: 10.3390/jcm11102890\. PMID: 35629016; PMCID: PMC9143601 5. Crawford KL, Stramiello JA, Orosco RK, Greene JJ. [Advances in facial nerve management in the head and neck cancer patient](https://pubmed.ncbi.nlm.nih.gov/32628417/?ref=theplasticsfella.com). Curr Opin Otolaryngol Head Neck Surg. 2020 Aug;28(4):235-240\. doi: 10.1097/MOO.0000000000000641\. PMID: 32628417. 6. Rovak JM, Tung TH, Mackinnon SE. [The surgical management of facial nerve injury](https://pubmed.ncbi.nlm.nih.gov/20574467/?ref=theplasticsfella.com). Semin Plast Surg. 2004 Feb;18(1):23-30\. doi: 10.1055/s-2004-823120\. PMID: 20574467; PMCID: PMC2884690. 7. Udagawa A, Arikawa K, Shimizu S, Suzuki H, Matsumoto H, Yoshimoto S, Ichinose M. [A simple reconstruction for congenital unilateral lower lip palsy](https://pubmed.ncbi.nlm.nih.gov/17572570/?ref=theplasticsfella.com). Plast Reconstr Surg. 2007 Jul;120(1):238-244\. doi: 10.1097/01.prs.0000264062.64251.10\. PMID: 17572570. 8. Garcia RM, Hadlock TA, Klebuc MJ, Simpson RL, Zenn MR, Marcus JR. [Contemporary solutions for the treatment of facial nerve paralysis](https://pubmed.ncbi.nlm.nih.gov/26017609/?ref=theplasticsfella.com). Plast Reconstr Surg. 2015 Jun;135(6):1025e-1046e. doi: 10.1097/PRS.0000000000001273\. PMID: 26017609. 9. Fagan, J., [Surgical Reanimation Techniques for Facial Palsy](https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Surgical%20reanimation%20techniques%20for%20facial%20palsy%20%5Fparalysis%5F.pdf?ref=theplasticsfella.com)/ Paralysis Open access atlas of otolaryngology, head & neck operative surgery. page 1-13 2014\. 10. Ciorba A, Corazzi V, Conz V, Bianchini C, Aimoni C. [Facial nerve paralysis in children](https://pmc.ncbi.nlm.nih.gov/articles/PMC4677084/?ref=theplasticsfella.com). World J Clin Cases. 2015 Dec 16;3(12):973-9\. doi: 10.12998/wjcc.v3.i12.973\. PMID: 26677445; PMCID: PMC4677084. 11. Walker NR, Mistry RK, Mazzoni T. [Facial Nerve Palsy](https://www.ncbi.nlm.nih.gov/books/NBK549815/?ref=theplasticsfella.com). \[Updated 2023 Jul 4\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549815/ 12. Ziahosseini K, Nduka C, Malhotra R. [Ophthalmic grading of facial paralysis: need for a closer look](https://pubmed.ncbi.nlm.nih.gov/25563764/?ref=theplasticsfella.com). Br J Ophthalmol. 2015 Sep;99(9):1171-5\. doi: 10.1136/bjophthalmol-2014-305716\. Epub 2015 Jan 6\. PMID: 25563764. 13. Finsterer J. [Management of peripheral facial nerve palsy](https://pubmed.ncbi.nlm.nih.gov/18368417/?ref=theplasticsfella.com). Eur Arch Otorhinolaryngol. 2008 Jul;265(7):743-52\. doi: 10.1007/s00405-008-0646-4\. Epub 2008 Mar 27\. PMID: 18368417; PMCID: PMC2440925. 14. Coyle M, Godden A, Brennan PA, Cascarini L, Coombes D, Kerawala C, McCaul J, Godden D. [Dynamic reanimation for facial palsy: an overview](https://pubmed.ncbi.nlm.nih.gov/23385066/?ref=theplasticsfella.com). Br J Oral Maxillofac Surg. 2013 Dec;51(8):679-83\. doi: 10.1016/j.bjoms.2012.12.007\. Epub 2013 Feb 4\. PMID: 23385066. ### Fellowship Reality, 3 Lymphedema Essentials, & Tips for LVA URL: https://www.theplasticsfella.com/february-16th/ Last updated: 2025-02-14T21:03:01.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/february-16th/#a-letter-from-pfella) Fellowship FOMO: Are we overselling the dream? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-16th/#the-sunday-quiz) How well do you know **lymphedema*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/february-16th/#image-of-the-week) Stemmer’s sign: Affected vs. unaffected limb. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-16th/#technique-tip) How to prepare for an LVA. 5. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/february-16th/#behind-the-fella) Taking suggestions for podcast guests! 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/february-16th/#what-does-the-evidence-say) Does LVA actually work for lymphedema? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-16th/#articles-of-the-week) Immediate lymphatic recon, consensus guidelines on lymphedema, & LVA in advanced stage: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/february-16th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Fellowship FOMO: Are We Overselling the Dream?* 👋 ****Hey Team!** Fellowships are ****a cornerstone of plastic surgery training** — no question. They offer exposure to cutting-edge techniques, new surgical systems, and mentorship that can define a career. But here’s the thing: ****if every fellowship is “amazing,” then are we really being honest?** The truth is, fellowships have become a **non-negotiable** in our field. The days of jumping straight from residency to consultant life are fading. Now, if you don’t do a fellowship, you’re the outlier. While some fellowships truly deliver on the promise of mastery and independence, others? They’re just expensive gap years dressed up as training. ### The Fellowship Illusion Why does *every* fellowship get hyped? - **No one wants to admit theirs was a letdown -** Who’s going to say, “I wasted a year doing cases I could’ve done as a senior resident”? - **Institutions sell prestige -** Whether it’s high-volume trauma, elite aesthetics, or reconstructive giants, every program has a PR machine. - **The unspoken rule -** Say good things, or risk burning bridges. But let’s be real — **fellowships are not created equal**. The best ones give you autonomy, technical finesse, and a global perspective on plastic surgery. The worst? You’re a glorified assistant, running clinics while someone else gets the real experience. ### So, Was It Worth It? If fellowships are **essential**, then we need to start talking about **which ones are actually worth it**. So let’s cut through the fluff. Drop your answers below. Let’s separate the true gold-standard fellowships from the ones running on reputation alone. With love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Lymphedema?** ****Are you ready to make it to the leaderboard?** Welcome to the next round of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-6.png) ## Image of the Week **Stemmer’s Sign: Affected vs. Unaffected Limb* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we're looking at ****Stemmer’s sign**, which is considered pathognomic for the presence of lymphedema. In ****unilateral lower extremity lymphedema**, the affected limb shows an inability to ‘tent’ the interdigital skin fold, unlike the normal limb (A). This finding is considered pathognomonic for lymphedema. ![Stemmer’s sign for diagnosing lymphedema](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-4.png) [Source](https://www.researchgate.net/figure/The-presence-of-Stemmers-sign-is-considered-pathognomic-for-the-presence-of-lymphedema%5Ffig1%5F44612802?ref=theplasticsfella.com) | Stemmer’s sign for diagnosing lymphedema ## Technique Tip **How to Prepare for an LVA* 🚑 ****Technique Tip of the Week** This week’s technique focuses on LVA incision planning. ****(A)** Lymphatic channels (solid green) are mapped with ICG lymphography, and veins (dotted blue) with an infrared vein finder. Incisions (2–3 cm) are placed where veins and lymphatics intersect (red lines). ICG injection sites (green circles) follow a distal-to-proximal sequence. ****(B)** Post-op image shows selected venules and lymphatics at each incision, with diagrams of anastomotic configurations. Blue staining from isosulfan blue enhances lymphatic visualization. ![LVA Incision Planning](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-5.png) [Source](https://www.oaepublish.com/articles/2347-9264.2021.61?ref=theplasticsfella.com) | LVA Incision Planning ## Behind the 'Fella **Give Us Your Podcast Guest Suggestions!* 🎧 ****Stay Tuned: Behind the 'Fella Season Two is Coming!** We're setting up an exciting ****new season** of exclusive team meetings, where we take you ****behind the scenes** of the platform and discuss ****hot topics in plastic surgery** with our fellows — this time with some new features in the mix! If you could have a conversation with one person in plastic surgery, who would it be? ## What Does the Evidence Say? **Does LVA Actually Work for Lymphedema?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Lymphovenous anastomosis** (LVA) has shown promising results in the management of lymphedema. Studies have reported significant improvements in ****quality of life**, ****reduction in limb volume**, and ****decreased incidence of cellulitis** following LVA (Qiu et al., 2020; Salgarello et al., 2018; Cha et al., 2020). The procedure appears to be effective for both ****upper and lower** extremity lymphedema, with upper extremity cases showing better outcomes (Klingelhoefer et al., 2019). Factors influencing success include ****early-stage** lymphedema, ****upper extremity** location, and ****discontinuation of conservative treatment** post-surgery (Klingelhoefer et al., 2019). The surgeon's experience does not significantly impact outcomes, although proficiency increases over time (Nicolás Pereira et al., 2018). Various techniques, such as ****sleeve-in anastomosis**, have demonstrated efficacy (Chung et al., 2019). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Preventing Secondary Lymphedema after Immediate Lymphatic Reconstruction** ([Chun](https://www.jprasurg.com/article/S1748-6815%2821%2900627-6/abstract?ref=theplasticsfella.com), 2022) Immediate lymphatic reconstruction reduces secondary lymphedema risk after lymph node surgery, with LYMPHA showing promising outcomes. ✅ ****Surgical Treatment of Lymphedema: Consensus Guidelines** ([Chang](https://journals.lww.com/plasreconsurg/fulltext/2021/04000/surgical%5Ftreatment%5Fof%5Flymphedema%5F%5Fa%5Fsystematic.31.aspx?ref=theplasticsfella.com), 2021) Evidence supports lymphovenous bypass and vascularized lymph node transfer as effective for lymphedema management, though optimal treatment and long-term efficacy remain uncertain. ✅ ****Lymphovenous Anastomosis in Advanced Stage Lower Extremity Lymphedema** ([Cha](https://journals.lww.com/plasreconsurg/abstract/2021/01000/changing%5Fthe%5Fparadigm%5F%5Flymphovenous%5Fanastomosis%5Fin.38.aspx?ref=theplasticsfella.com), 2021) Preoperative imaging can identify functional lymphatics in advanced lower extremity lymphedema, enabling lymphovenous anastomosis to reduce limb volume and cellulitis incidence. ## Feedback ### I hope you enjoyed it 😄 --- ### Upper Eyelid Reconstruction: Principles, Reconstruction Options, & Complications URL: https://www.theplasticsfella.com/upper-eyelid-reconstruction/ Last updated: 2025-02-13T16:10:57.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/upper-eyelid-reconstruction/#overview-of-upper-eyelid-reconstruction) Upper eyelid reconstruction is a complex surgical procedure aimed at restoring function and aesthetics following defects caused by trauma, tumors, burns, or congenital anomalies. [****Upper Eyelid Anatomy**](https://www.theplasticsfella.com/upper-eyelid-reconstruction/#anatomy-of-the-upper-eyelid) The upper eyelid consists of three structural layers — anterior, middle, and posterior lamellae — each contributing to mobility, stability, and function. [****Reconstruction Principles**](https://www.theplasticsfella.com/upper-eyelid-reconstruction/#principles-of-upper-eyelid-reconstruction) Reconstruction must restore the eyelid's lamellar structure, protect the cornea, prevent tension, and maintain aesthetic symmetry. [****Partial Thickness Defects**](https://www.theplasticsfella.com/upper-eyelid-reconstruction/#partial-thickness-defects-of-the-upper-eyelid) Small defects (<25%) are treated with direct closure or skin grafts, while larger defects (>25%) require local flaps for optimal reconstruction. [****Full-Thickness Defects**](https://www.theplasticsfella.com/upper-eyelid-reconstruction/#full-thickness-defects-of-the-upper-eyelid) Small defects (<25%) can be closed in layers, while larger defects (>25%) require flaps and posterior lamella grafts for structural stability. [****Complications & Management**](https://www.theplasticsfella.com/upper-eyelid-reconstruction/#complications-of-upper-eyelid-reconstruction) Complications can affect both functional and aesthetic outcomes, requiring additional interventions. These can be broadly classified into early and late complications. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Upper Eyelid Reconstruction ****Key Point** Upper eyelid reconstruction requires re‐establishing both the functional and aesthetic aspects of the upper eyelid through a tailored, layered approach. Upper eyelid reconstruction is challenging because of the eyelid’s complex anatomy and dual roles. It is essential to rebuild both its protective functions—such as safeguarding the eye and distributing tears—and its contribution to facial expression and aesthetics ([Dhar](https://journals.lww.com/co-otolaryngology/abstract/2016/08000/advances%5Fin%5Feyelid%5Freconstruction.14.aspx?ref=theplasticsfella.com), 2016). Defects that require reconstruction can be: - **Congenital:** Colobomas, dermoids, and other birth defects ([Morley](https://www.sciencedirect.com/science/article/abs/pii/S0039625709002689?ref=theplasticsfella.com), 2010) - **Acquired:** Trauma, cancers, burns The image below illustrates a left upper eyelid malignancy. ![Left upper eyelid malignancy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-12T014739.484.png) Left upper eyelid malignancy --- ## Anatomy of the Upper Eyelid ****Key Point** The upper eyelid is made up of two main layers — the anterior and posterior lamellae — each essential for mobility, stability, and function. The upper eyelid is traditionally described as a two-layer structure: an anterior lamella and a posterior lamella. The septum, which separates these layers, is sometimes referred to as the middle lamella. **Anterior Lamella** is composed of skin and orbicularis oculi muscle. - **Skin:** thinnest in the body (\~1 mm) ([Janis](https://shop.thieme.com/Essentials-of-Plastic-Surgery/9781626238473?srsltid=AfmBOortRic79qmH2Z0D%5FadEqzrwxxhNiZU%5Fwdj%5Fpu3CueTSA7iVdaSI&ref=theplasticsfella.com), 2022). Precise tissue matching is required to avoid contracture (Kakizaki et al., 2009). - **Muscle:** orbicularis oculi aids in eyelid closure and supports the tear pump mechanism ([Dhar](https://journals.lww.com/co-otolaryngology/abstract/2016/08000/advances%5Fin%5Feyelid%5Freconstruction.14.aspx?ref=theplasticsfella.com), 2016). It is innervated by the zygomatic branch of the facial nerve. **Posterior Lamella** is composed of the tarsal plate and conjunctiva. - **Tarsal Plate:** Provides structural support, measuring \~25 mm in length, 1 mm thick, and 7–12 mm vertically. It houses the meibomian glands and supports the insertion of the levator aponeurosis and Müller’s muscle (DiFrancesco et al., 2004). - **Conjunctiva:** Consists of palpebral, bulbar, and fornices. ❗ Some sources mention a "middle lamella," referring to the orbital septum along with the preseptal and postseptal fat pads. The medial and central fat pads are separated by the superior oblique tendon ([Janis](https://shop.thieme.com/Essentials-of-Plastic-Surgery/9781626238473?srsltid=AfmBOortRic79qmH2Z0D%5FadEqzrwxxhNiZU%5Fwdj%5Fpu3CueTSA7iVdaSI&ref=theplasticsfella.com), 2022). The image below illustrates upper eyelid anatomy. ![Anatomy of the upper eyelid](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-13T212527.245.png) Anatomy of the upper eyelid ### Other Anatomical Eyelid Structures - **Levator Aponeurosis:** Elevates the eyelid (allowing 10–15 mm movement) and forms the upper eyelid crease by inserting into the pretarsal dermis ([Morley](https://www.sciencedirect.com/science/article/abs/pii/S0039625709002689?ref=theplasticsfella.com), 2010). It is innervated by the oculomotor nerve. - **Müller’s Muscle:** Provides an extra 1–2 mm of eyelid elevation through sympathetic innervation. - **Medial Canthal Tendon:** Helps maintain eyelid position and tear drainage; its disruption can cause medial ectropion or telecanthus (Mathijssen & van der Meulen, 2010). - **Lateral Canthal Tendon:** Stabilizes the lateral lid margin by anchoring to Whitnall’s tubercle. Weakness or disruption can compromise globe protection, cause exposure keratopathy, and impair tear drainage ([Suryadevara](https://www.sciencedirect.com/science/article/abs/pii/S1064740609000601?ref=theplasticsfella.com), 2009). 😎 ****Fun Fact:** The upper eyelid's blood supply comes from the ophthalmic artery, with both marginal and peripheral arcades ensuring strong vascularity. --- ## Preoperative Assessment ****Key Point** A comprehensive evaluation should focus on the patient's overall status, oncological margins when relevant, and structural involvement. Pre-operative assessment should be centred on a patient's history and examination of their eyelid. ### History - Document **comorbidities** (e.g., smoking, prior surgeries, radiation, medications such as anticoagulants). - For malignancy-related defects, ensure **clear surgical margins** before reconstruction (O’Donnell & Mannor, 2009; Mathijssen & van der Meulen, 2010). ### Physical Examination Assess the depth of the planned defect and identify any structural involvement. - **Tissue Quality:** Assess tissue quality regarding vascularity, scarring, radiation damage, and laxity. - **Tarsus:** Assess the remaining tarsus and determine if one or both lamellae need reconstruction. - **Canthal Tendons:** Evaluate canthal support and the lacrimal drainage system, especially in medial defects. - **Vision:** Test visual acuity and obtain an ophthalmologic consultation if necessary. In trauma situations, identify any peripheral zones of injury; traumatic avulsions may compromise canalicular integrity, often necessitating secondary lacrimal reconstruction. --- ## Principles of Upper Eyelid Reconstruction ****Key Point** Reconstruction must restore the eyelid’s layered structure, protect the cornea, ensure a tension-free repair, and maintain aesthetic symmetry. Balancing functionality and aesthetics is crucial in upper eyelid reconstruction. Key principles include, 1. **Adhered to the Reconstructive Ladder:** Begin with the simplest technique and progress to more complex methods as needed (Spinelli & Jelks, 1993). 2. **Restore Lamellar Structure & Separation:** Replacing tissue with "like for like" to maintain mobility and integrity (Alghoul et al., 2013). For the anterior lamella, skin grafts or flaps are used, while the posterior lamella is reconstructed with tarsus, conjunctiva, or mucosal grafts. 3. **Tension:** A tension-free closure is essential to avoid lid malposition. Achieving symmetry with the contralateral eyelid is critical. 4. **Blood Supply:** Ensure a well-perfused recipient bed by pairing nonvascularized grafts with vascularized flaps. 5. **Consider Patient Factors:** Elderly patients often have lax skin, allowing for more extensive direct closures. 6. **Corneal Protection:** Maintain proper lid-globe contact to prevent exposure keratopathy and corneal abrasion. It is important to have a **stepwise** approach to eyelid reconstruction. For example, 1. For small defects, begin with direct closure when tissue laxity permits and tension is minimal. 2. If direct closure is not feasible, progress to local flaps—such as the Tenzel semicircular flap—which offer additional tissue mobilization while preserving adjacent structures. 3. For bilamellar defects, consider using separate grafts or flaps for the anterior and posterior lamellae. 4. Finally, for extensive or complex defects where local tissue is insufficient, lid-sharing procedures can be employed to achieve optimal functional and aesthetic outcomes. ### --- ## Partial Thickness Defects of the Upper Eyelid ****Key Point** Small defects (<25% of eyelid width) can be managed with direct closure or skin grafts, while defects larger than 25% often require local flaps. Partial-thickness defects affect only the anterior lamella—the skin and orbicularis muscle. The choice of reconstruction depends on the defect’s **size**, **location** (central, medial, or lateral), and the availability of nearby **tissue**. The table below summarizes eyelid width and treatment options. ![Eyelid width and treatment options](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-13T213558.648.png) Eyelid width and treatment options ### <25% of the Eyelid Width For small defects, two main options are used. 1. **Direct Closure** - **Indication:** Defects up to 25-30%, cantholysis can extend this to 50%. ([McCord & Codner](https://journals.lww.com/plasreconsurg/abstract/2010/11000/upper%5Fand%5Flower%5Feyelid%5Freconstruction.45.aspx?ref=theplasticsfella.com), 2008). - **Benefit:** Efficient, single-surgery that preserves mobility ([Codner](https://journals.lww.com/plasreconsurg/abstract/2010/11000/upper%5Fand%5Flower%5Feyelid%5Freconstruction.45.aspx?ref=theplasticsfella.com), 2010). - **Technique:** Often a wedge excision to avoid dog-ear deformities 1. **Skin Grafts** - **Indication:** When direct closure is not possible - **Benefit:** Helps maintain eyelid flexibility without causing functional impairment. - **Technique:** FTSGs are harvested from the postauricular or the contralateral upper eyelid ([Verity](https://journals.lww.com/co-otolaryngology/abstract/2004/08000/eyelid%5Freconstruction%5F%5Fthe%5Fstate%5Fof%5Fthe%5Fart.15.aspx?ref=theplasticsfella.com), 2004). Placing the graft pretarsally reduces contraction ([Morley](https://www.sciencedirect.com/science/article/abs/pii/S0039625709002689?ref=theplasticsfella.com), 2010). 💡 ****Tip:** Avoid split-thickness grafts, as they have higher contraction rates; use quilting sutures to improve graft adherence and minimize hematoma risk. ([Verity](https://journals.lww.com/co-otolaryngology/abstract/2004/08000/eyelid%5Freconstruction%5F%5Fthe%5Fstate%5Fof%5Fthe%5Fart.15.aspx?ref=theplasticsfella.com), 2004). ### \>25% Eyelid Width For larger defects, more advanced techniques are often required: 1. **Direct Closure with Cantholysis** - **Indication:** If significant skin laxity, releasing the lateral canthal tendon can allow primary closure of defects up to 50% ([Dhar](https://journals.lww.com/co-otolaryngology/abstract/2016/08000/advances%5Fin%5Feyelid%5Freconstruction.14.aspx?ref=theplasticsfella.com), 2016). - **Benefit:** Tension-free closure while maintaining the natural contour of the eyelid. 1. **Tenzel Semi-Circular Flap** - **Indication:** Partial or full-thickness defects involving 25–60% of the eyelid’s horizontal width - **Technique:** This technique uses a semicircular incision from the lateral canthus into the temporal region. The flap is elevated in a submuscular plane and advanced medially, with or without lateral cantholysis - **Advantages:** Tension-free closure, preserves eyelid contour, avoids occluding the visual axis, and is usually performed in a single stage. - **Disadvantages:** Requires sufficient tissue laxity and improper repair can lead to lateral canthal malposition. ([Verity](https://journals.lww.com/co-otolaryngology/abstract/2004/08000/eyelid%5Freconstruction%5F%5Fthe%5Fstate%5Fof%5Fthe%5Fart.15.aspx?ref=theplasticsfella.com), 2004). Intra-Operative Video of Tenzel Flap **Other Local Flaps** - **Hinged blepharoplasty flap** can be utilised in medial defects. It mobilizes skin from the upper eyelid using classic blepharoplasty incisions. - **Non-marginal defects** of the upper eyelid that cannot be closed directly are usually closed using local advancement or rotation flaps ([Harmon](https://shop.thieme.com/Mohs-Micrographic-Surgery-From-Layers-to-Reconstruction/9783132420175?srsltid=AfmBOor%5F5zL9gLGV8XevKlF9AFStUUkqs%5F3lMsaO2Qrpbp2ipUxfLQDr&ref=theplasticsfella.com), 2023). 😎 ****Fun Fact:** The marginal arcade lies only 2–3 mm from the eyelid margin, making it vulnerable during surgery. --- ## Full-Thickness Defects of the Upper Eyelid ****Key Point** Small defects (<25% of eyelid width) can be repaired by closing the layers directly, whereas larger defects (>25%) require flaps and posterior lamella grafts for proper structural support. Full-thickness defects affect all eyelid layers—skin, muscle, tarsus, and conjunctiva—and require a layered reconstruction to restore both function and appearance. ### Small Defects (<25%) Small defects can often be closed directly, whereas larger defects typically need flaps or posterior lamella grafts. In relation to the direct closure of full-thickness defects, - Suitable if good lid laxity. - Achieved by approximating the conjunctiva, tarsus, and skin in layers - May require cantholysis and canthopexy ([Jennings](https://www.tandfonline.com/doi/abs/10.1080/01676830.2020.1820045?ref=theplasticsfella.com), 2020). ### Larger Defects (>25%) 1. **Cutler-Beard flap** is indicated in full-thickness upper eyelid defect >50%. - **Technique:** A full-thickness rectangular flap—including skin, orbicularis, and conjunctiva—is harvested from the lower eyelid and sutured into the defect. 3-6 weeks later, a second-stage flaps division restores independent eyelid function ([Jennings](https://www.tandfonline.com/doi/abs/10.1080/01676830.2020.1820045?ref=theplasticsfella.com), 2020). - **Advantages:** Reliable for reconstructing large defects. - **Disadvantages:** Two-stage procedure, Temporary occlusion of the visual axis, risk of ectropion or lower eyelid retraction. 1. **Lid Switch Flap** is indicated in total eyelid defects or 50–75% of the lid. - **Technique:** A semicircular rotation flap is raised from the lower eyelid to replace the missing tissue. ([Jennings](https://www.tandfonline.com/doi/abs/10.1080/01676830.2020.1820045?ref=theplasticsfella.com), 2020). - **Advantages:** Provides composite tissue to reconstruct both the anterior and posterior lamellae - **Disadvantages:** Requires a second-stage separation; risks include donor site complications such as lower eyelid retraction or ectropion. 1. **Fricke Flap** is indicated inlarge anterior lamellar defects or full-thickness defects requiring robust skin coverage. - **Technique:** A two-stage procedure using a temporal skin flap based on the superficial temporal artery. The flap is transposed to cover the defect and later divided once healing is complete ([Codner](https://journals.lww.com/plasreconsurg/abstract/2010/11000/upper%5Fand%5Flower%5Feyelid%5Freconstruction.45.aspx?ref=theplasticsfella.com), 2010). - **Advantages:** Provides durable skin with excellent vascularity. - **Disadvantages:** Can result in a bulky donor site and aesthetic mismatch with adjacent tissue. 💡 ****Tip:** Reinforce the canthal tendons during full-thickness reconstructions to enhance stability and prevent malposition ([Suryadevara](https://www.sciencedirect.com/science/article/abs/pii/S1064740609000601?ref=theplasticsfella.com), 2009). ### Posterior Lamella Reconstruction Reconstructing the posterior lamella is essential for restoring eyelid stability by replicating the rigidity of the tarsus. For optimal healing, the graft must be placed on a well-vascularized recipient bed while preserving the integrity of the mucosal and cartilage/tarsal structures. Options for reconstruction include, - **Tarsoconjunctival Graft:** Harvested from the ipsilateral lower eyelid or contralateral upper eyelid, this graft is ideal for smaller defects, preserving donor eyelid integrity while providing an excellent tissue match. - **Chondral Graft:** For smaller defects, the nasal septum is preferred due to limited harvestable tissue. For greater support, auricular cartilage from the conchal bowl provides rigid structural reinforcement ([Verity](https://journals.lww.com/co-otolaryngology/abstract/2004/08000/eyelid%5Freconstruction%5F%5Fthe%5Fstate%5Fof%5Fthe%5Fart.15.aspx?ref=theplasticsfella.com), 2004). - **Mucosal Grafts:** These grafts reconstruct the conjunctiva, ensuring a smooth gliding surface to prevent corneal irritation. Donor sites include buccal mucosa, nasal mucosa (often harvested with the nasal septum as a composite graft), and hard palate mucosa for larger defects ([Verity](https://journals.lww.com/co-otolaryngology/abstract/2004/08000/eyelid%5Freconstruction%5F%5Fthe%5Fstate%5Fof%5Fthe%5Fart.15.aspx?ref=theplasticsfella.com), 2004). Below is a clinical image of the everted upper eyelid. ![Clinical image of the everted upper eyelid](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-12T020746.658.png) Clinical image of the everted upper eyelid 💡 ****Tip:** When reconstructing the posterior lamella, precisely harvest a tarsoconjunctival graft sized to the defect — include a 2 mm superior conjunctival margin to recreate the eyelid edge, avoid oversizing, and select a donor site that matches well. --- ## Complications of Upper Eyelid Reconstruction ****Key Point** Complications can affect both functional and aesthetic outcomes, requiring additional interventions. These can be broadly classified into early and late complications. Complications following upper eyelid reconstruction can be broadly categorized into early and late issues, each of which may compromise function and aesthetics if not promptly addressed. ### Early Complications - **Retrobulbar Hematoma:** Severe pain, swelling, and decreased vision requiring urgent decompression and cantholysis to prevent permanent visual impairment. - **Flap/Graft Failure:** Partial or complete necrosis due to insufficient vascular supply, hematoma, or infection ([Morley](https://www.sciencedirect.com/science/article/abs/pii/S0039625709002689?ref=theplasticsfella.com), 2010); meticulous surgical technique, proper vascularization, and tension-free closure with close monitoring are essential. - **Infection:** Occurring at the graft or donor site; early detection with prompt antibiotic therapy is crucial. - **Corneal Injury:** Abrasion or ulceration from exposure or improper eyelid closure ([Verity](https://journals.lww.com/co-otolaryngology/abstract/2004/08000/eyelid%5Freconstruction%5F%5Fthe%5Fstate%5Fof%5Fthe%5Fart.15.aspx?ref=theplasticsfella.com), 2004); using corneal lubricants and temporary protective measures like tarsorrhaphy can minimize damage. - **Eyelid Edema:** Temporary swelling that may impair function; typically resolves with supportive care and anti-inflammatory measures. ### Late Complications - **Lagophthalmos:** Incomplete eyelid closure leading to exposure keratopathy and dry eye ([Dhar](https://journals.lww.com/co-otolaryngology/abstract/2016/08000/advances%5Fin%5Feyelid%5Freconstruction.14.aspx?ref=theplasticsfella.com), 2016); careful initial alignment may prevent this, though revision surgery might be necessary. - **Eyelid Malposition (Ectropion/Entropion):** Outward or inward turning of the eyelid causing irritation ([Suryadevara](https://www.sciencedirect.com/science/article/abs/pii/S1064740609000601?ref=theplasticsfella.com), 2009); precise reconstruction of the tarsus and canthal tendons is key, with surgical correction often required. - **Lid Retraction:** Incomplete lid lowering from scar contracture or misalignment ([Codner](https://journals.lww.com/plasreconsurg/abstract/2010/11000/upper%5Fand%5Flower%5Feyelid%5Freconstruction.45.aspx?ref=theplasticsfella.com), 2010); proper tissue alignment and tension management are vital, with revision surgery as needed. - **Cosmetic Deformities:** Poor contour, asymmetry, or scarring that may require secondary procedures such as scar revision or flap debulking ([Verity](https://journals.lww.com/co-otolaryngology/abstract/2004/08000/eyelid%5Freconstruction%5F%5Fthe%5Fstate%5Fof%5Fthe%5Fart.15.aspx?ref=theplasticsfella.com), 2004); meticulous technique can minimize these issues. - **Donor Site Morbidity:** Scarring or functional impairment at donor sites (e.g., lower eyelid or forehead); careful planning, surgical technique, and postoperative care help reduce complications. - **Tumor Recurrence:** In oncologic cases, inadequate clearance can lead to recurrence ([Jennings](https://www.tandfonline.com/doi/abs/10.1080/01676830.2020.1820045?ref=theplasticsfella.com), 2020); achieving clear surgical margins and vigilant postoperative surveillance are essential. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Upper eyelid reconstruction restores function and aesthetics following defects caused by trauma, tumors, burns, or congenital anomalies. ****2\. Anatomy & Principles:** The upper eyelid consists of anterior, middle, and posterior lamellae. Reconstruction must restore these layers while ensuring corneal protection, tension-free closure, and aesthetic symmetry. ****3\. Reconstructive Techniques:** Partial-thickness defects <25% can be closed directly or with full-thickness skin grafts, while larger defects may require local flaps. Full-thickness defects <25% can be repaired in layers, whereas larger defects need advanced techniques. Total eyelid loss may require brow-based flaps or free tissue transfer. ****4\. Complications:** Risks include lagophthalmos, ectropion, flap necrosis, corneal exposure, and donor site morbidity. Preventative measures include reinforcing canthal tendons, optimizing flap vascularity, and ensuring proper corneal protection postoperatively. --- ## Further Reading 1. Codner, M. A., McCord, C. D., Mejia, J. D., & Lalonde, D. (2010). [Upper and Lower Eyelid Reconstruction.](https://journals.lww.com/plasreconsurg/abstract/2010/11000/upper%5Fand%5Flower%5Feyelid%5Freconstruction.45.aspx?ref=theplasticsfella.com) *Plastic and Reconstructive Surgery, 126*(3), 231e–243e. 2. Dhar, S. I., Kopp, R., & Tatum, S. A. (2016). [Advances in Eyelid Reconstruction. ](https://journals.lww.com/co-otolaryngology/abstract/2016/08000/advances%5Fin%5Feyelid%5Freconstruction.14.aspx?ref=theplasticsfella.com)*Current Opinion in Otolaryngology & Head and Neck Surgery, 24*(4), 352–358. 3. Janis, J. E. (2022). [*Essentials of Plastic Surgery: Third Edition*.](https://shop.thieme.com/Essentials-of-Plastic-Surgery/9781626238473?srsltid=AfmBOortRic79qmH2Z0D%5FadEqzrwxxhNiZU%5Fwdj%5Fpu3CueTSA7iVdaSI&ref=theplasticsfella.com) Thieme Medical Publishers. 4. Harmon, Christopher B., and Stanislav N. Tolkachjov. [*Mohs Micrographic Surgery: From Layers to Reconstruction*.](https://shop.thieme.com/Mohs-Micrographic-Surgery-From-Layers-to-Reconstruction/9783132420175?srsltid=AfmBOor%5F5zL9gLGV8XevKlF9AFStUUkqs%5F3lMsaO2Qrpbp2ipUxfLQDr&ref=theplasticsfella.com) Thieme, 2023. 5. Jennings, E., Krakauer, M., Nunery, W. R., & Aakalu, V. K. (2020). [Advancements in the Repair of Large Upper Eyelid Defects](https://www.tandfonline.com/doi/abs/10.1080/01676830.2020.1820045?ref=theplasticsfella.com): A 10-Year Review. *Orbit*. 6. Morley, A. M. S., deSousa, J.-L., Selva, D., & Malhotra, R. (2010). [Techniques of Upper Eyelid Reconstruction. ](https://www.sciencedirect.com/science/article/abs/pii/S0039625709002689?ref=theplasticsfella.com)*Survey of Ophthalmology, 55*(3), 256–271. 7. Suryadevara, A. C., & Moe, K. S. (2009). [Reconstruction of Eyelid Defects. ](https://www.sciencedirect.com/science/article/abs/pii/S1064740609000601?ref=theplasticsfella.com)*Facial Plastic Surgery Clinics of North America, 17*(4), 419–428. 8. Verity, D. H., & Collin, J. R. O. (2004). [Eyelid Reconstruction: The State of the Art. ](https://journals.lww.com/co-otolaryngology/abstract/2004/08000/eyelid%5Freconstruction%5F%5Fthe%5Fstate%5Fof%5Fthe%5Fart.15.aspx?ref=theplasticsfella.com)*Current Opinion in Otolaryngology & Head and Neck Surgery, 12*(5), 344–348. ### Lasers: Principles, Clinical Applications, & Complications URL: https://www.theplasticsfella.com/lasers/ Last updated: 2025-02-12T22:20:23.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/lasers/#overview-of-lasers) LASER technology enables precise, minimally invasive treatments through selective photothermolysis, with applications in resurfacing, scar revision, and lesion treatments. [****Mechanism of Action**](https://www.theplasticsfella.com/lasers/#mechanism-of-action-of-lasers) Lasers generate collimated, monochromatic, and coherent light, interacting with tissue through reflection, scattering, transmission, or absorption. [****Clinical Applications**](https://www.theplasticsfella.com/lasers/#clinical-applications-of-laser-types) Lasers are classified based on their target chromophore, which determines their clinical applications. [****Complications**](https://www.theplasticsfella.com/lasers/#complications-of-laser-treatment) Laser treatments pose risks including hyperpigmentation, hypopigmentation, scarring, infection, and ocular injury. ****Primary Contributor:** Benedetta Agnelli, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Lasers ****Key Point** Laser technology in plastic surgery enables targeted, minimally invasive treatments by selectively converting light to heat. **LASER** stands for "**L**ight **A**mplification by **S**timulated **E**mission of **R**adiation." It achieves targeted treatment of vascular lesions, pigmented disorders, tattoos, and scars by converting absorbed laser energy into heat through selective photothermolysis. Key milestones in LASER history: - **1960:** Maiman develops the first ruby laser. - **1964:** CO₂ laser introduced for ablative treatments. - **1984:** First laser-assisted blepharoplasty by Dr. Baker. - **Mid-1990s:** Er:YAG lasers introduced for skin resurfacing, alone or with CO₂ lasers 😎 ****Fun Fact:** In 1917, Albert Einstein described stimulated emission—the key principle behind lasers. --- ## Mechanism of Action of Lasers ****Key Point** Lasers produce collimated, monochromatic, and coherent light that interacts with tissue, inducing biological effects—most notably, selective photothermolysis. Laser systems produce coherent, monochromatic, and collimated light through stimulated emission. Their operation—comprising laser generation, wavelength-dependent tissue interactions, and biological effects (especially selective photothermolysis)—is detailed below. ### Laser Generation LASER is generated through three key components: 1. **Energy:** Provides excitation energy (e.g., flashlamp or electrical discharge). 2. **Laser Medium:** Determines the wavelength (e.g., solid Nd:YAG) 3. **Optical Resonator:** Uses reflective mirrors to guide & amplify the beam. This enables light to interact with tissue and generate heat. ![Components of a laser](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Lasers.png) Components of a laser 💡 ****Tip:** The ****laser medium** often determines the laser’s name (e.g., ****CO₂ laser** for carbon dioxide, ****Nd:YAG laser** for neodymium-doped YAG). ### Tissue Interactions Light produced by the LASER interacts with tissue. Its behaviour is determined by its wavelength can result in: - **Reflection:** The light bounces off the tissue surface with no effect. - **Scattering:** The light disperses in multiple directions, reducing precision. - **Transmission:** Unabsorbed light passes through the tissue without interaction - **Absorption:** Specific chromophores absorb the light, converting it into heat (e.g., haemoglobin, melanin, tattoo pigment, water). The specific **wavelength** of a laser determines its depth of penetration and interaction with biological tissues. **Higher wavelengths** correlate with **deeper** **tissue** **penetration**. ![The level of tissue penetration for each laser type](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Lasers--1-.png) The level of tissue penetration for each laser type ### ### Biological Effects This absorption of laser energy by specific chromophores converts the energy into heat and precisely targets tissue while sparing adjacent structures. This heat induces various biological effects: - **Photothermal:** Heat causes vaporization, coagulation, or protein denaturation (e.g., CO₂ laser for resurfacing, Nd:YAG for coagulation). - **Photomechanical:** High-energy pulses generate acoustic waves that fragment tissue (e.g., Q-switched lasers for tattoo removal). - **Photochemical:** Light triggers chemical reactions without significant heat (e.g., photodynamic therapy). - **Photoelectrical:** High-energy ionization occurs (rarely used in plastic surgery). **Selective photothermolysis** uses precise wavelengths and pulses to produce a **photothermal** effect that destroys target chromophores while sparing adjacent tissue. It underpins vascular ablation (PDL), hair removal (Alexandrite/Diode), and pigment reduction (Q-switched). Not all laser-tissue interactions are photothermal. --- ## Clinical Applications of Laser Types ****Key Point** Lasers are classified by their target chromophores, enabling specific wavelengths to treat vascular lesions, pigmentation, tattoos, and scars. Lasers are classified by the **chromophore** they target, which determines their clinical use. Specific wavelengths interact with chromophores—such as hemoglobin, melanin, tattoo pigments, or water—to treat vascular, pigmented, and textural abnormalities. ### Vascular Lesions Haemoglobin-Targeting Lasers exploit the selective absorption of oxy- and deoxyhemoglobin to induce thermal coagulation and destroy abnormal vessels while sparing adjacent tissue. **Devices** - **Superficial:** KTP (532 nm), IPL (560 nm), PDL (585–595 nm), Alexandrite (755 nm) - **Deeper**: Diode (810 nm) and Nd:YAG (1064 nm) **Conditions** - **Congenital Vascular Lesions:** Capillary vascular malformations, infantile hemangiomas, and angiomas. - **Acquired Vascular Lesions:** Telangiectasias, spider veins, reticular veins, postprocedural purpura, and erythematous scars. The image below showcases the pre-treatment and post-treatment results of a lower lip angioma successfully treated with laser therapy. ![Pre- and post- laser treatment results of a lower lip angioma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Lasers--2-.png) Pre- and post- laser treatment images of a lower lip angioma 💡 ****Tips:** 1\. For higher Fitzpatrick skin types, use longer wavelengths to reduce melanin absorption. 2\. Adjust pulse width to specifically target the vessel. 3\. Apply epidermal cooling to protect the skin. ### Pigmented Lesions Melanin is the primary chromophore responsible for **cutaneous pigmentation**. Absorption by melanin enables targeted destruction of pigmented lesions or hair follicles through Melanin-Targeting Lasers. Optimal wavelength selection is crucial based on whether the melanin is located in the epidermis, dermis, or both. **Devices:** - **Superficial:** KTP (532 nm), IPL (560 nm) - **Broad-Spectrum:** Q-Switched Nd:YAG (532 nm & 1,064 nm), Alexandrite (755 nm), Diode (800–810 nm) **Conditions:** - **Epidermal Pigmentation:** Lentigines, ephelides, seborrheic keratoses, café-au-lait macules, Becker nevi - **Dermal Pigmentation:** Nevus of Ota, nevus of Ito, Mongolian spots, drug-induced hyperpigmentation - **Mixed Lesions:** Post-inflammatory hyperpigmentation (PIH), melasma ![Pre- and post- laser treatment images of an angioma of solar lentigo](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Lasers--3-.png) Pre- and post- laser treatment images of an angioma of solar lentigo 💡 ****Tip:** Before laser treatment, evaluate pigmented lesions, and any suspicion of malignancy requires a biopsy. ### Hair Removal Laser hair removal works by targeting the melanin in hair follicles, converting laser energy into heat that selectively damages the follicle and prevents regrowth. - **Primary Wavelengths:** Alexandrite (755 nm) and Diode (800–810 nm) - **For Deeper Follicles:** Nd:YAG (1064 nm) 😎 ****Fun Fact:** Melanin within the hair shaft can also be targeted in order to perform ****laser hair reduction (LHR)**. ### Tattoo Pigment-Targeting Lasers Tattoo pigment-targeting lasers remove tattoos by using wavelengths absorbed by the ink. This triggers **photothermal** and **photomechanical** effects that fragment the pigment into smaller particles, which are then cleared via the lymphatic system or rendered visually imperceptible. The colour and wavelength required for tattoos includes Nd:YAG, Alexandrite, Ruby, KTP and Titanium Sapphire. This is detailed in the table below. ![Appropriate laser wavelengths for different tattoo pigment](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Lasers--4-.png) Appropriate laser wavelengths for different tattoo pigment 😎 ****Fun Fact:** It is estimated that 17% of patients with tattoos have considered elective removal ([Bencini](https://pubmed.ncbi.nlm.nih.gov/22986584/?ref=theplasticsfella.com), 2012). ### Water-Targeting Lasers Water, as a **ubiquitous chromophore** in skin, lacks structural selectivity due to its high absorption efficiency. Modern laser systems overcome this by employing central pattern generators and scanners to deliver controlled microinjury with precise penetration depths. The tissue response depends on the **wavelength of light**. - **Ablative Lasers: CO₂** (10,600 nm) and **Er:YAG** (2,940 nm) lasers induce rapid tissue vaporization, making them ideal for skin resurfacing, scar revision, and lesion excision. - **Non-Ablative Lasers: Er:YAG** and **Nd:YAG** lasers (1,550 nm, 1,927 nm) generate controlled thermal effects within the dermis without removing the epidermis. Stimulates collagen remodeling for wrinkle reduction, skin tightening, and acne scar treatment. - **Fractional ablative systems** (eg CO₂ fractional, Er:YAG fractional) create microthermal zones that promote faster healing by sparing surrounding tissue, while conventional non-fractional ablative lasers provide uniform ablation but require longer recovery times. These lasers are widely used for treating rhytides, atrophic scars, dyschromias, and photodamage, offering tailored approaches based on patient needs and skin types. --- ## Complications of Laser Treatment ****Key Point** Laser treatments carry risks including pigmentary changes, scarring, infection, and ocular injury, with darker skin types (Fitzpatrick IV–VI) at increased risk for post-inflammatory hyperpigmentation. While lasers offer precision, improper settings or techniques can lead to complications. Key issues include: - **Erythema & Edema:** Temporary redness and swelling that typically resolve without intervention. - **Pigmentary Changes:** Fitzpatrick I–III: Higher risk of hypopigmentation after aggressive treatments. Fitzpatrick IV–VI: Increased risk of post-inflammatory hyperpigmentation. - **Scarring:** More likely with excessive fluence or improper technique. - **Infection:** Particularly with ablative lasers; prophylactic antivirals or antibiotics are recommended for high-risk patients. - **Ocular Injury:** Direct or reflected laser beams can damage the retina; use of protective eyewear is mandatory. 💡 ****Tip:** Always perform a test spot to assess skin response and adjust parameters, especially in darker or sensitive skin. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Lasers enables precise, minimally invasive treatments through selective photothermolysis, with applications in resurfacing, scar revision, and lesion treatments. ****2\. Mechanism of Action:** Lasers emit collimated, monochromatic, and coherent light, interacting with tissue via absorption, reflection, scattering, or transmission. ****3\. Types & Clinical Applications:** Lasers are categorized based on their target chromophore. ****4\. Risks & Complications:** Hyperpigmentation, hypopigmentation, scarring, infection, and ocular injury are key risks. Test spots and cooling help reduce complications. --- ## Further Reading 1. Hersant B, SidAhmed-Mezi M, Bosc R, Meningaud JP. Current indications of low-level laser therapy in plastic surgery: a review. Photomed Laser Surg. 2015 May;33(5):283-97\. doi: 10.1089/pho.2014.3822\. PMID: 25954831. 2. Zhang DD, Zhao WY, Fang QQ, Wang ZC, Wang XF, Zhang MX, Hu YY, Zheng B, Tan WQ. The efficacy of fractional CO2 laser in acne scar treatment: A meta-analysis. Dermatol Ther. 2021 Jan;34(1):e14539\. doi: 10.1111/dth.14539\. Epub 2020 Nov 23\. PMID: 33190373. 3. Azadgoli B, Baker RY. Laser applications in surgery. Ann Transl Med. 2016 Dec;4(23):452\. doi: 10.21037/atm.2016.11.51\. PMID: 28090508; PMCID: PMC5220034. 4. Hernandez L, Mohsin N, Frech FS, Dreyfuss I, Vander Does A, Nouri K. Laser tattoo removal: laser principles and an updated guide for clinicians. Lasers Med Sci. 2022 Aug;37(6):2581-2587\. doi: 10.1007/s10103-022-03576-2\. Epub 2022 May 23\. PMID: 35604505. 5. Goldman A, Wollina U. Komplikationen nach Laserbehandlung vaskulärer Veränderungen des Gesichts \[Complications after laser treatment of facial vascular lesions\]. Hautarzt. 2021 May;72(5):421-425\. German. doi: 10.1007/s00105-021-04796-3\. Epub 2021 Mar 19\. PMID: 33740081. 6. Kauvar AN, Wang RS. Laser treatment of cutaneous vascular anomalies. Lymphat Res Biol. 2004;2(1):38-50\. doi: 10.1089/1539685041690391\. PMID: 15609926. 7. Grabb, W. C., Smith, J. W., & Thorne, C. H. (2013). *Grabb and Smith's Plastic Surgery* (7th ed.). Philadelphia: Wolters Kluwer. ### Flawed Literature, 3 Types of Tendon Transfers, & Textbook Update URL: https://www.theplasticsfella.com/february-9th/ Last updated: 2025-02-07T20:22:47.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/february-9th/#a-letter-from-pfella) Plastic surgery’s biggest lie? Its own literature 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-9th/#the-sunday-quiz) How well do you know median nerve tendon transfers? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/february-9th/#image-of-the-week) Intraoperative picture of an extensor tendon transfer. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-9th/#technique-tip) Pulvertaft weave technique 5. ****📙** [****Foundations Textbook**](https://www.theplasticsfella.com/february-9th/#foundations-textbook) Progress update: February 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/february-9th/#what-does-the-evidence-say) How many pulleys should we save? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-9th/#articles-of-the-week) Flexor tendon injuries in 2024, partial extensor tendon injuries, & tendon transfer review: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/february-9th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Plastic Surgery’s Biggest Lie? Its Own Literature* 👋 ****Hey Team!** Here’s the uncomfortable truth: a huge chunk of plastic surgery literature is wrong, yet we keep citing it like gospel. Take breast ptosis. Regnault’s ****1976 classification** was simple — ****three types and pseudoptosis**. But today? Some papers claim ****five classifications**, others tweak definitions, and suddenly, the field can’t even agree on a basic concept. Why? Because ****nobody reads the original research.** ### The Broken Game of Academic Telephone Regnault’s paper is **paywalled**, so instead of verifying the source, researchers **copy from the last paper** — errors and all. Over time, minor mistakes become accepted facts. The result? - **Textbooks are full of misinformation:** What’s taught today isn’t what was originally described. - **Systematic reviews are reinforcing bad data:** If the foundation is wrong, the conclusions are useless. - **Clinical decisions are based on a flawed understanding:** If we can’t even classify ptosis correctly, what else are we getting wrong? This isn’t just about breast ptosis — it’s happening **across plastic surgery**. ![Original drawings from Regnault's publication](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-2.png) Original drawings from Regnault's publication ### How Did We Let This Happen? Plastic surgery prides itself on being evidence-based — but what happens when the evidence itself is broken? We’ve built a system that rewards repetition over verification. Instead of going back to original sources, we trust whatever the last paper says. Paywalls keep key research locked away, so errors go unchallenged. And once misinformation makes it into a textbook or systematic review, it becomes fact — not because it’s true, but because it’s been repeated enough times. The fix? - Stop trusting secondhand sources. If a paper cites something, pull the original. - If an article gets it wrong, call it out — silence allows bad information to spread. - And if we actually care about advancing the field, we need to push for open access — because what good is knowledge if nobody can verify it? With love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Median Nerve Tendon Transfers?** ****Are you ready to make it to the leaderboard?** Welcome to the next round of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![Anatomy of the Median Nerve](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image.png) Anatomy of the Median Nerve ## Image of the Week **Extensor Tendon Transfer* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we’re looking at an intraoperative picture demonstrating the extensor carpi radialis longus (ECRL) sutured to the extensor digitorum communis using a Pulvertaft weave. Digital extensor hypoplasia (DEH) is a rare malformation that presents with loss of active finger extension at the metacarpophalangeal (MCP) joints. ![an intraoperative picture demonstrating the extensor carpi radialis longus (ECRL) sutured to the extensor digitorum communis using a Pulvertaft weave. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-1.png) Source: Bilateral Digital Extensor Hypoplasia Correction: A Case Report and Systematic Review - Scientific Figure on ResearchGate. Available from: [https://www.researchgate.net/figure/ntraoperative-tendon-transfer-Intraoperative-picture-demonstrating-the-extensor-carpi\_fig3\_367973068](https://www.researchgate.net/figure/ntraoperative-tendon-transfer-Intraoperative-picture-demonstrating-the-extensor-carpi%5Ffig3%5F367973068?ref=theplasticsfella.com) ## Technique Tip **Pulvertaft Weave* 🚑 ****Technique Tip of the Week** This week’s technique focuses on Pulvertaft Weave, a fundamental method in tendon transfer surgeries. This technique involves interlacing the donor tendon into the recipient tendon to ensure a secure and durable connection. For a visual demonstration, below is Dr. Badia's explanation of the Pulvertaft Weave technique. ## Foundations Textbook **February Update* 📙 ****Plastic Surgery Student Guide Update** In line with our "Building in Public" approach, we’re keeping you in the loop on the latest developments in the Plastic Surgery Student Guide. ![Subject pipeline of the student guide](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Fundraiser-Progress-Update-Stat-Graphic-Instagram-Post-in-Dark-Blue-Red-Style--1-.png) Subject pipeline of the student guide ## What Does the Evidence Say? **How Many Pulleys Should We Save?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Flexor tendon repairs in ****zone II** often require ****pulley release** to facilitate repair and prevent impingement. Contrary to traditional beliefs, releasing the ****A2 and A4 pulleys** does not appear to cause clinically significant bowstringing or negatively impact outcomes (Abdelmalek & Mcfarlane, 2021; Pan et al., 2017; Giesen et al., 2018; Moriya et al., 2016). Various techniques for pulley management during repair have been described, including ****venting, plasty,** and **complete release** (Goubier et al., 2014; Bunata, 2010; Pan et al., 2017). Strong core suture techniques, such as the ****6-strand M-Tang method**, allow for early active motion protocols without peripheral sutures (Giesen et al., 2018). Biomechanical studies have shown that intact pulleys can decrease repair strength (Cao & Tang, 2009). Overall, ****judicious pulley release** during flexor tendon repair appears to be safe and may improve outcomes by allowing better tendon gliding and reducing the risk of repair rupture (Zafonte et al., 2014; Pan et al., 2017; Giesen et al., 2018). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Flexor Tendon Repair: How to Minimize Complications and Enhance Outcomes** ([Kang](https://www.jhandsurg.org/article/S0363-5023%2824%2900240-5/abstract?ref=theplasticsfella.com#:~:text=Flexor%20tendon%20injuries%20are%20complex,rate%20for%20zone%202%20repairs.), 2024) Flexor tendon injuries pose high complication risks, especially in zone 2, requiring careful timing, technique, and soft tissue management for optimal outcomes. ✅ ****Surgery or Splinting for Partial Extensor Tendon Lacerations?** ([Dickson](https://www.jprasurg.com/article/S1748-6815%2823%2900330-3/abstract?ref=theplasticsfella.com), 2023) Non-operative management of selected partial extensor tendon lacerations is safe, with comparable grip strength and return-to-work times to surgical repair, but higher complication rates in repaired cases. ✅ ****The Role of Tendon and Nerve Transfers in Peripheral Nerve Injuries** ([Giuffre](https://journals.lww.com/plasreconsurg/abstract/2015/03000/the%5Fbest%5Fof%5Ftendon%5Fand%5Fnerve%5Ftransfers%5Fin%5Fthe.49.aspx?ref=theplasticsfella.com), 2015) Nerve transfers are increasingly favored for peripheral nerve injuries, often combined with tendon transfers to optimize function while preserving reconstruction options. ## Feedback ### I hope you enjoyed it 😄 --- ### Breast Ptosis: Classification, Assessment, & Surgical Management URL: https://www.theplasticsfella.com/breast-ptosis/ Last updated: 2025-02-12T22:21:00.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/breast-ptosis/#overview-of-breast-ptosis) Breast ptosis refers to the downward displacement of the nipple-areola complex (NAC) below the inframammary fold (IMF), commonly due to aging, pregnancy, weight fluctuations, and genetics. [****Aetiology**](https://www.theplasticsfella.com/breast-ptosis/#aetiology-of-breast-ptosis) Caused by loss of skin elasticity, stretching of Cooper’s ligaments, parenchymal involution, and genetic factors. Lifestyle factors like smoking and poor bra support exacerbate ptosis. [****Classification**](https://www.theplasticsfella.com/breast-ptosis/#classification-of-breast-ptosis) The Regnault classification categorizes ptosis into Grades 1–3 based on nipple position relative to the IMF. Pseudoptosis refers to the sagging of breast tissue with the nipple at or above the IMF. [****Clinical Assessment**](https://www.theplasticsfella.com/breast-ptosis/#clinical-assessment-of-breast-ptosis) Evaluation includes key measurements (nipple-to-IMF distance), breast symmetry, skin quality, and imaging (mammography or MRI) in high-risk patients. [****Investigations**](https://www.theplasticsfella.com/breast-ptosis/#investigations-for-breast-ptosis) Preoperative imaging and documentation ensure comprehensive evaluation, especially in high-risk patients. [****Treatment Algorithm**](https://www.theplasticsfella.com/breast-ptosis/#treatment-algorithm-for-breast-ptosis) Surgical correction of breast ptosis restores shape, symmetry, and proportion via mastopexy, augmentation, or a combination of techniques. [****Mastopexy**](https://www.theplasticsfella.com/breast-ptosis/#mastopexy-for-breast-ptosis) Mastopexy corrects breast ptosis by repositioning the NAC, reshaping the breast, and removing excess skin, with incision techniques tailored to ptosis severity and patient goals. [****Augmentation Mastopexy**](https://www.theplasticsfella.com/breast-ptosis/#augmentation-mastopexy-for-breast-ptosis) Augmentation mastopexy ****corrects volume loss and ptosis**, requiring decisions on ****surgical staging and procedural sequencing** based on ****ptosis severity and tissue quality**. [****Complications**](https://www.theplasticsfella.com/breast-ptosis/#complications-of-breast-ptosis-treatment) Mastopexy and augmentation mastopexy achieve high patient satisfaction. Complications include hematoma, infection, nipple necrosis, capsular contracture, and implant malposition. ****Primary Contributor:** Hatan Mortada, Educational Fellow ****Verified by thePlasticsFella ✅** --- ## Overview of Breast Ptosis ****Key Point** Breast ptosis refers to the descent of the nipple-areola complex (NAC) below the inframammary fold (IMF). It is classified based on severity and often corrected through mastopexy or augmentation. Breast ptosis is defined as the downward displacement of the nipple-areola complex (NAC) relative to the inframammary fold (IMF). Often accompanied by redundant lower pole skin, ptosis results from the gradual loss of skin firmness, weakening of pectoralis muscles, and stretching of Cooper’s ligaments. This condition is progressive: - **Early Stages:** Uniform descent of both the NAC and glandular tissue. Accompanied by glandular volume loss. - **Advanced Stages:** Disproportionate descent of the NAC compared to the gland. Marked asymmetry and sagging. The image below illustrates breast ptosis. ![Breast ptosis with the nipple below the inframammary fold](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-07T161614.904.png) Breast ptosis with the nipple below the inframammary fold 😎 ****Fun Fact:** The word "ptosis" originates from the Greek word "ptōsis," meaning "falling," which describes the downward displacement of the breast. --- ## Aetiology of Breast Ptosis ****Key Point** Breast ptosis results from aging, weight fluctuations, pregnancy, genetics, and lifestyle factors that weaken breast support structures. Breast ptosis arises from a combination of intrinsic and extrinsic factors that weaken the support structures of the breast. **Intrinsic Factors** - **Genetics:** Influences breast size, shape, skin quality, and collagen integrity. - **Aging:** Causes skin laxity, glandular atrophy, and increased adipose tissue. - **Hormonal Changes:** Fluctuations (e.g., estrogen decrease) lead to skin thinning and ligament laxity ([Saadat & Kaviani](https://www.archbreastcancer.com/index.php/abc/article/view/196?ref=theplasticsfella.com), 2018). **Extrinsic Factors** - **Weight Fluctuations:** Repeated cycles can stretch Cooper’s ligaments ([Rinker](https://pubmed.ncbi.nlm.nih.gov/20354434/?ref=theplasticsfella.com), 2010). - **Pregnancy:** Hormonal shifts and postpartum volume loss contribute to ptosis (note: breastfeeding is not a direct cause) ([Rinker](https://pubmed.ncbi.nlm.nih.gov/19083576/?ref=theplasticsfella.com), 2008). - **Lifestyle Factors:** Smoking, sun exposure, and inadequate bra support further accelerate the process. 😎 ****Fun Fact:** The colloquial term “Cooper's droop” refers to the stretching of Cooper’s ligaments, the natural suspensory elements of the breast. --- ## Classification of Breast Ptosis ****Key Point** The Regnault classification is the most widely used system for assessing breast ptosis, categorizing severity based on the nipple’s position relative to the inframammary fold (IMF). Breast Ptosis has several classification systems ([See](https://www.jprasurg.com/article/S1748-6815%2823%2900151-1/abstract?ref=theplasticsfella.com), 2023). A standardized classification is essential for accurate assessment and surgical planning. #### Regnault Classification The Regnault classification describes breast ptosis in 4 grades. It focuses on the position of the nipple in relation to the IMF. 1. **Mild**: Nipple is at the level of the IMF 2. **Moderate:** Nipple lies below the IMF but remains above the lower breast contour. 3. **Severe:** Nipple is positioned below both the IMF and the lower contour. 4. **Pseudoptosis:** nipple above IMF, but loose skin creates a ptotic appearance. 😎 ****Fun Fact:** Severe ptosis is often associated with glandular tissue loss, deflation, and lateral/axillary fullness. Pseudoptosis typically results from hypoplasia due to weight loss or pregnancy The image below illustrates the original drawings from Regnault's publication in 1976 showing different levels of ptosis. ![Original drawings from Regnault's publication](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-06T150150.332.png) Original drawings from Regnault's publication ### Other Classifications - [**Vandenbussche**](https://pubmed.ncbi.nlm.nih.gov/1456726/?ref=theplasticsfella.com) **(1992):** Categorizes ptosis based on etiology. - [**Velasco**](https://pubmed.ncbi.nlm.nih.gov/19336156/?ref=theplasticsfella.com) **(2004):** Focuses on postpartum ptosis, classifying it into four stages. - [**Kirwan**](https://www.google.com/search?q=10.1067%2Fmaj.2002.126746&oq=10.1067%2Fmaj.2002.126746&gs%5Flcrp=EgZjaHJvbWUyBggAEEUYOdIBBzE4NmowajeoAgCwAgA&sourceid=chrome&ie=UTF-8&ref=theplasticsfella.com) **(2002):** Uses a 1-cm staging system (A–F), where Stage A represents a nipple 2 cm above the IMF, and Stage F indicates >2 cm below the IMF. 💡 ****Tip:** In pseudoptosis, the nipple-to-IMF distance increases while the sternal notch-to-nipple distance remains stable. --- ## Clinical Assessment of Breast Ptosis ****Key Point** A comprehensive assessment of ****breast ptosis** includes a ****detailed history, physical examination, and key measurements** to guide ****surgical planning** and optimize patient outcomes. A thorough clinical assessment evaluates breast ptosis, asymmetries, and surgical risks. Identifying factors like smoking, high BMI, and prior surgeries helps reduce complications and improve outcomes. ### History & Patient Goals - **Expectations:** Understand the desired aesthetic outcome. - **Changes Over Time:** Consider postpartum changes, weight fluctuations, and menopausal effects. - **Family and Surgical History:** Assess for breast cancer risk and previous surgeries that may affect vascularity. - **Risk Factors:** Smoking, high BMI, prior surgeries, and chronic conditions (e.g., diabetes) can increase postoperative complications. ### Physical Examination Evaluate for asymmetries, volume deficits, and skin redundancy. Assess tissue elasticity and dermal integrity. Key measurements on examination include: - **Nipple-to-IMF:** Assesses ptosis severity. - **Suprasternal Notch-to-Nipple:** Evaluates breast position on the chest. - **Breast Width:** Useful for determining implant size in augmentation cases. 💡 ****Tip:** Always measure ****nipple-to-IMF distance in an upright, neutral position** to ensure ****accuracy and consistency** in surgical planning. The image below shows preoperative marking and key landmarks. ![Preoperative breast marking for breast ptosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-07T161648.224.png) Preoperative breast marking for breast ptosis 😎 ****Fun Fact:** Inter-observer reliability of clinical measurements has been found to be good, though slight variability exists ([Hansson](https://pubmed.ncbi.nlm.nih.gov/24987206/?ref=theplasticsfella.com), 2014). --- ## Investigations for Breast Ptosis ****Key Point** Preoperative imaging and documentation are essential for comprehensive evaluation, particularly in high-risk patients. Investigations assess breast anatomy, ptosis severity, and risks. Imaging, photography, and measurements guide surgical planning, patient education, and postoperative comparison. - **Imaging:** Screening mammography or breast MRI as indicated for cancer risk assessment. - **Clinical Photography:** Document preoperative findings for patient education and legal records. - **Anthropometric and Advanced Measurements:** Emerging methods like 3D stereophotogrammetry provide accurate breast volume and ptosis assessment ([Huang](https://pubmed.ncbi.nlm.nih.gov/28192525/?ref=theplasticsfella.com), 2017). 💡 ****Tip:** For patients ****under 40**, use ultrasound for preoperative imaging. For those ****over 40** or high-risk patients, opt for MRI or mammography to screen for malignancies before mastopexy. --- ## Treatment Algorithm for Breast Ptosis ****Key Point** Surgical correction of breast ptosis ****restores shape, symmetry, and proportion** via mastopexy, augmentation, or a combination of techniques. The management of breast ptosis involves **mastopexy, augmentation,** or **a combination of both.** This can be performed in a **single-stage** or a **two-stage approach**, depending on tissue quality, implant size, and procedural complexity. Treatment of breast ptosis is tailored to ptosis severity, patient goals, and long-term outcomes. A general guide is as follows. - **Mild: Grade I ptosis:** Augmentation or periareolar mastopexy. - **Moderate: Grade II ptosis:** Vertical or infra-areolar mastopexy. - **Severe : Grade III ptosis:** Wise pattern mastopexy. This treatment algorithm for breast ptosis is illustrated below. ![The Regnault staging of breast ptosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-04T152355.828.png) The Regnault staging of breast ptosis --- ## Mastopexy for Breast Ptosis ****Key Point** Mastopexy corrects breast ptosis by repositioning the NAC, reshaping the breast, and removing excess skin, with incision techniques tailored to ptosis severity and patient goals. Mastopexy remains the cornerstone of surgical correction for breast ptosis. The technique and incision pattern are tailored to ptosis severity, skin quality, and patient goals. The goals of this procedure are: - **Reposition the nipple-areola complex** (NAC) for natural projection. - **Reshape and symmetrize the breast** to enhance contour. - **Remove excess skin** to restore firmness and improve aesthetics. ### Incision Techniques The choice of incision depends on **breast anatomy, patient preferences,** andthe **extent of correction** needed. - **Wise-pattern:** Severe ptosis, allows maximum lift and skin removal. - **Vertical (Lollipop):** Moderate ptosis, providing lift with fewer scars. - **Periareolar:** Mild ptosis, often combined with augmentation. ### 💡 ****Tip:** For optimal outcomes, aim for a sternal notch-to-nipple (SSN-N) distance of 21–23 cm and an inferior limb of 5–7 cm. Positioning the nipple at Pitanguy’s point along the breast meridian yields a natural appearance --- ## Augmentation-Mastopexy for Breast Ptosis ****Key Point** Augmentation mastopexy corrects volume loss and ptosis, requiring decisions on surgical staging and procedural sequencing based on ptosis severity and tissue quality. Augmentation mastopexy combines breast implants and a mastopexy to correct **both** volume loss and ptosis. Two important decisions should be made based on ptosis severity, skin quality, implant size, and patient goals. 1. **Single-stage** or **two-stage** procedure 2. **Mastopexy** first or **augmentation** first ### Single-Stage vs. Two-Stage Approach - **Single-stage:** Suitable for mild ptosis with minimal volume loss. It increases the risk of complications in patients with compromised tissue quality or large implants but can be safely performed ([Sanniec](https://academic.oup.com/asj/article-abstract/39/12/1331/5284903?redirectedFrom=fulltext&ref=theplasticsfella.com), 2019). - **Two-stage procedures:** Recommended for significant ptosis or compromised skin quality to reduce risks of recurrent sagging and implant malposition.Itallows greater control over nipple positioning, skin adaptation, and soft tissue. This has a lower revision/complication rate ([Lindsay](https://www.semanticscholar.org/paper/Conservative-Augmentation-with-Periareolar-Reduces-Cannon-Lindsey/c99325c6dc2d92ca3364e8139c9ae7968b521d5e?ref=theplasticsfella.com), 2010). 💡 ****Tip:** If ptosis is borderline, augmentation alone may provide sufficient lift. However, if the ****nipple remains low** postoperatively****, a secondary mastopexy** will be required. ### Mastopexy-First vs. Augment-First Approach **Mastopexy-First** Thisis best suited for moderate to severe ptosis with adequate native breast volume. - **Benefits:** Ensures precise nipple-areola repositioning before adding volume. Allows tissue contraction and remodeling before placing an implant. - **Limitation:** Requires a second procedure if implants are desired later. **Augmentation-First** Thisis suitable for mild ptosis with volume loss, where implants may provide adequate lift. This is ideal for patients with small breasts primarily seeking augmentation. - **Benefits:** Potentially eliminating the need for mastopexy if the implant provides sufficient lift. - **Limitations:** Risk of waterfall deformity if ptosis correction is insufficient. Implant volume directly affects **NAC positioning** due to the **lift effect** from augmentation. More specifically, - **≤225 cc:** Approximate SSN-N distance of 21 cm. - **250–325 cc:** Approximate distance of 22 cm. - **≥350 cc:** Approximate distance of 23 cm ### 💡 ****Tip:** For mastopexy after implant removal, delay surgery at least 3 months if breast tissue is <4 cm or nipple elevation >4 cm is needed. This allows tissue remodeling and reduces NAC compromise risk. --- ## Complications of Breast Ptosis Treatment ****Key Point** Mastopexy and augmentation mastopexy achieve high patient satisfaction. Complications include hematoma, infection, nipple necrosis, capsular contracture, and implant malposition. While outcomes are generally favorable, awareness of potential complications is essential for risk management and patient counseling. ### Early Complications - **Hematoma:** May require prompt surgical evacuation. - **Infection:** Particularly in augmentation-mastopexy; may necessitate antibiotics or implant removal. - **Nipple Necrosis:** Higher risk in smokers or those with compromised vascularity. - **Fat Necrosis:** Can lead to palpable nodules. ### Long-Term Complications - **Capsular Contracture:** Results in implant hardening or distortion. - **Implant Rippling:** More common with subglandular placement or thin soft tissue. - **Areolar Spreading:** Particularly with periareolar mastopexy. - **Nipple Malposition and Recurrent Ptosis:** May require revision procedures. - **Implant Malposition:** Can result from postoperative tissue stretch or imprecise pocket dissection. 😎 ****Fun Fact:** The final postoperative breast shape evolves over 6–12 months as tissue relaxation occurs, often leading to a more natural contour. --- ## Conclusion ****Upon completing this article, you will have accomplished the following:** ****1\. Overview:** Breast ptosis is the downward displacement of the nipple-areola complex (NAC) below the inframammary fold (IMF), commonly caused by aging, pregnancy, weight changes, and genetics. ****2\. Aetiology:** Ptosis results from skin elasticity loss, Cooper’s ligament stretching, parenchymal involution, and lifestyle factors like smoking and poor bra support. ****3\. Classification & Assessment:** The Regnault system grades ptosis (1–3) based on nipple position relative to the IMF. Assessment includes nipple-to-IMF measurements, skin quality, and imaging if high risk. ****4\. Management & Complications:** Treatment involves mastopexy, augmentation mastopexy, or reduction mammoplasty, with complications including hematoma, infection, nipple necrosis, and capsular contracture. --- ## Further Reading 1. Hidalgo DA, Spector JA. Mastopexy. Plast Reconstr Surg. 2013;132(4):642e-656e. doi:10.1097/PRS.0b013e31829fe4b4 2. See MH, Yip KC, Teh MS, et al. Classification and assessment techniques of breast ptosis: A systematic review. J Plast Reconstr Aesthet Surg. 2023;83:380-395\. doi:10.1016/j.bjps.2023.04.003 3. Martinez AA, Chung S. Breast Ptosis. \[Updated 2023 Nov 12\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK567792/ 4. Kirwan L. A classification and algorithm for treatment of breast ptosis. Aesthet Surg J. 2002;22(4):355-363\. doi:10.1067/maj.2002.126746 5. Pferdehirt R, Nahabedian MY. Finesse in Mastopexy and Augmentation Mastopexy. Plast Reconstr Surg. 2021;148(3):451e-461e. doi:10.1097/PRS.0000000000008303 6. Ali A Qureshi, Terence M Myckatyn, Marissa M Tenenbaum, Mastopexy and Mastopexy-Augmentation, Aesthetic Surgery Journal, Volume 38, Issue 4, April 2018, Pages 374–384, https://doi.org/10.1093/asj/sjx181 7. Ramanadham SR, Rose Johnson A. Breast Lift with and without Implant: A Synopsis and Primer for the Plastic Surgeon. Plast Reconstr Surg Glob Open. 2020;8(10):e3057\. Published 2020 Oct 28\. doi:10.1097/GOX.0000000000003057 8. Abdelkader R, Raafat S, Sakr W, Abdelaziz M, ElNoamany S. Augmentation Mastopexy: A Five-step Standardized Strategy Approach. Plast Reconstr Surg Glob Open. 2022;10(6):e4349\. Published 2022 Jun 15\. doi:10.1097/GOX.0000000000004349 9. Payer J, Chalkidis N, Polackova P, Patzelt M. MAMAS (mastopexy-augmentation made applicable and safer): A standardized template of pre-operative marking and step-by-step surgical procedure. JPRAS Open. 2024;40:293-304\. Published 2024 Mar 27\. doi:10.1016/j.jpra.2024.03.007 10. Marrella D, Tornambene R, Delia G, Stagno d'Alcontres F. Marking the nipple-areola complex in mastopexy and reduction mammoplasty: a geometrical method. Updates Surg. 2024;76(4):1553-1558\. doi:10.1007/s13304-024-01765-y ### Gen "Shaky Hands", Skin Grafts Are Failing + The 4 Forgotten Principles of Grafting. URL: https://www.theplasticsfella.com/february-2nd/ Last updated: 2025-02-01T09:42:12.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/february-2nd/#a-letter-from-pfella) Forget gen-Z — gen “shaky hands” 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-2nd/#the-sunday-quiz) How well do you know the stages of skin grafting? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/february-2nd/#image-of-the-week) Fish skin for burn treatment. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/february-2nd/#technique-tip) Optimising skin grafts: Mesh measuring. 5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/february-2nd/#what-does-the-evidence-say) How to choose the best dressing for skin graft take? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/february-2nd/#articles-of-the-week) CT Angio before DIEP, why flaps fail, & microsurgical principles: with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/february-2nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Forget Gen Z — Gen “Shaky Hands”* 👋 ****Hey Team!** Let’s call it what it is — residents aren’t cutting anymore, and it’s a crisis. Surgical training has become a ****spectator sport**. Hours are capped, attendings are too risk-averse, and residents leave with pristine exam scores but ****shaky hands**. Watching isn’t learning. Reading isn’t operating. And yet, we act like this won’t have consequences. Share your experience below 👇 **What’s Really Happening?** - **Hands off, skills down.** Operative experience in **aesthetic breast and hand surgery has plummeted** (Hallam et al., 2013; Silvestre et al., 2017). Thanks to the European Working Time Directive and consultant-led services, **trainees are being sidelined** (de Blacam et al., 2017). - **Fellowships as damage control.** More trainees are forced into extra years just to get **basic** hands-on experience. Sure, independent fellows **log more cases overall** (Iglesias et al., 2022), but that’s a band-aid, not a solution. - **Fear-driven training.** Attendings, scared of complications or slowing down their lists, **step in too often**, leaving residents as glorified assistants. **A System Built to Fail** The next wave of surgeons will be **brilliant on paper but useless in the OR**. Microsurgery training? **Hit-or-miss depending on where you train** (Chang et al., 2023). Global surgery opportunities? **Barely tapped into** (Nayar et al., 2015; Park et al., 2018). If we don’t course-correct, we’ll be watching a generation of “plastic surgeons” who can consult and document — but can’t operate. **Fix It or Face the Consequences** Surgical exposure **needs to start earlier**. Medical students barely see plastic surgery, yet it’s a **key pipeline for future trainees** (Austin & Wanzel, 2015). If you’re a resident stuck on the sidelines, speak up. If you’re an attending watching skills decline, call it out. With love, P'Fella ❤️ **ps** \- **basic procedures will be outsourced to robots within the decade.. and robots don't take sick days.** ## The Sunday Quiz **How Well Do You Know* ***the** ***Stages of Skin Grafting?** ****Are you ready to make it to the leaderboard?** Welcome to ****a fresh round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-14.png) ## Image of the Week **Fish Skin for Burn Treatment* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we’re looking at the use of fish skin grafts in burn management. Rich in collagen and omega-3 fatty acids, these grafts promote healing, reduce pain, and serve as a natural biological dressing. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-15.png) [Source](https://cdn.24.co.za/files/Cms/General/d/10817/2e4e1a6b8c1749d78b2976d690841c9c.jpg?ref=theplasticsfella.com) ## Technique Tip **Optimising Skin Graft Meshing* 🚑 ****Technique Tip of the Week** This week’s technique focuses on mesh measurements for skin grafts. Meshing skin grafts increases coverage and promotes drainage, but choosing the right expansion ratio is key. This image compares ****non-meshed, standard** meshing (1:1), and **overmeshed** grafts (1:1.25 to 1:1.5). While larger expansion ratios maximize coverage, they may compromise dermal integrity and healing. ****Overmeshing** can lead to excessive contraction and scarring, so balance is crucial for optimal graft take and cosmetic outcomes. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/image-17.png) [Source](https://www.jprasurg.com/cms/10.1016/j.bjps.2020.02.048/asset/1af9883a-7016-4472-8e0d-b55fc0b7717d/main.assets/gr1%5Flrg.jpg?ref=theplasticsfella.com) ## What Does the Evidence Say? **Choosing the Best Dressing for Skin Graft Take* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Exploring various dressing techniques for skin grafts aims to improve graft take and patient outcomes. Traditional ****tie-over dressings** have been compared to simpler, faster methods using ****skin staplers**, showing comparable graft success rates with reduced operation times (Kim et al., 2018). Some research suggests that tie-over dressings may not be necessary for full-thickness skin grafts in certain circumstances (Marsidi et al., 2020). ****Hydrocolloid dressings** have shown promise, offering better graft survival and shorter treatment times compared to traditional methods (Jeong et al., 2011). ****Negative-pressure wound therapy** has demonstrated significant improvements in graft take rates, particularly in irregular, high-mobility areas, and reduced dressing time compared to tie-over bolster dressings (Cao et al., 2022). Other innovative techniques, such as ****barbed suture tie-overs** (Joyce et al., 2015) and ****redoable tie-over** dressings using multiple loop silk threads (Jo et al., 2013), have also shown successful outcomes in skin graft procedures. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****How to Skin Graft in 1924** (McWillians, 1924) Let's go back in time to the a seminal paper on skin grafting. One that shaped our current plastic surgery landscape. [PRINCIPLES OF THE FOUR TYPES OF SKIN GRAFTINGMcWilliams, 1924jama\_1924\_02660030021007 -- 38ba86ce13e8f88627387f4c46bb8170 -- Anna’s Archive.pdf7 MBdownload-circle](https://www.theplasticsfella.com/content/files/2025/02/jama%5F1924%5F02660030021007----38ba86ce13e8f88627387f4c46bb8170----Anna-s-Archive.pdf "Download") ✅ ****Use a grapefruit to practice skin grafting** ([Whallet](https://sci-hub.se/10.1016/j.bjps.2010.06.017?ref=theplasticsfella.com), 2011) "The orange or grapefruit is divided into two, therefore two trainees can work on each fruit at any one time, and several procedures can be performed on the same model" ✅ ****How to secure a skin graft** ([Seretis](https://www.jprasurg.com/article/S1748-6815%2824%2900381-4/abstract?ref=theplasticsfella.com), 2024) "NPWT is the most effective for skin graft adherence as opposed to traditional techniques. FIB and TOB reduce hematoma and seroma rates in patients at high risk of bleeding" ## Feedback ### I hope you enjoyed it 😄 --- ### The Instagram Scam, 7 Facial Flap Insights & Quiz Winners. URL: https://www.theplasticsfella.com/january-26th/ Last updated: 2025-01-25T16:46:59.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/january-26th/#a-letter-from-pfella) The Instagram Scam. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-26th/#the-sunday-quiz) Announcing the Winners! 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/january-26th/#image-of-the-week) How to Design a Cervicofacial Flap. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/january-26th/#technique-tip) Bilobed Flaps Done Right! 5. 📚 [****Book Review**](https://www.theplasticsfella.com/january-26th/#book-review) "Local Flaps in Facial Reconstruction" by Shan R. Baker. 6. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/january-26th/#the-fellows-corner) Introduction: Meet Our Fellows! 7. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/january-26th/#what-does-the-evidence-say) Better Cosmetic Outcome: Skin Graft vs. Flap on the Face 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/january-26th/#articles-of-the-week) Zitelli's Original Bilobed Flap, Overview of Local Flaps on the Face, & The Original Antia Buch Flap: With 1-Sentence Summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/january-26th/#feedback) Suggest Ideas & Give Feedback! ## A Letter from P'Fella **The Instagram Scam: Fake Plastic Surgeons* 👋 ****Hey all!** [Instagram](https://www.instagram.com/theplasticsfella/?ref=theplasticsfella.com) has become the Wild West of plastic surgery—a platform where credentials are optional, but the risks are real. This is more than misinformation; it’s malpractice waiting to happen. Here's why 👇 A [recent study](https://journals.lww.com/prsgo/fulltext/2025/01000/instagram%5Fversus%5Freality%5F%5Fwho%5Fare%5Factually%5Fplastic.12.aspx?ref=theplasticsfella.com) revealed that out of 1,141 [Instagram](https://www.instagram.com/theplasticsfella/?ref=theplasticsfella.com) profiles claiming to belong to "plastic surgeons," nearly **28% were not certified by the American Board of Plastic Surgery (ABPS)**. Even more alarming, **22% had no formal training in plastic surgery whatsoever** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-13-1.png) Training backgrounds of US plastic surgeons and board certification status ([Source](https://journals.lww.com/prsgo/fulltext/2025/01000/instagram%5Fversus%5Freality%5F%5Fwho%5Fare%5Factually%5Fplastic.12.aspx?ref=theplasticsfella.com)) Think about it: **nearly one in three so-called “plastic surgeons”** on Instagram lacks proper certification. These impostors, some with zero training in plastic surgery, are marketing high-risk procedures like Brazilian butt lifts and tummy tucks. Patients often assume Instagram’s shiny aesthetics equal skill, but behind many of these accounts lies a dangerous lack of expertise. #### Why Instagram Is the Perfect Playground for Frauds The problem is systemic. [Instagram’s](https://www.instagram.com/theplasticsfella/?ref=theplasticsfella.com) algorithms reward viral content, not qualifications. Non-certified practitioners often have more followers than board-certified plastic surgeons, thanks to flashy posts and aggressive marketing. This imbalance makes them appear more credible to unsuspecting patients, who might choose visibility over verification​. #### The Solution? Enough with passive awareness campaigns. A public database of board-certified surgeons and an Instagram “verified surgeon” badge can empower patients and expose frauds. Let’s protect our profession and patient safety. What’s your stance? Reply to this email, would love to hear your thougthts. With love, P'Fella ❤️ **p.s -** [**thePlasticsFella Instagram** ](https://www.instagram.com/theplasticsfella/?ref=theplasticsfella.com)**is 🔥 these days.** ## The Sunday Quiz **\*Drumroll*🥁**\* Winners Announcement!* ****Congratulations to the Winners** of The Weekly Quiz! We're thrilled to announce the winners of this edition's quiz. After six rounds of questions on plastic surgery, our top scorers are ****AL**, ****Nathan**, ****Roscoe**, ****Rehan**, and ****Jcalvo**. Can the winners please reply to this newsletter or contact us 😄 Thank you to everyone who participated and stay tuned for more fun quizzes in future editions! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Leaderboard-Team-Post-Template--4-.png) Here's the rest of the leaderboard! ## Image of the Week **Designing a Cervicofacial Flap* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we’re looking at designing a cervicofacial flap. The flap is elevated in the deep plane to preserve ****vascularity** and ****reduce tension**, ensuring optimal contour and coverage. Strategic planning along key landmarks (A-A' and B-B') allows for smooth rotation and precise defect closure, for both functional and aesthetic outcomes. ![Designing a cervicofacial flap](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/jcm-12-03700-g004-550.webp) Designing a cervicofacial flap ([Source](https://www.mdpi.com/jcm/jcm-12-03700/article%5Fdeploy/html/images/jcm-12-03700-g004-550.jpg?ref=theplasticsfella.com)) ## Technique Tip **Bilobed Flaps Done Right!* 🚑 ****Technique Tip of the Week** This week’s technique focuses on bilobed flaps; a common reconstructive option for nasal tip defects. ❗****Mark the Defect:** Measure the defect diameter (r). ❗****Plan the Pivot Point:** Position it one radius (r) away from the defect edge. ❗****Design the Lobes:** The first lobe is done at a 45° angle, same size as the defect. Second lobe is done at a 90° angle, slightly smaller. ❗****Perform Surgery:** Thin flaps for contour matching. Then close the secondary defect first and repair in layers to avoid distortion. ✅ **Pro Tip:** Follow the "3-2-1 Rule" (3 measurements, 2 angles, 1 pivot) for easy, precise design. ![Bilobed flaps for nasal reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Screenshot-2025-01-24-at-09-49-24.png) Bilobed flaps for nasal reconstruction: Source Baker, Local Flaps (see book review belw) ## Book Review **"Local Flaps in Facial Reconstruction" by Shan R. Baker* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/9780323683906.jpg) #### ****Local Flaps in Facial Reconstruction**" Hey there! If you're into facial reconstructive surgery, "****Local Flaps in Facial Reconstruction**" by Shan R. Baker is a fantastic resource. The book is loaded with clear, high-quality images that show patients before and after surgery. The design of the flaps is explained in a way that's easy to follow, making it super helpful for both beginners and experienced surgeons. It’s **practical*, **informative*, and **visually impressive* — a great addition to your medical library. ![Local Flaps in Facial Reconstruction](https://lh7-rt.googleusercontent.com/docsz/AD_4nXfABgzBZOPRRyBLfSHxNpzp41FEbeWw-f3fcZnJo3oWLlDpN73DxU-2VzKFNuGneb4y_GahxeeYAZLjWGECOruzDPkm_OihUhcw0YZzbAkblXNyxatLoT7wKX6k7RdtQUDjb9GdLOq2Ww3CHImLBaYSuGA?key=VE6BXUZFwhQudikkPVwgwA) ![Local Flaps in Facial Reconstruction](https://lh7-rt.googleusercontent.com/docsz/AD_4nXddIJl61gVypmCQ-oc9bnY8njEid62wYw3Ev4vePElXkzJmJJo4MofvL0I_Un5yU8AKXi9uJ7zE0WS202lC__I5h49JsXzxllQLH1f4efbFejjZ-VTLk5COQ76XFvZ1nSgXQWEKGOtvAfL6bc2WCRbFlGfT?key=VE6BXUZFwhQudikkPVwgwA) ## the Fellows' Corner **It's Time to Meet Our Fellows!* 🎓 ****The Plastics Fellows** We’re excited to introduce four incredible educational fellows who will be authoring articles and driving many of the projects you enjoy at The Plastics Fella! They bring a wealth of knowledge, expertise, and fresh perspectives to our platform. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Meet-Our-Fellows.png) ## What Does the Evidence Say? **Better Cosmetic Outcome: Skin Graft vs. Flap on the Face?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Facial reconstruction after skin cancer excision can be achieved using ****local flaps or skin grafts**, with local flaps generally providing superior cosmetic outcomes (Jacobs et al., 2010; Martinović et al., 2022; Ebrahimi et al., 2015; Lee et al., 2017). Local flaps demonstrate better skin ****quality**, including improved ****hydration**, sebum levels, and transepidermal water loss compared to skin grafts (Martinović et al., 2022). Patients report higher satisfaction with local flaps, particularly in terms of tissue coordination and skin color (Ebrahimi et al., 2015; Lee et al., 2017). However, the choice of reconstruction technique should be tailored to the specific facial subunit and defect characteristics (Russo et al., 2017). In cases where local flaps are not feasible, ****skin-grafted muscle flaps** can provide optimal contour and color match for facial reconstruction (Cordova et al., 2010). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Zitelli's Original: How to Optimize the Bilobed Flap for Nasal Reconstruction** ([Zitelli](https://jamanetwork.com/journals/jamadermatology/article-abstract/550671?ref=theplasticsfella.com), 1989) Bilobed flaps effectively reconstruct the lower third of the nose, with design refinements minimizing tissue protrusion and improving aesthetic outcomes. ✅ ****Facial Reconstruction: Local Flaps for Cutaneous Malignancies** ([Rao](https://pubmed.ncbi.nlm.nih.gov/28163451/?ref=theplasticsfella.com), 2016) Local flaps, including V-Y advancement, nasolabial, and forehead flaps, deliver high success and cosmetic outcomes for facial defect reconstruction with minimal complications. ✅ ****Precision in Ear Reconstruction: The Chondrocutaneous Advancement Flap for Marginal Defects** ([Antia](https://journals.lww.com/plasreconsurg/abstract/1967/05000/chondrocutaneous%5Fadvancement%5Fflap%5Ffor%5Fthe%5Fmarginal.6.aspx?ref=theplasticsfella.com), 1967) The chondrocutaneous advancement flap effectively reconstructs marginal ear defects by advancing the intact helical margin on a wide postauricular skin pedicle, ensuring a natural contour with minimal tissue use and operative time. ## Feedback ### I hope you enjoyed it 😄 --- ### 2 Tips for Acland's Patency Test, Venous Flaps & ALT Flap in Action URL: https://www.theplasticsfella.com/january-19th/ Last updated: 2025-01-18T17:06:41.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/january-19th/#a-letter-from-pfella) The shadow economy of plastic surgery is booming. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-19th/#the-sunday-quiz) How well do you know v**enous flaps*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/january-19th/#image-of-the-week) ALT musculocutaneous perforator flap in action. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/january-19th/#technique-tip) How to do Allen’s patency test. 5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/january-19th/#what-does-the-evidence-say) Vasopressors in microsurgery: Challenging the dogma. 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/january-19th/#articles-of-the-week) CT Angio before DIEP, why flaps fail, & microsurgical principles: with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/january-19th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Shadow Economy of Plastic Surgery is Booming* 👋 ****Hey all!** Let’s call this what it is: We’ve built a system that’s broken and hypocritical. In an attempt to reduce stress and level the playing field, medical schools moved away from traditional grades and honors to a pass/fail setup. But instead of fixing the problem, we just shifted the battlefield. Now, students are forced into a shadow economy of extracurricular effort to survive an arms race that does nothing to make them better doctors. They’re churning out abstracts, stacking volunteer experiences, and competing on a spreadsheet — not in the clinic, where it actually matters. Eric Warm’s post on [Twitter](https://x.com/CincyIM/status/1879934709519773910?ref=theplasticsfella.com) brought this to my attention. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Screenshot-2025-01-18-at-02.52.05.png) And here’s the dirty truth: None of this insanity predicts who will excel in residency. **The Reality** In 2022, neurosurgery applicants averaged **30** publications per person. The top 10% submitted **58 or more**. For perspective, that’s more than what many full-time academics publish in years. And this isn’t just isolated to the ultra-competitive specialties — plastic surgery is no different. Students are gaming the system because we’ve left them no choice. We’ve replaced grades with meaningless metrics and called it progress. The result? Students are ditching clinical teaching, their hands-on skills are deteriorating, and burnout is now baked into the process before residency even begins. **What We’re Really Doing** This pass/fail era creates triple harm. 1. **Clinical Excellence is Devalued:** Students are rewarded for looking good on paper, not for being great in practice. 2. **Burnout is Accelerating:** The bar is impossibly high. Even the strongest students are crumbling under the pressure. 3. **Superficial Academia is Thriving:** “Achievements” like mass-producing abstracts aren’t about quality or learning — they’re strategic resume padding. **A System That Eats Its Young** Sure, some students feel liberated to pursue meaningful work under pass/fail — but let’s not kid ourselves. Most are just trying to survive. This is not the meritocracy we claim it to be; it’s a system that eats its young and wonders why they’re burnt out by Day 1 of residency. P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Venous Flaps?** ****Are you ready to make it to the leaderboard?** Welcome to ****the last round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![Thatte and Thatte Venous Flap Classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-10.png) Thatte and Thatte Venous Flap Classification ## Image of the Week **ALT Musculocutaneous Perforator Flap in Action* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we’re looking at an intraoperative image of an elevated ALT musculocutaneous perforator flap with the deep fascia. Read more about the anterolateral thigh flap [here](https://www.researchgate.net/publication/259492840%5FExtended%5FAnterolateral%5FThigh%5FFlaps%5Ffor%5FReconstruction%5Fof%5FExtensive%5FDefects%5Fof%5Fthe%5FFoot%5Fand%5FAnkle?ref=theplasticsfella.com). ![Intraoperative view after elevation of the ALT musculocutaneous perforator flap with the deep fascia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-11.png) [Source](https://pubmed.ncbi.nlm.nih.gov/24376731/?ref=theplasticsfella.com) ## Technique Tip **How to Do A Patency Test* 🚑 ****Technique Tip of the Week** This week’s technique focuses on ****Patency Test**, a useful but minimally traumatic method to assess vessel patency. Use it judiciously to avoid unnecessary vessel trauma. ****Steps:** ****1\.** Occlude the vessel distal to the anastomosis with forceps. ****2\.** Use a second pair of forceps to empty a segment of the vessel. ****3\.** Release the proximal forceps and watch for segment refill. ****Tips:** ****\-** Use forceps with parallel jaws for reliable occlusion. ****\-** Perform the test distal to the anastomosis and follow the natural blood flow direction for accuracy. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-12.png) Source: Acland, Principles in Micorsurgery ## What Does the Evidence Say? **Vasopressors in Microsurgery: Challenging the Dogma* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Recent studies challenge the traditional avoidance of ****vasopressors** ****in microsurgery**, with large-scale analyses showing no significant increase in complications or flap failure rates associated with their use. (Chen et al., 2010; Zhu et al., 2023; Goh et al., 2019; Fang et al., 2017). Some studies even reported potential benefits, such as ****reduced fluid administration** and ****improved flap survival** (Zhu et al., 2023; Goh et al., 2019). Noradrenaline use did not adversely affect free flap survival in microvascular reconstructive surgeries (Rajan et al., 2019). Various vasopressors, including ****phenylephrine**, ****ephedrine**, and ****calcium chloride**, have been safely used in different surgical phases without increasing flap compromise or failure rates (Fang et al., 2017). While some studies noted a slightly ****higher re-exploration rate** with vasopressor use, overall flap outcomes remained unaffected (Rajan et al., 2019). The judicious use of vasopressors in microsurgery may be safe and potentially beneficial for maintaining hemodynamic stability without compromising flap viability. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Preoperative CT-Angiography for DIEP Flap Reconstruction** ([Teunis](https://onlinelibrary.wiley.com/doi/10.1002/micr.22119?ref=theplasticsfella.com), 2013) In DIEP flap breast reconstruction, preoperative CT-angiography significantly reduces both flap loss and operative time compared to Doppler ultrasound. ✅ ****What Drives Free Flap Failure? A Multi-Institutional Risk Factor Analysis** ([Wong](https://onlinelibrary.wiley.com/doi/10.1002/micr.22223?ref=theplasticsfella.com), 2014) microvascular free flaps show a 4.4% failure rate, with operative time exceeding 625 minutes identified as a significant independent risk factor. ✅ ****Reconstructive Microsurgery: Milestones, Principles, and the Road Ahead** ([Armstrong](https://www.plasticsurgery.theclinics.com/article/S0094-1298%2820%2932415-9/abstract?ref=theplasticsfella.com), 2001) Reconstructive microsurgery has evolved from free flap techniques to advanced procedures such as limb transplantation as its key principles continue to shape complex reconstructions. ## Feedback ### I hope you enjoyed it 😄 --- ### Paper vs Electronic Records?, 3 Must-Knows on Scars, Wounds, & Keloids URL: https://www.theplasticsfella.com/january-12th/ Last updated: 2025-01-11T20:43:54.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/january-12th/#a-letter-from-pfella) Was paper better than electornic? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-12th/#the-sunday-quiz) How well do you know **wound healing*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/january-12th/#image-of-the-week) What does a keloid scar look like after steroid injection**?* 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/january-12th/#technique-tip) How to pick the right wound dressing 5. 📚 [****Book Review**](https://www.theplasticsfella.com/january-12th/#book-review) Reviewing **Key Notes on Plastic Surgery* 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/january-12th/#what-does-the-evidence-say) How many injections for a keloid scar? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/january-12th/#articles-of-the-week) Algorithm for scar management, keloid treatment, & caring for your incision: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/january-12th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Was Paper Better Than* Electronic**?* 👋 ****Hey all!** Let’s face it — electronic medical records (EMRs) were supposed to be a game-changer. Designed to streamline workflows, reduce errors, and improve patient care. They’ve done some of that… but not without introducing their own headaches. So, let’s ask: ****Was paper really worse than what we’re dealing with today?** Here’s the truth. EMRs might be legible, but they’re often unintelligible. You’ve probably dealt with it — endless drop-down menus, duplicate medications, and alerts that serve the system more than the clinician. Worse, if you miss a step, the system doesn’t just flag it — it creates errors, from stopping critical meds to delaying discharges. **The Numbers Don’t Lie** A recent study showed that EMR has its downsides: On average, there were slightly more positive perceptions of EHR usage than negative. The most commonly perceived issues with EHR were wasted time and barriers to user-friendliness ([PRS](https://pmc.ncbi.nlm.nih.gov/articles/PMC7209869/?ref=theplasticsfella.com), 2020) With paper charts, you might have struggled with messy handwriting, but the notes had meaning. Today, we’ve traded that for legible, standardized gibberish. Add to this the endless hoops clinicians must jump through: fixing insurance issues from home, sorting mismatched med lists, or manually correcting system errors. **A System That Works for Us** EMRs weren’t built for us — they were built for billing and compliance. When tools meant to help create more work and errors, it’s time to rethink their design. We need systems that adapt to clinicians — not the other way around. P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Wound Healing?** ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![Phases of Wound Healing](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-6.png) Phases of Wound Healing ## Image of the Week **Keloid Scar After Steroid Injection* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we’re looking at a keloid scar following steroid injection. Read more about keloids [here](https://www.theplasticsfella.com/keloid-scars/). ![Keloid Scar After Steroid Injection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/AI-generated-image--18-.png) Keloid Scar After Steroid Injection ## Technique Tip **How to Pick the Right Dressing* 🚑 ****Technique Tip of the Week** This week’s technique focuses on ****picking the right wound dressing**. Select a dressing that balances wound needs (exudate, infection risk, healing phase) with patient factors (allergies, compliance). Adjust as conditions evolve. Key considerations include, ****\- Healing:** Maintain moisture and promote cell regeneration. ****\- Protection:** Prevent trauma, guard against infection, and regulate temperature. ****\- Safety:** Use sterile, non-toxic, and hypoallergenic options. Read in more detail [here](https://www.theplasticsfella.com/wound-dressings/#choice-of-wound-dressing). ![Dressing approaches for different types of wounds](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-7.png) Dressing Approaches for Types of Wounds ## Book Review **Key Notes on Plastic Surgery* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/images--1-.jpeg) #### ****Key Notes on Plastic Surgery** "****Key Notes on Plastic Surgery**" is a comprehensive guide to the field of plastic surgery, authored by two renowned plastic surgeons, Adrian Richards and Hywel Dafydd. The book covers a wide range of plastic surgery topics, including ****facial surgery**, ****breast surgery**, ****body contouring**, and ****non-surgical procedures**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-8.png) [Check Out the Full Review](https://www.theplasticsfella.com/key-notes-on-plastic-surgery-book-review/) ## What Does the Evidence Say? **How Many Injections for a Keloid Scar?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Intralesional corticosteroid injections, particularly ****triamcinolone acetonide**, are a widely used first-line treatment for keloid scars (Wang et al., 2021; Yin et al., 2023). Treatment protocols vary, with injection intervals ranging from ****weekly to monthly** and dosages from 1 to 20 mg/cm² (Yin et al., 2023). Corticosteroid injections can be effective alone or combined with ****surgical excision**, achieving recurrence rates as low as 14.3% for keloids and 16.7% for hypertrophic scars (Hayashi et al., 2012). Long-term studies show improvement in 82% of patients for subjective symptoms and 63% for objective symptoms, though treatment may require 20-30 injections over 3-5 years (Muneuchi et al., 2006). Combining corticosteroids with other treatments like ****5-fluorouracil** or ****laser therapy** may enhance efficacy and reduce side effects (Morelli Coppola et al., 2018). ****Three-dimensional imaging** can objectively assess treatment response, showing significant volume reduction after steroid therapy (Ardehali et al., 2007). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Scar Management Made Smarter for Hypertrophic Scars & Keloids** ([Ogawa](https://journals.lww.com/plasreconsurg/fulltext/2022/01000/the%5Fmost%5Fcurrent%5Falgorithms%5Ffor%5Fthe%5Ftreatment%5Fand.39.aspx?ref=theplasticsfella.com), 2022) Current scar management algorithms integrate compression, corticosteroids, and adjunctive radiotherapy, offering a structured approach to treating persistent fibroproliferative conditions. ✅ ****Wound Coverage, Adjuvant Treatments, & Surgical Outcomes for Keloid Scars** ([Cardenas](https://academic.oup.com/asjopenforum/advance-article/doi/10.1093/asjof/ojae129/7932569?ref=theplasticsfella.com), 2024) Combining surgical excision, local flap coverage, and radiotherapy reduces keloid recurrence to 21%, emphasizing integrated treatment strategies. ✅ ****A Simple Yet Effective Practical Guide to Wound Care** ([Lalonde](https://journals.lww.com/prsgo/fulltext/2019/10000/simple%5Feffective%5Fways%5Fto%5Fcare%5Ffor%5Fskin%5Fwounds%5Fand.24.aspx?ref=theplasticsfella.com), 2019) Effective wound management doesn’t always require costly resources. Clean water rinses, petroleum-based moisture barriers, & non-sterile clean dressings — a simplified care approach for open/closed wounds. ## Feedback ### I hope you enjoyed it 😄 --- ### BIA-ALCL: Risk Factors, Diagnosis, & Management URL: https://www.theplasticsfella.com/bia-alcl/ Last updated: 2025-02-08T19:51:16.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/bia-alcl/#overview-of-bia-alcl) A rare T-cell lymphoma linked to textured breast implants, characterised by delayed-onset seroma, swelling, or masses. [****Pathogenesis**](https://www.theplasticsfella.com/bia-alcl/#pathogenesis-of-bia-alcl) Chronic inflammation from textured implants, bacterial biofilm formation, and genetic predisposition drive disease development. [****Risk Factors**](https://www.theplasticsfella.com/bia-alcl/#risk-factors-of-bia-alcl) Associated with macrotextured implants, with most cases presenting 8–10 years post-implantation. [****Diagnosis**](https://www.theplasticsfella.com/bia-alcl/#diagnosis-of-bia-alcl) Diagnosis relies on clinical evaluation, imaging, and pathological confirmation via cytology, flow cytometry, and CD30 immunohistochemistry. [****Staging**](https://www.theplasticsfella.com/bia-alcl/#staging-of-bia-alcl) The TNM staging system for solid tumors is preferred over traditional lymphoma staging methods for BIA-ALCL. [****Management**](https://www.theplasticsfella.com/bia-alcl/#management-of-bia-alcl) Complete en bloc resection, including implant and capsule removal, is essential. Advanced cases may require chemotherapy (e.g., brentuximab vedotin) or radiotherapy. ****Primary Contributor:** Dr Hatan Mortada. ## --- ## Overview of BIA-ALCL ****Key Point** BIA-ALCL is a rare, distinct type of T-cell lymphoma associated primarily with textured breast implants, characterized by delayed seroma formation and favorable prognosis when treated early. Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare **type of T-cell lymphoma** linked to **textured** breast implants. First described by Keech and Creech in [1997](https://pubmed.ncbi.nlm.nih.gov/9252643/?ref=theplasticsfella.com), it predominantly arises in the fibrous capsule or fluid surrounding the implant. This original publication can be seen below. ![One of the first descriptions of Bi-ALCL in 1997](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Main-Article-Images---2025-01-04T011045.267-1.png) One of the first descriptions of Bi-ALCL in 1997 😎 ****Fun Fact:** In 2016, the World Health Organization (WHO) classified BIA-ALCL as a distinct disease due to its clinical significance and increasing recognition. --- ## Pathogenesis of BIA-ALCL ****Key Point** Chronic inflammation, bacterial biofilm, and genetic predisposition collectively contribute to BIA-ALCL development. The development of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is driven by a complex interplay of **chronic** **inflammation**, **bacterial** **contamination**, **genetic** **predisposition**, and **environmental** **factors** in susceptible individuals. - **Chronic Inflammation:** Textured implants incite prolonged immune activation through friction and particulate shedding, driving dysregulated JAK/STAT signaling. Persistent immune responses create a microenvironment conducive to T-cell transformation. - **Bacterial Biofilm:** Textured implants harbor higher bacterial loads, leading to chronic antigenic stimulation and T-cell monoclonality. This prolonged stimulation drives the development of monoclonal CD30+ T-cells, a hallmark of BIA-ALCL. - **Genetic Susceptibility:** Mutations in regulatory genes (e.g., STAT3, TP53), genetic syndromes (e.g., Li-Fraumeni) or polymorphisms, and germline predispositions enhance susceptibility when combined with chronic inflammation. - **Environmental Triggers:** The texture and particulate shedding from implants can modulate immune responses. Released silicone particles may further exacerbate local inflammation, amplifying the risk of lymphomagenesis. 💡 ****Tip:** Chronic inflammation resulting from textured implants highlights the importance of adopting smooth or innovative implant designs to minimize immune activation and reduce the risk of BIA-ALCL. --- ## Risk Factors of BIA-ALCL ****Key Point** BIA-ALCL is rare, with a higher risk associated with macrotextured implants and cases typically emerging 8–10 years post-implantation. Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is linked to **textured breast implants**. Over 1,300 cases have been reported across 35 countries. The risk varies based on implant type, with Allergan Biocell implants carrying an estimated risk of 1:2,207, significantly higher than other textured implants ([Clemens](https://pubmed.ncbi.nlm.nih.gov/31246800/?ref=theplasticsfella.com), 2019). While the overall incidence remains low, specific implant types and patient factors significantly elevate risk. These include, - **Textured Implant Type:** These carry a significantly higher risk compared to smooth implants. Increased surface area promotes bacterial colonization and biofilm formation, which may trigger chronic inflammation leading to lymphoma. - **History of Capsular Contracture:** Persistent immune responses in the capsule region might act as a catalyst for malignant transformations. - **Genetic Predisposition:** Mutations in pathways regulating immune responses have been associated with lymphoma development. Links to immune dysregulation syndromes like Li-Fraumeni syndrome are under investigation. - **Time Since Implantation:** Most cases emerge 8–10 years post-implantation. - **Delayed Onset:** Highlights the importance of long-term surveillance for patients with textured implants. 💡 ****Tip:** The long latency period underscores the importance of extended follow-up for patients, even in the absence of symptoms, to monitor for potential developments of BIA-ALCL. --- ## Diagnosis of BIA-ALCL ****Key Point** BIA-ALCL diagnosis requires clinical evaluation, imaging, and confirmation via CD30 immunohistochemistry and flow cytometry. BIA-ALCL is characterised by monoclonal CD30+ T-cells within a periprosthetic effusion or mass. This diagnosis is achieved with a triple assessment (clinical examination, imaging, and pathology). ### Clinical Evaluation BIA-ALCL typically presents **8–10 years** after **textured** implant placement, with symptoms often arising from the luminal aspect of the peri-implant capsule. **Classic Findings** - Persistent seroma >1-year post-implantation, often rapid onset. - Breast mass (\~10–40% of cases) ([Clemens](https://pubmed.ncbi.nlm.nih.gov/26628470/?ref=theplasticsfella.com), 2016). - Breast asymmetry, pain, or palpable masses. 🔴 Red Flag: Delayed seromas occur in \~0.1 to 0.2 per- cent of patients following implantation of textured implants ([McGuire](https://pubmed.ncbi.nlm.nih.gov/27627058/?ref=theplasticsfella.com), 2017). **Less Common Symptoms** - Lymphadenopathy, erythema, or skin lesions/ulceration ([Adrada](https://pubmed.ncbi.nlm.nih.gov/25073777/?ref=theplasticsfella.com), 2014). - Systemic “B” symptoms, such as unexplained weight loss, fever, or night sweats (\~9% of cases) ([Clemens](https://pubmed.ncbi.nlm.nih.gov/31246800/?ref=theplasticsfella.com), 2017). A right-sided capsular contracture is illustrated below. ![Right-sided capsular contracture with a chronic seroma at the inferior pole of the breast](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Main-Article-Images---2025-01-04T011505.279.png) Right-sided capsular contracture 😎 ****Fun Fact:** Rarely bilateral or incidental findings on routine histology post-capsulectomy (Miranda et al., 2014). ### Imaging Imaging confirms effusions, masses, and disease spread, essential for diagnosis and surgical planning. - **Ultrasound:** First-line modality with sensitivity >80% for effusion detection; useful for assessing masses and lymphadenopathy ([Adrada](https://pubmed.ncbi.nlm.nih.gov/25073777/?ref=theplasticsfella.com), 2014). - **MRI and PET/CT:** Excellent for detecting implant integrity, capsular enhancement, and masses; aids in surgical planning - **Mammography:** Limited utility due to low sensitivity and specificity; used to rule out primary breast cancer or other mimics - **FDG PET/CT:** Recommended for staging and assessing systemic involvement. PET/CT aids in differentiating post-surgical inflammation from residual disease (Turton, 2020). ![Right periprosthetic fluid collection (T1 hypointense, T2 hyperintense)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Main-Article-Images---2025-01-04T011811.270.png) Right periprosthetic fluid collection (T1 hypointense, T2 hyperintense) ### Pathological Confirmation Pathological evaluation is critical for definitive diagnosis. Fluid aspirates and tissue biopsies undergo cytological, immunohistochemical, and molecular analysis. - **Cytology:** Fine-needle aspiration (FNA) to collect peri-implant fluid, preferably ≥50 mL, to enhance diagnostic yield. - **Immunohistochemistry:** Identifies CD30+ T-cells; absence of ALK translocations confirms BIA-ALC. Additional markers include CD2, CD3, CD4, TIA-1, and Granzyme B to confirm phenotype. - **Flow Cytometry:** Detects T-cell clonality using T-cell receptor (TCR) gene rearrangement studies. 💡 ****Tip:** Differentials to rule out include silicone reactions, implant rupture, or benign late seroma or primary breast malignancies. . --- ## Staging of BIA-ALCL ****Key Point** The TNM staging system for solid tumors is preferred over traditional lymphoma staging methods for BIA-ALCL Staging is critical for tailoring treatment strategies and predicting outcomes in BIA-ALCL. Unlike other lymphoid neoplasms, BIA-ALCL often presents as a localized disease confined to the implant capsule. ### TNM Staging The American Joint Committee on Cancer (AJCC) Tumor-Node-Metastasis (TNM) system provides a robust framework for classifying BIA-ALCL. It better reflects the localized and infiltrative nature of BIA-ALCL compared to the **Lugano-modified** **Ann-Arbor** classification. **Tumor (T)** - **T1:** Disease limited to effusion or the luminal side of the capsule. - **T2:** Early infiltration into the capsule. - **T3:** Dense aggregates or sheets of lymphoma cells breaching the capsule. - **T4:** Lymphoma cells infiltrating beyond the capsule into surrounding soft tissue or breast parenchyma. **Node (N)** - **N0:** No lymph node involvement. - **N1:** Single regional lymph node involvement. - **N2:** Multiple regional lymph nodes are involved. **Metastasis (M)** - **M0:** No distant metastasis. - **M1:** Distant organ involvement. This can be visualised in the table below. ![Staging of BIA-ALCL](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Main-Article-Images---2025-01-04T023920.987.png) Staging of BIA-ALCL Key takeaway points from this classification are, - **Localized Disease (T1 or T2)** is confined to the capsule or effusion. It has an excellent prognosis with complete surgical excision; up to 93% achieve complete remission within 2 years ([Miranda](https://scholar.google.com/scholar%5Flookup?title=Breast%20implant-associated%20anaplastic%20large-cell%20lymphoma%3A%20long-term%20follow-up%20of%2060%20patients&author=RN%20Miranda&publication%5Fyear=2014&ref=theplasticsfella.com), 2014). - **Aggressive Disease (T3, T4, N1, N2, or M1)** extends beyond the capsule, involves lymph nodes, or metastasizes. Lower survival rates, requiring multimodal treatment (surgery, chemotherapy, radiotherapy). --- ## Management of BIA-ALCL ****Key Point** Complete en bloc resection is the gold standard for preventing recurrence and achieving optimal outcomes. Advanced cases may require chemotherapy, radiotherapy, or both. Management of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) emphasises c**omplete surgical excision** for localised disease, with **systemic therapies** reserved for advanced cases. ### Surgical Management The primary treatment for BIA-ALCL is surgical excision, which dramatically improves patient prognosis. **Total Capsulectomy** The primary surgical approach for managing BIA-ALCL is a **total capsulectomy**. - **Goal:** Complete removal of the breast implant, the surrounding capsule, and any associated capsular mass. - **Technical Considerations:** For retropectoral or dual-plane implants, adhesions to the ribcage may complicate resection. Tumescence of the anatomical plane can facilitate a safer and more effective capsulectomy. ![Post capsular contracture scar tissue removal surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/Main-Article-Images---2025-01-04T024430.089.png) Post capsular contracture scar tissue removal surgery **Lymph Node Biopsy** - **Suspicious Nodes:** Excisional biopsy of involved or suspicious lymph nodes is essential to assess disease spread and guide treatment. - **Clinical Importance:** Reduces recurrence risk by ensuring complete removal of potential sites of metastasis. **Prognostic Impact** - **High Remission Rates:** Complete en bloc resection with negative margins is strongly associated with favorable outcomes, including high remission rates for localized disease. - **Residual Disease Risks:** Retained disease necessitates adjuvant chemotherapy, which can increase the treatment burden and associated risks. 💡 ****Tip:** While inadvertent spillage of seroma fluid during surgery is not clinically observed to influence recurrence rates, every effort should be made to minimize contamination. #### ### Reconstruction Options - **Smooth Implants:** Used to replace textured implants to mitigate recurrence risk. - **Autologous Tissue Reconstruction:** Preferred for high-risk patients due to lower immunological reactivity. - **Timing:** Reconstruction may be immediate or delayed depending on disease extent and patient condition. 💡 ****Tip:** Consider contralateral implant removal in high-risk cases, as incidental findings have been reported in 4.6% of cases ([Clemens](https://pubmed.ncbi.nlm.nih.gov/30715173/?ref=theplasticsfella.com), 2017). ### Advanced Cases and Adjuvant Therapy Adjuvant therapies are essential for managing systemic disease or lymph node involvement (Ann Arbor Stage II or higher). **Chemotherapy** - Brentuximab vedotin, a CD30-directed monoclonal antibody, has shown effectiveness in refractory cases. - Anthracycline-based regimens (e.g., CHOP: cyclophosphamide, doxorubicin, vincristine, prednisone) are used for systemic disease ([Pro](https://pubmed.ncbi.nlm.nih.gov/22614995/?ref=theplasticsfella.com), 2012). **Radiotherapy** - Reserved for residual local disease post-surgery. - Typical doses range from 24 to 36 Gy, depending on residual disease extent. ### Surveillance and Prevention **Surveillance** - **Clinical Follow-ups:** Biannual checkups for the first two years post-treatment. - **Imaging:** PET/CT is utilized as needed to monitor for residual or recurrent disease. **Prevention** - **Smooth-Surfaced Implants:** Avoid textured devices linked to higher risks. - **Sterile Surgical Techniques:** Employ methods like the "no-touch" approach to minimize bacterial contamination and biofilm formation. - **Patient Education:** Inform patients about early symptoms such as delayed seroma, mass formation, and systemic signs like fever or night sweats. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Classification and Overview:** Gained a comprehensive understanding of BIA-ALCL, its classification, and key clinical features, including its association with textured breast implants. ****2\. Pathogenesis:** Recognized the multifactorial nature of BIA-ALCL pathogenesis, involving chronic inflammation, bacterial biofilms, and genetic susceptibility. ****3\. Diagnosis:** Learned the critical diagnostic steps, including clinical evaluation, imaging modalities, and pathological confirmation through CD30 immunohistochemistry. ****4\. Surgical Management:** Identified the importance of complete en bloc resection and reconstruction strategies to achieve optimal outcomes. ****5\. Advanced Cases:** Explored the role of chemotherapy and radiotherapy in treating advanced cases of BIA-ALCL with systemic involvement. ****6\. Surveillance and Prevention:** Understood the value of regular follow-ups, patient education, and preventive strategies to minimize recurrence and improve long-term outcomes. ### Professor or Surgeon?, Hand Trauma Highlights, & AI in Surgery URL: https://www.theplasticsfella.com/january-5th/ Last updated: 2025-01-03T19:24:44.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/january-5th/#a-letter-from-pfella) The conference or the operating room? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-5th/#the-sunday-quiz) How well do you know **Thumb MCPJ UCL injuries*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/january-5th/#image-of-the-week) The anatomy of a Seymour fracture. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/january-5th/#technique-tip) An overview of the flexor teno washout procedure. 5. ****👁️** [****What's Trending?**](https://www.theplasticsfella.com/january-5th/#whats-trending) Google's Gemini 2.0 AI diagnoses pancreatitis from a CT. 6. 📋 [****Featured This Week**](https://www.theplasticsfella.com/january-5th/#featured-this-week) Plastics wrapped of 2024: In case you missed it! 7. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/january-5th/#what-does-the-evidence-say) On reattaching ring avulsion injuries involving the PIPJ? 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/january-5th/#articles-of-the-week) Flexor tendon repairs, soft tissue defects of the hand, & hand burns management: with 1 sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/january-5th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Professor on Stage or Surgeon in Charge?* 👋 ****Hey all!** A recent tweet sparked a hot debate: Would you rather be the professor giving polished talks or the go-to surgeon trusted in critical moments? (See the original tweet [here](https://x.com/georgetolisjr/status/1868109810568409433?ref=theplasticsfella.com).) Here’s the twist: Is this question really about the candidates — or does it reveal more about the biases baked into the way we define success in surgery? Let’s unpack it. Let’s be real — patients care about results, not résumés. They want their surgeon to be the best in the OR, not the most sought-after speaker. Yet, without academics driving innovation, how would we advance as a field? The tension is clear: **Is it more valuable to perfect a skillset or spread knowledge?** And when these roles don’t overlap, who loses out? ![](https://lh7-rt.googleusercontent.com/docsz/AD_4nXdmyDUaqy2FvZ6_NmZGo-cgcXUcBzELUI8TdfgZbhc6gQyPo9JS2qXoZmFDkzrl60Y47SUTknlVioeVOGJAgShyjNmCEtyuQXK6a9RiY-kr7yUVkMfHRQDlPptDdGH0iMbym8XgfA?key=lO_ufs74G1Lzvi7eiFCcYVda) [Source](https://x.com/georgetolisjr/status/1868109810568409433?ref=theplasticsfella.com) Do A and B have to be mutually exclusive? Many surgeons combine technical mastery with academic leadership, proving a third option exists. This false dichotomy questions academics who rarely operate and technicians who don’t contribute to knowledge, but does it reveal more about the candidates — or our biases? P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Thumb MCPJ UCL Injury?** ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![Valgus Stress Test](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-5.png) Valgus Stress Test ## Image of the Week **Seymour Fracture Anatomy* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we’re looking at the anatomy of a ****Seymour fracture**. The injury presents as a ****pseudomallet**, characterized by a flexion deformity of the distal phalanx, due to asymmetric tendon insertions. Read more about Seymour fractures [here](https://www.theplasticsfella.com/seymour-fracture/). ![Seymour Fracture Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-3.png) Seymour Fracture Anatomy ## Technique Tip **Flexor Teno Washout* 🚑 ****Technique Tip of the Week** This week’s technique focuses on ****flexor teno washout**. Flexor tenosynovitis washout involves limited incisions, such as a chevron at the A1 pulley, for targeted access and large-volume irrigation from proximal to distal. Severe cases may require carpal tunnel decompression and Parona space washout, especially in horseshoe abscesses. Intraoperative cultures guide antibiotic therapy, and the Michon Classification assesses severity. Explore in more detail [here](https://www.theplasticsfella.com/flexor-tenosynovitis/). ![Incisions for Flexor Tenosynovitis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/01/image-4.png) Incisions for Flexor Tenosynovitis ## What's Trending? **Gemini AI Diagnoses Pancreatitis from a CT* 👁️ In this section, we'll make sure you stay ahead of the curve with the latest techniques and hot topics in plastic surgery! This edition looks at how ****Google's Gemini 2.0 AI diagnoses pancreatitis from a CT:** A peek into the future of radiology. From [X](https://x.com/kimmonismus/status/1867952384363860472?ref=theplasticsfella.com), [original source](https://www.reddit.com/r/singularity/comments/1hdop43/googles%5Fgemini%5F20%5Fai%5Fjust%5Fdiagnosed%5Fpancreatitis/?share%5Fid=7vY1QaH0Nitlc7oA23SGv&utm%5Fcontent=1&utm%5Fmedium=ios%5Fapp&utm%5Fname=ioscss&utm%5Fsource=share&utm%5Fterm=1&rdt=53333) 0:00 /1:32 1× ## ****Featured This Week** **Plastics Wrapped of 2024* ****Closing Up 2024: Your Year in Plastic Surgery, Wrapped** 7 million minutes of learning across 190 countries. Discover the trends, top articles, and moments that shaped your year in plastic surgery with the Plastics Fella. 0:00 /0:07 1× [Read Here](https://www.theplasticsfella.com/annual-letter-2024/) ## What Does the Evidence Say? **Should We Reattach Ring Avulsion Injuries Involving the PIPJ?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Ring avulsion injury treatment varies with injury severity, guided by the ****Urbaniak classification** (Crosby et al., 2014). For class II and IIIa injuries, ****microsurgical repair** often achieves favorable functional outcomes (Beris et al., 1994). In class III injuries, replantation may be successful with careful patient selection and meticulous surgical technique (Chiu et al., 2019). Extended debridement of the avulsed digital artery and the use of long venous grafts can enhance replantation success rates (Akyürek et al., 2002). However, replantation should be approached with caution in cases involving ****proximal phalanx fractures** or ****flexor tendon lacerations**, as these may result in significant mobility loss (Crosby et al., 2014). Long-term outcomes for complete ring avulsion amputations can be satisfactory in select patients (Adani et al., 2003). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Flexor Tendon Repairs: Navigating the Zone 2** ([Kang](https://www.jhandsurg.org/article/S0363-5023%2824%2900240-5/abstract?ref=theplasticsfella.com), 2024) Flexor tendon zone 2 repairs show high complication and reoperation rates; management emphasizes precise timing, surgical techniques, and tailored rehabilitation to optimize outcomes. ✅ ****Modern Flap Options for Soft Tissue Defects of the Hand** ([Yannascoli](https://www.jhandsurg.org/article/S0363-5023%2814%2901804-8/abstract?ref=theplasticsfella.com), 2015) The reconstructive "elevator" approach for soft tissue defects of the hand; advanced pedicled, free fasciocutaneous, and venous flap options for functional and aesthetic success. ✅ ****Essential Guide for Acute Hand Burn Management** ([Pan](https://www.jhandsurg.org/article/S0363-5023%2815%2900237-3/abstract?ref=theplasticsfella.com), 2015) A roadmap for managing acutely burned hands: Precise burn depth assessment, multidisciplinary care, and strategies to preserve hand function and aesthetics while minimizing postburn contractures. ## Feedback ### I hope you enjoyed it 😄 --- ### Special Edition 'Closing Up 2024': Your Year in Plastic Surgery, Wrapped. URL: https://www.theplasticsfella.com/annual-letter-2024/ Last updated: 2024-12-29T17:31:16.000Z [ ](https://www.canva.com/design/DAGapin1aZA/UNLnELSL7Emkaf-%5FWb8Fxw/view?utm%5Fcontent=DAGapin1aZA&utm%5Fcampaign=designshare&utm%5Fmedium=embeds&utm%5Fsource=link) ### Cleft Lip: Classification, Clinical Features, & Surgical Repair URL: https://www.theplasticsfella.com/cleft-lip/ Last updated: 2024-12-31T12:08:33.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/cleft-lip/#overview-of-cleft-lip) A congenital defect of the primary palate caused by incomplete embryologic fusion. [****Aetiology**](https://www.theplasticsfella.com/cleft-lip/#aetiology-of-cleft-lip) Genetic and environmental factors, including maternal behaviors, nutritional deficiencies. [****Embryology**](https://www.theplasticsfella.com/cleft-lip/#embryology-of-cleft-lip) Failure of the medial nasal and maxillary processes to fuse during weeks 4–7 of embryonic development. [****Anatomy**](https://www.theplasticsfella.com/cleft-lip/#anatomy-of-cleft-lip) Disruption of the lip, nasal floor, and maxilla, affecting landmarks like Cupid’s bow, vermilion, and white roll. [****Classification**](https://www.theplasticsfella.com/cleft-lip/#classification-of-cleft-lip) Classified by laterality, extent, and associated anomalies, using standardized systems, such as Veau or LAHSAL. [****Clinical Features** ](https://www.theplasticsfella.com/cleft-lip/#clinical-features-of-cleft-lip)Unilateral clefts cause nasal asymmetry & vermilion disruption. Bilateral clefts have absent philtral landmarks and broad nasal tip. [****Surgical Repair** ](https://www.theplasticsfella.com/cleft-lip/#surgical-repair-of-cleft-lip)Performed at \~6 months; common techniques include Millard’s rotation advancement and Fisher’s subunit repair ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow --- ## Overview of Cleft Lip ****Key Point** Cleft lip is a common congenital anomaly caused by incomplete fusion of embryologic structures. Genetic and environmental factors contribute to its formation. A cleft lip is a congenital malformation of the **primary** **palate** (lip, alveolus and hard palate anterior to the incisive foramen). It may be complete or incomplete, bilateral or unilateral, syndromic and non-syndromic. It is caused by **incomplete embryological fusion** during facial development. Below is an illustration of a left-side complete cleft lip deformity. ![Left side complete cleft lip deformity, Facial Cleft, cleft palate, congenital](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-20T001106.709-1.png) Left side complete cleft lip deformity --- ## Aetiology of Cleft Lip ****Key Point** Cleft lip results from genetic and environmental factors, often linked to maternal behaviors, nutritional deficiencies, and associated syndromes. The development of a cleft lip is influenced by genetic and environmental factors, including family history, maternal behaviors, and teratogenic exposures. #### Genetic Factors - **Genes**: Multifactorial genetic inheritance, such as **MSX1** and **TBX22** ([Zhang](https://journals.lww.com/plasreconsurg/abstract/2017/07000/evidence%5Fbased%5Fmedicine%5F%5Fthe%5Fbilateral%5Fcleft%5Flip.44.aspx?ref=theplasticsfella.com), 2017). - **Ethnicity**: high in Asians, low in African Americans ([Shaye](https://www.facialplastic.theclinics.com/article/S1064-7406%2815%2900051-6/abstract?ref=theplasticsfella.com), 2015). - **Gender**: Males predominate in cleft lip ± palate; females in isolated cleft palate. #### Environmental Factors - **Maternal Smoking**: Strongly associated, contributing to up to 20% of cases. - **Alcohol Consumption**: Correlated with increased risk. - **Nutritional Deficiencies**: Folic acid deficiency is a notable contributor to cleft formation. - **Teratogenic Exposures**: Linked to medications like phenytoin, retinoic acid, anticonvulsants, and corticosteroids. - **Maternal Age**: Higher risk in mothers younger than 20 or older than 39 years ([Shaye](https://www.facialplastic.theclinics.com/article/S1064-7406%2815%2900051-6/abstract?ref=theplasticsfella.com), 2015; [Tse](https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0033-1333884?ref=theplasticsfella.com), 2013). #### Associated Anomalies Approximately 29% of clefts are linked to other anomalies or syndromes: - **Van der Woude Syndrome**: Caused by **IRF6** gene mutations, characterized by cleft lip/palate and lower lip pits. - **22q11 Deletion Syndrome (DiGeorge Syndrome)**: Associated with cleft palate ± cleft lip, cardiac defects, thymic hypoplasia, and hypocalcemia due to parathyroid hypoplasia [(Tijare](https://docs.google.com/document/d/1KiTudJ76BBC4cYLvYJpkxFk3kevcwtnm2dHHevL3KUE/edit?tab=t.0&ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2012). --- ## Embryology of Cleft Lip ****Key Point** Cleft lip results from the failure of the medial nasal and maxillary processes to fuse during weeks 4–7 of embryonic development. Cleft lip arises from disruptions in the fusion of facial primordia, specifically the medial nasal and maxillary prominences, during weeks 4–7 of development. Failure of this fusion results in cleft lip ([Smarius](https://pmc.ncbi.nlm.nih.gov/articles/PMC5618146/?ref=theplasticsfella.com), 2017). - **Unilateral Cleft**: failure of one maxillary prominence to fuse with the medial nasal prominence. - **Bilateral Cleft**: both maxillary prominences fail to fuse with the medial nasal prominence. ### Normal Developmental Process - **Week 3**: Neural crest cells migrate into the frontonasal and visceral arch regions, forming five facial primordia (frontonasal, maxillary, and mandibular prominences). - **Week 4**: Facial prominences form around the stomodeum; nasal prominences develop from mesenchymal proliferation around nasal placodes. - **Weeks 5–6**: Medial nasal prominences merge to form the philtrum; maxillary prominences fuse with lateral nasal prominences, shaping the cheek and lateral nose. - **Weeks 7–8**: Maxillary prominences fuse with nasal prominences, forming the upper lip ![Cleft lip embryology](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Lip-Embryology.png) Cleft lip embryology ### --- ## Anatomy of Cleft Lip ****Key Point** Cleft lip disrupts the lip, nasal floor, and maxilla, affecting key neurovascular and muscular structures, as well as defining anatomical landmarks crucial for surgical repair. Cleft lip involves the loss of continuity in the skin, muscle, and mucosa of the lip, along with displacement of associated structures like the nasal septum and columella. ### Anatomy of the Lip The [lip](https://www.theplasticsfella.com/anatomy-of-the-lip/) is a complex structure composed of skin, fat, muscle, and mucosa, supported by essential neurovascular elements and muscular architecture. **Musculature** - **Primary Muscle**: Orbicularis oris, responsible for lip movement and forming the philtrum. - [**Other Muscles**](https://www.theplasticsfella.com/anatomy-of-the-lip/#muscles-of-the-lip): Include elevators (e.g., levator labii superioris) and depressors (e.g., depressor anguli oris). **Neurovascular Structures** - **Motor**: Buccal and mandibular branches of the facial nerve. - **Sensory**: Infraorbital (upper lip) and mental (lower lip) branches of the trigeminal nerve. - **Blood Supply**: The **superior labial artery**, a branch of the facial artery, is critical in cleft lip patients as it gives rise to the **columellar arteries** ([Thomas](https://journals.lww.com/plasreconsurg/abstract/2013/04000/normal%5Fnasolabial%5Fanatomy%5Fin%5Finfants%5Fyounger%5Fthan.34.aspx?ref=theplasticsfella.com), 2013). This is illustrated below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/image-6.png) 😎 ****Fun Fact:** The orbicularis oris muscle is made up of three distinct parts, including fibers that decussate at the midline and contribute to speech and expressions. ### Key Landmarks in Cleft Lip Cleft lip alters normal lip landmarks, resulting in characteristic disruptions: - **Philtral Columns & Dimple**: Bilateral vertical ridges formed by the dermal insertions of the orbicularis oris muscle, with the central philtral dimple created by the decussation of these fibers. - **White Roll**: A prominent ridge above the cutaneous–vermilion border. This is the insert point of the Levator Labii Superioris**,** which elevates the lip and supports Cupid’s bow peaks. - **Cupid’s Bow**: The central curve of the white roll, with its peaks aligning with the philtral columns. - **Tubercle**: The central fullness of the vermilion at the apex of Cupid’s bow. - **Vermilion**: Comprising both the **dry (keratinized)** and **wet (non-keratinized)** portions, the vermilion is widest at Cupid’s bow. The **red line** marks the junction between the dry and wet areas. These key landmarks in cleft lip are illustrated below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Cleft-Lip-Anatomy.png) Anatomical Landmarks in Cleft Lip 💡 ****Tip:** A slight notch in the vermilion may be the only sign of an incomplete cleft. --- ## Classification of Cleft Lip ****Key Point** Cleft lip is classified based on its laterality, extent, and associated anomalies, with multiple systems providing standardized frameworks for description. Classifying cleft lip is essential for accurate communication, documentation, and surgical planning. While established classification systems are widely used, a descriptive approach can provide a straightforward and practical assessment of each case. ### Descriptive Classification A practical method to describe cleft lip is by detailing observable features: - **Laterality**: Unilateral or bilateral. Unilateral is more common ([Tse](https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0033-1333884?ref=theplasticsfella.com), 2013). - **Extent**: Complete (extending through the lip, nasal floor, and alveolus) or incomplete (partial cleft without reaching the nasal floor). - **Associated Features**: Presence of a cleft palate, submucous cleft, or other craniofacial anomalies. - **Syndromic vs. Non-Syndromic**: Indicating whether the cleft is part of a syndrome (e.g., Van der Woude syndrome) or isolated. There is also a **microform variant** with a furrowed philtrum & vermilion notching ([Shkoukani](https://pmc.ncbi.nlm.nih.gov/articles/PMC3873527/?ref=theplasticsfella.com#:~:text=Orofacial%20clefts%20comprise%20a%20range,multidisciplinary%20team%20approach%20for%20management.), 2013). 😎 ****Fun Fact:** Left-sided cleft lip is most common (6:3:1 left:right:bilateral) ([Yilmaz](https://pmc.ncbi.nlm.nih.gov/articles/PMC6756567/?ref=theplasticsfella.com), 2019). ### Standardised Classification Systems **Veau Classification**: Groups cleft lip and palate into four categories: - Group 1: Soft palate only. - Group 2: Hard and soft palate. - Group 3: Palate extending to the alveolus. - Group 4: Complete bilateral clefts. **LAHSHAL System**: - **Lip, Alveolus, Hard Palate, Soft Palate** are labeled from **right to left**, using capital letters for complete clefts and lowercase for incomplete. - It classifies clefts by facial region: L (lip), A (alveolus), H (hard palate), S (soft palate), with uppercase for complete clefts, lowercase for incomplete, and "\_" for none ([Shah](https://journalofkcd.com/kcd/article/view/474?ref=theplasticsfella.com), 2011). **Kernahan Striped-Y Diagram**: - A visual classification system numbered 1–9, representing specific anatomical regions of the lip, alveolus, and palate. This method is often used in surgical planning and research. This classification system is visualised below ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/image-7.png) Cleft Lip Classification System 😎 ****Fun Fact:** Prenatal diagnosis of cleft lip is possible through second-trimester ultrasound, with detection rates of 60–90% ([Smarius](https://pmc.ncbi.nlm.nih.gov/articles/PMC5618146/?ref=theplasticsfella.com), 2017). --- ## Clinical Features of Cleft Lip ****Key Point** Cleft lip causes distinctive disruptions in the lip and nose, with severity influenced by laterality, completeness, and associated anomalies. Cleft Lip deformities arise from incomplete fusion of embryological structures, leading to discontinuities in the skin, abnormal muscle attachments, and misalignment of nasal and bony structures. ### The Lip Cleft lip deformities include muscle misalignment, vermilion deficiency, and alveolar gapping. - **Skin**: Vertical and transverse deficiencies with discontinuity. - **Muscle**: Abnormal insertions into the alar base and nasal spine pulls the alar base laterally and alters lip symmetry. This disrupts the philtrum, which is normally formed by the crossing of orbicularis oris fibers. - **Vermilion** Deficiencyand **White Roll** disruption - **Alveolus**: Gapping that often extends into the hard palate. ### The Nose Cleft lip affects nasal structure and symmetry, causing septal deviation, broadening of the nasal tip, and misalignment of cartilage. - **Columella and Septum**: Deviated posteriorly and away from the cleft, with dislocation from the vomer groove. - **Nasal Tip**: Broad and flattened due to separation of alar domes and sagging/kinking of the lateral crus. - **Cartilage and Bones**: Sagging of the lateral crus, separation of upper and lower lateral cartilages and flattened nasal bones. These clinical features are illustrated below ![Clinical features of a cleft lip](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Lip-Clinical-Findings.png) Clinical features of a cleft lip 💡 ****Tip:** ****Nordhoff's point**, 2 mm above the white roll on the non-cleft side, guides Cupid's bow reconstruction during cleft lip repair, ensuring symmetry - its where the vermillion height is at its greatest ([Tse](https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0033-1333884?ref=theplasticsfella.com), 2012). ### Deformities by Cleft Type Cleft lip deformities differ significantly between unilateral and bilateral presentations, with unique patterns affecting lip continuity, nasal alignment, and structural displacement. **Unilateral Cleft:** Unilateral cleft lips are characterized by asymmetry in both the lip and nose, with disruptions more pronounced on the cleft side. - **Lip**: - Asymmetric vermilion with disrupted white roll ([Vyas](https://www.plasticsurgery.theclinics.com/article/S0094-1298%2813%2900163-6/abstract?ref=theplasticsfella.com), 2014). - Shortened columella and philtral ridge. - Outward rotation of the medial maxillary segment, causing misalignment of the dental arch. - **Nose**: - Flattened nasal tip with asymmetric nostrils. - Lateral displacement of the alar base and deviation of the nasal septum toward the non-cleft side. - Broad nasal tip caused by separated alar domes and flattened lateral cartilages. **Bilateral Cleft:** Bilateral cleft lips involve significant disruption of midline structures, leading to central protrusion and bilateral nasal deformities. - **Lip**: - Protruding premaxilla due to lack of attachment to the palatal shelves. - Absent philtral landmarks, with flattened vermilion - Prolabium lacks muscle and has an indistinct white roll. - **Nose**: - Flattened nasal tip, widened by separation of alar domes ([Zhang](https://journals.lww.com/plasreconsurg/abstract/2017/07000/evidence%5Fbased%5Fmedicine%5F%5Fthe%5Fbilateral%5Fcleft%5Flip.44.aspx?ref=theplasticsfella.com), 2017). - Shortened columella, bilateral displacement of alar bases ([Sykes](https://europepmc.org/article/med/26616710?ref=theplasticsfella.com), 2016). - Horizontal nostril orientation, widened nasal appearance ([Tse](https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0033-1333884?ref=theplasticsfella.com), 2013) ### Additional Features to Assess Cleft lip is often accompanied by additional anomalies that provide clues for syndromic associations or the cleft’s overall severity. - **Palate**: Confirm anterior defect to the incisive foramen; ensure no involvement of the soft palate. - **Secondary Features**: Lower lip pitting, often seen in syndromic cases like Van der Woude syndrome. - **Simonart Band:** a fibrous tissue bridge that may partially connect the edges of a cleft lip or palate. It does not contain any muscle and does not convert a complete into an incomplete cleft lip. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/image-8.png) --- ## Surgical Repair of Cleft Lip ****Key Point** Cleft lip repair restores facial symmetry and function by reconstructing the orbicularis oris and aligning nasal structures. Timing and technique selection are crucial for optimal outcomes. Multiple techniques have been described in the repair of unilateral and bilateral cleft lip repair, each with their advantages and disadvantages. The primary goals of cleft lip repair are: - Achieving **symmetry** in the lip and nasal structures. - Restoring a **functional orbicularis oris** for feeding and speech. - Correcting **nasal alignment** to improve airflow and aesthetics. ### Timing Cleft Lip Repair Surgical timing is at the discretion of the cleft surgical team and the anaesthetist. The decision is is based on developmental needs and surgical/anesthetic safety. It is typically performed at **3–6 months of age** and ideally completed by **12 months** to support feeding, speech, and facial growth ([Slator](https://onlinelibrary.wiley.com/doi/abs/10.1111/ocr.12355?ref=theplasticsfella.com), 2020). It has *traditionally* been guided by the **Rule of 10s**: - Hemoglobin >10 g/dL - Weight >10 lbs - Age >10 weeks. ### Techniques for Cleft Lip Repair **Fisher Subunit Repair**: - **Technique**: Aligns aesthetic subunits of the lip for natural contour and symmetry. 25 points can be marked using callipers on the medial lip, nasal floor and lateral lip, as outlined in the initial [PRS publication in 2005](https://pubmed.ncbi.nlm.nih.gov/15988248/?ref=theplasticsfella.com). - **Benefits**: Superior cosmetic outcomes; increasingly preferred over Millard’s technique. **Millard’s Rotation-Advancement Technique**: - **Technique**: A triangular flap from the upper lip is rotated and advanced to reconstruct the philtrum ([Shaye](https://www.facialplastic.theclinics.com/article/S1064-7406%2815%2900051-6/abstract?ref=theplasticsfella.com), 2015). - **Benefits**: Versatile and allows intraoperative adjustments. Simplifies future revisions. - **Limitations**: May result in nasal base scarring or vertical lip deficiency. **Tennison-Randall Geometric Repair**: - **Technique**: Uses triangular flaps and Z-plasty to achieve tension-free closure. - **Benefits**: Effective at restoring tension balance across the lip. - **Limitations**: Difficult to adjust intraoperatively; does not restore philtral column. **Mohler Modification**: - **Technique**: Preserves and reconstructs the philtral column by modifying Millard’s approach - **Benefits**: Superior philtral symmetry and aesthetics ([Vyas](https://www.plasticsurgery.theclinics.com/article/S0094-1298%2813%2900163-6/abstract?ref=theplasticsfella.com), 2014) **Millard and Mulliken Techniques**: - Primarily used for bilateral cleft lip cases, addressing the central prolabium and lateral lip segments. Challenges include a protruding premaxilla and absent orbicularis oris in the prolabium ([Zhang](https://journals.lww.com/plasreconsurg/abstract/2017/07000/evidence%5Fbased%5Fmedicine%5F%5Fthe%5Fbilateral%5Fcleft%5Flip.44.aspx?ref=theplasticsfella.com), 2017). - **Single-Stage Repair**: Combines lip and nasal repair in one procedure. - **Staged Repair**: Lip repair is performed first, with columellar lengthening at **1–5 years**. ### Additional Considerations - **Lip Adhesion** can be indicated for **wide clefts** or bilateral clefts with a protruding premaxilla. It converts a wide cleft into a less challenging incomplete cleft for definitive repair. - **Bone Grafting** can be performed at **10 years of age** during mixed dentition to support permanent canine eruption. It Involves: - **Preparation**: Raising gingivoperiosteal flaps and closing the nasal mucosa. - **Harvesting**: Cancellous bone from the iliac crest. - **Insertion**: Packing the graft into the defect and closing the oral mucosa. - **Pre-Surgical Orthodontics** has Limited evidence supports its use, and it adds a significant burden of care. Key points: - Uses passive or dynamic appliances to narrow the cleft, align the alveolus, and mold the nasal deformity. - Aims to ease surgical repair and improve outcomes but may inhibit growth, raising concerns about long-term effects - **Primary Nasal Correction** is performed during primary lip repair to reposition the alar cartilage and improve nasal symmetry. It is considered in **wide clefts** using a **limited McComb technique**, which involves: - Dorsal supra-cartilaginous dissection. - Separation of cleft alar cartilage from the piriform aperture. - Percutaneous sutures and bolsters to lift the cartilage into the correct position. - **Secondary Rhinoplasty** typically performed in adolescence after nasal and midfacial growth is complete. Addresses persistent deformities such as deviated septum, shortened columella, and tip asymmetry ([Sykes](https://europepmc.org/article/med/26616710?ref=theplasticsfella.com), 2016). ### Complications Cleft Lip Repair Cleft lip repair involves both immediate and long-term risks that can impact surgical outcomes and patient quality of life: - **Immediate Risks**: Wound dehiscence, infection, hematoma formation. - **Long-Term Risks**: Asymmetric scarring, Persistent nasal deformities, Maxillary hypoplasia affecting facial growth, Speech and feeding difficulties ([Shaye](https://www.facialplastic.theclinics.com/article/S1064-7406%2815%2900051-6/abstract?ref=theplasticsfella.com), 2015). 😎 ****Fun Fact:** Intrauterine repair, although possible, is not recommended in view of the risk of inducing preterm labour, and is reserved for conditions deemed fatal if not corrected prior to delivery. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview**: Cleft lip is a congenital craniofacial anomaly caused by incomplete fusion of embryologic structures, requiring a multidisciplinary approach for functional and aesthetic management. ****2\. Epidemiology and Aetiology:** Cleft lip is more common in males, with left-sided clefts being the most frequent. Genetic and environmental factors, like smoking and folic acid deficiency, contribute to development. ****3\. Embryology and Classification:** Failure of medial nasal processes and maxillary prominences fusion during weeks 4–7 leads to cleft lip. It is classified by laterality and completeness. ****4\. Clinical Features and Repair:** Deformities affect the lip and nose, with more severe bilateral cases. Surgical repair aims to restore symmetry and function, using techniques like Millard’s and Fisher’s subunit repair. --- ## Further Reading 1. Shkoukani, Mahdi A., Michael Chen, and Angela Vong. "[Cleft lip–a comprehensive review](https://pmc.ncbi.nlm.nih.gov/articles/PMC3873527/?ref=theplasticsfella.com#:~:text=Orofacial%20clefts%20comprise%20a%20range,multidisciplinary%20team%20approach%20for%20management.)." *Frontiers in pediatrics* 1 (2013): 53. 2. Slator, Rona, et al. "[Range and timing of surgery, and surgical sequences used, in primary repair of complete unilateral cleft lip and palate: the cleft care UK study](https://onlinelibrary.wiley.com/doi/abs/10.1111/ocr.12355?ref=theplasticsfella.com)." *Orthodontics & Craniofacial Research* 23.2 (2020): 166-173. 3. Shaye, David, C. Carrie Liu, and Travis T. Tollefson. "[Cleft lip and palate: An evidence-based review.](https://www.facialplastic.theclinics.com/article/S1064-7406%2815%2900051-6/abstract?ref=theplasticsfella.com)" *Facial Plastic Surgery Clinics* 23.3 (2015): 357-372. 4. Yılmaz HN, Özbilen EÖ, Üstün T. [The Prevalence of Cleft Lip and Palate Patients: A Single-Center Experience for 17 Years.](https://pmc.ncbi.nlm.nih.gov/articles/PMC6756567/?ref=theplasticsfella.com) Turk J Orthod. 2019 Sep;32(3):139-144\. doi: 10.5152/TurkJOrthod.2019.18094\. Epub 2019 Sep 1\. PMID: 31565688; PMCID: PMC6756567. 5. Zhang, Jacques X., and Jugpal S. Arneja. "[Evidence-based medicine: the bilateral cleft lip repair.](https://journals.lww.com/plasreconsurg/abstract/2017/07000/evidence%5Fbased%5Fmedicine%5F%5Fthe%5Fbilateral%5Fcleft%5Flip.44.aspx?ref=theplasticsfella.com)" *Plastic and reconstructive surgery* 140.1 (2017): 152e-165e. 6. Tijare, Manisha, et al. "[Syndrome associated with cleft palate and cleft lip.](https://go.gale.com/ps/i.do?id=GALE%7CA325092532&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=22295038&p=HRCA&sw=w&userGroupName=anon%7E72bc9b20&aty=open-web-entry&ref=theplasticsfella.com)" *Indian Journal of Dental Advancements* 4.3 (2012): 920-926. 7. Tse, Raymond. "[Unilateral cleft lip: principles and practice of surgical management.](https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0033-1333884?ref=theplasticsfella.com)" *Seminars in plastic surgery*. Vol. 26\. No. 04\. Thieme Medical Publishers, 2012. 8. Smarius, Bram, et al. "[Accurate diagnosis of prenatal cleft lip/palate by understanding the embryology.](https://pmc.ncbi.nlm.nih.gov/articles/PMC5618146/?ref=theplasticsfella.com)" *World journal of methodology* 7.3 (2017): 93. 9. Thomas, Marc D., et al. "[Normal nasolabial anatomy in infants younger than 1 year of age.](https://journals.lww.com/plasreconsurg/abstract/2013/04000/normal%5Fnasolabial%5Fanatomy%5Fin%5Finfants%5Fyounger%5Fthan.34.aspx?ref=theplasticsfella.com)" *Plastic and Reconstructive Surgery* 131.4 (2013): 574e-581e. 10. Shah, Syed Nasir, Mariya Khalid, and Muhammad Sartaj Khan. "[A review of classification systems for cleft lip and palate patients-I. morphological classifications.](https://journalofkcd.com/kcd/article/view/474?ref=theplasticsfella.com)" *Journal of Khyber College of Dentistry* 1.02 (2011): 95-99. 11. Vyas, Raj M., and Stephen M. Warren. "[Unilateral cleft lip repair.](https://www.plasticsurgery.theclinics.com/article/S0094-1298%2813%2900163-6/abstract?ref=theplasticsfella.com)" *Clinics in plastic surgery* 41.2 (2014): 165-177. 12. Sykes, Jonathan M., Abel-Jan Tasman, and Gustavo A. Suárez. "[Cleft Lip Nose.](https://europepmc.org/article/med/26616710?ref=theplasticsfella.com)" *Clinics in plastic surgery* 43.1 (2016): 223-235. ### 100-Step DIEP Flap, Research Overload, & 2025 Plans URL: https://www.theplasticsfella.com/december-22nd/ Last updated: 2024-12-21T12:20:40.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/december-22nd/#a-letter-from-pfella) Navigating the Confidence Curve in Plastics! 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/december-22nd/#the-sunday-quiz) How well do you know **Breast Recon*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/december-22nd/#image-of-the-week) Abdominal DIEP flap harvesting: Step-by-step images. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/december-22nd/#technique-tip) Why does CT angio matter for DIEP flap recon? 5. ****👁️** [****What's Trending?**](https://www.theplasticsfella.com/december-22nd/#whats-trending) Too much research to become a resident. 6. 📋 [****Featured Article of the Week**](https://www.theplasticsfella.com/december-22nd/#featured-article-of-the-week) DIEP flap reconstruction: Surgical steps and complications. 7. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/december-22nd/#what-does-the-evidence-say) Impact of radiotherapy on breast reconstruction. 8. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/december-22nd/#articles-of-the-week) First DIEP flap evidence, 100 step DIEP flap process, & prepectoral breast reconstruction: with 1 sentence summaries. 9. 💕 [****Feedback**](https://www.theplasticsfella.com/december-22nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella Navigating the Confidence Curve in Plastic Surgery 👋 ****Hey all!** Ever think you’ve nailed something, only to realize later you were completely out of your depth? That’s the Dunning-Kruger Effect in action, and plastic surgery is full of it. From the “I can handle this flap” confidence boost as a junior to the quiet self-doubt of seasoned consultants who know **just* how complex things can get... **Here’s the deal: that early overconfidence is dangerous.** It’s the “I know enough to be risky” phase where shortcuts seem fine, and complications feel like they happen to *other* surgeons. But the flip side? As experience grows, many of us become overly cautious, second-guessing our expertise when we’re the best-equipped person in the room. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/image-5.png) [Source](https://x.com/IAmClintMurphy/status/1869045135075397711?ref=theplasticsfella.com) This curve isn’t just a theory—it’s something we need to own. Whether you’re flying high or battling imposter syndrome, staying humble, asking for feedback, and knowing when to challenge yourself is where the real growth happens. This phenomenon has been observed in various surgical specialties, including reconstructive microsurgery, general surgery, and cardiac surgery (Pafitanis et al., 2019; Porto et al., 2024; Heinemann, 2022) So, where are you on this curve? Early confidence? Mid-level panic? Quiet mastery? Just reply to this email 😄 P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Breast Recon?** ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![Left skin sparing mastectomy and implant reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/image-4.png) Left skin sparing mastectomy and implant reconstruction ## Image of the Week **Abdominal DIEP Flap Harvesting* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we’re looking at an intraoperative photo documentation of abdominal DIEP flap harvesting. Read more about DIEPs [****here**](https://www.theplasticsfella.com/diep-flap-reconstruction/) ![Intraoperative photo documentation of abdominal DIEP flap harvesting](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/jcm-13-02388-g001-550.webp) Intra-operative photo documentation of abdominal DIEP flap harvesting ## Technique Tip **Why Does CT Angio Matter for DIEP Flap Recon?* 🚑 ****Technique Tip of the Week** This week’s technique focuses on preoperative planning for DIEP flap reconstruction. ****Preoperative CT angiography** precisely identifies dominant perforators, ensuring efficient flap harvesting and improving surgical outcomes. Studies have shown that CTA reduces operative time, blood loss, and hospital stay (O'Connor et al., 2016). However, intraoperative changes are still necessary in 44% of cases due to CTA limitations (Keys et al., 2013). ![Marking and imaging for DIEP flap reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/image-3.png) Marking and imaging for DIEP flap reconstruction ## What's Trending? **Too Much Research* 👁️ In this section, we'll make sure you stay ahead of the curve with the latest techniques and hot topics in plastic surgery! This edition looks at the average research items required for residency. See the numbers below 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Ge4G10_XkAEGGVL.jpeg) [Source](https://x.com/jasonryanmd/status/1868438421724651919?ref=theplasticsfella.com) ## ****Featured Article of the Week** **DIEP Flap Reconstruction* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/IG-11-Posts--48-.png) #### DIEP Flap Reconstruction The DIEP flap is a gold standard for autologous breast reconstruction, offering superior vascularity and minimal donor-site morbidity. Explore the anatomy, surgical steps, and complications of DIEP flap reconstruction 👇 [Read the Article](https://www.theplasticsfella.com/diep-flap-reconstruction/) ## What Does the Evidence Say? **Impact of Radiotherapy on Breast Reconstruction* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Postmastectomy radiotherapy significantly impacts breast reconstruction outcomes. ****Irradiated** ****patients** experience higher complication rates, including reconstruction failure, capsular contracture, and inferior cosmetic results, particularly with ****implant-based** reconstruction (Zugasti & Hontanilla, 2021; Poroșnicu et al., 2021; Lam et al., 2013). Patient-reported outcomes, such as satisfaction with breasts and psychosocial well-being, are also negatively affected by radiotherapy (Devulapalli et al., 2018; Kronowitz, 2012). ****Autologous reconstruction** appears to mitigate some of these adverse effects, showing lower complication rates and higher patient satisfaction compared to implant-based approaches in irradiated patients (Jagsi et al., 2018). The timing of radiotherapy relative to reconstruction may influence outcomes, with radiation following reconstruction potentially increasing ****tumor recurrence** and ****patient mortality** (Nahabedian & Momen, 2008). Breast reconstruction requires thoughtful planning of type and timing relative to radiotherapy (Rozen & Ashton, 2012). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Inferior Epigastric Artery Skin Flap Without Rectus Abdominis Muscle** ([Koshima](https://pubmed.ncbi.nlm.nih.gov/2605399/?ref=theplasticsfella.com), 1989) Inferior epigastric artery skin flaps without rectus abdominis muscle reduce herniation and bulk issues, relying on single perforator survival for effective reconstruction. ✅ ****100-Step Process Mapping for DIEP Flap Surgery** ([Sharma](https://pmc.ncbi.nlm.nih.gov/articles/PMC6382232/?ref=theplasticsfella.com#:~:text=The%20100%20steps%20of%20the,identify%20nonoperative%20steps%20between%20processes.), 2019) A process mapping approach reduced DIEP flap surgery time by 56.1 minutes without compromising outcomes, demonstrating streamlined efficiency and potential for concurrent procedures. ✅ ****Prepectoral Breast Reconstruction: Balancing Innovation and Outcomes** ([Campbell](https://journals.lww.com/plasreconsurg/abstract/2021/09000/understanding%5Fthe%5Fevidence%5Fand%5Fimproving%5Foutcomes.29.aspx?ref=theplasticsfella.com), 2021) Prepectoral breast reconstruction shows comparable short-term complication rates to submuscular techniques but with increased upper pole rippling and implant palpability. ## Feedback ### I hope you enjoyed it 😄 --- ### Overview of Oncological Breast Reconstruction: Methods, Assessment, & Management URL: https://www.theplasticsfella.com/overview-of-oncological-breast-reconstruction/ Last updated: 2024-12-18T21:24:04.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/overview-of-oncological-breast-reconstruction/#overview-of-oncological-breast-reconstruction) Breast reconstructive surgery enhances patient satisfaction through autologous or implant-based methods. [****Preoperative Assessment**](https://www.theplasticsfella.com/overview-of-oncological-breast-reconstruction/#preoperative-assessment-in-oncoplastic-breast-reconstruction) A thorough clinical assessment is required to evaluate patient needs and individualize reconstructive plans. [****Timing**](https://www.theplasticsfella.com/overview-of-oncological-breast-reconstruction/#timing-of-oncological-reconstruction) Breast reconstruction timing and method depend on patient factors and radiation plans, balancing aesthetics, complexity, and recovery. [****Decision-Making Process**](https://www.theplasticsfella.com/overview-of-oncological-breast-reconstruction/#decision-making-process-for-oncoplastic-breast-reconstruction) Creating a tailored breast reconstruction plan involves balancing oncologic needs, radiation therapy, patient anatomy, and willingness for staged procedures. [****Autologous Breast Reconstruction**](https://www.theplasticsfella.com/overview-of-oncological-breast-reconstruction/#autologous-breast-reconstruction) Autologous flap reconstruction following mastectomy remains the gold standard approach, with high levels of patient satisfaction. [****Implant-Based Breast Reconstruction**](https://www.theplasticsfella.com/overview-of-oncological-breast-reconstruction/#implant-based-breast-reconstruction) Implant-based breast reconstruction is less invasive with shorter recovery but may require more maintenance and has risks. [****Secondary Breast Reconstruction**](https://www.theplasticsfella.com/overview-of-oncological-breast-reconstruction/#secondary-breast-reconstruction) Secondary revision procedures enhance aesthetic outcomes and correct deformities, making them a standard part of the process. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Overview of Oncological Breast Reconstruction ****Key Point** Oncoplastic breast surgery combines tumor resection, through partial or complete removal of the breast gland, with reconstruction using either alloplastic or autologous techniques Oncological breast reconstruction requires a patient-centered approach involving careful decision-making tailored to individual needs. Key factors include tumor size, location, and patient-specific considerations, which help guide critical decisions regarding, 1. **Timing of Reconstruction:** Immediate reconstruction performed at the time of mastectomy versus delayed reconstruction performed after cancer treatment. 2. **Type of Reconstruction:** Options include alloplastic (implant-based) or autologous (tissue-based) reconstruction methods. 3. **Cancer Treatment:** - **Mastectomy** removes all breast tissue, indicated for large/multicentric tumors or high-risk patients (e.g., BRCA mutations). Types include total, skin-sparing (preserves skin), & nipple-sparing (retains NAC and skin). - **Lumpectomy** is tumor excision with a margin of healthy tissue typically followed by radiation. - **Adjuvant/neoadjuvan**t chemotherapy, radiotherapy, and long-term hormone therapy (e.g., Tamoxifen, Anastrozole) are integral to surgical planning. The image below illustrates a left skin-sparing mastectomy and implant reconstruction. ![Left skin sparing mastectomy and implant reconstruction, Oncological Breast Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-12T162309.806.png) Left skin sparing mastectomy and implant reconstruction --- ## Preoperative Assessment in Oncoplastic Breast Reconstruction ****Key Point** A comprehensive preoperative assessment guides the choice of reconstructive options by evaluating oncological, anatomical, and patient-specific factors. ### History - **General Health:** Assess obesity, smoking, prior thromboembolic events, and hypercoagulable conditions. - **Oncological Background:** Include tumor size, location, prior treatments, and planned adjuvant therapies (e.g., radiation). Radiation can affect flap viability and timing. - **Hormonal Therapy:** Evaluate the impact of medications like tamoxifen on surgical planning and assess for hypercoagulable risks. - **Family History:** Discuss genetic risks, offering testing and prophylactic options for patients with a history of breast or ovarian cancer. ### Physical Examination A thorough physical examination is essential for planning oncoplastic breast reconstruction. Key factors include the breast footprint, soft tissue (conus), and skin envelope ([Blondeel](https://doi.org/10.1097/PRS.0b013e3181954cc1?ref=theplasticsfella.com), 2009). - **Footprint:** The breast’s outline on the chest wall, defined by the inframammary fold (IMF), anterior axillary line, and sternal midline. - **Soft Tissue (Conus):** Determines the three-dimensional breast shape and volume, with lower pole fullness and maximum projection at the nipple-areola complex. - **Skin Envelope:** Maintains breast shape. Excess skin causes ptosis, deficiency results in flattening, and quality impacts contour stability. These factors should be evaluated alongside formal measurements & assessments. **Breast Assessment** - **Breast Size, Ptosis, and Asymmetry:** Key for symmetry and reconstruction planning. - **Skin Quality and Tethering:** Includes scars and radiation effects that may impact reconstruction. - **Pinch Test Measurement:** Measures skin thickness at the superior pole and IMF to determine implant suitability ([Tepper](https://journals.lww.com/plasreconsurg/citation/2010/01000/mammometrics%5F%5Fthe%5Fstandardization%5Fof%5Faesthetic%5Fand.47.aspx?ref=theplasticsfella.com), 2010). The image below illustrates a post-radiotherapy breast assessment. ![Post-radiotherapy breast assessment](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-19T021920.481.png) Post-radiotherapy breast assessment **Donor Site Evaluation** - **Abdomen:** Assess for adequate soft tissue volume and prior scarring. Liposuction history is not a contraindication, but prior abdominoplasty typically is. - **Alternate Sites:** Evaluate thighs, gluteal regions, or lumbar areas for S-GAP, TUG, or stacked flaps ([Hamdi](https://www.sciencedirect.com/science/article/pii/S0960977613001549?ref=theplasticsfella.com), 2013). The donor site examination is illustrated below. ![Female patient examined for potential DIEP flap with abdominal scar.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-19T022235.266.png) Female patient examined for potential DIEP flap with abdominal scar. **Additional Measurements** - **Chest Circumference:** Crucial for implant sizing. - **BMI:** High BMI increases complication risk, while low BMI may limit autologous tissue options. This integrated approach ensures accurate evaluation of both the breast and donor sites, guiding individualised reconstructive plans. 💡 ****Tip:** Use CT angiography or MRA to map perforators and assess tissue perfusion, especially for complex reconstructions. --- ## Timing of Oncological Reconstruction ****Key Point** Reconstruction timing is determined by cancer stage, planned adjuvant therapies, and patient-specific factors to optimize safety, aesthetics, and recovery. The decision on reconstruction timing — **immediate**, **delayed**, or **delayed-immediate** — depends on individual oncologic and patient factors. Each approach has unique benefits and challenges, and the optimal choice requires collaboration between surgical teams. ### Immediate Reconstruction Immediate reconstruction is performed at the time of mastectomy. There is continual discussion in the literature regarding the impact on complication rates and enhanced psychological outcomes. - **Benefits:** Immediate reconstruction reduces the psychological impact of mastectomy, avoids multiple surgeries, and preserves the inframammary fold and skin envelope ([Albornoz](https://pubmed.ncbi.nlm.nih.gov/23271515/?ref=theplasticsfella.com), 2013). - **Outcomes:** Strong patient-reported outcomes, including improved body image and satisfaction, are associated with immediate reconstruction combined with symmetry procedures ([Colwell](https://pubmed.ncbi.nlm.nih.gov/24572843/?ref=theplasticsfella.com), 2014). - **Technical Considerations:** Adequate perfusion of the mastectomy flap is critical for success, particularly with implant-based methods ([Phillips](https://pubmed.ncbi.nlm.nih.gov/27307337/?ref=theplasticsfella.com) 2016). Intraoperative angiography can aid in assessing flap viability and decision-making ([Kalus](https://pubmed.ncbi.nlm.nih.gov/26954737/?ref=theplasticsfella.com), 2016). - **Radiation Considerations:** Contralateral symmetry procedures during initial surgery can account for post-radiation fibrosis by reconstructing the cancer side larger. A postoperative patient with a left-sided immediate unilateral DIEP flap reconstruction is illustrated below. ![Immediate reconstruction with DIEP flap.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-19T022515.312.png) Immediate reconstruction with DIEP flap. 💡 ****Tip:** Requires well-perfused mastectomy flaps for successful outcomes, especially in implant-based methods. ### Delayed Reconstruction Delayed reconstruction is performed in a separate operation after mastectomy, often reserved for high-risk patients or those requiring radiotherapy. - **Indications:** Patients with poor wound healing potential (e.g., active smokers) or post-mastectomy radiotherapy requirements benefit from delayed reconstruction to minimize complications ([El-Sabawi](https://pubmed.ncbi.nlm.nih.gov/26750435/?ref=theplasticsfella.com), 2016). - **Challenges:** Radiation-induced skin fibrosis often necessitates autologous flaps for volume and aesthetic restoration ([Muresan](https://pubmed.ncbi.nlm.nih.gov/28538549/?ref=theplasticsfella.com), 2017). - **Complications:** Complication rates are higher compared to immediate reconstruction (e.g., 57% vs. 24%), highlighting the need for careful patient counseling ([Davila](https://pubmed.ncbi.nlm.nih.gov/23547540/?ref=theplasticsfella.com), 2013). 💡 ****Tip:** Older patients, smokers, and those with significant comorbidities may benefit from delayed approaches to minimize risks ([McCarth](https://pubmed.ncbi.nlm.nih.gov/18520873/?ref=theplasticsfella.com)[y](https://pubmed.ncbi.nlm.nih.gov/18520873/?ref=theplasticsfella.com), 2008). ### Delayed-Immediate Reconstruction This hybrid approach involves placing a tissue expander during mastectomy, with final reconstruction delayed until after radiotherapy completion. - **Advantages:** Balances the aesthetic benefits of immediate reconstruction with oncologic safety ([Olsen](https://jamanetwork.com/journals/jamasurgery/fullarticle/2643998?ref=theplasticsfella.com), 2017). - **Flexibility:** Allows for clear margin assessment and radiotherapy before the final reconstruction, reducing risks of major complications while maintaining good aesthetic outcomes ([Sbitany](https://pubmed.ncbi.nlm.nih.gov/28574950/?ref=theplasticsfella.com) et al., 2017). A patient with bilateral tissue expanders and adjuvant radiotherapy is illustrated below. ![Delayed immediate reconstruction. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-19T022756.357.png) Delayed immediate reconstruction. 😎 ****Fun Fact:** Single-stage reconstruction avoids a second surgery but can stress the skin envelope, especially in cases of skin reduction or poor skin quality ([Roostaeian](https://pubmed.ncbi.nlm.nih.gov/22634689/?ref=theplasticsfella.com), 2012). --- ## Decision-Making Process for Oncoplastic Breast Reconstruction ****Key Point** Tailored breast reconstruction balances oncologic needs, radiation therapy, anatomy, and patient preferences to achieve optimal outcomes. Creating a patient-specific reconstruction plan requires integrating cancer treatment needs, anatomical considerations, patient goals, and psychosocial factors. **1\. Oncologic Requirements** - **Breast-Conserving Surgery:** Smaller tumors may only require minor reconstructions, often achieved with local tissue rearrangement. - **Mastectomy Candidates:** Larger tumors, multicentric disease, or extensive nodal involvement often necessitate mastectomy. Reconstruction options should account for oncologic safety, such as margin clearance and future treatment plans (e.g., re-excision risks). **2\. Anticipated Radiation Therapy** - **No Radiation:** Immediate implant or autologous reconstruction is appropriate, offering aesthetic and psychological benefits. - **Radiation Expected:** Delayed autologous reconstruction minimizes complications such as capsular contracture, fibrosis, or implant failure. Hybrid options, such as delayed-immediate reconstruction, may be beneficial for uncertain radiotherapy plans. **3\. Patient Anatomy and Body Habitus** - **Ample Donor Tissue:** Autologous techniques, like DIEP or PAP flaps, are ideal for patients with sufficient abdominal, thigh, or gluteal tissue. - **Low Body Fat:** Thin or low-BMI patients may benefit from implant-based reconstruction, though contour irregularities or rippling may require fat grafting. **4\. Patient Preferences and Psychosocial Factors** - **Willingness for Staged Procedures:** Patients comfortable with multiple procedures may benefit from two-stage implant reconstruction or delayed flap techniques for improved outcomes. - **Single-Stage Preference:** Direct-to-implant or immediate autologous reconstruction offers faster results with minimal operative stages ([Berlin](https://journals.sagepub.com/doi/abs/10.1177/0272989X18803879?ref=theplasticsfella.com), 2019). - **Psychosocial Goals:** Patients with a strong focus on body image and natural feel may prefer autologous techniques, while those prioritizing shorter recovery or minimal surgeries may opt for implant-based options. **5\. Additional Considerations** - **Comorbidities:** Active smokers, diabetics, or patients with poor healing potential may require delayed reconstruction for reduced risk. - **Symmetry Goals:** Consider contralateral procedures (reduction, augmentation, mastopexy) to enhance symmetry. --- ## Autologous Breast Reconstruction ****Key Point** Autologous reconstruction remains the gold standard, providing natural aesthetics, high patient satisfaction, and versatile options for diverse patient needs. **Autologous reconstruction** recreates the breast mound using the patient’s own tissue, offering natural aesthetics and long-lasting results. Techniques include local and free flaps from the **abdomen**, **back**, and **gluteal** regions, as well as free fat transfer ([Macadam](https://journals.lww.com/plasreconsurg/abstract/2017/01000/evidence%5Fbased%5Fmedicine%5F%5Fautologous%5Fbreast.47.aspx?ref=theplasticsfella.com), 2017). ### Abdomen-Based Flaps Abdominal flaps are the first-line option due to their volume, pliability, and similarity to breast tissue. - [**DIEP Flap**](https://www.theplasticsfella.com/diep-flap-reconstruction/)**:** Preserves muscle for reduced donor-site morbidity. Provides excellent outcomes but requires advanced microsurgical skills to avoid complications like fat necrosis or flap loss. - [**SIEA Flap**](https://www.theplasticsfella.com/diep-flap-reconstruction/#diep-flaps-compared-to-other-techniques)**:** Avoids muscle or fascia harvest but is limited by variable vascular anatomy, feasible in only 30% of patients. - **TRAM Flap (Pedicled and Free):** Pedicled relies on the superior epigastric artery; free TRAM uses the inferior epigastric artery for better perfusion and reduced fat necrosis. Risks include hernias and bulging, minimized by muscle-sparing techniques or mesh reinforcement. The zones of perfusion are illustrated below. ![Zones of perfusion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-19T023408.245.png) Zones of perfusion ### Gluteal-Based Flaps Gluteal flaps are secondary options for patients lacking adequate abdominal tissue, offering reliable volume but requiring technical expertise. - **Superior Gluteal Artery Perforator (SGAP) Flap:** Harvests upper gluteal tissue with scars concealed in clothing. Precise dissection is needed near the piriformis muscle. Risks include contour deformities and asymmetry if donor volume is insufficient. - **Inferior Gluteal Artery Perforator (IGAP) Flap:** Uses lower gluteal tissue with scars hidden in the infragluteal crease. Offers a longer pedicle than SGAP but risks sciatic nerve irritation. Careful dissection is required to protect the posterior femoral cutaneous nerve and ensure adequate perfusion. 😎 ****Fun Fact:** Autologous reconstruction, like DIEP flaps, delivers higher patient satisfaction and better aesthetic and psychosocial outcomes than implants ([Pirro](https://journals.lww.com/prsgo/fulltext/2017/01000/comparison%5Fof%5Fpatient%5Freported%5Foutcomes%5Fafter.1.aspx?ref=theplasticsfella.com), 2017). ### Thigh-Based Flaps Thigh flaps are versatile and increasingly popular for smaller reconstructions or as supplementary volume. - **PAP Flap:** Offers robust volume with well-concealed scars. Pedicle length and vessel caliber make it suitable for larger reconstructions. - **TUG Flap:** Suitable for small reconstructions but risks lymphedema and widened scars. ### Back-Based Flaps Back-based flaps provide alternative options for reconstruction when abdominal or thigh tissue is inadequate. - **Latissimus Dorsi (LD) Flap:** Reliable regional flap, often combined with implants. May impair shoulder function and is best for patients with limited tissue or prior abdominal surgeries ([Sood](https://journals.sagepub.com/doi/full/10.1177/1073274817744638?ref=theplasticsfella.com), 2018). - **Lumbar Artery Perforator (LAP) Flap:** Offers pliable tissue and flank contouring but has shorter pedicles and requires multiple position changes, increasing complexity. ![Commonly used flaps in autologous breast reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-12T161745.796.png) Commonly used flaps in autologous breast reconstruction ### Advantages and Limitations **Autologous reconstruction** offers significant benefits but comes with notable challenges that require careful patient selection and surgical expertise. **Advantages** - Provides natural-looking, durable results with superior texture and aesthetics. - Avoids synthetic materials, making it ideal for radiated tissues. - Fewer revisions compared to implants, ensuring long-term patient satisfaction. **Limitations** - Longer recovery periods due to complex surgical techniques. - Risk of donor-site complications, including hernias, lymphedema, and fat necrosis. - Requires advanced surgical expertise, increasing technical demands. --- ## Implant-Based Breast Reconstruction ****Key Point** Implant-based reconstruction offers a less invasive approach with shorter recovery times, suitable for patients seeking quicker results or those without suitable donor sites, but it carries risks such as radiation sensitivity and implant failure. Implant-based reconstruction is a less invasive option with shorter recovery times, making it ideal for patients seeking faster results or those without suitable donor sites. It carries risks such as radiation sensitivity and implant failure ([Colwell](https://journals.lww.com/plasreconsurg/abstract/2020/02000/recent%5Fadvances%5Fin%5Fimplant%5Fbased%5Fbreast.55.aspx?ref=theplasticsfella.com), 2020). Key considerations include choosing between **single- or two-stage reconstruction** and determining the **optimal implant pocket.** ### Single vs Two-Stage Reconstruction **Single-stage reconstruction is a direct-to-implant technique.** A permanent implant is placed immediately after mastectomy, providing immediate results in suitable patients. - **Indications:** Best suited for nipple-sparing mastectomies, older patients, or those seeking to avoid multiple surgeries. Ideal for cases with minimal skin tension, provided intraoperative flap perfusion is carefully assessed. - **Advantages:** Fewer operations, faster recovery, and reduced thinning of the skin envelope. - **Challenges:** Greater stress on the skin envelope, especially in cases requiring significant skin reduction. **Two-stage reconstruction** involves placing a [tissue expander](https://www.theplasticsfella.com/tissue-expansion/) initially, followed by a second surgery to replace it with a permanent implant. - **Indications:** Recommended for significant size adjustments, compromised skin flaps, or complex symmetry corrections. Safer for higher-risk patients (e.g., smokers, obese) or less experienced surgeons. - **Advantages:** Allows flexibility for size adjustments, symmetry corrections, and safer outcomes in radiation-exposed or compromised skin flaps. - **Challenges:** Requires two surgeries, extending the overall treatment process. The mechanism of tissue expansion is illustrated below. ![The mechanism of tissue expansion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-19T023641.285.png) The mechanism of tissue expansion 😎 ****Fun Fact:** Implant reconstructions need more maintenance, while autologous methods are more cost-effective long-term due to fewer revisions and higher satisfaction ([Hansson](https://bmjopen.bmj.com/content/14/7/e084025.abstract?ref=theplasticsfella.com), 2024). ### Implant Positioning **Prepectoral reconstruction** places the implant above the pectoralis muscle, avoiding muscle elevation. - **Advantages:** Reduces animation deformity and postoperative pain; optimal for well-vascularized skin flaps. - **Challenges:** May require fat grafting to address rippling or contour irregularities. **Subpectoral reconstruction** places the implant below the pectoralis muscle, providing superior coverage and lift. - **Advantages:** Better superior pole coverage, with ADM enhancing stability and aesthetics. - **Challenges:** Associated with animation deformity and higher postoperative pain. The implant pocket in the subpectoral and subglandular plane is illustrated below. ![Implant pocket in the subpectoral and subglandular plane](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-19T023950.199.png) Implant pocket in the subpectoral and subglandular plane 💡 ****Tip:** ADM is used to provide soft-tissue support, reduce capsular contracture rates, and improve implant stabilization and projection. It is beneficial in both one- and two-stage reconstructions. --- ## Secondary Breast Reconstruction ****Key Point** Secondary procedures are often essential in breast reconstruction to correct deformities and enhance aesthetic outcomes, making them a standard part of the reconstructive process. Secondary breast reconstruction addresses issues arising after initial surgery, including aesthetic refinements, correcting deformities, or managing complications ([Beahm](https://www.sciencedirect.com/science/article/abs/pii/S009412980600126X?ref=theplasticsfella.com), 2007). Common indications include dissatisfaction with results, radiation-induced deformities, capsular contracture, implant malposition, or failed reconstruction techniques. **Inframammary Fold (IMF) Reconstruction** The inframammary fold, a key anatomical landmark, is often disrupted during mastectomy. Restoring this structure is critical for natural breast contours. Techniques include, - **Local Tissue Rearrangement:** Skin flaps are used to reconstruct the fold. - **Suture Suspension:** The breast is re-suspended along the IMF. - **External Devices:** Templates help recreate the contralateral breast’s IMF shape. **Implant Malposition and Deformities** Significant malpositions or deformities may require, - **New Implant Pockets:** Adjusting the implant plane to improve position. - **LD Flap:** Used in patients with skin deficiencies or radiation-related issues. - **Free Fat Transfer:** Smooths contour irregularities and enhances volume. - **Acellular Dermal Matrices (ADM):** Provides support and improves aesthetic contours. **Contralateral Breast Symmetry** Achieving balance between the reconstructed and natural breast often requires adjustments, - **Breast Reduction:** Reduces the size of the contralateral breast for symmetry. - **Augmentation:** Enhances smaller contralateral breasts to match the reconstructed one. - **Mastopexy:** Addresses minor sagging for alignment. ### NAC Reconstruction [NAC reconstruction](https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/) is the final stage of breast reconstruction, performed after achieving symmetry and breast stabilization. Option include, - **Local Flaps:** Techniques like Skate, Star, and C-V flaps create a three-dimensional nipple structure, though projection may reduce over time. - **Tattooing:** Commonly used to recreate areola pigmentation for a realistic appearance. - **Composite Grafts:** Inner thigh grafts provide tissue and pigmentation closely resembling the natural NAC. This final step ensures optimal aesthetic results, tailored to each patient’s unique anatomy and preferences. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Purpose of Breast Reconstruction:** Oncological breast reconstruction supports patients post-mastectomy or lumpectomy, through autologous, implant-based, or combination methods. ****2\. Types of Reconstruction:** Reconstruction can be autologous, implant-based, or a mix. Timing depends on factors like radiation needs, cancer treatment, and patient anatomy. ****3\. Preoperative Assessment:** Patient history, physical exam, and evaluations of health, body type, and oncologic needs guide reconstruction choices. ****4\. Decision-Making Factors:** These include cancer stage, radiation plans, anatomy, and patient preferences. Patients with more body fat may benefit from autologous options, while others may prefer implants. ****5\. Autologous Reconstruction:** Autologous reconstruction options include abdominal, thigh, and back flaps, tailored to patient anatomy. ****6\. Implant-Based and Secondary Reconstruction:** Implant-based options allow shorter recovery but may need long-term adjustments. Secondary procedures refine outcomes and address complications. --- ## Further Reading 1. Czajka, Meghan L., and Christopher Pfeifer. "[Breast cancer surgery.](https://www.ncbi.nlm.nih.gov/books/NBK553076/?ref=theplasticsfella.com)" *StatPearls \[Internet\]*. StatPearls Publishing, 2023. 2. Gilmour, A., et al. "[Oncoplastic breast surgery: A guide to good practice](https://www.sciencedirect.com/science/article/pii/S0748798321004820?ref=theplasticsfella.com)." *European Journal of Surgical Oncology* 47.9 (2021): 2272-2285. 3. Kummerow, Kristy L., et al. "[Nationwide trends in mastectomy for early-stage breast cancer.](https://jamanetwork.com/journals/jamasurgery/fullarticle/1921808?ref=theplasticsfella.com)" *JAMA surgery* 150.1 (2015): 9-16. 4. Tepper, Oren M., et al. "[Mammometrics: the standardization of aesthetic and reconstructive breast surgery](https://journals.lww.com/plasreconsurg/citation/2010/01000/mammometrics%5F%5Fthe%5Fstandardization%5Fof%5Faesthetic%5Fand.47.aspx?ref=theplasticsfella.com)." *Plastic and reconstructive surgery* 125.1 (2010): 393-400. 5. Hamdi, Moustapha. "[Oncoplastic and reconstructive surgery of the breast.](https://www.sciencedirect.com/science/article/pii/S0960977613001549?ref=theplasticsfella.com)" *The breast* 22 (2013): S100-S105. 6. Blondeel, P. N., Hijjawi, J., Depypere, H., Roche, N., & Van Landuyt, K. (2009).[ Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle.](https://doi.org/10.1097/PRS.0b013e3181954cc1?ref=theplasticsfella.com) *Plastic and reconstructive surgery*, *123*(2), 455–462. 7. Olsen, Margaret A., et al. "[Comparison of wound complications after immediate, delayed, and secondary breast reconstruction procedures.](https://jamanetwork.com/journals/jamasurgery/fullarticle/2643998?ref=theplasticsfella.com)" *JAMA surgery* 152.9 (2017): e172338-e172338. 8. Hansson, Emma, et al. "[Gothenburg Breast reconstruction (GoBreast) II protocol: a Swedish partially randomised patient preference, superiority trial comparing autologous and implant-based breast reconstruction.](https://bmjopen.bmj.com/content/14/7/e084025.abstract?ref=theplasticsfella.com)" *BMJ open* 14.7 (2024): e084025. 9. Berlin, Nicholas L., et al. "[Feasibility and efficacy of decision aids to improve decision making for postmastectomy breast reconstruction: a systematic review and meta-analysis.](https://journals.sagepub.com/doi/abs/10.1177/0272989X18803879?ref=theplasticsfella.com)" *Medical Decision Making* 39.1 (2019): 5-20. 10. Macadam, Sheina A., et al. "[Evidence-based medicine: autologous breast reconstruction](https://journals.lww.com/plasreconsurg/abstract/2017/01000/evidence%5Fbased%5Fmedicine%5F%5Fautologous%5Fbreast.47.aspx?ref=theplasticsfella.com)." *Plastic and reconstructive surgery* 139.1 (2017): 204e-229e. 11. Sood, Rachita, et al. "[Latissimus dorsi flap in breast reconstruction: recent innovations in the workhorse flap](https://journals.sagepub.com/doi/full/10.1177/1073274817744638?ref=theplasticsfella.com)." *Cancer Control* 25.1 (2018): 1073274817744638. 12. Tseng, Charles Y., and Joan E. Lipa. "[Perforator flaps in breast reconstruction](https://www.plasticsurgery.theclinics.com/article/S0094-1298%2810%2900050-7/abstract?ref=theplasticsfella.com)." *Clinics in Plastic Surgery* 37.4 (2010): 641-654. 13. LoTempio, Maria M. M.D.; Allen, Robert J. M.D.. [Breast Reconstruction with SGAP and IGAP Flaps](https://journals.lww.com/plasreconsurg/abstract/2010/08000/breast%5Freconstruction%5Fwith%5Fsgap%5Fand%5Figap%5Fflaps.7.aspx?ref=theplasticsfella.com). Plastic and Reconstructive Surgery 126(2):p 393-401, August 2010\. | DOI: 10.1097/PRS.0b013e3181de236a 14. Pirro, Ortensia, et al. "[Comparison of patient-reported outcomes after implant versus autologous tissue breast reconstruction using the BREAST-Q](https://journals.lww.com/prsgo/fulltext/2017/01000/comparison%5Fof%5Fpatient%5Freported%5Foutcomes%5Fafter.1.aspx?ref=theplasticsfella.com)." *Plastic and Reconstructive Surgery–Global Open* 5.1 (2017): e1217. 15. Colwell, Amy S., and Erin M. Taylor. "[Recent advances in implant-based breast reconstruction](https://journals.lww.com/plasreconsurg/abstract/2020/02000/recent%5Fadvances%5Fin%5Fimplant%5Fbased%5Fbreast.55.aspx?ref=theplasticsfella.com)." *Plastic and Reconstructive Surgery* 145.2 (2020): 421e-432e. 16. Albornoz, Claudia R., et al. "[A paradigm shift in US breast reconstruction: increasing implant rates](https://journals.lww.com/plasreconsurg/fulltext/2013/01000/A%5FParadigm%5FShift%5Fin%5FU%5FS%5F%5FBreast%5FReconstruction%5F.3.aspx?ref=theplasticsfella.com)." *Plastic and reconstructive surgery* 131.1 (2013): 15-23. 17. Beahm, Elisabeth K., and Robert L. Walton. "[Revision in autologous breast reconstruction: principles and approach.](https://www.sciencedirect.com/science/article/abs/pii/S009412980600126X?ref=theplasticsfella.com)" *Clinics in Plastic Surgery* 34.1 (2007): 139-162. ### Keloids: Causes, Clinical Features, & Treatment URL: https://www.theplasticsfella.com/keloid-scars/ Last updated: 2024-12-16T20:39:14.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/keloid-scars/#definition-of-keloids) Keloid is a dermo-fibroproliferative disorder thought to result from abnormal proliferation of fibroblasts. [****Pathophysiology**](https://www.theplasticsfella.com/keloid-scars/#pathophysiology-of-keloids) Development involves genetic predisposition, inflammation, mechanical stress, and chronic inflammation of the reticular dermis, causing dysregulated fibroblast activity and excess ECM production. [****Clinical Features**](https://www.theplasticsfella.com/keloid-scars/#clinical-features-of-keloids) Keloids extend beyond the original wound boundary and may present with pain, itching, or burning. [****Treatment**](https://www.theplasticsfella.com/keloid-scars/#treatment-of-keloids) Keloid treatment includes non-pharmaceutical options like lasers and surgery and pharmaceutical options like corticosteroids and 5-FU. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Keloids ****Key Point** Keloid is a dermo-fibroproliferative disorder thought to result from abnormal proliferation of fibroblasts. Keloid scars are an **abnormal response** to dermal injury, characterized by persistent **fibroblast** hyperactivity and excessive **extracellular matrix** (ECM) deposition. Unlike typical scars, keloids **extend beyond** the boundaries of the original wound and fail to regress over time ([Wanjala](https://pubmed.ncbi.nlm.nih.gov/34642061/?ref=theplasticsfella.com), 2022). At a cellular level, keloid scars have the following features ([Lee](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com), 2023): - **Collagen Composition:** Keloids are marked by excessive Type I and III collagen, with an altered matrix composition compared to normal scar tissue. - **Persistent Inflammation:** Chronic activation of inflammatory pathways sustains fibroblast proliferation and ECM accumulation. - **Prolonged Remodeling Phase:** Unlike normal wound healing, where remodeling resolves fibrosis, keloids remain in an active state of tissue remodeling and expansion. Large keloid scars on the back are illustrated below. ![Large keloids on the back](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-26T160614.776.png) Large keloids on the back ### 😎 ****Fun Fact:** The ****proliferative phase** persists unchecked in keloid scar formation. ([Lee](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com), 2023). --- ## Pathophysiologyof Keloids ****Key Point** Keloid formation results from a combination of genetic predisposition, environmental triggers, and chronic inflammation that disrupts normal wound healing. The primary pathology involves dysregulated fibroblast activity and excessive extracellular matrix (ECM) deposition. Keloids arise from **chronic inflammation** in the reticular dermis ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). It usually has a triggering event which is then influenced by genetic predisposition, inflammatory processes, and mechanical stress. - **Triggering Event:** Skin injuries (e.g., surgery, burns, acne) commonly trigger keloids. - **Fibroblast Dysregulation:** Overactive fibroblasts synthesize excessive collagen and resist apoptosis, leading to persistent scarring ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). - **Cytokine Imbalance:** Elevated TGF-β levels drive fibroblast recruitment and chronic inflammation ([Lee](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com), 2023). - **Hormonal Influences:** Estrogen-induced vasodilation, especially during pregnancy, aggravates keloid formation ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). - **Metabolic and Environmental Factors:** Hypoxia, mechanical stress, and conditions like vitamin D deficiency or hypertension exacerbate keloid progression. 💡 ****Tip:** Hypercytokinemic diseases (e.g., Castleman disease) ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021) and genetic syndromes like Rubinstein-Taybi syndrome increase keloid risk ([Lee](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com), 2023). --- ## Clinical Features of Keloids ****Key Point** Keloids extend beyond the original wound boundary and are often associated with symptoms such as pain, itching, or burning. Keloid scars are **pathological** scars that **extend beyond the boundaries** of the original wound & persist indefinitely, often causing physical discomfort & psychological distress. Diagnosis is primarily clinical, confirmed by histologic findings such as keloidal collagen and fibroblast density. ### Clinical Features Their key **clinical features** include, - **Locations:** Deltoid, pre-sternal chest, upper back, and ear regions. - **Color:** erythematous in early stages to hyperpigmented over time. - **Onset:** 1–3 months after trauma but can develop up to a year later. - **Symptoms:** Pruritus, pain, and burning are reported. ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). **Risk Factors** for keloid scar formation include, - **Family history** increases keloid risk. - **Gender:** Female predominance is linked to estrogen's role in vasodilation and scar inflammation. - **Ethnicity:** Black 2.4%, Asian 1.1%, Caucasian 0.4% ([Ung](https://pubmed.ncbi.nlm.nih.gov/36598763/?ref=theplasticsfella.com), 2023). The table below categorizes keloids and hypertrophic scars along with their differences. ![Differences between keloids and hypertrophic scars](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Scars--1-.png) Differences between keloids and hypertrophic scars 😎 ****Fun Fact:** Malignant tumors, such as dermatofibrosarcoma protuberans, **may* mimic keloids clinically and require biopsy for confirmation ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). ### Histologic Features Histologically, keloids are characterized by large, irregular, hyalinized collagen bundles, known as **keloidal collagen**, and an abundance of fibroblasts, which are central to their pathological structure ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). Even in the absence of keloidal collagen, keloids can be identified by the following diagnostic features: 1. **Standard Epidermis and Papillary Dermis:** The epidermis appears normal, with no significant abnormalities in the papillary dermis. 2. **"Tongue-Like" Advancing Edge:** A projection of fibrous tissue extending below the papillary dermis is a hallmark of keloid expansion. 3. **Horizontal Fibrous Band:** A dense, horizontal band of fibrous tissue in the upper reticular dermis is typically observed. 4. **Prominent Fascia-Like Band:** A thick, fascia-like structure in the deep dermis contributes to the rigidity and persistence of keloids. A micrograph of a keloid is illustrated below. ![Micrograph of keloid](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-16T145636.254.png) Micrograph of keloid 💡 ****Tip:** Differences in clinical presentation and histology between keloids and hypertrophic scars arise from variations in the intensity and duration of reticular dermis inflammation​​ ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). --- ## Treatment of Keloids ****Key Point** Keloid management integrates non-pharmaceutical approaches like lasers, silicone sheeting, cryotherapy, and surgery with pharmaceutical treatments such as corticosteroids, 5-Fluorouracil (5-FU). Keloid treatment requires a tailored approach based on the lesion's characteristics, including size, number, and patient-specific risk factors. Both conservative and surgical strategies are often combined with adjuvant therapies to enhance outcomes and minimize recurrence. ### Conservative Options These methods target the physical and biological properties of keloids, improving outcomes in smaller or isolated lesions. - **Scar Massage:** Increases blood flow, releases tissue adhesions, and induces mechanotransduction to aid scar remodeling. - **Pressure Therapy via Taping:** Realigns collagen fibers, reduces collagen nodules, diminishes fibrotic activity, and reduces edema. - **Silicone Sheeting or Gel:** Enhances scar pliability and color, reduces collagen production through occlusion, and hydrates the stratum corneum. - **Laser Therapy:** Pulsed-dye laser (PDL), non-ablative fractional lasers, and carbon dioxide lasers. Laser-assisted topical steroid application for improved aesthetics. 💡 ****Tip:** Incomplete therapy can lead to worsening keloids ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). ### Procedural Options - **Intralesional Corticosteroid** injections at \~6-week intervals. Enhanced efficacy when paired with 5-FU or laser therapy but may cause pigmentation changes or tissue atrophy. - **Corticosteroid Tape** is a painless alternative to corticosteroid injections. These include ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021) Fludroxycortide tape or Deprodone propionate plaster (strong steroid). - **Cryotherapy** Reduces collagen synthesis by inducing tissue necrosis.This can be applied through direct contact, sprays, or intralesional probes. Limitation include post-treatment pigmentation changes. - **Surgical Excision:** Small keloids may be radically excised; large lesions require partial or core excision. Surgery alone has high recurrence rates (45–100%) and must be paired with adjuvant therapy such as radiation or steroids. - **Radiation Therapy** inhibits fibroblast activity and angiogenesis, making it effective in preventing keloid recurrence. It should Administered within 24–28 hours post-surgical excision via electron beam radiation or brachytherapy ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). 💡 ****Tip:** Monitor surgical sites prone to hypertrophic scars or keloids for 3–12 months. Start steroid tape or plaster at the first sign of induration, switching to steroid injections if it persists ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). Other, currently less commonly used agents include, 1. **5-Fluorouracil (5-FU):** Effective when combined with steroids, reducing erythema and elevation. 2. **Bleomycin:** Promotes apoptosis in fibroblasts. 3. **Retinoids:** Enhances new scar remodeling by suppressing sebum and excessive fibroblast activity. There are anecdotal reports of tissue-engineered allografts ([Jones](https://pubmed.ncbi.nlm.nih.gov/27300360/?ref=theplasticsfella.com), 2016) and platelet-rich plasma for the treatment of keloids ([Oswald](https://pubmed.ncbi.nlm.nih.gov/12522384/?ref=theplasticsfella.com), 2003). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition:** Keloids are a dermo-fibroproliferative disorder caused by abnormal fibroblast activity and excessive ECM production, resulting in scars that extend beyond the wound boundary. ****2\. Pathophysiology:** Keloids arise from genetic predisposition, mechanical stress, chronic reticular dermis inflammation, and dysregulated fibroblast activity. ****3\. Clinical Features and Diagnosis:** Keloids commonly appear on the chest, back, shoulders, and ears, presenting as firm, raised scars with pain or itching. Diagnosis is clinical, supported by histologic findings. ****4\. Treatment:** Management involves non-pharmaceutical methods (lasers, silicone sheeting, cryotherapy, surgery, radiation) and pharmaceuticals (corticosteroids, 5-FU, bleomycin). ****5\. Prevention:** Preventative strategies include tension-free wound closure, silicone gel application, scar massage, and avoiding elective procedures like tattoos or piercings in predisposed individuals. --- ## Further Reading 1. McGinty S, Siddiqui WJ. [Keloid](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com). \[Updated 2023 Jul 17\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. 2. Lee CC, Tsai CH, Chen CH, Yeh YC, Chung WH, Chen CB. [An updated review of the immunological mechanisms of keloid scars](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com). Front Immunol. 2023 Mar 22;14:1117630\. doi: 10.3389/fimmu.2023.1117630\. PMID: 37033989; PMCID: PMC10075205. 3. Ung CY, Warwick A, Onoufriadis A, Barker JN, Parsons M, McGrath JA, Shaw TJ, Dand N. [Comorbidities of Keloid and Hypertrophic Scars Among Participants in UK Biobank](https://pubmed.ncbi.nlm.nih.gov/36598763/?ref=theplasticsfella.com). JAMA Dermatol. 2023 Feb 1;159(2):172-181\. doi: 10.1001/jamadermatol.2022.5607\. PMID: 36598763; PMCID: PMC9857738. 4. Ogawa R. [The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com). Plast Reconstr Surg. 2022 Jan 1;149(1):79e-94e. doi: 10.1097/PRS.0000000000008667\. PMID: 34813576; PMCID: PMC8687618. 5. Jones ME, Hardy C, Ridgway J. [Keloid Management: A Retrospective Case Review on a New Approach Using Surgical Excision, Platelet-Rich Plasma, and In-office Superficial Photon X-ray Radiation Therapy](https://pubmed.ncbi.nlm.nih.gov/27300360/?ref=theplasticsfella.com). Adv Skin Wound Care. 2016 Jul;29(7):303-7\. doi: 10.1097/01.ASW.0000482993.64811.74\. PMID: 27300360; PMCID: PMC4915758. 6. Osswald SS, Elston DM, Vogel PS. [Giant right plantar keloid treated with excision and tissue-engineered allograft](https://pubmed.ncbi.nlm.nih.gov/12522384/?ref=theplasticsfella.com). J Am Acad Dermatol. 2003 Jan;48(1):131-4\. doi: 10.1067/mjd.2003.48\. PMID: 12522384. 7. Katta R, Kramer MJ. [Skin and Diet: An Update on the Role of Dietary Change as a Treatment Strategy for Skin Disease](https://pubmed.ncbi.nlm.nih.gov/29357214/?ref=theplasticsfella.com). Skin Therapy Lett. 2018 Jan;23(1):1-5\. PMID: 29357214. 8. Wanjala NF, Joseph G, Anthony M, Primus O, Ogeng'o JJ, Anzala O, Dohil I, Agak GW. [Keloids: Does patients' sex influence the presentation and recurrence post-excision?](https://pubmed.ncbi.nlm.nih.gov/34642061/?ref=theplasticsfella.com) J Plast Reconstr Aesthet Surg. 2022 Jan;75(1):366-368\. doi: 10.1016/j.bjps.2021.08.030\. Epub 2021 Sep 20\. PMID: 34642061. 9. Liu EK, Cohen RF, Chiu ES. [Radiation therapy modalities for keloid management: A critical review](https://pubmed.ncbi.nlm.nih.gov/35817711/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2022 Aug;75(8):2455-2465\. doi: 10.1016/j.bjps.2022.04.099\. Epub 2022 May 6\. PMID: 35817711. 10. Theplasticsfella. [Wound healing](https://www.theplasticsfella.com/wound-healing/) April 2022\. Accessed on 24th November 2024. ### DIEP Flap Reconstruction: Anatomy, Key Surgical Steps, & Complications URL: https://www.theplasticsfella.com/diep-flap-reconstruction/ Last updated: 2024-12-20T20:55:57.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/diep-flap-reconstruction/#overview-of-diep-flap) The DIEP flap (Deep Inferior Epigastric Artery Perforator) is an abdominally-based flap that spares rectus abdominis and rectus sheath. It is a gold standard for autologous breast reconstruction. [****Vascular Anatomy**](https://www.theplasticsfella.com/diep-flap-reconstruction/#vascular-anatomy-of-diep-flap) The DIEP flap blood supply originates from the external iliac artery, forming zones of abdominal wall perfusion. [****DIEP Flaps Compared to Other Techniques**](https://www.theplasticsfella.com/diep-flap-reconstruction/#diep-flaps-compared-to-other-techniques) The DIEP flap outperforms SIEA, TRAM, and expander-implant techniques in reliability, reduced donor-site morbidity, and long-term outcomes. [****Surgery Procedure**](https://www.theplasticsfella.com/diep-flap-reconstruction/#diep-flap-surgery-procedure) The DIEP flap procedure comprises four key steps: Planning, harvesting, anastomosis, and shaping. [****Complications**](https://www.theplasticsfella.com/diep-flap-reconstruction/#complications-of-diep-flaps) DIEP flap complications span intraoperative, perioperative, and long-term outcomes, affecting flap viability, donor site recovery, and overall surgical success. ****Primary Contributor:** Dr Hatan Mortada, Educational Fellow. --- ## Overview of DIEP Flap ****Key Point** The DIEP flap is the gold standard for autologous breast reconstruction, utilizing abdominal skin and fat while preserving muscles and fascia. The DIEP flap (Deep Inferior Epigastric Artery Perforator) is an abdominally-based flap that spares the rectus abdominis muscles and rectus sheath fascia. It offers significant advantages over other abdominal flaps. - **TRAM Flap:** Incorporates muscle and fascia, increasing the risk of postoperative complications such as abdominal wall weakness and hernia. - **Muscle-Sparing TRAM (ms-TRAM):** Reduces muscle removal but still involves variable fascia excision, with inconsistent techniques among surgeons. - **SIEA Flap:** A viable alternative when superficial vessels are dominant, but it provides reduced tissue volume and has a higher risk of venous congestion compared to the DIEP flap. A post-operative DIEP flap reconstruction is illustrated below. ![Post-operative image of a right sided breast reconstruction from a DIEP flap. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-14T012626.859.png) Post-operative image of a right sided breast reconstruction from a DIEP flap. --- ## Vascular Anatomy of DIEP Flap ****Key Point** The vascular anatomy of the DIEP flap primarily involves the deep inferior epigastric artery (DIEA) which originates from the external iliac artery and supplies the flap through perforators in the abdominal wall. The DIEP flap's blood supply originates from the external iliac artery, with perforators traversing the rectus abdominis to vascularize the flap. This creates a perfusion gradient in the abdominal wall, forming the basis for perfusion zones. ### DIEP Flap Blood Supply The **Deep Inferior Epigastric Artery (DIEA)** is the primary blood supply to the DIEP flap. - **Origin:** external iliac artery, \~1 cm cranial to the inguinal ligament. - **Course:** Traverses deep to the transversalis fascia and passes superficial to the arcuate line, supplying perforators to the anterior rectus sheath. - **Branches:** Typically bifurcates into medial and lateral branches, though in \~28% of patients, it remains a single vessel. - **Measurements:** 3–4 mm diameter, pedicle length: 14–18 cm, venous diameter: 3.5–4.5 mm. **Key** **Perforators** - **Position:** 2 cm above and 6 cm below the umbilicus, within 1–6 cm laterally (Ireton, [2014](https://pubmed.ncbi.nlm.nih.gov/25347657/?ref=theplasticsfella.com)) - **Medial Perforators:** Show greater branching and robust vascularity capable of crossing the midline (Wong, [2010](https://pubmed.ncbi.nlm.nih.gov/20195105/?ref=theplasticsfella.com)) - **Lateral Perforators:** Provide reliable vascularity only on the ipsilateral side, with limited midline perfusion. The anatomical structure is illustrated below. ![The exiting and entering vessels and other structures](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-14T013002.701.png) The exiting and entering vessels and other structures The **Superficial Inferior Epigastric Artery (SIEA)** is a secondary blood supply to the DIEP flap. It *can* be chosen when the superficial vessels are well-developed. - **Origin:** Common femoral artery, \~2–3 cm below the inguinal ligament (17% of cases), often sharing origin with the superficial circumflex artery (48%) but absent in \~35%. - **Measurements:** arterial diameter 0.75–3.5 mm, pedicle length 4–7 cm, venous diameter 3–5 mm. - **Limitations:** Inconsistent vessel presence (\~35% absence rate), reduced tissue volume compared to the DIEP flap, and higher risk of venous congestion if venous dominance shifts to superficial systems. These vessels are illustrated below. ![The superficial inferior epigastric artery (SIEA)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-14T013425.127.png) The superficial inferior epigastric artery (SIEA) ### Abdominal Zones of Perfusion [Hartrampf's Zones of Perfusion](https://www.theplasticsfella.com/hartrampfs-zones-of-perfusion/) classify the lower abdominal flap into **four zones**. It strongest at the central axis and decreasing toward the periphery across the adipocutaneous tissue. - **Zone I** **always** correlates to the zone of the selected perforator. This is most perfused and is the most reliable for flap reconstruction. - **Zone II** is adjacent to zone I on the contralateral hemi-abdomen. - **Zone III** is lateral to zone I - **Zone IV** is lateral to zone II. This is a distant one, least perfused and unlikely to be viable. In 2006, [Holm et al](https://pubmed.ncbi.nlm.nih.gov/16404245/?ref=theplasticsfella.com). revised the Hartrampf zones, dividing the lower abdominal flap into an ipsilateral half with axial supply and a contralateral half with random supply, recommending the reversal of zones II and III. The image below illustrates these four vascular zones described by Hartrampf. ![Four vascular zones described by Hartrampf](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/DIEP-Flap.png) Four vascular zones described by Hartrampf 💡 ****Tip:** Zone IV is typically avoided in flap design due to insufficient perfusion, but it may occasionally be included with careful vascular evaluation. --- ## DIEP Flaps Compared to Other Techniques ****Key Point** The DIEP flap outperforms SIEA, TRAM, and expander-implant techniques in reliability, reduced donor-site morbidity, and long-term outcomes, making it the preferred choice for autologous breast reconstruction. The DIEP flap stands out as the preferred choice for many surgeons due to its balance of reliable vascularity, reduced donor-site morbidity, and superior long-term outcomes compared to SIEA, TRAM, and expander-implant techniques. ### SIEA Flaps - **Arterial Complications:** Higher rates of arterial compromise and anastomotic revisions compared to DIEP flaps, reducing reliability ([Selber](https://doi.org/10.1097/PRS.0b013e31817d60b0?ref=theplasticsfella.com), 2008). - **Tissue Volume:** Provides less tissue volume than DIEP flaps, limiting its applicability in larger reconstructions. - **Indications:** Suitable when superficial vessels are dominant, but overall less favored due to higher complication rates. ![Indications and benefits of DIEP and SIEA flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-29T005504.640.png) Indications and benefits of DIEP and SIEA flaps ### TRAM Flaps - **Pedicled TRAM Flaps**: Involves muscle and fascia removal, leading to higher rates of donor-site complications such as hernia and abdominal wall weakness ([Jeong](https://doi.org/10.1016/j.breast.2017.12.003.?ref=theplasticsfella.com), 2018). - **Muscle-Sparing TRAM (ms-TRAM)**: Reduces muscle removal but still involves fascia excision, with variable techniques across surgeons, resulting in inconsistent outcomes. - **DIEP Advantage**: By preserving muscle and fascia, DIEP flaps have significantly lower rates of donor-site morbidity while maintaining similar flap viability. ### Expander-Implant Reconstruction - **Initial Complications**: Lower immediate complication rates compared to DIEP flaps. - **Long-Term Outcomes**: Higher reconstructive failure and infection rates make expander-implant reconstruction less durable over time ([Bennett](https://doi.org/10.1001/jamasurg.2018.1687?ref=theplasticsfella.com), 2018). - **Patient Satisfaction**: DIEP flaps provide better satisfaction and quality of life, as reported in studies using BREAST-Q scores ([Liu](https://doi.org/10.1007/s10549-014-2981-z?ref=theplasticsfella.com), 2014). --- ## DIEP Flap Surgery Procedure ****Key Point** The DIEP flap procedure comprises four key steps: Planning, harvesting, anastomosis, and shaping. The DIEP flap procedure can be broken down into four key components: **Preoperative** **planning**, **flap** **harvesting**, **microsurgical** **anastomosis**, and **flap** **shaping** and inset, each critical for achieving optimal reconstructive outcomes. ### Preoperative Preparation - **Imaging:** Preoperative CT or MR angiography identifies dominant perforators. - **Marking**: Surface markings design an elliptical flap (\~13 cm high, 35–40 cm wide) tapering laterally for closure, with the lower incision placed near the pubic tubercle for optimal vessel visualization. - **Anaesthetic Setup:** Includes venous access, Doppler monitoring, and patient positioning with calf pumps and drapes. The marking and imaging are as illustrated below. ![Marking and imaging for DIEP flap reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-14T014005.734.png) Marking and imaging for DIEP flap reconstruction 💡 ****Tip:** Cesarean scars can be incorporated into the design to prevent multiple transverse scars and minimize vascular compromise. ### Flap Elevation - **Incisions and Dissection:** Perform precise dermal and subcutaneous dissection to Scarpa’s fascia. Use beveling incisions cranially to recruit additional volume. - **Perforator Identification:** Match perforators to imaging for optimal vascular supply. Isolate the perforator, ensuring arterial pulsatility and adequate venous caliber. - **Pedicle Exposure:** A myotomy is performed to dissect deep inferior epigastric artery perforators through the rectus abdominis muscle, preserving muscle integrity, continuity, and innervation. - **Pedicle Dissection:** Trace the pedicle intramuscularly, preserving intercostal motor nerves, and gaining adequate length for vascular integrity. 💡 ****Tip:** **Some* Surgeons often assess the presence and adequacy of SIEA vessels, opting for an SIEA flap if the vessels are well-developed. ### Vessel Preparation & Inset - **Chest Preparation:** Rib-sparing techniques reduce morbidity without increasing flap complications. - **Recipient Vessel Dissection:** Expose internal mammary or thoracodorsal vessels, with internal mammary vessels now preferred for better flap positioning, enhanced medial and superior pole fullness, and preservation of the latissimus dorsi flap for future use. - **Microsurgical Anastomosis:** Complete arterial and venous connections, ensuring flow with Acland’s test. - **Flap Inset:** Rotate the flap 180° and inset into the breast pocket. Ensure tension-free placement with the pedicle free from kinking or compression. The related anatomy is illustrated below. ![Anterior thoracic wall, from behind](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-14T014414.115.png) Anterior thoracic wall, from behind 💡 ****Tip:** If the internal mammary vein is unavailable, the cephalic vein can be used as the primary recipient vein or as secondary outflow to enhance venous drainage in superficial-dominant flaps. ### Abdominal Closure - **Layered Closure:** Muscle and fascia are reapproximated in their original orientation to preserve abdominal wall strength. Barbed sutures and mesh may be used for reinforcement, especially in cases of umbilical hernia repair or increased risk of abdominal bulge. - **Umbilical Reconstruction:** The neo-umbilicus is reconstructed or preserved, depending on hernia presence and vascular integrity. ### Flap Monitoring Effective flap monitoring combines clinical assessment and technology, with most flap compromises occurring within the first 24 hours postoperatively. Clinical assessment of **flap viability** includes, - **Capillary Refill:** Ensures adequate perfusion. - **Doppler Signals:** Monitors arterial and venous flow. - **Flap Warmth and Color:** Indicators of proper circulation. Postoperative monitoring employs a range of techniques, including, - **Clinical Examination:** Reliable and cost-effective, with comparable flap salvage rates to advanced technologies. - **Handheld Doppler:** A widely used and effective tool for assessing flow. - **Implantable Doppler:** Offers continuous monitoring but may result in false positives (\~1.0%) and unnecessary reoperations (Carruthers, [2019](https://pubmed.ncbi.nlm.nih.gov/31327161/?ref=theplasticsfella.com)). - **Near-Infrared Tissue Oximetry:** Advanced imaging with high false-positive rates, requiring careful interpretation. ### Postoperative Care Key steps for postoperative care include, - **Drain Management:** Secure drains to maintain fluid balance. - **Patient Positioning:** Optimize positioning to reduce strain on the flap. - **Enhanced recovery after surgery** protocols. 💡 ****Tip:** In SIEA flap planning, the design is limited to Zones I and II, as the vascular supply does not reliably extend beyond these areas. --- ## Complications of DIEP Flaps ****Key Point** DIEP flap complications span intraoperative, perioperative, and long-term outcomes, affecting flap viability, donor site recovery, and overall surgical success. The DIEP Flap comes with potential complications that can affect the flap, donor site, and overall surgical outcome. Key complications to be aware of include: **Flap-Related Complications** - **Total Flap Loss:** Rates are low, ranging from 0.9% to 2.0% ([Heidekrueger](https://www.mdpi.com/2077-0383/10/5/1016?ref=theplasticsfella.com), 2021). - **Partial Flap Necrosis:** Varies between 0.1% and over 10%, depending on definition ([Lie](https://doi.org/10.1097/01.prs.0000434402.06564.bd?ref=theplasticsfella.com), 2013). - **Fat Necrosis:** Comparable to pedicled TRAM flaps but influenced by flap thickness and vascular supply ([Jeong](https://doi.org/10.1016/j.breast.2017.12.003.?ref=theplasticsfella.com), 2018). - **Venous Congestion:** The most common cause of flap failure, necessitating timely intervention ([Lie](https://doi.org/10.1097/01.prs.0000434402.06564.bd?ref=theplasticsfella.com), 2013). **Donor Site Complications** - **Hernias and Bulging:** Lower rates with DIEP flaps compared to TRAM flaps, reflecting reduced muscle and fascia removal ([Jeong](https://doi.org/10.1016/j.breast.2017.12.003.?ref=theplasticsfella.com), 2018). - **Wound Healing Issues:** Can arise from suboptimal donor site closure techniques **Long-Term Outcomes** - **Satisfaction and Quality of Life:** DIEP flaps outperform expander-implant reconstruction in patient-reported outcomes, including BREAST-Q scores for satisfaction and quality of life ([Liu](https://doi.org/10.1007/s10549-014-2981-z?ref=theplasticsfella.com), 2014). - **Additional Procedures:** Secondary surgeries such as nipple reconstruction, contour refinement, and scar revisions are often required to enhance aesthetic outcomes ([Hammond](https://doi.org/10.1007/s00266-020-01967-w?ref=theplasticsfella.com), 2021). 😎 ****Fun Fact:** Due to vascular variability, the SIEA flap has higher rates of flap loss and related complications compared to the DIEP flap (Coroneos, [2015](https://pubmed.ncbi.nlm.nih.gov/25919262/?ref=theplasticsfella.com)) --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Classification and Overview:** DIEP flaps are classified based on vascular anatomy and are a key technique in autologous breast reconstruction, prioritizing muscle preservation and reliable vascularity. ****2\. Vascular Anatomy:** The DIEP flap's vascular supply mainly comes from the DIEA, originating from the external iliac artery. An alternative, the SIEA, is used less frequently due to its inconsistent presence. ****3\. Procedure Steps:** DIEP flap surgery involves precise preoperative planning, perforator dissection, microsurgical anastomosis, and flap shaping to achieve optimal outcomes. ****4\. Advantages and Comparisons:** DIEP flaps surpass TRAM and SIEA flaps by minimizing donor-site morbidity, enhancing long-term satisfaction, and maintaining robust vascular supply. ****5\. Complications:** Potential risks include flap loss, fat necrosis, and venous congestion, but DIEP flaps have lower donor-site complications compared to TRAM flaps. --- ## Further Reading 1. Kehr, Pierre, and Alain G. Graftiaux. "[Kayvan Shokrollahi, Lain S. Whitaker, Foad Nahai: Flaps: Practical reconstructive surgery](https://www.researchgate.net/publication/321653653%5FKayvan%5FShokrollahi%5FLain%5FS%5FWhitaker%5FFoad%5FNahai%5FFlaps%5FPractical%5Freconstructive%5Fsurgery%5FThieme%5FVerlag%5FNew%5FYork%5FStuttgart%5FDelhi%5FRio%5Fde%5FJaneiro%5F2017%5F711%5Fpp%5Fnum%5FIll%5FHardcover%5F25337%5FISBN%5F978-1-60406-715-6?ref=theplasticsfella.com): Thieme Verlag New York, Stuttgart, Delhi, Rio de Janeiro, 2017, 711 pp.; num Ill. Hardcover, 253.37€, ISBN: 978-1-60406-715-6." (2018): 329-329. 2. Mathes SJ, Nahai F. [*Reconstructive Surgery: Principles, Anatomy, and Technique*](https://books.google.lk/books/about/Reconstructive%5FSurgery.html?id=KaZsAAAAMAAJ&redir%5Fesc=y&ref=theplasticsfella.com)*.* 1997. 3. Neligan, Peter, and James C. Grotting. [Plastic Surgery: Breast](https://books.google.lk/books/about/Plastic%5FSurgery.html?id=ldDMMaHvq4gC&redir%5Fesc=y&ref=theplasticsfella.com). Vol. 5\. Elsevier Health Sciences, 2012. 4. Hamdi M, Ghanem AM. "Deep Inferior Epigastric Perforator Flaps and Superficial Inferior Epigastric Artery Flaps for Breast Reconstruction." *Plastic Surgery Textbook.* 5. Cormack GC, Lamberty BG. "The Arterial Anatomy of Skin Flaps." *Springer-Verlag.* ### Everything Botox: 1973 Monkey Trials, Best Techniques, Duration & More! URL: https://www.theplasticsfella.com/december-15th/ Last updated: 2024-12-15T09:34:27.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/december-15th/#a-letter-from-pfella) Behind the 'Fella: Season 2 is coming! 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/december-15th/#the-sunday-quiz) How well do you know **Botox*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/december-15th/#image-of-the-week) Initial Botox experiments on monkeys in 1973. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/december-15th/#technique-tip) Tip on Botox injection for horizontal lines. 5. 📋 [****Featured Article of the Week**](https://www.theplasticsfella.com/december-15th/#featured-article-of-the-week) Welcoming a new fellow with an article feature! 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/december-15th/#what-does-the-evidence-say) How long does Botox actually last? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/december-15th/#articles-of-the-week) Can Botox cause Botulism?, Botox for finger replants, & use of Botox in plastics: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/december-15th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Behind the 'Fella: Season 2 is Coming!* 👋 ****Hey team!** After experimenting with different formats and ideas in Season 1 of [**Behind the Fella*](https://ilo.so/the-plastics-fella/?ref=theplasticsfella.com), we’re ready to take things up a notch. Season 2 is here, and it’s going to be bigger, sharper, and packed with practical takeaways. No fluff. No "why medicine" chatter. Just actionable insights from **legit experts in plastic surgery** — people at the top of their game, ready to share what works in the OR and beyond. ### **What’s New in Season 2?** This season is designed for **passive learning on the go** — perfect for your morning commute or a quick break between cases. Here’s a sneak peek at what we’re bringing to the table: - **Expert Interviews:** From the cutting edge of penis replantation and reconstruction to using intraoperative ultrasound for better flap outcomes, these aren’t just conversations; they’re masterclasses. - **No-Nonsense Takeaways:** Every episode will leave you with something tangible — tips, techniques, or ideas you can apply directly to your practice. **Here’s a Sneak Peek 👇** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Behind-the--Fella-Podcast-Cover.png) [Behind the 'Fella](https://ilo.so/the-plastics-fella/?ref=theplasticsfella.com): Season 2 **We Need Your Input!** We just wrapped an incredible episode on **penis replantation** with a global leader in the field. Next up, we’re diving into **ultrasound-guided flap optimization**. But we want to hear from you! If you work with an expert you think the community would benefit from hearing, let us know. We’ll reach out (no pressure or commitment required). This season is all about creating something valuable for you — the plastic surgery community. Your suggestions will help shape it. P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Botox?** ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![Cosmetic applications of Botox](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/image-1.png) Cosmetic applications of Botox ## Image of the Week **Botox on Monkeys in 1973* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This week, we’re spotlighting a study that takes us back to the early research days of botulinum toxin. The image shows its experimental use on monkeys in 1973. ![Botox on Monkeys in 1973](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Normal.png) Kudos to [Taylor Krivanek](https://x.com/TaylorKrivanek?ref=theplasticsfella.com) for sharing this article with us! ## Technique Tip **Botox Injection for Horizontal Lines* 🚑 ****Technique Tip of the Week** This week’s technique focuses on the treatment of horizontal lines using ****onabotulinumtoxinA**. Injections are made at five key sites, with the option of targeting two additional sites (indicated by circles) (left). ****\- Needle Depth:** Asterisks mark the one-third needle depth for each injection. ****\- Injection Method:** Gently pinch the skin until a papule forms. Insert the needle at an upward angle to one-third of its depth (right). ![Botox Injection Technique](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Normal--1-.png) Botox Injection Technique ## ****Featured Article of the Week** **Welcoming One of Our New Fellows!* 🩺 ****Exciting News: Welcome Our New Fellow!** We’re thrilled to announce that ****Dr. Benedetta Agnelli** will be soon joining our team as our newest fellow, from Milan 🇮🇹 To kick things off, Benedetta has contributed her very first article on ****Botulinum Toxin** — a must-read for anyone interested in the nuances of botox in both aesthetic and functional procedures. Read below for an overview. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-10T235508.254-1.png) #### Botulinum Toxin BoNT, derived from **Clostridium botulinum*, temporarily relaxes muscles by inhibiting acetylcholine release, offering diverse therapeutic and cosmetic applications. With popular brands like Botox® and Dysport®, it’s used to treat migraines, hyperhidrosis, and wrinkles. Precise injection techniques and tailored dosing are key, though contraindications like pregnancy and rare side effects must be considered. Learn more about everything Botox 👇 [Read the Article](https://www.theplasticsfella.com/botulinum-toxin/) ## What Does the Evidence Say? **How Long Does Botox Actually Last?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Botulinum toxin, widely used for facial wrinkles and cervical dystonia, typically lasts ****3–4 months**, occasionally extending to 6 months (Wright et al., 2018; Smith et al., 2018). A meta-analysis reported a ****median duration of 120–131 days** for glabellar lines (Glogau et al., 2012) and 93–95 days for cervical dystonia, with higher doses (≥180 U) prolonging effects (Marsh et al., 2014). AbobotulinumtoxinA shows ****onset within 2–3 days**, lasting 3–6 months (Nestor et al., 2020). Variability underscores the need for individualized treatment plans and further research (Wright et al., 2018; Smith et al., 2018). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Botulism and Cosmetic Injections: Can Botox Cause Botulism?** ([Chen](https://journals.lww.com/plasreconsurg/Fulltext/2021/08000/Botulism%5Fdue%5Fto%5FCosmetic%5FInjection%5Fof%5FBotulinum.72.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com), 2021) Cosmetic injection-induced botulism presents neuromuscular symptoms, often within 48 hours, with treatment including botulinum antitoxin and supportive therapy. ✅ ****Botox for Ischemic Hand Trauma: Finger Replants Following Vascular Injuries** ([Laarakker](https://pubmed.ncbi.nlm.nih.gov/31881617/?ref=theplasticsfella.com), 2020) Botulinum toxin type A improves blood flow and pain in ischemic hand trauma, achieving 100% digit salvage in cases of early vascular compromise, supporting its use as standard therapy. ✅ ****The Role of Botulinum Toxins: Current Indications in Plastic Surgery Beyond Aesthetics** ([Noland](https://journals.lww.com/plasreconsurg/abstract/2016/09000/current%5Fuses%5Fof%5Fbotulinum%5Fneurotoxins%5Fin%5Fplastic.34.aspx?ref=theplasticsfella.com), 2016) Botulinum neurotoxin addresses aging signs and medical conditions in plastic surgery, with key uses including rhytides, dystonias, hyperhidrosis, and spasticity. ## Feedback ### I hope you enjoyed it 😄 --- ### Botulinum Toxin: Mechanisms, Clinical Applications, & Injection Techniques URL: https://www.theplasticsfella.com/botulinum-toxin/ Last updated: 2024-12-17T17:41:35.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/botulinum-toxin/#overview-of-botulinum-toxin) Botulinum toxin (BoNT) from **Clostridium botulinum* temporarily relaxes muscles by inhibiting acetylcholine release, with serotypes A and B commonly used for therapeutic and aesthetic injections.. [****Mechanism of Action**](https://www.theplasticsfella.com/botulinum-toxin/#mechanism-of-action-of-botulinum-toxin) BoNT-A cleaves SNARE proteins at the neuromuscular junction, blocking acetylcholine release, causing reversible muscle paralysis typically lasting 3–6 months. [****Types** ](https://www.theplasticsfella.com/botulinum-toxin/#types-of-botulinum-toxin)BoNT-A brands (e.g., Botox®, Dysport®, Xeomin®, Jeuveau®) and BoNT-B (MyoBloc®) vary in potency, formulation, and clinical applications. [****Therapeutic Applications**](https://www.theplasticsfella.com/botulinum-toxin/#therapeutic-applications-of-botulinum-toxin) Indications include migraines, cervical dystonia, hyperhidrosis, and off-label uses such as bruxism, tremors, and cosmetic wrinkle reduction. [****Injection Technique**](https://www.theplasticsfella.com/botulinum-toxin/#injection-technique-of-botulinum-toxin) Dilute (about 2–2.5 mL/100 U) and inject precisely into target muscles, tailoring dose and placement to individual anatomical needs. [****Contraindications and Adverse Effects**](https://www.theplasticsfella.com/botulinum-toxin/#contraindications-and-adverse-effects) Avoid if infection, hypersensitivity, neuromuscular disorders, or pregnancy are present; potential adverse effects include local pain, bruising, and rare systemic complications. ****Primary Contributor:** Dr Benedetta Agnelli, Educational Fellow. --- ## Overview of Botulinum Toxin ****Key Point** Botulinum toxin (BoNT) from **Clostridium botulinum* temporarily relaxes muscles by inhibiting acetylcholine release, with serotypes A and B commonly used for therapeutic and aesthetic injections.. Botulinum toxin, also known as Botox or BTX, is produced by a **Gram-positive**, anaerobic bacterium - *Clostridium botulinum*. It works by **inhibiting ACh release**, leading to temporary muscle paralysis. Clinically, it is used to treat spasticity, dystonia, hyperhidrosis, and for aesthetic enhancements. There are several subtypes of Botox: - **Type A & B:** Most commonly used in clinical practice. Type A is preferred for its high potency and long duration of action, while Type B serves as an alternative for patients resistant to Type A. - **Types E & F:** Rarely cause human disease and have limited clinical application. 😎 ****Fun Fact:** Botulinum toxin holds FDA approval for various medical and cosmetic indications, with numerous additional off-label uses ### Historical Highlights - **1870:** Dr. Muller introduces the term "botulism." - **1970s:** Dr. Alan Scott uses BoNT-A for strabismus. - **1980s:** Dr. Jean Carruthers observes wrinkle reduction in patients treated for blepharospasm, recognizing BoNT-A’s aesthetic potential. - **1992:** A landmark [publication](https://pubmed.ncbi.nlm.nih.gov/1740562/?ref=theplasticsfella.com) highlights its cosmetic benefits. - **2002:** The FDA approves BoNT-A for glabellar lines. Below, you can see the first publication on Botox. ![First publication of Botox in 1992 showing its cosmetic use](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-10T142145.501-1.png) First publication of Botox in 1992 showing its cosmetic use 😎 ****Fun Fact:** In 2023, approximately 8.9 million BoNT-A procedures were performed worldwide—surpassing the combined total of liposuction, breast augmentation, rhinoplasty, abdominoplasty, and blepharoplasty procedures --- ## Mechanism of Action of Botulinum Toxin ****Key Point** BoNT-A cleaves SNARE proteins at the neuromuscular junction, blocking acetylcholine release, causing reversible muscle paralysis typically lasting 3–6 months. The primary action of Botulinum neurotoxin (BoNT) is the **inhibition of ACh release at neuromuscular junctions** results in reduced muscle contraction, leading to temporary flaccid paralysis. It does not impact adrenergic nerve endings, maintaining selective effects on cholinergic synapses. ### Structure Botulinum neurotoxin is a 150 kDa polypeptide, structurally and functionally divided into two main chains. - **Heavy Chain (100 kDa):** Facilitates neuronal targeting into presynaptic cholinergic nerve terminals. Binds specifically to ganglioside receptors and protein components of the presynaptic membrane. - **Light Chain (50 kDa):** Acts as a zinc-dependent endopeptidase (protease). Responsible for cleaving essential SNARE (Soluble NSF Attachment Protein Receptor) proteins, disrupting neurotransmitter release. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-10T143059.994.png) 3d ribbon model of botulinum neurotoxin serotype A (botox) ### Mechanism of Action 1. **Binding:** BoNT selectively attaches to presynaptic cholinergic nerve terminals via specific surface receptors, ensuring targeted delivery to motor neurons. 2. **Internalization:** The toxin-receptor complex is internalized through receptor-mediated endocytosis into the nerve terminal. 3. **Cleavage of SNARE Proteins:** The light chain exits the endosome into the cytoplasm and enzymatically cleaves SNARE proteins critical for the docking and fusion of acetylcholine (ACh)-containing vesicles with the presynaptic membrane. The image below illustrates the mechanism of action of Botox. ![Mechanism of action of Botox](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-10T235508.254.png) Mechanism of action of Botox 😎 ****Fun Fact:** BoNT-A/E cleave SNAP-25, BoNT-B/D/F/G cut synaptobrevin, and BoNT-C targets both SNAP-25 and syntaxin. ### Timeline - Clinical onset occurs within **3–5 days** post-administration. - Maximal effect is observed by **10 days.** - Recovery over **3–6 months** occurs through axonal sprouting and formation of new neuromuscular junctions 💡 ****Tip:** Duration varies based on individual metabolism and injection site. --- ## Types of Botulinum Toxin ****Key Point** BoNT-A brands (e.g., Botox®, Dysport®, Xeomin®, Jeuveau®) and BoNT-B (MyoBloc®) vary in potency, formulation, and clinical applications. **Several** botulinum toxin formulations are available, each with unique properties, production methods, and clinical uses. **Importantly**: Botulinum toxin units are not interchangeable between brands, Key preparations are noted in the **table below.** ![Types of botulinum toxin formulations, Botox types](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-03T165030.230.png) Types of botulinum toxin formulations 💡 ****Tip:** Botox should be stored at 2–8°C, and reconstituted toxin must be used within 4 hours if kept at room temperature or within 24 hours if refrigerated. Xeomin® offers superior stability at room temperature. --- ## Therapeutic Applications of Botulinum Toxin ****Key Point** Indications include migraines, cervical dystonia, hyperhidrosis, and off-label uses such as bruxism, tremors, and cosmetic wrinkle reduction. BoNT-A addresses both medical and aesthetic needs, with **FDA-approved** uses like treating chronic migraines and hyperhidrosis. **Off-label**, it aids in managing pain, movement disorders, and scars. ### Cosmetic Applications From a cosmetic perspective, Botulinum toxin’s ability to provide localized, long-lasting neuromuscular inhibition with minimal invasiveness has made it a cornerstone treatment. It plays a critical role: - **Facial Rhytids:** Treatment of facial muscles of expression and mastication. • - **Hypertrophic Scars:** Reduce tension & improve scar remodeling. - **Migraine:** Diagnostic & therapeutic adjunct before surgical interventions. - **Vasospastic:** Raynaud’s phenomenon & scleroderma-associated pathology. ![Cosmetic applications of Botox](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-10T235846.819-2.png) Cosmetic applications of Botox ### Other Applications Botulinum toxin is widely used in FDA-approved treatments and off-label applications, highlighting its neuromodulatory versatility. The toxin’s efficacy has led to formal **FDA-Approved uses** for several medical conditions: - **Neurologic:** Chronic migraines, cervical dystonia, focal spasticity. - **Hyperhidrosis:** Axillary hyperhidrosis refractory to topical treatments. - **Urologic:** Overactive bladder & urinary incontinence from detrusor overactivity Expanding beyond approved indications, BoNT is utilized for various **Off-Label** neuromodulatory applications: - **Dystonia/Bruxism:** Reducing involuntary movements \* clenching. - **Tremors:** Including essential and parkinsonian rest tremors. - **Pain:** Chronic pain, eg. myofascial pain syndrome & neuropathic pain. --- ## Injection Technique of Botulinum Toxin ****Key Point** Dilute (about 2–2.5 mL/100 U) and inject precisely into target muscles, tailoring dose and placement to individual anatomical needs. ### Preparation & Dilution Proper preparation ensures accurate dilution, toxin integrity, and optimal results. Importantly 1 unit = 0.02 mL when 50 U is diluted with 1 mL of sterile, preservative-free saline. - **Cosmetic applications:** 2 mL/100 U or 2.5 mL/100 U based on area/ effect. - **Hyperhidrosis**: Higher dilutions (4–5 mL/100 U) to cover larger areas. 💡 ****Tip:** Gently inject the sterile, preservative-free saline as a diluent to avoid frothing; do not shake the vial vigorously. ### Procedure Tailoring the approach to the patient’s anatomy and goals is crucial for natural and effective outcomes. 1. **Patient Communication:** Discuss the procedure and align expectations. Obtain informed consent. 2. **Needle Selection:** Use a fine-gauge needle (30–32G) for comfort and accuracy. 3. **Injection Site Planning:** Sterilize the area and mark sites based on functional anatomy and treatment goals. 4. **Anatomical Assessment:** Observe the patient’s expressions in repose and animation to ensure natural results. This dual analysis helps deliver results that maintain natural facial expressions while effectively reducing wrinkles, avoiding an undesired "frozen" appearance. ### Frontal Region Targeting specific anatomical regions ensures precise treatment outcomes, balancing efficacy with the preservation of natural expressions. - **Frontalis:** Elevates the eyebrows; treats horizontal forehead lines with 10–20 U injected superficially across 4–8 points. Avoid low injections to prevent brow ptosis. - **Corrugator Supercilii:** Pulls eyebrows medially, causing vertical frown lines; inject 8–12 U total, medially deep and laterally superficial, to address these lines effectively. - **Procerus:** Depresses the medial brow, forming horizontal nasal bridge lines; target these lines with 4–6 U injected superficially at the midline, if necessary. - **Orbicularis Oculi:** Closes eyelids and contributes to lateral crow’s feet; smooth crow’s feet with 6–15 U per side injected superficially near the lateral canthus across 3–4 points. - **Depressor Supercilii:** Pulls the eyebrows downward, enhancing vertical glabellar lines; softens frowning expressions by targeting this muscle with precise injections. The table below summarizes the above treatment techniques. ![Injection technique of Botulinum Toxin for the frontal region](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-11T000924.765.png) Injection technique of Botulinum Toxin for the frontal region ### Glabeller Regiojn The glabellar complex demonstrates distinct contraction patterns, requiring tailored injection approaches to address specific muscle dynamics: - **V-Pattern:** Strong approximation and depression of the medial eyebrows; treat with 7-point injections focusing on the corrugator and procerus using higher doses. - **U-Pattern:** Mild approximation and depression with arched brows at rest; use 5 classic injection points targeting the corrugator and procerus. - **Omega Pattern:** Medial brow elevation with lateral depression, forming an "Ω" shape; target the medial frontalis and corrugator with precise injections. - **Converging Arrows:** Horizontal approximation without notable lifting or depression; focus injections on the corrugator and orbicularis muscles. - **Inverted Omega:** Predominant lowering of the brows, forming an inverted "Ω"; emphasize injections in the procerus and depressor supercilii muscles. 💡 ****Tip:** Maintain at least 1,5 cm above the supraorbital rim for frontalis injections to avoid ptosis. ### Nasolabial and Perioral Region Targeting specific muscles in the nasolabial and perioral region ensures effective treatment of **bunny lines**, **perioral** **wrinkles**, and downward mouth corners while preserving natural movement. - **Nasalis:** Treats bunny lines with 4–6 U injected superficially into the muscle belly, avoiding adjacent muscles. - **Depressor Anguli Oris (DAO):** Addresses downward mouth corners with 3–5 U per side injected deeply at the lateral jawline. - **Orbicularis Oris:** Targets perioral wrinkles with 2–4 U per side injected superficially along the vermillion border. Avoid midline injections to maintain lip mobility. 💡 ****Tip:** Over-injection in the perioral area can lead to speech and eating difficulties. ### Masseter and Jawline Region Focused treatment of the masseter muscle enhances jawline contour and alleviates temporomandibular joint (TMJ) pain. It treats masseter hypertrophy for jawline contouring and TMJ pain relief. - **Anatomy:** Composed of superficial and deep layers, the masseter originates from the zygomatic arch and inserts on the mandible. Contraction causes jaw clenching and contributes to a square jawline. - **Injection Technique:** Inject 20–30 U per side deeply near the mandibular angle, dividing the dose into 3–5 points. Ensure deep placement and avoid the risorius muscle to prevent an asymmetrical smile. ### Platysmal Bands (Neck Region) Targeting the platysma muscle reduces visible vertical neck bands caused by hyperactivity. Botox injections address prominent neck bands. - **Anatomy:** Originates from the chest and inserts on the mandible, creating vertical bands when contracted. - **Injection Technique:** Pinch the bands and inject 4–6 U directly into each band using a pinch-and-release technique. Avoid deep structures to prevent dysphagia. Below is an illustration of the anatomy of platysmal bands. ![The anatomy of platysmal bands](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-11T001255.058.png) The anatomy of platysmal bands --- ## Contraindications and Adverse Effects ****Key Point** Avoid if infection, hypersensitivity, neuromuscular disorders, or pregnancy are present; potential adverse effects include local pain, bruising, and rare systemic complications. Proper use of botulinum toxin requires careful attention to contraindications such as neuromuscular disorders and allergies, along with vigilant monitoring for localized or systemic adverse effects to prevent complications. ### Contraindications Botulinum toxin should not be used in the following situations to prevent adverse outcomes: - **Infection at the Injection Site:** Active infection in the proposed treatment area. - **Hypersensitivity:** Allergic reactions to botulinum toxin preparations or excipients. - **Neuromuscular Disorders:** Conditions like myasthenia gravis or Lambert-Eaton syndrome, which increase sensitivity to the toxin. - **Pregnancy and Lactation:** The safety of botulinum toxin during pregnancy or breastfeeding is unproven, so it should be avoided. **Additional Considerations:** - Avoid in patients taking aminoglycosides or neuromuscular blockers, which may amplify the toxin's effects. - For certain formulations (e.g., Dysport), lactose sensitivity or cow’s milk protein allergy is a contraindication due to trace ingredients. ### Adverse Effects While botulinum toxin is generally safe, some adverse effects may occur: #### Local Effects - Pain, erythema, or bruising at the injection site. - Edema or transient headache. - Local muscle weakness or asymmetry due to unintended diffusion. 💡 ****Tip:** Topical α-adrenergic agents can counter eyelid ptosis caused by inadvertent levator palpebrae superioris injection. #### Systemic Effects (Rare) - Botulism-like symptoms, including dysphagia, dysphonia, or generalized muscle weakness. - Respiratory complications, particularly in patients with neuromuscular disorders or with high therapeutic doses. ### Warnings on Toxin Spread Post-marketing reports indicate that botulinum toxin effects may extend beyond the injection site, especially with high doses used therapeutically: - **Ocular Effects:** Diplopia, blurred vision, ptosis. - **Oropharyngeal and Respiratory Symptoms:** Dysphagia, dysphonia, and respiratory difficulties. 💡 ****Tip:** These effects may emerge hours to weeks after injection, emphasizing the need for careful patient selection and appropriate dosing. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview:** Botulinum toxin (BoNT), a neurotoxin derived from **Clostridium botulinum*, inhibits acetylcholine release at neuromuscular junctions, causing temporary muscle paralysis. ****2\. Mechanism of Action:** BoNT cleaves SNARE proteins required for acetylcholine release, preventing muscle contraction. Effects peak within 10 days and last 3–6 months. ****3\. Applications:** FDA-approved uses include chronic migraines, cervical dystonia, hyperhidrosis, and overactive bladder. Off-label uses extend to facial aesthetics, scar remodeling, myofascial pain, and Raynaud’s phenomenon. ****4\. Injection Techniques:** Successful outcomes depend on proper dilution, anatomy knowledge, and precise injection planning. ****5\. Contraindications and Adverse Effects:** BoNT is contraindicated in active infections, hypersensitivity, and neuromuscular disorders. --- ## Further Reading 1. de Almeida AR, da Costa Marques ER, Banegas R, Kadunc BV. Glabellar contraction patterns: a tool to optimize botulinum toxin treatment. Dermatol Surg. 2012 Sep;38(9):1506-15\. doi: 10.1111/j.1524-4725.2012.02505.x. Epub 2012 Jul 16\. PMID: 22804914\. 2. Muñoz-Gonzalez C, Fakih-Gomez N. Resolving the Controversy Surrounding the Function of the Corrugator Supercilii Muscle. Aesthetic Plast Surg. 2024 Oct 24\. doi: 10.1007/s00266- 024-04454-8\. Epub ahead of print. PMID: 39448446\. 3. Cotofana S, Freytag DL, Frank K, Sattler S, Landau M, Pavicic T, Fabi S, Lachman N, Hernandez CA, Green JB. The Bidirectional Movement of the Frontalis Muscle: Introducing the Line of Convergence and Its Potential Clinical Relevance. Plast Reconstr Surg. 2020 May;145(5):1155-1162\. doi: 10.1097/PRS.0000000000006756\. PMID: 32332530\. 4. Borba A, Matayoshi S, Rodrigues M. Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide. Aesthetic Plast Surg. 2022 Feb;46(1):385-394\. doi: 10.1007/s00266-021-02483-1\. Epub 2021 Aug 2\. PMID: 34341857; PMCID: PMC8328485\. 5. Kaplan JB. Consideration of Muscle Depth for Botulinum Toxin Injections: A Three Dimensional Approach. Plast Surg Nurs. 2017 Jan/Mar;37(1):32-38\. doi:10.1097/PSN.0000000000000172\. PMID: 28244963\. 6. Hsu TS, Dover JS, Arndt KA. Effect of volume and concentration on the diffusion of botulinum exotoxin A. Arch Dermatol. 2004 Nov;140(11):1351-4\. doi: 10.1001/archderm.140.11.1351\. PMID: 15545544. ### 4 Muscle Flaps in Reconstructive Surgery, Textbook Feedback, & new Sunday Quiz URL: https://www.theplasticsfella.com/december-8th/ Last updated: 2024-12-08T11:13:33.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/december-8th/#a-letter-from-pfella) The Annual Plastic Surgery Letter (new) 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/december-8th/#the-sunday-quiz) How well do you know the **VRAM flap*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/december-8th/#image-of-the-week) Gracilis muscle flap in reconstructive surgery. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/december-8th/#technique-tip) The original publication of latissimus dorsi flap from 1908. 5. 📘 [****Foundations Textbook**](https://www.theplasticsfella.com/december-8th/#foundations-textbook) Initial steps of building in public: Format review. 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/december-8th/#what-does-the-evidence-say) Donor site morbidity for muscle flaps. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/december-8th/#articles-of-the-week) Perfusion zones of the abdomen, original gastrocnemius flap publication, & muscle flaps in the lower limb: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/december-8th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella The Annual Plastic Surgery Letter 👋 ****Hey all!** This year, we've tackled the ****big questions** about plastic surgery: What’s thriving? What’s failing? What’s holding us back? Now, it’s time to bring it all together into an annual letter—a ****bold**, ****honest** look at where we are and where we’re headed. This annual letter we are creating isn't just about thePlasticsFella. It will reflect our community. Over the years, we've heard sharp insights and uncomfortable truths from many of you—now’s your chance to shape the conversation. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Annual-Letter.png) **What Should We Include?** I’ve got a shortlist of hot topics—trends, challenges, and breakthroughs. But what about you? What burning questions do you want answered? What’s not getting enough attention? Got advice everyone needs to hear? But now it's your chance to help shape this letter 👇 **Plastic surgery is in a tug-of-war between perception vs. reality**. This letter will cut through the noise and deliver something sharp and useful and be published at the end of the year. Let’s make this big. P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know the* **VRAM Flap?** ****Are you ready to make it to the leaderboard?** Welcome to ****a fresh round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a one-year subscription to thePlasticsPro. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/image.png) ## Image of the Week Gracilis Muscle Flap 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. Discover the detailed anatomy and clinical applications of the gracilis muscle flap in, highlighting its versatility in reconstructive surgery. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Gracilis-Muscle-Flap.png) Gracilis Muscle Flap ## Technique Tip The Original LD Flap from 1908 🚑 ****Technique Tip of the Week** This week’s edition dives into the original publication of the LD flap from 1908, shedding light on its historical significance and foundational role in surgical techniques. ![The Original LD Flap from 1908](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/LD-Flap.png) The Original LD Flap from 1908 ## Foundations Textbook **Initial Steps: Building in Public* 📘 ****Building in Public** Join us on the journey of creating the **Plastic Surgery Student Guide*! ****Step one:** Your feedback on the content format to ensure it’s impactful and student-friendly. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Textbook-Design-1.png) ## What Does the Evidence Say? **Donor Site Morbidity for Muscle Flaps* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Donor site morbidity associated with muscle flaps varies depending on the ****specific flap** and ****harvest technique**. The ****anterolateral thigh (ALT) flap** generally has low complication rates and minimal functional impairment, with most patients returning to preoperative activity levels (Hanasono et al., 2010). However, some studies report sensory disturbances and muscle weakness following ALT flap harvest (Weise et al., 2017; Collins et al., 2012). ****Latissimus dorsi flaps** may cause shoulder function impairment, particularly in extension, adduction, and internal rotation (Lee & Mun, 2014). Muscle-sparing techniques for latissimus dorsi flaps show reduced morbidity compared to extended flaps (Kim et al., 2013). The ****gracilis muscle flap** demonstrates similar functional outcomes to the ALT flap but with shorter scars and less numbness (Fricke et al., 2017). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****How Accurate Are the Traditional DIEP Flap Perfusion Zones?** ([Holm](https://pubmed.ncbi.nlm.nih.gov/16404245/?ref=theplasticsfella.com), 2006) This study challenges Hartrampf DIEP flap perfusion zones, revealing midline-separated perfusion patterns and suggesting zone rearrangement for accuracy. ✅ ****How Did the Gastrocnemius Myocutaneous Flap Redefine Lower Limb Reconstruction?** ([McCraw](https://pubmed.ncbi.nlm.nih.gov/351647/?ref=theplasticsfella.com), 1978) Explore the versatile use of medial and lateral gastrocnemius myocutaneous flaps, replacing cross-leg flaps for lower extremity reconstruction without prior delay. ✅ ****A Comparative Look at Muscle vs. Fasciocutaneous Flaps in Secondary Orthopedic Procedures** ([Guo](https://www.sciencedirect.com/science/article/abs/pii/S1748681522006660?ref=theplasticsfella.com#:~:text=Fasciocutaneous%20perforator%20flaps%20remain%20pliable,elevation%20for%20secondary%20orthopedic%20procedures.&text=Re%2Delevation%20of%20flaps%20is,flap%20loss%20%28Figure%201%29.), 2023) Fasciocutaneous flaps show fewer complications than muscle flaps in secondary orthopedic procedures, supporting their preferential use for lower extremity reconstruction. ## Feedback ### I hope you enjoyed it 😄 --- ### Pigmented Lesions in 2024: Spitz, Melanoma, Breslow (& Tips for a Skin MDT) URL: https://www.theplasticsfella.com/december-1st/ Last updated: 2024-11-29T19:04:49.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/december-1st/#a-letter-from-pfella) Can a skin MDT truly achieve perfection? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/december-1st/#the-sunday-quiz) Four winners achieve a perfect score! 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/december-1st/#image-of-the-week) Identifying giant CMN. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/december-1st/#technique-tip) Comparison of Mohs surgery and standard excision. 5. ❤️‍🩹 [****Case of the Week**](https://www.theplasticsfella.com/december-1st/#case-of-the-week) Clinical diagnosis and management of Spitz naevus. 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/december-1st/#what-does-the-evidence-say) Evidence on techniques for SLNB. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/december-1st/#articles-of-the-week) Pediatric spitz lesions, Breslow's original publication, & margins for primary cutaneous melanoma: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/december-1st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Skin MDT - Can It Ever Be Perfect?* 👋 ****Hey team!** Over the years, the messages I've been getting from people — especially junior staff managing logistics — highlight the same issues with the ****Skin MDT**. We all agree that the Skin MDT is crucial for patient care, but does it really work as well as we want it to? The challenges seem to be universal, and I don’t have all the answers — which is why I’m turning to you for insights. **The Problems** If we are totally honest about it, we can probably all relate to the usual struggles: - People running late or away. - Slides missing some nuanced details. - Disorganized mix of tools resulting in duplication of work. - Communication gaps leading to confusion. **A Better Way?** What if we made the Skin MDT **asynchronous**? Instead of cramming everyone into a room (or on Zoom), make it a **peer-reviewed process** throughout the week. **How an Asynchronous MDT Could Work** 1. **Log In and Review:** Everyone logs in during the week to review cases and provide feedback. 2. **Discuss Complex Cases:** Only cases with disagreement or complexity are discussed in real-time. 3. **Save Time:** This approach saves time, focuses on challenging cases, and ensures every case gets reviewed. This would mean **less waiting around**, **more efficiency**, and potentially **better outcomes** for patients. Every case gets the attention it needs, but we aren’t drowning in logistics. **What Do You Think?** Looking forward to your thoughts, P'Fella ❤️ ## The Sunday Quiz **Results from the Last Round: Winners Announced!* ****Congratulations to the winners** of the weekly quiz! After six challenging rounds of plastic surgery questions, the top scorers are ****Toby**, ****Paul**, ****Nathan**, and ****Alexander L**. We'll be in touch with you soon. Each of them achieved a perfect score — an impressive feat! A big thank you to everyone who took part. Stay tuned for more engaging quizzes in upcoming editions! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Leaderboard-Team-Post-Template--3-.png) Check out the leaderboard below! ## Image of the Week Signs of Giant CMN 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This edition features an anatomical illustration focusing on Giant Congenital Melanocytic Nevi (CMN). Read more [here](https://www.theplasticsfella.com/congenital-melanocytic-naevus/). ![Giant congenital melanocytic naevus](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image-10.png) Giant congenital melanocytic naevus ## Technique Tip **Mohs vs. Standard Excision* 🚑 ****Technique Tip of the Week** This week’s edition dives into the nuances of Mohs surgery vs standard excision highlighting their practical considerations. You can read more about the technique [here](https://www.theplasticsfella.com/mohs-micrographic-surgery/#mohs-vs-standard-excision). ![Standard Excision vs Moh's Surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image-11.png) Standard Excision vs Moh's Surgery ## Case of the Week **Spitz Naevus in a Clinical Setting* 🏥 Here's an overview of our ****Spitz Naevus Clinical Scenario**. Spitz naevus is a benign melanocytic lesion often seen in children and young adults. While generally non-threatening, it can mimic melanoma in appearance, posing a diagnostic challenge for clinicians. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/AI-generated-image--17--1.png) #### Spitz Naevus - Clinical Scenario 1. ****Describe the clinical and dermoscopy findings of Spitz Naevus.** 2. ****Describe the histopathological findings of Spitz Naevus.** 3. ****Appreciate the different types of Spitz naevi and their potential for malignant behaviour.** 4. ****Knowledge of the management of Spitz naevus in different age groups.** [Read the Article](https://www.theplasticsfella.com/spitz-naevus-clinical-scenario/) ## What Does the Evidence Say? **Evidence on Techniques for SLNB* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Sentinel lymph node biopsy (SLNB) is the standard procedure for staging ****melanoma**. The gold standard technique combines ****radioisotope** and ****blue dye** (Morton et al., 2014; Ferrucci et al., 2018). However, new methods have emerged, including indocyanine green (ICG) fluorescence, superparamagnetic iron oxide nanoparticles, and contrast-enhanced ultrasound (Ferrucci et al., 2018). ICG fluorescence has shown higher sensitivity and detection rates compared to traditional methods (Korn et al., 2014; Fujisawa et al., 2012). A meta-analysis revealed that radioisotope alone or combined with blue dye yielded the highest identification rates in melanoma (Niebling et al., 2016). SLNB has been shown to improve ****disease-free survival** in patients with ****intermediate**\-thickness and ****thick** ****melanomas** (Morton et al., 2014), highlighting its importance in cancer staging and management. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Clinical Insights into Pediatric Spitz Lesions: Features, Management, and Outcomes** ([Patel](https://www.jprasurg.com/article/S1748-6815%2824%2900404-2/fulltext?ref=theplasticsfella.com), 2024) Paediatric Spitz-type lesions are mostly benign, with no recurrence or mortality observed. Conservative management is sufficient for benign cases, with minimal excisions recommended for suspicious lesions. ✅ ****Breslow's Depth: A Critical Factor in Melanoma Prognosis and Survival** ([Breslow](https://journals.lww.com/annalsofsurgery/citation/1970/11000/thickness,%5Fcross%5Fsectional%5Fareas%5Fand%5Fdepth%5Fof.17.aspx?ref=theplasticsfella.com), 1970) Tumor thickness, cross-sectional area, and invasion depth predict melanoma survival more effectively than lesion diameter alone. ✅ ****1 Versus 2-cm Excision Margins for pT2-pT4 Primary Cutaneous Melanoma** ([Moncrieff](https://pubmed.ncbi.nlm.nih.gov/29850955/?ref=theplasticsfella.com), 2018) 1-cm margins reduced reconstruction (13.6% vs. 34.9%) and wound necrosis (0.5% vs. 3.6%) compared to 2-cm margins, with no QoL differences at 12 months. ## Feedback ### I hope you enjoyed it 😄 --- ### 6 Traits of Patients Who Sue Surgeons, Trending Nipple Fillers, & Cosmetic Breast Insights URL: https://www.theplasticsfella.com/november-24th/ Last updated: 2024-12-07T17:46:45.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/november-24th/#a-letter-from-pfella) SIMON will be disappointed, but FATIMA might sue you. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-24th/#the-sunday-quiz) **Final round:* How well do you know **breast augmentation?* 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/november-24th/#image-of-the-week) Classification of breast ptosis. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-24th/#technique-tip) How to do a breast reduction: Learn from Madeline Lejour's herself. 5. ****👁️** [****What's Trending?**](https://www.theplasticsfella.com/november-24th/#whats-trending) Injectable nipple fillers are trending at the moment! 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/november-24th/#what-does-the-evidence-say) A combined augmentation-mastopexy or two-stage? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-24th/#articles-of-the-week) Subfascial vs. subglandular breast augmentation, breast implant illness, & BIA-ALCL and textured breast implants: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/november-24th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **SIMON Will Be Disappointed, But FATIMA Might Sue You* 👋 ****Hey there!** Let's talk about two acronyms that have defined risk assessment in plastic surgery: ****SIMON** and ****FATIMA**. These aren’t just names — they’re essential tools for identifying patients who might become a nightmare post-op. **Meet SIMON** Back in 1999, Gorney and Martello gave us **SIMON:** **Single, Immature, Male, Over-expectant, Narcissistic**. SIMON patients were the ones you didn’t want to see on your schedule — likely to have unrealistic expectations and more likely to be dissatisfied no matter how perfect the surgery. SIMON was a way to spot those warning signs early before they turned into lawsuits or endless complaints. **Now Meet** [**FATIMA**](https://link.springer.com/article/10.1007/s00266-024-04476-2?ref=theplasticsfella.com) Fast forward to today, and we have [**FATIMA**](https://link.springer.com/article/10.1007/s00266-024-04476-2?ref=theplasticsfella.com), based on real litigation data from Spain. This acronym identifies traits common in plaintiffs who sue after plastic surgery: - **F**emale - Using **A**ntidepressants or Anxiolytics - **T**attoos - Breast **I**mplants - **M**iddle-aged - **A**ccess to free legal services FATIMA is about being proactive. It’s not about rejecting patients but about recognizing potential risks and managing them effectively — keeping communication clear and expectations realistic. **Why It Matters** Whether it's SIMON or FATIMA, the message is clear: managing expectations is just as important as surgical skills. Most legal issues don’t arise from technical mistakes—they come from patients feeling let down or misinformed. These acronyms are a way to help us navigate that delicate balance. Sure, these labels might feel harsh or simplistic, but they exist for a reason: to protect both the patient and the surgeon. If you know you’re dealing with a FATIMA, you can take extra steps to ensure everything is clear and understood—before anyone gets near the OR. **What Do You Think?** Have you encountered a SIMON or a FATIMA in your practice? Do you think these acronyms help or hurt when it comes to patient care? Share your thoughts! With love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Breast Augmentation**? ****Are you ready to make it to the leaderboard?** Welcome to ****the final round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Overview of breast augmentation - surgical incisions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image-9.png) Overview of breast augmentation - surgical incisions ## Image of the Week **Classification of Breast Ptosis* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This edition looks at the classification of breast ptosis. Read more [here](https://www.researchgate.net/figure/Artists-depiction-of-the-breast-ptosis-grading-system-proposed-by-Regnault-et-al%5Ffig1%5F323733586?ref=theplasticsfella.com). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Artists-depiction-of-the-breast-ptosis-grading-system-proposed-by-Regnault-et-al.png) Pontell, Matthew & Noah, Harry & Brown, A. & Rose, M. & Ashinoff, R. & Saad, A.. (2018). [Single Stage Nipple-Sparing Mastectomy and Reduction Mastopexy in the Ptotic Breast](https://www.researchgate.net/figure/Artists-depiction-of-the-breast-ptosis-grading-system-proposed-by-Regnault-et-al%5Ffig1%5F323733586?ref=theplasticsfella.com). Plastic Surgery International. 2018\. 1-9\. 10.1155/2018/9205805. ## Technique Tip **How to do a Breast Reduction* 🚑 ****Technique Tip of the Week** This edition looks at Madeline Lejour's technique for marking a breast reduction. You can read more on the technique [here](https://x.com/PlasticsFella/status/1619408975623262208?ref=theplasticsfella.com). 0:00 /4:22 1× Marking a breast reduction ## What's Trending? **New Trend Spotted: Nipple Fillers* 👁️ In this section, we'll make sure you stay ahead of the curve with the latest techniques and hot topics in plastic surgery! This edition looks at injectable nipple fillers. Read the full article below 👇 [Injectable filler in your nipples? The latest trend in breast aestheticsIt seems like not that long ago, it was a significant faux pas to let a little nip slip through your blouse. If it was a cold day or the office cranked up the A/C, you better be wearing a thick bra or have packed a sweater to keep from embarrassing yourself with visible nipples showing through your shirt.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/icon/apple-icon-180x180.png)American Society of Plastic SurgeonsAlia Willson![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/thumbnail/injectable-nipple-filler.jpg)](https://www.plasticsurgery.org/news/articles/injectable-filler-in-your-nipples-the-latest-trend-in-breast-aesthetics?utm%5Fsource=Twitter&utm%5Fmedium=Social&utm%5Fcampaign=PSEC) ## What Does the Evidence Say? **Single-Stage vs Two-Stage Augmentation-Mastopexy* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Should we do a combined augmentation-mastopexy or two-stage?** Simultaneous augmentation-mastopexy is a complex but increasingly popular procedure that combines breast augmentation with a lift. While some surgeons advocate for a ****two-stage approach** due to opposing force vectors (Kropf et al., 2011), several studies support the safety and efficacy of the one-stage procedure (Doshier et al., 2016; Stevens et al., 2014; Hedén, 2009; Swanson, 2013; Montemurro et al., 2019; Calobrace et al., 2013; Spring et al., 2015). Complication rates for the combined procedure range from 22.9% to 36.3%, with revision rates between 16.9% and 23.2% (Stevens et al., 2014; Swanson, 2013; Calobrace et al., 2013). These rates are comparable to or lower than the cumulative rates for separate procedures (Swanson, 2013). Common complications include ****poor scarring**, ****wound healing issues**, and ****recurrent ptosis** (Stevens et al., 2014; Calobrace et al., 2013). With proper patient selection, careful planning, and skilled surgical technique, simultaneous augmentation-mastopexy can be safely performed as a single-stage procedure with acceptable outcomes (Hedén, 2009; Spring et al., 2015). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Comparison of Subfascial vs. Subglandular Breast Augmentation** ([Yuan](https://academic.oup.com/asj/article-abstract/44/9/NP639/7686579?redirectedFrom=fulltext&ref=theplasticsfella.com), 2024) Subfascial breast augmentation reduces capsular contracture, hematoma, and rippling compared to the subglandular plane, with 93% diagnostic agreement. ✅ ****Breast Implant Illness: Insights, Patterns, and Controversies Explored** ([Kabir](https://academic.oup.com/asj/article-abstract/44/9/NP629/7651182?redirectedFrom=fulltext&ref=theplasticsfella.com), 2024) Breast Implant Illness (BII) symptoms were reported in 31.3% of patients, with 83.5% showing symptom improvement after implant removal, primarily in cosmetic rather than reconstructive cases. ✅ ****BIA-ALCL and Textured Breast Implants: Guidelines for Improved Safety and Outcomes** ([Clemens](https://journals.lww.com/plasreconsurg/fulltext/2024/09000/american%5Fassociation%5Fof%5Fplastic%5Fsurgeons%5Fconsensus.2.aspx?ref=theplasticsfella.com), 2024) BIA-ALCL is linked to textured implants, necessitating surgeon awareness, patient surveillance, and adherence to evidence-based recommendations for diagnosis and management. ## Feedback ### I hope you enjoyed it 😄 --- ### Trigger Finger: Anatomy, Clinical Features, & Management URL: https://www.theplasticsfella.com/trigger-finger/ Last updated: 2024-11-21T15:19:33.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/trigger-finger/#definition-of-trigger-finger) Trigger finger (stenosing tenosynovitis) is a condition where the flexor tendon becomes trapped at the A1 pulley. [****Anatomy**](https://www.theplasticsfella.com/trigger-finger/#anatomy-of-a-trigger-finger) Trigger finger results from mechanical pathology within the flexor tendon and pulley system, involving thickening of the A1 pulley and impaired tendon gliding. [****Clinical Features**](https://www.theplasticsfella.com/trigger-finger/#clinical-features-of-trigger-finger) Physical examination often reveals a palpable nodule, pain over the A1 pulley, and active triggering during movement. [****Grading**](https://www.theplasticsfella.com/trigger-finger/#grading-of-trigger-finger) The Green classification is commonly used to stratify trigger fingers based on the degree and reversibility of triggering. [****Management**](https://www.theplasticsfella.com/trigger-finger/#management-of-trigger-finger) Management of a trigger finger is initially conservative. Surgical release of the A1 pulley is reserved for severe cases. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Trigger Finger ****Key Point** Trigger finger (stenosing tenosynovitis) is a condition caused by flexor tendon entrapment at the A1 pulley, leading to painful locking or catching during finger movement. **Trigger finger**, also known as **stenosing tenosynovitis**, results from the entrapment of the flexor tendon as it passes through the **A1 pulley** of the digital sheath. This condition commonly causes **pain** & or **locking** during flexion and extension, impairing hand function. Trigger Finger affects **2–3%** of the general population with well-defined demographic patterns and risk factors, including, - **Age:** Adults aged 40 to 60 years ([Makkouk](https://pubmed.ncbi.nlm.nih.gov/19468879/?ref=theplasticsfella.com), 2008). - **Females:** Twice as likely to develop trigger finger than men ([Saldana](https://pubmed.ncbi.nlm.nih.gov/11476534/?ref=theplasticsfella.com), 2001). - **Affected Digits:** Ring & middle fingers are most common ([Makkouk](https://pubmed.ncbi.nlm.nih.gov/19468879/?ref=theplasticsfella.com), 2008). - **Systemic Conditions:** Bilateral cases are more common in patients with diabetes or rheumatoid arthritis ([Baumgarten](https://pubmed.ncbi.nlm.nih.gov/18056491/?ref=theplasticsfella.com), 2007). An example of a trigger finger can be seen below. ![Presentation of a trigger finger, stenosing tenosynovitis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-02T140708.859.png) Presentation of a trigger finger --- ## Anatomy of a Trigger Finger ****Key Point** Trigger finger results from mechanical pathology within the flexor tendon and pulley system, specifically involving thickening of the A1 pulley and impaired tendon gliding. The flexor tendon pulley system ensures smooth finger movement. A trigger finger arises from A1 pulley dysfunction and tendon inflammation, causing pain and locking during motion. ### Pulley Anatomy of the Fingers Flexor tendons glide through **annular** (A) and **cruciform** (C) pulleys, which maintain tendon alignment for smooth finger movement. The **A1 pulley** is most commonly involved in trigger fingers. - **Annular (A) Pulleys:** Ring-like structures that anchor the tendons close to the phalanges, named A1 to A5. - **A1:** Located at the MCP joint, frequently implicated in trigger finger. - **A2:** Over the proximal phalanx, essential for preventing bowstringing. - **A3:** Found at the PIP joint. - **A4:** Spanning the middle phalanx. - **A5:** Positioned at the DIP joint. - **Cruciform (C) Pulleys:** Cross-shaped structures located between annular pulleys (C1-C3). They maintain flexor sheath integrity but are less critical for function compared to annular pulleys. The anatomy of a trigger finger is illustrated below. ![Anatomy of a trigger finger - The A1 pulley is most commonly involved in trigger finger.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-21T203516.023.png) Anatomy of a trigger finger ### Pathology of Trigger Finger Trigger finger is characterized by changes within the A1 pulley and flexor tendon that disrupt normal tendon gliding. **Mechanical Pathology** - **A1 Pulley Thickening:** Narrows the tendon sheath and limits movement. - **Tendon Nodule Formation:** Caused by friction and inflammation of the flexor digitorum profundus tendon. - **Tendon Inflammation:** Leads to fibrosis, further impairing motion. **Pathophysiological Changes** ([Brozovich](https://journals.lww.com/prsgo/fulltext/2019/08000/a%5Fcritical%5Fappraisal%5Fof%5Fadult%5Ftrigger%5Ffinger%5F.18.aspx?ref=theplasticsfella.com), 2019) - **Fibrocartilaginous Metaplasia:** Abnormal tissue changes in the tendon and/or pulley. - **Increased Type III Collagen:** Contributes to fibrosis and structural abnormalities. - **Collagen Cross-linking:** Exacerbated by hyperglycemia, common in diabetes, impeding collagen breakdown. - **Triggering Mechanism:** During flexion, the thickened A1 pulley can trap the flexor tendon, causing locking or "triggering." ([Saldana](https://pubmed.ncbi.nlm.nih.gov/11476534/?ref=theplasticsfella.com), 2001) 😎 ****Fun Fact:** Damage to cruciform pulleys alone generally does not cause significant functional issues unless combined with annular pulley damage. --- ## Clinical Features of Trigger Finger ****Key Point** Trigger finger is characterized by pain, locking during finger movements, and difficulty straightening the affected digit. A palpable nodule and active triggering are hallmark findings during physical examination. **Trigger finger**, also known as stenosing tenosynovitis, presents with **progressive** symptoms affecting hand function. Diagnosis is primarily **clinical** and is often associated with specific systemic conditions, occupational factors, and demographic risk factors. #### History Trigger finger **symptoms** are typically progressive and worsen over time. - **Pain:** Localized at the base of the affected digit, near the A1 pulley. - **Locking or Triggering:** Difficulty straightening the finger, often accompanied by a locking sensation during movement. - **Stiffness:** Especially pronounced in the morning or after prolonged inactivity Trigger finger is linked to several **risk factors**. - **Systemic Conditions:** Diabetes, rheumatoid, sarcoidosis, gout, and amyloidosis ([Vasiliadis](https://www.worldscientific.com/doi/abs/10.1142/S021881041750023X?ref=theplasticsfella.com), 2017). - **Occupational Factors:** Frequent use of hand tools or repetitive manual labor is associated with increased risk. - **Demographics:** Females (2:1 ratio) aged 40–60 years ([Saldana](https://pubmed.ncbi.nlm.nih.gov/11476534/?ref=theplasticsfella.com), 2001). - **Congenital Cases:** Rarely seen in children, often involving the thumb. 💡 ****Tip:** ****Paediatric trigger finger** is a congenital condition, often presenting with ****Notta's node** and flexion contracture. Surgical intervention is recommended between 2-4 years of age to prevent interphalangeal joint contracture. #### Physical Examination Key findings during the clinical evaluation of trigger finger include, - **Palpable Nodule:** A tender nodule at the metacarpal head, associated with tendon thickening. - **Triggering:** Observable during active or passive flexion-extension movements. - **Pain:** Tenderness localized over the A1 pulley. The video below shows the clinical presentation of a trigger finger. 0:00 /0:11 1× Clinical presentation of a trigger finger #### Differential Diagnosis Trigger finger is rarely misdiagnosed. In unusual cases, other conditions that mimic trigger finger must be excluded. - **Dupuytren’s Contracture:** Fixed flexion deformity caused by palmar fascia thickening. - **Lumbrical Plus Finger:** Unexpected IP joint extension during attempted flexion, caused by FDP retraction. - **Extensor Tendon Injuries:** Lacerations or ruptures secondary to trauma. 😎 ****Fun Fact:** Lumbrical Plus Finger can cause unexpected extension of the IP joints during flexion attempts. Treatment includes FDP tenodesis or lumbrical release for symptomatic cases ([Schuind](https://www.sciencedirect.com/science/article/abs/pii/S0363502317319020?ref=theplasticsfella.com), 2018). --- ## Grading of Trigger Finger ****Key Point** The Green classification is a system for grading trigger finger, categorizing severity based on the degree of triggering and reversibility. Trigger finger is assessed using the Green classification, which stratifies the condition to guide treatment and prognosis ([Dala-Ali](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3504690/?ref=theplasticsfella.com#:~:text=Steroid%20injections%20have%20been%20found,from%20between%2067%20and%2090%25.), 2012) **Grade I: Pre-triggering** - Mild pain and tenderness over the A1 pulley. - No locking or mechanical obstruction. **Grade II: Triggering with Intermittent Locking** - Locking during movement that can be corrected passively. **Grade III: Locked Finger** - **Grade IIIa:** Patient can correct the locking manually. - **Grade IIIb:** Correction requires external force. **Grade IV: Fixed Flexion Contracture** - Irreversible flexion deformity due to prolonged mechanical obstruction or fibrosis. --- ## Management of Trigger Finger ****Key Point** Treatment for trigger finger starts with conservative measures like activity modification, splinting, NSAIDs, and corticosteroid injections. Surgical release of the A1 pulley is reserved for persistent or severe cases. Management of trigger finger is guided by the severity of symptoms and response to non-invasive treatments. Non-surgical interventions are typically first-line, with surgery considered for refractory or severe cases ([Gil](https://journals.lww.com/jaaos/abstract/2020/08010/current%5Fconcepts%5Fin%5Fthe%5Fmanagement%5Fof%5Ftrigger.5.aspx?ref=theplasticsfella.com), 2020). ### Non-Surgical Treatment #### - **Activity Modification:** Avoid repetitive hand movements or prolonged use of hand tools. - **Splinting:** Night splints are effective for reducing symptoms by immobilizing the affected finger. - **NSAIDs:** Alleviate pain and inflammation but are generally supportive rather than definitive. - **Corticosteroid Injections** - First-line for many patients, particularly effective for reducing inflammation in the tendon sheath. - Provides symptom relief in 50%-80% of cases ([Baumgarten](https://pubmed.ncbi.nlm.nih.gov/18056491/?ref=theplasticsfella.com) et al., 2007). - Less effective in diabetic patients due to altered tissue response. ### Surgical Management For patients with persistent or severe symptoms, surgery may be required to release the mechanical obstruction. - **Open A1 Pulley Release** - Standard surgical approach through a small incision. - Offers symptom relief in over 90% of cases ([Gil](https://journals.lww.com/jaaos/abstract/2020/08010/current%5Fconcepts%5Fin%5Fthe%5Fmanagement%5Fof%5Ftrigger.5.aspx?ref=theplasticsfella.com), 2020). - **Percutaneous Release** - Minimally invasive, performed with a needle to divide the A1 pulley. - Associated with quicker recovery but carries a higher risk of nerve injury compared to open techniques ([Cebesoy](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267599/?ref=theplasticsfella.com) et al., 2007). - **Excision of Flexor Digitorum Superficialis (FDS) Slip** - Used for recurrent or persistent triggering after A1 pulley release. - Typically involves releasing the ulnar slip of the FDS tendon. #### Complications of Surgery - **Nerve Injury:** Radial digital nerve injury, especially in thumb surgeries. - **Bowstringing:** Caused by damage to the A2 or A4 pulleys, requiring potential reconstruction. - **Other Risks:** Wound dehiscence, scar tenderness, stiffness, or tendon scoring (more common with percutaneous techniques). #### Postoperative Care - **Early Mobilisation:** Encouraged to prevent stiffness and improve recovery. - **Pain Management:** NSAIDs or analgesics are prescribed to manage postoperative pain. - **Physical Therapy:** May be recommended for patients with postoperative stiffness or functional limitations. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition of Trigger Finger:** Trigger finger involves the entrapment of the flexor tendon at the A1 pulley, causing painful locking during finger movement. ****2\. Risk Factors of Trigger Finger:** Common in adults 40-60 years old, especially in those with diabetes or engaging in repetitive hand use. ****3\. Anatomy and Pathology of Trigger Finger:** The condition stems from thickening of the A1 pulley and formation of tendon nodules, which disrupt normal tendon gliding. ****4\. Symptoms of Trigger Finger:** Presents with finger stiffness, pain at the base of the finger, and a palpable nodule, often accompanied by a clicking or locking sensation. ****5\. Diagnosis and Grading of Trigger Finger:** Diagnosed through clinical examination and supported by X-ray. Severity is graded from mild discomfort to severe locking requiring intervention. ****6\. Management of Trigger Finger:** Treatment ranges from splinting and NSAIDs to corticosteroid injections for mild cases, with surgical release of the A1 pulley reserved for severe or refractory cases. --- ## Further Reading 1. Baumgarten, K. M., Gerlach, D., & Boyer, M. I. (2007). [Corticosteroid injection in diabetic patients with trigger finger.](https://pubmed.ncbi.nlm.nih.gov/18056491/?ref=theplasticsfella.com) *The Journal of Bone and Joint Surgery*, 89(12), 2604-2611. 2. Cebesoy, O., Karakurum, G., Payzın, B., & Baltacı, E. T. (2007). [Percutaneous release of the trigger thumb: Is it safe, cheap, and effective?](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267599/?ref=theplasticsfella.com) *International Orthopaedics*, 31(3), 345-349. 3. Makkouk, A. H., Oetgen, M. E., Swigart, C. R., & Dodds, S. D. (2008). [Trigger finger: Etiology, evaluation, and treatment.](https://pubmed.ncbi.nlm.nih.gov/19468879/?ref=theplasticsfella.com) *Current Reviews in Musculoskeletal Medicine*, 1(2), 92-96. 4. Saldana, M. J. (2001). [Trigger digits: Diagnosis and treatment.](https://pubmed.ncbi.nlm.nih.gov/11476534/?ref=theplasticsfella.com) *The Journal of the American Academy of Orthopaedic Surgeons*, 9(4), 246-252. 5. Vasiliadis, Angelo V., and Iraklis Itsiopoulos. "[Trigger finger: an atraumatic medical phenomenon](https://www.worldscientific.com/doi/abs/10.1142/S021881041750023X?ref=theplasticsfella.com)." *The Journal of Hand Surgery (Asian-Pacific Volume)* 22.02 (2017): 188-193. 6. Zafonte, Brian, Dora Rendulic, and Robert M. Szabo. "[Flexor pulley system: anatomy, injury, and management](https://www.sciencedirect.com/science/article/abs/pii/S0363502314007485?ref=theplasticsfella.com)." *The Journal of Hand Surgery* 39.12 (2014): 2525-2532. 7. Brozovich, Nikolas, Devandra Agrawal, and Gangadasu Reddy. "[A critical appraisal of adult trigger finger: pathophysiology, treatment, and future outlook.](https://journals.lww.com/prsgo/fulltext/2019/08000/a%5Fcritical%5Fappraisal%5Fof%5Fadult%5Ftrigger%5Ffinger%5F.18.aspx?ref=theplasticsfella.com)" *Plastic and Reconstructive Surgery–Global Open* 7.8 (2019): e2360. 8. Schuind, Frédéric A., Fabian Moungondo, and Pierre Van Wetter. "[A new clinical sign of lumbrical plus finger.](https://www.sciencedirect.com/science/article/abs/pii/S0363502317319020?ref=theplasticsfella.com)" *The Journal of hand surgery* 43.6 (2018): 573-e1. 9. Dala-Ali, Benan M., et al. "[The efficacy of steroid injection in the treatment of trigger finger.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3504690/?ref=theplasticsfella.com#:~:text=Steroid%20injections%20have%20been%20found,from%20between%2067%20and%2090%25.)" *Clinics in Orthopedic Surgery* 4.4 (2012): 263-268. 10. Gil, Joseph A., Andrew M. Hresko, and Arnold-Peter C. Weiss. "[Current concepts in the management of trigger finger in adults.](https://journals.lww.com/jaaos/abstract/2020/08010/current%5Fconcepts%5Fin%5Fthe%5Fmanagement%5Fof%5Ftrigger.5.aspx?ref=theplasticsfella.com)" *JAAOS-Journal of the American Academy of Orthopaedic Surgeons* 28.15 (2020): e642-e650. ### Complex Regional Pain Syndrome: Clinical Features, Diagnosis, and Treatment URL: https://www.theplasticsfella.com/complex-regional-pain-syndrome/ Last updated: 2024-12-02T19:57:59.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/complex-regional-pain-syndrome/#overview-of-crps) Complex Regional Pain Syndrome (CRPS) is a chronic neuropathic pain disorder that presents with pain disproportionate to the degree of tissue injury and lasts beyond the expected healing time. [****Aetiology**](https://www.theplasticsfella.com/complex-regional-pain-syndrome/#pathophysiology-of-crps) The pathophysiology of CRPS is multifactorial, involving dysregulation of the central and peripheral nervous systems, with inflammatory and immunological components. [****Clinical Features**](https://www.theplasticsfella.com/complex-regional-pain-syndrome/#clinical-features-of-crps) Patients present with severe burning pain, often accompanied by sensory, motor, and autonomic disturbances. [****Diagnosis**](https://www.theplasticsfella.com/complex-regional-pain-syndrome/#diagnosis-of-crps) Diagnosis is clinical, using the Budapest Criteria. Adjunct investigations include thermography and bone scintigraphy. [****Treatment**](https://www.theplasticsfella.com/complex-regional-pain-syndrome/#treatment-of-crps) CRPS treatment is multidisciplinary, focusing on physical therapy, medications, and surgical options in refractory cases. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Overview of CRPS ****Key Point** Complex Regional Pain Syndrome (CRPS) is a neuropathic pain disorder characterized by disproportionate, persistent pain that exceeds the expected time of healing, often accompanied by sensory, vasomotor, sudomotor, and trophic changes. Complex Regional Pain Syndrome (CRPS) is a chronic condition where the pain experienced is disproportionate to the initial injury and persists far beyond the typical healing period: It is often accompanied by: - **Allodynia**: Pain from non-painful stimuli (e.g., light touch) ([He](https://www.ncbi.nlm.nih.gov/books/NBK537129/?ref=theplasticsfella.com#:~:text=Allodynia%20is%20defined%20as%20%22pain,produce%20sensation%29%2C%20causing%20pain.), 2023). - **Hyperalgesia**: Exaggerated pain response to painful stimuli. - **Sudomotor Dysfunction**: Altered sweating (hyper- or hypohidrosis) ([Cheshire](https://pubmed.ncbi.nlm.nih.gov/32906168/?ref=theplasticsfella.com#:~:text=Conditions%20that%20impair%20sudomotor%20function,and%20a%20host%20of%20medications.), 2020) - **Vasomotor Changes**: Skin temperature and color abnormalities. - **Trophic Changes**: Alterations in skin, nails, or hair ### ![Complex Regional Pain Syndrome (CRPS) of the leg following tibial bone fracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-16T020316.667.png) Complex Regional Pain Syndrome (CRPS) of the leg --- ## Classification of CRPS ****Key Point** CRPS is classified by the presence of ****nerve injury** (Type I or Type II) and ****sympathetic** involvement (sympathetically-maintained or independent), with clinical presentations further described as warm (early inflammatory) or cold (chronic autonomic dysfunction). CRPS is categorized into subtypes based on the presence of **nerve** damage, **sympathetic** involvement, and the **stage** of clinical presentation. ### Presence of a Nerve Injury CRPS is initially classified based on whether a nerve injury is present, which helps differentiate between the two primary subtypes. This is the most common method of CRPS classification. 1. **Type I (Reflex Sympathetic Dystrophy)**: no identifiable nerve damage. 2. **Type II (Causalgia)**: Associated with documented nerve injury. Although the clinical presentations are similar, undiagnosed nerve injuries may blur the distinction between these subtypes ([Dellon](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649919/?ref=theplasticsfella.com), 2009). ### Sympathetic Involvement Another important classification considers the role of the **sympathetic** nervous system in maintaining the pain: - **Sympathetically-Maintained Pain (SMP)**: Pain linked to abnormal sympathetic nervous system activity. - **Sympathetically-Independent Pain (SIP)**: Pain not related to sympathetic dysfunction. ### Temperature The clinical presentation of CRPS is often further described based on temperature-related characteristics, which indicate the stage of the condition: - **Warm CRPS**: Early, inflammatory changes (e.g., warmth, redness). - **Cold CRPS**: Chronic autonomic dysfunction with reduced limb temperature. 💡 ****Tip:** CRPS often develops within ****eight weeks** of trauma, with some patients showing improvement within three months, while others show little to no improvement even after a year ([Brunner](https://pubmed.ncbi.nlm.nih.gov/28573699/?ref=theplasticsfella.com), 2017). --- ## Pathophysiology of CRPS ****Key Point** CRPS is triggered by trauma or surgical events, involving dysregulation of sympathetic and central nervous systems, with contributions from genetic, inflammatory, and psychological factors. CRPS develops through complex interactions between the **peripheral** and **central** nervous systems, **immune** dysfunction, and **autonomic** dysregulation. These processes, often triggered by trauma or surgery within eight weeks, are influenced by genetic and psychological factors ([Ferraro](https://pubmed.ncbi.nlm.nih.gov/38631768/?ref=theplasticsfella.com), 2024). ### Peripheral Nervous System Nerve damage or compression leads to heightened pain sensitivity due to nociceptive sensitization ([Dellon](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649919/?ref=theplasticsfella.com), 2009) - **Pro-inflammatory mediators** (e.g., TNF-α, prostaglandin E2): Lower nerve depolarization thresholds, causing hyperalgesia - **Neuroma formation or compression**: Contributes to persistent pain. ### Central Nervous System Abnormal CNS excitability drives exaggerated pain responses. - **Dorsal horn neurons**: Increased sensitivity to mechanical and thermal stimuli. - **Neuropeptides** (e.g., glutamate, substance P): Lead to hyperpathia (heightened pain perception) and allodynia (pain from non-painful stimuli). ### Autonomic Dysregulation Disruption of the autonomic system intensifies pain by altering adrenergic-nociceptive interactions. - **Sympathetic dysfunction**: Pain worsens during or after sympathetic stimulation. - **Temperature changes**: Extremities may alternate between warmth (early stages) and coldness (chronic stages). ### Immunologic and Inflammatory Factors Inflammation plays a central role in CRPS onset and persistence ([Dey](https://www.ncbi.nlm.nih.gov/books/NBK430719/?ref=theplasticsfella.com), 2023) - **Elevated mediators**: Substance P, CGRP, TNF-α, IL-1β, IL-6, NGF increase peripheral sensitization. - **Autoantibodies**: Target adrenergic and muscarinic receptors, suggesting an autoimmune component . - **Inflammatory signs**: Redness, swelling, pain, and heat linked to cytokines in serum and cerebrospinal fluid. ### Genetic Factors Genetic predisposition heightens susceptibility to CRPS after injury. - **HLA variations**: Increase risk. - **TNF-α polymorphisms**: Linked to heightened inflammatory responses ([Ferraro](https://pubmed.ncbi.nlm.nih.gov/38631768/?ref=theplasticsfella.com), 2024). ### Psychological Factors Emotional stress during or after the injury exacerbates CRPS. - **Stress and distress**: Intensify symptoms and complicate management. - **Prognosis**: Psychological factors significantly influence recovery outcomes ([Dey](https://www.ncbi.nlm.nih.gov/books/NBK430719/?ref=theplasticsfella.com), 2023). 😎 ****Fun Fact:** Stress experienced during injury can amplify symptoms and influence long-term recovery. ([Dey](https://www.ncbi.nlm.nih.gov/books/NBK430719/?ref=theplasticsfella.com), 2023). --- ## Clinical Features of CRPS ****Key Point** CRPS is characterized by disproportionate pain accompanied by sensory, motor, and autonomic abnormalities, significantly impairing daily function and quality of life. CRPS encompasses diverse clinical manifestations that evolve over time, making diagnosis and management challenging. It disproportionately affects **females** and is more prevalent in the **upper extremities**, occurring in approximately 7% of patients after fractures, surgeries, or limb trauma ([Bruhel](https://pubmed.ncbi.nlm.nih.gov/26224572/?ref=theplasticsfella.com), 2015). ### A Triggering Event CRPS typically arises following trauma or surgical events ([Dey](https://www.ncbi.nlm.nih.gov/books/NBK430719/?ref=theplasticsfella.com), 2023) - **Fractures**: commonest cause - especially high-energy, intra-articular injuries. - **Surgical procedures**: Particularly nerve surgery or prolonged anesthesia. - **Sprains, contusions, and crush injuries**. - **Minor interventions**: Even IV line placements have been associated with CRPS onset ([de Mos](https://pubmed.ncbi.nlm.nih.gov/17084977/?ref=theplasticsfella.com), 2007). Surgical interventions, especially those involving prolonged anaesthesia or complex operations, are linked to increased nerve sensitivity, heightening CRPS risk ([Dey](https://www.ncbi.nlm.nih.gov/books/NBK430719/?ref=theplasticsfella.com), 2023; [Shin](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676230/?ref=theplasticsfella.com), 2007). 💡 ****Tip:** Risk factors for CRPS include asthma, menopause, rheumatoid arthritis, osteoporosis, smoking, and ACE inhibitor use ([de Mos](https://pubmed.ncbi.nlm.nih.gov/17084977/?ref=theplasticsfella.com), 2007) ### Progression The clinical features of CRPS evolve through distinct stages: - **Early**: Increased skin temperature, erythema, swelling, nail & hair growth. - **Later**: Decreased hair growth, brittle nails, muscle weakness, pallid, cool skin. - **Chronic**: Irreversible muscle atrophy, contractures, intractable pain ([Shim](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676230/?ref=theplasticsfella.com), 2019) 💡 ****Tip:** CRPS often transitions from warm CRPS (inflammatory changes like redness and warmth) to cold CRPS (autonomic dysfunction with reduced limb temperature) over time ([Bruhel](https://pubmed.ncbi.nlm.nih.gov/26224572/?ref=theplasticsfella.com), 2015). ![Clinical presentation of CRPS of the hand and wrist](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-16T020108.332.png) Clinical presentation of CRPS of the hand and wrist ### **Symptoms** CRPS presents with a range of symptoms that overlap and progress over time: **Pain**: - **Disproportionate pain** exceeding the expected severity of the initial injury. - **Spread**: Begins at trauma site & extends without a dermatomal pattern. - **Progressive**: Pain increases over time, regardless of the original injury. **Sensory Symptoms**: - **Allodynia**: Pain triggered by non-painful stimuli like light touch. - **Hyperalgesia**: Exaggerated pain response to typically painful stimuli. **Autonomic Symptoms**: - **Skin color changes**: Redness or pallor. - **Temperature fluctuations**: Due to vasomotor dysfunction. - **Sweating**: Excessive (hyperhidrosis) or reduced (hypohidrosis) sweating. - **Swelling**: Oedema, accompanied by skin color & temperature changes. **Motor Symptoms**: - **Weakness**: Reduced strength in the affected limb. - **Restricted range of motion**: Stiffness and impaired movement. - **Tremors and dystonia**: Involuntary contractions 😎 ****Fun Fact:** Vasomotor symptoms, including swelling, temperature fluctuations, and skin color changes, are among the most commonly reported features in CRPS ([Moss](https://pubmed.ncbi.nlm.nih.gov/17084977/?ref=theplasticsfella.com), 2007). ### Differential Diagnosis CRPS shares overlapping features with other conditions, necessitating careful exclusion of: - **Neurological disorders**: Guillain-Barré syndrome, multiple sclerosis, poliomyelitis, tabes dorsalis. - **Vascular conditions**: Arterial insufficiency, peripheral atherosclerotic disease, phlebothrombosis. - **Other rare causes**: Monometric amyotrophy, porphyria. --- ## Diagnosis of CRPS ****Key Point** CRPS is primarily diagnosed clinically using the Budapest Criteria, with imaging and other tools reserved for atypical or unclear cases. CRPS is a clinical diagnosis guided by the **Budapest Criteria**, a standardized framework ensuring accuracy in identifying the condition. The diagnosis requires persistent **disproportionate** **pain** to the inciting event, along with specific signs and symptoms across **sensory**, **vasomotor**, **sudomotor**, **motor & trophic** categories ([Urits](https://pubmed.ncbi.nlm.nih.gov/29404787/?ref=theplasticsfella.com), 2018). ### Budapest Criteria for CRPS Diagnosis The **Budapest Criteria** classify CRPS based on four distinct categories of symptoms and signs. Diagnosis requires continuing pain disproportionate to the inciting event and fulfillment of specific criteria across these categories. 1. **Continuing pain disproportionate to the injury or event.** 2. **At least 1 symptom in 3 of 4 categories:** 1. **Sensory**: Hyperalgesia or allodynia. 2. **Vasomotor**: Temperature asymmetry or skin color changes. 3. **Sudomotor/Edema**: Sweating asymmetry or edema. 4. **Motor/Trophic**: Decreased range of motion, motor dysfunction (e.g., tremor, dystonia), or trophic changes (skin, hair, nails). 3. **At least 1 sign in 2 or more categories** 1. **Sensory**: Hyperalgesia (pinprick) or allodynia (light touch). 2. **Vasomotor**: Temperature asymmetry or skin color changes. 3. **Sudomotor/Edema**: Sweating asymmetry or edema. 4. **Motor/Trophic**: Reduced range of motion, motor dysfunction, or trophic changes. 4. **No other diagnosis better explains the signs and symptoms** ### Diagnostic Adjuncts When clinical findings are inconclusive, these tools may support the diagnosis: - **Thermography**: Detects temperature asymmetry from vasomotor dysfunction. - **Bone Scintigraphy**: Identifies altered bone metabolism characteristic of CRPS. - **Electromyography (EMG)**: Evaluates muscle dysfunction and nerve involvement. - **Musculoskeletal Ultrasonography (MSK US)**: Assesses structural changes in muscles impacted by CRPS. 😎 ****Fun Fact:** Although pain is usually triggered mechanically, both ****thermal stimuli** and ****psychological stress** can exacerbate CRPS symptoms. --- ## Treatment of CRPS ****Key Point** CRPS management combines physical therapy, psychological interventions, medications, and interventional procedures, with surgical options reserved for select cases. Effective treatment for CRPS requires a **multidisciplinary** approach to manage symptoms, restore function, and prevent progression. Combining physical **rehabilitation**, **medication**, and **psychosocial** support is critical to improving patient outcomes. In more severe or refractory cases, interventional procedures and **surgery** may be considered ([Ferraro](https://pubmed.ncbi.nlm.nih.gov/38631768/?ref=theplasticsfella.com), 2024). Conservative Management - **Physical Therapy**: Maintains range of motion, prevents muscle atrophy, and reduces joint stiffness. - **Occupational Therapy**: Helps patients perform daily activities despite physical limitations. - **Psychological Therapy**: Cognitive-behavioral therapy (CBT) and other interventions address the emotional toll of chronic pain and improve coping strategies ### Medications Medications are used to manage symptoms and modulate neuropathic pain: - **Anti-Inflammatory Medications**: NSAIDs to reduce inflammation and provide pain relief. - **Bisphosphonates**: Target bone pain and prevent bone loss. - **Anticonvulsants and Antidepressants**: Drugs like gabapentin and amitriptyline help modulate pain pathways. - **NMDA Antagonists**: Ketamine reduces pain by targeting central sensitization mechanisms. - **Opioids**: Reserved for severe cases where other treatments fail, though long-term use is discouraged due to potential side effects. ### Interventional Procedures For refractory cases, interventional techniques can provide symptom relief: - **Sympathetic Blocks**: Injections targeting the sympathetic nervous system to alleviate pain. - **Spinal Cord Stimulation**: Devices deliver electrical impulses to the spinal cord, modulating pain signals. - **Dorsal Root Ganglion Stimulation**: Targets specific nerve roots for more localized pain control. ### Surgical Intervention Surgery is rarely indicated and is reserved for cases involving nerve injury or compression: - **Surgical Sympathectomy**: Cutting part of the sympathetic nervous system may relieve pain in select cases, though outcomes vary ([Happak](https://pubmed.ncbi.nlm.nih.gov/22695435/?ref=theplasticsfella.com), 2012) - **Nerve Surgery**: For neuromas or nerve entrapments contributing to CRPS ([Dellon](https://pubmed.ncbi.nlm.nih.gov/20123284/?ref=theplasticsfella.com), 2010) ### Prognosis CRPS outcomes vary widely, with most cases resolving within a year. However, some patients develop chronic symptoms, including intractable pain and disability, requiring intensive interventions. Early and aggressive treatment improves the likelihood of recovery ([Bruhel](https://pubmed.ncbi.nlm.nih.gov/26224572/?ref=theplasticsfella.com), 2015). Long-standing CRPS can by complicated by: - Dystonia - Cognitive dysfunction - Adrenal insufficiency - Gastroparesis - Irritable bowel syndrome 💡 ****Tip:** The UK Royal College of Physicians, with contributions from the BSSH, provides specific guidelines emphasizing early intervention and multidisciplinary care for CRPS --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition and Types:** CRPS is a chronic neuropathic disorder characterized by pain disproportionate to the tissue injury, lasting beyond expected healing. It's categorized into Type I and Type II. ****2\. Epidemiology:** CRPS primarily affects females and is more common in upper extremities. Key risk factors include asthma, menopause, and osteoporosis. ****3\. Pathophysiology:** CRPS involves a complex interaction between the central and peripheral nervous systems, characterized by inflammatory and immune responses, leading to symptoms like allodynia and hyperalgesia. ****4\. Clinical Presentation:** Symptoms include severe burning pain, sensory disturbances like allodynia, motor symptoms such as weakness, and autonomic dysfunctions such as changes in skin temperature and color. ****5\. Diagnosis:** Diagnosis is based on the Budapest Criteria, which require disproportionate pain and specific sensory, vasomotor, sudomotor, and motor symptoms. Diagnostic aids include thermography and bone scintigraphy. ****6\. Treatment:** Management is multidisciplinary; physical therapy, medications, and surgical interventions for refractory cases. Treatments aim to alleviate pain, improve function, and prevent progression. --- ## Further Reading 1. [Dey S](https://www.ncbi.nlm.nih.gov/books/NBK430719/?ref=theplasticsfella.com), Guthmiller KB, Varacallo M. Complex Regional Pain Syndrome. \[Updated 2023 Aug 7\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK430719/](https://www.ncbi.nlm.nih.gov/books/NBK430719/?ref=theplasticsfella.com) 2. [Brunner F](https://pubmed.ncbi.nlm.nih.gov/28573699/?ref=theplasticsfella.com), Bachmann LM, Perez RSGM, Marinus J, Wertli MM. Painful swelling after a noxious event and the development of complex regional pain syndrome 1: A one-year prospective study. Eur J Pain. 2017 Oct;21(9):1611-1617\. doi: 10.1002/ejp.1064\. Epub 2017 Jun 2\. PMID: 28573699\. 3. [Galer BS](https://pubmed.ncbi.nlm.nih.gov/9535313/?ref=theplasticsfella.com), Bruehl S, Harden RN. IASP diagnostic criteria for complex regional pain syndrome: a preliminary empirical validation study. International Association for the Study of Pain. Clin J Pain. 1998 Mar;14(1):48-54\. doi: 10.1097/00002508-199803000-00007\. PMID: 9535313. 4. [de Mos M](https://pubmed.ncbi.nlm.nih.gov/17084977/?ref=theplasticsfella.com), de Bruijn AG, Huygen FJ, Dieleman JP, Stricker BH, Sturkenboom MC. The incidence of complex regional pain syndrome: a population-based study. Pain. 2007 May;129(1-2):12-20\. doi: 10.1016/j.pain.2006.09.008\. Epub 2006 Nov 7\. PMID: 17084977. 5. [He Y,](https://www.ncbi.nlm.nih.gov/books/NBK537129/?ref=theplasticsfella.com#:~:text=Allodynia%20is%20defined%20as%20%22pain,produce%20sensation%29%2C%20causing%20pain.) Kim PY. Allodynia. \[Updated 2023 Sep 4\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK537129/](https://www.ncbi.nlm.nih.gov/books/NBK537129/?ref=theplasticsfella.com) 6. [Cheshire WP.](https://pubmed.ncbi.nlm.nih.gov/32906168/?ref=theplasticsfella.com#:~:text=Conditions%20that%20impair%20sudomotor%20function,and%20a%20host%20of%20medications.) Sudomotor Dysfunction. Semin Neurol. 2020 Oct;40(5):560-568\. doi: 10.1055/s-0040-1713847\. Epub 2020 Sep 9\. PMID: 32906168. 7. [Bruehl S.](https://pubmed.ncbi.nlm.nih.gov/26224572/?ref=theplasticsfella.com) Complex regional pain syndrome. BMJ. 2015 Jul 29;351:h2730\. doi: 10.1136/bmj.h2730\. PMID: 26224572\. 8. [Urits I](https://pubmed.ncbi.nlm.nih.gov/29404787/?ref=theplasticsfella.com), Shen AH, Jones MR, Viswanath O, Kaye AD. Complex Regional Pain Syndrome, Current Concepts and Treatment Options. Curr Pain Headache Rep. 2018 Feb 5;22(2):10\. doi: 10.1007/s11916-018-0667-7\. PMID: 29404787. 9. [Dellon AL](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649919/?ref=theplasticsfella.com), Andonian E, Rosson GD. CRPS of the upper or lower extremity: surgical treatment outcomes. J Brachial Plex Peripher Nerve Inj. 2009 Feb 20;4:1\. doi: 10.1186/1749-7221-4-1\. PMID: 19232118; PMCID: PMC2649919. 10. [Ferraro MC](https://pubmed.ncbi.nlm.nih.gov/38631768/?ref=theplasticsfella.com), O'Connell NE, Sommer C, Goebel A, Bultitude JH, Cashin AG, Moseley GL, McAuley JH. Complex regional pain syndrome: advances in epidemiology, pathophysiology, diagnosis, and treatment. Lancet Neurol. 2024 May;23(5):522-533\. doi: 10.1016/S1474-4422(24)00076-0\. PMID: 38631768. 11. [Happak W](https://pubmed.ncbi.nlm.nih.gov/22695435/?ref=theplasticsfella.com), Sator-Katzenschlager S, Kriechbaumer LK. Surgical treatment of complex regional pain syndrome type II with regional subcutaneous venous sympathectomy. J Trauma Acute Care Surg. 2012 Jun;72(6):1647-53\. doi: 10.1097/TA.0b013e318248bfc1\. PMID: 22695435. 12. [Dellon L](https://pubmed.ncbi.nlm.nih.gov/20123284/?ref=theplasticsfella.com), Andonian E, Rosson GD. Lower extremity complex regional pain syndrome: long-term outcome after surgical treatment of peripheral pain generators. J Foot Ankle Surg. 2010 Jan-Feb;49(1):33-6\. doi: 10.1053/j.jfas.2009.08.003\. PMID: 20123284. 13. [Dellon AL](https://pubmed.ncbi.nlm.nih.gov/26611391/?ref=theplasticsfella.com). Surgical Treatment of Upper Extremity Pain. Hand Clin. 2016 Feb;32(1):71-80\. doi: 10.1016/j.hcl.2015.08.008\. PMID: 26611391. 14. UK guideline for CRPS management [https://www.rcp.ac.uk/policy-and-campaigns/policy-documents/](https://www.rcp.ac.uk/policy-and-campaigns/policy-documents/?ref=theplasticsfella.com) Accessed 9th October 2024. ### Infantile Haemangioma: Classification, Diagnosis, & Management URL: https://www.theplasticsfella.com/infantile-haemangioma/ Last updated: 2024-11-18T09:32:40.000Z #### Summary Card [****Definition** ](https://www.theplasticsfella.com/infantile-haemangioma/#definition-of-infantile-haemangioma)Infantile haemangiomas are benign vascular tumours with a distinct growth and regression pattern, classified as superficial or deep based on presentation. [****Aetiology**](https://www.theplasticsfella.com/infantile-haemangioma/#aetiology-of-infantile-haemangioma) Infantile haemangiomas are caused by the dysregulation of both vasculogenesis and angiogenesis. [****Clinical Features**](https://www.theplasticsfella.com/infantile-haemangioma/#clinical-features-of-infantile-haemangioma) Infantile haemangiomas present shortly after birth as flat, erythematous patches and evolve through nascent, proliferation, plateau, and involution phases. [****Investigations**](https://www.theplasticsfella.com/infantile-haemangioma/#investigations-for-infantile-haemangioma) Infantile haemangiomas are primarily diagnosed clinically, with histology, immunohistochemistry, and imaging used to support or confirm the diagnosis in atypical cases. [****Management**](https://www.theplasticsfella.com/infantile-haemangioma/#management-of-infantile-haemangioma) Most infantile haemangiomas do not require treatment, but complicated cases can be managed with medications (e.g., propranolol), laser therapy, surgical excision, embolization, or liposuction. [****Complications**](https://www.theplasticsfella.com/infantile-haemangioma/#complications-of-infantile-haemangiomas) Complications of infantile haemangiomas can include ulcerations, airway obstruction, cosmetic disfigurement, skeletal distortion, and specific syndromes such as PHACES and LUMBAR. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow****.** ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Definition of Infantile Haemangioma ****Key Point** Infantile haemangiomas are benign vascular tumours with a distinct growth and regression pattern, classified as superficial or deep based on presentation. Infantile haemangiomas are the most common vascular tumours in infancy, characterized by rapid growth in the first year of life followed by spontaneous regression over several years. They are most often found on the face, scalp, chest, or back. They have **distinct features** that set them apart from other [vascular anomalies](https://www.theplasticsfella.com/vascular-malformations-and-tumours/). - **Benign** tumours arising from endothelial cell proliferation. - **Proliferative** growth phase in the first year of life. - Followed by slow **involution** over several years. The image below illustrates an infantile haemangioma. ![Infantile haemangioma on the nose of a one-year-old child.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-09T001959.238.png) Infantile haemangioma on the nose of a one-year-old child. 😎 ****Fun Fact:** Infantile haemangiomas are the most common benign tumour in infancy, affecting approximately 5% of newborns ([Haggstrom](https://www.ncbi.nlm.nih.gov/books/NBK538232/?ref=theplasticsfella.com), 2007 & [Léauté-Labrèze C](https://pubmed.ncbi.nlm.nih.gov/28089471/?ref=theplasticsfella.com), 2017). --- ## Aetiology of Infantile Haemangioma ****Key Point** Infantile haemangiomas arise from the dysregulation of vasculogenesis and angiogenesis, with hypoxia playing a key role in their pathogenesis. The exact cause of infantile haemangiomas remains unclear, but theories suggest a multifactorial origin involving hypoxia, progenitor cells, and placental anomalies. Dysregulated vasculogenesis and angiogenesis are central to their development ([Léauté-Labrèze C](https://pubmed.ncbi.nlm.nih.gov/28089471/?ref=theplasticsfella.com) 2017, [Chamli](https://www.ncbi.nlm.nih.gov/books/NBK538232/?ref=theplasticsfella.com) 2023). ### Pathophysiology - **Hypoxia:** Hypoxic stress upregulates the expression of **GLUT-1** and **VEGF**, leading to the mobilization of endothelial progenitor cells, which express markers **CD133** and **CD31**. - **Placental Trophoblast Theory:** Stem cells from placental trophoblasts are hypothesized to contribute to haemangioma formation. - **Dysregulated Vessel Formation:** Both vasculogenesis and angiogenesis are implicated in haemangioma development. The differences between various types of [vascular anomalies](https://www.theplasticsfella.com/vascular-malformations-and-tumours/) are illustrated below. ![Comparison of vascular tumours and vascular malformations](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-09T004047.351.png) Comparison of vascular tumours and vascular malformations. ### Risk Factors Certain demographics, maternal factors, and birth conditions increase susceptibility ([Hasbani](https://pubmed.ncbi.nlm.nih.gov/36243426/?ref=theplasticsfella.com) 2022, [Chamli](https://www.ncbi.nlm.nih.gov/books/NBK538232/?ref=theplasticsfella.com) 2023, [Léauté-Labrèze C](https://pubmed.ncbi.nlm.nih.gov/28089471/?ref=theplasticsfella.com) 2017). - **Demographics:** Female sex (3:1 ratio) and Caucasian ethnicity. - **Birth Factors:** Prematurity, low birth weight, and prenatal hypoxia. - **Maternal Factors:** Older maternal age, intrauterine complications (e.g., eclampsia), and chorionic villus sampling. - **Genetic Predisposition:** Family history of haemangiomas. - **Multiple Gestations:** Higher incidence in twins or multiples. ### --- ## Clinical Features of Infantile Haemangioma ****Key Point** Infantile haemangiomas present shortly after birth as flat, erythematous patches and evolve through nascent, proliferation, plateau, and involution phases. Differential diagnosis includes congenital haemangioma, pyogenic granuloma, and Kaposiform hemangioendothelioma. Infantile haemangiomas typically appear shortly after birth as well-demarcated, flat erythematous patches. Their unique growth phases and appearance help distinguish them from other [vascular anomalies](https://www.theplasticsfella.com/vascular-malformations-and-tumours/). ### Appearance The appearance of an infantile haemangioma varies based on its depth, leading to its subclassification into superficial and deep types. - **Superficial:** Elevated *red* papules, nodules, or plaques located in the upper dermis. This is illustrated below. - **Deep:** *Bluish* tumours with indistinct borders, typically noticeable 2–3 months after birth due to their extension into adipose tissue. Infantile haemangiomas are typically **located** on the limbs, face, and trunk. Head and neck lesions align with the trigeminal nerve, while a beard-like distribution is associated with subglottic haemangiomas in 60% of cases. ([Ritcher](https://pubmed.ncbi.nlm.nih.gov/22611412/?ref=theplasticsfella.com), 2012). ![Haemangioma on forearm](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-09T002236.191.png) Haemangioma on forearm ### Evolution The progression of infantile haemangiomas includes four distinct stages, each defined by unique changes in size and appearance. - **Nascent Phase:** Flat, erythematous patches that may resemble other birthmarks. - **Proliferation Phase:** Rapid growth and vertical expansion during the first year. This may cause ischemia, necrosis, ulceration, and bleeding ([Ritcher](https://pubmed.ncbi.nlm.nih.gov/22611412/?ref=theplasticsfella.com), 2012). - **Plateau Phase:** Stabilization of growth. - **Involution Phase:** Gradual regression over several years. The evolution of an infantile haemangioma is illustrated in the table below. ![Stages of evolution of infantile haemangioma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-09T010912.432.png) Stages of evolution of infantile haemangioma 😎 ****Fun Fact:** The timing of involution is a predictor of outcome, rather than the site, number, early growth rate, or ulceration ([Janis](https://shop.thieme.com/Essentials-of-Plastic-Surgery/9781626238473?srsltid=AfmBOoqpU47IbW1BY54Zk99kIcWvOuoKblTV-alGi%5FrGsrGhvJCpXjyV&ref=theplasticsfella.com), 2023). ### Associated Syndromes Infantile haemangiomas are linked to two key syndromes characterized by developmental anomalies. - **PHACES Syndrome:** Large segmental facial haemangiomas and - **Brain and Arteries:** Posterior fossa malformations, arterial anomalies. - **Heart and Eyes:** Cardiac anomalies, eye anomalies. - **Skin:** Sternal or umbilical raphe. - **LUMBAR Syndrome:** Lumbosacral haemangiomas and - **Spine and Organs:** Myelopathy, renal anomalies. - **Bones and Vessels:** Bony deformities, anorectal or arterial anomalies. - **Urogenital System:** Urogenital anomalies. ### Differential Diagnosis Accurate diagnosis of infantile haemangiomas requires differentiation from similar [vascular anomalies](https://www.theplasticsfella.com/vascular-malformations-and-tumours/). - **Congenital Haemangioma** (GLUT1-negative) - **RICH:** Fully formed at birth, regresses quickly, may cause cardiac failure. - **PICH:** Partial regression with unpredictable resolution. - **NICH:** Persistent lesions requiring cosmetic treatment. - **Pyogenic Granuloma** - Vascular papules following trauma, commonly on the face and neck. - Prone to bleeding; histology shows capillary proliferation. - **Kaposiform Hemangioendothelioma** - Aggressive tumours causing thrombocytopenia and coagulopathy. - Treated with vincristine. --- ## Investigations for Infantile Haemangioma ****Key Point** Infantile haemangiomas are primarily diagnosed clinically, with histology, immunohistochemistry, and imaging used to support or confirm the diagnosis in atypical cases. The diagnosis of infantile haemangioma is largely **clinical**, based on characteristic features observed during examination. In certain cases, additional investigations—such as **histology**, **immunohistochemistry**, or **imaging**—are employed to confirm the diagnosis or evaluate complex lesions. ### Histology Histological examination highlights characteristic features of infantile haemangiomas. - Multinodular pattern fed by a single arteriole. - Nodules composed of hyperplastic endothelial cells, pericytes, and prominent basement membranes. - **Proliferative Phase:** Increased vascular lumens with hyperplastic endothelial cells. - **Involution Phase:** Dilated vascular lumens, flattened endothelial cells, and increased fibrosis contributing to lobular architecture. ### Immunohistochemistry (IHC) IHC is used to confirm the diagnosis by identifying markers unique to infantile haemangiomas. - **GLUT1:** Differentiates IH (GLUT1-positive) from congenital haemangiomas (GLUT1-negative). - **Other markers:** CD31, von Willebrand factor, urokinase, LYVE-1, merosin, and antigen Lewis Y ([Chamli](https://www.ncbi.nlm.nih.gov/books/NBK538232/?ref=theplasticsfella.com), 2023 & [Léauté-Labrèze C](https://pubmed.ncbi.nlm.nih.gov/28089471/?ref=theplasticsfella.com), 2017) ### Imaging Imaging is reserved for atypical presentations or deep haemangiomas to assess lesion extent. - **Ultrasonography:** Useful for superficial haemangiomas, showing a high-flow vascular pattern. - **CT and MRI:** Evaluate deep or complex haemangiomas and their anatomical relationships. A CT image of infantile hemangioma can be seen below. ![CT of a haemangioma, Coronal C+ arterial phase of a haemangioma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-09T001342.362-1.png) CT of a haemangioma ### Special Investigations In specific cases, targeted investigations are required. - **Echocardiography:** For large or multifocal IHs, PHACE syndrome, or lumbosacral IHs. - **Coagulation Screening:** Rule out disseminated intravascular coagulation (DIC) in multifocal intrahepatic IHs by checking platelets, fibrinogen, and D-dimers. - **TSH Screening:** Assess for secondary hypothyroidism in large or multifocal IHs (>5 sites) ([Torres](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932334/?ref=theplasticsfella.com) 2015). 😎 ****Fun Fact:** GLUT1 is a definitive marker that differentiates infantile haemangiomas (GLUT1-positive) from congenital haemangiomas (GLUT1-negative). --- ## Management of Infantile Haemangioma ****Key Point** Most infantile haemangiomas regress without intervention, but complicated cases may require propranolol, laser therapy, surgery, or other targeted treatments. The majority of infantile haemangiomas resolve without intervention. However, **10–15%** develop complications like ulceration, bleeding, airway obstruction, or permanent disfigurement, requiring targeted treatment ([Léauté-Labrèze C](https://pubmed.ncbi.nlm.nih.gov/18550886/?ref=theplasticsfella.com), 2017) For these cases, a **multidisciplinary** approach ensures the best outcome. ### Medical Management Beta-blockers are the cornerstone of treatment for complicated haemangiomas. - **Propranolol:** First-line therapy for complicated IHs (2 mg/kg/day for \~6 months). Side effects include bradycardia, hypotension, bronchospasm, and hypoglycemia, necessitating close monitoring ([Léauté-Labrèze C](https://pubmed.ncbi.nlm.nih.gov/18550886/?ref=theplasticsfella.com), 2017). - **Timolol:** A topical beta-blocker for small, superficial, and uncomplicated haemangiomas. 😎 ****Fun Fact:** Propranolol, a nonselective β-blocker, was discovered serendipitously to regress haemangiomas in newborns treated for cardiac issues, possibly through regulating vascular growth factors and cytokines. ([Ritcher](https://pubmed.ncbi.nlm.nih.gov/22611412/?ref=theplasticsfella.com), 2012). **Flash Pulse Dye Laser Therapy** - Addresses both active and residual IH-related lesions. - Treats residual erythema and telangiectasias post-involution. - Promotes healing in ulcerative lesions during the proliferative phase ([Ritcher](https://pubmed.ncbi.nlm.nih.gov/22611412/?ref=theplasticsfella.com), 2012) ### Surgical Intervention Surgical excision is considered for severe complications or residual deformities in infantile haemangiomas. More specifically, - **Localized Lesions or Fibrofatty Remnants:** Post-involution changes requiring removal such as fibrofatty tissue, telangiectasia, or skin laxity. - **Persistent Visual Obstruction:** Risks amblyopia or other vision issues. - **Nasolaryngeal Obstruction:** Causes airway compromise and requires aggressive treatment. - **Auditory Canal Obstruction:** Leads to conductive hearing loss. - **Painful Ulceration:** Non-healing lesions causing significant discomfort. - **Contraindications to Propranolol:** asthma, congenital heart block. **Other Interventions** - **Embolization:** Reserved for life-threatening haemangiomas unresponsive to medical management, particularly visceral IHs. - **Liposuction:** Used to address subcutaneous tissue overgrowth associated with IH ([Couto](https://pubmed.ncbi.nlm.nih.gov/26397270/?ref=theplasticsfella.com), 2015). --- ## Complications of Infantile Haemangiomas ****Key Point** Infantile haemangiomas can lead to complications such as ulceration, airway obstruction, skeletal distortion, and specific syndromes like PHACES and LUMBAR. The severity of complications from infantile haemangiomas depends on factors like the patient’s age and the size, location, and growth rate of the haemangioma. Certain cases require intervention due to functional or cosmetic concerns ([Chamli](https://www.ncbi.nlm.nih.gov/books/NBK538232/?ref=theplasticsfella.com), 2023 & [Léauté-Labrèze C](https://pubmed.ncbi.nlm.nih.gov/28089471/?ref=theplasticsfella.com), 2017). - **Ulceration:** High-risk areas are anogenital region, lower lip, axilla, and neck. - **Ophthalmologic Issues:** Amblyopia, astigmatism, myopia, retrobulbar involvement, tear duct obstruction. - **Airway Obstruction:** Nasal, subglottic, and laryngeal regions. - **Feeding Difficulties:** Perioral or lip haemangiomas. - **Cosmetic Disfigurement:** Large facial haemangiomas affecting nasal tip, ears, or perioral regions. - **Visceral Haemangiomatosis:** Liver or GI involvement, >5 skin lesions. - **High-Output Heart Failure:** Large visceral or hepatic haemangiomas. - **Skeletal Distortion:** Bone deformation from haemangioma pressure. - **Hypothyroidism:** Due to iodothyronine deiodinase expression in diffuse or multifocal haemangiomas. - **Emotional/Psychological Distress:** Visible deformities. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview of Infantile Hemangiomas:** Outlined the prevalence and nature of infantile hemangiomas as common vascular tumors in children. ****2\. Causes and Risk Factors:** Discussed the etiology involving dysregulation of vasculogenesis and angiogenesis, with risk factors. ****3\. Classification and Types:** Described the classification into superficial and deep types, detailing their appearance and development stages. ****4\. Clinical Presentation:** Covered the typical presentation of hemangiomas and the significance of growth patterns and complications. ****5\. Diagnostic Approaches:** Reviewed the diagnostic process, incorporating clinical evaluation, histology, immunohistochemistry, and various imaging techniques. ****6\. Treatment Modalities:** Explained management strategies for complicated cases, including pharmacological treatments like propranolol, laser therapy, surgical options, and emerging techniques like embolization and liposuction. ****7\. Complications and Associated Disorders:** Addressed potential complications and differentiated infantile hemangiomas from similar conditions. --- ## Further Reading 1. Richter GT, Friedman AB. [haemangiomas and vascular malformations: current theory and management](https://pubmed.ncbi.nlm.nih.gov/22611412/?ref=theplasticsfella.com). Int J Pediatr. 2012;2012:645678\. doi: 10.1155/2012/645678\. Epub 2012 May 7\. PMID: 22611412; PMCID: PMC3352592. 2. Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. [Propranolol for severe haemangiomas of infancy](https://pubmed.ncbi.nlm.nih.gov/18550886/?ref=theplasticsfella.com). N Engl J Med. 2008 Jun 12;358(24):2649-51\. doi: 10.1056/NEJMc0708819\. PMID: 18550886. 3. haemangioma Investigator Group. Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, Horii KA, Lucky AW, Mancini AJ, Metry DW, Newell B, Nopper AJ, Frieden IJ. [Prospective study of infantile haemangiomas: demographic, prenatal, and perinatal characteristics](https://www.ncbi.nlm.nih.gov/books/NBK538232/?ref=theplasticsfella.com). J Pediatr. 2007 Mar;150(3):291-4. 4. Léauté-Labrèze C, Harper JI, Hoeger PH. [Infantile haemangioma](https://pubmed.ncbi.nlm.nih.gov/28089471/?ref=theplasticsfella.com). Lancet. 2017 Jul 01;390(10089):85-94 5. Chamli A, Aggarwal P, Jamil RT, et al. [haemangioma](https://www.ncbi.nlm.nih.gov/books/NBK538232/?ref=theplasticsfella.com). \[Updated 2023 Jun 12\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK538232/](https://www.ncbi.nlm.nih.gov/books/NBK538232/?ref=theplasticsfella.com) 6. ThePlasticsFella. [Classification of Vascular Anomalies, Malformations & Tumours](https://www.theplasticsfella.com/vascular-malformations-and-tumours/). May 2022\. Accessed on 31 August 2024 7. Hasbani DJ, Hamie L. [Infantile haemangiomas](https://pubmed.ncbi.nlm.nih.gov/36243426/?ref=theplasticsfella.com). Dermatol Clin. 2022 Oct;40(4):383-392\. doi: 10.1016/j.det.2022.06.004\. Epub 2022 Sep 16\. PMID: 36243426. 8. Couto JA, Maclellan RA, Greene AK. [Management of Vascular Anomalies and Related Conditions Using Suction-Assisted Tissue Removal](https://pubmed.ncbi.nlm.nih.gov/26397270/?ref=theplasticsfella.com). Plast Reconstr Surg. 2015 Oct;136(4):511e-514e. doi: 10.1097/PRS.0000000000001558\. PMID: 26397270. 9. Janis, J.E. ed., 2023\. [Essentials of aesthetic surgery](https://shop.thieme.com/Essentials-of-Plastic-Surgery/9781626238473?srsltid=AfmBOoqpU47IbW1BY54Zk99kIcWvOuoKblTV-alGi%5FrGsrGhvJCpXjyV&ref=theplasticsfella.com). Georg Thieme Verlag. 10. Torres E, Rosa J, Leaute-Labreze C, Soares-de-Almeida L. [Multifocal infantile haemangioma: a diagnostic challenge](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932334/?ref=theplasticsfella.com). BMJ Case Rep. 2016 Jun 17;2016:bcr2016214827\. doi: 10.1136/bcr-2016-214827\. PMID: 27317759; PMCID: PMC4932334. ### Pressure Sores: Causes, Clinical Assessment, & Management URL: https://www.theplasticsfella.com/pressure-sores/ Last updated: 2024-11-21T08:07:44.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/pressure-sores/#overview-of-pressure-sores) Pressure sores are localized injuries to the skin and underlying tissues, primarily over bony areas, caused by prolonged pressure. [****Pathophysiology**](https://www.theplasticsfella.com/pressure-sores/#pathophysiology-of-pressure-sores) Pressure sores form through a combination of ischemia and impaired skin integrity, driven by factors like prolonged pressure, shear forces, friction, and moisture. [****Risk Factors**](https://www.theplasticsfella.com/pressure-sores/#risk-factors-of-pressure-sores) The risk of pressure sores is elevated by factors such as infection, age, sensory loss, chronic disease, malnutrition, and incontinence. [****Grading**](https://www.theplasticsfella.com/pressure-sores/#grading-of-pressure-sores) The NPUAP classifies pressure ulcers into 4 stages, with additional categories for unstageable and suspected deep tissue injuries. [****Clinical Assessment**](https://www.theplasticsfella.com/pressure-sores/#clinical-assessment-of-pressure-sores) Evaluating pressure sores involves taking a comprehensive history, grading the ulcer, and using lab tests and imaging to identify complications such as osteomyelitis. [****Prevention**](https://www.theplasticsfella.com/pressure-sores/#prevention-of-pressure-sores) Preventing pressure sores involves regular repositioning, use of pressure-relieving devices, proper transfer techniques, skincare, nutritional support, and patient education. [****Management**](https://www.theplasticsfella.com/pressure-sores/#management-of-pressure-sores) Stages 1-2 typically require conservative treatment, while stages 3-4 may need debridement, antibiotics, NPWT, and surgical reconstruction. [****Reconstruction by Anatomic Site**](https://www.theplasticsfella.com/pressure-sores/#reconstruction-by-anatomic-site) Flap selection is guided by the ulcer’s location and the requirement for durable, long-lasting coverage. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Overview of Pressure Sores ****Key Point** Pressure sores are localized injuries to skin and underlying tissue caused by prolonged pressure, often over bony prominences. **Pressure sores**, also known as pressure **ulcers** or bedsores, occur when prolonged pressure disrupts blood flow, leading to **ischemia** and **tissue damage**. Commonly seen over areas like the **sacrum**, **hips**, and **heels**. Pressure sores disproportionately affect high-risk populations, with rates varying by care setting. For example: - **Elderly Patients:** 66% with femoral neck fractures develop sores ([Jaul](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2013). - **Quadriplegic Patients:** 60% experience pressure ulcers ([Bennett](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2000). - **Care Setting:** long-term care up to 24% (Bennett, 2000), home care up to 17% (Kottner, 2019). A common site for pressure ulcers is depicted in the image below. ![A common site for pressure ulcers - Heel pressure sore](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-04T235504.582.png) A common site for pressure ulcers - Heel pressure sore 💡 ****Tip:** Pressure sores do not directly increase mortality but worsen morbidity. Malnourished and immobile patients are especially vulnerable, facing delayed recovery and functional decline ([Jaul](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2013). --- ## Pathophysiology of Pressure Sores ****Key Point** Pressure sores form through a combination of ischemia and impaired skin integrity, driven by factors like prolonged pressure, shear forces, friction, and moisture. Pressure sores result from external **mechanical forces** and **physiological responses**, where prolonged pressure causes ischemia, and shear, friction, and moisture weaken defenses, leading to oxygen deprivation, oxidative stress, and tissue breakdown. ### External Mechanical Forces More specifically, the **mechanical forces** involved, - **Prolonged Pressure:** Sustained pressure exceeding capillary closing pressure (60–70 mm Hg) compresses blood vessels, leading to ischemia and tissue necrosis within as little as two hours ([Gefen](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2007) - **Shear Forces:** Displacement of skin layers relative to underlying tissues distorts blood vessels and causes deep tissue injury. - **Friction:** Continuous rubbing erodes the skin’s protective layers, increasing vulnerability to breakdown and ulceration. - **Moisture:** Excess moisture from perspiration or incontinence softens the skin, promoting maceration and weakening the barrier against injury. ### Physiological Responses The cellular effects of these contributing factors result in progressive tissue breakdown - including, - **Ischemic Necrosis:** Prolonged pressure restricts oxygen and nutrient delivery to tissues, leading to cell death and necrosis. - **Reperfusion Injury:** sudden return of blood flow to ischemic tissue generates oxidative stress and reactive oxygen species (ROS), which exacerbate cellular damage. - **Tissue Deformation:** Shear forces mechanically distort cells, damaging membranes and causing structural trauma that worsens deep tissue injury ([Stekelenburg](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2007). 😎 ****Fun Fact:** Pressure exceeding capillary closing pressure (approximately 60–70 mm Hg) for two hours can cause irreversible tissue damage (Ray, [2020](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg)). --- ## Risk Factors of Pressure Sores ****Key Point** Pressure sore risk increases with factors such as infection, age, sensory loss, chronic disease, malnutrition, incontinence, and reduced mobility. Pressure sores develop when patient-specific factors, such as impaired mobility and comorbidities, combine with external mechanical forces. Understanding these risk factors allows for targeted prevention and management strategies ([Jaul](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2018). - **Infection:** Sepsis reduces perfusion, increasing necrosis risk. - **Age:** Reduced elasticity and moisture in elderly skin - **Sensory Loss:** Paralysis or nerve damage impairs pressure detection. - **Chronic Disease:** Diabetes, vascular disease, & anaemia. - **Malnutrition:** Weakens skin and delays repair. - **Incontinence:** Moisture from urine or faeces softens skin. - **Altered Consciousness:** Impaired mobility prevents pressure relief. ### Risk Assessment The **Braden Scale** standardized global measure that evaluates six key categories to assess a patient’s risk for pressure sores ([Chen](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2017). Scores range from 6 (highest risk) to 23 (lowest risk). **Categories Assessed** - Sensory Perception - Skin Moisture - Activity - Mobility - Friction and Shear - Nutritional Status Each category is scored individually, with a total score indicating overall risk. Lower scores indicate higher susceptibility to pressure sores. 😎 ****Fun Fact:** Common organisms found in infected pressure sores include **Staphylococcus aureus*, **Proteus mirabilis*, **Escherichia coli*, **Pseudomonas aeruginosa*, and **Enterococcus* spp. --- ## Grading of Pressure Sores ****Key Point** The NPUAP classifies pressure ulcers into four stages, with additional categories for unstageable ulcers and suspected deep tissue injuries. Pressure sores are categorized based on the **depth** and **severity** of tissue damage, helping guide management and prognosis. The **National Pressure Ulcer Advisory Panel** (NPUAP) provides a standardized grading system, which includes **four primary stages** and two additional classifications for complex cases ([Downie](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2016). - **Stage 1:** Non-blanchable erythema on intact skin, localized redness. - **Stage 2:** Partial-thickness skin loss involving epidermis & dermis, often a shallow ulcer or blister. - **Stage 3:** Full-thickness tissue loss extending into the subcutaneous layer, sometimes with tunneling or undermining. - **Stage 4:** Full-thickness tissue loss with exposed bone, tendon, or muscle, increasing infection risk and potential osteomyelitis. The table below summarises these stages and their features. ![The NPUAP classification of pressure ulcers](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-18T144201.471.png) The NPUAP classification of pressure ulcers **Additional Classifications** - **Unstageable Ulcers:** Full-thickness tissue loss where the wound depth is obscured by slough or eschar. Typically staged as III or IV after debridement. - **Suspected Deep Tissue Injury:** Purple discoloration or blood-filled blister on intact skin. Final staging is determined after the wound evolves. 💡 ****Tip:** Stable eschar on the heels should not be debrided, as it acts as a natural biological cover, protecting against infection ([Rivolo](https://www.researchgate.net/publication/306146754%5FThe%5Fevidence%5Ffor%5Ftreating%5Fpressure%5Finjury%5Flocated%5Fon%5Fthe%5Fpatient's%5Fheel?ref=theplasticsfella.com), 2016). --- ## Clinical Assessment of Pressure Sores ****Key Point** Pressure sore evaluation requires a detailed history, wound staging, and targeted diagnostics to assess severity and complications like infection or osteomyelitis. A thorough clinical assessment of pressure sores identifies **risk factors**, evaluates **wound severity**, and **detects complications**. This includes gathering a detailed patient history, conducting a focused examination, and utilising laboratory and imaging studies to guide management. ### History Focus on factors that predispose to pressure sores or hinder healing. - **Mobility:** Prolonged immobility or frequent transfers. - **Incontinence:** Chronic moisture exposure weakening skin barriers. - **Comorbidities:** Conditions like diabetes, vascular disease, and poor nutrition. ### Physical Examination - **Ulcer Grading:** Use the NPUAP classification to stage the pressure sore. - **Wound Details:** Identify undermining, tunneling, induration, and signs of infection such as purulence, erythema, or odor. - **Overall Health:** Look for systemic signs of delayed healing and evaluate fitness for surgical intervention. 😎 ****Fun Fact:** Pressure sores often develop over the sacrum (40%), heel (30%), ischial tuberosity, and trochanter (15–20%), with less common sites including the scalp, elbow, shoulder, and scapula ([Gefen](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2013). ### Investigations - **Bloods:** Complete blood count, albumin, and inflammatory markers. - **Wound cultures** to identify pathogens and antibiotic sensitivity. - **MRI or CT:** Essential for identifying osteomyelitis, abscesses, or deep tissue involvement. The image below illustrates the clinical assessment of a left buttock ulcer extending to the ischial tuberosity. ![Spina bifida at the lumbosacral spine with a left buttock ulcer extending to the ischial tuberosity, pressure sores clinical assessment](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-18T144436.132.png) Spina bifida at the lumbosacral spine with a left buttock ulcer extending to the ischial tuberosity --- ## Prevention of Pressure Sores ****Key Point** Preventing pressure sores requires regular repositioning, pressure-relieving devices, proper skincare, nutritional support, and patient education. Prevention is critical for reducing the incidence and complications of pressure sores, particularly in high-risk individuals. Strategies focus on minimizing pressure, protecting the skin, and optimizing patient care through education and support ([Kottner](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?pli=1&ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2019). **Minimizing Pressure** - **Regular repositioning:** Every 10 minutes if seated; every 2 hours if supine. - **Bed Elevation:** Below 45 degrees to reduce shear on the sacrum. **Protective Measures** - **Devices:** Pressure-relieving devices, such as specialized mattresses and heel protectors, to evenly distribute pressure. - **Skin:** Maintain skin cleanliness and apply moisture barrier creams to prevent breakdown. **Supportive Care** - **Nutrition:** Adequate caloric and protein intake for skin integrity. - **Spasticity:** Address involuntary movements to prevent trauma. **Education** - **Patients:** Proper repositioning, device usage, and regular skin inspections. - **Caregivers:** Proper transfer techniques to minimize shear and friction. --- ## Management of Pressure Sores ****Key Point** Pressure sore management involves offloading, infection control, and wound care. Stages 1–2 is often conservative, while stages 3–4 may require debridement, antibiotics, NPWT, or surgical reconstruction. Effective management of pressure sores depends on their severity. Initial treatment focuses on pressure offloading and wound care, with advanced therapies reserved for deeper or infected ulcers. Optimizing patient factors like nutrition and addressing comorbidities is critical for successful outcomes ([Qaseem](https://docs.google.com/document/d/1QOao6yKr9WduMr0RqFRSpBTuyWGfWF8Ws4pr-ShHY0s/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2015). ### Stages 1 and 2 Management of early-stage pressure sores emphasizes conservative care to restore skin integrity and prevent progression. - **Pressure Offloading:** Relieve pressure from the affected area to reduce ischemia. - **Daily Wound Care:** Clean and dress wounds to maintain a suitable healing environment. - **Patient Optimization:** Address nutritional deficits and conditions like anemia. - **Incontinence Control:** Manage moisture exposure, potentially with a defunctioning stoma. ### Stages 3 and 4 Advanced-stage pressure sores require more aggressive interventions to remove necrotic tissue, control infection, and facilitate wound closure. - **Debridement:** Remove necrotic tissue using surgical, enzymatic, or autolytic methods. - **Infection Control:** Use systemic antibiotics for signs of cellulitis or osteomyelitis. - **NPWT:** Apply negative pressure wound therapy to stimulate granulation tissue formation. - **Surgical Reconstruction:** Perform flap reconstruction for non-healing ulcers. An example of a stage 4 ulcer requiring debridement is shown in the image below. ![Stage 4 pressure sore](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-04T235659.402-1.png) Stage 4 pressure sore 💡 ****Tip:** Avoid potent antiseptics like betadine during dressing changes, as they can irritate the wound. --- ## Reconstruction by Anatomic Site ****Key Point** Flap selection for pressure sore reconstruction is determined by the ulcer's location and the need for durable coverage that withstands mechanical forces and promotes healing. Reconstructive options vary based on the anatomical site of pressure sores. Each region presents unique challenges due to its vascularity, exposure to pressure, and functional requirements. Flap selection aims to achieve durable coverage while minimizing the risk of recurrence. Pressure sore reconstructive options are detailed in the table below. ![Common flap options for frequently treated pressure sore sites](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-05T001107.989.png) Common flap options for frequently treated pressure sore sites **Sacral Region** The sacrum is a common site for large pressure ulcers, often requiring robust flaps for coverage. Typical options include, - Gluteal fasciocutaneous or myocutaneous rotation flaps for broad defects. - Unilateral or bilateral gluteal V-Y advancement flaps for midline closures. - Lumbar artery perforator flaps, particularly for extended defects needing reach and mobility. **Ischial Tuberosity** This region is highly prone to recurrence due to sitting pressure. Flaps commonly used include, - Tensor fascia lata flaps for large defect coverage. - Posterior thigh V-Y advancement flaps for stable and durable outcomes. - Gluteal fasciocutaneous flaps for extensive or recurrent sores. **Trochanteric Region** Trochanteric ulcers often require flaps that can tolerate friction and enhance mobility. Recommended flaps: - Tensor fascia lata flap for moderate-sized ulcers. - Vastus lateralis flap for extended defects needing robust coverage. **Heel** The heel is exposed to high mechanical stress, requiring flaps resistant to shear forces. Effective options: - Medial plantar artery flap for precise plantar coverage. - Reverse sural artery flap for large or posterior heel defects. ### Postoperative Management Comprehensive postoperative care is critical to successful healing. This involves, - **Bed Rest:** Use specialized beds for pressure relief with frequent repositioning. - **Infection Control:** Administer antibiotics based on wound culture results. - **Spasticity and Bowel Care:** Manage spasticity and incontinence to protect surgical outcomes. - **Nutritional Support:** Ensure high-protein, high-calorie diets to promote healing. - **Rehabilitation:** Implement range-of-motion exercises, seat mapping, and sitting protocols to prevent recurrence 💡 ****Tip:** Single-stage reconstruction is ideal, but in staged reconstruction, prioritize closure of larger defects to ensure effective wound coverage and healing. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition of Pressure Sores:** Pressure sores, or bedsores, are localized skin and tissue injuries from prolonged pressure, especially over bony prominences like the sacrum, hips, and heels, leading to ischemia and tissue damage. ****2\. Risk Factors of Pressure Sores:** Major risk factors include immobility, age, sensory loss, malnutrition, incontinence, and chronic diseases like diabetes. The Braden Scale helps assess individual risk levels. ****3\. Pathophysiology and Mechanism:** Pressure sores develop from sustained pressure, shear forces, friction, and moisture, which disrupt blood flow and lead to tissue ischemia, reperfusion injury, and cellular damage. ****4\. Grading of Pressure Sores:** The NPUAP categorizes pressure sores into stages from 1 to 4, based on tissue involvement, with additional categories for unstageable and suspected deep tissue injuries. ****5\. Prevention of Pressure Sores:** Key prevention strategies include regular repositioning, pressure-relieving devices, proper skincare, nutritional support, and educating patients and caregivers on preventive measures. ****6\. Management of Pressure Sores:** Treatment depends on the sore's stage, with conservative care like offloading and dressings for early stages, and debridement, antibiotics, and possible surgical reconstruction for advanced stages. --- ## Further Reading 1. Jaul E. (2013). [Who determines the treatment for pressure ulcers in the elderly?](https://pubmed.ncbi.nlm.nih.gov/24340845/?ref=theplasticsfella.com) *The Israel Medical Association journal: IMAJ*, *15*(9), 512–515. 2. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. [Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. ](https://pubmed.ncbi.nlm.nih.gov/25732279/?ref=theplasticsfella.com)Ann Intern Med. 2015 Mar 3;162(5):370-9\. doi: 10.7326/M14-1568\. PMID: 25732279. 3. Braden, Barbara, and Nancy Bergstrom. "[A conceptual schema for the study of the etiology of pressure sores.](https://journals.lww.com/rehabnursingjournal/abstract/2000/05000/a%5Fconceptual%5Fschema%5Ffor%5Fthe%5Fstudy%5Fof%5Fthe%5Fetiology.7.aspx?ref=theplasticsfella.com)" *Rehabilitation Nursing Journal* 25.3 (2000): 105-110. 4. Kottner, Jan, et al. "[Prevention and treatment of pressure ulcers/injuries: The protocol for the second update of the international Clinical Practice Guideline 2019.](https://www.sciencedirect.com/science/article/pii/S0965206X18301190?ref=theplasticsfella.com)" *Journal of tissue viability* 28.2 (2019): 51-58. 5. Gefen A. (2007). [The biomechanics of sitting-acquired pressure ulcers in patients with spinal cord injury or lesions](https://pubmed.ncbi.nlm.nih.gov/17924879/?ref=theplasticsfella.com). *International wound journal*, *4*(3), 222–231\. https://doi.org/10.1111/j.1742-481X.2007.00330.x 6. Ray, Carle. [*Case Analysis of Acute Care Guidelines for the Prevention of Pressure Ulcers*.](https://www.proquest.com/openview/f83e917583873b18776939034857b4ec/1?pq-origsite=gscholar&cbl=44156&ref=theplasticsfella.com) Diss. Walden University, 2020. 7. Stekelenburg, Anke, et al. "[Role of ischemia and deformation in the onset of compression-induced deep tissue injury: MRI-based studies in a rat model](https://journals.physiology.org/doi/full/10.1152/japplphysiol.01115.2006?ref=theplasticsfella.com)." *Journal of Applied Physiology* 102.5 (2007): 2002-2011. 8. Gefen, A., Farid, K. J., & Shaywitz, I. (2013).[ A review of deep tissue injury development, detection, and prevention: shear savvy. ](https://pubmed.ncbi.nlm.nih.gov/23388395/?ref=theplasticsfella.com)*Ostomy/wound management*, *59*(2), 26–35. 9. Jaul, Efraim, et al. "[An overview of co-morbidities and the development of pressure ulcers among older adults.](https://link.springer.com/article/10.1186/s12877-018-0997-7?ref=theplasticsfella.com)" *BMC geriatrics* 18 (2018): 1-11. 10. Chen HL, Cao YJ, Zhang W, Wang J, Huai BS. B[raden scale (ALB) for assessing pressure ulcer risk in hospital patients: A validity and reliability study](https://pubmed.ncbi.nlm.nih.gov/28096013/?ref=theplasticsfella.com). Appl Nurs Res. 2017 Feb;33:169-174\. doi: 10.1016/j.apnr.2016.12.001\. Epub 2016 Dec 5\. PMID: 28096013. 11. Downie, Fiona, and Heidi Guy. "[LATEST DEVELOPMENTS IN THE GRADING OF PRESSURE ULCERS](https://openurl.ebsco.com/EPDB%3Agcd%3A2%3A25678882/detailv2?sid=ebsco%3Aplink%3Ascholar&id=ebsco%3Agcd%3A84480101&crl=c&ref=theplasticsfella.com)." *Wounds UK* 8.3 (2012). ### Baseline neutrophil lymphocyte ratio predicts survival in soft-tissue sarcoma: 17-year cohort study URL: https://www.theplasticsfella.com/journal-sarcoma/ Last updated: 2024-11-17T11:19:34.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/JPRAS-Infographic-2.png) #### In this Journal Club [****5-Point Summary**](https://www.theplasticsfella.com/journal-sarcoma/#5-point-summary) 401 patients, NLR ≥3 predicts poorer survival, not recurrence, aids risk stratification & treatment planning. [****4-Key Findings**](https://www.theplasticsfella.com/journal-sarcoma/#4-key-findings) Elevated NLR reduces survival, links to tumor size and stage, has no link with recurrence, and histological subtype impacts survival. [****3-Critiques**](https://www.theplasticsfella.com/journal-sarcoma/#3-critiques) Lack of adjustment for co-morbidities, cohort heterogeneity from recurrent tumuors, unclear link between NLR and recurrence [****2-Practical Takeaways** ](https://www.theplasticsfella.com/journal-sarcoma/#2-practical-takeaways) Use NLR for identifying high-risk patients and guide closer monitoring for elevated NLR. [****1-Recommended Reading**](https://www.theplasticsfella.com/journal-sarcoma/#1-recommended-reading) Szkandera J. et al. (Br J Cancer, 2013) found elevated preoperative NLR predicts poor prognosis in STS, reinforcing its prognostic role. ✍️ ****Note from the Editor** Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum --- ## 5 Point Summary Baseline NLR predicts overall survival in extremity STS, with higher NLR linked to worse survival. Useful for identifying high-risk patients. 1️⃣ ****Hypothesis** Baseline neutrophil-lymphocyte ratio predicts overall survival in extremity soft-tissue sarcoma (STS). 2️⃣ ****Method** 17-year retrospective study of 401 adults. Preoperative NLR tests analysed with multivariable Cox regression. 3️⃣ ****Results** NLR ≥3 linked to poorer overall survival but not disease-free survival or recurrence. 4️⃣ ****Conclusion** NLR predicts survival in STS, aiding risk stratification & treatment planning 5️⃣ ****Implication** High NLR identifies patients needing aggressive therapy and monitoring. ## 4 Key Findings Elevated NLR reduces survival, links to tumor size and stage, has no link with recurrence, and histological subtype impacts survival. 1️⃣ ****NLR Predicts Survival** Elevated NLR (≥3) independently predicts reduced survival (HR 1.44; 95% CI 1.01–2.03), even after adjusting for age, tumor size, and grade. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Journal-Club--1.png) 2️⃣ ****Association with Tumor Burden and Stage** Higher NLR correlates with larger tumors and advanced stages, reflecting systemic inflammation and tumor aggressiveness. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Journal-Club--3.png) 3️⃣ ****No Link to Recurrence** NLR did not significantly predict recurrence or disease-free survival after adjustment, limiting its utility to mortality prediction. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Journal-Club--4.png) 4️⃣ ****Histological Subtypes Matter** Patients with lipomatous sarcomas had better survival regardless of NLR, emphasising the role of tumour biology. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Journal-Club--10.png) --- ## 3 Critiques Lack of adjustment for comorbidities, cohort heterogeneity from recurrent tumors, unclear link between NLR and recurrence 1️⃣ ****Confounding Variables Not Fully Addressed** Key factors like diabetes and performance status were not adjusted for, potentially influencing both NLR and survival. Future studies should address these to confirm NLR's independent role. 2️⃣ ****Heterogeneity from Recurrent Tumors** Including primary and recurrent STS cases may have diluted outcome associations. Separate analyses could yield clearer insights. 3️⃣ ****Unclear Link to Recurrence** While NLR predicts overall survival, its lack of association with recurrence raises questions about its relevance to STS progression, warranting further study. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Journal-Club--11.png) --- ## 2 Practical Takeaways Use NLR for identifying high-risk patients and guide closer monitoring for elevated NLR. 1️⃣ ****Follow-Up Strategies** High NLR can guide closer post-treatment monitoring to detect disease progression early. 2️⃣ ****Personalized Treatment** Elevated NLR identifies high-risk STS patients who may benefit from tailored neoadjuvant or adjuvant therapies to improve survival. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Journal-Club--12.png) ## 1 Recommended Reading Szkandera J. et al. (Br J Cancer, 2013) found elevated preoperative NLR predicts poor prognosis in STS, reinforcing its prognostic role. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/23558897/?ref=theplasticsfella.com) ### Med Students No Longer Learn Plastic Surgery, 200+ Job Applications, & Everything Nerves! URL: https://www.theplasticsfella.com/november-17th/ Last updated: 2024-11-15T20:18:36.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/november-17th/#a-letter-from-pfella) Plastic Surgery: The forgotten specialty in med school. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-17th/#the-sunday-quiz) How well do you know **median nerve tendon transfers*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/november-17th/#image-of-the-week) Anatomy of a peripheral nerve injury. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-17th/#technique-tip) Comparing nerve repair techniques for simple nerve lacerations. 5. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/november-17th/#behind-the-fella) We want to hear your thoughts! 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/november-17th/#what-does-the-evidence-say) The best microsurgical nerve technique for the median nerve. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-17th/#articles-of-the-week) 'Hand of Benediction' in high median nerve injuries, surgeon experience in CTS diagnosis, & amyloid detection in carpal tunnel surgery: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/november-17th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Med Students No Longer Learn Plastic Surgery* 👋 ****Hey there!** I recently ran a [Twitter poll](https://x.com/PlasticsFella/status/1854191073767104581?ref=theplasticsfella.com) about plastic surgery exposure during medical school, and the results were eye-opening: ****30% had no exposure at all**, and only ****19% experienced it as part of their formal syllabus**. Most had to ****self-organize any exposure** — highlighting a major gap in medical education. This isn’t just anecdotal. Studies ([Hatan](https://pubmed.ncbi.nlm.nih.gov/30942694/?ref=theplasticsfella.com), et al) confirm that **medical students lack proper awareness** of plastic surgery. Most see it as just cosmetic procedures, but it’s much broader — **reconstructive surgeries, hand trauma, burns**, and more. Without proper teaching, misconceptions grow, and interest in the specialty falls. You might be asking, **Why does this matter?** - Without proper understanding of plastic surgery, patients are misdirected, limiting outcomes and shrinking the specialty. - Lack of exposure also deters diverse voices, as fewer opportunities discourage students from varied backgrounds, reducing future specialist diversity. **To help solve this, we’re building a textbook.** A more streamlined integration into curriculums. We’re building a pretty strong team to get this over the line. The interviews are done (over 200 people applied to work with The Plastics Fella in the last 9 months!) and we're excited to move forward. I’d love your input 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/2.png) Drop your thoughts above or on social media. With love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Median Nerve Tendon Transfers**? ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![The anatomy of the median nerve](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image-6.png) The anatomy of the median nerve ## Image of the Week **Anatomy of the Peripheral Nerve* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This edition looks at the anatomy of a peripheral nerve injury. Read more on nerve injuries [here](https://www.theplasticsfella.com/nerve-injury/). ![Anatomy of a Peripheral Nerve Injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image-5.png) Anatomy of a Peripheral Nerve Injury ## Technique Tip **Comparison of Nerve Repair Techniques* 🚑 ****Technique Tip of the Week** This edition looks at a comparison of simple nerve laceration repair techniques. Fascicular and epineural suture techniques for simple nerve lacerations show comparable outcomes in preserving axonal continuity, while interfascicular sutures lead to poorer axonal recovery, highlighting their limited utility in direct nerve repair. You can read more details on the techniques [here](https://thejns.org/view/journals/j-neurosurg/47/5/article-p744.xml?ref=theplasticsfella.com). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Technqiues--1.png) [Source](https://thejns.org/view/journals/j-neurosurg/47/5/article-p744.xml?ref=theplasticsfella.com) ## Behind the ‘Fella **What Are Your Thoughts So Far? Let Us Know* 🎧 Join us for exclusive insights from our team meetings and engaging discussions on plastic surgery with our fellows and special guests. Get a unique, behind-the-scenes look at our practice! You can now tune in on [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) or [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). We appreciate your thoughts and feedback on our podcast releases so far. Your input directly shapes the output as we grow with you — our community. So, share your ideas below 👇 ## What Does the Evidence Say? **What Is the Best Microsurgical Nerve Technique for the Median Nerve?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****The Best Microsurgical Nerve Technique for the Median Nerve** Conventional methods like epineural end-to-end suturing and nerve grafting remain standard approaches (Mafi et al., 2012). Fibrin glue has shown promise, with studies indicating comparable outcomes to microsutures in terms of nerve regeneration and functional recovery (Anani & El-Sadek, 2013). However, ****combining sutures with fibrin glue** may provide the strongest repair (Mitchell et al., 2022). ****Collagen conduits** have demonstrated equivalent sensory and motor recovery to direct suture for small nerve gaps (Boeckstyns et al., 2013). ****End-to-side neurorrhaphy** has shown potential but with inferior functional outcomes compared to conventional techniques (Kettle et al., 2013). ****Nerve transfers** are increasingly used, particularly for brachial plexus injuries (Mackinnon, 2018). Factors affecting prognosis include patient age, repair timing, injury level, and scar formation (Mafi et al., 2012). Despite advancements, many patients still experience permanent sequelae following median nerve injuries (Pederson, 2014). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Is the 'Hand of Benediction' a Misleading Sign in High Median Nerve Injuries?** ([Duraku](https://journals.lww.com/prsgo/fulltext/2022/10000/high%5Fmedian%5Fnerve%5Fparalysis%5F%5Fis%5Fthe%5Fhand%5Fof.59.aspx?ref=theplasticsfella.com), 2022) The "Hand of Benediction" is not diagnostic of high median nerve injury; true presentation involves MCP flexion of the index finger, requiring more accurate clinical assessment. ✅ ****Carpal Tunnel Syndrome: Surgeon Experience and Trends in Testing and Treatment** ([Hooper](https://www.jhandsurg.org/article/S0363-5023%2824%2900310-1/abstract?ref=theplasticsfella.com), 2024) Surgeon experience influences CTS diagnosis. Experienced surgeons favor EDS over CTS-6 criteria, highlighting the call for standardized assessment protocols. ✅ ****Amyloid Detection in Carpal Tunnel Surgery: Tenosynovium and Transverse Carpal Ligament Biopsies** ([Ozdag](https://www.jhandsurg.org/article/S0363-5023%2824%2900210-7/abstract?ref=theplasticsfella.com), 2024) Tenosynovial and transverse carpal ligament biopsies show 93% concordance, backing single-source sampling in carpal tunnel diagnosis. ## Feedback ### I hope you enjoyed it 😄 --- ### Penile Reconstruction: Anatomy, Causes, & Management URL: https://www.theplasticsfella.com/penile-reconstruction/ Last updated: 2025-02-13T20:19:17.000Z #### Summary Card [****Penile Anatomy**](https://www.theplasticsfella.com/penile-reconstruction/#penile-anatomy) The penis contains unique erectile tissues — corpora cavernosa and corpus spongiosum (enveloping the urethra) — with specialized structures essential for reconstructive procedures. [****Causes of Penile Tissue Loss/Dysfunction**](https://www.theplasticsfella.com/penile-reconstruction/#causes-of-penile-tissue-lossdysfunction) Penile tissue loss may result from benign or malignant conditions, infections, circumcision complications, burns, trauma, and fibrosis (such as Peyronie’s disease). [****Penile Reconstruction** ](https://www.theplasticsfella.com/penile-reconstruction/#penile-reconstruction)The primary aim of penile reconstruction is to construct a phallus with a neo-urethra that enables standing urination and sufficient bulk to support a prosthesis for penetrative intercourse. [****Penis Replant**](https://www.theplasticsfella.com/penile-reconstruction/#penis-replant) Penis reimplantation is indicated for sharp, non-avulsive injuries with controlled contamination and ischemia time. [****Penile Prosthesis Implantation**](https://www.theplasticsfella.com/penile-reconstruction/#penile-prosthesis-implantation) In patients with impotence and penile fibrosis, a penile prosthesis may be the only viable solution for restoring erectile function.. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Penile Anatomy ****Key Point** The penis contains unique erectile tissues — corpora cavernosa and corpus spongiosum (enveloping the urethra) — with specialized structures that must be reconstructed. The penis is structured cylindrically, with two corpora cavernosa situated adjacent to each other and the corpus spongiosum located inferiorly, each enabling erectile function ([Kropp](https://pmc.ncbi.nlm.nih.gov/articles/PMC6408249/?ref=theplasticsfella.com), 2019). ![Cross-section anatomy of the penis, penile reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-05T001523.591.png) Cross-section anatomy of the penis **Anatomical Structures** - **Urethra:** resides within the corpus spongiosum. - **Dartos Fascia:** Encloses the penis beneath the skin. - **Buck’s Fascia:** Encloses the corpora cavernosa and corpus spongiosum. **Blood Supply** - **Common Penile Artery**: arises from the internal pudendal artery (branch of internal iliac artery and branches into: - **Deep Cavernosal Arteries**: In the corpora cavernosa & branches into helicine arteries to support erectile tissue. - **Bulbourethral Artery** - **Dorsal Artery** (supplies the glans) - **Venous Outflow:** Venous drainage occurs through emissary veins within the tunica albuginea. **Innervation** - **Sensory and Motor:** Supplied by the pudendal nerve. - **Erectile Function:** Innervated by cavernous nerves, enabling erectile response. 😎 ****Fun Fact:** The penis has separate blood supplies for the glans and shaft. The shaft skin is nourished by a dermal plexus, while the dorsal artery supplies the glans ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). --- ## Causes of Penile Tissue Loss/Dysfunction ****Key Point** Penile tissue loss can result from various benign and malignant conditions, infections, circumcision complications, burns, trauma, and fibrosis, including Peyronie’s disease. Penile tissue loss or dysfunction arises from a variety of causes, affecting the **glans**, **shaft**, and **scrotum** in unique ways. Each area has specific vulnerabilities and typical conditions that may lead to tissue damage, impacting function and requiring targeted management. ### Glans Common causes of tissue loss in the glans include chronic inflammatory conditions, early-stage cancer, and surgical intervention. - **Lichen Sclerosus:** Chronic inflammation leading to scarring and tissue loss. - **Carcinoma In Situ (CIS):** Early-stage cancer that may require excision. - **Surgical Procedures:** Partial or complete removal of the glans may be necessary in severe cases ([Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013). Surgical procedures involving partial or complete excision of the glans are illustrated in the table below ([Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013). ![Surgical procedures involving partial or complete excision of the penile glans](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-05T001945.921.png) Surgical procedures involving partial or complete excision of the penile glans ### Penile Shaft Tissue loss or dysfunction in the shaft can result from trauma, infections, surgical complications, and fibrosis. - **Trauma and Burns:** Injury from accidents, burns, or animal bites can lead to significant tissue damage. - **Necrotizing Fasciitis:** A rapidly progressing infection causing extensive tissue destruction. - **Surgical Excision and Excessive Circumcision:** Tissue loss from removal of lesions or over-removal during circumcision. - **Complications from Hypospadias/Epispadias Surgery:** Scarring and dysfunction following corrective procedures. - **Peyronie’s Disease:** Fibrosis resulting in scar tissue formation, which affects structure and function. ### Scrotum Scrotal tissue loss commonly arises from severe infections, trauma, or surgical procedures. - **Necrotizing Fasciitis:** extensive tissue damage specific to the scrotal area. - **Trauma and Surgical Excision:** Tissue loss due to direct injury or the removal of bulky tumors affecting the scrotal or penile region. ### Glans Common causes of glans tissue loss include, - **Lichen Sclerosus** - **Carcinoma In Situ** (CIS) of the glans penis 😎 ****Fun Fact:** Necrotizing fasciitis (NF) is traditionally classified by anatomical region. Fournier’s gangrene, a form of NF, affects the scrotum, penis, or perineum ([The Plastics Fella](https://www.theplasticsfella.com/necrotising-fasciitis/), 2024). --- ## Penile Reconstruction ****Key Point** The primary aim of penile reconstruction is to construct a phallus with a neo-urethra that enables standing urination and sufficient bulk to support a prosthesis for penetrative intercourse. ### Overview of Penile Reconstruction The ultimate goal is a phallus that meets cosmetic and functional standards, with an integrated neo-urethra for voiding and sufficient structure to house prosthetic cylinders for adequate rigidity ([Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013). - **Functional Length and Skin Adequacy:** Ensure sufficient penile length and skin coverage to allow unrestricted erections. - **Protective Sensation:** Achieve protective sensation to prevent chronic skin breakdown. - **Standing Voiding Capability:** Enable spontaneous voiding while standing, with urine flow from the phallic tip. - **Erectile Function** 💡 ****Tip:** Tailor reconstruction to patient expectations, habitus, and history. Thick adipose may limit thigh/forearm flaps; abdominal scars may exclude infraumbilical flaps ([Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013). ### Glans Reconstruction For patients undergoing glansectomy, reconstructive techniques—such as skin **grafts**, and urethral & tissue **flaps** —can help restore both form and function. ([Smith](https://pubmed.ncbi.nlm.nih.gov/17349734/?ref=theplasticsfella.com), 2007 & [Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013). - **Split-Thickness Skin Graft (STSG):** Applied to the denuded corpora to restore coverage post-glansectomy. Risks include graft loss and overgrowth at the external urethral meatus, which may require urethral dilation. - **Urethral Flap:** The urethra is reshaped and inverted to form a “pseudo-glans,” restoring glans structure. A minor ventral curvature may occur due to bowstringing if the urethra is shortened during the process. - **Alternative Flaps:** Additional options include flaps from urethral mucosa, rectus abdominis muscle, or palmaris longus tendon, chosen based on the extent of tissue needed. ([Smith](https://pubmed.ncbi.nlm.nih.gov/17349734/?ref=theplasticsfella.com), 2007 & [Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013). 💡 ****Tip:** Most patients retain sexual and urinary function, with the majority able to resume penetrative intercourse approximately three months post-surgery. ### Shaft Reconstruction Shaft reconstruction prioritizes **preserving any existing penile stump** to maintain function and appearance. When full phalloplasty is required, flaps like the radial forearm free flap (RFFF) and anterolateral thigh (ALT) flap are used to restore form and function. **Types of Shaft Reconstruction** Shaft reconstruction techniques are tailored to the extent of tissue loss, ranging from skin grafts to structural modifications that enhance length and appearance. - **Skin-Only Reconstruction: STSG** commonly used but may contract over time. **FTSG** from non-hair-bearing areas are preferred, as they provide better cosmetic outcomes. - **Corpus Reconstruction:** For partial amputations with sufficient length, **conservative** management may include **suspensory ligament division** and **suprapubic fat pad excision**, both of which optimize visible length and enhance the appearance of the penile stump ([Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013). ### Scrotal Reconstruction Reconstruction techniques for the scrotum vary based on defect size, location, and desired functional outcomes ([Khan](https://link.springer.com/article/10.1007/s00238-013-0833-4?ref=theplasticsfella.com#citeas), 2013). Options range from **direct closure** for small defects to **grafts**, **flaps**, and **tissue expansion.** - **Direct Closure:** For scrotal defects under 50%, direct closure is often achievable with acceptable cosmetic outcomes. ([Selvan](https://pubmed.ncbi.nlm.nih.gov/20368872/?ref=theplasticsfella.com), 2009) - **Split-Skin Graft:** Used to create a smooth graft bed and shallow intertesticular groove, though contraction at the penoscrotal junction can affect erectile function. - **Tissue Expansion:** A two-stage process with **Stage 1** placing expanders under the dartos fascia, **Stage 2** testicular mobilization, orchidopexy, and defect closure are achieved with a V–Y advancement. - **Advancement Flaps:** Based on scrotal vascular supply; three zones of perfusion (two lateral, one central) with lateral supply from the inferior external pudendal artery and central supply from perineal artery branches. - **Fasciocutaneous Flaps:** Options include posterior neurovascular pedicled pudendal thigh flaps, modified medial thigh flaps, and medial circumflex femoral artery perforator flaps. - **Myofasciocutaneous Flaps:** Incorporate muscles like adductor magnus, longus, semitendinosus, and semimembranosus in flap design. - **Omental Pedicle Flaps:** Suitable for large defects when other options are insufficient. 😎 ****Fun Fact:** ****Testicular Relocation** was previously performed to the medial thigh, but is now rare due to risks of pain, atrophy, and functional compromise. ### Full Penile Reconstruction (Phalloplasty) Full penile reconstruction aims to restore both urinary and sexual function. Key principles for an ideal reconstruction include establishing urethral continuity and sensory restoration. Various flaps are available for penile reconstruction, each with specific benefits based on tissue requirements and patient needs. Ideal reconstruction principles are listed below ([Chung](https://shop.lww.com/Grabb-and-Smith-s-Plastic-Surgery--Print---eBook-with-Multimedia/p/9781975214265?ref=theplasticsfella.com), 2024). - **Tube-within-a-Tube Construct:** This technique is used to create a continuous urethral passage, enabling urination. - **Sensory Neurotization:** Restores sensation to improve sexual function and tactile feedback. Urethral complications are frequent, including, - **Strictures and Fistulas:** Narrowing or abnormal connections in the urethra can impair function. - **Rigidity Challenges:** Difficulties in achieving adequate rigidity for intercourse are common in phalloplasty procedures. Flaps can be considered for penile reconstruction, see table below. ![Flaps for penile reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-05T011318.304.png) Flaps for penile reconstruction 😎 ****Fun Fact:** Full-thickness grafts from non-hair-bearing areas are ideal for patients with good erectile function who prioritize cosmetic appearance and intend to resume penetrative sex ([Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013). --- ## Penis Replant ****Key Point** Penis replant is recommended for sharp, non-avulsive injuries with controlled contamination and limited ischemia time. Penis replantation involves a complex surgical procedure aimed at restoring function and appearance following traumatic amputation. Success depends on careful selection based on injury type, contamination level, and ischemia duration. Key decision-making requirements include, - **Indications:** suitable for sharp, non-avulsive injuries. - **Contraindications:** Gross Contamination (high risk of infection), extended Warm Ischemia Time >8 hours. - **Psychiatric Conditions:** relative contraindications due to risk of recurrence ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). ### Surgical Approach to Penis Replant A structured, stepwise approach ensures effective replantation by restoring critical structures and functionality ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). 1. **Debridement and Dissection:** Remove nonviable tissue and identify dorsal arteries, veins, and nerves for reattachment. 2. **Urethral and Corporal Repair:** Spatulate and repair the urethra over a Foley catheter, followed by direct repair of tunica albuginea and corpora cavernosa to preserve function. 3. **Vascular Anastomoses:** End-to-end anastomosis of dorsal arteries and veins restores blood flow. 4. **Closure and Dressing:** Close Buck’s fascia and skin loosely to prevent tension, and apply protective dressings. 5. **Postoperative Care:** Foley Catheter retain for 2–3 weeks postoperatively to minimize the risk of urethral stricture. **Order of Repair** The recommended sequence for replantation is urethra → deep arteries → tunica albuginea → corpus cavernosum → dorsal veins → dorsal arteries → dorsal nerves → fascia → skin ([Biswas](https://pmc.ncbi.nlm.nih.gov/articles/PMC3842340/?ref=theplasticsfella.com), 2013). 😎 ****Fun Fact:** Postoperative edema is common and can increase skin tension; creating multiple skin incisions can help reduce edema. ([Chou](https://pubmed.ncbi.nlm.nih.gov/18286649/?ref=theplasticsfella.com), 2008) --- ## Penile Prosthesis Implantation ****Key Point** For patients with both erectile dysfunction and extensive penile fibrosis, a penile prosthesis is often the only effective solution for restoring erectile function. Penile prosthesis implantation is indicated for patients with significant fibrosis where conventional therapies are ineffective. This approach addresses fibrosis causes, requires corporeal reconstruction when tunical defects are present, and entails managing specific implant-related complications. **Indications** Penile prosthesis implantation is recommended for patients with erectile dysfunction stemming from fibrosis where other therapies are ineffective. This can be caused by: - **Acute Conditions:** Priapism, Trauma - **Chronic Conditions:** Peyronie’s disease, Chronic intracavernous injections - **Iatrogenic:** Implant removal, infection, erosion or malfunction **Corporeal Reconstruction** For cases with significant **tunical defects during implantation**, grafting is often necessary to reconstruct the tunica and support the prosthesis. **Autologous Graft Options** include, - Fascia Options: Rectus ([Tran](https://pubmed.ncbi.nlm.nih.gov/19009028/?ref=theplasticsfella.com), 2008), Fascia Lata, Temporalis Fascia. - Dermis - Saphenous Vein - Tunica Albuginea **Implant-Related Complications** Common complications include, - **Infection** of the device - **Erosion** of the prosthesis - **Mechanical Failure** of the device ([Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013) 💡 ****Tip:** Preserve native penile tissue whenever possible, reserving total phallic reconstruction as a last option ([Garaffa](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com), 2013) --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Penile Anatomy:** The penis consists of two corpora cavernosa and a corpus spongiosum, which houses the urethra. It has distinct fascial layers, blood supply, and innervation for erectile function and reconstruction. ****2\. Causes of Penile Tissue Loss/Dysfunction:** Tissue loss or dysfunction in the penis may result from trauma, infections, cancer, circumcision complications, or fibrosis. ****3\. Approach and Goals of Penile Reconstruction:** Penile reconstruction aims to create a functional phallus with sufficient bulk, a neo-urethra for standing urination, and the potential for a prosthesis. ****4\. Glans Reconstruction:** Following glansectomy, reconstruction techniques include split-thickness skin grafts and urethral flaps. While most patients retain function, graft loss and minor curvature may occur. ****5\. Shaft Reconstruction:** Shaft reconstruction involves skin grafts for minor defects and complete phalloplasty using free flaps for full reconstruction, aiming to preserve existing penile tissue whenever possible. ****6\. Penis Reimplantation:** Suitable for clean, sharp injuries with limited ischemia time. Reimplantation involves vascular anastomoses, urethral repair, and staged postoperative care to minimize complications. ****7\. Penile Prosthesis Implantation:** For patients with fibrosis and impotence, prostheses restore function, though complications include infection, erosion, and mechanical failure. ****8\. Scrotal Reconstruction:** Depending on defect size, reconstruction may involve direct closure, skin grafts, flaps, or tissue expansion to optimize aesthetics and function. ****9\. Peyronie’s Disease:** This fibrotic disorder of the tunica albuginea causes penile curvature and pain, managed with plication, grafting, or prostheses in severe cases. --- ## Further Reading 1. Garaffa G, Sansalone S, Ralph DJ. [Penile reconstruction](https://pubmed.ncbi.nlm.nih.gov/22426595/?ref=theplasticsfella.com). Asian J Androl. 2013 Jan;15(1):16-9\. doi: 10.1038/aja.2012.9\. Epub 2012 Mar 19\. PMID: 22426595; PMCID: PMC3739136. 2. Brown D. [Michigan Manual of Plastic Surgery](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian) 3rd edition 2023 Oct page 545-548 3. Cavayero CT, Leslie SW, McIntosh GV. [Penile Prosthesis Implantation](https://www.ncbi.nlm.nih.gov/books/NBK563292/?ref=theplasticsfella.com). \[Updated 2024 Apr 20\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. 4. Smith Y, Hadway P, Biedrzycki O, Perry MJ, Corbishley C, Watkin NA. [Reconstructive surgery for invasive squamous carcinoma of the glans penis](https://pubmed.ncbi.nlm.nih.gov/17349734/?ref=theplasticsfella.com). Eur Urol. 2007 Oct;52(4):1179-85\. doi: 10.1016/j.eururo.2007.02.038\. Epub 2007 Feb 20\. PMID: 17349734. 5. Kropp B, Cohn JE, Wang W, Sokoya M, Ducic Y. [Free Tissue Transfer Penile Reconstruction](https://pmc.ncbi.nlm.nih.gov/articles/PMC6408249/?ref=theplasticsfella.com). Semin Plast Surg. 2019 Feb;33(1):24-29\. doi: 10.1055/s-0039-1677879\. Epub 2019 Mar 8\. PMID: 30863209; PMCID: PMC6408249. 6. Yao A, Ingargiola MJ, Lopez CD, Sanati-Mehrizy P, Burish NM, Jablonka EM, Taub PJ. [Total penile reconstruction: A systematic review](https://pubmed.ncbi.nlm.nih.gov/29622476/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2018 Jun;71(6):788-806\. doi: 10.1016/j.bjps.2018.02.002\. Epub 2018 Feb 14\. PMID: 29622476. 7. Tran VQ, Lesser TF, Kim DH, Aboseif SR. [Penile corporeal reconstruction during difficult placement of a penile prosthesis](https://pubmed.ncbi.nlm.nih.gov/19009028/?ref=theplasticsfella.com). Adv Urol. 2008;2008:370947\. doi: 10.1155/2008/370947\. Epub 2008 Nov 4\. PMID: 19009028; PMCID: PMC2581727. 8. Biswas G. [Technical considerations and outcomes in penile replantation](https://pmc.ncbi.nlm.nih.gov/articles/PMC3842340/?ref=theplasticsfella.com). Semin Plast Surg. 2013 Nov;27(4):205-10\. doi: 10.1055/s-0033-1360588\. PMID: 24872770; PMCID: PMC3842340. 9. Chou EK, Tai YT, Wu CI, Lin MS, Chen HH, Chang SC. [Penile replantation, complication management, and technique refinement](https://pubmed.ncbi.nlm.nih.gov/18286649/?ref=theplasticsfella.com). Microsurgery. 2008;28(3):153-6\. doi: 10.1002/micr.20470\. PMID: 18286649. 10. Chung 2024\. [Grabb and Smith's Plastic Surgery](https://shop.lww.com/Grabb-and-Smith-s-Plastic-Surgery--Print---eBook-with-Multimedia/p/9781975214265?ref=theplasticsfella.com): 9th Edition September 2024 page 1169, 1211-1217 11. Mulhall JP, Schiff J, Guhring P. [An analysis of the natural history of Peyronie's disease](https://pmc.ncbi.nlm.nih.gov/articles/PMC3739136/?ref=theplasticsfella.com). J Urol. 2006 Jun;175(6):2115-8; discussion 2118\. doi: 10.1016/S0022-5347(06)00270-9\. PMID: 16697815. 12. Selvan SS, Alagu GS, Gunasekaran R. [Use of a hypogastric flap and split-thickness skin grafting for a degloving injury of the penis and scrotum: A different approach](https://pubmed.ncbi.nlm.nih.gov/20368872/?ref=theplasticsfella.com). Indian J Plast Surg. 2009 Jul;42(2):258-60\. doi: 10.4103/0970-0358.59296\. PMID: 20368872; PMCID: PMC2845379. 13. Khan, Q., Knight, R.J.W. & Goodwin-Walters, A. [Scrotal reconstruction: a review and a proposed algorithm](https://link.springer.com/article/10.1007/s00238-013-0833-4?ref=theplasticsfella.com#citeas). *Eur J Plast Surg* **36**, 399–406 (2013). ### Wound Dressings: Healing, Dressing Types, & How to Choose URL: https://www.theplasticsfella.com/wound-dressings/ Last updated: 2025-01-20T18:49:41.000Z #### Summary Card [****Wound Healing**](https://www.theplasticsfella.com/wound-dressings/#wound-healing) Wound healing occurs in four distinct phases: Hemostasis (Day 1-3), Inflammation (Day 3-7), Proliferation (Day 3-21), and Maturation (Week 3 to 1 year). [****Classification of Wound Dressings**](https://www.theplasticsfella.com/wound-dressings/#classification-of-wound-dressings) Wound dressings can be categorized into non-occlusive, semi-occlusive, and occlusive dressings, depending on their permeability and function. [****Non-Occlusive & Semi-Occlusive Dressings**](https://www.theplasticsfella.com/wound-dressings/#non-occlusive-and-semi-occlusive-dressings) Non-occlusive dressings, like gauze and tulle, cover wounds without sealing them, while semi-occlusive dressings, such as Tegaderm, trap exudate while allowing air and moisture vapor to pass through. [****Occlusive Dressings**](https://www.theplasticsfella.com/wound-dressings/#occlusive-dressings) Occlusive dressings keep wounds moist and shield them from trauma. Types include hydrogels, hydrocolloids (e.g., Duoderm), foams, and alginates. [****Antimicrobial Dressings**](https://www.theplasticsfella.com/wound-dressings/#antimicrobial-dressings) Antimicrobial dressings, found across various dressing categories, are impregnated with agents like silver, bismuth, and chlorhexidine to help prevent infection. [****Choice of Wound Dressing**](https://www.theplasticsfella.com/wound-dressings/#choice-of-wound-dressing) Ideal wound dressing selection depends on local factors (e.g., exudate, tissue condition) and patient factors (e.g., allergies, compliance), which may change as conditions evolve. [****Other Adjuncts to Wound Healing**](https://www.theplasticsfella.com/wound-dressings/#other-adjuncts-to-wound-healing) Wound healing adjuncts include biophysical therapies (e.g., NPWT, electrical stimulation) and biological products (e.g., hyperbaric oxygen, growth factors, and stem cells) to speed and enhance healing. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Wound Healing ****Key Point** Wound healing occurs in four distinct phases: ****Hemostasis** (Day 1-3), ****Inflammation** (Day 3-7), ****Proliferation** (Day 3-21), and ****Maturation** (Week 3 to 1 year). The [wound healing](https://www.theplasticsfella.com/wound-healing/) process is sequential and highly organized, involving four distinct phases, each with specific cellular and molecular activities. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image-3.png) #### Hemostasis (Day 1-3) The first stage focuses on controlling bleeding and laying the groundwork for cellular migration. - **Vasoconstriction**: Reduces blood flow to minimize bleeding. - **Coagulation**: Platelets degranulate, releasing thromboxane A2 to initiate clot formation. - **Growth Factors**: Platelet-derived growth factor (PDGF) acts as a chemotactic signal for fibroblasts and macrophages. - **Thrombus Formation**: Stabilizes the wound and forms a provisional matrix. ### Inflammation (Day 3-7) The inflammatory phase initiates the body's defense and cleanup response, recruiting immune cells to the wound. - **Vasodilation & Increased Permeability**: Enables white blood cell (WBC) migration into the wound area. - **Cellular Response**: - **Neutrophils**: Arrive within 24 hours as initial responders. - **Macrophages**: Become predominant by days 2-3, releasing cytokines and growth factors (e.g., PDGF, TGF-β1) to attract fibroblasts and support healing. #### Proliferation (Day 3-21) During the proliferative phase, cells focus on forming new tissue, restoring blood supply, and strengthening the wound. - **Fibroblasts**: Convert into myofibroblasts by days 3-5, facilitating wound contraction and ECM formation. - **Extracellular Matrix (ECM)**: Composed of proteoglycans, fibronectin, and type III collagen. - **Collagen Synthesis**: High rates of type III and type I collagen production provide initial tensile strength from days 4-5. - **Keratinocyte Migration**: Re-epithelializes the wound surface. - **Neovascularization**: Driven by vascular endothelial growth factor (VEGF), providing a blood supply for new tissue. #### Maturation/Remodeling (Week 3 to 1 Year) This final phase focuses on collagen reorganization, strength restoration, and long-term remodeling. - **Collagen Remodeling**: Collagen replaces proteoglycans and fibronectin, with type I collagen forming cross-links for strength. - **Matrix Metalloproteinases (MMPs)** and **Tissue Inhibitors of Metalloproteinases (TIMPs)** regulate this remodeling process, ultimately achieving a type I collagen ratio of 4:1. - **Epithelialization**: Re-establishes the skin barrier from the basal layer to the stratum corneum. - **Contraction**: Occurs in full-thickness wounds as fibroblasts transform into myofibroblasts, peaking between days 10-21. 😎 ****Fun Fact:** A wound reaches 5% tensile strength at 1 week, 20% at 3 weeks, 50% at 4 weeks, and 80% by 6 weeks to 1 year, maxing at 80% of uninjured skin strength ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). --- ## Classification of Wound Dressings ****Key Point** Wound dressings can be categorized into ****non-occlusive**, ****semi-occlusive**, and ****occlusive** dressings, depending on their permeability and function. Wound dressings are categorized by permeability—non-occlusive, semi-occlusive, and occlusive—each designed to create an environment that best supports wound healing ([Shi](https://pubmed.ncbi.nlm.nih.gov/32266224/?ref=theplasticsfella.com), 2020). - **Non-Occlusive Dressings** (e.g., gauze, cotton pads): Traditional dressings that cover and protect but lack moisture retention, potentially delaying healing and risking trauma if adhered. - **Semi-Occlusive Dressings**: Impermeable to fluids but permit gas exchange, balancing moisture to reduce drying and prevent fluid buildup. - **Occlusive Dressings**: Fully seal the wound, retaining moisture, supporting autolysis, and protecting new tissue. These dressings stabilize temperature and humidity, promoting faster healing by encouraging cell growth and migration. ### **Traditional vs. Modern Dressings** Modern wound dressings address the limitations of traditional options, offering enhanced wound stability and reduced risk of reinjury, particularly beneficial in complex or slow-healing wounds. - **Traditional Dressings (Inert)**: Gauze, cotton pads, and bandages offer basic protection but lack moisture retention, risking wound adherence and disruption of healing tissue. - **Modern Dressings**: Designed to maintain a moist environment, modern dressings support faster healing by promoting autolysis and reducing necrotic tissue. They provide a stable temperature and humidity, prevent trauma to new granulation tissue, and encourage cell proliferation and epithelial migration. 😎 ****Fun Fact:** The amount of secondary contraction depends on the dermal content of the wound — more dermis results in less contraction ([Brown](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian), 2023). --- ## Non-Occlusive and Semi-Occlusive Dressings ****Key Point** Non-occlusive dressings, such as gauze and tulle, cover wounds without sealing them, while semi-occlusive dressings, like Tegaderm, retain moisture by trapping exudate while allowing air and moisture vapor to pass through. In wound care, dressing choice is guided by the need to balance protection, moisture retention, and infection prevention. **Non-occlusive** and **semi-occlusive** dressings each offer unique benefits depending on the wound's requirements for healing. ### **Non-Occlusive Dressings** Passive dressings primarily used for wound coverage and protection. - **Examples**: Gauze, tulle. - **Function**: Provide basic wound coverage without maintaining a moist environment, which can delay healing. ### **Semi-Occlusive Dressings** Designed to maintain moisture by trapping exudate while permitting air and moisture vapor exchange, supporting optimal wound healing. - **Examples**: Biofilm, Bioclusive, Hydrofilm, Mepilex Film, OpSite, and OpSite Flexifix Gentle. - **Function**: Impermeable to bacteria and fluids, these dressings create a moist, protective barrier while allowing gas exchange to reduce the risk of infection. 😎 ****Fun Fact:** Silver ions (Ag+) play a critical role in wound care by killing pathogens and disrupting biofilms. They work by binding to tissue proteins and bacterial cell walls, causing cell lysis and inhibiting bacterial DNA and RNA synthesis, which halts bacterial replication ([May](https://pubmed.ncbi.nlm.nih.gov/34806300/?ref=theplasticsfella.com), 2022). --- ## Occlusive Dressings ****Key Point** Occlusive dressings maintain a moist environment and protect wounds from trauma, aiding in faster healing. Types include hydrogels, hydrocolloids (e.g., Duoderm), foams, and alginates. Occlusive dressings are crucial for wounds that benefit from a stable, moisture-rich environment. By maintaining moisture, these dressings accelerate healing, protect new tissue from trauma, and reduce the risk of infection. **How Occlusive Dressings Work** Occlusive dressings preserve moisture at the wound site, promoting faster healing and providing a protective barrier. Typically available in sheet form, these dressings can be cut to fit the wound. In some cases, a secondary dressing may be needed for complete sealing. **Benefits** - **Accelerates Re-Epithelialization**: Can increase healing rates by up to 40% in partial-thickness wounds (Mir, 2018). - **Promotes Healing Factors**: Maintains exposure to proteinases, growth factors, and chemotactic agents. - **Encourages Collagen Synthesis and Angiogenesis**: Creates a mildly hypoxic, low-pH environment that supports collagen formation and new blood vessel growth, reducing infection risk. **Contraindications** Occlusive dressings should be avoided in: - **Macerated Skin**: Excess moisture can worsen skin damage. - **Infected Wounds**: Traps bacteria, potentially worsening infection. The table below summarises the types of occlusive dressings and their characteristics. ![occlusive dressings and their characteristics - wound dressing](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-17T004602.573.png) Occlusive dressings and their characteristics 😎 ****Fun Fact:** Contrary to past beliefs, occlusive dressings have been shown to lower infection rates by maintaining a moist environment ([Tan](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=The+Benefits+Of+Occlusive+Dressings+In+Wound+Healing+May+2019The+Open+Dermatology+Journal+13%281%29%3A27-33+DOI%3A10.2174%2F1874372201913010027&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1728784500039&u=%2Fscholar%3Fq%3Dinfo%3Aczi3xJlk1iUJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2019). --- ## Antimicrobial Dressings ****Key Point** Antimicrobial dressings are available across dressing categories and are impregnated with agents like silver, bismuth, and chlorhexidine to prevent infection. Antimicrobial dressings exist in both occlusive and non-occlusive forms, categorized broadly as silver-impregnated and non-silver-impregnated dressings. ### Silver-Impregnated Dressings Silver-based dressings are favored for their broad-spectrum antimicrobial properties and can be either non-occlusive or occlusive. - **Non-Occlusive Silver Dressings**: These can be sheets (Acticoat, Urgotu) or **Bandages** (Silverlon) - **Occlusive Silver Dressings** can be **Alginate Dressings** (Aquacel Ag) or Foam Dressings (Mepilex Ag) ### **Non-Silver Antimicrobial Dressings** These dressings incorporate agents like bismuth, chlorhexidine, or honey to provide antimicrobial coverage without silver. **Non-Occlusive Non-Silver Dressings**: - **Xeroform**: Gauze with bismuth and petroleum. - **Bactigras**: Gauze with paraffin and chlorhexidine. - **Inadine**: Fabric with polyethylene glycol. **Occlusive Non-Silver Dressings**: - **Honey-Based and Other Agents**: Honey or other antimicrobial agents can be applied under an occlusive dressing to help prevent infection. 😎 ****Fun Fact:** Acute wounds generally heal within 8–12 weeks with minimal scarring, while chronic wounds often take longer than 12 weeks and have a higher risk of recurrence ([Tan](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=The+Benefits+Of+Occlusive+Dressings+In+Wound+Healing+May+2019The+Open+Dermatology+Journal+13%281%29%3A27-33+DOI%3A10.2174%2F1874372201913010027&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1728784500039&u=%2Fscholar%3Fq%3Dinfo%3Aczi3xJlk1iUJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den), 2023). --- ## Choice of Wound Dressing ****Key Point** Selecting an ideal wound dressing requires consideration of local wound factors (e.g., exudate level, tissue health) and patient-specific factors (e.g., allergies, compliance). These needs may shift as healing progresses. ### **Factors to Consider in Dressing Selection** An ideal dressing should meet the following criteria ([Degreef](https://pubmed.ncbi.nlm.nih.gov/9589210/?ref=theplasticsfella.com), 1998): - **Healing Support:** Maintain a moist environment, enhance epidermal migration for faster regeneration, and promote angiogenesis and connective tissue synthesis. - **Trauma Prevention:** Avoid disrupting new tissue during dressing changes and be non-adherent to prevent trauma on removal. - **Protection:** Allow gas exchange, protect against bacterial infection, and maintain temperature to encourage blood flow. - **Safety:** Be sterile, non-toxic, and non-allergenic to avoid adverse reactions. ### **Factors in Dressing Selection** As wound and patient conditions evolve, dressing adjustments may be necessary. - **Local Wound Factors:** Dressing choice should match the wound’s exudate level, infection risk, and healing phase. - **Systemic Patient Factors:** Consider the patient’s allergies, compliance with dressing changes, access to resources, and dressing change frequency needs. The table below summarises dressing approaches for different wounds ([Chung](https://shop.lww.com/Grabb-and-Smith-s-Plastic-Surgery--Print---eBook-with-Multimedia/p/9781975214265?ref=theplasticsfella.com), 2024). ![Dressing approaches for different types of wounds](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-17T011856.867.png) Dressing approaches for different types of wounds --- ## Other Adjuncts to Wound Healing ****Key Point** Wound healing adjuncts include biophysical therapies (e.g., NPWT, electrical stimulation) and biological products (e.g., hyperbaric oxygen, growth factors, and stem cells) to speed and enhance healing. Multiple adjuncts to wound healing are available ([Chung](https://shop.lww.com/Grabb-and-Smith-s-Plastic-Surgery--Print---eBook-with-Multimedia/p/9781975214265?ref=theplasticsfella.com), 2024). These can be categorised as, **Biophysical Therapies** - **Negative Pressure Wound Therapy (NPWT):** Applies negative pressure to the wound bed, promoting granulation tissue formation. - **Transcutaneous Electrical Nerve Stimulation (TENS):** Uses non-invasive electrical stimulation to promote healing, such as epithelialization, fibroblast migration, and angiogenesis. - **Extracorporeal Shock Wave Therapy (ESWT):** Uses high-energy acoustic pulses to stimulate cell proliferation, angiogenesis, and cavitation of necrotic tissue. - **Photobiomodulation (PBM):** Utilises light to stimulate angiogenesis, ECM deposition, and reduce inflammation, enhancing wound healing. - **Photodynamic Therapy (PDT):** Combines a photosensitizer with external light to produce an antibacterial effect, particularly against biofilm. - **Electromagnetic Fields:** Low-frequency pulsed electromagnetic fields support collagen deposition, angiogenesis, and the release of nitric oxide. **Biological Products** - **Hyperbaric Oxygen Therapy (HBOT):** Administers enriched oxygen in a pressurised environment, improving oxygenation and promoting healing. - **Growth Factors (GFs):** GFs help stimulate cell growth and tissue repair, aiding wound healing. - **Platelet Rich Plasma (PRP):** PRP contains high concentrations of platelets, growth factors, and cytokines that promote epithelial cell proliferation, angiogenesis, collagen deposition, and wound closure. - **Stem Cells:** Stem cells from various sources release growth factors that promote healing. Their use remains experimental due to concerns about safety in humans. - **Exosomes:** Exosomes are extracellular vesicles that mediate communication between cells, delivering a mixture of growth factors and cytokines. Exosome-based therapies mimic stem cell effects without the challenges of cell-based treatments. 😎 ****Fun Fact:** The mechanism of NPWT is debated. Some suggest it doesn’t increase perfusion but raises tissue pressure, altering mechanical properties (Young's modulus), which may drive its regenerative effect ([Kairinos](https://pubmed.ncbi.nlm.nih.gov/23783056/?ref=theplasticsfella.com), 2013). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Phases of Wound Healing:** Hemostasis immediately post-injury promotes clot formation; the Inflammation phase follows with immune activation; the Proliferation phase rebuilds the wound with new tissue and collagen; Maturation strengthens and remodels the wound over time. ****2\. Wound Dressings:** Dressings are categorized by their interaction with the wound: Non-occlusive dressings like gauze allow air exposure; semi-occlusive dressings like Tegaderm manage moisture; occlusive dressings maintain a moist environment to facilitate healing. ****3\. Antimicrobial Dressings:** These dressings, including silver-impregnated varieties, are used to prevent infections by disrupting pathogens and promoting a conducive healing environment. ****4\. Adjuncts to Wound Healing:** Incorporates biophysical therapies like Negative Pressure Wound Therapy (NPWT) and biological products like hyperbaric oxygen therapy, which enhance cellular repair and reduce healing time. ****5\. Importance of Moist Environment:** Effective modern dressings maintain a moist wound environment, essential for faster healing by promoting autolysis and tissue regeneration. ****6\. Innovations in Wound Care:** Advances include technologies and treatments that improve healing rates, minimize complications, and enhance patient outcomes for complex wounds. --- ## Further Reading 1. Shi C, Wang C, Liu H, Li Q, Li R, Zhang Y, Liu Y, Shao Y, Wang J. [Selection of Appropriate Wound Dressing for Various Wounds](https://pubmed.ncbi.nlm.nih.gov/32266224/?ref=theplasticsfella.com). Front Bioeng Biotechnol. 2020 Mar 19;8:182\. doi: 10.3389/fbioe.2020.00182\. PMID: 32266224; PMCID: PMC7096556. 2. Theplasticsfella [Wound healing](https://www.theplasticsfella.com/wound-healing/) April 2022\. Accessed on 12th October 2024 3. Brown D. [Michigan Manual of Plastic Surgery](https://shop.lww.com/Michigan-Manual-of-Plastic-Surgery/p/9781975197391?ref=theplasticsfella.com#editor%5Faccordian) 3rd edition 2023 Oct page 3-4 4. Guo S, Dipietro LA. [Factors affecting wound healing](https://pubmed.ncbi.nlm.nih.gov/20139336/?ref=theplasticsfella.com). J Dent Res. 2010 Mar;89(3):219-29\. doi: 10.1177/0022034509359125\. Epub 2010 Feb 5\. PMID: 20139336; PMCID: PMC2903966. 5. Tan, S.T., Winarto, N., Dosan, R. and Aisyah, P.B., 2019\. [The benefits of occlusive dressings in wound healing](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=The+Benefits+Of+Occlusive+Dressings+In+Wound+Healing+May+2019The+Open+Dermatology+Journal+13%281%29%3A27-33+DOI%3A10.2174%2F1874372201913010027&btnG=&ref=theplasticsfella.com#d=gs%5Fcit&t=1728784500039&u=%2Fscholar%3Fq%3Dinfo%3Aczi3xJlk1iUJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den). The Open Dermatology Journal, 13(1). 6. Chung 2024 [Grabb and Smith's Plastic Surgery: 9th Edition](https://shop.lww.com/Grabb-and-Smith-s-Plastic-Surgery--Print---eBook-with-Multimedia/p/9781975214265?ref=theplasticsfella.com) September 2024 page 8-13 7. Kairinos N, Holmes WJM, Solomons M, Hudson DA, Kahn D. [Does a zone of increased perfusion exist around negative-pressure dressings?](https://pubmed.ncbi.nlm.nih.gov/23783056/?ref=theplasticsfella.com) Plast Reconstr Surg. 2013 Oct;132(4):978-987\. doi: 10.1097/PRS.0b013e31829f4ad9\. PMID: 23783056. 8. Degreef HJ. [How to heal a wound fast](https://pubmed.ncbi.nlm.nih.gov/9589210/?ref=theplasticsfella.com). Dermatol Clin. 1998 Apr;16(2):365-75\. doi: 10.1016/s0733-8635(05)70019-x. PMID: 9589210. 9. May A, Kopecki Z, Carney B, Cowin A. [Antimicrobial silver dressings: a review of emerging issues for modern wound care](https://pubmed.ncbi.nlm.nih.gov/34806300/?ref=theplasticsfella.com). ANZ J Surg. 2022 Mar;92(3):379-384\. doi: 10.1111/ans.17382\. Epub 2021 Nov 21\. PMID: 34806300.\\ 10. Mir M, Ali MN, Barakullah A, Gulzar A, Arshad M, Fatima S, Asad M. [Synthetic polymeric biomaterials for wound healing: a review](https://pubmed.ncbi.nlm.nih.gov/29446015/?ref=theplasticsfella.com). Prog Biomater. 2018 Mar;7(1):1-21\. doi: 10.1007/s40204-018-0083-4\. Epub 2018 Feb 14\. PMID: 29446015; PMCID: PMC5823812. ### Young Doctors Refuse to Burn Out, Flap Tips, & Must Read Articles on Infections URL: https://www.theplasticsfella.com/november-10th/ Last updated: 2024-11-15T10:56:19.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/november-10th/#a-letter-from-pfella) Young docs want balance. Old docs say tough luck. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-10th/#the-sunday-quiz) How well do you know pressure ulcers? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/november-10th/#image-of-the-week) Grade 4 pressure sore featured. 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-10th/#technique-tip) Designing the SGAP flap. 5. 🎓 [****The Fellow's Corner**](https://www.theplasticsfella.com/november-10th/#the-fellows-corner) This week's feature: **Osteomyelitis.* 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/november-10th/#what-does-the-evidence-say) What's the best flap for a pressure sore? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-10th/#articles-of-the-week) Cierny/Mader staging system for osteomyletitis, Necrotisiig fasciitis management, & classic paper from Mathes himself: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/november-10th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella Young Docs Want Balance. Old Docs Say Tough Luck. 👋 ****Hey there!** I just came across an article from the Wall Street Journal titled, **"Young Doctors Want Work-Life Balance. Older Doctors Say That’s Not the Job"*. It’s a hot topic, and it’s stirring up some serious debate — and I want you in on it. There is a **generational clash** in medicine. Older doctors argue that long, grueling hours are just part of the job—a rite of passage they endured, so younger doctors should too. But should we keep this tradition simply because “that’s how it’s always been”? Where is this mindset really getting us? !["Young Doctors Want Work-Life Balance. Older Doctors Say That’s Not the Job"](https://lh7-rt.googleusercontent.com/docsz/AD_4nXenfRML4OnhmNWrI9peGd3e3SqIy6RV4_mQ2Og6rFtc3dXhOC0emhuvBzbx9izzRntPPypq4mEST7NEF_Y6ls_lcZdPyRSe84kqPw_gnUXS7vj7-JIqLslq51MNz7NQ-wtlLUBtiHyqi7k3qMpNZaLpOFAK?key=lO_ufs74G1Lzvi7eiFCcYVda) "Young Doctors Want Work-Life Balance. Older Doctors Say That’s Not the Job" The crazy residency schedules that became tradition weren’t about excellence—they were born from one physician trying to cover up his own issues. And yet here we are, decades later, clinging to this exhausting model like it’s some badge of honor. But let’s face it, the old expectations of endless availability are still very much in play. And those who stick to this mentality often end up in leadership, perpetuating the very culture that drives burnout. Here’s what [Twitter](https://x.com/BenMazer/status/1853042755112448489?ref=theplasticsfella.com) thought about this article: - **“If we’re just replaceable cogs, why should we sacrifice everything?”** It’s true — why give your whole life to a job that treats you like you’re disposable? - **“Younger doctors have it different.”** Crushing student loans, skyrocketing living costs, burnout awareness, and constant tech overload make it impossible to justify the same approach of past generations. The game has changed. - **“We need to invest in future doctors.”** Without solid support from day one — better education, recruitment, and training — we’re just stuck in a cycle of poor working conditions and chronic shortages. - **“Autonomy is key.”** Many younger attendings say that autonomy makes all the difference. Running their own practice means they can work long hours without feeling like cogs in a machine. But that kind of freedom is hard to come by today, especially for young docs employed by massive health systems. - **“Patient safety should come first.”** Who wants a doctor who’s been awake for 24 hours? Exhausted doctors make mistakes. We should all care about changing that. - **“Older doctors have played a part in this mess.”** Selling out to private equity, and letting insurers dictate care — these decisions by past generations have made things tougher for today’s doctors. We’re working harder for less, and it shows. So here’s the big question: **How do we strike a balance?** I want to hear what you think. Drop your thoughts above. With love, P'Fella ❤️ ## The Sunday Quiz How Well Do You Know ***Pressure Ulcers**? ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Clinical Spectrum of Pressure Sores (Grades 1-4)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image-2.png) Clinical Spectrum of Pressure Sores (Grades 1-4) ## Image of the Week **Grade 4 Pressure Sore* 🖼️ ****Image of the Week** In this section, we feature an anatomical illustration. This edition looks at an infected Grade 4 pressure ulcer over the right ischial tuberosity, with exposed bone. ![ Infected Grade 4 pressure ulcer over the right ischial tuberosity, with exposed bone](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Clinical-Case-Main-Image--32--3-1.png) Infected Grade 4 pressure ulcer ## Technique Tip **Designing the SGAP Flap* 🚑 ****Technique Tip of the Week** This edition looks at designing the SGAP flap. You can read more details on the technique [here](https://pubmed.ncbi.nlm.nih.gov/21217972/?ref=theplasticsfella.com). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Schematics-for-facilitating-the-design-of-the-superior-gluteal-artery-perforator-SGAP.png) TY - JOUR AU - k m, Pradeoth AU - Allalasundaram, Kv AU - Balakrishnan, Thalaivirithan PY - 2010/07/01 SP - 151 EP - 7 T1 - Perforator propeller flaps for sacral and ischial soft tissue reconstruction VL - 43 DO - 10.4103/0970-0358.73427 JO - Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India ER - ## the Fellows' Corner **This Week's Focus:* ***Osteomyelitis** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Osteomyelitis**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-10-22T144520.635.png) #### Osteomyelitis [****Definition**](https://www.theplasticsfella.com/osteomyelitis/#definition-of-osteomyelitis) Osteomyelitis is inflammation due to infection of the bone by bacteria, mycobacteria, or fungus. [****Aetiology**](https://www.theplasticsfella.com/osteomyelitis/#aetiology-of-osteomyelitis) Osteomyelitis can result from haematogenous seeding, direct inoculation, or contiguous spread. Staphylococcus aureus is the most common pathogen. [****Clinical Features**](https://www.theplasticsfella.com/osteomyelitis/#clinical-features-of-osteomyelitis) Osteomyelitis presents with pain and reduced movement. Acute cases show systemic signs of infection, while chronic cases may involve overlying skin changes and drainage through a sinus tract. [****Investigations**](https://www.theplasticsfella.com/osteomyelitis/#investigations-for-osteomyelitis) A diagnosis of suspected osteomyelitis is confirmed by positive bone microbiology samples. MRI and FDG-PET are the most sensitive and specific imaging techniques. [****Management**](https://www.theplasticsfella.com/osteomyelitis/#management-of-osteomyelitis) Targeted antibiotic therapy is the first choice for acute osteomyelitis. In subacute and chronic cases, aggressive debridement combined with an orthoplastic approach is required for definitive management. [Read the Article](https://www.theplasticsfella.com/osteomyelitis/) ## What Does the Evidence Say? **What's the Best Flap for a Pressure Sore?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Pressure sore reconstruction using flap coverage is a challenging but an effective treatment option. Various flap types have been studied, including ****musculocutaneous**, ****fasciocutaneous**, and ****perforator-based** flaps. While some studies found no significant difference in complication or recurrence rates among these flap types (Sameem et al., 2012; Thiessen et al., 2011), others reported lower recurrence rates with musculocutaneous flaps and lower complication rates with combined flaps (Vathulya et al., 2021). Factors associated with higher complication risks include ****low BMI**, ****smoking**, ****ischial location**, and ****preoperative osteomyelitis** (Bamba et al., 2017). Flap selection is crucial for successful outcomes, with specific flaps showing high success rates for different pressure sore locations (Foster et al., 1997). ****Gluteal perforator flaps** have demonstrated excellent results with low recurrence rates (Lee et al., 2006). Despite improvements in surgical techniques, pressure sore recurrence remains a significant challenge, with historical rates as high as ****75-77%** (Lee et al., 2006). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Cierny/Mader Staging for Osteomyelitis: Biofilm Management, Antibiotics, and Reconstruction** ([Cierny](https://journals.lww.com/plasreconsurg/abstract/2011/01001/surgical%5Ftreatment%5Fof%5Fosteomyelitis.28.aspx?ref=theplasticsfella.com), 2011) Chronic osteomyelitis demands surgical biofilm removal and adjunctive antibiotics, guided by the Cierny/Mader staging system, with reconstruction tailored to bone stability and soft-tissue health. ✅ ****Essential Insights on Managing Necrotizing Soft-Tissue Infections** ([Dennis](https://www.nejm.org/doi/abs/10.1056/NEJMra1600673?ref=theplasticsfella.com), 2017) Necrotizing fasciitis is marked by rapid tissue destruction, friable fascia, and gray exudate without pus, requiring urgent surgical debridement and antibiotics. ✅ ****Advances in Muscle Flap Technique for Managing Chronic Osteomyelitis** ([Mathes](https://www.nejm.org/doi/abs/10.1056/NEJM198202043060509?ref=theplasticsfella.com), 1982) Explore muscle flaps in osteomyelitis management in Mathes' publication. This approach covers infected wounds and exposed bones using microsurgical techniques for transposing muscle to various sites. ## Feedback ### I hope you enjoyed it 😄 --- ### Osteomyelitis: Clinical Features, Investigations, & Management URL: https://www.theplasticsfella.com/osteomyelitis/ Last updated: 2024-11-08T16:18:11.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/osteomyelitis/#definition-of-osteomyelitis) Osteomyelitis is inflammation due to infection of the bone by bacteria, mycobacteria, or fungus. [****Aetiology**](https://www.theplasticsfella.com/osteomyelitis/#aetiology-of-osteomyelitis) Osteomyelitis can result from haematogenous seeding, direct inoculation, or contiguous spread. Staphylococcus aureus is the most common pathogen. [****Clinical Features**](https://www.theplasticsfella.com/osteomyelitis/#clinical-features-of-osteomyelitis) Osteomyelitis presents with pain and reduced movement. Acute cases show systemic signs of infection, while chronic cases may involve overlying skin changes and drainage through a sinus tract. [****Investigations**](https://www.theplasticsfella.com/osteomyelitis/#investigations-for-osteomyelitis) A diagnosis of suspected osteomyelitis is confirmed by positive bone microbiology samples. MRI and FDG-PET are the most sensitive and specific imaging techniques. [****Management**](https://www.theplasticsfella.com/osteomyelitis/#management-of-osteomyelitis) Targeted antibiotic therapy is the first choice for acute osteomyelitis. In subacute and chronic cases, aggressive debridement combined with an orthoplastic approach is required for definitive management. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## Definition of Osteomyelitis ****Key Point** Osteomyelitis is inflammation due to infection of the bone by bacteria, mycobacteria, or fungus. It is usually secondary to direct inoculation through trauma or local soft tissue infection, but haematogenous spread can occur, particularly in pediatric patients. Osteomyelitis is a **bone infection** commonly caused by **direct inoculation**, haematagenous or contiguous spread. The infection causes bone tissue death (**necrosis**) and leads to the formation of dead bone fragments (**sequestra**). Subperiosteal abscesses may develop, prompting new bone formation (**involucrum**) as a protective response. It can be classified as: - **Acute:** Within 2 weeks of the initial infection. - **Subacute:** Occurs between 2 weeks to several months after the insult. - **Chronic:** Manifests several months post-infection. 💡 ****Tip:** It has a ****slight predominance in adult males**. It occurs around 20 cases per 100,000 person-years ([Momudu](https://www.ncbi.nlm.nih.gov/books/NBK532250/?ref=theplasticsfella.com#:~:text=Stage%201%3A%20Disease%20confined%20to,Stage%204%3A%20Diffuse%20disease), 2023) and \~8 cases per 100,000 person-years ([Foong](https://pubmed.ncbi.nlm.nih.gov/34895166/?ref=theplasticsfella.com), 2023). ![Acute and chronic osteomyelitis result in different symptoms, signs and radiographic findings. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-08T200315.956.png) Acute and chronic osteomyelitis result in different symptoms, signs and radiographic findings --- ## Aetiology of Osteomyelitis ****Key Point** Osteomyelitis can result from ****haematogenous** seeding, ****direct** inoculation, or ****contiguous** spread. Staphylococcus aureus is the most common pathogen, with risk factors including conditions that impair blood supply. ### Types of Pathogens The **most common causative organism of osteomyelitis is** Staphylococcus aureus (80% of cases). Other pathogens associated with osteomyelitis include: - **Escherichia coli, Pseudomonas spp., Klebsiella spp.:** Common in IV drug users and those with genitourinary infections. - **Salmonella spp.:** Frequently found in patients with sickle cell disease. - **Haemophilus influenzae, Group B streptococci:** Common in neonates. ### Types of Transmission These organisms can cause **osteomyelitis** through 3 mechanisms: 1. **Haematogenous Spread** is a common method in paediatrics due to high bone vascularity. In adults**,** vertebrae are most commonly affected. 2. **Direct Inoculation** from trauma (e.g., fractures) or surgery. Poor vascularity in the affected area increases susceptibility to infection. 3. **Contiguous Spread** from adjacent soft tissue infections, such as paronychia. 😎 ****Fun Fact:** There is a seasonal variation in acute haematogenous osteomyelitis in children, with the majority of cases presenting during the summer months ([Lindsay](https://pubmed.ncbi.nlm.nih.gov/29045692/?ref=theplasticsfella.com#:~:text=Symptom%20onset%20occurred%20most%20commonly,020%29.), 2015). ![Direct inoculation from a cat bit resulting in Osteomyelitis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-08T200942.009-2.png) Direct inoculation from a cat bit resulting in Osteomyelitis ### 😎 ****Fun Fact:** In rare cases, osteomyelitis can occur without bacterial infection, as seen in chronic recurrent multifocal osteomyelitis (CRMO), a non-suppurative inflammatory disorder. ([Pinder](https://pubmed.ncbi.nlm.nih.gov/26482914/?ref=theplasticsfella.com), 2015) --- ## Clinical Features of Osteomyelitis ****Key Point** Osteomyelitis presents with distinct acute and chronic symptoms. Acute cases show systemic signs of infection, while chronic cases may involve overlying skin changes and sinus tract. ### History Osteomyelitis is characterised bylocalized **bone pain**, typically worsening with movement or weight-bearing. In chronic cases, pain may be persistent but less intense than in acute cases. There can often be associated systemic symptoms, such as: - **Acute:** fever, malaise, and lethargy - **Chronic:** fewer systemic signs but could have chronic low-grade fever. Patient history might identify **risk factors** such as: - **Vascular Insufficiency:** Poor blood flow (e.g., in diabetes or peripheral vascular disease) increases risk. - **Chronic Illnesses:** Diabetes, sickle cell disease, and immunosuppression. - **IV Drug Use:** Associated with direct bacterial inoculation risk. 💡 ****Tip:** A history of recent antibiotic use is important to note, as it can mask classic signs of osteomyelitis, making diagnosis more challenging. ### Examination In osteomyelitis, clinical examination reveals distinct local signs based on the stage of infection, with acute cases displaying inflammatory symptoms and chronic cases showing structural changes and potential drainage **Local Signs** - **Acute:** Erythema, warmth, and swelling over the affected area, with tenderness on palpation. - **Chronic:** skin induration or thickening, a sinus tract allowing for spontaneous discharge of purulent material. In both types, reduced mobility in nearby joints, especially in chronic cases where pain limits function. 💡 ****Tip:** The most common site of bone involvement differs by age: ****\- Neonates:** Metaphysis and epiphysis. ****\- Children:** Metaphysis. ****\- Adults:** Epiphysis and subchondral regions. ### **Differential Diagnosis** - **Septic Arthritis:** Presents similarly with pain, warmth, and swelling but is joint-centered rather than bone-centered. - **Cellulitis:** May mimic local signs of osteomyelitis but without deep bone involvement. - **Bone Tumors:** Particularly in chronic cases, differentiate osteomyelitis from neoplastic causes of localized bone pain. - **Gout/Pseudogout:** Acute joint pain and erythema may resemble osteomyelitis but typically show crystal deposits on imaging or aspiration. 😎 ****Fun Fact:** Osteomyelitis of the hand is rare, comprising only 1-6% of all hand infections and about 10% of all osteomyelitis cases ([Pinder](https://pubmed.ncbi.nlm.nih.gov/26482914/?ref=theplasticsfella.com), 2015). --- ## Investigations for Osteomyelitis ****Key Point** Diagnosis of osteomyelitis relies on ****microbiological** confirmation from bone samples, with ****MRI** and ****FDG-PET** as the most accurate imaging methods. ****Antibiotics** should be withheld until samples are obtained to avoid masking the infection. **Investigating** osteomyelitis requires a structured approach involving **blood** tests, **microbiological** analysis, and **imaging** studies. This approach aids in confirming the infection source, identifying causative organisms, and assessing the extent of bone and soft tissue involvement. ### Blood Tests Blood tests provide initial clues and help monitor the inflammatory response, though they are not diagnostic on their own. - **White Cell Count (WCC):** Elevated in acute cases, though less reliable in chronic infection. - **C-Reactive Protein (CRP):** Sensitive marker for inflammation, often elevated in osteomyelitis. - **Erythrocyte Sedimentation Rate (ESR):** Elevated ESR can suggest chronic inflammation or bone involvement. ### Microbiological Diagnosis Direct microbiological analysis from bone samples is essential for a definitive diagnosis and should be prioritized before starting antibiotics. - **Bone biopsy:** Gold standard for microbiological confirmation. Antibiotic therapy should be withheld until samples are collected to avoid interference with pathogen detection. As stated before, the **most common** pathogen is **Staphylococcus aureus**. Other organisms include Escherichia coli, Pseudomonas spp., Klebsiella spp, Salmonella spp. Haemophilus influenzae, and Group B streptococci. ### Radiological Investigations Imaging is crucial for identifying the extent of bone and soft tissue involvement, with MRI and FDG-PET offering the highest sensitivity and specificity. **MRI** is ideal for early detection and assessing soft tissue involvement. Key signs include: - **Bone Marrow Edema:** Detectable within 1-2 days of infection onset. - **Brodie’s Abscess:** Intraosseous abscess, common in children near growth plates. - **Penumbra Sign:** Seen on T1-weighted MRI as an enhancing rim around an intraosseous abscess, further defined with contrast. The image below illustrates a T1-weighted MRI of osteomyelitis. ![T1 weighted MRI showing penumbra sign of Brodie’s abscess in tibial epiphyseal osteomyelitis.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-22T144520.635.png) T1-weighted MRI of osteomyelitis 💡 ****Tip:** ****FDG-PET:** Highly sensitive for detecting infected areas through increased metabolic activity. **Plain X-ray** Detects bone changes only after significant mineral loss (≥40%) and infection spread (≥1 cm). Findings include: - **Periosteal Reaction:** Formation of Codman’s triangle due to rapid periosteal elevation. - **Endosteal Scalloping and Osteopenia:** Indicators of chronic bone involvement. - Sequestrum and involucrum ![Radiological findings of osteomyelitis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-08T214550.876-1.png) Radiological findings of osteomyelitis --- ## Management of Osteomyelitis ****Key Point** ****Targeted antibiotic therapy** is the primary treatment for acute osteomyelitis. For ****subacute** and ****chronic** cases, effective management requires aggressive debridement and an orthoplastic approach, addressing both infection and structural defects. The **management of osteomyelitis** depends on the infection’s **acuity**. Acute osteomyelitis primarily involves antibiotics, while chronic or subacute cases require a combination of surgical debridement and reconstruction to eradicate infection and restore function. ### Acute Osteomyelitis In acute cases without abscess formation or bony sequestrum, antibiotics remain the mainstay. - **Targeted Therapy:** Antibiotics should be tailored based on culture results, with initial broad-spectrum coverage adjusted once the causative organism is identified. - **Duration:** Typically, a 6-week antibiotic course is required. Collaboration with microbiology helps refine the regimen. ### Subacute and Chronic Osteomyelitis Subacute and chronic osteomyelitis requires a combined approach, addressing both the infection and any associated bone or soft tissue defects. **Surgical Debridement** - **Bone Biopsies:** Should be taken before starting antibiotics to avoid masking pathogens. - **Pre-operative Imaging:** Guides the extent of debridement. - **Debridement Procedure:** All infected tissue, abscesses, and necrotic bone must be meticulously removed. **Reconstruction** - **Soft Tissue Coverage:** Essential to promote healing, prevent recurrence, and enhance antibiotic delivery. - **Tissue Flaps:** Local or distant flaps may be used to cover defects, ensuring robust coverage for optimal recovery. **Adjunctive Measures** - **Antibiotic-Impregnated Materials:** Sutures, spacers, and bone substitutes can assist with localized infection control. ![The single AP view of the femur, Osteomyelitis Management](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-08T214952.840.png) The single AP view of the femur **Post-operative Monitoring** involvesClinical observation, temperature tracking, and C-reactive protein (CRP) levels are used to assess recovery and guide the transition to oral antibiotics ([Gornitzky](https://pubmed.ncbi.nlm.nih.gov/33006465/?ref=theplasticsfella.com), 2020). 😎 ****Fun Fact:** Periosteal flaps, known for enhancing blood supply, can be used to support bone healing after debridement in cases of osteomyelitis ([Kakar](https://pubmed.ncbi.nlm.nih.gov/21268108/?ref=theplasticsfella.com), 2011). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition of Osteomyelitis:** Osteomyelitis is an infection of the bone, typically caused by bacteria such as Staphylococcus aureus and spread through direct inoculation, local soft tissue infection, or, less commonly, haematogenous spread, particularly in children. ****2\. Epidemiology of Osteomyelitis:** The incidence of osteomyelitis is around 8-20 cases per 100,000 annually. It affects males more frequently, with risk factors including diabetes, vascular disease, and IV drug use. ****3\. Presentation of Osteomyelitis:** Acute osteomyelitis presents with localized pain, swelling, fever, and systemic symptoms, while chronic cases involve persistent pain and reduced mobility, sometimes with sinus tract formation and drainage. ****4\. Investigations for Osteomyelitis:** Diagnosis is confirmed by bone biopsy and microbiology. MRI and FDG-PET are the most sensitive imaging techniques, while blood tests reveal elevated CRP, ESR, and WCC. ****5\. Management of Osteomyelitis:** Acute osteomyelitis is treated with targeted antibiotics, while chronic cases require surgical debridement and reconstruction, often using an orthoplastic approach to restore function and prevent recurrence. --- ## Further Reading 1. Gornitzky AL, Kim AE, O'Donnell JM, Swarup I. [Diagnosis and Management of Osteomyelitis in Children: A Critical Analysis Review](https://pubmed.ncbi.nlm.nih.gov/33006465/?ref=theplasticsfella.com). JBJS Rev. 2020 Jun;8(6):e1900202\. doi: 10.2106/JBJS.RVW.19.00202\. PMID: 33006465. 2. Smith IM, Austin OM, Batchelor AG. [The treatment of chronic osteomyelitis: a 10 year audit](https://pubmed.ncbi.nlm.nih.gov/16482785/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2006;59(1):11-5\. doi: 10.1016/j.bjps.2005.07.002\. PMID: 16482785. 3. Pinder R, Barlow G. [Osteomyelitis of the hand](https://pubmed.ncbi.nlm.nih.gov/26482914/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2016 May;41(4):431-40\. doi: 10.1177/1753193415612373\. Epub 2015 Oct 19\. PMID: 26482914. 4. Foong B, Wong KPL, Jeyanthi CJ, Li J, Lim KBL, Tan NWH. [Osteomyelitis in Immunocompromised children and neonates, a case series](https://pubmed.ncbi.nlm.nih.gov/34895166/?ref=theplasticsfella.com). BMC Pediatr. 2021 Dec 11;21(1):568\. doi: 10.1186/s12887-021-03031-1\. PMID: 34895166; PMCID: PMC8665553. 5. Momodu II, Savaliya V. [Osteomyelitis](https://www.ncbi.nlm.nih.gov/books/NBK532250/?ref=theplasticsfella.com#:~:text=Stage%201%3A%20Disease%20confined%20to,Stage%204%3A%20Diffuse%20disease). \[Updated 2023 May 31\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532250/ 6. Lindsay EA, Tareen N, Jo CH, Copley LA. [Seasonal Variation and Weather Changes Related to the Occurrence and Severity of Acute Hematogenous Osteomyelitis in Children](https://pubmed.ncbi.nlm.nih.gov/29045692/?ref=theplasticsfella.com#:~:text=Symptom%20onset%20occurred%20most%20commonly,020%29.). J Pediatric Infect Dis Soc. 2018 May 15;7(2):e16-e23\. doi: 10.1093/jpids/pix085\. PMID: 29045692. 7. Collins 2024, [Radiopedia osteomyelitis](https://radiopaedia.org/articles/osteomyelitis?lang=gb&ref=theplasticsfella.com), accessed October 2024. 8. Gornitzky AL, Kim AE, O'Donnell JM, Swarup I. [Diagnosis and Management of Osteomyelitis in Children: A Critical Analysis Review](https://pubmed.ncbi.nlm.nih.gov/33006465/?ref=theplasticsfella.com). JBJS Rev. 2020 Jun;8(6):e1900202\. doi: 10.2106/JBJS.RVW.19.00202\. PMID: 33006465. 9. Kakar S, Duymaz A, Steinmann S, Shin AY, Moran SL. [Vascularized medial femoral condyle corticoperiosteal flaps for the treatment of recalcitrant humeral nonunions](https://pubmed.ncbi.nlm.nih.gov/21268108/?ref=theplasticsfella.com). Microsurgery. 2011 Feb;31(2):85-92 ### Pressure Sores - Clinical Scenario URL: https://www.theplasticsfella.com/pressure-sores-clinical-scenario/ Last updated: 2024-11-07T10:15:51.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Clinical-Case-Main-Image--32--1.png) #### Clinical Scenario A 55-year-old male with paraplegia due to a spinal cord injury from a motor vehicle accident 10 years ago presents with a chronic, non-healing wound over his right ischial tuberosity. He has been bedbound for three months, attributed to recurrent urinary tract infections and worsening muscle spasticity. The wound has worsened over the past month, with purulent discharge and a malodor. His caregiver reports an increase in the wound’s size despite regular dressings. ****Objectives:** ****1\.** Understand the aetiology and risk factors of pressure ulcers, including immobility and comorbidities. ****2\.** Outline the assessment of pressure ulcers, including grading and clinical evaluation. ****3\.** Outline the principles of multidisciplinary management. ****4\.** Consider flap options available for reconstruction. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Halloween Special Edition: Firework Injuries, Pumpkin Carving, & Replants. URL: https://www.theplasticsfella.com/november-3rd/ Last updated: 2024-11-03T14:15:37.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/november-3rd/#a-letter-from-pfella) Trainee Support, No-BS Guide 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-3rd/#the-sunday-quiz) NEW ROUND! Start early! 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/november-3rd/#image-of-the-week) Pumpkin botox! 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/november-3rd/#technique-tip) How to quickly calculate burn depth. 5. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/november-3rd/#behind-the-fella) Episode released: 28 days in Gaza with Victoria Rose. 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/november-3rd/#what-does-the-evidence-say) What is the best way to carve a pumpkin? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/november-3rd/#articles-of-the-week) Thumb amputation from fireworks, hand injuries from pumpkin carving, & firework injury patterns: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/november-3rd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella Trainee Support, No-BS Guide 👋 ****Hey there!** Let’s cut to it. Training in plastic surgery isn’t just tough – it’s relentless. The cases, the exams, the endless hours, and somehow always needing more answers than you’re given. I know because I’ve been there. That’s why we’re launching ****“Trainee Support”** – a space where we get real about the challenges you’re facing and give you practical, straight-up advice every week. Here’s how it’s going to work. You send in your questions – no matter how specific or complicated – and every week we’ll dive into them, both in this newsletter and on the podcast. Whether it’s about handling tough cases, getting ready for exams, or just figuring out what’s next, we’re here to help you keep moving forward with confidence. ### Threads (Soon!) And here’s something exciting: **Trainee Support** will also be the warm-up for **Threads** – our invite-only community designed specifically for trainees. This is where we’ll go deeper, connect you with other trainees, and give you access to exclusive conversations and insights. We’re creating a space where you can share, learn, and get real support from people who are right there with you. Look out for our first “Trainee Support” issue coming soon. And if you’ve got a question or topic you’re wrestling with, hit reply – I’m all ears. With love, P'Fella ❤️ ## The Sunday Quiz NEW ROUND! Start Early! ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![How to Replant a Finger Amputation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image-1.png) How to Replant a Finger Amputation ## Image of the Week **Pumpkin Botox* 🖼️ ****Image of the Week** In this special Halloween edition, we take a look at this cartoon; Halloween prep gone “cosmetic" as our favorite jack-o’-lantern might need a little extra help! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Nobleworks-Botox-Pumpkin-Funny-Halloween-Card_1a1e07ab-a103-4638-8d1d-a53ca7c2b30e.5e3bbbbb7f6472ffd8562bf109e3f3e5.webp) [Source](https://www.walmart.com/ip/Nobleworks-Botox-Pumpkin-Funny-Halloween-Card/342665788?ref=theplasticsfella.com) ## Technique Tip **How to Quickly Calcluate Burn Depth* 🚑 ****Technique Tip of the Week** This edition looks at quickly assessing burn depth. ****\- Superficial:** Red, painful, blanches with no blisters — similar to a sunburn. ****\- Partial-thickness:** Blisters with a moist surface, blanches if superficial, mottled, and non-blanching if deep. ****\- Full-thickness:** Charred, leathery, and insensate — no blanching, minimal pain. Read our [burn depth article](https://www.theplasticsfella.com/burn-depth/) for an in-depth look. The image below shows the classification of burn depth👇 ![Burn Depth Classification Chart](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/image.png) Burn Depth Classification Chart ## Behind the ‘Fella **28 Days in Gaza: A Conversation with Ms Victoria Rose* 🎧 ****New episode out now!** ****28 Days in Gaza: A Conversation with Ms Victoria Rose** In our latest episode featuring Ms. Victoria Rose, we discuss her experiences as a plastic surgeon in Gaza. **What’s it like to handle complex trauma and reconstructive cases in such challenging conditions? How do surgeons manage under intense pressure and with limited resources?* Tune in as we address your requested questions and more! Subscribe on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /0:54 1× ## What Does the Evidence Say? **Best Way to Carve a Pumpkin* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. In this Halloween edition, we explore the science behind pumpkin processing — explore carving techniques and extraction of health-boosting compounds like carotenoids. Research on ****pumpkin carving and processing** has explored various aspects, from artistic techniques to scientific extraction methods. While some papers focus on the creative aspects of pumpkin carving for Halloween (Anton, 2013; Bill, 2010), others investigate more technical approaches. For instance, rotary cutters have been studied for efficient pumpkin peeling (Emadi & Yarlagadda, 2006). Several studies have examined the extraction of valuable compounds from pumpkins, particularly ****carotenoids** and ****α-tocopherol**, using methods such as enzyme-aided extraction (Ghosh & Biswas, 2016) and supercritical carbon dioxide extraction (Wang et al., 2017; Durante et al., 2014). The optimal conditions for extracting these compounds have been investigated, considering factors like ****temperature**, ****pressure**, and ****solvent** choice (Hakimzadeh & Abedi, 2022). These extraction techniques aim to preserve the nutritional and pharmacological properties of carotenoids, which are known for their health-promoting effects (Durante et al., 2014). Overall, pumpkin processing research spans from traditional carving methods to advanced extraction techniques for valuable compounds. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Injury Patterns and a Treatment Algorithm for Firework-Related Thumb Injuries** ([Cardenas](https://www.jhsgo.org/article/S2589-5141%2824%2900099-9/fulltext?ref=theplasticsfella.com#:~:text=found%20that%2015%25%20of%20injured,in%20considerable%20life%2Dlong%20impairment.), 2024) Firework blasts commonly cause severe hand injuries, with the thumb and first web space being most affected, often necessitating amputations, skin grafts, or flap reconstructions. ✅ ****Pumpkin Carving Knife Injuries: Trends and Incidence of Hand Injuries** ([Johnson](https://pubmed.ncbi.nlm.nih.gov/35930995/?ref=theplasticsfella.com), 2022) Pumpkin carving leads to thousands of hand injuries each fall, with 87.6% affecting the hand, especially the thumb and index finger. Injuries peak in late October, with young people (10–19 years) being most at risk. ✅ ****Firework Injuries: A Ten-Year Study on Incidence, Causes, and Prevention in India** ([Puri](https://pubmed.ncbi.nlm.nih.gov/18603491/?ref=theplasticsfella.com), 2009) Firework injuries, common during celebrations like Diwali in India, often impact unsupervised children aged 5-14\. Misuse and device failures are the main causes, with flares and fountains leading to injury cases. ## Feedback ### I hope you enjoyed it 😄 --- ### Osteomyelitis - Clinical Scenario URL: https://www.theplasticsfella.com/osteomyelitis-clinical-scenario/ Last updated: 2024-10-26T12:02:34.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Clinical-Case-Main-Image--31--1.png) #### Clinical Scenario A 70-year-old active runner, previously treated with internal fixation for an open tibial fracture on his right leg three months ago, now presents with progressive pain, swelling, and difficulty in weight-bearing. His initial injury was managed with a tibial plate fixation and direct wound closure. He reported gradual improvement until six weeks ago when he began experiencing increasing pain and weight-bearing difficulties. ****Objectives:** 1. Describe the comprehensive management approach for a patient with osteomyelitis. 2. Explain the different classifications of osteomyelitis and their clinical relevance. 3. Outline the pathophysiology of subacute and chronic osteomyelitis. 4. Identify and justify appropriate investigations for suspected osteomyelitis. 5. Discuss the orthoplastic principles in managing this case. _This post is for subscribers on the thePlastics Pro tier only._ ### 28 Days in Gaza, Journal Partnership & Technique Tips. URL: https://www.theplasticsfella.com/october-27th/ Last updated: 2024-10-26T12:49:12.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/october-27th/#a-letter-from-pfella) 5 Ideas for a Journal Partnership 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-27th/#the-sunday-quiz) How well do you know the **types & classification of flaps*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Image of the Week**](https://www.theplasticsfella.com/october-27th/#image-of-the-week) Reverse anterolateral thigh flap 4. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/october-27th/#technique-tip) Zitelli's geometric bilobed flap design 5. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/october-27th/#behind-the-fella) 28 Days in Gaza with Victoria Rose. 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/october-27th/#what-does-the-evidence-say) The best technique for scalp rotation flaps. 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-27th/#articles-of-the-week) Ponten publication on fasciocutaneous flaps, original Ziteli publication, & original Antia Buch publication: with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/october-27th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **5 Ideas for a Journal Partnership* 👋 ****Hey Team!** I’m super excited to let you know that we’re looking into a ****potential partnership with some big journals** to make evidence-based content way more accessible for all of you. But before we jump in, I really want your thoughts—your input is what will make this work best for everyone. From the feedback we’ve gotten, it’s pretty clear that some of the biggest barriers to using plastic surgery journals are **paywalls**, **too many logins**, **lack of concise content**, and sometimes, **relevance** to what you actually need day-to-day. These are real challenges, and we want to find **solutions** that really work for you. Imagine if getting high-quality, evidence-based info was simple, easy, and actually useful to your practice. ### How would you prefer to access more evidence-based content through our journal partnership? **Your voice is key to making this work**. Your feedback will help us create something that’s actually helpful and makes keeping up-to-date easier and more impactful. Let’s make this happen together. With love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Types & Classification of Flaps?** ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![How to Classify and Describe a Flap - A Mnemonic](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/image-5.png) How to Classify and Describe a Flap - A Mnemonic ## Image of the Week **Reverse Anterolateral Thigh Flap* 🖼️ ****Anatomy Illustration of the Week** In this section, we feature an anatomical illustration. This edition looks at a reconstruction option for the lower limbs: ****Reverse anterolateral thigh flap**. ![Mobilization of the flap, Reverse anterolateral thigh flap.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/1983-5175-rbcp-33-04-0493-gf03-en.jpg) [Source](https://www.rbcp.org.br/details/2214/reverse-anterolateral-thigh-flap--a-reconstruction-option-for-the-lower-limbs?ref=theplasticsfella.com) ## Technique Tip **Bilobed Flaps* 🚑 ****Technique Tip of the Week** This edition looks at Zitelli's geometric bilobed flap design. Read our [article](https://www.theplasticsfella.com/bilobed-flaps/) for an in-depth look at the bilobed flap technique and its applications. 👇 ![Comparision of the Esser (Left) and Zitelli (Right) Bilobed Flap Designs](https://lh7-rt.googleusercontent.com/docsz/AD_4nXfgGX5wrJCpWncJ6XMzy3_-5DV1VObSSmbjf9BXyOLfApde5N_DKp2wYnXdh8qM4L9JCl6vNi5Bp4Kiw91_SG3DiGrCJ8FXUjnvTeesE-T5THYmux7L2kJmQerR3pGONepidcuil4VZUnZFzKdkwNW3iyjb?key=VE6BXUZFwhQudikkPVwgwA) Comparison of the Esser (Left) and Zitelli (Right) Bilobed Flap Designs ## Behind the ‘Fella **28 Days in Gaza: A Conversation with Ms Victoria Rose* 🎧 ****Next Episode on Monday** ****28 Days in Gaza: A Conversation with Ms Victoria Rose** In our upcoming episode, we sit down with Ms. Victoria Rose to discuss her experiences as a plastic surgeon in Gaza. **What’s it like to handle complex trauma and reconstructive cases in such challenging conditions? How do surgeons manage under intense pressure and with limited resources?* Tune in as we address these questions and more, diving into the realities of frontline surgical care. Subscribe on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) on Monday 0:00 /0:48 1× Listen on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) on Monday. ## What Does the Evidence Say? **The Various Modifications of the Scalp Rotation Flap* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Scalp rotation flaps are effective for reconstructing complex soft tissue defects, providing ****hair-bearing skin** and respecting hairlines (Costa et al., 2015; Christopoulos et al., 2020). The design and measurements of these flaps are crucial for optimal outcomes. Traditionally, flaps are planned to be up to 8 times the defect diameter, but modified techniques like the "****snail flap**" can use smaller ratios (Christopoulos et al., 2020). Personalized computational models can predict mechanical stress and tension distribution in scalp flaps, potentially improving surgical planning (Lee et al., 2020). Various modifications, such as double-opposing unilobar rotation flaps, have been developed to address larger defects (Moulton-Barrett & Vanderschelden, 2015). Experimental studies have explored optimal flap designs, including the use of tissue expanders (Vendroux et al., 1977; Lo & Kimble, 2008). Geometric considerations are essential for successful reconstruction, with ****transposition flaps** being a reliable option for full-thickness scalp defects (Ahuja, 1988; Shah et al., 2022). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****The Original Ponten Publication for Fasciocutaneous Flaps** ([Pontén](https://www.sciencedirect.com/science/article/abs/pii/S0007122681800975?ref=theplasticsfella.com), 1981) The fasciocutaneous flap offers reliable vascular support for lower leg soft tissue reconstruction, enabling large, stable flaps with straightforward postoperative management and compatibility. ✅ ****The Original Zitelli Modification for Bilobed Flaps** ([Zitelli](https://jamanetwork.com/journals/jamadermatology/article-abstract/550671?ref=theplasticsfella.com), 1989) The bilobed flap is a double transposition flap ideal for covering defects on the lower third of the nose, addressing both functional and aesthetic needs with reduced risks of tissue protrusion and "pincushioning". ✅ ****The Original Antia-Buch Flap for the Ear** ([Antia](https://pubmed.ncbi.nlm.nih.gov/5336914/?ref=theplasticsfella.com), 1967) The chondrocutaneous advancement flap technique combines cartilage and skin advancement to restore form and function effectively in cases of ear deformities. ## Feedback ### I hope you enjoyed it 😄 --- ### Apert's Hand - Clinical Scenario URL: https://www.theplasticsfella.com/aperts-hand-clinical-scenario/ Last updated: 2024-10-23T11:26:58.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Clinical-Case-Main-Image--30--1.png) #### Clinical Scenario A 2-month-old child with a diagnosis of ****Apert syndrome** is referred to your paediatric hand clinic for evaluation and consideration of surgical intervention for their upper limb deformities. ****Objectives:** 1. Describe the key clinical features of ****Apert syndrome** with a focus on craniofacial and limb anomalies. 2. Discuss the detailed hand anomalies visible in the images. 3. List investigations necessary to assess the condition. 4. Explain the involvement of a multidisciplinary team (MDT) in the management of a child with Apert syndrome. 5. Outline surgical treatment options and their timing. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Wound Dressings - Clinical Scenario URL: https://www.theplasticsfella.com/wound-dressings-clinical-scenario/ Last updated: 2024-10-22T20:58:12.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Clinical-Case-Main-Image--28--1.png) #### Clinical Scenario A 97-year-old woman with well-controlled diabetes presents to the clinic with a sloughy wound on her right foot. The wound has been present for 3 months and has been dressed weekly in her nursing home. She is not a candidate for general aneasthesia due to her frailty and age. Her HbA1c is 5, her ankle-brachial index (ABI) is 0.9, and there are no signs of peripheral vascular disease. The wound is sloughy and superficial, with no exposed structures. ****Objectives:** 1. Take a relevant history from a patient with a chronic wound. 2. Discuss the clinical examination and necessary adjuncts for a chronic wound. 3. Identify non-surgical wound management strategies. 4. Select appropriate wound dressings as the wound evolves over time. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### CRPS - Clinical Scenario URL: https://www.theplasticsfella.com/crps-clinical-scenario/ Last updated: 2024-10-22T20:58:38.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Clinical-Case-Main-Image--27--1.png) #### Clinical Scenario A 51-year-old female presents with a 4-month history of persistent burning pain in her right hand following a distal radius fracture. The fracture was treated conservatively in a cast for 6 weeks. She reports that the pain has worsened since the cast was removed, and it radiates up her arm without a specific dermatomal pattern. The patient describes severe allodynia—simple touch, such as clothing brushing against the skin, causes extreme pain. She has also noticed swelling, a slight color change to her hand, and increased sweating. Past medical history includes a 10-year history of migraines and a diagnosis of osteoporosis, for which she is on alendronate. ****Objectives:** 1. Perform a focused history and clinical examination for the diagnosis of CRPS 2. Generate a differential diagnosis for her symptoms and justify each diagnosis. 3. Identify and justify key investigations that will confirm the diagnosis. 4. Formulate an appropriate management plan, including non-surgical and surgical interventions. 5. Discuss the potential complications of CRPS and their management. 6. Explore advanced theoretical aspects, including CRPS pathophysiology and the role of the sympathetic nervous system. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Plastic Surgery in Gaza, Burns, & New Podcast Episode URL: https://www.theplasticsfella.com/october-20th/ Last updated: 2024-10-20T08:43:42.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/october-20th/#a-letter-from-pfella) Plastic surgery in Gaza: Your questions, answered 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-20th/#the-sunday-quiz) New winner announcement! 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Illustration of the Week**](https://www.theplasticsfella.com/october-20th/#illustration-of-the-week) Subglottic inhalation injury 4. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/october-20th/#behind-the-fella) New episode: Oral exam guide with tips 5. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/october-20th/#the-fellows-corner) This week's feature: **Chemical burns* 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/october-20th/#what-does-the-evidence-say) What is the most accurate way to determine burn depth? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-20th/#articles-of-the-week) Pediatric hand burns, acute burn care, & crow's feet in corneal injury: 3 articles with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/october-20th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Plastic Surgery in Gaza: Your Questions, Answered* 👋 ****Hey Team!** I’m really excited to share that in an upcoming podcast episode, I’ll be chatting with a plastic surgeon working in Gaza. This conversation will focus on the unique challenges of practicing surgery in a conflict zone — where the work is as much about restoring lives as it is about saving them. Gaza is a complex region, with a lot of different perspectives, and we know there are so many layers to what’s happening there. But for this episode, we’re keeping the focus on plastic surgery. What’s it like to handle trauma and reconstructive cases in such an environment? **How do surgeons manage with limited resources and under intense pressure?** There is some evidence published on this topic in [PRS Journal](https://pmc.ncbi.nlm.nih.gov/articles/PMC10566911/?ref=theplasticsfella.com). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/image-4.png) Plastic surgery has a deep connection to wartime. Back in World War I, Sir Harold Gillies pioneered facial reconstruction for soldiers with devastating injuries. Then in World War II, Sir Archibald McIndoe pushed burn care forward, helping RAF pilots recover after severe injuries. The surgeon I’ll be speaking with continues that legacy in Gaza, dealing with modern-day war injuries like burns, blast trauma, and reconstructive challenges. I also want to hear from you! What would you like to ask a plastic surgeon working in Gaza? Send in your questions via the form below or social media, and let’s bring them into the conversation. With love, P'Fella ❤️ ## The Sunday Quiz **\*Drumroll🥁\* New Winner Announcement!* ****Congratulations to the Winner** of The Weekly Quiz! We're thrilled to announce the winner of this edition's quiz. After six rounds of questions on plastic surgery, our top scorer is ****Simba**! We'll be in touch with the winner soon. Thank you to everyone who participated! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Leaderboard-Team-Post-Template--2-.png) ****Are you ready to make it to the leaderboard?** Welcome to ****a fresh round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Signs of an inhalation injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/image-3.png) Signs of an inhalation injury ## Illustration of the Week **Subglottic Inhalation Injury* 🖼️ ****Anatomy Illustration of the Week** This section we feature an anatomical illustration. This edition looks at a subglottic inhalation injury. 👇 ![Inhalation Injury effect on the lungs](https://lh7-rt.googleusercontent.com/docsz/AD_4nXcQ1IO85HPlTBYsvZ4NYLaipmSVTaXQh_tZOzAqr_Y9KLLzImUHoiIMZ70DSKmpnXvII819hqz1KrZ1uQHDZd2ZBVH9kOU6hG8xdYQqzeJBremJhxbwBVeQpyxjxZvL3hlrbA7-s0ILJTWkbOp4R1iLcY1O?key=VE6BXUZFwhQudikkPVwgwA) Inhalation Injury effect on the lungs ## Behind the ‘Fella **New Episode: Oral Exam Guide with Tips* 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. Tune in to our latest episode featuring Prof Andy Hart. We get into the viva oral exam for plastic surgery trainees; preparation strategies, the exam process, and the dynamics between examiners and candidates with a focus on the FRCS exam. You can now listen on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /0:52 1× ## the Fellows' Corner **This Week's Focus:* ***Chemical Burns** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Chemical Burns**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Chemical-Burns-on-SKin.png) #### Chemical Burn [****Overview**](https://www.theplasticsfella.com/chemical-burns/#overview-of-chemical-burns) There are 4 main groups: acids, burns, organic solvents, and inorganic solvents. [****Features**](https://www.theplasticsfella.com/chemical-burns/#features-of-chemical-burns) The degree of chemical burn is dependent on the chemical, its concentration, and the extent of exposure. [****Complications**](https://www.theplasticsfella.com/chemical-burns/#complications-of-chemical-burns) Each chemical has specific secondary effects. For example, hydrofluoric acid has severe pain, low calcium, and raised potassium. [****Management**](https://www.theplasticsfella.com/chemical-burns/#management-of-chemical-burns) Treat with prompt & constant water irrigation (some exceptions!). After neutralisation, manage similar to a thermal burn. [Read the Article](https://www.theplasticsfella.com/chemical-burns/) ## What Does the Evidence Say? **Most Accurate Way to Determine Burn Depth* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Accurate burn depth assessment is crucial for determining treatment and prognosis. While ****clinical examination** remains the most common method, its accuracy ranges from 50-76% (Resch et al., 2014; Agarwal et al., 2018; Wyllie & Sutherland, 1991; Jaskille et al., 2009). Various techniques have been developed to improve accuracy, including ****thermography**, ****biopsy**, and laser Doppler imaging (****LDI**) (Monstrey et al., 2008; Devgan et al., 2006). ****Infrared thermometry** has shown promise in conjunction with clinical examination (Agarwal et al., 2018), while ****noncontact ultrasonography** demonstrated 96% accuracy in predicting healing within 3 weeks (Iraniha et al., 2000). ****Photographic evaluation** may be useful for early distance diagnosis, with 76% equivalence to clinical evaluation (Boccara et al., 2011). Despite the availability of advanced technologies, their adoption in U.S. burn centers is limited due to cost, availability, and perceived lack of evidence (Resch et al., 2014). LDI and ****indocyanine green video angiography** currently offer the most accurate data-supported estimates for burn depth assessment (Devgan et al., 2006). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Comparative Outcomes of Full Thickness vs. Split Thickness Skin Grafts in Pediatric Hand Burns** ([Alsaif](https://www.sciencedirect.com/science/article/pii/S0305417922002492?ref=theplasticsfella.com), 2023) In pediatric hand burns, FTSG reduce the risk of post-graft contracture and the need for surgical release, while STSG tend to provide better cosmetic results, including superior scar appearance and color. ✅ ****Current Approaches in Wound Assessment, Fluid Resuscitation, and Surgical Management** ([Davis](https://journals.lww.com/plasreconsurg/abstract/2024/04000/acute%5Fburn%5Fcare.41.aspx?ref=theplasticsfella.com), 2024) In acute burn care, plastic surgeons play a key role including wound assessment, systematic emergency management, precise fluid resuscitation, and wound closure with autografts or skin substitutes. ✅ ****Crow's Feet Sign as a Reliable Indicator of Corneal Injury in Patients with Facial Burns** ([Dancey](https://www.jprasurg.com/article/S1748-6815%2807%2900457-3/abstract?ref=theplasticsfella.com), 2008) In facial burns, the absence of the "Crow's feet sign" (preservation of skin creases around the eyes during forced eyelid closure) may indicate a corneal injury that requires an ophthalmological assessment. ## Feedback ### I hope you enjoyed it 😄 --- ### De Quervians: Presentation, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/de-quervians/ Last updated: 2024-10-23T11:40:23.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/de-quervians/#definition-of-de-quervians) de Quervain disease, also known as stenosing tenosynovitis, affects the first dorsal compartment of the wrist. [****Clinical Features**](https://www.theplasticsfella.com/de-quervians/#clinical-features-of-de-quervians) Presents with pain that is worsened by grasping, thumb abduction, and radial and ulnar deviation of the wrist. [****Investigations**](https://www.theplasticsfella.com/de-quervians/#investigations-for-de-quervians) Diagnosis is primarily clinical, using provocative tests such as Finkelstein and Eichoff. [****Treatment**](https://www.theplasticsfella.com/de-quervians/#treatment-of-de-quervians) First line treatment is conservative. Surgical release of the first write compartment can be done if conservative measures are not successful. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Definition of De Quervians ****Key Point** de Quervain disease, also known as stenosing tenosynovitis, affects the first dorsal compartment of the wrist, often seen in individuals with repetitive wrist movements or during pregnancy and postpartum. de Quervain's disease involves entrapment of the APL and EPB tendons in the first dorsal compartment due to inflammatory, attritional, and degenerative changes. - **Repetitive Movements:** Repeated thumb abduction, extension, and radial deviation increase stress on the tendons. - **Pathological Changes:** Thickened tendon sheaths compress the compartment, causing stenosing tenosynovitis. Fibrocartilage formation and myxoid degeneration further contribute to the condition. - **Systemic Factors:** Systemic inflammatory conditions like rheumatoid arthritis can sometimes exacerbate the pathology. It is also known as stenosing tendinitis, peritendinitis, styloid tenovaginitis, and stenosing tendovaginitis. ![1st compartment of wrist (abductor pollicis longus and extensor pollicis brevis)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-14T185449.403-1.png) Anatomical presentation of de Quervians The condition often affects women, particularly in late pregnancy or the postpartum period, due to specific repetitive movements and hormonal changes ([Shuaib](https://pubmed.ncbi.nlm.nih.gov/25148441/?ref=theplasticsfella.com), 2014). Other risk factors include: - Manual labor - Repetitive wrist movements - Activities requiring thumb stabilization ([Ilyas](https://pubmed.ncbi.nlm.nih.gov/18063716/?ref=theplasticsfella.com), 2007) 😎 ****Fun Fact:** Anatomical variations, such as septation in the first dorsal compartment, occur in 60% of symptomatic cases, while multiple APL tendons are present in 76% of patients. --- ## Clinical Features of De Quervians ****Key Point** de Quervain's disease presents with pain that is worsened by activities like grasping, thumb abduction, and radial or ulnar deviation of the wrist. **History** - Pain and tenderness localized to the radial styloid area. - Pain worsens with activities such as thumb abduction, grasping, and wrist deviation. - Bilateral involvement is common, especially in new mothers or caregivers. - Rare symptoms may include thumb triggering, locking, or development of a dorsal ganglion cyst. ![1st compartment of wrist (abductor pollicis longus and extensor pollicis brevis)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-24T131859.589.png) Presentation of de Quervians **Examination** - Swelling may be present proximal to the radial styloid. - Tenderness along the first dorsal compartment. - **WHAT Test:** Wrist hyperflexion and thumb abduction to provoke symptoms and confirm de Quervain's diagnosis. - **Finkelstein Test** and **Eichoff Test:** Highly sensitive for de Quervain’s tenosynovitis, aiming to reproduce sharp pain along the radial wrist. ![Comparison of Finkelstein Test and Eichoff Test: Highly sensitive for de Quervain’s tenosynovitis, aiming to reproduce sharp pain along the radial wrist.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-14T192653.686.png) Comparison of Finkelstein Test and Eichoff Test **Differential Diagnosis for Radial-Sided Wrist Pain** Differentiating de Quervain's from thumb CMC osteoarthritis is critical. In de Quervain's, pain is typically localized to the first dorsal compartment, while CMC arthritis involves the base of the thumb. - **Thumb Carpometacarpal Joint Osteoarthritis:** Typically presents with pain at the base of the thumb and crepitus on movement. - **Intersection Syndrome:** Pain is usually located more proximal to the radial styloid, with crepitus during wrist extension and radial deviation. - **Wartenberg Syndrome:** Involves compression of the superficial radial nerve, presenting with pain and paresthesia along the dorsum of the thumb. 😎 ****Fun Fact:** Histopathology of de Quervain's disease typically shows no inflammation, but instead thickening of the extensor tendons and the surrounding retinaculum ([Ilyas](https://pubmed.ncbi.nlm.nih.gov/18063716/?ref=theplasticsfella.com), 2007). 😎 ****Fun Fact:** Extensor triggering or locking of the thumb, as well as dorsal ganglion cyst formation, are rare but recognized presentations of de Quervain's disease. ([Ilyas 2007](https://pubmed.ncbi.nlm.nih.gov/18063716/?ref=theplasticsfella.com)) --- ## Investigations for De Quervains ****Key Point** Diagnosis is clinical: X-ray rules out fractures, ultrasound identifies septation, and MRI is for atypical cases. - **X-Ray:** Useful to rule out other causes of radial wrist pain, such as thumb CMC joint osteoarthritis or fractures. - **Ultrasound:** Highly effective for identifying septation in the first dorsal compartment, crucial for surgical planning to ensure a comprehensive release. Doppler ultrasound may help assess dynamic changes during wrist movement. - **MRI:** Reserved for atypical cases to assess for alternative diagnoses, including soft tissue tumors or other tenosynovitis. 💡 ****Tip:** Ultrasound is helpful for identifying septation in the first dorsal compartment to ensure complete release. 😎 ****Fun Fact:** Anatomical variations, such as septation or multiple APL tendons, are common in de Quervain's and can affect both non-operative and surgical management --- ## Treatment of De Quervains ****Key Point** First-line treatment is conservative, with surgical intervention considered when conservative measures fail to relieve symptoms. ### Non-Surgical Management - Rest and avoidance of aggravating activities (especially repetitive thumb movements). - Splinting (thumb spica splint) to immobilize and rest the affected tendons. - Nonsteroidal anti-inflammatory drugs (NSAIDs) to manage inflammation and pain. **Steroid Injections** Corticosteroid injection into the first dorsal compartment (shown to have up to 80% success rate in reducing symptoms, though recurrence is possible if activity modifications are not made). ![Steroid injections in De Quervains management](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-14T233937.648.png) Steroid injections in De Quervains management ### Surgical Treatment Surgical release if conservative treatment fails after 2-3 months or if persistent symptoms significantly impact function. The procedure overview is as follows: - **Incision:** The use of a zigzag or longitudinal incision - **Dissection:** protect the superficial radial nerve branches. - **Release:** Release of the fibro-osseous roof of the compartment to decompress APL and EPB tendons. Septation between APL and EPB must be carefully released to avoid incomplete decompression. ![Surgical release to decompress APL and EPB tendons in De Quervians ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-14T234212.228.png) Surgical release to decompress APL and EPB tendons in De Quervians In cases where a septum divides the APL and EPB, the surgeon must release both compartments to ensure complete pain relief. 💡 ****Tip:** A septum is often present between the APL and EPB tendons in the first dorsal compartment, reducing the space and impacting both operative and non-operative management. ### Complications - **Injury to the Superficial Radial Nerve:** Can result in neuroma and persistent pain. Managing scar sensitivity and preventing neuroma formation are crucial. - **Entrapment of the APL or EPB:** Incomplete release may lead to persistent symptoms. - **Tendon Subluxation:** Can occur if the retinaculum is excessively released. Proper post-operative monitoring and rehabilitation are needed to prevent this. 😎 ****Fun Fact:** Intraoperative identification of superficial radial nerve branches is critical to avoid neuroma formation, which can result in chronic pain --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview of De Quervain's Disease:** Explained de Quervain's disease as a form of stenosing tenosynovitis affecting the first dorsal compartment of the wrist. ****2\. Risk Factors and Epidemiology:** Highlighted pregnancy and manual labor as significant risk factors, with an increased prevalence observed in new mothers due to repetitive lifting motions. ****3\. Pathophysiology and Etiology:** Discussed the underlying causes of de Quervain's, focusing on the thickening and myxoid degeneration of the tendon sheaths. ****4\. Clinical Presentation and Diagnosis:** Detailed the typical presentation with diagnosis primarily based on clinical findings and confirmed through provocative tests like Finkelstein's test. ****5\. Treatment Approaches:** Outlined conservative treatments as the first line, with surgical intervention recommended for cases resistant to non-operative measures. ****6\. Potential Complications:** Noted possible complications from surgical treatment, such as injury to the superficial radial nerve and tendon subluxation. --- ## Further Reading 1. Satteson E, Tannan SC. [De Quervain Tenosynovitis](https://www.ncbi.nlm.nih.gov/books/NBK442005/?ref=theplasticsfella.com). \[Updated 2023 Nov 22\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK442005/](https://www.ncbi.nlm.nih.gov/books/NBK442005/?ref=theplasticsfella.com) 2. Suwannaphisit S, Chuaychoosakoon C. [Effectiveness of surgical interventions for treating de Quervain's disease: A systematic review and meta-analysis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9142670/?ref=theplasticsfella.com). Ann Med Surg (Lond). 2022 Apr 13;77:103620\. doi: 10.1016/j.amsu.2022.103620\. PMID: 35638053; PMCID: PMC9142670. 3. Shuaib W, Mohiuddin Z, Swain FR, Khosa F. [Differentiating common causes of radial wrist pain](https://pubmed.ncbi.nlm.nih.gov/25148441/?ref=theplasticsfella.com). JAAPA. 2014 Sep;27(9):34-6\. doi: 10.1097/01.JAA.0000451875.71319.17\. PMID: 25148441. 4. Ilyas AM, Ast M, Schaffer AA, Thoder J. [De quervain tenosynovitis of the wrist](https://pubmed.ncbi.nlm.nih.gov/18063716/?ref=theplasticsfella.com). J Am Acad Orthop Surg. 2007 Dec;15(12):757-64\. doi: 10.5435/00124635-200712000-00009\. Erratum in: J Am Acad Orthop Surg. 2008 Feb;16(2):35A. Ilyas, Asif \[corrected to Ilyas, Asif M\]. PMID: 18063716. ### Soft Tissue Sarcoma - Clinical Scenario URL: https://www.theplasticsfella.com/soft-tissue-sarcoma-clinical-scenario/ Last updated: 2024-10-15T20:41:32.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Scaroma-chest.png) #### Clinical Scenario A 55-year-old male presents with a progressively enlarging subcutaneous swelling located at the midline of the sternum, which has been increasing in size over the past year. The patient previously consulted a healthcare provider and was informed that the mass was likely a lipoma, with no follow-up recommended. Due to persistent growth, the patient has become increasingly concerned and is seeking further evaluation. ****Objectives:** 1. Outline the assessment of a patient presenting with a suspicious swelling on the trunk. 2. Detail the diagnosis and staging of soft tissue sarcomas. 3. Discuss the management of soft tissue sarcomas. 4. Discuss the reconstructive options for large sternal defects. 5. Discuss complications and follow-up in the management of soft tissue sarcomas. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow****.** ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow****.** _This post is for subscribers on the thePlastics Pro tier only._ ### Infantile Haemangioma - Clinical Scenario URL: https://www.theplasticsfella.com/infantile-haemangioma-clinical-scenario/ Last updated: 2024-10-11T20:04:32.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Clinical-Case-Main-Image--19-.png) #### Clinical Scenario A 2-month-old infant presents to the clinic with a large, 5x12 cm erythematous lesion on the upper limb. The parents are uncertain if it has been present since birth, but it appears to be growing as the patient grows. ****Objectives:** ****1\.** History and examination of an infantile hemangioma. ****2\.** Diagnosis and investigations for infantile hemangioma. ****3\.** Treatment options for infantile hemangioma. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow****.** ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Trigger Finger - Clinical Scenario URL: https://www.theplasticsfella.com/trigger-finger-clinical-scenario/ Last updated: 2024-11-12T19:03:48.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Clinical-Case-Main-Image--23--1.png) #### Clinical Scenario A 52-year-old man with a 10-year history of poorly controlled type 2 diabetes presents to the outpatient clinic, distressed by frequent locking of his right middle finger when trying to open a fist. His symptoms have progressively worsened over the past 6 months, and he now has to manually straighten the finger when it locks. As a mechanic, this issue is interfering with his work. He denies any recent trauma or hand injuries but notes occasional mild swelling around the affected joint. His HbA1c is 8.5%. ****Objectives:** ****1\.** Clinical examination of the hand. ****2\.** Understanding the pathophysiology of trigger finger. ****3\.** Clinical diagnosis of trigger finger. ****4\.** Discussion of management options. ****5.** Understanding surgical indications and techniques. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Mallet Finger - Clinical Scenario URL: https://www.theplasticsfella.com/mallet-finger-clinical-scenario/ Last updated: 2024-10-11T18:56:31.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Clinical-Case-Main-Image--24--1.png) #### Clinical Scenario A 67-year-old man presents with mild pain and inability to extend the tip of his middle finger after trapping it in a car door. The injury mechanism was low energy, leading to a closed mallet deformity. The patient has a background of basal thumb steoarthritis but no other associated injuries. ****Objectives:** 1. Plan appropriate investigations for a mallet injury. 2. Describe the difference between tendinous and bony mallet injuries. 3. Discuss the classification systems for mallet injuries. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### De Quervians - Clinical Scenario URL: https://www.theplasticsfella.com/de-quervians-clinical-scenario/ Last updated: 2024-10-11T17:27:11.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Wrist-pain.png) #### Clinical Scenario A 36-year-old right-handed woman presents with a 3-month history of progressively worsening radial wrist pain, primarily on her dominant side. She describes the pain as sharp and localized around the base of the thumb, and she has significant difficulty performing activities such as lifting her baby and opening jars. She recently gave birth and is currently breastfeeding. There is no history of trauma to the wrist, but she reports repetitive lifting and gripping associated with childcare. ****Objectives:** 1. Perform a comprehensive history focused on identifying risk factors and potential triggers for De Quervain's tenosynovitis. 2. Conduct a targeted physical examination and determine appropriate investigations to confirm the diagnosis and rule out differential conditions. 3. Develop a personalized treatment plan, considering both conservative and surgical options, tailored to the patient's postpartum status and functional needs. 4. Counsel the patient on the risks, benefits, and expected outcomes of various treatment approaches, including corticosteroid injections and surgical intervention if necessary. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### You Now Operate 10% Less Than 4 Years Ago, Z-Plasty Technique, & Student Textbook Updates URL: https://www.theplasticsfella.com/october-13th/ Last updated: 2024-10-11T14:08:56.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/october-13th/#a-letter-from-pfella) You now operate 10% less than 4 years ago 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-13th/#the-sunday-quiz) How well do you know **angiosomes*? 3. ****🚑** [****Technique Tip**](https://www.theplasticsfella.com/october-13th/#technique-tip) Tip for Z-plasty flap design 4. ****📚** [****Book Review**](https://www.theplasticsfella.com/october-13th/#book-review) A Student Guide by P'Fella 5. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/october-13th/#the-fellows-corner) This week's feature: **Tissue expansion* 6. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/october-13th/#what-does-the-evidence-say) How much LA can we actually use? 7. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-13th/#articles-of-the-week) Quick LA calculation, original angiosomes publication , & the delay phenomenon: 3 articles with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/october-13th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **You now operate 10% less than 4 years ago.* 👋 ****Hey Team!** Looking at the data from the last few years, one thing is clear: Plastic surgery trainees in the UK are operating ****10%** less than they were in 2019\. That’s a significant reduction, and it’s part of a broader trend across various surgical specialties. Let's dive into the numbers and what they really mean. In 2020, elective surgeries plummeted across the board, with many specialties seeing their operating numbers drop to **60-70%** of 2019 levels. This decline is evident in almost all surgical disciplines, and although there’s been some recovery in 2021 and 2022, plastic surgery still lags by about 10% compared to pre-pandemic levels. ![](https://lh7-rt.googleusercontent.com/docsz/AD_4nXc4pGPibAqX_FLc0dh_UERy3Yp0mEjZ_O4GdKosYxhnJozsrmDXFfdqi__xEPGxDqu8e9jwj1AJpAlPDkeWQzvZhU9K0QSRLW9b9dV19QzyR1Vn8Cn9CpUOGprjD5x8kJyiMmePSvMKTCA3prP6rZCiKgY?key=VE6BXUZFwhQudikkPVwgwA) Source: [https://x.com/Schoolofsurg/status/1843670160668033278/photo/1](https://x.com/Schoolofsurg/status/1843670160668033278/photo/1?ref=theplasticsfella.com) Other specialties, like **general surgery** and **orthopedics**, have bounced back more effectively, nearing their 2019 levels by 2023\. However, plastic surgery, along with a few others, remains behind. The lost experience, represented visually in the data, points to a significant gap in surgical exposure that trainees have yet to fully recover. ### Why is this happening? - **Consultant-Centric Operating:** With a surgical backlog to clear, consultants are often forced to take on more cases themselves, limiting the number of cases trainees can lead or even assist on. With fewer opportunities to be in the operating room, trainees miss out on the hands-on experience that’s critical to their education. - **Fewer Elective Lists:** Many consultants have fewer elective lists compared to four years ago. This could be due to a number of factors, including staffing shortages, bed pressures, and a need to reduce waiting times for essential surgeries. This drop in available lists directly impacts how many cases trainees can participate in. - **Post-COVID Prioritization:** During the pandemic, hospitals shifted their focus to urgent and emergency cases. As a result, elective surgeries — which are crucial for trainee development — were drastically cut back. Even now, hospitals are still feeling the pressure to prioritize these urgent cases, leaving less room for elective lists where trainees can gain experience. ### So, what can we do about it? - **Incorporate Simulation-Based Training:** High-fidelity simulations can help bridge the gap in lost OR time. While nothing replaces real-world experience, advanced simulations can provide critical skills training, especially in complex plastic surgery procedures. - **Maximize the Learning from Each Case:** Since the number of elective surgeries isn’t likely to rise quickly, we need to make every case count. Trainees should be involved in every aspect of the surgery — from pre-op to post-op — to ensure they gain as much experience as possible from each case. - **Create Trainee-Focused Lists:** We need to push for more operating lists that are specifically designed for trainee development, where trainees take the lead on surgeries under supervision. This will ensure they get the experience they need while still contributing to the hospital’s surgical output. The numbers show the challenge, but with the right focus, we can turn things around and make sure our future surgeons are ready to lead. Best, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Angiosomes** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Original Taylor Publication in British Journal of Surgery: Angiosomes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/image-2.png) Original Taylor [Publication](https://pubmed.ncbi.nlm.nih.gov/3567445/?ref=theplasticsfella.com) in British Journal of Surgery ## Technique Tip **Tip for Z-Plasty Flap Design* 🚑 ****Technique Tip of the Week** When designing a Z-Plasty, ensure the central limb is aligned along the contracture, with ****two diagonal limbs** branching off at angles typically around ****60°**. This design helps increase the length of the scar while reorienting it. The angle of the limbs determines the amount of length gained, but remember that larger angles may cause more ****transverse shortening**. For optimal outcomes, ensure there is enough ****transverse skin laxity** and keep the flap base wide to minimize complications like flap necrosis. 👇 ![Z-Plasty Flap Design](https://lh7-rt.googleusercontent.com/docsz/AD_4nXdDfr3OzmTUujnytGYt-qC1xZPy0j8PqtOyoyvIqmZWNOpQmVG23SLdN6P9IMA8n3DGI_E1TCnMATylWmAL28GcGgDt7J2_wWaamRzmyuc38SFSReUPPVjywvtFQD4BAcVeuB3Mz6aZ1kYuSILDTdlvU82G?key=VE6BXUZFwhQudikkPVwgwA) Z-Plasty Flap Design ## Book Review *A Student Guide by P'Fella* We’re launching an initiative targeting medical students with a three-pronged approach: **theory**, **practice**, and **mentorship**. We'd like your support with the first step, a comprehensive plastic surgery student manual/guide. Let us know your thoughts and experiences with textbooks below 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/2.png) Email ****tara@theplasticsfella.com** if you are interested in getting involved. If you're interested in building our textbook for students, email *tara@theplasticsfella.com.* ## the Fellows' Corner **This Week's Focus:* ***Tissue Expansion** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Tissue Expansion**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/image-1-1.png) #### Tissue Expansion 1. [****Definition**](https://www.theplasticsfella.com/tissue-expansion/#definition-of-tissue-expansion) 2. [****Mechanism of Tissue Expansion**](https://www.theplasticsfella.com/tissue-expansion/#mechanism-of-tissue-expansion) 3. [****Changes in Tissue Expansion**](https://www.theplasticsfella.com/tissue-expansion/#changes-in-tissue-expansion) 4. [****Capsule Formation**](https://www.theplasticsfella.com/tissue-expansion/#capsule-formation) 5. [****Types of Tissue Expanders**](https://www.theplasticsfella.com/tissue-expansion/#types-of-tissue-expanders) 6. [****Clinical Indications**](https://www.theplasticsfella.com/tissue-expansion/#clinical-application-of-tissue-expanders) [Read the Article](https://www.theplasticsfella.com/tissue-expansion/) ## What Does the Evidence Say? **How much LA can we actually use?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Local anesthetic**s are widely used in plastic surgery, but calculating safe volumes can be challenging. The '****WiMP**' formula (****V = W.1M/P**) was developed to simplify this process (Diver, 2008). Other methods include a simple formula for bupivacaine (Wilson & Oliver, 2009) and a nomogram for calculating maximum doses (Williams & Walker, 2014). Studies have shown that large volumes of dilute lidocaine can be safely used in liposuction, with mean doses of 33.3 mg/kg reported without complications (Klein, 1993). In a study of 322 patients undergoing liposuction and abdominoplasty, maximum lidocaine and bupivacaine doses of 3243 mg and 550 mg, respectively, were used without clinical toxicity (Swanson, 2012). For dermatologic procedures, mean lidocaine volumes of 3.44 mL for excision and 11.70 mL for reconstruction were reported, with an extremely low incidence of adverse events (Alam et al., 2016). These findings suggest that local anesthetics can be safely used in various plastic surgery procedures when appropriate guidelines are followed. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****How to Use the "WiMP" Formula to Calculate the Maximum Safe Volume of Local Anesthetic** ([Diver](https://www.jprasurg.com/article/S1748-6815%2808%2900106-X/abstract?ref=theplasticsfella.com), 2008) The "WiMP" formula calculates the maximum safe volume of local anesthetic you can use: multiply the patient's weight (in kg) by 0.1, then by the maximum dose of the anesthetic (in mg/kg), and divide by the concentration of the anesthetic solution. ✅ ****Angiosomes and Hidden Skin Flap Potential, with 374 Major Perforator Arteries Mapped** ([Taylor & Palmer](https://pubmed.ncbi.nlm.nih.gov/3567445/?ref=theplasticsfella.com), 1987) The original publication of angiosomes: The skin and deeper tissues are supplied by a complex, three-dimensional network of vessels, which can map tissue zones for reconstructive surgery. ✅ ****Surgical Delay of a Flap: Theory behind the Delay phenomenon** ([Pearl](https://pubmed.ncbi.nlm.nih.gov/6457549/?ref=theplasticsfella.com), 1981) Pearl’s 1981 study suggests that delaying a surgical flap clears norepinephrine from the tissue, reducing vasoconstriction and improving blood flow during transfer, which enhances flap survival. ## Feedback ### I hope you enjoyed it 😄 --- ### Lymphoedema - Clinical Scenario URL: https://www.theplasticsfella.com/lymphoedema-clinical-scenario/ Last updated: 2024-11-07T10:23:14.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Clinical-Case-Main-Image--26-.png) #### Clinical Scenario A 48-year-old female presents with a 3-month history of progressive swelling in her left arm. She underwent a left mastectomy and axillary lymph node dissection for breast cancer 6 months prior. Initially, the swelling improved with elevation but has since worsened, leading to significant discomfort and impaired daily functioning. The patient also reports a sensation of heaviness and tightness in the affected arm. ****Objectives:** 1. Provide a comprehensive clinical assessment of lymphoedema. 2. Grade the severity of lymphoedema. 3. Evaluate surgical options for lymphoedema management. 4. Discuss post-operative complication management. 5. Outline the fundamental principles of Vascularized Lymph Node Transfer (VLNT). ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Lymphoedema: Anatomy, Diagnosis, & Management URL: https://www.theplasticsfella.com/lymphoedema/ Last updated: 2024-11-06T10:39:04.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/lymphoedema/#definition-of-lymphoedema) Lymphoedema is a chronic condition caused by impaired lymphatic drainage, resulting in progressive swelling, primarily affecting the limbs. [****Overview of the Lymphatic System** ](https://www.theplasticsfella.com/lymphoedema/#overview-of-the-lymphatic-system)Lymphoedema primarily affects the superficial, epifascial lymphatic system, while the subfascial system remains largely uninvolved. [****Types of Lymphoedema**](https://www.theplasticsfella.com/lymphoedema/#types-of-lymphoedema) Primary lymphoedema results from congenital or genetic abnormalities, while secondary lymphoedema arises due to external factors such as surgery, radiation, infections, trauma, or malignancy. [****Pathophysiology**](https://www.theplasticsfella.com/lymphoedema/#pathophysiology-of-lymphoedema) Lymphoedema involves lymphatic obstruction, inflammation, fibrosis, adipose deposition, and impaired lymphangiogenesis, with non-specific histologic changes such as dermal edema and hyperkeratosis. [****Grading**](https://www.theplasticsfella.com/lymphoedema/#grading-of-lymphoedema) Lymphoedema grading is based on symptoms, reversibility, and the chronicity of the condition. [****Clinical Features**](https://www.theplasticsfella.com/lymphoedema/#clinical-features-of-lymphoedema) Patients with lymphoedema typically present with swelling, heaviness, skin changes, and frequent infections. Diagnosis requires a thorough history and clinical examination. [****Management**](https://www.theplasticsfella.com/lymphoedema/#management-of-lymphoedema) First-line treatment for lymphoedema is complete decongestive therapy (CDT), with surgery reserved for severe, debilitating cases or specific patient groups. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Lymphoedema ****Key Point** Lymphoedema is a chronic condition caused by impaired lymphatic drainage, resulting in progressive swelling, primarily affecting the limbs. Lymphoedema is characterized by **protein-rich fluid accumulation** in tissues, leading to swelling and tissue changes over time. Lymphoedema arises from the abnormal buildup of protein-rich fluid in the interstitial space due to impaired lymphatic drainage. This blockage increases protein levels in the tissues, causing water retention and soft tissue swelling. The elevated protein content promotes **fibroblast activity**, which contributes to fluid organization and the development of non-pitting swelling in the affected areas. This chronic process leads to progressive limb enlargement, as seen in the image below. ![Lymphoedema, elephantiasis, lower limb swelling](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-07T233714.818.png) Left sided lymphoedema 😎 ****Fun Fact:** ****Elephantiasis Nostra Verrucosa** (ENV) is a rare skin condition from chronic lymphoedema, marked by thick, hardened, wart-like skin ([Fredman](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479949/?ref=theplasticsfella.com), 2012). --- ## Overview of the Lymphatic System ****Key Point** Lymphoedema primarily affects the superficial, epifascial lymphatic system, while the subfascial system remains largely uninvolved. ### Normal Lymphatic System **Normal Anatomy** - **Lymphatic Capillaries:** Blind-ended capillaries begin in the dermal papillae's interstitial spaces. These unvalved capillaries drain into interconnected subdermal channels. - **Epifascial System:** Running parallel to the superficial venous system, this system consists of valved trunks with smooth muscle cells located above the deep fascia. It drains lymph from the skin and subcutaneous tissues. - **Subfascial System:** Parallels the deep venous system and drains lymph from deeper structures like muscles, joints, periosteum, and bones. Although it operates independently from the epifascial system, the two systems connect in regions such as the popliteal, inguinal, antecubital, and axillary areas ([Null](https://europepmc.org/article/NBK/nbk513247?ref=theplasticsfella.com), 2023). **Normal Flow** Lymph flow is facilitated by variations in tissue pressure, driven by: - Skeletal muscle contractions - Pulsatile blood flow - Smooth muscle contractions around larger lymphatic channels ### Abnormal Lymphatic System - Lymphoedema primarily affects **the epifascial system.** - The subfascial system usually remains uninvolved. - Reverse flow through perforators decompresses the epifascial system. - Surgical interventions are focused on addressing the **epifascial system**. --- ## Types of Lymphoedema ****Key Point** Primary lymphoedema results from congenital or genetic abnormalities, while secondary lymphoedema arises due to external factors such as surgery, radiation, infections, trauma, or malignancy. Lymphoedema is classified as either primary or secondary, depending on the underlying cause. ### Primary Lymphoedema Primary lymphoedema is a chronic condition caused by congenital or genetic abnormalities that affect lymphatic system development. It can be divided into three main types: - **Congenital (Milroy Disease):** Accounts for 10% of primary lymphoedema. It is present at birth and often associated with mutations in the FLT4 gene, affecting lymphatic development. - **Lymphoedema Praecox (Meige Disease):** Typically develops between puberty and age 35, most commonly in women. - **Lymphoedema Tarda:** Occurs after the age of 35\. Its cause is often unknown, but it is linked to hormonal changes or obesity in many cases ([Warren](https://pubmed.ncbi.nlm.nih.gov/17901744/?ref=theplasticsfella.com), 2007). **Primary lymphoedema is more common in females**. Advances in molecular genetics have identified nine causal mutations, highlighting the need for a phenotype-based classification system in the future. An example of bilateral primary lymphoedema is shown in the image below. ![Bilateral lymphoedema, primary lymphoedema](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-07T234001.789.png) Lymphoedema Tarda ### Secondary Lymphoedema Secondary lymphoedema is a chronic condition that develops when the lymphatic system is damaged or obstructed by external factors. The most common secondary cause is **iatrogenic** \- in particular oncological lymph node surgery. More specifically: - After **breast cancer surgery**, occurs in \~5% of cases after sentinel lymph node biopsy, \~20% after axillary lymphadenectomy, and up to 40% with combined axillary lymphadenectomy and radiation ([Petronic-Rosic](https://pubmed.ncbi.nlm.nih.gov/36314715/?ref=theplasticsfella.com), 2022) - After **gynecological cancer surgery**, occurs in 37% of cases likely due to lymph node dissection, chemotherapy, and radiotherapy ([Hayes](https://doi.org/10.1016/j.ygyno.2017.06.004?ref=theplasticsfella.com), 2017). Other causes to consider include: - **Infections:** Filariasis (caused by *Wuchereria bancrofti*) and tuberculosis - **Trauma:** Damage to lymphatic vessels - **Malignancy:** Obstruction of lymphatic drainage pathways 😎 ****Fun Fact:** Globally, filariasis is the leading cause of lymphoedema, while in high-income countries, it’s mostly iatrogenic from oncological treatments and interventions. --- ## Pathophysiology of Lymphoedema ****Key Point** Lymphoedema involves lymphatic obstruction, inflammation, fibrosis, adipose deposition, and impaired lymphangiogenesis, with non-specific histologic changes such as dermal edema and hyperkeratosis. Lymphoedema results from a combination of mechanisms that lead to tissue changes over time: - **Lymphatic Obstruction:** The initial blockage of lymphatic vessels leads to the accumulation of protein-rich interstitial fluid, causing swelling in the affected area ([Brown](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10233555/?ref=theplasticsfella.com), 2023). - **Inflammation and Fibrosis:** Inflammatory cytokines, such as TNF-α and IL-6, accumulate, leading to chronic inflammation. Macrophages infiltrate the tissues, resulting in increased deposition of collagen and extracellular matrix, which ultimately leads to fibrosis. - **Adipose Tissue Deposition:** Increased adipogenesis occurs in the affected limb, contributing to both limb enlargement and tissue stiffness. - **Impaired Lymphangiogenesis:** The formation of new lymphatic vessels is disrupted, worsening lymphatic stasis. Over time, the lymphatic vessels themselves become sclerotic and lose functionality ([Grada](https://pubmed.ncbi.nlm.nih.gov/29132848/?ref=theplasticsfella.com), 2017). ### **Histologic Findings** Although there is no pathognomonic histologic feature of lymphoedema, the following non-specific changes are often observed: - Dermal edema (more pronounced in earlier stages) - Hyperkeratosis - Epidermal papillomatosis and hyperplasia - Telangiectasia with thickened-walled dermal vessels - Thickened upper dermis with fibrillar collagen and increased fibroblast numbers ([Sleigh](https://europepmc.org/article/nbk/nbk537239/?ref=theplasticsfella.com), 2019) 😎 ****Fun Fact:** ****Stewart-Treves syndrome** is a rare complication of chronic lymphoedema, leading to ****lymphangiosarcoma**. While often linked to post-mastectomy lymphoedema, it can arise from any chronic lymphoedema ([Murgia](https://pubmed.ncbi.nlm.nih.gov/29939610/?ref=theplasticsfella.com), 2023). --- ## Grading of Lymphoedema ****Key Point** Lymphoedema grading is based on symptoms, reversibility, and the chronicity of the condition as per the International Society of Lymphology (ISL) staging system. Lymphoedema is a progressive condition, and its severity is classified by the International Society of Lymphology (ISL) staging system ([ISL](https://pubmed.ncbi.nlm.nih.gov/39207406/?ref=theplasticsfella.com), 2023): - **Stage 0 (Latency):** Subclinical stage where lymphatic drainage is impaired, but limb size appears normal. Patients may experience a sensation of heaviness or tightness without visible swelling. - **Stage I (Pitting Edema):** Characterized by reversible swelling that improves with limb elevation. The accumulated fluid is protein-rich, promoting inflammation and activation of fibroblasts, but the swelling remains soft and pitting. - **Stage II (Non-Pitting Edema):** Swelling becomes permanent and non-pitting due to the development of fibrosis. The affected tissues harden as collagen is deposited and adipose tissue proliferates, making the condition irreversible without intervention. - **Stage III (Lymphostatic Elephantiasis):** The most severe form of lymphoedema, characterized by significant swelling, fibrosis, hyperkeratosis, papillomatosis, and wart-like skin changes. Chronic inflammation leads to sclerosis of lymphatic vessels, causing severe functional impairment and deformity. The stages represent a continuum of worsening severity, as illustrated in the image below. ![Lymphoedema, post-axillary dissection, non-pitting oedema](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-07T234252.226.png) Progression of lymphoedema following left sided Axillary lymphadenectomy --- ## Clinical Features of Lymphoedema ****Key Point** Patients with lymphoedema typically present with swelling, heaviness, skin changes, and frequent infections. Diagnosis requires a thorough history and clinical examination, including circumferential limb measurements. ### History A detailed history is crucial. For suspected primary lymphoedema, family history is key. Other potential causes, such as cancer, surgery, injuries, and severe burns, should also be ruled out. A **typical** **presentation** of lymphoedema is: - **Swelling:** Gradual onset, often unilateral but can be bilateral, especially in congenital lymphoedema. - **Heaviness and Aching:** Affected limbs often feel heavy and achy. - **Frequent Infections:** The compromised immune response in the affected area makes infections more likely. Several syndromes are associated with lymphoedema, including: - **Turner Syndrome:** Features short stature, webbed neck, and lymphoedema. - **Noonan Syndrome:** Involves short stature, congenital heart defects, and lymphoedema. - **Klippel-Trenaunay Syndrome:** port-wine stain, varicose veins, lymphoedema. - **Yellow Nail Syndrome:** Involves lymphoedema, yellow, thickened nails, and respiratory abnormalities. ### Clinical Examination On clinical examination, the following should be noted: - **Inspection:** dry, thickened skin, hyperkeratosis, lymphangiomas (lymph fluid-filled blisters), and papillomatosis, which can cause a cobblestone-like appearance, darkened skin, lymphorrhea. - **Palpation:** increased warmth, a positive Stemmer's sign. ![Stemmer's sign in the clinical examination of lymphoedema, lymphoedema diagnosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-10T173446.719.png) Stemmer's sign in the clinical examination of lymphoedema **Circumferential limb measurements** using fixed anatomical landmarks: - ≥**2 cm increase** or **10% increase** indiagnoses of lymphoedema ([Houwen](https://www.liebertpub.com/doi/full/10.1089/lrb.2019.0082?ref=theplasticsfella.com), 2022). - **Mild to Moderate:** Less than a 20% difference in the affected limb. - **Severe:** More than a 20% difference. ![Diagnosis of lymphoedema requires a circumferential limb measurements](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-10T174150.061.png) Diagnosis of lymphoedema requires a circumferential limb measurements ### Investigations - **Lymphoscintigraphy:** The gold standard for assessing the lymphatic system. It measures radiolabeled Technetium-99m colloid uptake, helping define lymphatic anatomy and evaluate flow dynamics without causing tissue damage. - **ICG Lymphangiography:** Offers real-time visualization of lymphatic flow patterns. It is invasive and mainly used intraoperatively due to its potential to worsen the disease. MRI can be used in certain circumstances as illustrated below. ![MRI can be used in certain circumstances in diagnosing lymphoedema](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/Main-Article-Images---2024-10-10T174611.658.png) MRI can be used in certain circumstances in diagnosing lymphoedema **Other diagnostic tools** include bioimpedance spectroscopy, perometry, & skin tonometry. 💡 ****Tip:** A ****positive Stemmer's sign** refers to the inability to pinch a fold of skin at the base of the second toe or middle finger — a hallmark of lymphoedema ([Goss](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635205/?ref=theplasticsfella.com), 2019). --- ## Management of Lymphoedema ****Key Point** First-line treatment for lymphoedema is complete decongestive therapy (CDT), with surgery reserved for severe, debilitating cases or specific patient groups. ### Non-Surgical Management Non-surgical treatment is the cornerstone of lymphoedema management, aiming to prevent disease progression and alleviate symptoms. **Complete Decongestive Therapy (CDT):** - **Phase I (Reduction):** Intensive treatment with a lymphoedema specialist, including manual lymphatic drainage, compression therapy, skin care, and physiotherapy. - **Phase II (Maintenance):** Focuses on patient self-care, including skin care, use of compression garments, self-lymph drainage, and physical exercise. - **Effectiveness:** Although time-consuming and requiring patient commitment, CDT remains the most effective management strategy for lymphoedema ([Lasinski](https://www.sciencedirect.com/science/article/abs/pii/S0749208112000836?ref=theplasticsfella.com), 2013). **Pharmacological Agents:** Some agents, such as benzopyrones and retinoids, may be used alongside conservative treatments, but they come with potential complications due to toxicity. ### Surgical Treatment Surgical interventions are considered for late-stage lymphoedema or when conservative measures fail to control the condition. **Direct Excision (e.g., Charles Procedure):** Involves excising excess adipose tissue and requires lifelong post-operative compression therapy. It carries risks, such as infection and poor cosmetic outcomes, and is reserved for severe cases. **Liposuction:** Targets excess adipose tissue and reduces limb volume. **Vascularized Lymph Node Transfer (VLNT):** Involves transferring lymph nodes from one area (e.g., groin, submental region) to the affected region to restore lymphatic function. Minimally invasive super microsurgical techniques have shown symptom improvement and limb volume reduction in many cases. **Lymphovenous Anastomosis (LVA):** A microsurgical technique that creates a bypass between lymphatic vessels and venules, restoring lymph flow. It is most effective in early-stage cases with functional lymphatic channels. ### Outcomes Both LVA and VLNT have shown promising results in reducing limb volume and improving symptoms, though further research is needed to standardize protocols ([Carl](https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0037-1599100?ref=theplasticsfella.com), 2017). 💡 ****Tip:** Patient-reported tools assess the impact of lymphoedema on quality of life. The most widely used are: ****\- LYMQOL:** A 21-question tool for upper and lower limb lymphoedema. ****\- ULL-27:** A validated tool for breast cancer-related lymphoedema. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition:** Lymphoedema is a chronic condition characterized by the accumulation of protein-rich fluid due to impaired lymphatic drainage, leading to swelling, primarily in the limbs. ****2\. Lymphatic Anatomy:** It primarily affects the superficial epifascial lymphatic system, which consists of networks running parallel to the superficial venous system. ****3\. Types of Lymphoedema:** There are two main types. Primary lymphoedema is caused by congenital or genetic abnormalities. Secondary Lymphoedema results from external damage to the lymphatic system. ****4\. Pathology:** The condition involves lymphatic obstruction and inflammation, leading to fibrosis and adipose deposition, which impair lymphangiogenesis and exacerbate fluid accumulation. ****5\. Clinical Features and Diagnosis:** Symptoms include limb swelling, heaviness, and skin changes like thickening and hyperpigmentation. Diagnosis is primarily clinical, supported by imaging. ****6\. Management:** The primary treatment is complete decongestive therapy, which includes manual lymphatic drainage, compression therapy, and exercise. Severe cases may require surgical interventions. --- ## Further Reading 1. Null, Manda, and Manuj Agarwal. "[Anatomy, lymphatic system](https://europepmc.org/article/NBK/nbk513247?ref=theplasticsfella.com)." (2018). 2. Keeley, Vaughan, et al. "[A quality of life measure for limb lymphoedema (LYMQOL).](https://lymphoedemaeducation.com.au/wp-content/uploads/2019/03/JoL%5FQuality%5Fof%5FLife%5FMeasures1.pdf?ref=theplasticsfella.com)" *Journal of Lymphoedema* 5.1 (2010): 26-37. 3. Warren AG, Brorson H, Borud LJ, Slavin SA. [Lymphedema: a comprehensive review](https://pubmed.ncbi.nlm.nih.gov/17901744/?ref=theplasticsfella.com). Ann Plast Surg. 2007 Oct;59(4):464-72\. doi: 10.1097/01.sap.0000257149.42922.7e. PMID: 17901744. 4. Petronic-Rosic V. [Treatment of Skin Disease: Comprehensive Therapeutic Strategies.](https://pubmed.ncbi.nlm.nih.gov/36314715/?ref=theplasticsfella.com) Skinmed. 2022 Oct 31;20(5):400\. PMID: 36314715. 5. Hayes, S. C., Janda, M., Ward, L. C., Reul-Hirche, H., Steele, M. L., Carter, J., Quinn, M., Cornish, B., & Obermair, A. (2017). [Lymphedema following gynecological cancer: Results from a prospective, longitudinal cohort study on prevalence, incidence and risk factors](https://doi.org/10.1016/j.ygyno.2017.06.004?ref=theplasticsfella.com). *Gynecologic oncology*, *146*(3), 623–629\. https://doi.org/10.1016/j.ygyno.2017.06.004 6. Brown S, Campbell AC, Kuonqui K, Sarker A, Park HJ, Shin J, Kataru RP, Coriddi M, Dayan JH, Mehrara BJ. [The Future of Lymphedema: Potential Therapeutic Targets for Treatment](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10233555/?ref=theplasticsfella.com). Curr Breast Cancer Rep. 2023 Jun 1:1-9\. doi: 10.1007/s12609-023-00491-5. Epub ahead of print. PMID: 37359311; PMCID: PMC10233555. 7. Grada AA, Phillips TJ. [Lymphedema: Pathophysiology and clinical manifestations](https://pubmed.ncbi.nlm.nih.gov/29132848/?ref=theplasticsfella.com). J Am Acad Dermatol. 2017 Dec;77(6):1009-1020\. doi: 10.1016/j.jaad.2017.03.022. PMID: 29132848. 8. Sleigh, Bryan C., and Biagio Manna. "[Lymphedema](https://europepmc.org/article/nbk/nbk537239/?ref=theplasticsfella.com)." (2019). 9. Murgia RD, Gross GP. [Stewart-Treves Syndrome.](https://pubmed.ncbi.nlm.nih.gov/29939610/?ref=theplasticsfella.com) 2023 Aug 14\. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29939610. 10. Executive Committee of the International Society of Lymphology. [The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of The International Society of Lymphology.](https://pubmed.ncbi.nlm.nih.gov/39207406/?ref=theplasticsfella.com) Lymphology. 2023;56(4):133-151\. PMID: 39207406. 11. Houwen, Frans, et al. "[Estimates for assessment of lymphedema: Reliability and validity of extremity measurements](https://www.liebertpub.com/doi/full/10.1089/lrb.2019.0082?ref=theplasticsfella.com)." *Lymphatic Research and Biology* 20.1 (2022): 48-52. 12. Goss JA, Greene AK. [Sensitivity and Specificity of the Stemmer Sign for Lymphedema: A Clinical Lymphoscintigraphic Study](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635205/?ref=theplasticsfella.com). Plast Reconstr Surg Glob Open. 2019 Jun 25;7(6):e2295\. doi: 10.1097/GOX.0000000000002295. PMID: 31624689; PMCID: PMC6635205. 13. Fredman R, Tenenhaus M. [Elephantiasis nostras verrucosa.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479949/?ref=theplasticsfella.com) Eplasty. 2012;12:ic14\. Epub 2012 Oct 12\. PMID: 23150746; PMCID: PMC3479949. 14. Lasinski, Bonnie B. "[Complete decongestive therapy for treatment of lymphedema.](https://www.sciencedirect.com/science/article/abs/pii/S0749208112000836?ref=theplasticsfella.com)" *Seminars in oncology nursing*. Vol. 29\. No. 1\. WB Saunders, 2013. 15. Carl, H. M., Walia, G., Bello, R., Clarke-Pearson, E., Hassanein, A. H., Cho, B., ... & Sacks, J. M. (2017). [Systematic review of the surgical treatment of extremity lymphedema.](https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0037-1599100?ref=theplasticsfella.com) *Journal of reconstructive microsurgery*, *33*(06), 412-425. ### The 20% Dilemma: Why Med Students Are Leaving Plastic Surgery (+ Hand Tumour Updates, Illustrations & More) URL: https://www.theplasticsfella.com/october-6th/ Last updated: 2024-10-04T22:18:24.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/october-6th/#a-letter-from-pfella) Only 20% stick with plastic surgery: What’s behind the drop-off? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-6th/#the-sunday-quiz) How well do you know **giant cell tumours of the tendon sheath*? 3. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Anatomy Illustration of the Week**](https://www.theplasticsfella.com/october-6th/#anatomy-illustration-of-the-week) Henry Gray’s original drawing of the hand. 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/october-6th/#the-fellows-corner) This week's feature: Glomus tumors - clinical scenario. 5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/october-6th/#what-does-the-evidence-say) Should we actually operate on Enchondromas? 6. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/october-6th/#articles-of-the-week) Hand tumours of soft tissue and bone, malignant melanoma in hand, & pediatric hand and wrist ganglion cysts: 3 articles with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/october-6th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella Only 20% Stick with Plastic Surgery: What’s Behind the Drop-Off? 👋 ****Hey Team!** I’ve been looking at some interesting numbers recently, and one thing really stands out: Only 20.3% of medical students who start with an interest in plastic surgery actually stick with it through to graduation. It’s a surprising stat when you consider how dynamic and rewarding our field can be. So what’s going on? Let’s unpack it. **1\. Why the Drop-Off?** When students first enter med school, many of them don’t fully understand the scope of each specialty. Plastic surgery often isn’t fully appreciated until later — by then, they might have already committed to another field. It’s like walking into a restaurant for a salad, only to realize halfway through that they serve the best steak in town — but you’re already full. ![](https://lh7-rt.googleusercontent.com/docsz/AD_4nXf48m8NUDsvGtpc4hjp9sLympcAKoALn2TUD82smxgon6BA6qjz2JPfuNji7S6uU72nsCJ8dhGnpx141WA8b9Ae8yF4_DiJp8q5cscN0N3-6UH5EK3pXd1WXp8x1PVsW7kmveXp7CTv1B3Fy0YcxU1G1N7A?key=VE6BXUZFwhQudikkPVwgwA) Image Source: [https://x.com/jbcarmody/status/1840842261761847496/photo/1](https://x.com/jbcarmody/status/1840842261761847496/photo/1?ref=theplasticsfella.com) **2\. Late Exposure & Misconceptions** Most students think of plastic surgery as just cosmetic work, not realizing it involves critical reconstructive procedures — trauma, cancer reconstruction, hand surgery. By the time they see this diversity, many have already built connections in other fields. Without seeing the broader picture early on, students often move on. **3\. Mentorship Matters** The real key here is mentorship. Early guidance and exposure to the full range of what we do can make all the difference. Getting students into the OR or giving them a chance to interact with surgeons early on could prevent them from drifting away. 👉 ****So, what’s The Plastics Fella going to do about it?** Over the next 6 months, we’re launching a massive initiative targeting medical students with a three-pronged approach: **theory**, **practice**, and **mentorship**. The first step? A comprehensive student manual and guide tailored for those interested in plastic surgery. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/2.png) Email ****tara@theplasticsfella.com** if you are interested in getting involved. The takeaway? We’re losing talented future surgeons because they don’t see the full picture soon enough. Let’s change that through early exposure and mentorship. If you're interested in building our textbook for students, email *tara@theplasticsfella.com.* Lot of Love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Giant Cell Tumours of the Tendon Sheath** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Giant Cell Tumours of the Tendon Sheath](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/IG-11-Posts--30-.png) Giant Cell Tumours of the Tendon Sheath ## Anatomy Illustration of the Week Henry Gray’s Original Drawing of the Hand 🖼️ ****Anatomy Illustration of the Week** This section we feature an anatomical illustration. This edition looks at Henry Gray’s original drawing of the hand. 👇 ![Gray, H. (1858). Anatomy, Descriptive and Surgical. John W. Parker and Son, Henry Gray’s original drawing of the hand](https://lh7-rt.googleusercontent.com/docsz/AD_4nXcR_t2PXK3GHuUdQU47HLE-SsIjKpiChmsZYYKep-vCoA3cMC_er4_O5LgsnHze9sbIxFmQZNiWVz6fKuKBDmqhd3DX7oWYV7CihaaW2rGRQ8Enr02nRAjS38u-Pvl7PHoGNGjkc0pHJXJgDWc6MFRm-r0e?key=VE6BXUZFwhQudikkPVwgwA) ****Gray, H.** (1858). **Anatomy, Descriptive and Surgical*. John W. Parker and Son. ## the Fellows' Corner **This Week's Focus:* ***Glomus Tumours - Clinical Scenario** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our **Clinical Scenario** on **Glomus Tumours**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/10/IG-11-Posts--29-.png) #### Glomus Tumours - Clinical Scenario 1. ****Understand the classical presentation of a glomus tumour.** 2. ****Describe the pathophysiology of a glomus tumour.** 3. ****Provide a differential diagnosis for a painful digit swelling.** 4. ****Outline the investigations indicated for a glomus tumour.** 5. ****Discuss the treatment options available.** [Read the Article](https://www.theplasticsfella.com/glomus-tumours-clinical-scenario/) ## What Does the Evidence Say? Should We Actually Operate on Enchondromas? In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Enchondromas are the most common ****benign bone tumors** in the hand, often discovered incidentally or due to pathological fractures (Tang et al., 2015; Lubahn & Bachoura, 2016). Management typically involves conservative treatment for small, asymptomatic lesions and ****surgical curettage** for symptomatic or expanding lesions (Tang et al., 2015). Curettage without void augmentation is effective and cost-efficient, with low complication rates (Bachoura et al., 2015). However, some surgeons use ****bone grafts**, ****bioactive materials**, or ****cement** for reconstruction (Bickels et al., 2002; Żyluk, 2021). ****Pathological fractures** do not significantly impact treatment outcomes, and early surgical intervention is recommended for these cases (Zhou et al., 2016). Most patients achieve complete healing and full range of motion post-surgery, regardless of the graft material used (Sassoon et al., 2012). ****Malignant transformation** is rare, occurring mainly in patients with multiple enchondromatosis syndromes (Sassoon et al., 2012; Redgrave et al., 2021). Overall, surgical management of hand enchondromas yields satisfactory results with low recurrence rates (Żyluk, 2021). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Diagnostic and Treatment Approaches for Hand Tumours of Soft Tissue and Bone** ([Hsu](https://www.thelancet.com/journals/lanonc/article/PIIS1470204507700359/abstract?ref=theplasticsfella.com), 2007) Hand tumors require differentiation between benign and malignant forms, with treatment outcomes dependent on malignancy, recurrence risk, and survival rates. ✅ ****How to Overcome Challenges in Managing Malignant Melanoma in the Hand** ([Blessley-Redgrave](https://journals.sagepub.com/doi/abs/10.1177/17531934241245028?ref=theplasticsfella.com), 2024) Malignant melanoma of the hand has significant diagnostic and management challenges, often diagnosed at a later stage and associated with poorer prognosis. ✅ ****History and Outcomes of Pediatric Hand and Wrist Ganglion Cysts** ([Dearden](https://www.sciencedirect.com/science/article/abs/pii/S0363502323003593?ref=theplasticsfella.com), 2023) Around two-thirds of pediatric hand and wrist ganglion cysts are resolved spontaneously within two years without surgery or aspiration, with higher resolution rates in hand cysts compared to wrist cysts. ## Feedback ### I hope you enjoyed it 😄 --- ### 3 New Plastic Surgery Trends, Burn Resuscitation & New Podcast Episode URL: https://www.theplasticsfella.com/september-29th/ Last updated: 2024-09-28T09:15:49.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/september-29th/#a-letter-from-pfella) Top 3 Plastic Surgery Trends (Backed by Data) 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-29th/#the-sunday-quiz) How well do you know **Fluid Resuscitation in Burns*? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/september-29th/#behind-the-fella) 5 Must-Know Surgical Techniques for Plastic Surgeons 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/september-29th/#the-fellows-corner) This week's feature: Macrodactyly. 5. 📖 [****What Does the Evidence Say**](https://www.theplasticsfella.com/september-29th/#what-does-the-evidence-say) What is the best fluid resus in burns? 6. ****🔥**[ **Articles of the Week**](https://www.theplasticsfella.com/september-29th/#articles-of-the-week) Split-thickness skin graft donor-sites, burn debridement, & a fluid resuscitation formula: 3 articles with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/september-29th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella Top 3 Plastic Surgery Trends (Backed by Data) 👋 ****Hey everyone!** As we move further into 2023, I wanted to highlight some key trends from the latest ****ASPS Procedural Statistics** that are shaping the future of plastic surgery. These insights reflect evolving patient preferences and procedural growth that are worth paying attention to 👇 1\. **Facial Procedures Are on the Rise** Facelifts have seen an impressive **8% increase**, signaling a growing interest in facial rejuvenation. Likewise, **eyelid surgery** and **rhinoplasty** are up by **5% and 6%** respectively. Patients seem to be seeking procedures that deliver noticeable improvements while minimizing downtime—many opting for local anesthesia and less invasive methods. 2\. **Body Contouring Continues to Surge** **Liposuction** remains the most in-demand procedure, with a **7% rise** this year. Patients are increasingly looking to address areas resistant to diet and exercise, particularly in the wake of pandemic weight changes. Additionally, **tummy tucks** have risen by **5%**, highlighting the growing interest in transformative procedures that refine and contour the body. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Screenshot-2024-09-28-at-10.03.15-1-1.png) 3\. **Minimally Invasive Treatments Are the Preferred Choice** With **Botox** and **dermal fillers** up by **6% and 4%**, respectively, it’s clear that patients are opting for non-surgical solutions that offer quick results with minimal recovery time. The continued rise in minimally invasive procedures reflects a strong demand for effective, time-efficient aesthetic treatments. These trends aren’t just numbers—they’re insights into the future of our field Lot of Love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Fluid Resuscitation in Burns** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ## Behind the ‘Fella 5 Must-Know Surgical Techniques for Plastic Surgeons 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. Check out the latest episode where we discuss essential techniques and skills required in plastic surgery including wound management, suturing, flap surgery, and advanced techniques like hemostasis and negative pressure wound therapy. You can subscribe on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /0:40 1× Snippet from Episode ## the Fellows' Corner **This Week's Focus:* ***Macrodactyly** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Macrodactyly**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Macrodactyly-Definition.png) #### Macrodactyly [****Definition**](https://www.theplasticsfella.com/macrodactyly/#definition-of-macrodactyly) Macrodactyly is the term for the overgrowth of a digit, out of proportion to the rest of the hand or foot. [****Clinical Features**](https://www.theplasticsfella.com/macrodactyly/#clinical-features-of-macrodactyly) Macrodactyly results in overgrowth of the entire digit(s) out of proportion with the rest of the hand or foot. [****Investigations**](https://www.theplasticsfella.com/macrodactyly/#investigations-for-macrodactyly) X-rays, MRI, and gene analysis may be offered as part of the diagnostic process. [****Management**](https://www.theplasticsfella.com/macrodactyly/#management-of-macrodactyly) Surgical management aims to stop overgrowth and debulk the digit. Addressing the nerve is important in reducing recurrence. [Read the Article](https://www.theplasticsfella.com/macrodactyly/) ## What Does the Evidence Say? Optimal Fluid Resuscitation in Burns In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Fluid resuscitation is crucial for treating severe burns, with the Parkland formula long considered the gold standard (Mitra et al., 2006). Traditional research suggested that a more restrictive fluid approach may be beneficial (Artz & Larson, 1965). Hyperosmotic solutions have shown promise in reducing fluid load compared to isoosmotic solutions (Yuan Kao et al., 2018). The addition of albumin to resuscitation fluids has demonstrated improved outcomes, including better cardiac output restoration and reduced edema in unburned tissues (Carvajal & Parks, 1988). The BET formula, which uses high albumin concentrations, has shown success in limiting fluid administration while effectively resuscitating patients (Blanco-Schweizer et al., 2019). Despite these advances, there is still no universally accepted method for burn resuscitation (Foster, 2016). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Split-Thickness Skin Graft Donor-Site Morbidity** ([Asuku](https://www.sciencedirect.com/science/article/pii/S0305417921000504?ref=theplasticsfella.com), 2021) Explore the variability in donor-site outcomes, such as healing time, pain, and scarring while highlighting the need for standardized outcome measures and innovations to reduce donor-site morbidities. ✅ ****Surgical and Nonsurgical Debridement Techniques of Burn Wounds** ([Kwa](https://www.jprasurg.com/article/S1748-6815%2819%2930339-0/abstract?ref=theplasticsfella.com), 2019) Analysis of various burn wound debridement techniques — both surgical and nonsurgical — found no conclusive evidence to recommend one method over another in terms of efficiency and safety. ✅ ****A Simplified Fluid Resuscitation Formula for Burns in Mass Casualty Scenarios** ([Leclerc](https://www.sciencedirect.com/science/article/pii/S0305417921000589?ref=theplasticsfella.com), 2021) The WHO Technical Working Group on Burns proposed a fluid resuscitation formula for mass casualty burn incidents, recommending an initial rate of 100 mL/kg/24 h for burns over 20% TBSA. ## Feedback ### I hope you enjoyed it 😄 --- ### Meet Threads: The Invite-Only Community for Plastic Surgery Trainees. URL: https://www.theplasticsfella.com/september-22nd/ Last updated: 2024-09-21T14:10:06.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/september-22nd/#a-letter-from-pfella) Community building: meet threads! 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-22nd/#the-sunday-quiz) How well do you know neck dissection? 3. **📑** [****Guides**](https://www.theplasticsfella.com/september-22nd/#guides) Launch of our new guides feature! 4. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Anatomy Illustration of the Week**](https://www.theplasticsfella.com/september-22nd/#anatomy-illustration-of-the-week) Cervical lymph nodes of the neck. 5. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/september-22nd/#the-fellows-corner) This week's feature: Mandibular defects. 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/september-22nd/#what-does-the-evidence-say) How do CAD outcomes compare to traditional techniques in mandibular reconstruction? 7. ****🔥**[ **Articles of the Week**](https://www.theplasticsfella.com/september-22nd/#articles-of-the-week) Staging for HNcSCC, oral cavity reconstruction, & melanoma management: 3 articles with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/september-22nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Meet Threads* 👋 ****Hey everyone!** I’m genuinely excited to welcome you to ****Threads by thePlasticsFella**! This isn’t just another online group; it’s a cozy corner of the internet where current and future plastic surgeons can come together, share, and grow in a supportive environment. In **Threads**, you’ll find a place where we can truly connect—free from the noise of algorithms or the worry of what others may think. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/THRREADSS--1.png) Threads by thePlasticsFella Here’s what you can look forward to: - **Exchange study tips**: Whether it’s about that tricky exam or the latest techniques, we’re here to learn from one another. - **Share your stories**: We all have unique journeys, and your experiences can make a difference for someone else. - **Get insights on interviews and applications**: You’re not alone in this—let’s help each other navigate the ups and downs. - **Stay in the loop**: Discover events and opportunities that are tailored just for us. And there’s so much more to come! Imagine diving into clinical cases together, hosting discussions on topics you’re passionate about, and learning directly from the pros through live masterclasses and coaching sessions. If this sounds like the community for you, I’d love for you to **join the waiting list**. Your voice and ideas will help shape **Threads** into a space where we can all thrive and support one another. I can’t wait to welcome you inside! Lot of Love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Neck Dissection** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/image.png) ## Guides **Launch of Our New Guides Feature!* 📑 We’re excited to announce the launch of our new ****Guides** feature! thePlasticsFella will be building out in-depth, step-by-step resources tailored for plastic surgery education. These Guides are designed to simplify complex topics and provide essential knowledge in an easy-to-follow format. Check out our new guide below 👇 #### ✅ [FRCS Plastic Surgery (Plast) Exam](https://www.theplasticsfella.com/frcs-plastic-surgery/) ****What's the FRCS Plast All About?** A rigorous JCIE-governed exam that certifies a surgeon's consultant-level expertise in plastic surgery. ****Are You Eligible?** Entry requirements span a recognized medical degree, years of experience, curriculum adherence, and professional references. ****Structure of the FRCS Plast Exam** The exam unfolds in two stages: a computer-based test followed by a two-day hands-on clinical evaluation. ****Key Dates for the FRCS Plast Exam** The exam takes place multiple times a year; don't miss the application deadlines! ****Tools to Boost Your FRCS Plast Prep** Discover specialized tools like thePlasticsPro, tailor-made to help you succeed. ****Success Rates and the Coveted Gold Medal** CCT trainees tend to shine, and standout performances can earn the prestigious Ian McGregor Medal. ****Unraveling the Cost** The £1904 fee is a comprehensive package, supporting various operational and developmental aspects of the exam. [Read more](https://www.theplasticsfella.com/frcs-plastic-surgery/) ## Anatomy Illustration of the Week **Cervical Neck Nodes* 🖼️ ****Anatomy Illustration of the Week** In this new section, we feature an anatomical illustration. This edition looks at the anatomy of hard and soft palates. 👇 ![](https://lh7-rt.googleusercontent.com/docsz/AD_4nXfltf8uVkYnSkmFSzX6jrmwS8PrQvuv3CdNI6we7M8qTmzelnbHtJs6ihQJNCsFHWRNb5r3aKie82Zm9mr44cTyUponvLCZFWpkWQbUcaoiQaSc_J5rsf_kZMl5i_p1tLGAgIJME0sSj0jdL2v2KJaoNHo?key=VE6BXUZFwhQudikkPVwgwA) [Cervical Lymph Nodes of the Neck: Drainage & LevelsThe cervical lymph nodes of the neck are organized into levels based on their anatomical locations and drainage patterns. These nodes drain specific areas of the head and neck, aiding in identifying primary tumor sites and guiding surgical management.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/size/w256h256/2022/07/Logo-Small-2.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/size/w1200/2021/12/P-Fella-13.png)](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/) ## the Fellows' Corner **This Week's Focus:* ***Mandibular Defects** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Mandibular Defects**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Types-of-Mandibular-Resections.png) #### Mandibular Defects [****Classification**](https://www.theplasticsfella.com/mandibular-defects/#classification-of-mandibular-defects) Jewer-Boyd classification is used to describe hemi-mandibular, central, and lateral defects. It guides the therapeutic algorithm. [****Pathophysiology**](https://www.theplasticsfella.com/mandibular-defects/#pathophysiology-of-mandibular-invasion) Directly in lymphatics or via nerves. Periosteum and teeth provide relative resistance to invasion. [****Types of Mandibular Resections**](https://www.theplasticsfella.com/mandibular-defects/#types-of-mandibular-resections) 3 types based on their width and length of resection: marginal (rim), segmental, and hemimandile. [****Types of Mandibular Reconstruction**](https://www.theplasticsfella.com/mandibular-defects/#types-of-mandibular-reconstruction) No reconstruction, plates, non-vascularised bone grafts, and vascularized bone flaps. [Read the Article](https://www.theplasticsfella.com/mandibular-defects/) ## What Does the Evidence Say? **CAD Vs. Traditional Techniques in Mandibular Reconstruction* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Recent studies have compared the outcomes of ****computer-aided design and manufacturing** (CAD-CAM) techniques versus traditional methods for mandibular reconstruction using ****fibula-free flaps**. Mahendru et al. (2020) found that CAD-CAM significantly reduced intraoperative time and improved aesthetic outcomes, with fewer cases of postoperative malocclusion. Bouchet et al. (2018) reported no significant differences in functional and aesthetic outcomes, suggesting the need for further research. Gil et al. (2015) demonstrated reduced operating times and lower malocclusion rates with CAD-CAM. Tarsitano et al. (2016) highlighted improved morphological results with CAD-CAM, while their economic analysis indicated cost-effectiveness due to reduced surgical time. Ritschl et al. (2017) found comparable functional results between both techniques. Powcharoen et al. (2019) concluded that CAD-CAM offers increased efficiency with shorter operative times but called for more research on accuracy and costs. Overall, CAD-CAM techniques show promise in enhancing surgical outcomes in mandibular reconstruction (Mahendru et al., 2020; Bouchet et al., 2018; Gil et al., 2015; Tarsitano et al., 2016; Ritschl et al., 2017; Powcharoen et al., 2019). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****TNM Staging for HNcSCC with Lymph Node Metastases: A Comparison to N1S3 Stage and ITEM Risk Score** ([Ebrahimi](https://pubmed.ncbi.nlm.nih.gov/33721339/?ref=theplasticsfella.com), 2021) Explore a critical evaluation of the 8th edition AJCC staging for head and neck cutaneous squamous cell carcinoma (HNcSCC) with nodal metastases, comparing it to the N1S3 and ITEM risk models. ✅ ****Reconstruction Techniques for Oral Cavity Sites:** ****Soft Tissue and Bone Reconstruction** ([Quadri](https://pubmed.ncbi.nlm.nih.gov/37164898/?ref=theplasticsfella.com), 2023) Explore key methods and considerations in oral cavity reconstruction for oral sites including lips, tongue, and mandible, along with the appropriate use of grafts and flaps. ✅ ****Completion Dissection vs. Observation for Sentinel-Node Metastasis in Melanoma** ([Faries](https://www.nejm.org/doi/10.1056/NEJMoa1613210?ref=theplasticsfella.com), 2017) Immediate completion lymph-node dissection in patients with sentinel-node metastasis from melanoma offers enhanced regional disease control, yet does not significantly impact melanoma-specific survival. ## Feedback ### I hope you enjoyed it 😄 --- ### Special 100th Edition: The Best of ThePlasticsPaper (& What You Might Have Missed) URL: https://www.theplasticsfella.com/15th-september/ Last updated: 2024-09-14T13:53:07.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/15th-september/#a-letter-from-pfella) How We Hit 100: The Journey of ThePlasticsPaper 2. ****🚀** [****Top Hits that trended.** ](https://www.theplasticsfella.com/15th-september/#top-hits) Most read, Most discussed & fan favourites. 3. ****🔢** [****The Numbers are growing.**](https://www.theplasticsfella.com/15th-september/#the-numbers) 3.3 Million Minutes of Reading in 12 months. 4. ****🔥** [****You can shape the future**](https://www.theplasticsfella.com/15th-september/#the-future) Textbooks, communities & more. 5. 💕 [****Wall of Love**](https://www.theplasticsfella.com/15th-september/#feedback) Show thePlasticsFella some love ## A Letter from P'Fella ****How We Hit 100: The Journey of ThePlasticsPaper** 👋 ****It's hard to believe we've hit 100 editions.** When I first started ThePlasticsPaper back in April 2021—over three years ago—the goal was simple: to share the best bits of plastic surgery with those who love the field as much as I do. **It's grown into something far greater than I ever imagined.** From those early days of figuring out what mattered to you, to our first piece that truly resonated, it's been an incredible ride. We've covered so much—from debates on the reconstructive ladder and tissue expansion to tackling controversial topics like the "perfect" male bum and the complexities of open-access fees. It hasn't been all smooth. About a year ago, I burned out and took a two-month break, unsure if I could continue. But after some time to recharge, I realized how much this paper meant to both of us. So, I got back on the horse, and here we are, stronger than ever. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/thePlasticsPaper-Logos.png) 2021 --> 2024 The logo has changed a bit since that first edition, just like ThePlasticsPaper has. Some experiments worked, others didn’t, but every step of the way, your feedback, questions, and support have driven this journey forward. From launching the [Oral Exams](https://www.theplasticsfella.com/oral-exams/) section, [Podcast](https://www.theplasticsfella.com/behind-the-fella-podcast/) to incorporating [AI-powered study tools](https://www.theplasticsfella.com/#chatbotContainer), it's been about pushing boundaries together. Thank you for being part of this journey. This edition is to share the moments and the data over the last 100 editions. Lot of Love, P'Fella ❤️ *ps - there was a funny hiccup back in June when I mistakenly thought we'd hit the 100th edition (check it out* [*here*](https://www.theplasticsfella.com/june-16th/)*). Turns out I was a bit ahead of myself!* ## Top Hits The Most Loved Moments in ThePlasticsPaper ****Most-Read Newsletter: "RIP original journal submissions, Pie-crusting & Tuberous Breasts"** This one was a crowd favourite! With 3033 readers diving in, it sparked lively conversations about the state of research and the nuances of pie-crusting and tuberous breasts. It wasn't just about the content but the discussions it ignited within our community. ****Fan Favorite: "A Letter from P'Fella"** This section has always been close to my heart, and it seems you all feel the same. For this specific section, there has been over 8000 clicks onto the platform. It's the place where we connect on a more personal level, share stories, and reflect on the journey. Your engagement here shows just how much these letters mean to you, making them a core part of every edition. ****Quizzes and Cases: Your Go-To for Fun Learning** Over 1,000 of you have taken part in the Sunday Quiz, turning it into a weekly tradition. It's more than just a quiz—it's a fun, quick way to test your knowledge. Comments like "Short quizzes always make my day" tell me we're on the right track, mixing learning with a bit of fun. ****Reader Engagement: Your Voice Matters** Your feedback has been the heartbeat of ThePlasticsPaper. From "Love the 'What does the evidence say' section!" to helpful nudges like, "Great as ever, thanks, distracting typo on scaphoid bone label 😬"—each comment helps shape what comes next. It's this back-and-forth that makes this journey special. ## The Numbers 3.3 Million Minutes of Reading ### ### **In the past year, you've spent an incredible 3.3 million minutes (over 55,170 hours or nearly 6.3 years) on thePlasticsFella platform.** 😎 ****Fun Fact:** Walking around the Earth (40,075 km at 5 km/h) takes 50,000 hours. You've collectively walked the globe! Each edition captivates you for an average of **4.9 minutes**. Whether it's a quick read or a deep dive, your engagement shows a real thirst for knowledge. The [April 21st](https://www.theplasticsfella.com/april-21st/) issue was a standout, holding readers' attention for over 9 minutes on average! In terms of countries, here's some other stats you might be interested in: - **United Kingdom**: 25.1% of readers - **United States**: 21.2% - **Australia**: 8.5% - **India and Canada**: 4.4% and 4.2% ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/100.png) We're also seeing exciting growth in emerging markets, with a surge in readership from Asia and South America. These regions are quickly becoming key players in our global community, reflecting the expanding interest in plastic surgery education across diverse cultures. There 3 most read articles on thePlasticsFella are 1\. [Total Body Surface Area in Burns](https://www.theplasticsfella.com/total-body-surface-area-in-burns/) 2\. [Lymph Nodes of the Neck](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/) 3\. [Zones of the Hand](https://www.theplasticsfella.com/zones-of-the-hand/) ## The Future **You can help shape this platform* We’re thrilled to share what’s on the horizon for ThePlasticsFella community. As always, expect a fresh wave of articles, clinical cases, and [**podcast episodes**](https://tally.so/r/w4jNGB?ref=theplasticsfella.com) that delve deeper into plastic surgery topics you care about. Here are two new things you will be interested in: ### **Exclusive Community Coming Soon** Get ready for our invite-only community, where you’ll connect with peers and experts in a more personal setting. Stay tuned for updates on how and when you can join! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Threads.png) ### **Student Textbook** We’re developing a comprehensive textbook for students. This is an amazing project. Email **support@theplasticsfella.com** if you are interested in getting involved. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/2.png) Email ****support@theplasticsfella.com** if you are interested in getting involved. ## Feedback ### I hope you enjoyed it 😄 --- ### 4 Tips for the FRCS Plastic Surgery Part 2 (Oral/Viva) Exam URL: https://www.theplasticsfella.com/frcs-plastic-surgery-exam-tips/ Last updated: 2024-09-07T16:19:16.000Z The FRCS Plastic Surgery Part 2 Exam is widely recognised as one of the most challenging components of the certification process. It's not enough to know the theory—you need to demonstrate that you can think and act like a consultant. #### FRCS Guide Summary Card 1. ****Tip 1: Get to the Point—Fast** Quickly identify the key issue and demonstrate decisive judgment. 2. ****Tip 2: Use the Correct Vocabulary** Confident language is key. Use “I will” instead of “I would” and avoid speculation. 3. ****Tip 3: Listen** Pause, listen carefully to the examiner, and reflect before answering to avoid mistakes. 4. ****Tip 4: Higher-Order Thinking** Think beyond immediate management—anticipate complications, long-term outcomes, and rehabilitation. Bonus Tip: Check out these [oral exam scenarios](https://www.theplasticsfella.com/oral-exams/). 💡 ****Bonus Tip:** Our new [****Oral Exams**](https://www.theplasticsfella.com/oral-exams/) feature has real [FRCS scenarios](https://www.theplasticsfella.com/oral-exams/). Perfect for getting those last-minute reps in. Get ready to ace the exam. --- ## **Tip 1: Get to the Point—Fast in your FRCS Part 2 exam.** ****Key Point** Quickly identify and address the core issue in the case. Show that you can make decisive, consultant-level judgments without getting bogged down in unnecessary details. In the **FRCS Plastic Surgery Part 2 Exam**, you’ll often be given a scenario with limited information. The key is to identify the critical issue and address it promptly. Instead of getting bogged down in unnecessary details, demonstrate your ability to prioritise. ### **Be Efficient in Your Answer** Always focus on the primary concern and avoid unnecessary details. When presented with a scenario, quickly identify the most pressing issue. ❓ ****Example: Melanoma** When presented with a melanoma histology, don’t waste time asking basic questions. Say: "In addition to performing a wide local excision with 2 cm margins, I would confirm sentinel lymph node biopsy to assess metastasis risk based on Breslow depth, considering any patient-specific contraindications." This direct approach shows the examiner that you understand the primary concern and are ready to take action. ### **Use Conditional Statements in Ambiguous Scenarios** In cases where you’re given limited information, it's important to show that you can adapt while maintaining a decisive approach. Conditional statements allow you to offer a tailored plan while acknowledging potential uncertainties. ❓ ****Example: Reconstruction** **"In a fit patient without contraindications, I would proceed with free flap reconstruction."* This demonstrates to the examiner that you can make well-reasoned decisions even with incomplete data, signaling your flexibility and clinical judgment. ### **Focus on Immediate Priorities in Complex Cases** When dealing with complex cases like hand trauma, avoid listing every basic protocol. Show that you can prioritize and manage the key issues first. ❓ ****Example: Major Trauma** **"My immediate priority is to assess neurovascular integrity of the lower limb. Once vascularity if confirmed, I would then proceed..."* This approach demonstrates your ability to focus on the critical concerns and handle complex cases efficiently, rather than getting lost in unnecessary details. ### **Always Anticipate Next Steps in the Oral Exam** Once you’ve addressed the immediate concern, it’s crucial to show that you're considering the patient's long-term management. This demonstrates your ability to plan beyond the initial intervention. ❓ ****Example: Hand Injury** **"Following imaging, I would consult with the patient about the options for tendon repair and rehabilitation, depending on the severity of the injury."* This approach signals to the examiner that you’re not just solving the current problem, but also thinking ahead about the patient’s recovery and future care. --- ## **Tip 2: Use the Correct Vocabulary in your FRCS answers.** ****Key Point** Confident, assertive language shows you’re ready to take ownership of the case. Avoid speculative phrases, and use decisive language to demonstrate consultant-level thinking. The way you speak in the viva reflects your readiness to be a consultant. Confident, assertive language demonstrates that you’re in control of the situation. Avoid speculative language and use decisive phrases like “I will” instead of “I would.” #### **Why Vocabulary Matters in FRCS** Confident language reflects your preparedness for consultant-level responsibilities. When you say “I will” instead of “I would,” you show that you are ready to take ownership of the case. Avoid using language like "might" or "could."Clearly communicate your plan with confidence. Avoid hesitation, and show that you have a structured approach in mind. ❓ ****Example: Soft Tissue Reconstruction** In a challenging case, demonstrate clear decision-making and consideration of patient outcomes. Instead of just stating the basics, say: **"I will assess the defect and, based on tissue viability and blood supply, I will opt for a local rotational flap to provide optimal coverage and preserve function. Additionally, I will ensure minimal tension on the closure to reduce complications such as wound dehiscence."* This approach not only shows your ability to manage the case confidently but also highlights your attention to preventing postoperative complications and improving patient outcomes. ### Decisive and Prepared in Uncertain Situations In the FRCS Plastic Surgery Oral Exam, demonstrating confidence and preparedness, even when information is limited, is crucial. Show that you can act decisively and anticipate potential complications. ❓ ****Example: Sarcoma** In a case of high-grade sarcoma, demonstrate clear oncological planning and consideration of post-treatment outcomes. Instead of a generic response, say: "I will perform an en bloc resection with a 3 cm margin to ensure clear oncological boundaries. Post-operatively, I will follow up with adjuvant radiotherapy to reduce recurrence risk." This approach not only shows your decisive surgical planning but also highlights your focus on comprehensive, long-term patient care. --- ## **Tip 3: Listen to your FRCS Oral Examiners** ****Key Point** Pause, listen, and reflect on both the examiner’s question and your internal thought process before answering. This helps you provide more structured, relevant responses. One of the most common mistakes candidates make in the **FRCS Plastic Surgery Oral Exam** is misinterpreting the examiner's question. Listening is an active skill—it's not just about hearing the words but understanding the intent behind them. Take a moment to process the question fully before responding, and avoid jumping to a pre-rehearsed answer. ### **Listen Carefully and Tailor Your Response** Examiners want to see that you're truly engaging with the specific scenario they present, not just giving a rehearsed, one-size-fits-all answer. Take a moment to process the question fully before responding. ❓ ****Example: Managing an Extensive Burn** Consider a scenario where the examiner asks, "How would you manage this patient?" It’s crucial to recognize the distinction between managing a specific patient versus managing a condition. If you jump into discussing the general treatment protocol, you might miss key elements of the individual case. Instead, pause and say: **"For this specific patient, given their medical history and current condition, I would first stabilize them and then proceed with debridement, tailored to their comorbidities."* This shows you’ve listened carefully and adapted your approach to the specific scenario, not just the general disease management. #### ### **Pause for 2 Seconds Before Responding** Develop the habit of pausing for 2–3 seconds after the examiner finishes speaking. This brief pause allows you to digest the question fully and structure your response, ensuring you address the examiner’s specific concerns. ❓ ****Example: When to pause.** When faced with an open-ended question like "What’s your next step?" don’t rush. Instead, pause and then say: **"I will first evaluate the viability of the surrounding tissues to determine whether a local or regional flap is most appropriate."* This pause and measured response shows that you’re carefully considering the best course of action. #### #### --- ## **Tip 4: Demonstrate Higher-Order Thinking in your FRCS viva exam.** ****Key Point** Think beyond the immediate management and consider long-term outcomes, complications, and rehabilitation when discussing your treatment plan. The **FRCS Plastic Surgery Oral Exam** is designed to test whether you can think beyond immediate management. You need to show that you can anticipate complications and long-term outcomes, especially in complex cases. ### Avoid Over-Simplification Many candidates make the mistake of offering simple, one-size-fits-all solutions. Instead, focus on real-world complexities—discuss how you’ll manage potential complications, surgical challenges, and long-term rehabilitation. ❓ ****Example: Replantation Case** In a case requiring replantation, don’t just stop at vascular repair. Instead, say: **"In addition to vascular repair, I will focus on early mobilization and coordinate with the physiotherapy team to ensure functional recovery."* This shows that you are considering not just the surgery but the entire rehabilitation process. ### **Preempt Complications** In complex cases, especially those with high complication risks, it’s essential to show the examiner that you’re thinking proactively. Anticipating complications and planning ahead demonstrates comprehensive, consultant-level care. ❓ ****Example: Facial Reconstruction** **"Given the facial location of this reconstruction, I will carefully monitor for infection and wound dehiscence, ensuring early intervention if necessary to prevent further surgical procedures."* By showing that you’re thinking through these steps, you reassure the examiner that you can anticipate, recognize, and manage potential complications in real-time. ### **Always Incorporate a Rehabilitation Plan** Examiners expect you to think beyond the immediate surgical procedure and consider the patient’s long-term recovery. Including a clear rehabilitation plan shows that you’re focused on holistic care and the best possible outcomes. ❓ ****Example: Post-Surgery Rehabilitation** **"Following surgery, I will implement an early rehabilitation program to optimize range of motion and minimize scarring."* This demonstrates that you understand the importance of recovery in achieving optimal functional and aesthetic outcomes for your patients. --- The **FRCS Plastic Surgery Oral/Viva Exam** is your chance to demonstrate that you’re ready to step into the role of a consultant. By getting to the point quickly, using confident language, listening carefully, and showcasing higher-order thinking, you can stand out as a top candidate. Approach each case with these strategies, and you’ll be well on your way to acing the **FRCS Plastic Surgery Part 2 Exam**. --- ### 4 Tips for the FRCS Vivas, New Oral Exams, & All Things Paediatric Plastic Surgery. URL: https://www.theplasticsfella.com/september-8th/ Last updated: 2024-09-08T10:08:45.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/september-8th/#a-letter-from-pfella) 4 Tips for the FRCS Viva 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-8th/#the-sunday-quiz) How well do you know congenital dermoid cysts? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/september-8th/#behind-the-fella) Underrated Plastic Surgery Resources Every Surgeon Needs 4. [🖼️](https://emojipedia.org/framed-picture?ref=theplasticsfella.com) [****Anatomy Illustration of the Week**](https://www.theplasticsfella.com/september-8th/#anatomy-illustration-of-the-week) Anatomy of hard and soft palate. 5. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/september-8th/#the-fellows-corner) This week's feature: Macrodactyly. 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/september-8th/#what-does-the-evidence-say) Should we operate on paediatric trigger thumbs? 7. ****🔥**[ **Articles of the Week**](https://www.theplasticsfella.com/september-8th/#articles-of-the-week) Pediatric trigger thumb, syndactyly surgical outcomes, & velopharyngeal dysfunction: 3 articles with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/september-8th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella 4 Tips for the FRCS Viva 👋 ****Hey P’Fella Fam!** With FRCS oral exams around the corner, I had a chat with ****Professor Andy Hart**—an experienced examiner and ****JPRAS** editor—who knows what it takes to pass the viva. Here are some tips you can put into action right now. 1. **Tip 1: Cut to the Chase** Skip the small talk—get straight to the diagnosis and management. “Examiners want to see you think like a consultant,” Andy says. Whether it’s melanoma or a surgical plan, go straight to the key points and show you’re in control. 2. **Tip 2: Keep it Short and Sharp** Know when to stop. Give a precise answer and let it land. “Finish with a full stop,” Andy emphasizes. Don’t ramble—concise answers are what examiners are after. 3. **Tip 3: Handle the Silence** Examiners might give no feedback, but don’t let that rattle you. Stay composed. “Keep the flow going,” Andy advises. Ask for details if needed, but stay focused and in charge of the case. 4. **Tip 4: Practice Out Loud** You can’t just think your answers—say them out loud. Andy insists: “Practice mock exams, whether it’s with peers or by yourself.” Verbal practice builds confidence and clarity under pressure. 💡 ****Bonus Tip:** Our new [****Oral Exams**](https://www.theplasticsfella.com/oral-exams/) feature has over 35+ real [FRCS scenarios](https://www.theplasticsfella.com/oral-exams/), with two added every week. Perfect for getting those last-minute reps in. Get ready to ace the exam. Also, keep an eye out for my full conversation with Andy on [**Behind the 'Fella**](https://www.theplasticsfella.com/behind-the-fella-podcast/)—packed with insights to help you go into the viva with confidence. Lot of Love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Congenital Dermoid Cysts** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/IG-11-Posts--4-.png) Presentation of congenital dermoid cysts ## Behind the ‘Fella Underrated Plastic Surgery Resources Every Surgeon Needs 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. In our upcoming episode, we discuss our favourite resources for plastic surgery learning. ****You can listen now on** [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) **&** [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)****!** 0:00 /0:57 1× Listen to the Full Episode now on [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) **&** [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)****!** ## Anatomy Illustration of the Week **Anatomy of Hard and Soft Palate* 🖼️ ****Anatomy Illustration of the Week** In this new section, we feature an anatomical illustration. This edition looks at the anatomy of hard and soft palates. 👇 ![](https://lh7-rt.googleusercontent.com/docsz/AD_4nXdX-GRQJrM_SQ3J7UzrmByN4l9dukbAmcBKBU5MdMRkomMTCOxyofpv-LFUPgXNWNJ6CXED9a-GBEPrTyAXr2G5tcdwBAifP-n3CCLg-K8HrCcWSnK_pAkW9I27-5I84AAH0Hvlrt5j4hUQDFTyZI6SWQ_L?key=VE6BXUZFwhQudikkPVwgwA) Mucosa of the palate [Anatomy of Hard & Soft Palate: Bones, Muscle, Artery, and NervesThe hard and soft palate is composed of bone and soft tissue. This article details structures, neuromuscular supply and abnormal anatomy.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/size/w256h256/2022/07/Logo-Small-2.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Hard-and-Soft-Palate.png)](https://www.theplasticsfella.com/anatomy-of-hard-and-soft-palate/) ## the Fellows' Corner **This Week's Focus:* ***Macrodactyly** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Macrodactyly**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/IG-11-Posts--15-.png) #### Macrodactyly [****Definition**](https://www.theplasticsfella.com/macrodactyly/#definition-of-macrodactyly) Macrodactyly is the term for the overgrowth of a digit, out of proportion to the rest of the hand or foot. [****Clinical Features**](https://www.theplasticsfella.com/macrodactyly/#clinical-features-of-macrodactyly) Macrodactyly results in overgrowth of the entire digit(s) out of proportion with the rest of the hand or foot. [****Investigations**](https://www.theplasticsfella.com/macrodactyly/#investigations-for-macrodactyly) X-rays, MRI, and gene analysis may be offered as part of the diagnostic process. [****Management**](https://www.theplasticsfella.com/macrodactyly/#management-of-macrodactyly) Surgical management aims to stop overgrowth and debulk the digit. Addressing the nerve is important in reducing recurrence. [Read the Article](https://www.theplasticsfella.com/macrodactyly/) ## What Does the Evidence Say? **Should We Operate on Paediatric Trigger Thumbs?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ****Pediatric trigger thumb management** remains controversial, with both conservative and surgical approaches showing benefits. ****Spontaneous recovery** rates vary widely, from 12-66% (Dinham & Meggitt, 1974; Dunsmuir & Sherlock, 2000; Farr et al., 2014). Conservative treatments like ****splinting** and ****passive exercises** can be effective, with success rates of 55-67% (Farr et al., 2014). However, ****surgical release** consistently demonstrates higher success rates of ****95-100%** (Farr et al., 2014; van den Borne et al., 2000; Marek et al., 2011). Complications from surgery are generally minor and rare (Marek et al., 2011; Dittmer et al., 2020). Some studies suggest observing younger children for 6-12 months before considering surgery (Dinham & Meggitt, 1974; Dittmer et al., 2020). A network meta-analysis found splinting to be the most appropriate initial intervention, with open surgery recommended if conservative methods fail (Sirithiantong et al., 2020). Overall, treatment decisions should consider the child's ****age**, ****thumb stage**, and the ****potential for spontaneous recovery**. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****History of Pediatric Trigger Thumb in the US** ([Hutchinson](https://pubmed.ncbi.nlm.nih.gov/33436280/?ref=theplasticsfella.com), 2021) About one-third of pediatric trigger thumbs resolve naturally, but spontaneous resolution is less likely for severe interphalangeal joint flexion (>30°) and therefore benefits from early surgical intervention. ✅ ****Long-Term Outcomes of Syndactyly Surgical Management** ([Lumenta](https://pubmed.ncbi.nlm.nih.gov/20638200/?ref=theplasticsfella.com), 2010) Simple syndactyly surgical outcomes revealed a low incidence of web creep, with most patients experiencing good scar quality, normal function, and minimal complications. ✅ ****Velopharyngeal Dysfunction: Surgical Interventions and Outcomes** ([de Blacam](https://pubmed.ncbi.nlm.nih.gov/29437504/?ref=theplasticsfella.com), 2018) The effectiveness of ICG-A in enhancing tissue perfusion visualization, thus leading to better patient safety and reconstructive success in both mastectomy flaps and autologous procedures. ## Feedback ### I hope you enjoyed it 😄 --- ### Soft Tissue Sarcoma: Classification, Diagnosis, & Management URL: https://www.theplasticsfella.com/soft-tissue-sarcoma/ Last updated: 2024-10-02T20:51:13.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/soft-tissue-sarcoma/#overview-of-sarcomas) Soft tissue sarcomas are malignant tumors of mesenchymal origin, affecting soft tissues such as muscles, fat, and connective tissues. [****Classification**](https://www.theplasticsfella.com/soft-tissue-sarcoma/#classification-of-soft-tissue-sarcomas) The WHO classifies soft tissue sarcomas into over 70 subtypes based on tissue origin, using immunohistochemical markers to guide treatment and predict outcomes. [****Risk Factors**](https://www.theplasticsfella.com/soft-tissue-sarcoma/#risk-factors-of-soft-tissue-sarcomas) Risk factors for soft tissue sarcomas include environmental and chemical exposures, radiation, genetic predispositions like Li-Fraumeni syndrome, and chronic lymphedema leading to angiosarcoma. [****Clinical Features**](https://www.theplasticsfella.com/soft-tissue-sarcoma/#clinical-features-of-soft-tissue-sarcomas) Slow-growing, painless mass; physical examination shows a palpable, encapsulated mass, with the assessment of fascial involvement and lymph nodes being critical for prognosis. [****Diagnosis**](https://www.theplasticsfella.com/soft-tissue-sarcoma/#diagnosis-of-soft-tissue-sarcomas) The evaluation of suspected soft tissue sarcomas involves specialised imaging, biopsy techniques, rigorous pathological assessment per 2020 WHO guidelines, and staging via the AJCC system. [****Management**](https://www.theplasticsfella.com/soft-tissue-sarcoma/#management-of-soft-tissue-sarcomas) Management of soft tissue sarcomas involves surgical excision, radiotherapy to reduce recurrence, and selective use of chemotherapy for high-grade or aggressive tumours. [****Specific Soft Tissue Sarcomas**](https://www.theplasticsfella.com/soft-tissue-sarcoma/#specific-soft-tissue-sarcomas) Undifferentiated pleomorphic sarcoma, rhabdomyosarcoma, and Dermatofibrosarcoma protuberans are among the commonest soft tissue sarcomas seen in clinical practice. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Overview of Sarcomas ****Key Point** Soft tissue sarcomas are malignant tumors of mesenchymal origin, affecting soft tissues such as muscles, fat, and connective tissues. Sarcomas are a diverse group of rare, malignant solid tumours originating from mesenchymal tissues. They account for about 1% of adult malignancies and 15% of pediatric malignancies ([Gilbert](https://journals.lww.com/jaaos/abstract/2009/01000/soft%5Ftissue%5Fsarcoma.6.aspx?ref=theplasticsfella.com), 2009). Sarcomas are categorized into two main types. - **Soft Tissue Sarcomas:** These affect fat, muscle, nerve tissues, blood vessels, and other connective tissues. - **Malignant Bone Tumors:** Examples include osteosarcoma and Ewing’s sarcoma. The lungs are the most common site for metastatic deposits in soft tissue sarcomas. Among adults, the most common soft tissue sarcoma is undifferentiated pleomorphic sarcoma (UPS), while rhabdomyosarcoma is the most frequent subtype in children ([Gilbert](https://journals.lww.com/jaaos/abstract/2009/01000/soft%5Ftissue%5Fsarcoma.6.aspx?ref=theplasticsfella.com), 2009). 😎 ****Fun Fact:** Undifferentiated pleomorphic sarcoma (UPS), formerly known as malignant fibrous histiocytoma (MFH), is now thought to originate from mesenchymal stem cells rather than histiocytes. --- ## Classification of Soft Tissue Sarcomas ****Key Point** The WHO classifies soft tissue sarcomas into over 70 subtypes based on tissue origin, using immunohistochemical markers to guide treatment and predict outcomes. Soft tissue sarcomas are classified according to their tissue of origin. The World Health Organization (WHO) categorizes these tumors into more than 70 subtypes ([Sbaraglia](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167394/?ref=theplasticsfella.com), 2020). Diagnosis of these subtypes relies on specific immunohistochemical markers, typically including keratins, S100 protein and/or SOX10, smooth muscle actin (SMA), and desmin. Key categories include: - **Undifferentiated Pleomorphic Sarcoma** - **Fibroblastic/Myofibroblastic Tumors:** Dermatofibrosarcoma Protuberans (DFSP) - **Lipomatous Malignant Tumors:** Liposarcoma - **Smooth Muscle Tumors:** Leiomyosarcoma - **Nerve Sheath Tumors:** Malignant Peripheral Nerve Sheath Tumors (MPNST) - **Vascular Tumors:** Angiosarcoma - **Rhabdomyosarcomatous Tumors:** Rhabdomyosarcoma The classification of soft tissue sarcomas is illustrated in the table below. ![WHO classification of soft tissue sarcomas](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-05T005559.489.png) WHO classification of soft tissue sarcomas 😎 ****Fun Fact:** Lymph node metastasis occurs in about 5% of cases, with certain subtypes more prone to lymphatic spread, remembered by the acronym "RACES": Rhabdomyosarcoma, Angiosarcoma, Clear cell sarcoma, Epithelioid sarcoma, and Synovial sarcoma ([Sinha](https://www.bmj.com/content/341/bmj.c7170?ref=theplasticsfella.com), 2010). --- ## Risk factors of Soft Tissue Sarcomas ****Key Point** Risk factors for soft tissue sarcomas include environmental exposures (e.g., chemicals like herbicides and radiation), genetic predispositions (e.g., Li-Fraumeni syndrome, Neurofibromatosis type 1), and chronic lymphedema. Several factors have been identified as potentially increasing the risk of developing soft tissue sarcomas ([Brennan](https://journals.lww.com/annalsofsurgery/abstract/2014/09000/lessons%5Flearned%5Ffrom%5Fthe%5Fstudy%5Fof%5F10,000%5Fpatients.2.aspx?ref=theplasticsfella.com), 2014). - **Environmental Exposure** - Chemicals, such as herbicides, dioxin, and chlorophenols. - Radiation, either through medical diagnostics or environmental sources. - **Genetic Predisposition** - Inherited syndromes such as Li-Fraumeni syndrome, Neurofibromatosis type 1, and Gardner's syndrome are associated with an increased risk of soft tissue sarcomas. - **Chronic Lymphedema** - Predisposes to angiosarcoma, as seen in conditions like Stewart-Treves syndrome. 😎 ****Fun Fact:** ****Stewart-Treves syndrome** is a rare angiosarcoma in chronic lymphedema, mainly associated with post-mastectomy but can also occur in primary or chronic lymphedema. ([Pereira](https://www.scielo.br/j/abd/a/MjH5dfz5K4pz8yHrNDh6qSL/?ref=theplasticsfella.com), 2015). --- ## Clinical Features of Soft Tissue Sarcomas ****Key Point** History often reveals a rapidly growing, painful mass; physical examination shows a palpable, firm mass, with the assessment of fascial involvement and lymph nodes being critical for prognosis. The onset of symptoms in soft tissue sarcoma (STS) varies with the affected tissue and anatomic site. However, there are key features common that strongly suggest a diagnosis (Misra, [2009](https://pubmed.ncbi.nlm.nih.gov/19036655/?ref=theplasticsfella.com)). The presence of more **cardinal signs** increases the risk of malignancy; when all four signs are present, the likelihood of STS is 86% (Johnson, [2001](https://pubmed.ncbi.nlm.nih.gov/11432141/?ref=theplasticsfella.com)): 1. Size > 5cm 2. Deep to fascia 3. Associated pain 4. Increase in size 5. Any recurrence of a previously excised lump should also raise the possibility of malignancy. The image below illustrates a rapidly growing soft tissue sarcoma on the foot. ![Clinical features of soft tissue sarcoma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-05T010536.225.png) Clinical features of soft tissue sarcoma It is important to determine whether the mass is separate from or involves the underlying fascia, as fascial involvement is a poor prognostic indicator. The absence of ecchymosis/bruising suggests an encapsulated mass. Assessment of local **lymph nodes** is crucial. 💡 ****Tip:** History of trauma can sometimes highlight the ****pre-existing** presence of a mass. --- ## Diagnosis of Soft Tissue Sarcomas ****Key Point** In suspected soft tissue sarcomas, a multidisciplinary diagnosis using MRI, CT, and targeted biopsies, aligned with WHO classifications and molecular assessments, optimizes treatment planning and staging. In cases of suspected soft tissue sarcomas, a detailed and multidisciplinary approach is crucial to ensure accuracy and optimal treatment planning **Biopsy Techniques** - **Core Needle Biopsy:** standard diagnostic approach, using ≥14-16G needles. - **Excisional Biopsy:** Suitable for superficial lesions smaller than 3 cm. - **Open Biopsy:** Not recommended except in specialized centers for specific cases. - **Fine Needle Aspiration:** Usually insufficient for diagnosis and not recommended. **Pathological and Molecular Assessment** - **Diagnosis:** Align with 2020 WHO Classification for soft tissue & bone tumors. - **Molecular Diagnostics:** complement morphology & immunohistochemistry. - **Grading:** FNCLCC system, categorizing tumors based on differentiation, necrosis, and mitotic rate. - **Mitotic Rate:** Should be independently reported when possible. **Imaging** - **MRI:** rimary imaging modality for tumors in the extremities, pelvis, and trunk. - **CT:** Important for assessing calcified lesions, pleuropulmonary, and retroperitoneal sarcomas, with comparable effectiveness to MRI. - **Ultrasound:** May serve as initial imaging but should lead to CT or MRI if soft tissue sarcoma is suspected. The image below illustrates an MRI image of a soft tissue sarcoma. ![MRI of Soft Tissue Sarcoma for the diagnosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-05T011055.350.png) MRI of Soft Tissue Sarcoma In cases of confirmed diagnosis, the AJCC system is used for staging ([Tanaka](https://academic.oup.com/jjco/article/49/2/103/5179391?ref=theplasticsfella.com), 2019). This staging system is summarised in the table below. ![The AJCC system for staging soft tissue sarcomas](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-03T044032.001.png) The AJCC system for staging soft tissue sarcomas 💡 ****Tip:** When planning a biopsy for suspected soft tissue sarcoma, ensure the tract and scar can be removed in future surgery. Consider tattooing the entry point for accuracy. --- ## Management of Soft Tissue Sarcomas ****Key Point** Soft tissue sarcoma management involves surgery and radiotherapy for local control, with chemotherapy added for high-risk cases, depending on the specific subtype. ### Surgery Surgery is the primary treatment for soft tissue sarcomas, with the approach tailored to the tumor's location, size, and patient comorbidities. The **Enneking classification** outlines four types of surgical margins (Misra, [2009](https://pubmed.ncbi.nlm.nih.gov/19036655/?ref=theplasticsfella.com)). - **Wide Local Excision:** The tumor and its reactive zone are removed within the same anatomical compartment, through normal tissue. The standard approach for most STS aims for complete resection while preserving limb function. The local Recurrence Rate is 10%. - **Intra-lesional Excision:** Theexcision margin passes through the tumor, leaving residual tumor tissue. Local Recurrence Rate: 80-100%. Indicated primarily for palliative cases due to high recurrence risk. - **Marginal Excision:** The surgical plane includes the tumor’s pseudocapsule and reactive zone, often resulting in higher recurrence. Local Recurrence Rate is 40-60% - **Radical Excision:** Entire tumor and surrounding compartments are removed.Local Recurrence Rate is 0.5%. Rarely performed if limb salvage is possible; amputation may be necessary for extensive involvement of critical structures. There are specific surgical **considerations** in sarcoma surgery: - **En-bloc Removal:** Needed for tumors encasing critical structures. - **Close Margins:** Acceptable near critical structures without compromising outcomes. - **Prophylactic Nailing:** Advised if periosteal stripping >10 cm to prevent fractures. - **Contaminated Tissues:** Excise biopsy sites and drain tracts en bloc with the tumor. - **Tissue Resistance:** Muscle requires wider margins (2-3 cm); fascia/periosteum provide adequate margins if intact; preserve uninvolved vessels and nerves. This structured approach to surgical margins helps optimize outcomes while balancing the goals of oncologic safety and limb preservation. Live Soft Tissue Sarcoma Surgery ### Limb Salvage Surgery Limb salvage surgery (LSS) provides acceptable local recurrence rates using wide excision and radiotherapy, comparable to those of amputation or radical excision. Since amputation does not significantly improve survival outcomes, limb preservation is often preferred to enhance the patient's postoperative quality of life (Misra, [2009](https://pubmed.ncbi.nlm.nih.gov/19036655/?ref=theplasticsfella.com)). Some important data includes: - LSS can be achieved in approximately 90-95% of soft tissue sarcoma cases. - Recurrence rates for LSS vary between 9% and 22%, with rates higher than this considered unacceptable. 1. **Amputation:** when negative margins can't be achieved, resection risks major nerve damage, or patient comorbidities limit recovery from limb-sparing surgery 😎 ****Fun Fact:** Surgery is not first line for synovial sarcoma, which typically requires chemotherapy. ### (Neo)Adjuvant Therapies **Radiotherapy:** - **Purpose:** Enhances local control and facilitates limb-salvage surgery, particularly when clear surgical margins are difficult to achieve. - **Benefits:** Preserves critical structures while maintaining low recurrence rates. - **Standard Dosage:** Doses over 60 Gy are generally recommended for maximum benefit. - **Techniques:** - **External-Beam Radiation Therapy:** Commonly used after wide surgical excision for improved outcomes. - **Brachytherapy:** Used in some centers, offering similar local control as external-beam radiation. - **Intensity-Modulated Radiation Therapy (IMRT):** Targets the tumor precisely, minimizing damage to surrounding tissues and reducing complications like wound breakdown and fractures. **Chemotherapy:** - **Purpose:** Aims to improve survival rates in high-risk STS patients with poor 5-year survival (50-60%). - **Use Cases:** Routine in treating rhabdomyosarcomas and soft tissue Ewing’s sarcomas, especially in younger patients. - **Effectiveness:** Limited evidence for survival benefits in adult STS, but chemotherapy can reduce the risk of local recurrence and metastasis. - **Recent Advances:** Studies show that adjuvant chemotherapy with drugs like doxorubicin and ifosfamide may delay metastatic disease onset in high-risk adult STS patients. ### Follow-Up No standardized follow-up schedule exists, but regular clinical reviews are essential to monitor for local recurrence and metastatic disease. Some hospitals may consider this as their follow-up routine. - Every 3 months for the first 2 years, including a chest X-ray. - Every 6 months for the next 3 years. Monitoring continues for up to 5 years for high-grade tumors and may be longer for low-grade tumors. 😎 ****Fun Fact:** The risk of metastasis is highest in the first 2 years. --- ## Specific Soft Tissue Sarcomas ****Key Point** Undifferentiated pleomorphic sarcoma, rhabdomyosarcoma, and Dermatofibrosarcoma protuberans are among the most common soft tissue sarcomas encountered in clinical practice. ### Undifferentiated Pleomorphic Sarcoma (UPS) UPS is one of the most aggressive types of soft tissue sarcomas, primarily affecting patients over 60 years of age, with a slightly higher incidence in men ([Robles-Tenorio](https://europepmc.org/article/nbk/nbk570612?ref=theplasticsfella.com), 2021). Common types and their typical locations include, - **Deep Soft Tissue UPS:** Frequently occurs in the deep soft tissues of the limbs, especially the thigh. Often found in muscle tissue and can grow large before detection. - **Retroperitoneal UPS:** These tumors are often very large and may affect multiple organs due to their location. - **Subcutaneous UPS:** Found just under the skin; less common and typically smaller with a better prognosis. - **Visceral UPS:** Very rare, affecting internal organs like the liver, kidneys, and spleen, making diagnosis and treatment challenging. **Clinical Assessment** - Typically presents as a painless, enlarging mass in the deep soft tissues of the extremities or retroperitoneum. - MRI is used to assess the extent of the tumor and its relation to adjacent structures. - Definitive diagnosis requires a biopsy, preferably a core needle biopsy. **Management** - Treatment is primarily surgical, aiming for wide local excision with negative margins. - Radiotherapy is often employed either preoperatively or postoperatively to reduce recurrence rates. - Chemotherapy is reserved for advanced or metastatic disease. - Reconstructive procedures are usually required following extensive resection in cases affecting the extremities. ### Dermatofibrosarcoma Protuberans (DFSP) DFSP is a rare, slow-growing skin cancer known for its aggressive local spread. Key types include, - **Giant Cell Fibroblastoma:** Juvenile form, seen in children. - **Myxoid DFSP:** Gelatinous due to mucoid substance. - **Pigmented DFSP (Bednar Tumor):** Contains melanin, giving a darker appearance. - **Fibrosarcomatous DFSP (FS-DFSP):** More aggressive, with higher recurrence and metastatic potential. - **Classic DFSP:** The most common, presenting as a slowly enlarging plaque or nodule. **Clinical Assessment** - DFSP presents as a slow-growing, firm dermal nodule that can become plaque-like, often resembling a benign skin condition. It tends to infiltrate deeply into surrounding tissues, including muscle and bone. - Diagnosis is confirmed through biopsy, with MRI used to define the subcutaneous extent of the disease. **Management** - The primary treatment is surgical, involving wide local excision or Mohs micrographic surgery. - Imatinib may be used for unresectable or metastatic cases, particularly those expressing the platelet-derived growth factor receptor (PDGFR). ### Rhabdomyosarcoma in Children Rhabdomyosarcoma is the most prevalent soft tissue sarcoma in children, with a peak incidence in those under 10 years of age. It is the third most common extracranial solid tumor in the pediatric population, following neuroblastoma and Wilm’s tumor ([Wexler](https://www.sciencedirect.com/science/article/abs/pii/S0887217111000473?ref=theplasticsfella.com), 2011). The main types include: - **Embryonal:** Frequently found in the head, neck, genital, or urinary organs; the most common variant. - **Alveolar:** Typically appears in the arms, legs, chest, abdomen, genital organs, or anal area. - **Spindle Cell/Sclerosing:** Commonly located in the paratesticular area, with subtypes primarily found in infants (trunk area) and a more aggressive form in the head and neck region. - **Pleomorphic:** The least common in children, with variable appearance. **Clinical Assessment** - Children typically present with a rapidly enlarging mass, which may be associated with pain or functional impairment depending on its location. - Imaging studies, including MRI and CT scans, are crucial for assessing the tumor's size and spread. A core biopsy is essential for histological diagnosis. **Management** - Treatment involves a multimodal approach including surgery, radiotherapy, and chemotherapy. The goal is to achieve complete resection where possible, supplemented by systemic therapy to address micrometastatic disease. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview of Sarcomas:** Discussed the basic understanding of sarcomas, their significance in pediatric and adult oncology, and highlighted the most common types. ****2\. Classification of Sarcomas:** Explained the WHO classification system which categorizes over 70 sarcoma subtypes based on tissue origin, enhancing treatment through immunohistochemical markers. ****3\. Risk Factors:** Identified environmental, genetic, and other risk factors contributing to sarcoma development, emphasizing the need for awareness and preventive measures in at-risk populations. ****4\. Clinical Presentation:** Outlined typical symptoms and physical findings in sarcoma cases, noting the importance of detailed physical examinations. ****5\. Diagnostic Process:** Covered the multidisciplinary diagnostic approach required for sarcomas, including advanced imaging and biopsy techniques aligned with current WHO guidelines. ****6\. Management Strategies:** Discussed the integrated treatment approach involving surgery, radiotherapy, and chemotherapy, tailored to sarcoma types and individual patient cases to optimize outcomes. ****7\. Specific Sarcoma Types:** Provided insights into three prevalent sarcoma types — Undifferentiated Pleomorphic Sarcoma, Dermatofibrosarcoma Protuberans, and Rhabdomyosarcoma. --- ## Further Reading 1. Gilbert, Nathan F., et al. "[Soft-tissue sarcoma](https://journals.lww.com/jaaos/abstract/2009/01000/soft%5Ftissue%5Fsarcoma.6.aspx?ref=theplasticsfella.com)." *JAAOS-Journal of the American Academy of Orthopaedic Surgeons* 17.1 (2009): 40-47. 2. Stein-Wexler, Rebecca. "[Pediatric soft tissue sarcomas.](https://www.sciencedirect.com/science/article/abs/pii/S0887217111000473?ref=theplasticsfella.com)" *Seminars in Ultrasound, CT and MRI*. Vol. 32\. No. 5\. WB Saunders, 2011. 3. Sbaraglia M, Bellan E, Dei Tos AP. [The 2020 WHO Classification of Soft Tissue Tumours: news and perspectives](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167394/?ref=theplasticsfella.com). Pathologica. 2021 Apr;113(2):70-84\. doi: 10.32074/1591-951X-213\. Epub 2020 Nov 3\. PMID: 33179614; PMCID: PMC8167394. 4. Brennan, Murray F., et al. "[Lessons learned from the study of 10,000 patients with soft tissue sarcoma](https://journals.lww.com/annalsofsurgery/abstract/2014/09000/lessons%5Flearned%5Ffrom%5Fthe%5Fstudy%5Fof%5F10,000%5Fpatients.2.aspx?ref=theplasticsfella.com)." *Annals of surgery* 260.3 (2014): 416-422 5. Pereira, Elisangela Samartin Pegas, et al. "[Stewart treves syndrome](https://www.scielo.br/j/abd/a/MjH5dfz5K4pz8yHrNDh6qSL/?ref=theplasticsfella.com)." *Anais Brasileiros de Dermatologia* 90.3 suppl 1 (2015): 229-231. 6. Sinha, Shiba, and A. Howard S. Peach. "[Diagnosis and management of soft tissue sarcoma.](https://www.bmj.com/content/341/bmj.c7170?ref=theplasticsfella.com)" *Bmj* 341 (2010). 7. Tanaka, Kazuhiro, and Toshifumi Ozaki. "[New TNM classification (AJCC eighth edition) of bone and soft tissue sarcomas: JCOG Bone and Soft Tissue Tumor Study Group](https://academic.oup.com/jjco/article/49/2/103/5179391?ref=theplasticsfella.com)." *Japanese journal of clinical oncology* 49.2 (2019): 103-107. 8. Umer, Hafiz Muhammad, et al. ["Impact of unplanned excision on prognosis of patients with extremity soft tissue sarcoma](https://onlinelibrary.wiley.com/doi/full/10.1155/2013/498604?ref=theplasticsfella.com)." *Sarcoma* 2013.1 (2013): 498604. 9. Robles-Tenorio, Arturo, and Guillermo Solis-Ledesma. "[Undifferentiated pleomorphic sarcoma](https://europepmc.org/article/nbk/nbk570612?ref=theplasticsfella.com)." (2021). 10. Llombart, Beatriz, et al. "[Dermatofibrosarcoma protuberans: a comprehensive review and update on diagnosis and management](https://www.sciencedirect.com/science/article/abs/pii/S074025701200007X?ref=theplasticsfella.com)." *Seminars in diagnostic pathology*. Vol. 30\. No. 1\. WB Saunders, 2013. ### Median Nerve Tendon Transfers: Anatomy, Principles, & Procedure URL: https://www.theplasticsfella.com/median-nerve-tendon-transfers/ Last updated: 2024-09-02T11:46:13.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/median-nerve-tendon-transfers/#overview-of-median-nerve-tendon-transfers) In median nerve pathology, tendon transfer restores thumb opposition and flexion of the thumb, index, and middle fingers. [****Anatomy**](https://www.theplasticsfella.com/median-nerve-tendon-transfers/#anatomy-of-the-median-nerve) The median nerve, originating from the brachial plexus, innervates the LOAF muscles and provides sensory input to the lateral volar hand. [****Principles**](https://www.theplasticsfella.com/median-nerve-tendon-transfers/#principles-of-median-nerve-tendon-transfers) There are key principles of tendon transfer surgery that guide optimal outcomes. Consider the function that has been lost, the available donor tendons, and the priorities for restoration. [****Indications**](https://www.theplasticsfella.com/median-nerve-tendon-transfers/#indications-for-median-nerve-tendon-transfer) High median nerve palsy impacts pronation, wrist, lateral digit flexion, and opposition, whereas low median nerve palsy impacts only opposition. [****Management**](https://www.theplasticsfella.com/median-nerve-tendon-transfers/#management-of-median-nerve-tendon-transfers) If conservative treatment has been exhausted, tendon transfers from radial and ulnar nerve-innervated muscles can restore opposition, pinch, and finger flexion. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## Overview of Median Nerve Tendon Transfers ****Key Point** Tendon transfer relocates a muscle-tendon unit to restore lost movement. In median nerve pathology, it restores thumb opposition and flexion of the index, middle fingers, and thumb. A tendon transfer involves moving a muscle-tendon unit to a new location to restore or improve movement and function. This technique redirects a working tendon to optimize its mechanical advantage, enhancing functional outcomes. Initially developed for obstetric brachial plexus palsies and polio, tendon transfers became more prominent in: - World War I with Jones, Meyer, and Steindler - World War II with Boyes, Bunnell, and Zancolli - 1949 with Littler, who popularized the method ([Littler](https://pubmed.ncbi.nlm.nih.gov/18116560/?ref=theplasticsfella.com), 1949). The image below illustrates the median nerve and median nerve innervated muscles. 😎 ****Fun Fact:** Galen advised against suturing tendons due to their link to nerves, a view that prevailed until tendon transfer surgery emerged in the 1800s. --- ## Anatomy of the Median Nerve ****Key Point** The median nerve, originating from the brachial plexus, innervates the LOAF muscles and provides sensory input to the lateral volar hand. ### Overview The median nerve originates from the lateral (C5-7) and medial (C8-T1) cords of the brachial plexus. It runs alongside the brachial artery, passes under the bicipital aponeurosis, and travels between the two heads of the pronator teres. It continues deep to the flexor digitorum superficialis (FDS), where the anterior interosseous nerve (AIN) branches off to the following muscles: - **Flexor pollicis longus (FPL)** - **Flexor digitorum profundus (FDP)** to the index and middle fingers - **Pronator quadratus (PQ)** Before entering the carpal tunnel, the median nerve gives off the palmar sensory branch for the palm. Inside the carpal tunnel, it divides into: - **Recurrent Motor Branch**: LOAF muscles—1st and 2nd lumbricals, opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis. This branch varies in its pattern. - **Sensory Branch**: radial volar half of the hand. Anatomy of the median nerve is illustrated below. ![The anatomy of the median nerve, The median nerve, originating from the brachial plexus, innervates the LOAF muscles and provides sensory input to the lateral volar hand.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/Main-Article-Images---2024-09-02T170336.286-1.png) The anatomy of the median nerve ### Branches of the Median Nerve (Proximal to Distal) The median nerve branches proximally to distally, supplying forearm and hand muscles, including the anterior interosseous and recurrent motor branches. **"Proper" Median Nerve** - Articular branch to elbow - Palmaris longus - Pronator teres - Flexor carpi radialis (FCR) - All of FDS **Recurrent motor branch** - **L**umbricals (1st and 2nd) - **O**pponens pollicis - **A**bductor pollicis brevis - **F**lexor pollicis brevis (ulnar nerve innervates deep head) **Anterior interosseous branch:** - FPL - FDP to index and middle fingers - PQ --- ## Principles of Median Nerve Tendon Transfers ****Key Point** There are key principles of tendon transfer surgery that guide optimal outcomes. Consider the function that has been lost, the available donor tendons, and the priorities for restoration. Successful tendon transfers should be considered before muscle atrophy occurs in acute denervation for median nerve injuries, hingeing on a few **key principles.** 1. Understanding the lost function. 2. Identifying suitable donor tendons. 3. Prioritising functional restoration. #### General Principles 1. **Soft Tissue and Joint Preparation** - Ensure good soft tissue coverage. - Achieve full joint range of motion before tendon transfer. - Stabilize non-functional joints through muscles or arthrodesis. 1. **Donor Tendon Selection** - Use expendable tendons that don’t compromise essential functions. - Match donor muscle power and amplitude to the lost function (e.g., using pronator teres for extensor carpi radialis brevis). - Select muscles with sufficient excursion: approximately 3 cm for ECU/FCU/FCR, 5 cm for EDC/FPL/EPL, and 7 cm for FDS/FDP. - Prefer synergistic muscle pairs (e.g., wrist flexors for finger extensors). 1. **Specific Considerations for Median Nerve Injuries** - **Low Median Nerve Injury:** Focus on reconstructing thumb opposition. - **High Median Nerve Injury:** Requires reconstruction of thumb opposition and flexion of the index and middle fingers. 💡 ****Tip:** Nerve transfers can also restore sensation, aiding in functional hand use (e.g., brachioradialis to the anterior interosseous nerve) ([MacKinnon](https://www.youtube.com/watch?v=r3Hxtl9wJjk&rco=1&ref=theplasticsfella.com), 2019). 😎 ****Fun Fact:** The Blix curve describes muscle power relative to length. A muscle can shorten 40% before output ceases and stretch 40% before rupture ([Gardenier](https://pubmed.ncbi.nlm.nih.gov/32884184/?ref=theplasticsfella.com), 2020). --- ## Indications for Median Nerve Tendon Transfer ****Key Point** A tendon transfer may be indicated secondary to neurological or musculoskeletal pathology or trauma. Tendon transfers for median nerve injuries are typically indicated due to neurological, musculoskeletal, or traumatic causes, aiming to restore lost functions such as thumb opposition, finger flexion, and forearm pronation. #### **Common Causes of Median Nerve Injuries** 1. **Neurological Conditions** - Compressive neuropathies (e.g., carpal tunnel syndrome, lacertus fibrosis) - Penetrating trauma (e.g., lacerations) - Conditions like polio, cerebrovascular accidents (CVA), tetraplegia - Congenital issues such as brachial plexus palsy 1. **Muscle and Tendon Pathology** - Trauma leading to muscle or tendon damage - Ischemic events causing necrosis - Tumors affecting nerve or tendon structures - Chronic conditions, like rheumatoid arthritis, cause tendon rupture 😎 ****Fun Fact:** Double crush syndrome involves nerve compression at multiple sites. Hagerty et al. found lacertus fibrosus compression in 78% of carpal tunnel cases during median nerve decompression ([Kong](https://pubmed.ncbi.nlm.nih.gov/37714514/?ref=theplasticsfella.com), 2023). ### High vs Low Clinical assessment should distinguish between high and low median nerve palsy. - **High Median Nerve Palsy:** Loss of forearm pronation, wrist radial deviation, thumb IPJ flexion, PIPJ flexion in all fingers, DIPJ flexion in the index and middle fingers, and thumb opposition. - **Low Median Nerve Palsy:** Loss of thumb opposition only. 💡 ****Tip:** In chronic carpal tunnel syndrome, severe atrophy of the APB muscle may require tendon transfer to restore thumb opposition. --- ## Management of Median Nerve Tendon Transfers ****Key Point** If conservative treatment fails, tendon transfers from radial and ulnar nerve-innervated muscles can restore opposition, pinch, and finger flexion. Initial supportive management includes splinting, physiotherapy, and occupational therapy. If there is no chance of nerve recovery, a tendon transfer is indicated. **Opponensplasty** Various techniques transfer a donor tendon to the abductor pollicis brevis (APB) insertion, with the choice depending on donor muscle function and patient needs: - **Palmaris longus (Camitz procedure):** Routed through the transverse carpal ligament to create a pulley. - **Abductor digiti minimi (Huber):** Common in pediatric cases, may cause loss of the palmar valley. - **Flexor digitorum superficialis to ring finger** (Thompson-Royle)**.** - **Extensor indicis proprius** (Burkhalter's popularised technique)**.** EIP Opponesplasty **Thumb IPJ Flexion** - Brachioradialis to flexor pollicis longus (FPL). **Index and Middle Finger Flexion** - **Side-to-side transfer** of little and ring finger flexor digitorum profundus (FDP) to the index and middle fingers. 😎 ****Fun Fact:** Altering the location and design of pulleys in tendon transfers can change the pull direction and friction levels, enhancing tendon gliding ([Duymaz](https://pubmed.ncbi.nlm.nih.gov/23985635/?ref=theplasticsfella.com), 2013). ### Post-Operative Care Optimal follow up care to protect the repair whilst optimising range and glide of movement should be guided by a close working relationship between patient, surgeon, OT and PT. Initial splinting protects the repair followed by tendon gliding and relearning exercises provided ([Ratner JA](https://pubmed.ncbi.nlm.nih.gov/20684937/?ref=theplasticsfella.com), 2010). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview of Tendon Transfers:** Discussed the historical evolution and technical application of tendon transfers. ****2\. Median Nerve Anatomy and Function:** Explained the anatomical pathway, key muscular innervations, and the median nerve's critical role in hand and finger movements. ****3\. Principles for Tendon Transfers:** Outlined essential considerations for effective tendon transfer surgeries. ****4\. Causes of Median Nerve Injuries:** Identified potential neurological, musculoskeletal, or traumatic causes leading to median nerve injuries. ****5\. Symptoms and Diagnostic Approach:** Reviewed how median nerve palsy presents and the specific tests used to diagnose the extent of nerve damage. ****6\. Tendon Transfer Procedures:** Detailed surgical techniques to restore crucial hand functions, depending on the severity and location of the nerve injury. ****7\. Post-Operative Care and Outcomes:** Emphasized the importance of coordinated post-operative care. --- ## Further Reading 1. LITTLER JW. [Tendon transfers and arthrodeses in combined median and ulnar nerve paralysis](https://pubmed.ncbi.nlm.nih.gov/18116560/?ref=theplasticsfella.com). J Bone Joint Surg Am. 1949 Apr;31A(2):225-34\. PMID: 18116560. 2. https://youtu.be/r3Hxtl9wJjk?feature=shared 3. Gardenier J, Garg R, Mudgal C. [Upper Extremity Tendon Transfers: A Brief Review of History, Common Applications, and Technical Tips](https://pubmed.ncbi.nlm.nih.gov/32884184/?ref=theplasticsfella.com). Indian J Plast Surg. 2020 Aug;53(2):177-190\. doi: 10.1055/s-0040-1716456\. Epub 2020 Aug 29\. PMID: 32884184; PMCID: PMC7458847. 4. Ducic I, Dellon AL, Bogue DP. [Radial sensory neurotization of the thumb and index finger for prehension after proximal median and ulnar nerve injuries](https://pubmed.ncbi.nlm.nih.gov/16456766/?ref=theplasticsfella.com). J Reconstr Microsurg. 2006 Feb;22(2):73-8\. doi: 10.1055/s-2006-932500\. PMID: 16456766. 5. Kong G, Brutus JP, Vo TT, Hagert E. [The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb](https://pubmed.ncbi.nlm.nih.gov/37714514/?ref=theplasticsfella.com). Hand Surg Rehabil. 2023 Dec;42(6):475-481\. doi: 10.1016/j.hansur.2023.09.002\. Epub 2023 Sep 14\. PMID: 37714514. 6. Sammer DM, Chung KC. [Tendon transfers: Part II. Transfers for ulnar nerve palsy and median nerve palsy](https://pubmed.ncbi.nlm.nih.gov/19730287/?ref=theplasticsfella.com). Plast Reconstr Surg. 2009 Sep;124(3):212e-221e. doi: 10.1097/PRS.0b013e3181b037c7\. PMID: 19730287; PMCID: PMC2741332. 7. Ratner JA, Peljovich A, Kozin SH. [Update on tendon transfers for peripheral nerve injuries](https://pubmed.ncbi.nlm.nih.gov/20684937/?ref=theplasticsfella.com). J Hand Surg Am. 2010 Aug;35(8):1371-81\. doi: 10.1016/j.jhsa.2010.05.023\. PMID: 20684937. 8. Duymaz A, Karabekmez FE, Zhao C, An KN, Amadio PC, Moran SL. [Tendon transfer for the restoration of thumb opposition: the effects of friction and pulley location](https://pubmed.ncbi.nlm.nih.gov/23985635/?ref=theplasticsfella.com). Plast Reconstr Surg. 2013 Sep;132(3):604-609\. doi: 10.1097/PRS.0b013e31829ad20e. PMID: 23985635. 9. Brand PW. [Tendon transfers for median and ulnar nerve paralysis](https://pubmed.ncbi.nlm.nih.gov/5521866/?ref=theplasticsfella.com). Orthop Clin North Am. 1970 Nov;1(2):447-54\. PMID: 5521866. ### NAC Reconstruction - Clinical Scenario URL: https://www.theplasticsfella.com/nac-reconstruction-clinical-scenario-2/ Last updated: 2024-09-06T13:13:05.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/09/NAC-recon.png) #### Clinical Scenario A 50-year-old female presented for nipple reconstruction 4 months after a delayed DIEP flap reconstruction. She is satisfied with the breast mound and is interested in options for NAC reconstruction. She has no major co-morbidities. ****Objectives:** ****1.** Indication for nipple-areolar reconstruction (NAC) reconstruction. ****2.** Discuss treatment choice for nipple reconstruction. ****3\.** Discuss treatment choice for areolar reconstruction. ****Primary Contributors:** Maitumelo Imeldah Di Loreto, Maxim Devine, and Richard Zinn _This post is for subscribers on the thePlastics Pro tier only._ ### BiALCL in 2024, This Theory Improves your Knowledge & New Newsletter (Soon!) URL: https://www.theplasticsfella.com/september-1st/ Last updated: 2024-09-01T09:29:44.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/september-1st/#a-letter-from-pfella) How can Information Theory improve your surgical approach? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-1st/#the-sunday-quiz) New winners on board! 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/september-1st/#behind-the-fella) Episode 05 released: Dive deep into skin grafts. 4. ****🩺** [****Technique Review**](https://www.theplasticsfella.com/september-1st/#technique-review) Options in nipple flap reconstruction. 5. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/september-1st/#the-fellows-corner) This week's feature: Tuberous breast deformity. 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/september-1st/#what-does-the-evidence-say) What is the actual incidence of BIA-ALCL? 7. ****🔥**[ **Articles of the Week**](https://www.theplasticsfella.com/september-1st/#articles-of-the-week) BIA-ALCL management, breast augmentation outcomes, & breast reconstruction: 3 articles with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/september-1st/#feedback) Suggest ideas & give feedback! ps - Coming soon: P'Fella's [new weekly newsletter](https://www.theplasticsfella.com/september-1st/#a-letter-from-pfella) with one practical lesson delivered straight to your inbox! ## A Letter from P'Fella **Information Theory Will Improve Your Surgery* 👋 ****Hey everyone!** I’ve been diving deep into something that could change the way we approach learning in plastic surgery: Information Theory. This isn’t just for the tech-savvy or the mathematically inclined — it’s for all of us looking to master our craft more efficiently. Think of it as a better 2.0 version of spaced repetition. **What is Information Theory?** Originating from the brilliant mind of Claude Shannon in the 1940s, Information Theory is all about ensuring that information is transmitted effectively and efficiently. It provides a framework for measuring the amount of information in a message and designing better ways to encode and transmit it. **Core Features of Information Theory:** - **Data Compression:** Simplifying information into compact forms without losing crucial details — think of it as condensing a complex surgical procedure into a few, crucial steps that are easy to grasp. - **Entropy and Redundancy Reduction:** In Information Theory, entropy is a measure of unpredictability or the amount of randomness in data. Reducing redundancy and increasing entropy ensures that every part of the educational content is necessary and that no unnecessary repetition occurs, making learning more streamlined and focused. - **Signal to Noise Ratio:** Enhancing the clarity of the information transmitted, which in our case, could mean distinguishing critical learning content from less essential details. **So, What’s Next?** Inspired by the potential of Information Theory to enhance our educational practices, I’m excited to announce the launch of a.... ### **A new newsletter that promises to be the only practical concise lesson you'll need each week, delivered directly to your inbox.** ### We’ll distill **complex surgical knowledge into actionable lessons**, leveraging the best that Information Theory has to offer. Can’t wait to kick this off with you all! Lot of Love, P'Fella ❤️ 🗞️ ***Sign up below!** ## The Sunday Quiz **\*Drumroll🥁\* New Winners on Board!* ****Congratulations to the Winners** of The Weekly Quiz! We're thrilled to announce the winners of this edition's quiz. After six rounds of questions on plastic surgery, our top scorers are ****Ntokozo**, ****Umer**, and ****Javier**. With a tie at the top, we're planning on another live playoff live on our podcast! We'll contact the finalists soon. Thank you to everyone who participated! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Leaderboard-Team-Post-Template--1-.png) ****Are you ready to make it to the leaderboard?** Welcome to ****a fresh round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. This week's question is from our latest release: Nipple-Areolar Complex (NAC) Reconstruction. A huge shoutout to Maitumelo Imeldah Motoroko, Maxim Devine, and Richard Zinn for their outstanding contributions! ![Overview of Nipple-Areolar Complex Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-24T020734.831-2.png) Overview of Nipple-Areolar Complex Reconstruction ## Behind the ‘Fella **Have a Listen to Episode 05!* 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. Check out the latest episode where we discuss our experiences in skin grafting! You can subscribe on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /0:51 1× ## Technique Review **Nipple Flap Recon Options* 😷 ****Technique Review** In this new section, we explore approaches or techniques in surgery. This edition looks at flap options for nipple reconstruction. 👇 ![](https://lh7-rt.googleusercontent.com/docsz/AD_4nXeRO8yTwl5NyNKzCsPFOng8FzySoRvB_fi7md-k6uzn6v8UOyqcChX3orevLwwXgV5M-HU8kw1OgznyidVlIhsTVwv4BqPJaGEzBD7M3Nqd10cFjAQbZHNm5Uh7lYmLEy670FP-wjjmG-ZbnImkK-4gIK4?key=VE6BXUZFwhQudikkPVwgwA) ## the Fellows' Corner **This Week's Focus:* ***Tuberous Breast Deformity** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Tuberous Breast Deformity**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Tuberous-Breast-Deformity--1-.png) #### Tuberous Breast Deformity [****Definition**](https://www.theplasticsfella.com/tuberous-breast-deformity/#definition-of-tuberous-breasts) A congenital deformity characterized by constricted, elevated, herniated, and hypoplastic features, while maintaining normal function. [****Clinical Features**](https://www.theplasticsfella.com/tuberous-breast-deformity/#clinical-features-of-tuberous-breasts) Features include asymmetry, hypoplasia, constricted base, IMF elevation, herniated nipple, ptosis, and skin envelope insufficiency. [****Classification**](https://www.theplasticsfella.com/tuberous-breast-deformity/#classification-of-tuberous-breasts) Von Heimburg's 1996 system helps identify specific affected areas to inform surgical strategies. [****Surgery**](https://www.theplasticsfella.com/tuberous-breast-deformity/#surgery-for-tuberous-breasts) Aims to release constrictions, restore volume, reposition the inframammary fold, and achieve symmetry and may require single or two-stage procedures depending on severity. [Read the Article](https://www.theplasticsfella.com/tuberous-breast-deformity/) ## What Does the Evidence Say? **What Is the Actual Incidence of BIA-ALCL?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare but serious complication associated with ****textured** breast implants. The reported incidence and risk of BIA-ALCL have increased significantly over time, from initial estimates of 1 per million to more recent figures of ****1 in 2,832** for high-textured implants (Collett et al., 2019). Studies have shown varying risk estimates, ranging from 1 in 355 to 1 in 30,000 patients with textured implants (Nelson et al., 2020; Lynch et al., 2021). The incidence appears to increase with ****longer implant exposure**, particularly after 10 years (Nelson et al., 2020). In Europe, the overall prevalence is estimated at 1:13,745 cases, with higher rates in countries implementing specific measures to address BIA-ALCL (Santanelli di Pompeo et al., 2020). In the United States, despite textured implants representing less than 10% of the market, the prevalence is estimated at 1:913 for textured implants (Santanelli di Pompeo et al., 2023). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****American Association of Plastic Surgeons Consensus on the Management of BIA-ALCL** ([Clemens](https://journals.lww.com/plasreconsurg/fulltext/2024/09000/american%5Fassociation%5Fof%5Fplastic%5Fsurgeons%5Fconsensus.2.aspx?ref=theplasticsfella.com), 2024) Effectively managing BIA-ALCL requires awareness of the implant surface type, patient surveillance, and adherence to guidelines. ✅ ***Subfascial Vs. Subglandular Planes: Outcomes in Breast Augmentation** ([Yuan](https://academic.oup.com/asj/article-abstract/44/9/NP639/7686579?redirectedFrom=fulltext&ref=theplasticsfella.com), 2024) The comparison of subfascial and subglandular planes suggests that subfascial plane reduces the risks of capsular contracture, hematoma, and rippling compared to the subglandular approach. ✅ ****Indocyanine Green Angiography in Autologous- and Implant-Based Breast Reconstruction** ([Lauritzen](https://www.jprasurg.com/article/S1748-6815%2821%2900124-8/fulltext?ref=theplasticsfella.com), 2021) The effectiveness of ICG-A in enhancing tissue perfusion visualization, thus leading to better patient safety and reconstructive success in both mastectomy flaps and autologous procedures. ## Feedback ### I hope you enjoyed it 😄 --- ### Thoracic Outlet Syndrome (TOS) - Clinical Scenario URL: https://www.theplasticsfella.com/thoracic-outlet-syndrome-clinical-scenario/ Last updated: 2024-08-29T19:58:00.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/AI-generated-image--15--1.png) #### Clinical Scenario A 40-year-old woman presents with increasing bilateral arm heaviness and paraesthesia that worsens when elevating her arms. Initially, these symptoms appeared only after prolonged overhead activities but have begun to manifest almost immediately upon arm elevation. Additionally, she notes the transient loss of radial pulse in the right arm when elevated. She has been using crutches due to a past sciatic nerve surgery, which she believes may be exacerbating her symptoms. ****Objectives:** ****1\.** Describe the anatomy of the thoracic outlet. ****2\.** Take a detailed history of a patient with TOS. ****3\.** Consider the differential diagnosis of TOS. ****4\.** Request appropriate investigations for a patient with likely TOS. ****5\.** Create a management plan for a patient with TOS. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Nipple-Areolar Complex (NAC) Reconstruction: Anatomy, Indications, & Techniques URL: https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/ Last updated: 2024-12-18T19:55:06.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/#overview-of-nac-reconstruction) NAC reconstruction uses flaps, grafts, tattooing, and combined techniques for aesthetic restoration after cancer, trauma, or surgery. [****Goals**](https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/#goals-of-nac-reconstruction) The goal of NAC reconstruction is to match the opposite nipple in size, color, position, and projection, achieving a natural appearance. [****Anatomy**](https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/#anatomy-of-nac-reconstruction) The nipple features dense fibrous tissue and smooth muscle fibers, connected to 15-20 lactiferous ducts. The pigmented areola houses lubricating Montgomery glands. [****Indications**](https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/#indications-for-nac-reconstruction) NAC reconstruction is indicated post-mastectomy, for congenital issues, trauma, and gender-affirming surgery; contraindications include active cancer and poor health ± smoking. [****Preoperative Marking and Positioning**](https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/#preoperative-marking-and-positioning-for-nac-reconstruction) Preoperative NAC marking uses key landmarks to ensure symmetry, positioning the nipple 19-21 cm from the sternal notch. [****NAC Reconstruction Techniques**](https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/#nac-reconstruction-techniques) Nipple reconstruction uses flap techniques and augmentation methods, while areolar reconstruction can be done simultaneously or delayed, such as with 3D tattooing. [****Areolar Reconstruction Techniques**](https://www.theplasticsfella.com/nipple-areolar-complex-reconstruction/#areolar-reconstruction-techniques) Areolar reconstruction can be done at the time of nipple reconstruction or as a delayed procedure (e.g. 3D tattooing). ****Primary Contributors:** Maitumelo Imeldah Motoroko, Maxim Devine, and Richard Zinn --- ## Overview of NAC Reconstruction ****Key Point** NAC reconstruction uses flaps, grafts, tattooing, and combined techniques for aesthetic restoration after cancer, trauma, or surgery. Nipple Areolar Complex (NAC) Reconstruction, first introduced in the 1940s using grafting techniques, has expanded to include **local flaps**, **tattooing**, **combination** methods, and **tissue engineering** ([Braza](https://www.ncbi.nlm.nih.gov/books/NBK558981/?ref=theplasticsfella.com) et. al, 2024). Common **indications** for NAC reconstruction include: 1. Oncology/Cancer excision 2. Post-traumatic events 3. Developmental pathology 4. Cosmetic breast surgery complications The image below illustrates a patient requiring an NAC reconstruction. ![Patient requiring nipple reconstruction post-oncological treatment for breast cancer - Nipple-areolar complex reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-24T020734.831.png) Patient requiring nipple reconstruction post-oncological treatment --- ## Goals of NAC Reconstruction ****Key Point** The goal of NAC reconstruction is to match the opposite nipple in size, color, position, and projection, achieving a natural appearance. The main goal of NAC reconstruction is to create a symmetrical nipple-areolar complex that matches the opposite side in **size**, **colour**, **position**, and **projection** for a natural appearance. **Key objectives include:** 1. **Symmetry:** Align the reconstructed nipple and areola with the opposite side, or the overall breast aesthetics. 2. **Projection:** Ensure adequate nipple projection to enhance the breast's three-dimensional appearance. 3. **Pigmentation:** Match the reconstructed NAC’s color to the patient's natural pigmentation, using tattooing or grafts as needed. 4. **Durability:** Maintain the NAC's shape, size, and projection over time, preventing flattening or pigment loss. 5. **Minimizing Complications:** Use careful surgical techniques to reduce risks like infection, necrosis, and scarring. 6. **Sensation:** preserve/restore sensation in reconstructed NAC if possible. The image below illustrates the goals of NAC reconstruction. ![Goals of nipple-areolar complex reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-24T021142.644.png) Goals of nipple-areolar complex reconstruction 💡 ****Tip:** Tailor the reconstruction to the patient’s specific cultural and personal preferences regarding NAC appearance, including size, shape, and colour ([Farhadi](https://pubmed.ncbi.nlm.nih.gov/16482789/?ref=theplasticsfella.com), 2006). --- ## Anatomy of NAC Reconstruction ****Key Point** The nipple features dense fibrous tissue and smooth muscle fibers, connected to 15-20 lactiferous ducts. The pigmented areola houses lubricating Montgomery glands. A clear understanding of the nipple-areolar complex (NAC) anatomy, including the distinction between the nipple and areola and their neurovascular components, is crucial for effective reconstruction. ### Areolar The pigmented area around the nipple, typically 38-50mm in diameter, contains Montgomery glands that secrete oil to protect and lubricate the nipple during breastfeeding. ### Nipple The nipple is a central, protruding structure composed of dense fibrous tissue and smooth muscle fibers, connected to approximately 15-20 lactiferous ducts, each linked to a lobe of the mammary gland. The smooth muscle fibers, both circular and longitudinal, enable the nipple to become erect in response to stimuli like cold, touch, or arousal. The image below illustrates the anatomy of the nipple-areolar complex. ![Anatomical illustration of the nipple-areolar complex (NAC), detailing the dense fibrous tissue of the nipple, the pigmented areola with Montgomery glands, and their critical neurovascular components essential for successful reconstruction.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-24T021539.446.png) Anatomy of the nipple-areolar complex Other anatomical features to consider include: - **Arterial Supply:** internal mammary, lateral thoracic, thoracoacromial, & intercostal arteries. - **Venous Drainage:** into the internal thoracic and axillary veins. - **Sensation:** primarily innervated by the fourth intercostal nerve. - **Autonomic Control:** Smooth muscle fibers in the nipple respond to stimuli, enabling erection ([Zucca-Matthes](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716863/?ref=theplasticsfella.com) et. al, 2016). 💡 ****Tip:** Areolar pigmentation can vary widely among individuals. --- ## Indications for NAC Reconstruction ****Key Point** NAC reconstruction is indicated post-mastectomy, for congenital issues, trauma, and gender-affirming surgery; contraindications include active cancer and poor health ± smoking. NAC reconstruction is considered only after completing breast reconstruction and chemoradiation, with a thorough evaluation of medical history, including prior surgeries, donor site availability, and patient preferences. ### Indications - **Post-Mastectomy:** Restores breast appearance after mastectomy. - **Breast Reduction/Mastopexy:** Repositions or reconstructs NAC after large reductions or complications. - **Congenital Conditions:** Corrects anomalies like Poland syndrome. - **Trauma/Burns:** Reconstructs NAC lost to injury. - **Gender-Affirming Surgery:** Essential for transgender chest reconstruction. ### Contraindications Avoid NAC reconstruction in cases of active cancer treatment, poor tissue viability, or compromised health. Other considerations include psychosocial factors and conditions that may affect healing (smoking, obesity, radiation, nutritional) --- ## Preoperative Marking and Positioning for NAC Reconstruction ****Key Point** Preoperative NAC marking uses key landmarks to ensure symmetry, positioning the nipple 19-21 cm from the sternal notch. Preoperative marking of the NAC is crucial for achieving a natural, symmetrical outcome in breast reconstruction. Use fixed landmarks such as the sternum, clavicle, and inframammary fold to ensure symmetry. ### Identify Landmarks Several well-established landmarks guide the 'ideal' nipple position: - **19-21 cm** from the nipple to the suprasternal notch - **Midhumeral point** - **8-10 cm** from the upper pole of the breast - **Pitanguy's point** (Inframammary fold transposed onto the anterior breast) - **Areola diameter:** Typically **38-50mm** The image below illustrates the landmarks for 'ideal' nipple positions. ![Preoperative diagram for NAC reconstruction, illustrating key landmarks such as the 19-21 cm distance from the sternal notch and midhumeral point, essential for achieving accurate symmetry and positioning.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-24T035210.795.png) Landmarks for 'ideal' nipple positions. ### Measure Position Before designing new nipple-areola complexes, accurately measure the following landmarks: - **Position the patient standing.** - **Mark the midline, inframammary fold (IMF), and breast meridian** (midclavicular line to nipple). - **Mark the nipple height** at the 4th intercostal space, just lateral to the midclavicular line. - **Mark the horizontal location** midway between the sternal notch and the lateral border of the breast mound. ### Tips for NAC Reconstruction - Prioritize nipple position over shape. - Use existing NAC as a reference in unilateral cases. - Adjust for planned position with contralateral lift. - Base nipple position on breast shape and size in bilateral cases. - Confirm placement with the patient in a full-length mirror. 💡 ****Tip:** It's easier to lift a low nipple than to lower an excessively high one, which may become visible above the bra cup's upper edge ([Paolini](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144123/?ref=theplasticsfella.com) et al., 2021). --- ## NAC Reconstruction Techniques ****Key Point** Nipple reconstruction uses flap techniques and augmentation methods, while areolar reconstruction can be done simultaneously or delayed, such as with 3D tattooing. Nipple-areolar reconstruction involves **flap** **reconstruction**, **nipple** **augmentation**, and **areolar** **reconstruction**. Flap options include subdermal pedicled, center-based local, and combined subdermal-pedicle with central-core flaps, while augmentation methods include autologous grafting, alloplastic techniques, and allografts. ### Flap Reconstruction Techniques There is no gold standard for NAC reconstruction. Flap options include subdermal pedicled, centre-based local, and combined subdermal-pedicle with central-core flaps. These techniques are detailed in the table below. ![Flap choices for NAC reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-06T041306.367.png) Flap choices for NAC reconstruction ### NAC Flap Reconstruction These NAC flap reconstructions are explained in more detail below. **Arrow Flap** - **Raising:** Subdermal flap raised from lateral ends to base. - **Inset:** Opposing ends wrapped together; C-flap forms roof. - **Closure:** Primary closure at the donor site. - **Limitation:** May lose projection. **Skate Flap** - **Raising:** Full-thickness wings raised. - **Inset:** Adipose tissue column incorporated for projection. Wings wrap around the nipple's central body. - **Closure:** Direct closure. - **Benefit:** Optimal for providing projection **CV Flap** - **Design:** Two lateral V-shaped limbs connected by a C-shaped curve. - **Raising:** Lateral limbs towards the midline in the subcutaneous plane. Subcutaneous fat may be included to enhance vascularity and volume. - **Inset:** Lateral limbs wrapped towards each other, C-flap forms the roof. - **Closure:** Direct closure These flap designs are illustrated in the image below. ![Illustration of NAC flap reconstruction techniques, including Arrow, Skate, and CV flaps, detailing the steps of flap raising, inset, and closure for achieving optimal nipple projection and symmetry.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-24T035127.888.png) Flap techniques for NAC flap reconstruction **Post-operatively,** dressing choices vary, often including topical antibiotics or petroleum jelly. Key points include: - **Protective Dressing:** Applied with a hole for the neo-nipple, sometimes using a nipple guard, breastfeeding shield, or 10ml syringe base. - **Bra and Compression:** Use a non-compressing bra; avoid direct compression for 6-8 weeks, or up to 3 months for significant projection. ### Nipple Augmentation Techniques Nipple augmentation techniques include autologous grafting, alloplastic methods, and allografts, each with specific advantages and disadvantages. These are detailed in the table below. ![Augmentation techniques for nipple reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-06T041324.600.png) Augmentation techniques for nipple reconstruction --- ## Areolar Reconstruction Techniques ****Key Point** Areolar reconstruction uses skin grafting for natural texture or dermal tattooing for a less invasive option, with the purse string suture technique enhancing definition. Areolar reconstruction can be performed either simultaneously with nipple reconstruction or as a delayed procedure. The two primary methods are skin grafting and dermal tattooing. ### **Skin Grafting** Skin grafting involves harvesting skin from donor sites such as the contralateral areola, medial thighs, abdominal-inguino-perineal region, or areas with excess skin. This method offers a textured and wrinkled appearance similar to a natural areola and allows for pigment variations. Techniques like pie-crusting can mimic the Montgomery tubercles, enhancing the natural look. - **Advantages** of skin grafting include its ability to closely resemble natural areolar texture. - **Disadvantages** include the risk of graft failure, contracture, loss of sensation, and donor site morbidity. Long-term color can be unpredictable. ### **Dermal Tattooing** Dermal tattooing, introduced in the 1970s ([Bunchman](https://pubmed.ncbi.nlm.nih.gov/4421739/?ref=theplasticsfella.com) et al., 1975), is a less invasive option that can be used alone or in conjunction with nipple reconstruction. This technique involves applying pigment to the skin to replicate the appearance of an areola. - **Advantages**: quick and straightforward, no hospitalization or general anesthesia, no donor site morbidity, good initial color match - **Disadvantages**: lacks texture and projection of natural tissue. The success of this technique heavily depends on the skill of the tattooist. ### **Purse String Suture Technique** [Caterson](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527627/?ref=theplasticsfella.com) et al. (2015) used this technique during nipple reconstruction with a C-V flap. Key steps to the procedure are: - Once the neo-areolar is marked, small incisions (\~2mm) are made, 8mm apart and 5mm from the areolar diameter. - The areolar is then cinched with a purse string suture. This elevates the areolar and reduces radial pull at the base of the nipple. 💡 ****Tip:** To avoid areolar tightness and deformity, it is advisable to harvest skin grafts with a diameter slightly larger than the areolar diameter. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of NAC Reconstruction:** Gained a comprehensive understanding of the various aspects and challenges of NAC reconstruction, including the latest techniques and methodologies. ****2\. Techniques of NAC Reconstruction:** Explored the technical aspects of NAC reconstruction, such as the different flap techniques and the importance of preoperative planning. ****3\. Clinical Considerations**: Explored the clinical considerations of NAC reconstruction, including patient-specific factors and potential contraindications. ****4\. Complications and Management:** Learned about the potential complications associated with NAC reconstruction and the strategies for managing them. --- ## Further Reading 1. Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. [Reconstruction of the nipple–areola complex: an update](https://pubmed.ncbi.nlm.nih.gov/16482789/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2006;59:40-5\. 2. Braza ME, Sisti A. [Nipple-Areolar Complex Reconstruction](https://www.ncbi.nlm.nih.gov/books/NBK558981/?ref=theplasticsfella.com).StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. 3. Zucca-Matthes G, Urban C, Vallejo A. [Anatomy of the nipple and breast ducts](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716863/?ref=theplasticsfella.com). Gland Surg. 2016 Feb;5(1):32-6\. doi: 10.3978/j.issn.2227-684X.2015.05.10\. PMID: 26855906; PMCID: PMC4716863. 4. Mayer AP, Goodreau AM, Blanchet NP. [Accurate Nipple Areolar Positioning in Nipple-sparing Mastectomy Reconstruction](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382234/?ref=theplasticsfella.com). Plast Reconstr Surg Glob Open. 2019 Jan 14;7(1):e2064\. doi: 10.1097/GOX.0000000000002064\. PMID: 30859033; PMCID: PMC6382234. 5. Paolini, G., Firmani, G., Briganti, F. *et al.* [Guiding Nipple-Areola Complex Reconstruction: Literature Review and Proposal of a New Decision-Making Algorithm](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144123/?ref=theplasticsfella.com). *Aesth Plast Surg* 45, 933–945 (2021). https://doi.org/10.1007/s00266-020-02047-9 6. Zenn MR, Garofalo JA. [Unilateral nipple reconstruction with nipple sharing: time for a second look](https://pubmed.ncbi.nlm.nih.gov/19483562/?ref=theplasticsfella.com). Plast Reconstr Surg. 2009 Jun;123(6):1648-53\. https://doi.org/10.1097/PRS.0b013e3181a3f2f. 7. Millard DR Jr. [Nipple and areola reconstruction by split-skin graft from the normal side](https://pubmed.ncbi.nlm.nih.gov/4561575/?ref=theplasticsfella.com). Plast Reconstr Surg. 1972 Oct;50(4):350-3\. doi: 10.1097/00006534-197210000-00006\. PMID: 4561575. 8. Little JW. Nipple-areolar reconstruction. In: Spear SL, editor. Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-Raven Publisher; 1998\. 9. Little III JW. [Nipple-areola reconstruction](https://pubmed.ncbi.nlm.nih.gov/6373095/?ref=theplasticsfella.com). Clin Plast Surg. 1984;11:351-64. 10. Ramakrishnan VV, Mohan D, Villafane O, Krishna A. [Twin flap technique for nipple reconstruction](https://pubmed.ncbi.nlm.nih.gov/9326703/?ref=theplasticsfella.com). Ann Plast Surg 1997;39: 241–4. 11. Sisti A, Grimaldi L, Tassinari J, et al. [Nipple-areola complex reconstruction techniques: A literature review](https://pubmed.ncbi.nlm.nih.gov/26868167/?ref=theplasticsfella.com). Eur J Surg Oncol. 2016;42:441–465. 12. Antón, M.A., Eskenazi, L.B., & Hartrampf, C.R. (1991). [Nipple Reconstruction With Local Flaps: Star and Wrap Flaps](https://www.semanticscholar.org/paper/Nipple-Reconstruction-With-Local-Flaps%3A-Star-and-Ant%C3%B3n-Eskenazi/a25545dc464a5bf03ad0b1940536dc22161eafec?ref=theplasticsfella.com). *Seminars in Plastic Surgery, 5*, 67 - 78. 13. Hamori, C.A., & Larossa, D. (1998). [The Top Hat Flap: For One Stage Reconstruction of a Prominent Nipple (Top Hat Flap)](https://link.springer.com/article/10.1007/s002669900181?ref=theplasticsfella.com). *Aesthetic Plastic Surgery, 22*, 142-144. 14. Jones G, Bostwick 3rd J. Nipple-areolar reconstruction. Operative Tech Plastic Reconstr Surg.1994; 1:35-8. 15. Guerra, A. B., Khoobehi, K., Metzinger, S. E., & Allen, R. J. (2003). [New technique for nipple areola reconstruction: arrow flap and rib cartilage graft for long-lasting nipple projection](https://pubmed.ncbi.nlm.nih.gov/12545106/?ref=theplasticsfella.com). *Annals of plastic surgery*, *50*(1), 31–37\. https://doi.org/10.1097/00000637-200301000-00006. 16. Cronin, E. D., Humphreys, D. H., & Ruiz-Razura, A. (1988). [Nipple reconstruction: the S flap](https://europepmc.org/article/med/3362992?ref=theplasticsfella.com). *Plastic and reconstructive surgery*, *81*(5), 783–787\. https://doi.org/10.1097/00006534-198805000-00026. 17. DiPirro ME. [Reconstruction of the nipple and areolar after burn](https://pubmed.ncbi.nlm.nih.gov/5448358/?ref=theplasticsfella.com). Case report. Plast Reconstr Surg 1970;46:299-300. 18. Barton Jr FE. [Latissimus dermal-epidermal nipple reconstruction](https://pubmed.ncbi.nlm.nih.gov/7048370/?ref=theplasticsfella.com). Plast Reconstr Surg 1982;70:234–7. 19. Cohen, I. K., Ward, J. A., & Chandrasekhar, B. (1986). [The pinwheel flap nipple and barrier areola graft reconstruction](https://europepmc.org/article/med/3520620?ref=theplasticsfella.com). *Plastic and reconstructive surgery*, *77*(6), 995–999\. https://doi.org/10.1097/00006534-198606000-00025. 20. Hallock, G. G., & Altobelli, J. A. (1993). Cylindrical nipple reconstruction using an H flap. *Annals of plastic surgery*, *30*(1), 23–26\. [https://doi.org/10.1097/00000637-199301000-00003](https://doi.org/10.1097/00000637-199301000-00003?ref=theplasticsfella.com). 21. Kroll SS, Hamilton S. [Nipple reconstruction with the double-opposing-tab flap](https://pubmed.ncbi.nlm.nih.gov/2762412/?ref=theplasticsfella.com). Plast Reconstr Surg. 1989;84(3):520-5. 22. Teimourian, B., & Duda, G. (1994). [The propeller flap: a one-stage procedure for nipple-areola reconstruction](https://pubmed.ncbi.nlm.nih.gov/8122582/?ref=theplasticsfella.com). *Aesthetic plastic surgery*, *18*(1), 81–84\. https://doi.org/10.1007/BF00444253. 23. Rees TD. [Reconstruction of the breast areola by intradermal tattooing and transfer](https://pubmed.ncbi.nlm.nih.gov/1144541/?ref=theplasticsfella.com). Case report. *Plast Reconstr Surg*1975;55:620-1. 24. Spear SL, Convit R, Little JW., 3[rd Intradermal tattoo as an adjunct to nipple-areola reconstruction](https://pubmed.ncbi.nlm.nih.gov/2710843/?ref=theplasticsfella.com). *Plast Reconstr Surg*1989;83:907-11. 25. Bunchman HH, Larson DL, Huang TT, Lewis SR. [Nipple and areola reconstruction in the burned breast. The ‘double bubble’ technique](https://pubmed.ncbi.nlm.nih.gov/4421739/?ref=theplasticsfella.com). Plast Reconstr Surg 1974;54:5. 26. Caterson, Stephanie A. MD; Singh, Mansher MD; Talbot, Simon G. MD; Eriksson, Elof MD, PhD. [Reconstruction of Areolar Projection Using a Purse-String Suture Technique](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527627/?ref=theplasticsfella.com). Plastic and Reconstructive Surgery Global Open 3(7):p e453, July 2015\. | DOI: 10.1097/GOX.0000000000000431 ### Ganglions Are Your Garden Weeds, Technique Review, & Evidence on Ganglion Recurrence URL: https://www.theplasticsfella.com/august-25th/ Last updated: 2024-08-23T19:44:24.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-25th/#a-letter-from-pfella) Ganglions are your garden weeds. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-25th/#the-sunday-quiz) How well do you know ganglion cysts? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/august-25th/#behind-the-fella) Episode 05 released: All about skin grafts. 4. ****🩺** [****Technique Review**](https://www.theplasticsfella.com/august-25th/#technique-review) The double dart technique for ganglions. 5. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/august-25th/#the-fellows-corner) This week's feature: Ganglion Cyst - Clinical Case. 6. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-25th/#what-does-the-evidence-say) What is the actual recurrence of ganglion cysts? 7. ****🔥**[ **Articles of the Week**](https://www.theplasticsfella.com/august-25th/#articles-of-the-week) Ganglion cyst management: 3 articles with 1 sentence summaries. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/august-25th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Ganglions Are Your Garden Weeds* 👋 ****Hey everyone!** Ganglions are like those stubborn weeds in the garden — annoying for both the gardener and the onlooker. They pop up without warning, disrupt the view, and no matter how often we deal with them, they seem to return. For us surgeons, ganglions are the garden's dandelions, sprouting up just when we thought we had cleared them out. Here’s why 👇 Managing ganglions feels like a never-ending battle against weeds. We can try aspiration, excision, or simply watch and wait. Yet, much like weeds, ganglions have a way of reappearing, sometimes in the same spot, sometimes elsewhere. Our approaches vary as widely as opinions on weed control — some dig deep with excision, others opt for the less invasive route of aspiration, and some prefer to leave them alone, knowing they can be messy and unpredictable. ![](https://lh7-rt.googleusercontent.com/docsz/AD_4nXebIF-xD1LvxHeyJwHYiOSmP-L8Pj0EKYNujK9ep5pkmAvln0PgM_mzGkFgYSYiUyUlP4w9xlKbiohzxBUTT2urmC_jYIEEuZ1oYbhEtkaDTOfNOxS_FRW29lfWgfvU0npGXXpt5XJH_zxqhfFqZgaCdLmd?key=VE6BXUZFwhQudikkPVwgwA) For patients, ganglions are just as frustrating. They bring discomfort and confusion, especially when different doctors give different advice. One may say, “Leave it alone,” while another suggests, “Let’s remove it.” This inconsistency can make patients feel lost in a garden of conflicting opinions. Ganglions, like weeds, are a reminder of the inherent uncertainty in our practice. They show us that not every problem has a straightforward solution So, the next time a ganglion pops up, think of it as a part of the garden's natural state. It's not about eradicating every weed but about managing the garden in a way that keeps the patient satisfied with their care. Lot of Love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Ganglion Cysts** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Definition of Ganglion Cysts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/image-6.png) Definition of Ganglion Cysts ## Behind the ‘Fella **Sneak Peek from Episode 05* 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. Check out the latest episode where we discuss our experiences in skin grafting! You can subscribe on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /0:44 1× ## Technique Review **The Double Dart Technique for Ganglions* 😷 ****Technique Review** In this new section, we explore approaches or techniques in surgery. This edition looks at the double dart technique in managing ganglion cysts. 👇 In 2010, [Paramhans](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890133/?ref=theplasticsfella.com) introduced the double dart technique: using concurrent 16-gauge (for aspiration) and 24-gauge needles (for triamcinolone acetonide injection) in the ganglion. This is visualised below. ![Visualised the double dart technique in managing ganglion cysts. ](https://lh7-rt.googleusercontent.com/docsz/AD_4nXdBSKV6kZAYkbPujNbXRLevirpn4ueRc4ysX4HPSML91IVp10ToVWopS1bjUpHg9f7b9GRh5c3U5TJIZ75QS7AwGmt6TBXbS2WOhYZ9wcrYp2hU31MPcVC5l-FyiSG8cv8MP09chalUQsqRuwmdh9P45YO_?key=VE6BXUZFwhQudikkPVwgwA) Double dart technique in managing ganglion cysts Let us know your approach for treatment 👇 ## the Fellows' Corner **This Week's Focus:* ***Ganglion Cyst - Clinical Case** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our clinical case on **Ganglion Cysts**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Clinical-Case-Ganglion-Cyst-1-1.png) #### Ganglion Cyst - Clinical Scenario ****Objectives** 1. Clinical diagnosis of a ganglion. 2. Describe the anatomical origins of ganglions. 3. Be aware of different aetiological theories. 4. Provide justified investigations to the patient. 5. Joint decision-making process for treatment options. [Read the Article](https://www.theplasticsfella.com/ganglion-cysts-clinical-case/) ## What Does the Evidence Say? **What Is the Actual Recurrence of Ganglion Cysts?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Ganglion cysts are common ****soft tissue masses** of the hand and wrist, with recurrence rates varying widely after surgical excision. Studies report recurrence rates ranging from ****3.8%** to ****40%** (Graham et al., 2021; Cluts & Fowler, 2020). Risk factors for recurrence include male sex, surgeon inexperience, older age in pediatric patients, symptomatic masses, and previous aspiration (Cluts & Fowler, 2020; Mooney et al., 2020; Meyerson et al., 2019). Open ****surgical** ****excision** appears to have a lower recurrence rate compared to arthroscopic excision (Konigsberg et al., 2021). ****Ultrasound-guided** aspiration does not significantly reduce recurrence rates compared to ****blind aspiration** (Kurkis et al., 2018). For ****intraneural ganglion cysts**, addressing the joint connection is crucial to prevent recurrence (Desy et al., 2015; Yunga Tigre et al., 2023). Despite the risk of recurrence, patient satisfaction remains high after ganglion cyst excision, with most patients willing to undergo repeat surgery if necessary (Graham et al., 2021). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Double Dart Technique for Treating Ganglions Over the Wrist** ([Paramhans](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890133/?ref=theplasticsfella.com), 2010) Explore the "double dart" technique of triamcinolone instillation; A non-invasive method to treat wrist ganglia with minimal side effects and a significantly lower recurrence rate than surgical excision. ✅ ***Surgical Management of Ganglion Cysts: Complete Excision** ([Minotti](https://www.jhandsurg.org/article/S1531-0914%2802%2950015-2/abstract?ref=theplasticsfella.com), 2002) Discuss the management of ganglion cysts through complete cyst and pedicle excision, guided by the regional anatomy to minimize recurrence rates. ✅ ****Untreated Dorsal Wrist Ganglia Outcomes vs Surgical Treatment** ([Dias](https://pubmed.ncbi.nlm.nih.gov/17950209/?ref=theplasticsfella.com), 2007) Explore untreated dorsal wrist ganglia in comparison to excision and aspiration outcomes; surgical excision results in higher patient satisfaction despite recurrence and complications. ## Feedback ### I hope you enjoyed it 😄 --- ### Thoracic Outlet Syndrome (TOS): Aetiology, Presentation, & Management URL: https://www.theplasticsfella.com/thoracic-outlet-syndrome/ Last updated: 2024-08-22T19:44:36.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/thoracic-outlet-syndrome/#definition-of-thoracic-outlet-syndrome) Thoracic outlet syndrome (TOS) is the compression of neurovascular structures at the brachial plexus, caused by soft tissue or bony anomalies. [****Anatomy**](https://www.theplasticsfella.com/thoracic-outlet-syndrome/#anatomy-of-thoracic-outlet-syndrome) Compression of neurovascular structures at the brachial plexus occurs in three key areas: the interscalene triangle, costoclavicular space, and subcoracoid space, each with specific boundaries and components. [****Aetiology**](https://www.theplasticsfella.com/thoracic-outlet-syndrome/#aetiology-of-thoracic-outlet-syndrome) Thoracic outlet syndrome (TOS) is often caused by compression at the interscalene triangle, costoclavicular, or subcoracoid spaces. Anatomical anomalies, tumors, or trauma are predisposing factors. [****Presentation**](https://www.theplasticsfella.com/thoracic-outlet-syndrome/#presentation-of-thoracic-outlet-syndrome) Neurophysiological testing and imaging (X-rays, CT, MRI) help exclude other compression sites and detect anatomical anomalies; surgical exploration provides a definitive diagnosis. [****Investigations**](https://www.theplasticsfella.com/thoracic-outlet-syndrome/#investigations-for-thoracic-outlet-syndrome) Investigating Thoracic Outlet Syndrome involves neurophysiological tests and imaging to rule out other causes, with surgery as the definitive diagnostic tool. [****Management**](https://www.theplasticsfella.com/thoracic-outlet-syndrome/#management-of-thoracic-outlet-syndrome) Thoracic outlet syndrome management involves a multidisciplinary approach: physiotherapy, pain control, occupational therapy, psychology, early anticoagulation for vascular TOS, and surgery. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## Definition of Thoracic Outlet Syndrome ****Key Point** Thoracic outlet syndrome (TOS) is compression of the neurovascular structures at the level of the brachial plexus (supraclavicular, posterior triangle, or subclavicular) and can be due to soft tissue or bony anomalies. **Thoracic outlet syndrome (TOS)** is compression of the **neurovascular** structures at the level of the brachial plexus due to anatomical features of the brachial plexus and subclavian vessels or **fibrous**, **muscular**, or bony anomalies. It was first described in 1860 by Willshire, attributed to an accessory 1st rib. Now, it is classified into several types: - **Neurogenic:** Most common - **Venous:** More common than arterial - **Arterial** - or **mixed** The image below illustrates the definition and anatomy of thoracic outlet syndrome. ![Definition of Thoracic Outlet Syndrome illustrated with the neurovascular anatomy of the thoracic outlet.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-23T002315.675.png) Definition of Thoracic Outlet Syndrome It is relatively uncommon, with an estimated annual incidence of 1-3 cases per 100,000 population ([Illig](https://pubmed.ncbi.nlm.nih.gov/33220767/?ref=theplasticsfella.com#:~:text=Based%20on%20a%20prospectively%20maintained,1%20per%20100%2C000%20population%2C%20respectively.), 2021). Important epidemiological facts are: - Primarily occurs in adults. - Vascular compression is commoner in children ([Abdalla BA](https://pubmed.ncbi.nlm.nih.gov/39003407/?ref=theplasticsfella.com), 2024). - Slight female predominance, ratio of approximately 3:1. 🚨 ****Important**: Neurogenic subtype is more common than vascular, of which venous is more frequent than arterial. --- ## Anatomy of Thoracic Outlet Syndrome ****Key Point** Compression of neurovascular structures at the brachial plexus occurs in three key areas: the interscalene triangle, costoclavicular space, and subcoracoid space, each with specific boundaries and components. Compression of the **neurovascular** structures at the level of the brachial plexus can occur at **three** distinct anatomical locations. 1. **Interscalene triangle** - **Structures:** Brachial plexus, subclavian artery, vein runs below anterior scalene - **Boundaries:** Scalenus anterior, Scalenus medius, 1st rib 1. **Costoclavicular space** - **Structures:** Brachial plexus divisions, subclavian artery and vein - **Boundaries:** Clavicle/subclavius, 1st rib, Costoclavicular ligament, Upper border of the scapula 1. **Subcoracoid space** - **Structures:** Brachial plexus cords, axillary artery, and vein - **Boundaries:** Coracoid, Pectoralis minor, Ribs 2- 4 The image below illustrates the neurovascular anatomy of the thoracic outlet. ![An illustration of the relevant neurovascular anatomy in anterior supraclavicular neurosurgical approach to the brachial plexus and subclavian vessels for thoracic outlet syndrome.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-23T003111.053.png) Thoracic outlet on the right side --- ## Aetiology of Thoracic Outlet Syndrome ****Key Point** Thoracic Outlet Syndrome (TOS) may arise from a variety of factors including anatomical anomalies, neoplasms, and traumatic injuries. The aetiology of thoracic outlet syndrome can be categorised into anatomical anomalies and pathological factors, such as trauma and tumours. ### Anatomical Anomalies Bone irregularities, muscle variations, and ligament issues all contribute to compression and subsequent thoracic outlet syndrome. **Bone Irregularities:** - **Accessory First Rib:** Often implicated in congenital anomalies like brachial plexus palsy but usually undetectable on MRI scans. - **Elongated Cervical Vertebrae Processes:** These can contribute to compression. The image below illustrates cervical ribs. ![Imaging of the relevant anatomy of cervical ribs.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-23T003801.248.png) Imaging of the relevant anatomy of cervical ribs for thoracic outlet syndrome. **Muscle Variations:** - **Scalene Muscle Anomalies:** Anomalous origins or insertions and the presence of a scalenus minimus muscle, which originates from cervical transverse processes and attaches to the first rib between the subclavian artery and the T1 nerve root. - **Muscle Hypertrophy:** Enlarged scalene or pectoralis minor muscles can intensify compression symptoms. The image below illustrates the scalene muscles. ![Anatomical illustration of the scalene muscles, showcasing common variations such as anomalous origins, insertions, and the presence of a scalenus minimus muscle.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-23T004803.683.png) Scalene muscles in thoracic outlet syndrome. **Ligament Issues:** - **Fibrous Bands:** Located between scalene muscles, the first rib, and the clavicle. - **Costoclavicular Ligament:** A potential cause of Paget-Schroetter syndrome, a type of venous compression that can lead to subclavian deep vein thrombosis (DVT), especially in athletes. ### Pathological Tumors such as Pancoast tumors and schwannomas, alongside trauma from repetitive athletic movements or vertebral artery compression, all contribute to compression and subsequent Thoracic Outlet Syndrome. **Tumors** - **Pancoast Tumor:** Impacts the lower part of the brachial plexus. - **Schwannoma:** Can significantly compress nearby neurovascular structures. The radiographed image below illustrates a Pancoast tumor. ![Chest radiograph showing a Pancoast tumor (labeled as P, non-small cell lung carcinoma, right lung), from a smoker of 47-years-old.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-23T010148.690.png) Chest radiograph of a Pancoast tumor (labeled as P, non-small cell lung carcinoma, right lung) **Trauma** - **Repetitive Athletic Movements:** Sports requiring extensive shoulder movements, like swimming and weightlifting, frequently contribute to TOS development. - **Vertebral Artery Compression:** Although uncommon, this condition can cause visual disturbances and is linked to TOS. 😎 ****Fun Fact:** Sibson’s fascia, which extends over the parietal pleura up to the first rib without attaching to it, can contribute to compression ([Reddenbach](https://pubmed.ncbi.nlm.nih.gov/9641331/?ref=theplasticsfella.com), 1998). --- ## Presentation of Thoracic Outlet Syndrome ****Key Point** TOS can present with a range of symptoms, often reflecting neurological or vascular compression, or both, leading to frequent delays in diagnosis. ### History Clinical features of thoracic outlet syndrome include numbness and tingling in the upper limb and hand, especially in the C8/T1 dermatomes, along with fatigue and weakness. These symptoms are often accompanied by severe pain in the neck or upper limb. Key points to note on history are: - **Pain:** Upper arm, shoulder, and trapezius. It may be diffuse or well localised due to the location of proximal compression. - **Paraesthesia:** Generalized or localized to C8/T1 distribution - **Weakness:** Progressive, worsens with repetitive activity Secondary non-specific features can be associated with thoracic outlet syndrome, such as: - Headache & visual disturbance due to vertebral artery compression. - Facial and tongue symptoms may also occur. 💡 ****Tip:** Symptoms may be dynamic and depend on upper limb position due to the pathophysiology of proximal compression. ### Examination A thorough examination for Thoracic Outlet Syndrome (TOS) involves systematic inspection and palpation to identify signs of neurovascular compression. **Inspection** - **Neck and Posture:** Short or "pecking" neck, kyphosis, rounded shoulders. - **Trauma Signs:** Clavicular fractures or surgical scars. - **Skin Changes:** Pallor, swelling, Raynaud’s, or ischemic ulcers. - **Muscle Wasting:** Thenar, hypothenar, interosseous (Gilliatt-Sumner hand). The image below illustrates the wasting of left thenar and hypothenar muscles. ![Wasting of the left thenar and hypothenar muscles, investigations for thoracic outlet syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-23T010837.135.png) Wasting of the left thenar and hypothenar muscles. **Palpation and Percussion** - **Neck Masses:** Palpate for any abnormal masses. - **Shoulder Movement:** Clicking during movement. - **Muscle Asymmetry:** Muscle wasting or asymmetry. - **Distal Coolness:** Coolness in the extremities - **Medial Cutaneous Nerve:** Involvement of lower trunk of brachial plexus. **Eponymous Tests** - **Tinel-Hoffman Sign:** Test for nerve irritation over the brachial plexus. - **Adson Test:** Evaluate for a collapsing pulse during hand elevation. Other eponymous tests are detailed in the table below. ![Provocative tests for TOS, diagnosis of TOS](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-12T235912.084.png) Provocative tests for TOS ### **Differential Diagnosis** Neurogenic subtype is more common than vascular, of which venous is more frequent than arterial. - **Neurogenic:** Cervical radiculopathy, ulnar nerve entrapment - **Venous:** Arm swelling and discoloration with activity, generalized upper limb pain (Differential: Lymphoedema) - **Arterial:** Unilateral pallor, tingling in the hand (worse in cold), distal arterial compromise (Differential: Raynaud's disease) --- ## Investigations for Thoracic Outlet Syndrome ****Key Point** Investigating Thoracic Outlet Syndrome involves neurophysiological tests and imaging to rule out other causes, with surgery as the definitive diagnostic tool. When evaluating Thoracic Outlet Syndrome (TOS), a combination of neurophysiological tests and imaging studies is essential to rule out other potential compression sites and to support the diagnosis. Surgery remains the most definitive diagnostic tool. - **Neurophysiology:** primarily used to exclude compression at other anatomical sites, ensuring that symptoms are specific to TOS - **X-ray/CT Scan (C-spine and Chest):** identifying structural anomalies, such as a cervical rib or a prominent C7/T1 spinous process. - **MRI:** MRI is valuable for identifying anatomical abnormalities and nerve or vessel compression, with serial exams useful for tracking progression. **Surgical exploration** provides the most definitive diagnosis for TOS. It allows direct visualization of the neurovascular structures, confirming the presence and extent of compression. ![Cervical rib left side - CT 3D reconstruction for TOC, Thoracic Outlet Syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-13T000551.466.png) Cervical rib left side - CT 3D reconstruction for TOC --- ## Management of Thoracic Outlet Syndrome ****Key Point** A multidisciplinary approach with physiotherapy, pain management, and surgery, which serves as both a diagnostic tool and treatment to relieve neurovascular compression. Effective management of Thoracic Outlet Syndrome requires a multidisciplinary approach, combining non-surgical therapies with surgical intervention when necessary. Surgery not only serves as a definitive diagnostic tool but also provides the opportunity for decompression to relieve symptoms. ### Non-Surgical Management - **Early Anticoagulation and Thrombolysis:** Specifically recommended for vascular TOS to prevent and treat thrombosis ([Ohman](https://pubmed.ncbi.nlm.nih.gov/32514995/?ref=theplasticsfella.com), 2023). - **Physiotherapy:** Focuses on exercises designed to improve range of motion, strengthen muscles, and reduce pain associated with TOS. - **Occupational Therapy:** Helps patients adapt to daily activities and reduce strain on the affected area. - **Psychological Support:** Counseling and psychological support may be necessary for patients coping with chronic pain or disability. ### Surgical Management The primary objective of surgery is to confirm the diagnosis and alleviate any constriction affecting the neurovascular structures. **Surgical Approaches** There are **two** commonly utilised surgical approaches: - **Supraclavicular Approach:** Commonly used due to its effectiveness in providing access to the thoracic outlet. Other approaches, such as trans-axillary, posterior, or inferior, are also viable depending on the specific case ([Giehle](https://www.youtube.com/watch?v=cbPlVt%5FEfKY&ref=theplasticsfella.com), 2023). - **Robotic-Assisted Surgery (RATS):** An emerging technique for first rib removal in TOS, offering enhanced precision and minimally invasive options ([Azenha](https://pubmed.ncbi.nlm.nih.gov/36327061/?ref=theplasticsfella.com), 2022). **Surgical Procedure Overview:** The following outlines the essential steps in the surgical management of Thoracic Outlet Syndrome, covering patient preparation, surgical access, nerve protection, and closure. - **Patient Preparation:** Position in a beach chair and apply local anesthesia - **Incision and Access:** Make a skin incision, raise platysma flaps, and protect nerves and vessels; divide and repair the omohyoid if needed. - **Nerve Protection:** safeguard the phrenic and suprascapular nerves. - **Address Anatomical Anomalies:** Resect scalenus muscle anomalies or fibrous bands, and consider removing part of the scalenus anterior or first rib. - **Closure:** Close the site in layers for optimal healing. Here is video of a Roo's procedure for Thoracic Outlet Syndrome. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basic of Thoracic Outlet Syndrome (TOS):** Gained an understanding of Thoracic Outlet Syndrome as a compression of neurovascular structures. ****2\. Epidemiology and Aetiology:** Learned about the epidemiology of TOS; its higher prevalence in adults with a female dominance and neurogenic form being the most common. Discussed the etiological factors including anatomical anomalies, tumors, or trauma leading to the condition. ****3\. Diagnosis and Presentation:** Explored the diagnostic process involving neurophysiological testing and imaging such as X-rays, CT, and MRI. Discussed how TOS can present variably with symptoms often leading to a delay in diagnosis. ****4\. Management Strategies:** Reviewed the multidisciplinary approach in managing TOS, which includes physiotherapy, pain control, occupational therapy, psychology, early anticoagulation for vascular TOS, and surgical interventions. ****5\. Surgical and Non-Surgical Treatments:** Explored the definitive diagnostic and therapeutic roles of surgery in TOS, alongside conservative treatments and the significance of early and accurate intervention. --- ## Further Reading 1. Dolan RT, Moosa A, Giele HP. [The Adipofascial Deltopectoral Flap to Cover the Brachial Plexus in Thoracic Outlet Syndrome and Radiation Plexitis](https://www.jprasurg.com/article/S1748-6815%2820%2930116-9/abstract?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2020 Aug;73(8):1465-1472\. doi: 10.1016/j.bjps.2020.02.039\. Epub 2020 Mar 13\. PMID: 32467081. 2. Jammeh ML, Yang A, Abuirqeba AA, Ohman JW, Thompson RW. [Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series. Oper Neurosurg (Hagerstown)](https://pubmed.ncbi.nlm.nih.gov/32467081/?ref=theplasticsfella.com). 2022 Aug 1;23(2):125-132\. doi: 10.1227/ons.0000000000000252\. Epub 2022 May 9\. PMID: 35838452; PMCID: PMC9287103. 3. Tzou CH, Paternostro-Sluga T, Frey M, Aszmann OC. [Birth brachial plexus palsy caused by cervical rib](https://pubmed.ncbi.nlm.nih.gov/24630141/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2014 Jul;67(7):1004-5\. doi: 10.1016/j.bjps.2014.02.020\. Epub 2014 Feb 26\. PMID: 24630141. 4. Nagasao T, Morotomi T, Kuriyama M, Kogure T, Kudo H, Hamamoto Y, Tamai M. [Thoracic outlet syndrome after the Nuss procedure for pectus excavatum: Is it a rare complication?](https://pubmed.ncbi.nlm.nih.gov/28662867/?ref=theplasticsfella.com) J Plast Reconstr Aesthet Surg. 2017 Oct;70(10):1433-1439\. doi: 10.1016/j.bjps.2017.05.043\. Epub 2017 Jun 3\. PMID: 28662867. 5. Hearn SL, Medley K, Liao EA. [Kinked again! From congenital brachial plexus palsy to adult neurogenic thoracic outlet syndrome: Case Report](https://pubmed.ncbi.nlm.nih.gov/38954650/?ref=theplasticsfella.com). Am J Phys Med Rehabil. 2024 Jul 2\. doi: 10.1097/PHM.0000000000002572\. Epub ahead of print. PMID: 38954650. 6. Dengler NF, Ferraresi S, Rochkind S, Denisova N, Garozzo D, Heinen C, Alimehmeti R, Capone C, Barone DG, Zdunczyk A, Pedro MT, Antoniadis G, Kaiser R, Dubuisson A, Kretschmer T, Rasulic L. [In Reply: Thoracic Outlet Syndrome Part I: Systematic Review of the Literature and Consensus on Anatomy, Diagnosis, and Classification of Thoracic Outlet Syndrome, and Thoracic Outlet Syndrome Part II: Consensus on the Management of Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery](https://pubmed.ncbi.nlm.nih.gov/38990007/?ref=theplasticsfella.com). Neurosurgery. 2024 Jul 11\. doi: 10.1227/neu.0000000000003112\. Epub ahead of print. PMID: 38990007. 7. Abdalla BA, Kakamad FH, Namiq HS, Asaad SK, Abdullah AS, Mustafa AM, Ghafour AK, Kareem HO, Ahmed SQM, Mohammed BA, Hasan KM, Mohammed SH. [Pediatric thoracic outlet syndrome: a systematic review with metadata](https://pubmed.ncbi.nlm.nih.gov/39003407/?ref=theplasticsfella.com). Pediatr Surg Int. 2024 Jul 13;40(1):186\. doi: 10.1007/s00383-024-05769-y. PMID: 39003407. 8. Davies MG, Hart JP. [Endovascular management of acute and subacute venous thoracic outlet syndrome](https://pubmed.ncbi.nlm.nih.gov/38440414/?ref=theplasticsfella.com). Front Surg. 2024 Feb 19;11:1302568\. doi: 10.3389/fsurg.2024.1302568\. PMID: 38440414; PMCID: PMC10909919. 9. Thompson JF, Winterborn RJ, Bays S, White H, Kinsella DC, Watkinson AF. [Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management](https://pubmed.ncbi.nlm.nih.gov/21448772/?ref=theplasticsfella.com). Cardiovasc Intervent Radiol. 2011 Oct;34(5):903-10\. doi: 10.1007/s00270-011-0148-4\. Epub 2011 Mar 30\. PMID: 21448772. 10. Teijink SBJ, Goeteyn J, Pesser N, van Nuenen BFL, Thompson RW, Teijink JAW. [Surgical approaches for thoracic outlet decompression in the treatment of thoracic outlet syndrome](https://pubmed.ncbi.nlm.nih.gov/38249887/?ref=theplasticsfella.com). J Thorac Dis. 2023 Dec 30;15(12):7088-7099\. doi: 10.21037/jtd-23-546\. Epub 2023 Dec 14\. PMID: 38249887; PMCID: PMC10797336. 11. Jammeh ML, Yang A, Abuirqeba AA, Ohman JW, Thompson RW. [Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series](https://pubmed.ncbi.nlm.nih.gov/35838452/?ref=theplasticsfella.com). Oper Neurosurg (Hagerstown). 2022 Aug 1;23(2):125-132\. doi: 10.1227/ons.0000000000000252\. Epub 2022 May 9\. PMID: 35838452; PMCID: PMC9287103. 12. Willshire WH. [Supernumerary first rib: clinical records](https://scholar.google.com/scholar%5Flookup?journal=Lancet.&title=Supernumerary+first+rib:+clinical+records&author=WH+Willshire&volume=2&publication%5Fyear=1860&pages=633&&ref=theplasticsfella.com). *Lancet.* 1860;2:633. 13. Giehle H. [Thoracic outlet syndrome Pulvertaft video](https://youtu.be/cbPlVt%5FEfKY?feature=shared&ref=theplasticsfella.com) [https://youtu.be/cbPlVt\_EfKY?feature=shared](https://youtu.be/cbPlVt%5FEfKY?feature=shared&ref=theplasticsfella.com) 14. Illig KA, Rodriguez-Zoppi E. [How Common Is Thoracic Outlet Syndrome?](https://pubmed.ncbi.nlm.nih.gov/33220767/?ref=theplasticsfella.com#:~:text=Based%20on%20a%20prospectively%20maintained,1%20per%20100%2C000%20population%2C%20respectively.) Thorac Surg Clin. 2021 Feb;31(1):11-17\. doi: 10.1016/j.thorsurg.2020.09.001\. PMID: 33220767. 15. Tzou CH, Paternostro-Sluga T, Frey M, Aszmann OC. [Birth brachial plexus palsy caused by cervical rib](https://pubmed.ncbi.nlm.nih.gov/24630141/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2014 Jul;67(7):1004-5\. doi: 10.1016/j.bjps.2014.02.020\. Epub 2014 Feb 26\. PMID: 24630141. 16. Redenbach DM, Nelems B. [A comparative study of structures comprising the thoracic outlet in 250 human cadavers and 72 surgical cases of thoracic outlet syndrom](https://pubmed.ncbi.nlm.nih.gov/9641331/?ref=theplasticsfella.com)e. Eur J Cardiothorac Surg. 1998 Apr;13(4):353-60\. doi: 10.1016/s1010-7940(98)00037-2\. PMID: 9641331. 17. Ohman JW, Thompson RW. [Thoracic Outlet Syndrome in the Overhead Athlete: Diagnosis and Treatment Recommendations](https://pubmed.ncbi.nlm.nih.gov/32514995/?ref=theplasticsfella.com). Curr Rev Musculoskelet Med. 2020 Aug;13(4):457-471\. doi: 10.1007/s12178-020-09643-x. PMID: 32514995; PMCID: PMC7340704. 18. Azenha LF, Kocher GJ, Kestenholz PB, Gioutsos K, Minervini F. [Thoracic outlet syndrome: a retrospective analysis of robotic-assisted first rib resections](https://pubmed.ncbi.nlm.nih.gov/36327061/?ref=theplasticsfella.com). J Robot Surg. 2023 Jun;17(3):891-896\. doi: 10.1007/s11701-022-01486-7\. Epub 2022 Nov 3\. PMID: 36327061. 19. Hart AM, [BAPRAS National Teaching, Peripheral nerve](https://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-sac-plasta-national-teaching-programme---series-2?ref=theplasticsfella.com). Accessed 10th August 2024. 20. Lewis, Mark, et al. "[The diagnosis of thoracic outlet syndrome.](https://www.tandfonline.com/doi/full/10.2147/JVD.S47387?ref=theplasticsfella.com)" *Journal of Vascular Diagnostics* (2014): 113-120. ### Capsular Contracture: Aetiology, Classification, & Management URL: https://www.theplasticsfella.com/capsular-contracture/ Last updated: 2024-11-21T16:42:20.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/capsular-contracture/#definition-of-capsular-contracture) Capsular contracture is the thickening and hardening of the capsule formed around breast implants, leading to breast shape changes, tenderness, and pain. [****Aetiology**](https://www.theplasticsfella.com/capsular-contracture/#aetiology-of-capsular-contracture) This is caused by subclinical infection, foreign body reactions, and bacterial seeding. Risk factors include smooth implants, subglandular positioning, periareolar incisions, etc. [****Risk Factors**](https://www.theplasticsfella.com/capsular-contracture/#risk-factors-for-capsular-contracture) Capsular contracture risk is heightened by factors such as smooth implants, subglandular placement, periareolar incisions, radiotherapy, and biological factors like pregnancy and infection. [****Clinical Assessment**](https://www.theplasticsfella.com/capsular-contracture/#clinical-assessment-of-capsular-contracture) A comprehensive triple assessment is required for diagnosis, including a full breast examination, imaging, and a biopsy of any suspicious lesions. [****Classification**](https://www.theplasticsfella.com/capsular-contracture/#baker-classification-of-capsular-contracture) This presents with breast pain and deformity, graded by Baker's classification from soft (I) to hard and painful (IV). Diagnosis involves a breast exam, MRI, and biopsy of suspicious lesions. [****Management**](https://www.theplasticsfella.com/capsular-contracture/#management-of-capsular-contracture) Capsular contracture management depends on severity. Grades 1 and 2 are managed conservatively; grades 3 and 4 require surgery like capsulotomy or capsulectomy. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Definition of Capsular Contracture ****Key Point** Capsular contracture is the tightening of a previously normal implant capsule, causing implant distortion. Capsular contracture is a **natural** response where the tissue capsule around a breast implant tightens and distorts the implant. The progression typically follows these steps: 1. **Formation**: The capsule forms as a thin and soft layer, initially having minimal impact on the breast's appearance. 2. **Progresson**: Over time, the capsule progressively thickens, hardens, and begins to contract. 3. **Symptom**: As the capsule constricts, it alters the contours of the breast and can lead to symptoms ranging from mild tenderness to severe pain, significantly affecting the appearance and comfort of the breast ([Headon](https://www.thieme-connect.com/products/ejournals/html/10.5999/aps.2015.42.5.532?ref=theplasticsfella.com), 2015). The image below illustrates the implant and capsule which can cause capsular contracture. ![capsular contracture definition, implant and capsule](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-19T145016.808.png) Definition of capsular contracture --- ## Aetiology of Capsular Contracture ****Key Point** Capsular contracture's causes include subclinical infections and inflammatory pathways. Higher risks are linked to smooth implants, subglandular positioning, and periareolar incisions. The pathology of capsular contracture remains uncertain, but multiple aetiological factors have been described. The two most popular ones are: **Subclinical Infective Process** - Correlation is well established, but causation remains uncertain. - Staphylococcus epidermidis is the most common, though various other bacteria are involved ([Dobke](https://doi.org/10.1097/00000637-199506000-00001?ref=theplasticsfella.com), 1995). **Hypertrophic Ccar/Inflammatory Process Hypothesis** - Talc and fibres from operative towels have been found in capsule histologic studies ([Chandler](https://doi.org/10.1097/00006534-199909030-00007?ref=theplasticsfella.com), 1999). - Foreign body reaction is considered a possible cause. 💡 ****Tip:** Most early contractures occur within 2 years, with ****late presentations** attributed to ****systemic bacterial seeding** or ****capsular maturation**. --- ## Risk Factors for Capsular Contracture ****Key Point** Capsular contracture risk is heightened by factors such as smooth implants, subglandular placement, periareolar incisions, radiotherapy, and biological factors like pregnancy and infection. Capsular contracture can be influenced by several factors related to the implant's characteristics and the surgical approach: **Implant Characteristics**: - **Surface Type**: Smooth implants have shown higher contracture rates compared to textured varieties (Wong, 2006). - **Placement**: Implants positioned under the glandular tissue (subglandular) are more prone to contracture than those placed under the muscle. - **Incision Site**: Periareolar incisions, which are near the nipple, may introduce bacteria from the breast ducts, increasing the risk of contracture. ✅ Evidence: Studies tracking popular implant brands over ten years report contracture rates ranging from 6% to 20%, indicating variability based on implant texture, filler type, and placement ([Nichter](https://doi.org/10.1097/PRS.0000000000004460?ref=theplasticsfella.com), 2018, [Stevens](https://doi.org/10.1097/PRS.0000000000004350?ref=theplasticsfella.com), 2018 **Treatment Pathway** 1. **Surgical:** Contractures occur more frequently following breast reconstruction than cosmetic augmentation, with a reported incidence of 10.4% at about three years post-surgery. 2. **Radiotherapy**: Exposure to radiation, either before or after surgery, heightens the risk of complications, including contracture, infection, and implant rupture. While spontaneous swelling is the most common presentation, lumps in the breast or armpit can also indicate BIA-ALCL and should be considered in the differential diagnosis for changes in heavily textured implants ([Mercer](https://www.gov.uk/guidance/breast-implants-and-anaplastic-large-cell-lymphoma-alcl?ref=theplasticsfella.com), 2023). 😎 ****Fun Fact:** Chemotherapy does not increase immediate wound complications after implant reconstruction, but its long-term effects on contracture remain unclear ([Araco](https://journals.lww.com/plasreconsurg/abstract/2009/12000/capsular%5Fcontractures%5F%5Fa%5Fsystematic%5Freview.11.aspx?ref=theplasticsfella.com), 2009). --- ## Clinical Assessment of Capsular Contracture ****Key Point** Females present with symptoms such as breast pain or abnormal breast shape. A comprehensive triple assessment is required for diagnosis, including a full breast examination, imaging, and a biopsy of any suspicious lesions. Females typically present with breast **pain** or discomfort accompanied by an abnormal or distorted breast shape. These severity of the contracture can be classified as per Baker Classification, which is discussed in the next section. All patients should undergo a comprehensive triple assessment before diagnosing capsular contracture. This includes: 1. **Full breast examination** 2. **Imaging (preferably MRI)** 3. **A biopsy of any suspicious lesions** The image below illustrates the fluid collection and granulation tissue within the capsule. ![Fluid collections and granulation tissue within the fibrous capsule around an intact implant in capsular contracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-19T145357.580-1.png) Fluid collections and granulation tissue within the fibrous capsule around an implant --- ## Baker Classification of Capsular Contracture ****Key Point** Capsular contracture is diagnosed using Baker's classification (I-IV), and requires triple assessment before definitive treatment. Baker’s classification is the most widely used grading system for capsular contracture ([Baker](https://journals.lww.com/plasreconsurg/abstract/1995/10000/classification%5Fof%5Fcapsular%5Fcontracture%5Fafter.18.aspx?ref=theplasticsfella.com), 1995): - **I:** *Normal,* soft, nonpalpable implant - **II:** *Palpable,* minimally firm to touch, not visible - **III:** *Visible,* easily palpated, and moderately firm - **IV:** *Painful,* hard, and breast distorted This classification system can help guid surgical interventions, which is discussed in the next section. An example of a Grade IV capsular contracture is depicted in the image below. ![Grade 4 capsular contracture of the right breast, Baker classification, capsular contracture, breast implant](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-13T003847.185.png) Grade 4 capsular contracture of the right breast --- ## Management of Capsular Contracture ****Key Point** Capsular contracture is managed conservatively for mild cases (grades 1 and 2) and surgically for severe cases (grades 3 and 4). Capsular contracture management is guided by its severity, grading, and the patient's expectations. The condition is graded on a scale from 1 to 4: **Grades 1 and 2:** These milder forms are typically managed conservatively. Management strategies include regular follow-ups and patient counseling to monitor progression and address concerns. **Grades 3 and 4:** Severe capsular contracture requires surgical intervention. The choice between capsulotomy and capsulectomy depends on the contracture's severity, patient health, and surgical experience, with capsulectomy generally providing a more definitive solution ([Susini](https://journals.lww.com/prsgo/fulltext/2023/06000/Advances%5Fon%5FCapsular%5FContracture%5FPrevention%5Fand.9.aspx?ref=theplasticsfella.com), 2023). - **Implant Removal and Capsulotomy:** An open capsulotomy involves multiple incisions to release the capsule's tension, allowing the implant to expand more naturally. This option has a higher rate of recurrence but lower morbidity compared to capsulectomy. - **Implant Removal and Capsulectomy:** This procedure can be total—removing both anterior and posterior capsule walls—or partial, typically removing only the anterior wall. Capsulectomy is more definitive but also more invasive, presenting higher morbidity and a lower recurrence rate. It also involves technical challenges such as the potential thinning of anterior soft tissue coverage. Intra-Op video of Capsular Contracture 😎 ****Fun Fact:** Capsulectomy can prevent calcium accumulation in capsules, which can interfere with routine mammography ([Araco](https://journals.lww.com/plasreconsurg/abstract/2009/12000/capsular%5Fcontractures%5F%5Fa%5Fsystematic%5Freview.11.aspx?ref=theplasticsfella.com), 2009). **Specific Considerations for Implant Placement:** - **Subglandular Implants:** A total capsulectomy is advised to minimize recurrence of contracture. - **Submuscular Implants:** A partial capsulectomy is preferable due to the risk of pneumothorax from dissecting closely adhered posterior capsules. Instead, the posterior capsule is usually scored or curetted. **Emerging Treatments and Studies:** Recent retrospective studies suggest acellular dermal matrices may be promising in treating and potentially preventing capsular contracture, though more evidence is needed to confirm their efficacy ([Hidalgo](https://journals.lww.com/plasreconsurg/abstract/2020/09000/surgical%5Ftreatment%5Ffor%5Fcapsular%5Fcontracture%5F%5Fa%5Fnew.11.aspx?context=featuredarticles&ref=theplasticsfella.com), 2020). 💡 ****Tip:** In submuscular implants, a partial capsulectomy is preferred to avoid the risk of pneumothorax from dissection near the chest wall. Typically, the posterior capsule is scored or curetted instead. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Capsular Contracture:** Gained an understanding of capsular contracture, its definition, aetiology, and physiological processes. ****2\. Classification and Diagnosis:** Learned about Baker's classification system for grading capsular contracture and the importance of a thorough triple assessment for accurate diagnosis. ****3\. Treatment Options:** Explored various management strategies for different grades of capsular contracture, including conservative measures and surgical interventions such as capsulotomy and capsulectomy. ****4\. Preventative Measures:** Reviewed the development of capsular contracture and discussed techniques that may help reduce its occurrence, such as the selection of implant types and surgical techniques. ****5\. Complications:** Identified potential complications associated with capsular contracture and its treatment, and understood the importance of postoperative care to ensure the best outcomes. --- ## Further Reading 1. Headon, Hannah, Adbul Kasem, and Kefah Mokbel. "[Capsular contracture after breast augmentation: an update for clinical practice](https://www.thieme-connect.com/products/ejournals/html/10.5999/aps.2015.42.5.532?ref=theplasticsfella.com). *Archives of plastic surgery* 42.05 (2015): 532-543. 2. Dobke, M. K., Svahn, J. K., Vastine, V. L., Landon, B. N., Stein, P. C., & Parsons, C. L. (1995). [Characterization of microbial presence at the surface of silicone mammary implants](https://doi.org/10.1097/00000637-199506000-00001?ref=theplasticsfella.com). *Annals of plastic surgery*, *34*(6), 563–571\. 3. Chandler P. J., Jr (1999). [The deposition of talc in patients with silicone gel-filled breast implants](https://doi.org/10.1097/00006534-199909030-00007?ref=theplasticsfella.com). *Plastic and reconstructive surgery*, *104*(3), 661–668\. 4. Dancey, Anne, Abdul Nassimizadeh, and Paul Levick. "[Capsular contracture–what are the risk factors? A 14 year series of 1400 consecutive augmentations.](https://www.sciencedirect.com/science/article/abs/pii/S1748681511005365?ref=theplasticsfella.com)" Journal of plastic, reconstructive & aesthetic surgery 65.2 (2012): 213-218. 5. Nichter, L. S., Hardesty, R. A., & Anigian, G. M. (2018). [IDEAL IMPLANT Structured Breast Implants: Core Study Results at 6 Years](https://doi.org/10.1097/PRS.0000000000004460?ref=theplasticsfella.com). *Plastic and reconstructive surgery*, *142*(1), 66–75\. 6. Stevens, W. G., Calobrace, M. B., Alizadeh, K., Zeidler, K. R., Harrington, J. L., & d'Incelli, R. C. (2018). [Ten-year Core Study Data for Sientra's Food and Drug Administration-Approved Round and Shaped Breast Implants with Cohesive Silicone Gel](https://doi.org/10.1097/PRS.0000000000004350?ref=theplasticsfella.com). *Plastic and reconstructive surgery*, *141*(4S Sientra Shaped and Round Cohesive Gel Implants), 7S–19S. 7. Araco, Antonino, et al. "[Capsular contractures: a systematic review](https://journals.lww.com/plasreconsurg/abstract/2009/12000/capsular%5Fcontractures%5F%5Fa%5Fsystematic%5Freview.11.aspx?ref=theplasticsfella.com)." Plastic and reconstructive surgery 124.6 (2009): 1808-1819. 8. Spear, Scott L. M.D.; Baker, James L. Jr. M.D.. [Classification of Capsular Contracture after Prosthetic Breast Reconstruction](https://journals.lww.com/plasreconsurg/abstract/1995/10000/classification%5Fof%5Fcapsular%5Fcontracture%5Fafter.18.aspx?ref=theplasticsfella.com). Plastic and Reconstructive Surgery 96(5):p 1119-1123, October 1995. 9. Susini, Pietro MD; Nisi, Giuseppe MD; Pierazzi, Diletta Maria MD; Giardino, Francesco Ruben MD; Pozzi, Mirco MD; Grimaldi, Luca MD; Cuomo, Roberto MD. [Advances on Capsular Contracture—Prevention and Management Strategies: A Narrative Review of the Literature](https://journals.lww.com/prsgo/fulltext/2023/06000/Advances%5Fon%5FCapsular%5FContracture%5FPrevention%5Fand.9.aspx?ref=theplasticsfella.com). Plastic & Reconstructive Surgery-Global Open 11(6):p e5034, June 2023\. | DOI: 10.1097/GOX.0000000000005034 10. Hidalgo, David A., and Andrew L. Weinstein. "[Surgical treatment for capsular contracture: a new paradigm and algorithm](https://journals.lww.com/plasreconsurg/abstract/2020/09000/surgical%5Ftreatment%5Ffor%5Fcapsular%5Fcontracture%5F%5Fa%5Fnew.11.aspx?context=featuredarticles&ref=theplasticsfella.com)." Plastic and Reconstructive Surgery 146.3 (2020): 516-525. 11. Dancey A, Nassimizadeh A, Levick P. [Capsular contracture - What are the risk factors? A 14 year series of 1400 consecutive augmentations](https://pubmed.ncbi.nlm.nih.gov/21930448/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2012 Feb;65(2):213-8\. doi: 10.1016/j.bjps.2011.09.011\. Epub 2011 Sep 17\. PMID: 21930448. 12. Turton P, El-Sharkawi D, Lyburn I, Sharma B, Mahalingam P, Turner SD, MacNeill F, Johnson L, Hamilton S, Burton C, Mercer N. [UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group (PRASEAG)](https://pubmed.ncbi.nlm.nih.gov/33483089/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2021 Jan;74(1):13-29\. doi: 10.1016/j.bjps.2020.10.064\. Epub 2020 Nov 12\. PMID: 33483089. 13. Wong CH, Samuel M, Tan BK, Song C. [Capsular contracture in subglandular breast augmentation with textured versus smooth breast implants: a systematic review](https://pubmed.ncbi.nlm.nih.gov/17016195/?ref=theplasticsfella.com). Plast Reconstr Surg. 2006 Oct;118(5):1224-1236\. doi: 10.1097/01.prs.0000237013.50283.d2\. PMID: 17016195. ### Capsular Contracture - Clinical Scenario URL: https://www.theplasticsfella.com/capsular-contracture-clinical-scenario/ Last updated: 2024-09-04T17:01:50.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Clinical-Case-Main-Image--15--1.png) #### Clinical Scenario A 35-year-old woman presents with complaints of pain, discomfort, and noticeable changes in the shape of both breasts. She reports that these symptoms have been gradually worsening over the past six months. She has a history of bilateral breast augmentation performed five years ago. On examination, both breasts are firm to the touch, with noticeable distortion and tenderness. ****Objectives:** ****1\.** Assessment of a patient presenting with breast implant-related complications. ****2\.** Discuss the causes of capsular contracture. ****3\.** Knowledge of Baker’s classification. ****4\.** Treatment options for capsular contracture. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### End of the Reconstructive Ladder, Local Flaps & Tissue Expansion & more. URL: https://www.theplasticsfella.com/august-18th/ Last updated: 2024-08-17T15:41:06.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-18th/#a-letter-from-pfella) The end of the reconstructive ladder. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-18th/#the-sunday-quiz) How well do you know the types & classification of flaps? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/august-18th/#behind-the-fella) Sneak peek from episode 05: All about skin grafts. 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/august-18th/#the-fellows-corner) This week's feature: Tissue expansion. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-18th/#what-does-the-evidence-say) Evidence behind the Reconstructive Ladder 6. ****🔥**[ **Articles of the Week**](https://www.theplasticsfella.com/august-18th/#articles-of-the-week) Reconstructive surgery: 3 articles with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/august-18th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The End of the Reconstructive Ladder* 👋 ****Hey everyone!** Let’s cut to the chase: the reconstructive ladder—our old reliable—might just be past its prime. We’ve been climbing this ladder step by step, but it’s time to ask: are we really serving our patients best by following a one-size-fits-all approach? 👇 The ladder was great for its time, guiding us through complexity in a neat, orderly fashion. But let's face it, surgery isn’t cookie-cutter, and neither are our patients. Sticking rigidly to this method can sometimes feel like wearing blinders, missing out on innovative techniques that could offer better results, faster. ### Why Change The introduction of technologies like negative-pressure wound therapy and the use of dermal matrices are game changers. These aren’t just minor tweaks; they represent a significant shift in how we can manage wounds more effectively and with better outcomes. It’s comfortable, sure. Climbing the traditional ladder step by step is safe because it’s familiar. But what if I told you that jumping straight to what works—skipping unnecessary steps—could save time, reduce patient discomfort, and lead to better overall results? ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/DALL-E-2024-08-16-21.46.52---A-modern-3D-vector-image-of-a-traditional-wooden-ladder-broken-in-half--symbolizing-obsolescence.-The-ladder-should-appear-cracked-with-visible-splint-1.webp) ### A Different Way to Think Think of the **reconstructive elevator** as your express pass to the right solution. This isn't a new idea, it's been around for a couple of decades (at least) in the [literature](https://pubmed.ncbi.nlm.nih.gov/11176642/?ref=theplasticsfella.com). No more unnecessary steps—just straight to the level of complexity needed for each unique case. It’s about working smarter, not harder, and definitely not slower. **And the Reconstructive Triangle?** That's an idea in the [literature](https://pubmed.ncbi.nlm.nih.gov/12832931/?ref=theplasticsfella.com) too. This isn’t just a shift; it’s a whole new game. Flaps, microsurgery, tissue expansion—all the tools in our kit considered simultaneously to tailor the best possible outcome from the get-go. It’s a creative, multidimensional way of thinking about reconstruction that really puts the patient’s needs front and centre. It’s time to let go of the ladder. P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Types & Classification of Flaps** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![How to Classify and Describe a Flap - A Mnemonic](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/image-4.png) How to Classify and Describe a Flap - A Mnemonic ## Behind the ‘Fella **Sneak Peek from Episode 05* 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. In our upcoming episode, we discuss our experiences in skin grafting! You can subscribe on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /0:45 1× Let us know your thoughts on podcasts here 👇 ## the Fellows' Corner **This Week's Focus:* ***Tissue Expansion** In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Tissue Expansion**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Tissue-Expansion-Surgery.png) #### Tissue Expansion [****Definition**](https://www.theplasticsfella.com/tissue-expansion/#definition-of-tissue-expansion) Tissue expansion optimises the viscoelastic properties of skin and increases tissue availability. [****Mechanisms**](https://www.theplasticsfella.com/tissue-expansion/#mechanism-of-tissue-expansion) Tissue expansion involves 3 processes: mechanical creep, biological creep, and stress relaxation. [****Changes in Tissue Expansion**](https://www.theplasticsfella.com/tissue-expansion/#changes-in-tissue-expansion) During the tissue expansion, histological changes occur. The epidermis is the only anatomical layer that increases in thickness. [****Capsule Formation**](https://www.theplasticsfella.com/tissue-expansion/#capsule-formation) After insertion, a capsule forms around the tissue expander. This has been shown to develop in 4 layers of different cellular structures. [****Types of Tissue Expanders**](https://www.theplasticsfella.com/tissue-expansion/#types-of-tissue-expanders) Tissue expanders are designed in different shapes, sizes, textures, and expansion directions to fit their specific indication. [****Clinical Indications**](https://www.theplasticsfella.com/tissue-expansion/#clinical-application-of-tissue-expanders) Tissue expansion can be used for a diverse group of reasons. It is commonly used in delayed breast reconstruction. It should not be used in wounds with a high risk of wound breakdown. [Read the Article](https://www.theplasticsfella.com/tissue-expansion/) ## What Does the Evidence Say? **Evolution of the Reconstructive Ladder* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The reconstructive ladder, a traditional model in plastic surgery, has evolved to incorporate new technologies and patient-centered approaches. While the original ladder emphasized increasing complexity of procedures (Glat & Davenport, 2017), newer models like the reconstructive elevator (Janis et al., 2011) and matrix (Erba et al., 2010) allow for more flexible decision-making. Recent advancements include negative-pressure wound therapy, dermal matrices, and perforator flaps (Janis et al., 2011). The integration of regenerative medicine and smart technologies has added new "rungs" to the ladder (De Francesco et al., 2023). Some researchers propose a reconstructive grid to accommodate multiple options and future techniques (Mohapatra & Thiruvoth, 2020). Others suggest a plastic surgery compass to navigate patient-specific solutions in the era of personalized healthcare (Sandberg, 2016). These evolving models aim to guide surgeons in selecting optimal reconstructive approaches while considering wound complexity, available resources, and patient preferences (Marchesi et al., 2016). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* ✅ ****Modified reconstructive ladder to optimise patient outcomes** ([Janis](https://journals.lww.com/plasreconsurg/abstract/2011/01001/the%5Fnew%5Freconstructive%5Fladder%5F%5Fmodifications%5Fto.29.aspx?ref=theplasticsfella.com), 2011) Modern updates to the traditional reconstructive ladder incorporate techniques like negative-pressure wound therapy, dermal matrices, and perforator flaps to enhance wound closure options. ✅ ***Tissue expansion in head and neck reconstruction: Alternative flaps & complications** ([Baker & Swanson](https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/619140?ref=theplasticsfella.com), 1990) Explore tissue expansion techniques to reconstruct defects when adjacent tissue is insufficient, particularly in the cheek and neck areas. ✅ ****Why algorithms in reconstructive surgery can sometimes fail** ([Freshwater](https://www.jprasurg.com/article/S1748-6815%2812%2900621-3/fulltext?ref=theplasticsfella.com), 2013) Discover how the traditional reconstructive ladder model can lead to rigid, ineffective solutions when misapplied, and the need for adaptability and creativity in complex surgical decision-making. ## Feedback ### I hope you enjoyed it 😄 --- ### Designing the Perfect Local Flap, Book Review, & Eyelid Reconstruction. URL: https://www.theplasticsfella.com/august-11th/ Last updated: 2024-08-11T12:14:59.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-11th/#a-letter-from-pfella) How I Pick the Right Skin Flap 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-11th/#the-sunday-quiz) How well do you know Bilobed Flaps? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/august-11th/#behind-the-fella) Sneak peek from episode 04: Best plastic surgery resources. 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/august-11th/#the-fellows-corner) This week's feature: Venous Flaps. 5. 📚 [****Book Review**](https://www.theplasticsfella.com/august-11th/#book-review) "Local Flaps in Facial Reconstruction" by Shan R. Baker. 6. ****🔥**[ **Articles of the Week**](https://www.theplasticsfella.com/august-11th/#articles-of-the-week) Tips on nasal and eyelid reconstruction; 3 articles with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/august-11th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella "How I Pick the Right Skin Flap" 👋 ****Hey everyone!** Let’s get real about choosing the right local skin flap—it’s all about understanding the skin you’re working with and making practical decisions on the fly. 👇 **First, not all skin is the same**. Take nasal alar skin, for example—it’s thick, firm, and doesn’t stretch much, unlike cheek skin, which is softer and more pliable. This difference matters big time. If I’m covering a defect on the nose, I’m probably not going to use the same flap I’d choose for the cheek. The goal is to pick a flap that matches the skin’s texture and mobility so it blends in naturally. **Now, location is key.** On the face, it’s all about aesthetics. I often go for rotation or advancement flaps that follow natural lines. They’re reliable and give a nice, seamless finish. But if I’m dealing with something larger or in a tricky spot, like the nose, a bilobed flap can work wonders—it lets me move skin around without creating too much tension. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Screenshot-2024-08-11-at-13.05.33-1.png) Image from [Baker](https://www.theplasticsfella.com/august-11th/#book-review) **Size and shape? Also super important.** Small defects? A simple advancement flap usually does the trick. But for bigger or oddly shaped ones, I might opt for a transposition flap. It gives good coverage and helps spread out the tension, so everything heals up nicely. **So, here’s the takeaway: Know your skin—whether it’s thick, thin, mobile, or tight—and pick a flap that matches.** Keep it simple but effective, and always aim for the best cosmetic result with the least tension. Trust your gut, but also let the skin guide your decision. Lots of love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Bilobed Flaps** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Esser's Original Publication of Bilobed Flaps](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/image-1.png) Image from Esser's Original Publication of Bilobed Flaps in 1918 ## Behind the ‘Fella **Sneak Peek from Episode 04* 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. In our upcoming episode, we explore the best plastic surgery resources for learning! You can subscribe on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /1:00 1× Let us know your thoughts on podcasts here 👇 ## the Fellows' Corner **This Week's Focus: Venous Flaps* In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Venous Flaps**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Venous-Flaps-Classification.png) #### Venous Flaps [****Physiology**](https://www.theplasticsfella.com/venous-flaps/#physiology-of-venous-flaps) The exact physiology of venous flaps is relatively unknown. [****Classification**](https://www.theplasticsfella.com/venous-flaps/#classification-of-venous-flaps) Thatte and Thatte is the standard classification for venous flaps. There are 3 types of venous flaps based on the number of veins & their function. [****Evaluation**](https://www.theplasticsfella.com/venous-flaps/#evaluation-of-venous-flaps) They do not have a high survival rate and are not used regularly due to this. [Read the Article](https://www.theplasticsfella.com/venous-flaps/) ## Book Review **"Local Flaps in Facial Reconstruction" by Shan R. Baker* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/9780323683906.jpg) #### ****Local Flaps in Facial Reconstruction**" Hey there! If you're into facial reconstructive surgery, "****Local Flaps in Facial Reconstruction**" by Shan R. Baker is a fantastic resource. The book is loaded with clear, high-quality images that show patients before and after surgery. The design of the flaps is explained in a way that's easy to follow, making it super helpful for both beginners and experienced surgeons. It’s **practical*, **informative*, and **visually impressive* — a great addition to your medical library. ![Local Flaps in Facial Reconstruction](https://lh7-rt.googleusercontent.com/docsz/AD_4nXfABgzBZOPRRyBLfSHxNpzp41FEbeWw-f3fcZnJo3oWLlDpN73DxU-2VzKFNuGneb4y_GahxeeYAZLjWGECOruzDPkm_OihUhcw0YZzbAkblXNyxatLoT7wKX6k7RdtQUDjb9GdLOq2Ww3CHImLBaYSuGA?key=VE6BXUZFwhQudikkPVwgwA) ![Local Flaps in Facial Reconstruction](https://lh7-rt.googleusercontent.com/docsz/AD_4nXddIJl61gVypmCQ-oc9bnY8njEid62wYw3Ev4vePElXkzJmJJo4MofvL0I_Un5yU8AKXi9uJ7zE0WS202lC__I5h49JsXzxllQLH1f4efbFejjZ-VTLk5COQ76XFvZ1nSgXQWEKGOtvAfL6bc2WCRbFlGfT?key=VE6BXUZFwhQudikkPVwgwA) ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* 1️⃣ ****Nasal reconstruction insights on restoring both appearance and function** ([Menick](https://pubmed.ncbi.nlm.nih.gov/20335833/?ref=theplasticsfella.com), 2010) Preoperative planning for nasal reconstruction: Staged procedures using forehead tissue and cartilage grafts to achieve optimal results. 2️⃣ ***Using the bilobed flap in nasal reconstruction for defects on the lower third of the nose** ([Zitelli](https://pubmed.ncbi.nlm.nih.gov/2742390/?ref=theplasticsfella.com)****,** 1989) Discover design improvements that minimize issues like tissue protrusions, enhancing the overall outcome of nasal reconstruction using the bilobed flap. 3️⃣ ****How to achieve a successful eyelid reconstruction** ([Alghoul](https://journals.lww.com/prsgo/fulltext/2019/11000/eyelid%5Freconstruction.26.aspx?ref=theplasticsfella.com) et al., 2019) Explore eyelid reconstruction techniques that ensure proper function, aesthetics, and blend with surrounding tissues, focusing on normal eyelid positioning, distinct margins, and sharp canthal angles. ## Feedback ### I hope you enjoyed it 😄 --- ### Full Thickness Grafts: Origin Story, Best Techniques & tips. URL: https://www.theplasticsfella.com/august-4th/ Last updated: 2024-08-03T08:53:25.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-4th/#a-letter-from-pfella) Full Thickness Skin Graft: The Origin Story 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-4th/#the-sunday-quiz) How well do you know the Mathes and Nahai classification? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/august-4th/#behind-the-fella) Sneak peek from episode 04: Best plastic surgery resources. 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/august-4th/#the-fellows-corner) This week's feature: Macrodactyly. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/august-4th/#what-does-the-evidence-say) Best graft insetting/fixation technique 6. ****🔥**[ **Articles of the Week**](https://www.theplasticsfella.com/august-4th/#articles-of-the-week) How to examine the breast & more! 3 articles with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/august-4th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella Full Thickness Skin Graft: The Origin Story 👋 ****Hey everyone!** Ever done an operation and wondered, "****Who was brave enough to do this first**?" Take full-thickness skin grafts, for example. Doing one back in the day must have been pretty wild. So, who did it first? Turns out, a couple of guys might be getting credit for someone else's work. 👇 Let’s go back to the **late 19th century**. No internet, no modern anesthesia, just raw scientific curiosity and a drive to innovate. Enter the pioneers of full-thickness skin grafts: **Wolfe, Lawson, and Krause.** **🌟 Wolfe's Leap Forward** In 1875, John Reissberg Wolfe—probably a name most people haven’t heard of—made a significant contribution. The graft was initially called the Wolfe graft. He corrected an ectropion with a graft cut—pretty brave stuff. **But did he really do it first?** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Screenshot-2024-08-03-at-09.34.03-1.png) "Wolfie" 🇬🇧 Lawson’s Unsung Contribution A few years earlier, George Lawson had been experimenting with similar techniques, but his work never got the spotlight it deserved. He described it around 1870 and 1871. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Screenshot-2024-08-03-at-09.35.47-1.png) Wolfe's Letter (Museo Centrale del Risorgimento, Roma) 🇩🇪 Krause’s Impact Fast forward to 1893, Fedor Krause took the stage at the XXIII Congress of the German Surgical Association, advocating strongly for the Wolfe graft. His endorsement and successful transplantation of 21 cases cemented the technique’s reliability. Lots of love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***The Mathes and Nahai Classification** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Mathes and Nahai Muscle Flap Classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/image.png) Mathes and Nahai Muscle Flap Classification ## Behind the ‘Fella **Sneak Peek from Episode 04* 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. In our upcoming episode, we explore the best plastic surgery resources! You can subscribe on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /0:47 1× If there's a specific discussion you're interested in, let us know below. ## the Fellows' Corner **This Week's Focus: Macrodactyly* In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on **Macrodactyly**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images--92-.png) #### Macrodactyly [****Definition**](https://www.theplasticsfella.com/macrodactyly/#definition-of-macrodactyly) Macrodactyly is the term for the overgrowth of a digit, out of proportion to the rest of the hand or foot. [****Clinical Features**](https://www.theplasticsfella.com/macrodactyly/#clinical-features-of-macrodactyly) Macrodactyly results in overgrowth of the entire digit(s) out of proportion with the rest of the hand or foot. [****Investigations**](https://www.theplasticsfella.com/macrodactyly/#investigations-for-macrodactyly) X-rays, MRI, and gene analysis may be offered as part of the diagnostic process. [****Management**](https://www.theplasticsfella.com/macrodactyly/#management-of-macrodactyly) Surgical management aims to stop overgrowth and debulk the digit. Addressing the nerve is important in reducing recurrence. [Read the Article](https://www.theplasticsfella.com/macrodactyly/) ## What Does the Evidence Say? Best skin graft ****insetting** technique In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Full-thickness skin grafts (FTSGs) are a common reconstructive technique following skin cancer excision. Various methods exist for securing FTSGs, including tie-over bolster dressings, quilting sutures, and continuous quilting techniques (Cameron Harrison & Kristian Sørensen, 2023; H. Mehta, 1979; J. Adnot & Salasche, 1987). The beveled edge technique for harvesting FTSGs can improve graft placement and cosmetic outcomes (B. A. Shook et al., 2005). A simple method for bloodless FTSG harvest has been described, saving time during the procedure (M. Taifour Suliman, 2009). A donor skin-sparing technique allows for smaller donor sites while maintaining graft viability (J. Lane & Margaret Symington, 2009). Absorbable sutures, particularly plain gut, are preferred for FTSG placement, and various securing methods have shown efficacy (Mitchell Davis et al., 2021). To improve accuracy, a technique for transferring the contour of the skin defect from the recipient to the donor site has been developed (A. Rennie & L. Hanu-Cernat, 2013). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* 1️⃣ ****What does the literature say on Full-thickness Skin Graft Fixation Techniques (**[****Steele**](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646424/?ref=theplasticsfella.com#:~:text=For%20a%20skin%20graft%20to,a%20bolus%20dressing%20after%20suturing.)****, 2020)** No studies have found a significant difference between tie-over dressings and alternative graft fixation technique, with the most evidence for simple pressure dressings and quilting/mattress suturing. 2️⃣ ***A** **double suture fixation technique from the 1970s? (**[****Mehta**](https://pubmed.ncbi.nlm.nih.gov/371666/?ref=theplasticsfella.com)****, 1979)** A technique of free full thickness skin graft fixation utilising central and paracentral sutures between the graft and the depths of the recipient bed is described. 3️⃣ ****How to quilt a full thickness skin graft (**[****Harrison**](https://ajops.com/article/68033-how-to-insert-a-full-thickness-skin-graft-a-continuous-quilting-technique?ref=theplasticsfella.com)****, 2023)** The continuous quilting technique provides a faster, more efficient FTSG inset, surpassing interrupted sutures and tie-over dressings without compromising graft success. ## Feedback ### I hope you enjoyed it 😄 --- ### Congenital and Nasal Dermoid Cysts - Clinical Scenario URL: https://www.theplasticsfella.com/congenital-and-nasal-dermoid-cysts-clinical-scenario/ Last updated: 2024-11-07T10:23:39.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/AI-generated-image--14--1.png) #### Clinical Scenario A 4-year-old boy is presented in your clinic accompanied by his parents, who are concerned about a swelling at the outer corner of his right eye. This swelling has been apparent since the child's birth but has seen a noticeable increase in size over the last few months, prompting concerns about both cosmetic outcomes and the child’s overall health. The parents are concerned about the cosmetic appearance and potential implications for their child's health. ****Objectives:** 1. Gather a detailed medical and family history. 2. Identify imaging techniques for diagnosing dermoid cysts. 3. Describe the pathology of dermoid cysts. 4. Surgical treatment options for an external angular dermoid cyst ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Giant Cell Tumours of Tendon Sheath - Clinical Scenario URL: https://www.theplasticsfella.com/giant-cell-tumours-of-tendon-sheath-clinical-scenario/ Last updated: 2024-09-04T17:07:01.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/AI-generated-image--13--1.png) #### Clinical Scenario A 40-year-old woman presents with a 2x2 cm mass, just proximal to the PIPJ of her index finger on the volar aspect. ****Objectives:** ****1\.** Take an accurate history for this presentation. ****2\.** Request appropriate diagnostic measures. ****3\.** Provide surgical and non-surgical management options ****4\.** Identify common complications. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Macrodactyly - Clinical Scenario URL: https://www.theplasticsfella.com/macrodactyly-clinical-scenario/ Last updated: 2024-10-02T21:12:20.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/AI-generated-image--12-.png) #### Clinical Scenario A family present to the congenital hand clinic with their 3-year-old son who has isolated overgrowth of the right index finger. The child is otherwise fit and well. ****Objectives:** ****1\.** Take a history from the patient and family. ****2\.** Describe the aetiology of macrodactyly to parents. ****3\.** Request appropriate investigations. ****4\.** Describe a treatment algorithm. ****5\.** Outline the role of medical treatments in macrodactyly. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Macrodactyly: Aetiology, Investigations, & Management URL: https://www.theplasticsfella.com/macrodactyly/ Last updated: 2024-07-29T11:59:04.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/macrodactyly/#definition-of-macrodactyly) Macrodactyly is the term for the overgrowth of a digit, out of proportion to the rest of the hand or foot. [****Clinical Features**](https://www.theplasticsfella.com/macrodactyly/#clinical-features-of-macrodactyly) Macrodactyly results in overgrowth of the entire digit(s) out of proportion with the rest of the hand or foot. [****Investigations**](https://www.theplasticsfella.com/macrodactyly/#investigations-for-macrodactyly) X-rays, MRI, and gene analysis may be offered as part of the diagnostic process. [****Management**](https://www.theplasticsfella.com/macrodactyly/#management-of-macrodactyly) Surgical management aims to stop overgrowth and debulk the digit. Addressing the nerve is important in reducing recurrence. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## Definition of Macrodactyly ****Key Point** Macrodactyly is the descriptive term for the overgrowth of a digit, out of proportion to the rest of the hand or foot. Macrodactyly is the disproportionate overgrowth of a digit, typically affecting one digit or nerve territory (e.g., thumb, index, and middle fingers in the median nerve territory). The majority are associated with lipofibromatosis of the nerve and a **PiK3CA mutation** ([Wu](https://pubmed.ncbi.nlm.nih.gov/32299688/?ref=theplasticsfella.com), 2020). It is classified into two types: - **Static:** The enlarged digit maintains a consistent size difference relative to the rest of the hand or foot. - **Progressive:** The enlarged digit grows more rapidly than the others. It can occur in isolation or as part of a syndrome. It is a non-hereditary condition with no significant sex or geographical predilection. The image below illustrates macrodactyly of the foot. ![Presentation of macrodactyly in the foot](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--92-.png) Presentation of macrodactyly in the foot 😎 ****Fun Fact:** Macrodactyly affects about 1 in 100,000 live births and accounts for approximately 1% of all upper limb congenital anomalies ([Wu](https://pubmed.ncbi.nlm.nih.gov/32299688/?ref=theplasticsfella.com), 2020). --- ## Clinical Features of Macrodactyly ****Key Point** Macrodactyly results in overgrowth of an entire digit(s) out of proportion with the rest of the hand or foot. It is usually noticed at birth. Macrodactyly leads to the overgrowth of one or more digits, disproportionate to the rest of the hand or foot. It is usually **unilateral** and affects nerves and bones: - **Nerve**: Typically affects one nerve territory, but can involve multiple in syndromic cases. Enlarged nerves may cause compression, like [carpal tunnel](https://www.theplasticsfella.com/carpal-tunnel-syndrome/) - **Bone**: Early osteophytes, osteoarthritis, & stiffness in the affected digit are common. The image below illustrates macrodactyly of the index finger. ![macrodactyly of the index finger, clinical features of macrodactyly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images---2024-07-29T172234.758.png) Macrodactyly of the index finger 😎 ****Fun Fact:** Bony overgrowth stops at physeal fusion, soft tissue grows into adulthood. ### Classification It is traditionally classified into **four** types, as described by Flatt and modified by Upton. Gigantism is combined with: 1. **Lipofibromatosis:** common, associated with enlarged, fat-infiltrated nerves 2. **Neurofibromatosis:** linked to plexiform neurofibromatosis, often bilateral 3. **Hyperostosis:** rare, bony hyperostosis without nerve enlargement 4. **Hemihypertrophy:** rare, hypertrophy of whole limb & intrinsic muscles, deformity with flexion contractures, ulnar deviation, adducted thumb 😎 ****Fun Fact:** The index finger is most commonly affected by macrodactyly. Radial digits with macrodactyly deviate radially, while ulnar digits deviate ulnarly. ### Associated Syndromes Several syndromes also feature digital enlargement and are characterized by various associated symptoms. - **Neurofibromatosis:** Café au lait spots, skin pigmentation, multiple neurofibromas, pedunculated skin lesions, ocular lesions. - **Ollier's Disease:** Multiple enchondromas. - **Maffucci's Syndrome:** Multiple enchondromas and hemangiomas. - **Parkes-Weber Syndrome:** Limb hypertrophy, length discrepancies, capillary malformations, arteriovenous malformations. - **CLOVES Syndrome:** Congenital lipomatous overgrowth, vascular malformations, epidermal nevi, scoliosis/spinal deformity. - **Klippel-Trenaunay-Weber Syndrome:** Cutaneous hemangioma, atypical varicose veins, hemihypertrophy. - **Proteus Syndrome:** Hamartomatous dysplasia, macrodactyly, pigmented linear epidermal nevi, subcutaneous hamartomas ([Greens](https://search.worldcat.org/title/Green's-operative-hand-surgery/oclc/806295798?ref=theplasticsfella.com), 2011). 😎 ****Fun Fact:** Macrodactyly occurs more often in the hands than the feet. --- ## Investigations for Macrodactyly ****Key Point** X-rays, MRI, and gene analysis may be offered as part of the diagnostic process. A standard workup for macrodactyly includes: 1. **Routine lab investigations** 2. **X-ray** to demonstrate growth plates and exostosis 3. **MRA/angiography** for surgical planning 4. **Gene analysis**, specifically for the Pi3KCA somatic mutation in severe cases The image below illustrates the radiographical imaging of Macrodactyly of the hand. ![Left-hand radiograph - Macrodactyly investigations](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images---2024-07-29T172610.696.png) Left-hand radiograph - Macrodactyly investigations --- ## Management of Macrodactyly ****Key Point** Surgical management aims to stop overgrowth and debulk the digit, with addressing the nerve being important to reduce recurrence. The main goal in managing macrodactyly is to stop digit overgrowth before it surpasses adult size. **Surgery** is usually performed for functional and cosmetic reasons, while **medical** treatment is for refractory or extreme cases with Pi3KCA mutations. ### Surgical Management Surgical intervention requires thorough counseling due to the diffuse nature of the condition and its high likelihood of recurrence. **Limiting Growth Techniques:** 1. **Ligation of Digital Arteries:** Reduces blood supply to the digit. 2. **Compression Bandaging:** Restricts growth. 3. **Epiphysiodesis:** Arrests growth at the growth plate. 4. **Nerve Stripping and Nerve Resection:** Reduces nerve-related growth and recurrence. **Debulking Procedures:** - **Bone:** Includes reducing osteotomies or removal of the middle phalanx. - **Soft Tissue:** Involves excision of skin and fat, nail bed reduction. Techniques such as Tsuge’s method reduce length and bulk at the tip through a midlateral incision. - **Nerve Surgery:** Stripping, resection, and decompression, especially for enlarged nerves traveling through the carpal tunnel. - **Liposuction:** Useful for whole limb enlargement. - **Free Toe Transfer:** Provides more functional and aesthetic digits, particularly in cases with syndactyly. - **Amputation:** Ray amputation, with or without transposition, if the central digit is affected. ### Medical Treatment mTOR inhibitors like sirolimus are used to reduce tissue regeneration. This pathway is unchecked in cases with Pi3KCA mutations. 😎 ****Fun Fact:** Following nerve resection, reconstruction may be performed to improve sensation and function ([Kobreia](https://pubmed.ncbi.nlm.nih.gov/31772904/?ref=theplasticsfella.com), 2019). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Macrodactyly:** Gained a comprehensive understanding of macrodactyly including its definition, pathophysiology related to genetic mutations, and the implications of nerve-associated overgrowth. ****2\. Clinical Presentation:** Recognized the typical presentation patterns of macrodactyly and associated syndromic manifestations. ****3\. Diagnostic Approaches:** Reviewed the necessary imaging and genetic tests used to confirm the diagnosis of macrodactyly, which assists in differentiating it from other digital anomalies. ****4\. Treatment Strategies:** Explored surgical and medical treatment options aimed at managing overgrowth, addressing functional impairments, and minimizing aesthetic concerns. ****5\. Management of Complications:** Discussed potential complications, particularly the recurrence of growth post-surgery, and strategies to mitigate these risks. --- ## Further Reading 1. Ms Gill Smith [BFIRST/BSSH Global webinar - Congenital hand](https://youtu.be/tMGcnGUtmJw?feature=shared&ref=theplasticsfella.com) on YouTube 2. Ezaki M, Beckwith T, Oishi SN. [Macrodactyly: decision-making and surgery timing](https://pubmed.ncbi.nlm.nih.gov/30208752/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2019 Jan;44(1):32-42\. doi: 10.1177/1753193418796441\. Epub 2018 Sep 12\. PMID: 30208752. 3. Kobraei EM, Dusch MN, Meisel EM, Stevanovic M. [A Novel Method of Treatment of Macrodactyly with Digital Nerve Resection and Nerve Allograft](https://pubmed.ncbi.nlm.nih.gov/31772904/?ref=theplasticsfella.com). Plast Reconstr Surg Glob Open. 2019 Oct 29;7(10):e2483\. doi: 10.1097/GOX.0000000000002483\. PMID: 31772904; PMCID: PMC6846287. 4. Ezaki M. [Insights into the pathogenesis of macrodactyly](https://pubmed.ncbi.nlm.nih.gov/30086673/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2019 Jan;44(1):25-31\. doi: 10.1177/1753193418790928\. Epub 2018 Aug 7\. PMID: 30086673. 5. Wu J, Tian G, Ji Y, Higgins JP, Lee WPA. [Clinical Characteristics of 90 Macrodactyly Cases](https://pubmed.ncbi.nlm.nih.gov/32299688/?ref=theplasticsfella.com). J Hand Surg Am. 2020 Oct;45(10):982.e1-982.e5\. doi: 10.1016/j.jhsa.2020.03.002\. Epub 2020 Apr 13\. PMID: 32299688. 6. Bernhard SM, Adam L, Atef H, Häberli D, Bramer WM, Minder B, Döring Y, Laine JE, Muka T, Rössler J, Baumgartner I. [A systematic review of the safety and efficacy of currently used treatment modalities in the treatment of patients with PIK3CA-related overgrowth spectrum](https://pubmed.ncbi.nlm.nih.gov/34358672/?ref=theplasticsfella.com). J Vasc Surg Venous Lymphat Disord. 2022 Mar;10(2):527-538.e2\. doi: 10.1016/j.jvsv.2021.07.008\. Epub 2021 Aug 3\. PMID: 34358672. 7. Green DP, Wolfe SW. [*Green’s Operative Hand Surgery*](https://search.worldcat.org/title/Green's-operative-hand-surgery/oclc/806295798?ref=theplasticsfella.com). 6th ed. Elsevier/Churchill Livingstone; 2011. 8. Tan O, Atik B, Dogan A, Alpaslan S, Uslu M. [Middle phalangectomy: a functional and aesthetic cure for macrodactyly](https://pubmed.ncbi.nlm.nih.gov/17118902/?ref=theplasticsfella.com). Scand J Plast Reconstr Surg Hand Surg. 2006;40(6):362-5\. doi: 10.1080/02844310500369938\. PMID: 17118902. ### Congenital Dermoid Cysts: Pathology, Presentation, & Treatment URL: https://www.theplasticsfella.com/congenital-dermoid-cysts/ Last updated: 2024-07-29T11:43:38.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/congenital-dermoid-cysts/#definition-of-a-congenital-dermoid-cyst) A dermoid cyst is a benign congenital anomaly from ectodermal entrapment along embryonic closure lines, mainly in the head and neck region. [****Pathology**](https://www.theplasticsfella.com/congenital-dermoid-cysts/#pathology-of-congenital-dermoid-cysts) Dermoid cysts arise from ectodermal entrapment during embryonic development. They are lined by keratinizing squamous epithelium and often contain sebaceous glands and hair. [****Orbital Dermoid Cysts**](https://www.theplasticsfella.com/congenital-dermoid-cysts/#orbital-dermoid-cysts) More than 80% of congenital dermoid cysts occur in the upper outer quadrant of the orbital rim. These cysts typically present as painless, non-pulsatile, firm upper eyelid swellings fixed to the underlying bone. [****Nasal Dermoid Cysts**](https://www.theplasticsfella.com/congenital-dermoid-cysts/#nasal-dermoid-cysts) Nasal dermoids, uncommon and comprising 4-12% of head and neck dermoid cysts, are the most frequent congenital midline nasal lesions, presenting as painless, noncompressible midline masses. [****Complications**](https://www.theplasticsfella.com/congenital-dermoid-cysts/#complications-of-congenital-dermoid-cysts) Dermoid cysts with intracranial or intraspinal extensions can lead to meningitis, cerebral abscesses, local mass effects, and additional complications. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of a Congenital Dermoid Cyst ****Key Point** A dermoid cyst is a benign, congenital skin anomaly from trapped ectodermal elements, often diagnosed in childhood and mainly found in the head and neck region. A dermoid cyst is a **benign** skin anomaly arising from trapped **ectodermal** and **mesodermal** elements along embryonic lines. Typically **congenital**, these cysts are not always identified at birth: - \~40% of dermoid cysts are identified at birth - \~60% are diagnosed by the age of five. - \~84% occurring in the **head and neck** region ([Shareef](https://europepmc.org/article/nbk/nbk560573?ref=theplasticsfella.com), 2023). A congenital dermoid cyst is illustrated in the image below. ![Definition of a congenital dermoid cyst](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images---2024-07-29T170626.695.png) Definition of a congenital dermoid cyst --- ## Pathology of Congenital Dermoid Cysts ****Key Point** Dermoid cysts stem from abnormal fetal development and are commonly found in the supraorbital area, cranial sutures, and nose. It is composed of ectodermal and mesodermal elements. Dermoid cysts are benign tumors formed from ectodermal and mesodermal cells trapped during the neural tube closure in the 5th and 6th weeks of embryonic development. ([Cavazza](https://link.springer.com/article/10.1007/s10792-011-9419-y?ref=theplasticsfella.com), 2011). The typical **structure** of a dermoid cyst is: - **Shape**: Round or ovoid - **Lining**: skin-like epithelium, dermal layer with sebaceous glands & appendages. - **Contents**: hair, nails ± dental or bone-like structures (depends on location) The **most common location** of a dermoid cyst is the periorbital lateral eyebrow (external angular dermoid). Other common locations include: - **Supraorbital area**: Above the eye socket. - **Cranial sutures**: Along the skull bone joints. - **Nose**: Especially near the nasal root. Less common locations include midline neck, Forehead, scalp, behind the ear (posterior auricular or mastoid) --- ## Orbital Dermoid Cysts ****Key Point** Dermoid cysts typically appear in the upper outer quadrant of the orbital rim or lacrimal fossa. They are usually painless, firm, and fixed to the bone, without pulsation. Orbital Dermoid Cysts, the most common congenital type, typically occur in the upper outer quadrant of the orbital rim or lacrimal fossa - near the zygomaticofrontal suture ([Eldesouky](https://www.tandfonline.com/doi/abs/10.1080/08820538.2016.1182636?ref=theplasticsfella.com), 2016). They can classified **radiologically** or **anatomically**: - **Radiology**: superficial or deep based on their position relative to the interzygomatic line on CT or MRI ([Eldesouky](https://www.tandfonline.com/doi/abs/10.1080/08820538.2016.1182636?ref=theplasticsfella.com), 2016) - **Anatomically**: juxtasutural, sutural, or soft tissue variants depending on their relation to the underlying bone ([Shields](https://pubmed.ncbi.nlm.nih.gov/15110666/?ref=theplasticsfella.com), 2004). 😎 ****Fun Fact:** Orbital Dermoid Cysts account for 3-9% of all periorbital tumours in the paediatric population ([Dutton](https://link.springer.com/chapter/10.1007/978-1-4419-0374-7%5F3?ref=theplasticsfella.com), 2011). ### Clinical Features Orbital dermoid cysts typically present as **painless** upper eyelid swellings without overlying cutaneous features. On palpation, these lesions are: - **Non-pulsatile** - **Firm** - **Fixed to the underlying bone** These characteristics of an orbital dermoid cyst are illustrated below. ![Clinical features of orbital dermoid cysts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images---2024-07-29T170237.480.png) Clinical features of orbital dermoid cysts 💡 ****Tip:** An orbital dermoid cyst may leak into surrounding tissues, causing inflammation that mimics primary inflammation and leads to diagnostic uncertainty. ### Diagnosis Imaging is vital in confirming the diagnosis and evaluating for intracranial extension: - **CT:** Reveals a well-defined mass with an enhancing wall and non-enhancing lumen, luminal debris, and a bony fossa overlying the suture line. - **MRI:** Shows a well-defined ovoid structure, hypointense on T1 and hyperintense on T2 relative to surrounding orbital fat, with no enhancement due to the lack of blood vessels within the cyst. The image below illustrates the CT presentation of an orbital dermoid cyst. ![CT imaging of an orbital dermoid cyst](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images---2024-07-29T170252.005.png) CT imaging of an orbital dermoid cyst ### Treatment Treatment involves surgical excision, typically preferred over conservative methods to avoid complications. Key steps in the **supratarsal approach** include: - **Incision:** Made at the upper eyelid crease for optimal access. - **Dissection:** The orbicularis oculi muscle is dissected to locate the cyst in the subperiosteal plane. - **Excision:** Complete removal of the cyst without rupturing its wall is crucial. If the cyst wall ruptures, thorough irrigation is required to remove all remnants and prevent recurrence, as incomplete removal can necessitate more complex repeat surgeries. The image below illustrates the surgical treatment of an orbital dermoid cyst. ![Surgical treatment of an orbital dermoid cyst, managing orbital dermoid cysts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images---2024-07-29T170310.595.png) Surgical treatment of an orbital dermoid cyst 💡 ****Tip:** An orbital dermoid cyst may form a dumbbell shape across the zygomaticofrontal suture, causing pulsating proptosis during mastication, a distinct sign of this condition ([Kerdoud](https://www.sciencedirect.com/science/article/pii/S2667147621001229?ref=theplasticsfella.com), 2021). --- ## Nasal Dermoid Cysts ****Key Point** Nasal dermoids are rare, presenting as painless, non-transilluminating midline masses with a negative Furstenberg sign. They require imaging and complete surgical removal for management. Nasal dermoids, which make up 4-12% of dermoid cysts in the head and neck region, are less common than their orbital counterparts and typically manifest as the predominant congenital midline nasal lesions with a slight male bias ([Van Wyhe](https://pubmed.ncbi.nlm.nih.gov/27895540/?ref=theplasticsfella.com), 2016). These cysts develop from the incomplete regression of the neuroectodermal tract during the eighth week of embryogenesis, potentially extending intracranially through the foramen cecum ([Zapata](https://pubmed.ncbi.nlm.nih.gov/17099348/?ref=theplasticsfella.com), 2006). ### Clinical Features Nasal dermoids typically appear as **painless** midline masses located anywhere from the base of the columella to the nasoglabellar region. Hair protruding from a nasal punctum is pathognomonic for nasal dermoids. Other typical features include: - Noncompressible - Does not transilluminate - Negative Furstenberg sign - ± sinus with intermittent discharge The image below illustrates the presentation of a nasal dermoid cyst. ![Clinical presentation of a nasal dermoid cyst](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images---2024-07-29T171209.282.png) Clinical presentation of a nasal dermoid cyst 💡 ****Tip:** The Furstenberg sign tests if head masses swell with increased intracranial pressure. Positive results indicate brain connections (e.g., encephaloceles); negative results occur in conditions like nasal dermoids. ([Van Wyhe](https://pubmed.ncbi.nlm.nih.gov/27895540/?ref=theplasticsfella.com), 2016) ### Investigations Imaging is vital for diagnosing nasal dermoids, with MRI and CT scans as the gold standard, particularly important given that up to 45% of these cases may have intracranial extensions. Key Indicators of Intracranial Extension: - Enlarged foramen cecum - Bifid crista galli These imaging findings help rule out other potential diagnoses: - **Brain-related conditions:** Encephaloceles, Gliomas - **Soft tissue conditions:** Epidermal inclusion cysts, Lipomas, Hemangiomas, Teratomas, Neurofibromas, Lymphangiomas ### Management Effective management of nasal dermoids requires a multidisciplinary team (MDT) including plastic surgeons and neurosurgeons. The primary goal is the complete surgical excision of the cysts and any associated sinus tracts to prevent recurrence, which can occur in 50-100% of cases if any dermal components are left behind ([Bloom](https://pubmed.ncbi.nlm.nih.gov/11788143/?ref=theplasticsfella.com), 2002). **Surgical Approaches:** - **Midline Vertical Incision:** Provides adequate exposure for excising both intracranial and extracranial components in a single stage. - **Open Rhinoplasty Approach:** Allows thorough access to the skull base for complete removal. - **Bicoronal Craniotomy:** Necessary for cases with extensive intracranial extension. Complete excision is essential for a cure, with the chosen surgical approach tailored to the extent of the cyst and its intracranial involvement ([Miller](https://www.sciencedirect.com/science/article/abs/pii/S1043181019300065?ref=theplasticsfella.com), 2019) 😎 ****Fun Fact:** Epidermal inclusion cysts lack skin adnexal structures and contain a friable keratin core. In contrast, nasal dermoids are well-defined cysts lined with keratinizing squamous epithelium and mesodermal adnexal structures. --- ## Complications of Congenital Dermoid Cysts ****Key Point** Dermoid cysts without intracranial or intraspinal extension do not usually cause complications. Dermoid cysts without intracranial or intraspinal extension typically do not cause complications. However, those with such extensions can lead to: - **Meningitis** - **Cerebral abscesses** - **Local mass effects** Additional complications of orbital dermoid cysts include bony erosions, eyelid displacement, and proptosis. Nasal dermoid cysts may present with persistent discharge or infection, including osteomyelitis ([Blake](https://pubmed.ncbi.nlm.nih.gov/17060735/?ref=theplasticsfella.com), 2006). Rupture of dermoid cysts can result in localized inflammation and infection, making complete surgical removal more challenging. Malignant transformation to squamous cell carcinoma (SCC) is a rare but possible complication in long-standing dermoid cysts (Shareef, 2023). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Dermoid Cysts:** Acquired a comprehensive understanding of dermoid cysts, including their congenital origin, common locations, and how they develop from ectodermal entrapment. ****2\. Identifying Symptoms:** Recognized the typical presentation of dermoid cysts in various anatomical locations, which can help in early detection. ****3\. Diagnostic Processes:** Learned about the essential imaging techniques used for diagnosing dermoid cysts and distinguishing these from other similar lesions. ****4\. Treatment Options:** Reviewed the primary treatment approach —surgical excision — and understood the importance of complete resection to prevent recurrence and manage potential complications. ****5\. Complications:** Aware of the potential complications associated with dermoid cysts, especially those with intracranial or intraspinal extensions. --- ## Further Reading 1. Shareef, Shahjahan, and Leila Ettefagh. "[Dermoid cyst.](https://europepmc.org/article/nbk/nbk560573?ref=theplasticsfella.com)" (2020). 2. Blake WE, Chow CW, Holmes AD, Meara JG. [Nasal dermoid sinus cysts: a retrospective review and discussion of investigation and management](https://pubmed.ncbi.nlm.nih.gov/17060735/?ref=theplasticsfella.com). Ann Plast Surg. 2006 Nov;57(5):535-40\. doi: 10.1097/01.sap.0000229060.20055.07\. PMID: 17060735. 3. Cavazza, Stefano, et al. "[Orbital dermoid cyst of childhood: clinical pathologic findings, classification and management.](https://link.springer.com/article/10.1007/s10792-011-9419-y?ref=theplasticsfella.com)" *International ophthalmology* 31 (2011): 93-97. 4. Choi, June Seok, et al. "[Dermoid cysts: epidemiology and diagnostic approach based on clinical experiences.](https://www.thieme-connect.com/products/ejournals/html/10.5999/aps.2018.00017?ref=theplasticsfella.com)" *Archives of Plastic Surgery* 45.06 (2018): 512-516. 5. Eldesouky, Mohammed Ashraf, and Molham Abdelhafez Elbakary. "[Orbital dermoid cyst: classification and its impact on surgical management.](https://www.tandfonline.com/doi/abs/10.1080/08820538.2016.1182636?ref=theplasticsfella.com)" *Seminars in ophthalmology*. Vol. 33\. No. 2\. Taylor & Francis, 2018. 6. Dutton, Jonathan J., and George K. Escaravage. "[Pediatric orbital tumors.](https://link.springer.com/chapter/10.1007/978-1-4419-0374-7%5F3?ref=theplasticsfella.com)" *Ophthalmic Oncology* (2011): 23-59. 7. Shields JA, Shields CL. [Orbital cysts of childhood--classification, clinical features, and management](https://pubmed.ncbi.nlm.nih.gov/15110666/?ref=theplasticsfella.com). Surv Ophthalmol. 2004 May-Jun;49(3):281-99\. doi: 10.1016/j.survophthal.2004.02.001\. PMID: 15110666. 8. Kerdoud, Ouassime, et al. "[Dumbbell-shaped dermoid cyst of the orbit: Case report.](https://www.sciencedirect.com/science/article/pii/S2667147621001229?ref=theplasticsfella.com)" *Advances in Oral and Maxillofacial Surgery* 3 (2021): 100135. 9. Van Wyhe RD, Chamata ES, Hollier LH. [Midline Craniofacial Masses in Children](https://pubmed.ncbi.nlm.nih.gov/27895540/?ref=theplasticsfella.com). Semin Plast Surg. 2016 Nov;30(4):176-180\. doi: 10.1055/s-0036-1593482\. PMID: 27895540; PMCID: PMC5115923. 10. PRATT LW. [MIDLINE CYSTS OF THE NASAL DORSUM: EMBRYOLOGIC ORIGIN AND TREATMENT](https://pubmed.ncbi.nlm.nih.gov/14301067/?ref=theplasticsfella.com). Laryngoscope. 1965 Jun;75:968-80\. doi: 10.1288/00005537-196506000-0010\. PMID: 14301067. 11. Zapata S, Kearns DB. [Nasal dermoids](https://pubmed.ncbi.nlm.nih.gov/17099348/?ref=theplasticsfella.com). Curr Opin Otolaryngol Head Neck Surg. 2006 Dec;14(6):406-11\. doi: 10.1097/MOO.0b013e32801042db. PMID: 17099348. 12. Pensler JM, Bauer BS, Naidich TP. [Craniofacial dermoids](https://pubmed.ncbi.nlm.nih.gov/3200958/?ref=theplasticsfella.com). Plast Reconstr Surg. 1988 Dec;82(6):953-8\. doi: 10.1097/00006534-198812000-00003\. PMID: 3200958. 13. Rahbar R, Shah P, Mulliken JB, Robson CD, Perez-Atayde AR, Proctor MR, Kenna MA, Scott MR, McGill TJ, Healy GB. [The presentation and management of nasal dermoid: a 30-year experience](https://pubmed.ncbi.nlm.nih.gov/12707196/?ref=theplasticsfella.com). Arch Otolaryngol Head Neck Surg. 2003 Apr;129(4):464-71\. doi: 10.1001/archotol.129.4.464\. PMID: 12707196. 14. Bloom DC, Carvalho DS, Dory C, Brewster DF, Wickersham JK, Kearns DB. [Imaging and surgical approach of nasal dermoids](https://pubmed.ncbi.nlm.nih.gov/11788143/?ref=theplasticsfella.com). Int J Pediatr Otorhinolaryngol. 2002 Feb 1;62(2):111-22\. doi: 10.1016/s0165-5876(01)00590-0\. PMID: 11788143. 15. Miller, Craig, Scott Manning, and Randall Bly. "[Surgical management of nasal dermoid lesions.](https://www.sciencedirect.com/science/article/abs/pii/S1043181019300065?ref=theplasticsfella.com)" *Operative Techniques in Otolaryngology-Head and Neck Surgery* 30.1 (2019): 16-21. ### Venous Flaps: Physiology, Classification, & Evaluation URL: https://www.theplasticsfella.com/venous-flaps/ Last updated: 2024-07-29T20:43:09.000Z #### Summary Card [****Physiology**](https://www.theplasticsfella.com/venous-flaps/#physiology-of-venous-flaps) The exact physiology of venous flaps is relatively unknown. [****Classification**](https://www.theplasticsfella.com/venous-flaps/#classification-of-venous-flaps) Thatte and Thatte is the standard classification for venous flaps. There are 3 types of venous flaps based on the number of veins & their function. [****Evaluation**](https://www.theplasticsfella.com/venous-flaps/#evaluation-of-venous-flaps) They do not have a high survival rate and are not used regularly due to this. --- ## Physiology of Venous Flaps ****Key Point** The exact physiology of venous flaps is relatively unknown and there are different theories regarding this. The exact mechanism of venous flaps is currently not completely understood. There are different theories and contributing factors that relate to: - Perfusion pressures: reverse shunting and reverse flow - Arteriovenous anastomosis - Plasmatic imbibition - Vascular connections 💡 ****Tip:** An example of a venous flap is the saphenous vein flap. --- ## Classification of Venous Flaps ****Key Point** Thatte and Thatte is the standard classification for venous flaps. There are 3 types of venous flaps based on the number of veins & their function. **Thatte and Thatte** classify venous flaps into 3 categories based on the number of veins and their function. They are generally quite thin flaps as they contain skin and fat only, not the fascia. - **Type 1:** Uni-pedicled venous flap - **Type 2:** Bi-pedicled venous flow-through flap - **Type 3:** Arterialisation of a venous flap through a proximal AV anastomosis and a distal vein This classification of venous flaps is illustrated in the image below. ![Thatte and Thatte Venous Flap Classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Venous-Flaps-Classification.png) Thatte and Thatte Venous Flap Classification --- ## Evaluation of Venous Flaps ****Key Point** Venous flaps do not have a high survival rate and are not used regularly due to this. Venous flaps are not routine reconstruction surgical practices due to their poor survival rates and general lack of understanding of their physiology. There are some *small* advantages to this type of flap: - Reliable anatomy (for example saphenous vein) - Minimal donor site morbidity. 💡 ****Tip:** A common complication of a venous flap is venous congestion. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Venous Flap Physiology:** Gained insights into the complex and not fully understood physiology of venous flaps. ****2\. Classification of Venous Flaps:** Learned about the Thatte and Thatte classification, which categorizes venous flaps into three types based on the number of veins and their function. ****3\. Limitations and Pitfalls:** Recognized the challenges and limitations associated with venous flaps, particularly their low survival rates and the common issue of venous congestion. ### Mathes and Nahai Classification URL: https://www.theplasticsfella.com/mathes-and-nahai-classification/ Last updated: 2024-07-29T20:19:16.000Z #### Summary Card [****Origin and Publication**](https://www.theplasticsfella.com/mathes-and-nahai-classification/#origin-of-mathes-and-nahai-classification) The Mathes and Nahai Classification was introduced as a way of describing the blood supply to muscle and musculocutaneous flaps. [****Mathes and Nahai Classification**](https://www.theplasticsfella.com/mathes-and-nahai-classification/#mathes-and-nahai-classification) Mathes and Nahai classification describes the number of major & minor pedicles of a muscle flap. --- ## Origin of Mathes and Nahai Classification ****Key Point** The Mathes and Nahai Classification was introduced as a way of describing the blood supply to muscle and musculocutaneous flaps. The Mathes and Nahai Classification system was first described in 1981 as a way of describing the blood supply to muscle and musculocutaneous flaps. It was first described by Mathes and Nahai in a 1981 [PRS publication](https://www.ncbi.nlm.nih.gov/pubmed/7465666?ref=theplasticsfella.com). This classification is illustrated in the image below. ![Mathes and Nahai Muscle Flap Classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/mathes-and-nahai-classification.png) Mathes and Nahai Muscle Flap Classification There are some important points for context: - There is no commonly used alternative classification for muscle flaps. - It does not relate to local flaps, such as [rotation](https://www.theplasticsfella.com/rotation-flap/) or [rhomboid](https://www.theplasticsfella.com/rhomboid-flap/) flaps, only muscle. - It is different from Mathe and Nahai's [fasciocutaneous](https://www.theplasticsfella.com/fasciocutaneous-flaps/) flap classification. - Blood supply to muscles and musculocutaneous flaps can be read [here](https://www.theplasticsfella.com/classification-of-flaps/). ![Mathes and Nahai published their original publication for muscle flaps in 1981 in PRS Journal](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Mathes-and-Nahai-Classification-Original-Publication.png) Mathes and Nahai 1981 Publication --- ## Mathes and Nahai Classification ****Key Point** Mathes and Nahai classification describes the number of major & minor pedicles of a muscle flap. The Mathes and Nahai classification for muscle flaps can be visualised in the image below. ![The Mathes and Nahai Muscle Flap Classification can be visualised base on the number of major and minor pedicles](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/3.png) Mathes and Nahai Muscle Flap Classification Key points on the Mathes and Nahai classification system are: - **Type 1:** 1 major pedicle (gastrocnemius) - **Type 2:** 1 major and 1 minor pedicle ([gracilis flap](https://www.theplasticsfella.com/gracilis-flap/)) - **Type 3:** 2 major pedicles ([rectus abdominis](https://www.theplasticsfella.com/vram-flap/)) - **Type 4:** Minor segmental pedicles (sartorius) - **Type 5:** 1 major and minor segmental pedicles (latissimus dorsi flap) These types are illustrated in the diagram below. ![The number of major and minor pedicles for each muscle is used in the Mathes and Nahai Muscle Flap Classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/4.png) Mathes and Nahai Muscle Flap Classification ⚡ ****Tip:** Type I, III, and V muscle flaps have the most reliable blood supply. A mnemonic for Mathes and Nahai Classification is as follows: **Ten Graceful Glutes Sat on Latrines.** - **Type I:** TFL flap - **Type II:** [Gracilis flap](https://www.theplasticsfella.com/gracilis-flap/) - **Type III:** Gluteus maximus flap, [VRAM flap](https://www.theplasticsfella.com/vram-flap/) - **Type IV:** Sartorius flap - **Type V:** Lattisimus dorsi flap Another mnemonic for Muscles flaps is: "Get Good Remembering Supply Lines" · - **Type 1:** Gastrocnemius - **Type 2:** Gracilis - **Type 3:** Rectus abdominis - **Type 4:** Sartorius - **Type 5:** Latissumus dorsi ⚡ Tip: Muscle flaps are more bacterial-resistant than [fasciocutaneous flaps](www.theplasticsfella.com/fasciocutaneous-flaps/). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Mathes and Nahai Classification:** Gained a detailed understanding of the Mathes and Nahai classification system which describes the vascular supply to muscle and musculocutaneous flaps based on the number and type of vascular pedicles. ****2\. Classification:** Learned the specific types of vascular pedicles that categorize muscle flaps into five different types, enhancing your ability to plan reconstructive surgeries with appropriate flaps. ****3\. Application in Clinical Practice:** Appreciated the relevance of this classification in clinical practice, particularly in reconstructive surgery, to ensure optimal flap survival and functional outcomes. ****4\. Differentiation of Flap Types:** Distinguished between different types of muscle flaps based on their vascular anatomy, which is critical for surgical planning and execution. --- ## References 1. [Classification of the vascular anatomy of muscles: experimental and clinical correlation.](https://www.ncbi.nlm.nih.gov/pubmed/7465666?ref=theplasticsfella.com)[ ](https://www.ncbi.nlm.nih.gov/pubmed/7465666?ref=theplasticsfella.com)Mathes SJ, Nahai F. Plast Reconstr Surg. 1981 Feb;67(2):177-87. 2. [A Practical Guide to Free Tissue Transfer](https://journals.lww.com/plasreconsurg/Abstract/2013/07000/A%5FPractical%5FGuide%5Fto%5FFree%5FTissue%5FTransfer.43.aspx?ref=theplasticsfella.com)[.](https://journals.lww.com/plasreconsurg/Abstract/2013/07000/A%5FPractical%5FGuide%5Fto%5FFree%5FTissue%5FTransfer.43.aspx?ref=theplasticsfella.com) Roehl, Kendall R. M.D et al. Plastic and Reconstructive Surgery: July 2013 – Volume 132 – Issue 1 – p 147e–158e doi: 10.1097/PRS.0b013e3182910fba 3. [The Concepts of Propeller, Perforator, Keystone, and Other Local Flaps and Their Role in the Evolution of Reconstruction](https://www.ncbi.nlm.nih.gov/pubmed/27673542?ref=theplasticsfella.com)[.](https://www.ncbi.nlm.nih.gov/pubmed/27673542?ref=theplasticsfella.com) Mohan, Anita T et al. Plastic and Reconstructive Surgery: October 2016 – Volume 138 – Issue 4 – p 710e-729edoi: 10.1097/PRS.0000000000002610 4. [Advances in muscle and musculocutaneous flaps](https://www.ncbi.nlm.nih.gov/pubmed/6988141?ref=theplasticsfella.com). Mathes SJ, Alpert BS. Clin Plast Surg. 1980 Jan;7(1):15-26. ### Breast Augmentation - Clinical Scenario URL: https://www.theplasticsfella.com/breast-augmentation-clinical-scenario/ Last updated: 2024-09-04T17:08:20.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Clinical-Case-Main-Image--8--1.png) #### Clinical Scenario ****A 25-year-old female presents for a plastic surgery consultation regarding breast augmentation. She is in good health with no significant medical history.** ****She expresses that she is unhappy with the size and shape of her breasts and desires a fuller and more proportionate appearance. She has done some research online and is interested in learning about her options for breast implants and what the surgery entails.** ****Objectives:** ****1\.** Outline the steps in the consultation process for breast augmentation. ****2\.** Describe the different implants available and their advantages and disadvantages. ****3\.** Discuss the potential complications and their treatment. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Cervical Lymph Nodes of the Neck: Drainage & Levels URL: https://www.theplasticsfella.com/lymph-nodes-of-the-neck/ Last updated: 2024-07-29T20:23:00.000Z #### Summary Card [****Cervical Lymphatic Drainage Pattern**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#cervical-lymphatic-drainage-pattern) The lymphatic flow is from superficial to deeper and from the upper to lower parts of the neck. [****Level 1 Cervical Lymph Nodes**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-1-cervical-lymph-nodes) ****Superior:** Mandible ****Inferior:** Anterior and posterior digastric muscle, hyoid. ****Walls:** N/A ****Structures:** Submental nodes, submandibular nodes & glands. [****Level 2 Cervical Lymph Nodes**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-2-cervical-lymph-nodes) ****Superior:** Jugular fossa ****Inferior:** Hyoid bone ****Walls:** Sternohyoid to sternocleidomastoid ****Structures:** Spinal accessory nerve divides 2A & 2B [****Level 3 Cervical Lymph Nodes**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-3-cervical-lymph-nodes) ****Superior:** Hyoid bone ****Inferior:** Lower border of the cricoid ****Walls:** Sternohyoid to sternocleidomastoid ****Structures:** N/A [****Level 4 Cervical Lymph Nodes**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-4-cervical-lymph-nodes) ****Superior:** Lower border of the cricoid ****Inferior:** Clavicle ****Walls:** Sternohyoid to sternocleidomastoid ****Structures:** Thoracic duct on the left [****Level 5 Cervical Lymph Nodes**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-5-cervical-lymph-nodes) ****Superior:** Cranium at convergence of SCM & trapezius ****Inferior:** Clavicle ****Walls:** Posterior border of SCM and anterior border of trapezius. ****Key Contents:** Spinal accessory nerve. [****Level 6 Cervical Lymph Nodes**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-6-cervical-lymph-nodes) ****Superior:** Hyoid bone ****Inferior:** Suprasternal notch ****Walls:** Carotid sheaths ****Structures:** Pre- and para-tracheal nodes. [****Level 7 Cervical Lymph Nodes**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-7-cervical-lymph-nodes) ****Superior:** Suprasternal notch ****Inferior:** Aortic arch ****Walls:** Carotid sheaths ****Sublevel:** None Listen to Levels of the Neck 0:00 /137.04 1× --- ## Cervical Lymphatic Drainage Pattern ****Key Point** The lymphatic flow is from superficial to deeper and from the upper to lower parts of the neck. The lymphatic system of the neck is divided into three systems. ### Overview In general, the lymphatic flow is from superficial to deeper and from the upper to lower parts of the neck. The lymphatic system of the neck is divided into three systems: 1. **Waldeyer’s internal ring:** Nodes in adenoids, tonsils, and posterior pharyngeal wall which are at high risk for lymphatic spread. 2. **Waldeyer’s external ring:** Nodes in the occipital, post-auricular, parotid, superficial cervical, submandibular, submental, and anterior cervical region. They drain superficial tissues from the scalp, eyelids, face, sinuses, and oral cavity. 3. **Deep lymph node system:** Nodes in the upper, middle, and lower cervical regions near the internal jugular vein, a spinal accessory group, and neck midline. 😎 ****Fun Fact:** The hard palate and soft palate will drain to the retropharyngeal space and deep cervical nodes. ### Drainage Patterns Each anatomical subgroup of lymph nodes acts as a reservoir for a specific site in the head and neck region. This creates the potential to identify the primary tumour based on the site of a specific group of lymph nodes. - **Level 1:** Lips, gums, teeth, tongue, and anterior hard palate - **Level 2:** Naso-/oro-/hypopharynx and parotid - **Level 3:** Naso-/oro-/hypopharynx and larynx - **Level 4:** Larynx, cervical oesophagus, and hypopharynx - **Level 5:** Naso- and oropharynx - **Level 6:** Thyroid, parathyroid, cervical oesophagus, and larynx 💡 ****Tip:** Lymphatic involvement increases anterior to posterior in the aerodigestive tract. Tongue tumours have the highest incidence of metastasis, followed by the floor of the mouth, buccal mucosa, hard palate, and lips. ([Farr](https://pubmed.ncbi.nlm.nih.gov/7425241/?ref=theplasticsfella.com), 1980) Clinically speaking, there are some generally accepted pathological draining routes. For example: - The floor of mouth and tongue tumors tend to spread to **levels I through III** - Laryngeal tumors tend to spread to **levels II through IV** 😎 ****Fun Fact:** Lymphatic drainage corresponds to embryologic origins. The tragus, helical root, and superior helix originate from the first branchial arch and drain to the parotid nodes. The antihelix, antitragus, and lobule arise from the second branchial arch and drain to the cervical nodes. --- ## Level 1 Cervical Lymph Nodes ****Key Point** Level 1 cervical lymph nodes contain the submental (1A) and submandibular (1B) triangles. Level 1 cervical lymph nodes have **two** sublevels: **submental** (1A) & **submandibular** (1B). This can be visualized in the illustration below. ![Level 1 Cervical Lymph Nodes, Level 1A, Level 1B, submental, submandibular, cervical nodes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/Cervical-Lymph-Nodes-of-the-Neck-11.png) Level 1 Cervical Lymph Nodes **Level 1A: Submental** - **Location:** Between anterior digastric bellies and hyoid bone - **Structures:** Submental nodes - **Drainage:** From lips, gum, tongue, anterior hard palate **Level 1B: Submandibular** - **Location:** Between the digastric muscle and the body of the mandible - **Structures:** Submandibular nodes and gland - **Drainage:** From lips, gum, tongue, anterior hard palate --- ## Level 2 Cervical Lymph Nodes ****Key Point** Upper jugular neck nodes have anterior (2A) & posterior (2B) divisions. Upper jugular neck nodes have **anterior** (2A) & **posterior** (2B) divisions. This is illustrated in the image below. ![Level 2 Cervical Lymph Nodes, Level 2A, Level 2B, spinal accessory nerve, upper jugular, cervical nodes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/Cervical-Lymph-Nodes-of-the-Neck-12.png) Level 2 Cervical Lymph Nodes The **location** of level 2 cervical neck nodes are: - **Superior:** Skull base at jugular fossa - **Inferior:** Hyoid bone or carotid bifurcation - **Posterior:** Posterior border sternocleidomastoid (SCM) - **Anterior:** Continuation from level 1B (lateral border of the sternohyoid or posterior belly of digastric depending on resource) Key points on level 2 neck nodes are: - **Contents: S**pinal accessory nerve and upper jugular nodes - **Divisions**: Anterior (2A) & posterior (2B) divided by spinal accessory nerve - **Drainage:** Naso-/oro-/hypopharynx and parotid --- ## Level 3 Cervical Lymph Nodes ****Key Point** The middle jugular group does not have sublevels. The middle jugular group does not have sublevels. The **location** of level 3 cervical nodes are: - **Superior:** Hyoid bone or carotid bifurcation - **Inferior:** Lower cricoid or superior belly of the omohyoid muscle - **Anterior: Sterno**hyoid (don't get confused with **stylo**hyoid) - **Posterior:** Posterior border of sternocleidomastoid (SCM) Level 3 tends to drain the naso-/oro-/hypopharynx and larynx. ![Level 3 Cervical Lymph Nodes, Level 3, nodes ,middle jugular, cervical nodes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/Cervical-Lymph-Nodes-of-the-Neck-6.png) Level 3 Cervical Lymph Nodes --- ## Level 4 Cervical Lymph Nodes ****Key Point** The lower jugular group has 4A & 4B sublevels containing the thoracic duct and Virchow's node. The lower jugular group has 4A & 4B sublevels containing the thoracic duct and Virchow's node. This is illustrated in the image below. ![Level 4 Cervical Lymph Nodes, Level 4, nodes, lower jugular, cervical nodes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Level-4-Cervical-Neck-Lymph-Nodes.png) Level 4 Cervical Lymph Nodes The **location** of level 4 cervical nodes are: - **Superior:** Cricothyroid notch or omohyoid muscle - **Inferior:** Clavicle - **Anterior:** Lateral border of sternohyoid muscle (same as level 3) - **Posterior:** Posterior border of sternocleidomastoid (same as level 3) The sublevels are described as follows: - **Divisions:** 4Ais deep to sternal SCM, 4B isdeep to clavicular SCM - **Contents:** Lower jugular nodes, left thoracic duct, right lymphatic duct --- ## Level 5 Cervical Lymph Nodes ****Key Point** The posterior triangle group is divided into sublevels 5A & 5B by omohyoid. The posterior triangle group is divided into sublevels 5A & 5B by omohyoid. Level 5 cervical neck lymph nodes drain the naso- and oro-pharynx. The anatomical locations are: - **Superior:** Skull base SCM and trapezius muscles - **Inferior:** Clavicle - **Anterior:** Posterior border of the SCM muscle - **Posterior:** Anterior border of the trapezius muscle The sublevels are described as follows: - **5A:** Superior to the omohyoid and contains the spinal accessory nodes - **5B:** Inferior to the omohyoid and contains the transverse cervical and supraclavicular nodes ![Level 5 Cervical Lymph Nodes, Level 5A, Level 5B, nodes, posterior triangle, cervical nodes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/Cervical-Lymph-Nodes-of-the-Neck-8.png) Level 5 Cervical Lymph Nodes 😎 ****Fun Fact:** Omohyoid originates from the clavicle and first rib to insert into the hyoid bone. It is supplied by the inferior thyroid artery. --- ## Level 6 Cervical Lymph Nodes ****Key Point** The anterior compartment contains the paratracheal and Delphian nodes. The anterior compartment contains the paratracheal and Delphian nodes. Level 6 is medial to levels III and IV. It drains the thyroid, parathyroid, cervical oesophagus, and larynx. The anatomical landmarks are: - **Superior:** Hyoid bone - **Inferior:** Manubrium/suprasternal notch - **Walls:** Left and rightcommon carotid arteries ![Level 6 Cervical Lymph Nodes, Level 6, nodes, anterior compartment, cervical nodes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/Cervical-Lymph-Nodes-of-the-Neck-9.png) Level 6 Cervical Lymph Nodes --- ## Level 7 Cervical Lymph Nodes ****Key Point** Upper mediastinal nodes lie outside the borders of the neck. Upper mediastinal nodes lie outside the borders of the neck. The anatomical location of Level VII nodes are: - **Superior:** Suprasternal notch - **Inferior:** Aortic arch - **Lateral:** Carotid arteries These nodes are an extension of the paratracheal lymph node chain. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Cervical Lymph Nodes:** Gained an understanding of the anatomical arrangement of cervical lymph nodes and their significance in lymphatic drainage in the neck region. ****2\. Anatomical Landmarks:** Learned about the anatomical landmarks that define each cervical lymph node level. ****3\. Lymphatic Drainage Patterns:** Recognized the specific drainage patterns associated with each group of lymph nodes, crucial for diagnosing the primary sites of tumors. ****4\. Clinical Implications:** Understood the clinical implications of lymphatic drainage in the management of various head and neck conditions. ****5\. Surgical Relevance:** Reviewed the importance of these lymph nodes in surgical planning, particularly in oncology, to ensure comprehensive management of malignancies in the head and neck. --- ## References 1. Haynes J, Arnold K, Aguirre-Oskins C, Chandra S. [Evaluation of neck masses in adults](https://www.ncbi.nlm.nih.gov/pubmed/25978199?ref=theplasticsfella.com). *Am Fam Physician*. 2015;91(10):698-706\. 2. Robbins K, Shaha A, Medina J, et al. [Consensus statement on the classification and terminology of neck dissection](https://doi.org/10.1001/archotol.134.5.536?ref=theplasticsfella.com). *Arch Otolaryngol Head Neck Surg*. 2008;134(5):536-538\. doi:10.1001/archotol.134.5.536 3. [Lymph nodes of the neck.](https://pubs.rsna.org/doi/abs/10.1148/radiology.165.3.3317494?ref=theplasticsfella.com) P M SomRadiology1987165:3, 593-600 4. Martin G. Mack, Jörg Rieger, Mehran Baghi, Sotirios Bisdas, Thomas J. Vogl, [Cervical lymph nodes](https://www.sciencedirect.com/science/article/pii/S0720048X08000399?ref=theplasticsfella.com), European Journal of Radiology, Volume 66, Issue 3, 2008, Pages 493-500, ISSN 0720-048X, https://doi.org/10.1016/j.ejrad.2008.01.019. 5. Farr HW, Goldfarb PM, Farr CM. [Epidermoid carcinoma of the mouth and pharynx at Memorial Sloan-Kettering Cancer Center, 1965 to 1969](https://pubmed.ncbi.nlm.nih.gov/7425241/?ref=theplasticsfella.com). Am J Surg. 1980 Oct;140(4):563-7\. doi: 10.1016/0002-9610(80)90213-5\. PMID: 7425241. ### Top 3 Plastic Surgery Resources, How to Assess a Breast, & New “Lessons” URL: https://www.theplasticsfella.com/july-28th/ Last updated: 2024-07-27T20:06:28.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-28th/#a-letter-from-pfella) The top 3 plastic surgery resources? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/july-28th/#the-sunday-quiz) How well do you know breast augmentation? 3. 📚 [****New Feature: "Lessons"**](https://www.theplasticsfella.com/july-28th/#new-feature-lessons) How-to guides for the essentials. 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/july-28th/#the-fellows-corner) This week's feature: Tuberous breast deformity. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-28th/#what-does-the-evidence-say) What are the causes of capsular contracture? 6. ****🔥** [****Recommended Articles of the Week**](https://www.theplasticsfella.com/july-28th/#articles-of-the-week) How to examine the breast & more! 3 articles with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/july-28th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella What are the top 3 plastic surgery resources? 👋 ****Hey everyone!** Let’s talk resources —what makes them truly great? Are we too attached to old favorites, or are new platforms the way to go? Time to challenge some norms. 👇 ### Tell me what you think! Before I dive in👇 ### We're dealing with three main categories: **traditional** (journals, textbooks), **digital** (online platforms, social media), and **face-to-face** (workplace learning, conferences). Let's unpack these: ### **Traditional: Journals & Textbooks** Are we hooked on these because they're the best, or just because they're familiar? While journals like 'Plastic and Reconstructive Surgery' cater to niche specialties, **PRS CME articles** hit the mark with practical, relevant content. Textbooks, thorough as they are, often end up as more decorative than useful. Remember, any textbook is good—if you actually read it. ❤️ My favourite: [Key Notes on Plastic Surgery ](https://www.theplasticsfella.com/key-notes-on-plastic-surgery-book-review/) ### **Digital: Online Platforms & Social Media** The digital world is buzzing. How do you sift through the digital clutter to find gems that truly enhance your skills? But are we learning, or just scrolling through "surgery porn"? Platforms like Twitter/X foster real-time, meaningful discussions, while **Instagram** tends to showcase life highlights rather than practical lessons like the 'zones of the hand.' ❤️ My favourite: Twitter (here's me getting heat for "[piecrusting](https://x.com/PlasticsFella/status/1771588869781164442?ref=theplasticsfella.com)" opinion) ### **Face-to-Face: Conferences, Courses** Direct interactions offer unmatched learning opportunities. Yet, how often do conferences go beyond networking, and do those intensive courses make a lasting impact? Nothing (obviously) will ever replace the **work environment** for clinical experience. ❤️ My favourite: A well-designed course (when I'm ****already** familiar with the surgery/theory; it's just fine-tuning.). ### I'll dive deeper into my top 3 resources and discuss this in an upcoming episode of [Behind the 'Fella](https://www.theplasticsfella.com/behind-the-fella-podcast/). ### P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Breast Augmentation** *?* ****Are you ready to make it to the leaderboard?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![Overview of Breast Augmentation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--94--2.png) Overview of Breast Augmentation ## New Feature: “Lessons” **The "How to" Guides for Plastic Surgery* ### We are brainstorming this new concept called "Lessons," a new educational tool offering concise, step-by-step guides for specific plastic surgery topics. Forget the hassle of navigating through the library, cases, or other resources. With "Lessons," you'll receive guided, hands-on instructions, making learning seamless and efficient. It's like having a mentor by your side, every step of the way. Here's an example 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Screenshot-2024-07-27-at-20.57.31-1.png) ### Help us design this new feature 👇 ## the Fellows' Corner **This Week's Focus: Tuberous Breast Deformity* In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our clinical case on **Tuberous Breast Deformity**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Tuberous-Breast-Deformity.png) #### Tuberous Breast Deformity [****Definition**](https://www.theplasticsfella.com/tuberous-breast-deformity/#definition-of-tuberous-breasts) A congenital deformity characterized by constricted, elevated, herniated, and hypoplastic features, while maintaining normal function. [****Clinical Features**](https://www.theplasticsfella.com/tuberous-breast-deformity/#clinical-features-of-tuberous-breasts) Features vary widely, commonly including asymmetry, hypoplasia, constricted base, IMF elevation, herniated nipple, ptosis, and skin envelope insufficiency. [****Classification**](https://www.theplasticsfella.com/tuberous-breast-deformity/#classification-of-tuberous-breasts) Von Heimburg's 1996 system is crucial for assessing the condition, emphasizing the identification of specific affected areas to inform surgical strategies. [****Surgical Management** ](https://www.theplasticsfella.com/tuberous-breast-deformity/#surgery-for-tuberous-breasts) Aims to release constrictions, restore volume, reposition the inframammary fold, and achieve symmetry, involving techniques like periareolar incisions, radial scoring, and dual-plane pocket creation. [Read the Article](https://www.theplasticsfella.com/tuberous-breast-deformity/) ## What Does the Evidence Say? **Causes of Capsular Contracture* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Capsular contracture is the most common complication following breast implant surgery, with an overall incidence of **10.6%** (Headon et al., 2015). Several **risk factors** have been identified, including smooth implant surfaces, subglandular placement, silicone-filled implants, and previous radiotherapy (Headon et al., 2015; Bachour et al., 2018). **Subclinical bacterial infection**, particularly with Staphylococcus epidermidis, may play a role in capsular contracture development (Shah et al., 1981; Adams, 2009; Bachour et al., 2017). The immune system's response to implants is also implicated, with macrophages often associated with contracture (Bachour et al., 2017). Other factors such as implant size, incision site, and postoperative care may also influence contracture rates (Calobrace et al., 2018). Preventive measures include precise surgical techniques, antibiotic irrigation, and minimizing contamination (Adams, 2009). Despite advances in understanding and prevention, capsular contracture remains a significant challenge in breast implant surgery (Luvsannyam et al., 2020; Steiert et al., 2013). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* 1️⃣ ***How to minimize the risks of breast augmentation in 5 minutes** ([Tebbetts](https://pubmed.ncbi.nlm.nih.gov/16327616/?ref=theplasticsfella.com), 2005) The "High Five" decision in breast augmentation covers the preoperative assessment and planning into five critical decisions using five key measurements, all within five minutes. 2️⃣ ***Direct-to-implant vs tissue expander placement in immediate breast reconstruction** ([Chiang](https://academic.oup.com/asj/article-abstract/44/8/839/7624033?redirectedFrom=fulltext&ref=theplasticsfella.com), 2024) Discover the comparative outcomes of direct-to-implant (DTI) versus tissue expander (TE) placement in immediate breast reconstruction post-mastectomy. 3️⃣ ****Predicting the cup size after reduction mammaplasty** ([Turner](https://www.jprasurg.com/article/S0007-1226%2804%2900338-8/fulltext?ref=theplasticsfella.com), 2005) Explore advancements in predicting postoperative cup size after reduction mammaplasty and measurement techniques that improve the accuracy of predicting breast tissue reduction. ## Feedback ### I hope you enjoyed it 😄 --- ### Congenital Brachial Plexus Palsy: Anatomy, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/congenital-brachial-plexus-palsy/ Last updated: 2024-07-26T14:45:30.000Z #### Summary Card [****Aeitology**](https://www.theplasticsfella.com/congenital-brachial-plexus-palsy/#aetiology-of-congenital-brachial-plexus-palsy) Congenital brachial plexus palsy is reduced movement in the upper limb, most often thought to be secondary to traction during the birthing process. [****Anatomy**](https://www.theplasticsfella.com/congenital-brachial-plexus-palsy/#anatomy-of-the-brachial-plexus) Arising from C5 - T1 of the spinal cord, the brachial plexus has 5 main terminal branches; musculocutaneous, median, ulnar, axillary, and radial. [****Presentation**](https://www.theplasticsfella.com/congenital-brachial-plexus-palsy/#presentation-of-congenital-brachial-plexus-palsy) A flaccid upper limb at birth, with or without Horner’s syndrome. Joint creases are present. [****Classification**](https://www.theplasticsfella.com/congenital-brachial-plexus-palsy/#classification-of-congenital-brachial-plexus-palsy) Nerve injury severity is graded by the Seddon and Sunderland classification. The extent of obstetric brachial plexus palsy is classified by Narakas. [****Scoring Systems**](https://www.theplasticsfella.com/congenital-brachial-plexus-palsy/#scoring-systems) Outcome measures like the Brachial Plexus Outcome Measure, Mallet Score, and Toronto Test Score help evaluate and track progress over time. [****Investigations**](https://www.theplasticsfella.com/congenital-brachial-plexus-palsy/#investigations-for-congenital-brachial-plexus-palsy) Non-invasive imaging and electrophysiology are useful adjuncts, but surgical exploration is currently the most specific investigation. [****Multidisciplinary Management**](https://www.theplasticsfella.com/congenital-brachial-plexus-palsy/#management-of-congenital-brachial-plexus-palsy) Dedicated multidisciplinary management improves outcomes. Early surgical exploration is advised for complete injuries or if biceps function fails to return in 3 months. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. ****Please note:** Obstetric brachial plexus injury, used synonymously with congeital brachial plexus palsy, implies causation. --- ## Aetiology of Congenital Brachial Plexus Palsy ****Key Point** Congenital brachial plexus palsy is reduced movement in the upper limb, most often thought to be secondary to traction during the birthing process. Congenital brachial plexus palsy is a **flaccid paralysis of the arm at birth**, where the passive range of movement is greater than the active ([Evans-Jones](https://fn.bmj.com/content/fetalneonatal/88/3/F185.full.pdf?casa%5Ftoken=SPZpa8VzpSQAAAAA:%5FrXVUYql4BlYF9sWjTDSpbFOdNVvN2DKJKUm2BLty46v5-TH7lCJ2gyCGdlzKTTcBJEay2suK41o&ref=theplasticsfella.com), 2003). It can arise after both **vaginal** and **cesarean** deliveries due to: - Excessive head traction away from the shoulder during labor. - Pubic traction or fetal malposition, even without dystocia ([Doumouchtsis](https://pubmed.ncbi.nlm.nih.gov/19691859/?ref=theplasticsfella.com), 2009) - Birth hypoxia, indicating a multifactorial etiology ([DeFrancesco](https://pubmed.ncbi.nlm.nih.gov/29016426/?ref=theplasticsfella.com), 2019). Risk factors for this condition can be maternal, fetal, or at delivery. - **Maternal:** Diabetes, Primigravida (first-time mother), Black & Hispanic race - **Fetal:** Macrosomia, Female sex ([DeFrancesco](https://pubmed.ncbi.nlm.nih.gov/29016426/?ref=theplasticsfella.com), 2019) - **Delivery**: Shoulder dystocia, Low Apgar scores, Birth hypoxia ### 😎 ****Fun Fact:** The first description of obstetric brachial plexus palsy is attributed to William Smellie, of Lanark, Scotland in 1764 ([Smellie](https://books.google.co.uk/books?id=jmc2AQAAMAAJ&dq=Smellie+W+Collection+of+Preternatural+Cases+and+Observations+in+Midwifery+1764+3+London+Wilson+and+Durham+&lr=&source=gbs%5Fnavlinks%5Fs), 1764). --- ## Anatomy of the Brachial Plexus ****Key Point** The brachial plexus arises from C5 - T1 of the spinal cord. It has 5 main terminal branches; musculocutaneous, median, ulnar, axillary, and radial. The brachial plexus originates from roots C5 to T1, potentially extending from C4 to T2, and forms a key sensory and motor network connecting the upper limb to the central nervous system. It is organized into **roots**, **trunks**, **divisions**, **cords**, and **branches**. ![Anatomy of the brachial plexus, Congenital brachial plexus palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--60-.png) Anatomy of the left brachial plexus ### Roots Located at the dorsal root ganglion for sensory neurons and anterior horn of the spinal cord for motor neurons; exit behind the vertebral artery. ### Trunks & Divisions Merge from roots passing between the anterior and middle scalene muscles—C5 and C6 (upper trunk), C7 (middle trunk), C8 and T1 (lower trunk). Each trunk splits into **anterior** and **posterior** **divisions**. ### Cords Cords are named for their position relative to the axillary artery, extending from over the first rib under the clavicle: - **Lateral Cord:** Originates from anterior divisions of the upper and middle trunks, leading to the lateral pectoral nerve (C5-C7). - **Medial Cord:** Emerges from the anterior division of the lower trunk, connecting to the medial pectoral, medial brachial cutaneous, and medial antebrachial cutaneous nerves (C8, T1). - **Posterior Cord:** Formed by the posterior divisions of all trunks, it gives rise to subscapular and thoracodorsal nerves (C5-C8). ![Anatomy of the brachial plexus, Congenital brachial plexus palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--61-.png) Brachial plexus - roots, trunks, divisions, cords and branches ### **Terminal Branches** Each cord supplies nerves to specific regions of the upper limb. - **Lateral Cord:** Musculocutaneous nerve. - **Medial Cord:** Ulnar nerve. - **Posterior Cord:** Radial and axillary nerves. - **Combined Contribution:** Median nerve from both lateral and medial cords. --- ## Presentation of Congenital Brachial Plexus Palsy ****Key Point** A flaccid upper limb at birth, with or without Horner’s syndrome. Joint creases are present. Erb's palsy is the most common. The presentation of congenital brachial plexus palsy at birth may include a **flaccid** upper limb, **with or without Horner’s syndrom**e. A temporal examination is important to determine the severity and the resolution. Most cases are noticed immediately following delivery and may be transient or permanent depending on the severity of injury. 💡 ****Tip:** Horner’s syndrome is ptosis, miosis, and anhidrosis due to damage of the sympathetic stellate ganglion. ### Erb's Palsy Erb’s Palsy, named after the German neurologist who first described it in 1874, primarily affects the upper plexus (C5, C6) and results in a “waiter's tip” posture. - **Shoulder:** Abducted and internally rotated, affected by weakened abductors, latissimus dorsi, and pectoralis muscles. - **Elbow:** Extended from biceps weakness with unopposed triceps action. - **Forearm:** Pronated due to weakness in supination. - **Wrist:** Flexed because of extensor weakness. Importantly, normal creases are present, indicating movement occurred in utero. This is illustrated in the image below. ![Presentation of Erb's palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--96-.png) Presentation of Erb's palsy 😎 ****Fun Fact:** Erb’s palsy is often used as a term to describe all congenital brachial plexus palsies but in fact, describes the most common clinical presentation of C5 and C6 nerve root injury. ### Other Manifestations - **Phrenic Nerve Involvement (C3, C4, C5):** Can lead to respiratory symptoms or might only be detected via chest X-ray. - **Pan-Plexus Injury:** Affects the entire plexus, resulting in a limp arm and possibly Horner’s syndrome if the stellate ganglion (near T1) is impacted. - **Klumpke’s Paralysis (C7, C8, T1):** Noted for adequate shoulder control but limited wrist movement and diminished fine motor skills in the hand, making it the rarest type in birth-related injuries. ### Differential Diagnosis The most common differential diagnoses for pseudoparalysis are secondary to fractures (humerus or clavicle) and arthrogryposis (characterized by the absence of skin creases). Other potential differentials include: - Spinal cord lesion - Cerebral palsy - Glenohumeral joint sepsis - Infective plexopathy - Radial nerve injury (usually self-limiting) - Biceps trauma (very rare) 😎 ****Fun Fact:** ****Spontaneous recovery** may occur but is usually incomplete, especially in children where the lower roots are involved. --- ## Classification of Congenital Brachial Plexus Palsy ****Key Point** Nerve injury severity is graded by the Seddon and Sunderland classification. The extent of obstetric brachial plexus palsy is classified by Narakas. ### Classic Classifications **Seddon** and **Sunderland** classified nerve injury according to the degree of structural damage. Grade 3-5 injuries (axonotmesis and neurotmesis) will not recover fully and operative intervention is indicated. **MacKinnon** added a sixth grade, to include the coexistence of mixed grades of injury within a scarred nerve. This is detailed in the image below. ![characteristics of Seddon and Sunderland classifications, Congenital Brachial Plexus Palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--59-.png) Characteristics of Seddon and Sunderland classifications ### **Narakas classification** This classification is widely used to describe the extent of congenital brachial plexus injury. - **Grade 1 (C5, C6):** Lack of shoulder abduction, elbow flexion, forearm supination. (80% spontaneous recovery) - **Grade 2 (C5, C6, C7):** Also includes lack of wrist extension. (60% spontaneous recovery) - **Grade 3:** Pan-plexus with complete flaccid paralysis. (< 50% spontaneous recovery) - **Grade 4:** Pan-plexus with complete flaccid paralysis and Horner’s syndrome. (< 50% spontaneous recovery) 💡 ****Tip:** In Narakas 2 palsy, the most common birth palsy, patients have a "good hand" whose usefulness is limited by lack of shoulder motion. --- ## **S**coring Systems ## ****Key Point** Outcome measures like the Brachial Plexus Outcome Measure, Mallet Score, and Toronto Test Score help evaluate and track progress over time. Outcome measures help evaluate and track progress over time. Key systems include [Brachial Plexus Outcome Measure](https://www.brachialplexus.scot.nhs.uk/documents/Brachial%20Plexus%20Outcome%20Measure%20%28BPOM%29.pdf?ref=theplasticsfella.com), Mallet Score ([Al Quattan](https://pubmed.ncbi.nlm.nih.gov/24527447/?ref=theplasticsfella.com), 2024) and Toronto Test Score ([Michelow](https://pubmed.ncbi.nlm.nih.gov/8134425/?ref=theplasticsfella.com), 1994) The Mallet Score is visualised below. ![The Mallet score in outcome measures of congenital brachial plexus palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--62-.png) The Mallet score in outcome measures of congenital brachial plexus palsy ### Toronto Score This evaluates active joint movements against gravity to determine the need for surgery: - **Measurements:** Elbow flexion/extension, wrist/finger/thumb extension. - **Scoring:** 0 (no motion) to 2 (full motion), max score 10. - **Indicator:** <3.5 at 3 months post-injury suggests surgical exploration. 😎 ****Fun Fact:** [Tassin](https://scholar.google.com/scholar?q=Tassin%20JL.%20Paralysies%20obst%C3%A9tricales%20du%20plexus%20brachial%2C%20%C3%A9volution%20spontan%C3%A9e%2C%20r%C3%A9sultats%20des%20interventions%20r%C3%A9paratrices.%20Th%C3%A8se%2C%20Universit%C3%A9%20Paris%20VIII.%201983.&ref=theplasticsfella.com), and [Gilbert](https://pubmed.ncbi.nlm.nih.gov/18313907/?ref=theplasticsfella.com) show that functional recovery within 3 months predicts further functional return. Thus, lack of elbow flexion by 3 months suggests the need for surgical exploration and repair (Kay, 1999). ([Kay](https://pubmed.ncbi.nlm.nih.gov/10466658/?ref=theplasticsfella.com), 1999). --- ## Investigations for Congenital Brachial Plexus Palsy ### ****Key Point** Surgical exploration is the most definitive method for investigation, although non-invasive imaging and electrophysiology can also provide valuable insights. Primarily diagnosed clinically, with prognosis and surgical decisions supported by investigations. Surgical exploration is the most thorough assessment method. **Diagnostic Imaging** - **X-ray:** Detects fractures or a raised hemidiaphragm. - **Ultrasound:** Assesses shoulder joint alignment. - **MRI:** - **T2-Weighted:** Identifies nerve avulsions. - **Diffusion Tract Imaging (dTI):** Analyzes nerve microstructure. **Intraoperative Electrophysiology** Stimulates muscles and detects sensory-evoked action potentials, enabling precise nerve function mapping during surgery. 😎 ****Fun Fact:** Combining clinical evaluation of the phrenic nerve, nerve to serratus anterior, Tinel-Hoffman sign, Horner’s syndrome, and MRI increases diagnostic accuracy to 89%, compared to 80% with MRI alone for root avulsion. ([Echalier](https://pubmed.ncbi.nlm.nih.gov/31185314/?ref=theplasticsfella.com), 2019). --- ## Management of Congenital Brachial Plexus Palsy ****Key Point** Early surgical exploration is recommended for complete injuries or if biceps function does not return within 3 months, involving procedures like nerve reconstruction, neurolysis, grafting, transfers, osteotomies, and fusion. Treatment for congenital brachial plexus palsy requires a **multidisciplinary team** including surgeons, nurses, physiotherapists, occupational therapists, psychologists, and orthotists. Surgery options include: - **Early** Surgery: Directed at reconstructing the nerve injury. - **Late** Surgery: Optimising function and correcting deformity. ### **Early Surgery** Early surgery focuses on nerve reconstruction. It is **indicated** in the following circumstances: - Biceps function does not return by 3 months. - Toronto test score below 3.5 at 3 months. - Complete lesion (Narakas 4) with no recovery signs. - Poor shoulder and forearm function at 9 months, despite some elbow function recovery ([Argenta](https://pdf.sciencedirectassets.com/273464/1-s2.0-S1748681516X00058/1-s2.0-S1748681516000048/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjENb%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJGMEQCIHBmGJlTYRJBi3HiyLsROg0ckST0hpPMv55Azr15XWfTAiA7oISTDzaLwxSCEoc4JPwGaY7glQVA%2Frfi9O%2FLRhqCOCqzBQh%2BEAUaDDA1OTAwMzU0Njg2NSIM2QqLhIjjR%2BRRnK2jKpAF3EmbNposjrnvrLYR228txl5ONyEiu7s3Jn5dJ62pL2WALBsXcRBv684oTu2STRSXtT5GlXLOOMwOBHYnDzGPkd1OfUwHbNDic63ksgn5QiTsUImnNFPn%2FJLg%2FWvaQiR4Pafny0VWafBFH12OECoIC23ty98O8zV5Z5xb4axbVx8nEll58Hg9Q8McyZXIvp2N0KFhTvcRZpN0Y5N%2FyNYtv%2BUTkinmPg1XB05mj73%2BCfs7yu3EW9%2FlAYn8rhReQ%2FM%2B%2BwL09HMtikZ4dhKc4XykCOeWjHeU%2Bm8Im4Dkk2dIWqePVF3z%2BOrFzGlnhxwPn6acua0ulWLLQ4fsGi5dSftI0ADxxmMDLqU6iKmIu96fASXwoGGd9nftTap2QlGI2pk75bZeYdYFbS%2Fm1hWo1TBsZHP4cl7uRtUX6ix82RXRc2wyzn1N8PQEjCop6FEL6uB2YL%2B5nduK0j743I6QWhwcOaVnXUqZ9x5LBBSjsTV4L3ZDyHdeESQRKIzsHOA%2BPvvcjhwzdTx%2Bn0ArdTqDNUzGv8%2FCJ38r5kMlTias1ioyAjZ94HURzEIvS07x0Wbjeq8jSDyRQdvVeHCHZ2UAmqjsrGDdoBtt%2BbL4qJY%2Bo94%2BHBvcxSYEY8NxhyOcU6iVbLuM0eP91VKZZ%2FVT6RstMdTd1gBpv0kKmPEFSuh7JSg7%2FCtWidEsHkif0OiL67H7Tm%2FY2BAGS%2FqL%2Bl8T1PADfnYDpkhBNBi2TMkN8WizTZd6JHHJK1sM%2FOtfcI8xskgzJLEi%2Fuu5snlQXbxCdVTkwAe51Vcm2IwaRWKmZ%2FjTBJJo1gZmxc6NvkZlvW%2BU%2BtGpYPyDh%2FNRjQgpm37ZccPHzIuP9H%2BOnHorr9DLtYNkoRtx3JswnvncswY6sgE8dX1X78d8Aa4WUNAU0jOkSsqVcDhNw31w3f1CsQnq9cCzdDLfh1XhYX%2Fs27eHh8JND0iobRhH5b4EGQWfDS8xa%2BSbtdli9bYwi9qZa2IbRpvwEVmIBZI4juR%2FuCvig2XKqqg3DCbwnv8TeIMtObrV0kTch8G7aP1%2B0QN2idqoDORmr0RHNZL7E0BYkKcPKbEVqvbbErWrB5VQD4TwGbsz%2BnY5e9b78p5QMntpGW24zaXV&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20240622T215133Z&X-Amz-SignedHeaders=host&X-Amz-Expires=300&X-Amz-Credential=ASIAQ3PHCVTY2RZCZAUM%2F20240622%2Fus-east-1%2Fs3%2Faws4%5Frequest&X-Amz-Signature=69c9d2a8a7608ec028f7567f0dce417e8a7cfa8eea7bc51cfaadbb66c2b1fead&hash=ffe935165e7b5e7c626d5f91be67d32232cbec338ee8bf866121612cf0ad482e&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=S1748681516000048&tid=spdf-8355187b-b325-47a3-b1d3-b9a61afa0bde&sid=204557e6190220457f3b5df823e35763b0c5gxrqb&type=client&tsoh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&ua=010d5e5e57035154045d&rr=897f75d80ade6aaa&cc=gb&ref=theplasticsfella.com), 2016). Nerve reconstruction is not recommended over 2 years post-injury due to muscle atrophy; muscle and tendon transfers are the preferred treatment. The **goal** of early surgical exploration is to: - Define the nerve injury - Provide neurolysis - Reconstruct nerve defect - sural nerve grafts or nerve transfers - Optimise sensory return - important for central nervous system programming 😎 ****Fun Fact:** Evidence supports early nerve repair for neuroprotection and better outcomes, with surgery ideally performed between 3-6 months. ([Bourke](https://pubmed.ncbi.nlm.nih.gov/28950736/?ref=theplasticsfella.com), 2018, [Birch](https://pubmed.ncbi.nlm.nih.gov/25005560/?ref=theplasticsfella.com), 2015) ### **Nerve Transfers** Nerve transfers are used primarily for root avulsions when nerve grafting isn't feasible. The most frequently employed early transfer is the spinal accessory to suprascapular nerve transfer for shoulder stabilisation. There are two main types: **Intra-Plexal Transfers:** - Nerve to flexor carpi ulnaris (from ulnar) and nerve to flexor carpi radialis (from the median) to biceps and brachialis branches of musculocutaneous (Oberlin/MacKinnon transfer). - Medial pectoral to musculocutaneous (Brandt and MacKinnon). - Triceps branch to axillary nerve (Leechongavong). **Extra-Plexal Transfers:** - Intercostal to musculocutaneous. - Contralateral C7 transfer, often performed endoscopically. - Supraclavicular C4 sensory nerves to C6, 7, and 8 stumps, if grafting is not possible - aims to restore C6 thumb and index finger sensation. - Phrenic nerve transfer is less common due to its impact on respiratory function. Nerve transfers can also be used to manage shoulder external rotation and elbow flexion deficiency at 12-18 months if there are sufficient donor nerves available to cover all targets (C5-C6 injuries) ([Tse](https://pubmed.ncbi.nlm.nih.gov/25936735/?ref=theplasticsfella.com), 2015). 💡 ****Tip:** Increasingly, Botox is used early to target internal muscle rotators and reduce the risk of glenohumeral subluxation, complementing surgery, or serial casting *(*[**Grahn*](https://pubmed.ncbi.nlm.nih.gov/37503533/?ref=theplasticsfella.com)**, 2023).* ### Muscle and Tendon Transfers Muscle and tendon transfers correct deformities such as shoulder abduction, internal rotation, elbow flexion, forearm supination, wrist flexion, and ulnar deviation with specific corrective strategies. - **Shoulder:** Subscapularis release, L’episcipo anterior release, teres major transposition, and rotator cuff/deltoid muscle transfers ([Elhassan](https://pubmed.ncbi.nlm.nih.gov/20610066/?ref=theplasticsfella.com), 2010). - **Elbow:** Elbow deformity correction involves anterior capsule release, biceps lengthening, Steindler flexorplasty, and muscle transfers including latissimus dorsi and pectoralis. For insufficient local muscle, gracilis transfer with intercostal nerves is used. ([Kay](https://pubmed.ncbi.nlm.nih.gov/19525160/?ref=theplasticsfella.com), 2010). - **Forearm:** Z-lengthening of the biceps for supination correction, FCU to brachioradialis transfer, and osteotomy for supination deformities ([Hamdi](https://pubmed.ncbi.nlm.nih.gov/36002839/?ref=theplasticsfella.com), 2022) - **Wrist:** FCU or FCR to ECRB, PQ to ECRB, and ECU to ECRB. - **MCPJ and IPJ Extensions:** FCR and ECRL to EDC, distal EDC advancement, and lumbrical replacement by FDS. - **Thumb:** EIP to APB, FDS to EPL transfers --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Congenital Brachial Plexus Palsy:** Gained knowledge about the condition, including its definition, causes, and anatomical aspects. ****2\. Clinical Presentation:** Learned how the condition manifests at birth and the common forms it may take, such as Erb's palsy. ****3\. Diagnostic Approaches:** Understood the key diagnostic tools and techniques used to evaluate brachial plexus palsy. ****4\. Treatment Strategies:** Grasped the surgical and non-surgical management options available for treating the condition. --- ## Further Reading 1. Smellie W. Vol. 3\. London: Wilson and Durham; 1764\. [Collection of Preternatural Cases and Observations in Midwifery](https://books.google.co.uk/books?id=jmc2AQAAMAAJ&dq=Smellie+W+Collection+of+Preternatural+Cases+and+Observations+in+Midwifery+1764+3+London+Wilson+and+Durham+&lr=&source=gbs%5Fnavlinks%5Fs). 2. Evans-Jones G, Kay SP, Weindling AM, Cranny G, Ward A, Bradshaw A, Hernon C. [Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland](https://fn.bmj.com/content/fetalneonatal/88/3/F185.full.pdf?casa%5Ftoken=SPZpa8VzpSQAAAAA:%5FrXVUYql4BlYF9sWjTDSpbFOdNVvN2DKJKUm2BLty46v5-TH7lCJ2gyCGdlzKTTcBJEay2suK41o&ref=theplasticsfella.com). Arch Dis Child Fetal Neonatal Ed. 2003 May;88(3):F185-9\. doi: 10.1136/fn.88.3.f185\. PMID: 12719390; PMCID: PMC1721533. 3. Hardie CM, Bourke G, Salt E, Fort-Schaale A, Clark S, Wiberg M, Bains R. [Demographics and deprivation in obstetric brachial plexus palsy: a retrospective cohort study](https://pubmed.ncbi.nlm.nih.gov/37694876/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2024 May;49(5):570-575\. doi: 10.1177/17531934231196421\. Epub 2023 Sep 11\. PMID: 37694876. 4. Thomson SE, Ng NY, Riehle MO, Kingham PJ, Dahlin LB, Wiberg M, Hart AM. [Bioengineered nerve conduits and wraps for peripheral nerve repair of the upper limb](https://pubmed.ncbi.nlm.nih.gov/36477774/?ref=theplasticsfella.com). Cochrane Database Syst Rev. 2022 Dec 7;12(12):CD012574\. doi: 10.1002/14651858.CD012574.pub2\. PMID: 36477774; PMCID: PMC9728628. 5. Kay S, Pinder R, Wiper J, Hart A, Jones F, Yates A. [Microvascular free functioning gracilis transfer with nerve transfer to establish elbow flexion](https://pubmed.ncbi.nlm.nih.gov/36601858/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2010 Jul;63(7):1142-9\. doi: 10.1016/j.bjps.2009.05.021\. Epub 2009 Jun 13\. PMID: 19525160. 6. Gilbert A. La réparation du plexus brachial dans les lésions obstétricales du nouveau-né \[[Repair of the brachial plexus in the obstetrical lesions of the newborn](https://pubmed.ncbi.nlm.nih.gov/18313907/?ref=theplasticsfella.com)\]. Arch Pediatr. 2008 Mar;15(3):330-3\. French. doi: 10.1016/j.arcped.2007.12.008\. Epub 2008 Mar 3\. PMID: 18313907. 7. Birch R. [Timing of surgical reconstruction for closed traumatic injury to the supraclavicular brachial plexus](https://pubmed.ncbi.nlm.nih.gov/25005560/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2015 Jul;40(6):562-7\. doi: 10.1177/1753193414539865\. Epub 2014 Jul 8\. PMID: 25005560. 8. Doumouchtsis SK, Arulkumaran S. 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Epub 2015 May 1\. PMID: 25936735. ### Overview of Breast Augmentation: Implants, Surgery, & Complications URL: https://www.theplasticsfella.com/overview-of-breast-augmentation/ Last updated: 2024-11-21T16:42:36.000Z #### Summary Card [****Introduction**](https://www.theplasticsfella.com/overview-of-breast-augmentation/#introduction-to-breast-augmentation) Breast augmentation addresses cosmetic and reconstructive needs, with contraindications including unrealistic expectations, body dysmorphia, infections, cancer, and pregnancy/lactation. [****Implants** ](https://www.theplasticsfella.com/overview-of-breast-augmentation/#implants-for-breast-augmentation)Implants vary by composition (silicone vs. saline), surface (smooth vs. textured), and shape (round vs. anatomical), and implant selection can be based on patient desires, anatomy, and surgeon experience. [****Clinical Assessment**](https://www.theplasticsfella.com/overview-of-breast-augmentation/#clinical-assessment-for-breast-augmentation) A thorough aesthetic consultation for breast augmentation includes a detailed history, comprehensive breast examination, photographic documentation, and breast metrics. [****Surgical Incisions**](https://www.theplasticsfella.com/overview-of-breast-augmentation/#surgical-incisions-for-breast-augmentation) Breast augmentation involves selecting an incision at an inframammary, periareolar, or transaxillary site. [****Surgical Planes** ](https://www.theplasticsfella.com/overview-of-breast-augmentation/#surgical-planes-for-breast-augmentation) Implant pocket planes include subglandular, subfascial, subpectoral, or dual plane. [****Complications**](https://www.theplasticsfella.com/overview-of-breast-augmentation/#complications-of-breast-augmentation) Complications of breast augmentation, though rare, can include infection, hematoma, seroma, changes in nipple sensation, capsular contracture, implant leakage or rupture, asymmetry, implant migration, BIA-ALCL, and interference with breast cancer screening. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Introduction to Breast Augmentation ****Key Point** Breast augmentation is the surgical increase in breast volume, commonly with the use of implants, for cosmetic or reconstructive purposes. **Breast augmentation**, also known as augmentation mammoplasty, is defined as the surgical increase in breast volume. ### Indications The main indications for breast augmentation surgery are: - Cosmetic enhancement - Post-pregnancy volume loss - Asymmetry correction - Reconstructive purposes - Congenital anomalies (eg: tuberous breast deformity, Poland syndrome) ### Contraindications Certain conditions and factors contraindicate breast augmentation: - Unrealistic expectations - Body dysmorphia - Active infections - Breast cancer: untreated or active breast malignancy, ongoing oncological treatment - Pregnancy and lactation The most common form of breast augmentation is in the form of non-autologous breast implants. However, autologous fat transfer is another option where lower volumes of augmentation are desired. A combination of implant-based augmentation with lipofilling to mask implant edges has also been described ([Adams](https://journals.lww.com/plasreconsurg/abstract/2012/10000/breast%5Faugmentation.40.aspx?ref=theplasticsfella.com), 2012) --- ## Implants for Breast Augmentation ****Key Point** Silicone implants are the most commonly used worldwide, with their shape and surface attributes contributing to implant choice based on individual needs. Implants differ in their composition, surface characteristics, and shape, being utilised in different circumstances to achieve the desired result. - **Composition:** silicone implants vs saline implants - **Surface:** textured vs. smooth - **Shape:** round vs. anatomical The characteristics of implants with the advantages and disadvantages guiding implant choice are summarised in the table below ([Coombs](https://www.ccjm.org/sites/default/files/additional-assets/PDFs/86%5F2%5F111.pdf?ref=theplasticsfella.com), 2019). ![Characteristics of breast implants, breast augmentation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--56-.png) Characteristics of breast implants Selecting the right implant involves considering several factors. - **Patient's preference:** The desired size, shape, and projection. - **Patient's anatomy:** Breast analysis and accurate measurements. - **Surgeon's experience:** Surgeon's familiarity with different types of implants ([Adams](https://journals.lww.com/plasreconsurg/abstract/2016/11000/matching%5Fthe%5Fimplant%5Fto%5Fthe%5Fbreast%5F%5Fa%5Fsystematic.9.aspx?ref=theplasticsfella.com), 2016). - **Cost:** Payers (patient or health system’s) ability to afford the specific implant. --- ## Clinical Assessment for Breast Augmentation ****Key Point** A detailed history, physical examination, and breast metrics are vital for decision-making in breast augmentation surgery. An aesthetic consultation should be thorough, gathering all the useful information to aid in implant choice and surgical approach. ### History - Personal and familial history of breast disease and malignancy - Pregnancy history and family planning - Current and desired breast size - Up to date with cancer screening protocols ### Examination - Breast examination of all 4 quadrants and axillary tail - looking for masses, dimpling, NAC changes, or discharge - Skin quality - Chest wall and breast symmetry noting any changes in size, IMF, and NAC height. - Breast footprint – vertical and horizontal dimensions - BMI ### Breast Measurements - Sternal notch to nipple distance (SN-N) - Nipple to IMF distance (N-IMF) - Breast base width - Parenchymal coverage (pinch test) - Anterior pull skin stretch - length of the stretch from resting to maximal projection with pull at the edge of the areola - Parenchymal fill - the percentage of skin envelope filled by parenchyma ([Xi](https://doi.org/10.1007/s00266-014-0412-5?ref=theplasticsfella.com), 2014) Consider **imaging** (such as mammogram ± ultrasound), if not already performed as part of screening. 💡 ****Tip:** The ‘High-Five System’ is an objective algorithm for determining breast implant size based on standardised measurements and has reported excellent results and low complication rates. ([Tebbetts](https://journals.lww.com/plasreconsurg/abstract/2005/12000/five%5Fcritical%5Fdecisions%5Fin%5Fbreast%5Faugmentation.25.aspx?ref=theplasticsfella.com), 2006). --- ## Surgical Incisions for Breast Augmentation ****Key Point** There are various incision sites for breast augmentations. These include, but are not limited to inframammary, periareolar, or transaxillary. The surgical technique for breast augmentation requires selecting a suitable incision site and determining the optimal pocket plane for implant placement. Popular incision placements include: **Inframammary fold incision** - Well hidden scar - Allows great access and control of pocket dissection **Periareolar Incision** - Well hidden scar - Unlikely to cause sensory disturbance of the nipple compared to the inframammary technique - Contamination theory – ductal commensals more likely to cause biofilm and contracture The image below illustrates surgical incisions for breast augmentation. ![Surgical incisions for breast augmentation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--93-.png) Surgical incisions for breast augmentation The **transaxillary incision** is less commonly used. The benefit is that there is no scar on the breast. It is limited, however, by a difficult dissection and implant insertion. 😎 ****Fun Fact:** A transumbilical approach also exists but is not widely used as it involves blind dissection is limited to using saline implants, and is associated with less satisfactory outcomes. --- ## Surgical Planes for Breast Augmentation ****Key Point** A breast implant can be inserted/placed into the subglandular, subpectoral, subfascial, or dual plane. Pocket dissection and choosing the right plane for implant placement depend upon implant characteristics, surgeon preference, patient anatomy, and lifestyle. The implants can be inserted into a **single plane** or **dual plane**. ### Single Plane The most commonly used single pockets/plans are listed below. - **Subglandular:** Dissection and pocket development are deep to the breast gland but superficial to the pectoralis major muscle and fascia. - **Subfascial** dissection, lifting the pectoralis fascia but superficial to the pectoralis major. - **Subpectoral:** Dissection is deep to the pectoralis major muscle but superficial to the pectoralis minor. The image below illustrates the implant pocket for breast augmentation. ![Implant pocket in the subpectoral and subglandular plane](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--94--1.png) Implant pocket in the subpectoral and subglandular plane ### Dual Plane Dissection in both planes with the upper portion of the implant being covered by pectoralis major and the lower portion being subglandular. The extent of subglandular dissection depends on the degree of ptosis. 3 types of **dual-plane** approaches are described, depending on the extent of dissection: - **Type 1** involves releasing the muscle at IMF and is used when no ptosis exists. - **Type 2** involves releasing the muscle at IMF and subglandular dissection up to the lower border of NAC. - **Type 3** is similar to type 2 but subglandular dissection is taken up to the superior border of NAC. ### Comparison of Implant Location The advantages and disadvantages of each pocket plane are summarised in the table below ([Stutman](https://doi.org/10.1007/s00266-012-9918-x?ref=theplasticsfella.com), 2012): ![Advantages and disadvantages of pocket planes for breast augmentation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--57-.png) Advantages and disadvantages of each pocket plane --- ## Complications of Breast Augmentation ****Key Point** Similar to any cosmetic procedure, complications may be implant-related, requiring revision surgery, or more serious complications such as BIA-ALCL. ### General Complications Complications are rare but can lead to unsatisfactory aesthetic results and potential medical morbidity ([Bengtson](https://www.sciencedirect.com/science/article/abs/pii/S0094129808000850?ref=theplasticsfella.com), 2009). These can relate to soft tissue and implant issues. More specifically: - **Cosmetic**: Asymmetry, scar hypertrophy/keloid. - **Soft Tissue:** infection, wound dehiscence, haematoma and seroma, changes in nipple sensation. - **Implant**: infection, leakage or rupture, implant rotation, double bubble deformity. ### Specific Complications **Capsular Contracture** This was classified by Baker into 4 grades depending upon the palpability and visibility of an implant ([Baker](https://journals.lww.com/plasreconsurg/abstract/1995/10000/classification%5Fof%5Fcapsular%5Fcontracture%5Fafter.18.aspx?ref=theplasticsfella.com), 1995). - **Grade I:** Breast is soft and appears natural. - **Grade II:** Breast is firm with implant palpable but not visible. - **Grade III:** Breast is firm, with implant palpable and visible. - **Grade IV:** Breast is hard, painful, and distorted. **Breast Implant-ALCL (BIA-ALCL)** This is a rare type of **T-cell lymphoma** that develops in the scar tissue and fluid surrounding breast implants, predominantly associated with textured implants. It typically presents as a late-onset seroma or palpable mass and requires prompt treatment with en bloc capsulectomy and implant removal. It is recommended that all late-onset seromas should be aspirated under ultrasound guidance, with mandatory cytology and CD30+ immunohistochemistry to rule out BIA-ALCL ([di Pompeo](https://www.jprasurg.com/article/S1748-6815%2818%2930133-5/fulltext?ref=theplasticsfella.com), 2018). It also interferes with c**ancer screening,** specifically subglandular implants To ensure accurate screening protocols, patients with subglandular implants should get an Eklund view in mammography apart from the standard views ([Sa dos Reis](https://link.springer.com/article/10.1186/s13244-019-0816-5?ref=theplasticsfella.com), 2020). **Breast Implant Illness** This is an emerging clinical condition with **inflammatory** and **autoimmune** symptoms. It is yet to be universally recognized as an accepted clinical entity. Common presenting symptoms include fatigue, anxiety, chronic pain, and endocrine, autonomic, and peripheral nervous system dysfunction. It currently has no standard of care or guideline, but the majority of affected patients have a bilateral implant explantation with an aim to relieve symptoms. ([Serena](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10208020/?ref=theplasticsfella.com), 2023) --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding of Breast Augmentation:** Gained insights into the surgical enhancement of breast volume, including cosmetic and reconstructive uses. ****2\. Clinical Assessment:** Understood the necessity of detailed pre-surgical consultations including history, physical examination, and measurements. ****3\. Surgical Techniques:** Learned about different surgical approaches and the importance of implant pocket placement. ****4\. Complications:** Recognized potential complications like infection, capsular contracture, and implant issues such as rupture. --- ## Further Reading 1. Adams, William P. Jr. M.D.; Mallucci, Patrick M.D. [Breast Augmentation. Plastic and Reconstructive Surgery](https://journals.lww.com/plasreconsurg/abstract/2012/10000/breast%5Faugmentation.40.aspx?ref=theplasticsfella.com) 130(4):p 597e-611e, October 2012\. | DOI: 10.1097/PRS.0b013e318262f607 2. Coombs, Demetrius M., et al. "[Breast augmentation surgery: Clinical considerations.](https://www.ccjm.org/sites/default/files/additional-assets/PDFs/86%5F2%5F111.pdf?ref=theplasticsfella.com)" Cleve Clin J Med 86.2 (2019): 111-122. 3. Adams, William P. Jr. M.D.; Mckee, Daniel M.D. [Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation](https://journals.lww.com/plasreconsurg/abstract/2016/11000/matching%5Fthe%5Fimplant%5Fto%5Fthe%5Fbreast%5F%5Fa%5Fsystematic.9.aspx?ref=theplasticsfella.com). Plastic and Reconstructive Surgery 138(5):p 987-994, November 2016\. | DOI: 10.1097/PRS.0000000000002623 4. Xi, W., Perdanasari, A.T., Ong, Y. et al. [Objective Breast Volume, Shape and Surface Area Assessment: A Systematic Review of Breast Measurement](https://doi.org/10.1007/s00266-014-0412-5?ref=theplasticsfella.com) https://doi.org/10.1007/s00266-014-0412-5 5. Tebbetts, John B., and William P. Adams. "[Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process.](https://journals.lww.com/plasreconsurg/abstract/2005/12000/five%5Fcritical%5Fdecisions%5Fin%5Fbreast%5Faugmentation.25.aspx?ref=theplasticsfella.com)" Plastic and reconstructive surgery 116.7 (2005). 6. Stutman, R.L., Codner, M., Mahoney, A. et al. [Comparison of Breast Augmentation Incisions and Common Complications](https://doi.org/10.1007/s00266-012-9918-x?ref=theplasticsfella.com). Aesth Plast Surg 36, 1096–1104 (2012). https://doi.org/10.1007/s00266-012-9918-x 7. Bengtson, Bradley P. "[Complications, reoperations, and revisions in breast augmentation.](https://www.sciencedirect.com/science/article/abs/pii/S0094129808000850?ref=theplasticsfella.com)" Clinics in plastic surgery 36.1 (2009): 139-156. 8. Sá dos Reis, Cláudia, Isabelle Gremion, and Nicole Richli Meystre. "[Study of breast implants mammography examinations for identification of suitable image quality criteria.](https://link.springer.com/article/10.1186/s13244-019-0816-5?ref=theplasticsfella.com)" Insights into imaging 11 (2020): 1-11. 9. Spear, Scott L., and James L. Baker Jr. "[Classification of capsular contracture after prosthetic breast reconstruction.](https://journals.lww.com/plasreconsurg/abstract/1995/10000/classification%5Fof%5Fcapsular%5Fcontracture%5Fafter.18.aspx?ref=theplasticsfella.com)" Plastic and reconstructive surgery 96.5 (1995): 1119-1123. 10. di Pompeo, Fabio Santanelli, and Michail Sorotos. "[EURAPS editorial: BIA-ALCL, a brief overview.](https://www.jprasurg.com/article/S1748-6815%2818%2930133-5/fulltext?ref=theplasticsfella.com)" Journal of Plastic, Reconstructive & Aesthetic Surgery 71.6 (2018): 785-787. 11. Serena TJ, Habib P, Derosa A. [Breast Implant Illness: A Cohort Study](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10208020/?ref=theplasticsfella.com). Cureus. 2023 Apr 24;15(4):e38056\. doi: 10.7759/cureus.38056\. PMID: 37228535; PMCID: PMC10208020. ### Giant Cell Tumours of the Tendon Sheath: Presentation, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/giant-cell-tumours-of-the-tendon-sheath/ Last updated: 2024-07-22T16:37:12.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/giant-cell-tumours-of-the-tendon-sheath/#definition-of-giant-cell-tumours-of-the-tendon-sheath) Giant Cell Tumours (GCTs) are nodular tumours found on the tendon sheath, commonly in the hands. [****Pathophysiology**](https://www.theplasticsfella.com/giant-cell-tumours-of-the-tendon-sheath/#pathophysiology-of-giant-cell-tumours-of-the-tendon-sheath) Previously thought to be inflammatory, GCTs are now considered a neoplastic process due to the discovery of a chromosomal abnormality in synovial cells expressing CSF1. [****Clinical Features**](https://www.theplasticsfella.com/giant-cell-tumours-of-the-tendon-sheath/#clinical-features-of-giant-cell-tumours-of-the-tendon-sheath) It is a slow-growing lesion with occasional pain or sensory disturbances. [****Investigations**](https://www.theplasticsfella.com/giant-cell-tumours-of-the-tendon-sheath/#investigations-of-giant-cell-tumours-of-the-tendon-sheath) Diagnosed through physical examination of a firm nodular mass that does not transilluminate. Imaging techniques such as X-ray, ultrasound, or MRI can be used for confirmation. [****Treatment**](https://www.theplasticsfella.com/giant-cell-tumours-of-the-tendon-sheath/#treatment-of-giant-cell-tumours-of-the-tendon-sheath) Treatment is through marginal surgical excision. Radiation and CSF receptor inhibitors can also be considered. [****Complications**](https://www.theplasticsfella.com/giant-cell-tumours-of-the-tendon-sheath/#complications-of-giant-cell-tumours-of-the-tendon-sheath) Recurrence is common, often due to incomplete resection. Factors increasing recurrence include tendon involvement, joint extension, and extracapsular spread. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Definition of Giant Cell Tumours of the Tendon Sheath ****Key Point** Giant Cell Tumours are nodular tumours commonly found on the tendon sheath, particularly in the hands. Giant cell tumour can also be referred to as tenosynovial giant cell tumours, localized nodular tenosynovitis, xanthoma, or Pigmented Villonodular Synovitis (PVS). They are the **second most common** soft-tissue tumour seen in the hand, following ganglion cysts. They are classified into **localised** or **diffuse** ([Somerhausen NSA](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=+Fletcher+DM%2C+Unni+KK%2C+Mertens+F%2C+editors.+Pa-+thology+and+genetics+of+tumours+of+soft+tissue+and+bone.+Lyon%3A+IARC+Press%3B+2002.+p.+110%E2%80%951.&btnG=&ref=theplasticsfella.com), 2002). - **Localized:** Clear boundaries. - **Diffuse:** tends to invade adjacent tissues with poorly defined margins, even when only a small area is involved ([Kitagawa](https://pubmed.ncbi.nlm.nih.gov/32350187/?ref=theplasticsfella.com), 2020). There are 2 types of tumours: - **Type I:** Single lesions, and are more frequently detected. - **Type II:** Two or more distinct tumours that are not joined together. The image below illustrates a giant cell tumour of the tendon sheath. ![Definition of a giant cell tumour of the tendon sheath](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--89-.png) Definition of a giant cell tumour of the tendon sheath ### 😎 ****Fun Fact:** Although rare, GCT can also occur in other parts of the body such as the spine, ankle, knee, and feet. --- ## Pathophysiology of Giant Cell Tumours of the Tendon Sheath ****Key Point** Giant cell tumours were once thought to be inflammatory, but are now considered neoplastic due to a discovered chromosomal abnormality in synovial cells expressing CSF1. Giant Cell Tumours (GCT) were initially believed to be caused by inflammation ([Reilley](https://pubmed.ncbi.nlm.nih.gov/10584957/?ref=theplasticsfella.com), 1999). However, they are now recognized as neoplastic due to a clonal chromosomal abnormality in synovial cells that express CSF1 (Kitagawa, 2020). **Pathogenesis** - Chromosomal**:** Clonal chromosomal abnormality in synovial cells. - CSF1 Gene Translocation**:** \~65 of patients with TSGCT ([Kitagawa](https://pubmed.ncbi.nlm.nih.gov/32350187/?ref=theplasticsfella.com), 2020). - Macrophages**:** CSF1 attracts macrophages, aiding tumour formation. **Cellular Characteristics** GCTs feature diverse cell types: - Lipid-laden foam cells - Multinucleated giant cells - Round or polygonal stromal cells - Hemosiderin deposits in a collagenous stroma ([Khurana](https://pubmed.ncbi.nlm.nih.gov/37881282/?ref=theplasticsfella.com), 2023) --- ## Clinical Features of Giant Cell Tumours of the Tendon Sheath ****Key Point** Diagnosis is through a physical exam of a firm nodular mass that does not transilluminate. It is a ****slow-growing** lesion with occasional pain or sensory disturbances. ### Classic Symptoms Giant Cell Tumours of the Tendon Sheath typically present in women between the ages of 30-50 with these distinct symptoms: - **Growth:** These tumours are typically painless and slow-growing, sometimes entering a dormant stage ([Kitagawa](https://pubmed.ncbi.nlm.nih.gov/32350187/?ref=theplasticsfella.com), 2020). - **Texture:** Firm and nodular. - **Transilluminate:** It does not transilluminate. - **Location:** Usually affects the tendon sheath, joint capsule, ligaments, tendons, palmar plate, and periosteum, but rarely the skin. Rarely, they involve extensor, lateral or circumferential areas. ([Khurana](https://pubmed.ncbi.nlm.nih.gov/37881282/?ref=theplasticsfella.com), 2023). - **Sensory Effects:** Sensory disturbances are rare (Fotiadis, 2011). The image below illustrates the clinical presentation of a Giant cell tumour. ![Clinical presentation of a Giant cell tumour of the tendon sheath](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--90-.png) Clinical presentation of a Giant cell tumour of the tendon sheath 😎 ****Fun Fact:** The most affected finger is the index finger ([Fotiadis](https://pubmed.ncbi.nlm.nih.gov/22942846/?ref=theplasticsfella.com), 2011). ### Differential Diagnosis The differential diagnoses for Giant Cell Tumours include: - **Ganglion cyst:** Common, non-cancerous lumps on tendons or joints. - **Desmoid tumour:** Rare, non-metastasizing fibrous tumours. - **Fibroma/Fibrosarcoma:** Benign or malignant fibrous tissue tumours. - **Glomangioma:** Benign vascular tumours causing pain. - **Foreign body granuloma:** Inflammatory reactions to foreign substances. - **Epidermoid cyst:** Benign cysts from the epidermis. - **Sebaceous gland cyst:** Benign cysts from blocked sebaceous glands. --- ## Investigations of Giant Cell Tumours of the Tendon Sheath ****Key Point** Investigations focus on pre-operative imaging (X-ray, ultrasound, or MRI) which can be confirmed histologically. When diagnosing Giant Cell Tumours (GCT), several imaging techniques are used to identify and characterize the tumour. - **X-ray:** - Reveals pressure-type bone erosion. - **Ultrasound:** - Shows a solid, homogeneous, hypoechoic mass, often related to the flexor tendons of the fingers. - Doppler studies indicate increased vascularity. - **MRI:** - **T1-weighted images:** Typically show isointense to slightly hyperintense signals compared to muscle. - **T2-weighted images:** Display heterogeneous signal intensity with a mix of high and low signals. - **Gadolinium contrast:** Highlights a contrast effect, enhancing visualization of the tumour. The image below illustrates an MRI of the finger. ![MRI of the finger sowing GCT of the finger. T1 image ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--87-.png) GCT on MRI - low T1 signal ### Histology Microscopically, all tumours contain multinucleated giant cells, histiocytes, and hemosiderin deposits. 😎 ****Fun Fact:** Differentiating between GCT and a ruptured ganglion cyst is difficult using an ultrasound. --- ## Treatment of Giant Cell Tumours of the Tendon Sheath ****Key Point** The main treatment is marginal surgical excision, with radiation therapy and CSF receptor inhibitors as additional options. Effective treatment of Giant Cell Tumours (GCT) of the tendon sheath is crucial for preserving hand function and preventing recurrence. The primary approach is surgical, with other therapies available for specific cases. ### Surgical Treatment Marginal excision is the primary treatment for Giant Cell Tumours of the tendon sheath. This surgical approach aims to remove the tumour while preserving hand function. **Procedure Tips:** - **Careful Resection:** The surgery should be performed cautiously, ideally under loupe magnification, to ensure precision. - **Pseudocapsule Presence:** GCTs often have a pseudocapsule with clear boundaries, which helps in identifying the tumour margins. - **Adhesion and Invasion:** Despite the clear boundaries, GCTs may partially adhere to or invade surrounding tissues, requiring meticulous surgical technique to avoid damage to adjacent structures. This is detailed in the video below. The main objectives are to achieve complete tumour excision and to maintain the function and neurovascular integrity of the affected digit. ### ### Other Treatments - **Radiation Therapy:** Occasionally recommended for progressive GCT cases, particularly those at risk of requiring amputation([Kitagawa](https://pubmed.ncbi.nlm.nih.gov/32350187/?ref=theplasticsfella.com), 2020). - **CSF Receptor Inhibitors:** May be considered in certain cases as part of the treatment plan. --- ## Complications of Giant Cell Tumours of the Tendon Sheath ****Key Point** Recurrence of GCT is common and often results from incomplete resection. Factors such as tendon involvement, joint extension, and extracapsular spread increase the risk of recurrence. Understanding the complications associated with Giant Cell Tumours (GCT) of the tendon sheath is crucial for effective treatment and management. Recurrence is a common issue, often due to incomplete resection. ### Recurrence Rates and Causes - **Reported Recurrence Rates:** Range from 5-50%. - **Main Cause of Recurrence:** Incomplete resection is the primary reason for tumour recurrence. ### Risk Factors for Recurrence - **Tendon and Joint Involvement:** Higher recurrence risk due to infiltration and joint spread. - **Type II Tumours:** Undetected satellite lesions cause incomplete excision. - **Primary Location:** Higher recurrence at DIPJ or thumb IPJ, especially with osteoarthritis or bone erosion. - **Neurovascular and Extracapsular Spread:** Increases recurrence risk and complicates resection. - **Piecemeal Resection:** Leads to incomplete removal and recurrence. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Tenosynovial Giant Cell Tumors (TSGCTs):** Gained a comprehensive understanding of the nature, classification, and epidemiology of TSGCTs. ****2\. Pathophysiology:** Learned about the shift in understanding from inflammatory to neoplastic nature of TSGCTs due to genetic discoveries, emphasizing the role of CSF1 in their development. ****3\. Diagnostic Techniques:** Reviewed the diagnostic process for TSGCTs, emphasizing the importance of physical examination, imaging modalities like X-ray, ultrasound, and MRI, and the role of histology in confirming the diagnosis. ****4\. Treatment Options:** Explored treatment methods including surgical excision, radiation therapy, and novel treatments like CSF1 receptor inhibitors. ****5\. Complications:** Discussed the common complications associated with TSGCTs, particularly recurrence, and factors that influence it. --- ## Further Reading 1. Fotiadis E, Papadopoulos A, Svarnas T, Akritopoulos P, Sachinis NP, Chalidis BE. [Giant cell tumour of tendon sheath of the digits. A systematic review](https://pubmed.ncbi.nlm.nih.gov/22942846/?ref=theplasticsfella.com). Hand (N Y). 2011 Sep;6(3):244-9\. doi: 10.1007/s11552-011-9341-9\. Epub 2011 Jun 1\. PMID: 22942846; PMCID: PMC3153624. 2. Reilly KE, Stern PJ, Dale JA. [Recurrent giant cell tumours of the tendon sheath](https://pubmed.ncbi.nlm.nih.gov/10584957/?ref=theplasticsfella.com). J Hand Surg Am. 1999 Nov;24(6):1298-302\. doi: 10.1053/jhsu.1999.1298\. PMID: 10584957. 3. Briët JP, Becker SJ, Oosterhoff TCh, Ring D. [Giant cell tumour of tendon sheath](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322119/?ref=theplasticsfella.com). Arch Bone Jt Surg. 2015 Jan;3(1):19-21\. Epub 2015 Jan 15\. PMID: 25692164; PMCID: PMC4322119. 4. Somerhausen NSA, Cin PD. [Giant cell tumour of tendon sheath](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=+Fletcher+DM%2C+Unni+KK%2C+Mertens+F%2C+editors.+Pa-+thology+and+genetics+of+tumours+of+soft+tissue+and+bone.+Lyon%3A+IARC+Press%3B+2002.+p.+110%E2%80%951.&btnG=&ref=theplasticsfella.com). In Fletcher, C.D., Unni, K.K. and Mertens, F. eds., 2002\. p. 110―1\. Pathology and genetics of tumours of soft tissue and bone(Vol. 4). Iarc. 5. Anderson WJ, Doyle LA. [Updates from the 2020 World Health Organization Classification of Soft Tissue and Bone Tumours](https://pubmed.ncbi.nlm.nih.gov/33438273/?ref=theplasticsfella.com). Histopathology. 2021 Apr;78(5):644-657\. doi: 10.1111/his.14265\. Epub 2021 Jan 12\. PMID: 33438273. 6. Kitagawa Y, Takai S. [Optimal Treatment for Tenosynovial Giant Cell tumour of the Hand](https://pubmed.ncbi.nlm.nih.gov/32350187/?ref=theplasticsfella.com). J Nippon Med Sch. 2020 Sep 9;87(4):184-190\. doi: 10.1272/jnms.JNMS.2020\_87-408\. Epub 2020 Apr 30\. PMID: 32350187. 7. Khurana A, Singh JP, Preeti, Littlefield Z, Young S, Shah A. [Demystifying Giant Cell Tumours of Tendon Sheath (GCTTS): A Case Series of 18 Cases with Review of Literature](https://pubmed.ncbi.nlm.nih.gov/37881282/?ref=theplasticsfella.com). Indian J Orthop. 2023 Sep 21;57(11):1858-1873\. doi: 10.1007/s43465-023-00990-8\. PMID: 37881282; PMCID: PMC10593659. ### Glomus Tumours - Clinical Scenario URL: https://www.theplasticsfella.com/glomus-tumours-clinical-scenario/ Last updated: 2024-09-04T17:08:50.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Clinical-Case-Main-Image--10--1.png) #### Clinical Scenario A 35-year-old female presents with severe, sharp, stabbing pain and tenderness in her left thumb, especially intense with cold exposure or pressure. The pain often wakes her at night. On examination, there is a small, bluish discolouration under the nail of the affected thumb. ****Objectives:** 1. Understand the classical presentation of a glomus tumour. 2. Describe the pathophysiology of a glomus tumour. 3. Provide a differential diagnosis for a painful digit swelling. 4. Outline the investigations indicated for a glomus tumour. 5. Discuss the treatment options available. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Toxic Quizzing, Sunday Quiz Round 1, Dupuytren's Management Tips. URL: https://www.theplasticsfella.com/july-21st/ Last updated: 2024-07-21T09:31:22.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-21st/#a-letter-from-pfella) Removing Toxic Quizzing in MedEd 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/july-21st/#the-sunday-quiz) How well do you know Pronator syndrome? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/july-21st/#behind-the-fella) Sneak peek from episode 03: All things research. 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/july-21st/#the-fellows-corner) Fresh drop: Clinical scenario of Dupuytren's disease. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-21st/#what-does-the-evidence-say) Management of PIPJ contractures in Dupuytren's disease. 6. ****🔥** [****Recommended Articles of the Week**](https://www.theplasticsfella.com/july-21st/#articles-of-the-week) Insights on Dupuytren contracture management; 3 articles with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/july-21st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella Toxic *Quizzing* 👋 ****Hey Team!** Today, I want to dive into a controversial topic that’s been sparking debates in medical education circles: toxic quizzing. You might know it by another name—“pimping,” “grilling,” or “teaching by humiliation.” 👇 No matter what you call it, the practice of "toxic quizzing" involves asking rapid-fire, difficult questions meant to induce stress and expose knowledge gaps. It's a method some educators swear by, but is it truly effective, or does it do more harm than good? **Some educators believe that increasing learner stress** can enhance learning, citing the Yerkes-Dodson law, which suggests performance improves with arousal up to a point, after which it declines. They argue that a bit of stress can motivate students to learn better and faster, summed up in the sentiment, “It worked for me, so it should work for you.” ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/599594-What-the-Yerkes-Dodson-Law-Says-About-Stress-and-Performance1296x728-header-body.20200921052900517-1296x985-1.webp) **But here’s the flip side: there’s scant evidence that toxic quizzing actually improves learning outcomes**. Studies show this method can demoralize students, create anxiety, and even lead some to regret their choice of profession. Imagine being a student, asked obscure eponyms related to plastic surgery, and being berated for not knowing the answers. This doesn’t foster a love for learning; it breeds resentment and fear This was detailed in the recent publication below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/GSFat9TbAAAsjwt-1.jpeg) ### So, What Should We Do Instead? Effective quizzing should foster a safe learning environment where students feel free to explore their knowledge boundaries without fear of humiliation. Here’s how: 1. **Clarify Your Intentions**: Let students know the purpose of questioning is to promote learning, not to assess their worth. 2. **Create Educational Safety**: Foster a nonjudgmental, supportive environment. Encourage students to say, “I don’t know,” and treat it as a starting point for learning. 3. **Use Open-Ended Questions**: Ask questions that stimulate critical thinking, like “Why do you think this bruising is happening?” or “How would you approach managing this condition?” 4. **Model Humility and Curiosity**: Show that learning is continuous. Ask questions you don’t know the answers to, and explore together. As educators, our goal should be to lift our learners up, not push them down. Yes, challenge them—**push them to think deeply and critically—but do so in a way that builds their confidence, not tears it down.** Looking forward to your thoughts and experiences on this topic. Lots of love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know* ***Pronator Syndrome** *?* ****Are you ready for a fresh round of The Weekly Quiz?** Welcome to ****the first round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--25-.png) Definition - Pronator Syndrome ## Behind the ‘Fella **Sneak Peek from Episode 03* 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. In our latest episode, we explore all things research! You can now listen on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /1:11 1× Listen now on [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) and [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)! If there's any specific discussion you're interested in, let us know below. ## the Fellows' Corner **This Week's Focus: Dupuytren's Disease* In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our clinical case on Dupuytren's Disease. #### Dupuytren's Disease ****Clinical Scenario** A 65-year-old male farmer presents with stiffness in the middle finger of his right hand, affecting his ability to grip objects and shake hands. He has uncontrolled diabetes on insulin, benign prostatic hyperplasia, and a history of carpal tunnel release 5 years ago. His father had similar hand problems but did not seek medical attention. ****Objectives:** ****1\.** Outline the clinical assessment of this patient. ****2\.** Knowledge of the fascial anatomy of the hand. ****3\.** Describe the management options available for Dupuytren’s disease. [Read the Article](https://www.theplasticsfella.com/dupuytrens-disease-clinical-scenario/) ## What Does the Evidence Say? **Management of PIPJ Contractures in Dupuytren's Disease* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Surgical management of proximal interphalangeal joint (PIPJ) contractures in Dupuytren's disease is challenging. While fasciectomy alone can improve contractures (Stepić et al., 2017), combining it with capsuloligamentous release may yield better outcomes for severe cases (Ritchie et al., 2004). However, some studies found no significant difference between fasciectomy alone and when combined with capsulotomy (Beyermann et al., 2002; Weinzweig et al., 1996). Collagenase injection has shown better outcomes for PIPJ contractures compared to surgical release (Povlsen & Povlsen, 2014), and ultrasound-guided aponeurotomy with capsular release demonstrated promising results (Villanueva et al., 2022). Factors affecting surgical outcomes include age, preoperative flexion, and number of prior procedures (Ghidella et al., 2002). A recent systematic review concluded that fasciectomy provides superior long-term outcomes compared to collagenase and needle fasciotomy (Nann et al., 2023). The optimal treatment approach may depend on individual patient factors and contracture severity. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* 1️⃣ ***Dupuytren contracture management: Best practices and innovations** ([Boe](https://www.jhandsurg.org/article/S0363-5023%2821%2900427-5/fulltext?ref=theplasticsfella.com#%20), 2021) Treating Dupuytren contractures, including the increased use of collagenase Clostridium histolyticum (CCH), alongside traditional methods like needle aponeurotomy (NA) and surgical fasciectomy. 2️⃣ ***Updated algorithm for managing Dupuytren's contracture** ([Mella](https://pubmed.ncbi.nlm.nih.gov/30161050/?ref=theplasticsfella.com), 2018) When to use different maangement techniques? An algorithm for traditional open fasciotomy or fasciectomy and modern, collagenase and needle aponeurotomy (PNA). 3️⃣ ***Tips and tricks for treating Dupuytren's contracture** ([Denkler](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8849405/?ref=theplasticsfella.com), 2022) Discover comprehensive management strategies for Dupuytren's disease highlighting the benefits and limitations of various treatments, practical tips for surgical management, and an algorithm for treatment selection. ## Feedback ### I hope you enjoyed it 😄 --- ### Glomus Tumours: Pathology, Diagnosis, & Management URL: https://www.theplasticsfella.com/glomus-tumours/ Last updated: 2024-08-01T16:31:23.000Z #### Summary Card [****Definition** ](https://www.theplasticsfella.com/glomus-tumours/#definition-of-glomus-tumours)A glomus tumour is a benign lesion from glomus cells in the Sucquet-Hoyer canal, typically on the nail bed or palm. [****Classification**](https://www.theplasticsfella.com/glomus-tumours/#classification-of-glomus-tumours) The glomus body, aiding thermoregulation and common in the finger dermis, can develop benign hamartomas called glomus tumours. [****Diagnosis**](https://www.theplasticsfella.com/glomus-tumours/#diagnosis-of-glomus-tumours) A glomus tumour typically presents with fingertip pain, tenderness, cold sensitivity, and nail changes, diagnosed through clinical tests, imaging (US and MRI), and histology. [****Management**](https://www.theplasticsfella.com/glomus-tumours/#management-of-glomus-tumours) Complete excision of glomus tumours is advised for pain relief and to reduce recurrence; laser or sclerotherapy is recommended for multiple, inoperable lesions. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Glomus Tumours ****Key Point** Glomus tumour is a benign vascular neoplasm originating from the cells of the glomus body, a rich microvascular network of cells involved in thermoregulation. Glomus tumours are described as **benign hamartomas** of the glomus apparatus, originating from **modified smooth muscle cells** of the Sucquet-Hoyer canal ([Morey](https://www.sciencedirect.com/science/article/abs/pii/S0976566216300339?ref=theplasticsfella.com), 2016). Demographic analysis shows: - 1 to 5% of all hand tumours, usually in the subungual region. - More common in females. - Usually occurs between the 2nd-5th decade ([Trehan](https://doi.org/10.1177/1938640015583514?ref=theplasticsfella.com), 2015). Extradigital glomus tumours show equal distribution between the genders ([Chou](https://doi.org/10.1097/SAP.0000000000000684?ref=theplasticsfella.com), 2016). A glomus tumour is illustrated in the image below. ![Definition of a glomus tumour](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/08/Main-Article-Images---2024-08-01T220219.535-1.png) Definition of a glomus tumour 😎 ****Fun Fact:** The glomus body, in the finger's reticular dermis, regulates skin temperature and includes an afferent arteriole, Sucquet-Hoyer canal, primary collecting vein, and intraglomerular reticulum. --- ## Classification of Glomus Tumours ****Key Point** The WHO classifies glomus tumors into three types: solid glomus tumors (glomus cells), glomangiomas (vascular cells), and glomangiomyomas (vascular and smooth muscle cells). ### WHO Classification The World Health Organization (WHO) classifies glomus tumours according to the predominance of glomus cells, vascular structures, and smooth muscle cells into **3** **distinct entities** ([Sethu](https://doi.org/10.1308/rcsann.2016.0005?ref=theplasticsfella.com), 2016): - **Solid glomus tumours:** Most common, with a predominance of glomus cells. - **Glomangioma:** With a predominance of vascular cells. - **Glomangiomyoma:** With a predominance of both vascular and smooth muscle cells. ### Benign vs. Malignant Glomus Tumors Glomus tumors are typically benign, but they can occasionally transform into malignant forms or arise as malignant glomus tumors, known as glomangiosarcomas. These malignant lesions have a high rate of local recurrence but a very low rate of metastasis. Risk factors for malignancy include: - Deeper location - Size greater than 2 cm - Rapid growth - Atypical mitosis - High pathological grade 😎 ****Fun Fact:** A familial variant of glomus tumour has been associated with **chromosome 1p21–22** and involves truncating mutations in the glomulin gene ([Brouillard](https://pubmed.ncbi.nlm.nih.gov/11845407/?ref=theplasticsfella.com), 2002). --- ## Diagnosis of Glomus Tumours ****Key Point** Glomus Tumours usually exhibit a triad of symptoms: sharp pain in the fingertips, pinpoint tenderness, and heightened sensitivity to cold. It can be confirmed on ultrasound or MRI. ### Clinical Assessment Glomus tumors typically present as small (<2 cm), solitary lesions in the acral regions, often subungual. They appear as blue or red blanchable papules or nodules in the deep dermis or subcutis. Multiple tumors may be present in up to 10% of cases ([Sethu](https://doi.org/10.1308/rcsann.2016.0005?ref=theplasticsfella.com), 2016) **Typical Symptoms** ([Chou](https://doi.org/10.1097/SAP.0000000000000684?ref=theplasticsfella.com), 2016)**:** - Stabbing pain in the fingertips - Pinpoint tenderness - Cold hypersensitivity **Diagnostic Signs** ([Tang](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785579/?ref=theplasticsfella.com), 2013)**:** - **Love’s Maneuver:** Pinpoint pressure applied to the nail elicits pain using a fine needle. - **Hildreth’s Sign:** Pain and pinpoint tenderness reduce with proximal inflation of a tourniquet, causing transient ischemia. Subungual glomus tumors can cause nail changes such as ridging, erythronychia, splitting, and thickening. Any subungual nodule that alters nail color or structure should raise suspicion for a glomus tumor ([Lu](https://doi.org/10.1186/s12885-018-4377-7?ref=theplasticsfella.com), 2018). 😎 ****Fun Fact:** Glomus tumours are rare outside the fingers, with case reports noting occurrences in the gastrointestinal tract, mediastinum, trachea, mesentery, cervix, and vagina ([Chou](https://doi.org/10.1097/SAP.0000000000000684?ref=theplasticsfella.com), 2010 & [Filice](https://doi.org/10.1097/SAP.0000000000000684?ref=theplasticsfella.com), 2008 & [Almaghrabi](https://doi.org/10.1097/SAP.0000000000000684?ref=theplasticsfella.com), 2017). ### Imaging - **Ultrasound:** detection of lesions as small as 3mm, and helps with depth assessment ([Matsunaga](https://doi.org/10.1684/ejd.2007.00190?ref=theplasticsfella.com), 2007). - **MRI:** Tumours show a high signal intensity on T2-weighted and STIR images ([Drape](https://doi.org/10.1016/s0190-9622%2896%2990678-7?ref=theplasticsfella.com), 1996). ### Histology Glomus tumor cells have round to oval nuclei, pale eosinophilic cytoplasm, distinct borders, and minimal mitotic activity & pleomorphism. They are immunoreactive for αSMA, MSA, and h-caldesmon, and contain type IV collagen. These markers distinguish glomus tumors from hemangiomas and S100-positive paragangliomas ([Mravic](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498398/?ref=theplasticsfella.com), 2015). 😎 ****Fun Fact:** Type I neurofibromatosis is associated with glomus tumors, showing similar sex distribution, tumor location, and burden as isolated glomus tumors ([Harrison](https://doi.org/10.1097/GOX.0000000000000144?ref=theplasticsfella.com), 2014). ### Differential Diagnosis Benign and malignant lesions can resemble glomus tumors. The most common tumor presenting similarly is an **epithelial inclusion cyst**. Initially thought to be a subset of glomus tumors, it can be distinguished by the following characteristics: - Prominent vascular components with dilated vessels, possible thrombosis, and phlebolith formation - Positive for epithelial markers with focal ductal differentiation - Naevus cells positive for S100 and Melan-A, unlike glomus tumors Other tumors to consider include: - **Blue Naevus:** Rare in the subungual region but may cause diagnostic uncertainty. - **Angioleiomyoma** - **Dermatologic Manifestation of Kaposi Sarcoma** - **Glomangioma:** More common in children and adolescents, typically multifocal, hereditary, and generally painless ([Boon](https://pubmed.ncbi.nlm.nih.gov/15313813/?ref=theplasticsfella.com), 2004). --- ## Management of Glomus Tumours ****Key Point** Complete excision is advised for solitary glomus tumours to alleviate pain and prevent recurrence, with varied techniques for different locations and low recurrence rates if completely excised. **Solitary Glomus Tumours** For solitary glomus tumours, complete removal of the tumour capsule is advised to alleviate pain and reduce the risk of recurrence. Most subungual lesions are treated by removing the entire nail and excising the tumour, though other techniques include: - Excision via the nail bed margin - The trap-door method - A nail-conserving technique by [Lee et al](https://doi.org/10.3109/2000656X.2013.861842?ref=theplasticsfella.com) ([Pahwa](https://doi.org/10.3109/09546630903277610?ref=theplasticsfella.com), 2010). In the **transungual approach**, the nail plate is removed, the tumour is excised, and the nail bed is repaired. **Multiple Glomus Tumours** For multiple glomus tumours, excision is challenging due to poor circumscription and numerous lesions, making **laser therapy** (argon, CO2, Nd) and sclerotherapy more effective options ([Gould](https://pubmed.ncbi.nlm.nih.gov/1645758/?ref=theplasticsfella.com), 1991). These tumours have a low incidence of recurrence if completely excised. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basic Characteristics of Glomus Tumors:** You've gained a foundational understanding of glomus tumors, including their origin from glomus cells, typical locations, and the severe pain they can cause. ****2\. Pathology and Classification:** You are now familiar with the components of the glomus body, the classification of glomus tumors into different types based on cell predominance, and the potential for malignant transformation. ****3\. Diagnostic Techniques:** You've recognized the importance of clinical examination, imaging techniques like ultrasound and MRI, and histology in diagnosing glomus tumors. ****4\. Management Strategies:** You've learned that complete surgical excision is the preferred treatment for solitary tumors to alleviate pain and prevent recurrence, and alternative therapies like laser or sclerotherapy for multiple lesions. ****5\. Complications and Outcomes:** Understanding potential complications and outcomes of treatment for better preparation and management of patient expectations regarding glomus tumors. --- ## Further Reading 1. Morey, Vivek Machhindra, Bhavuk Garg, and Prakash P. Kotwal. "[Glomus tumours of the hand: review of literature.](https://www.sciencedirect.com/science/article/abs/pii/S0976566216300339?ref=theplasticsfella.com)"Journal of clinical orthopaedics and trauma 7.4 (2016): 286-291. 2. Trehan, S. K., Soukup, D. S., Mintz, D. N., Perino, G., & Ellis, S. J. (2015). [Glomus Tumors in the Foot: Case Series](https://doi.org/10.1177/1938640015583514?ref=theplasticsfella.com). *Foot & ankle specialist*, *8*(6), 460–465\. https://doi.org/10.1177/1938640015583514 3. Chou, T., Pan, S. C., Shieh, S. J., Lee, J. W., Chiu, H. Y., & Ho, C. L. (2016). [Glomus Tumor: Twenty-Year Experience and Literature Review](https://doi.org/10.1097/SAP.0000000000000684?ref=theplasticsfella.com). *Annals of plastic surgery*, *76 Suppl 1*, S35–S40\. https://doi.org/10.1097/SAP.0000000000000684 4. Chou, H. P., Tiu, C. M., Chen, J. D., & Chou, Y. H. (2010). [Glomus tumor in the stomach](https://doi.org/10.1007/s00261-009-9552-5?ref=theplasticsfella.com). *Abdominal imaging*, *35*(4), 390–392\. https://doi.org/10.1007/s00261-009-9552-5 5. Filice, M. E., Lucchi, M., Loggini, B., Mussi, A., & Fontanini, G. (2008). [Glomus tumour of the lung: case report and literature review](https://pubmed.ncbi.nlm.nih.gov/18686523/?ref=theplasticsfella.com). Pathologica, 100(1), 25–30. 6. Almaghrabi, A., Almaghrabi, N., & Al-Maghrabi, H. (2017). [Glomangioma of the Kidney: A Rare Case of Glomus Tumor and Review of the Literature](https://doi.org/10.1155/2017/7423642?ref=theplasticsfella.com). *Case reports in pathology*, *2017*, 7423642\. https://doi.org/10.1155/2017/7423642 7. Sethu, C., & Sethu, A. U. (2016). [Glomus tumour](https://doi.org/10.1308/rcsann.2016.0005?ref=theplasticsfella.com). *Annals of the Royal College of Surgeons of England*, *98*(1), e1–e2\. https://doi.org/10.1308/rcsann.2016.0005 8. Mravic M, LaChaud G, Nguyen A, Scott MA, Dry SM, James AW. [Clinical and histopathological diagnosis of glomus tumor: an institutional experience of 138 cases](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498398/?ref=theplasticsfella.com). Int J Surg Pathol. 2015 May;23(3):181-8\. doi: 10.1177/1066896914567330\. Epub 2015 Jan 22\. PMID: 25614464; PMCID: PMC4498398. 9. De Chiara A, Apice G, Mori S, Silvestro G, Losito SN, Botti G, Ninfo V. [Malignant glomus tumour: a case report and review of the literature](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395518/?ref=theplasticsfella.com). Sarcoma. 2003;7(2):87-91\. doi: 10.1080/1357714031000081207\. PMID: 18521375; PMCID: PMC2395518. 10. Harrison, B., & Sammer, D. (2014). [Glomus tumors and neurofibromatosis: a newly recognized association](https://doi.org/10.1097/GOX.0000000000000144?ref=theplasticsfella.com). *Plastic and reconstructive surgery. Global open*, *2*(9), e214\. https://doi.org/10.1097/GOX.0000000000000144 11. Brouillard P, Boon LM, Mulliken JB, Enjolras O, Ghassibé M, Warman ML, Tan OT, Olsen BR, Vikkula M. [Mutations in a novel factor, glomulin, are responsible for glomuvenous malformations ("glomangiomas")](https://pubmed.ncbi.nlm.nih.gov/11845407/?ref=theplasticsfella.com). Am J Hum Genet. 2002 Apr;70(4):866-74\. doi: 10.1086/339492\. Epub 2002 Feb 13\. PMID: 11845407; PMCID: PMC379115. 12. Lu, H., Chen, L. F., & Chen, Q. (2018). [Rupture of a subungual glomus tumor of the finger](https://doi.org/10.1186/s12885-018-4377-7?ref=theplasticsfella.com). *BMC cancer*, *18*(1), 505\. https://doi.org/10.1186/s12885-018-4377-7 13. Tang CY, Tipoe T, Fung B. [Where is the Lesion? Glomus Tumours of the Hand](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785579/?ref=theplasticsfella.com). Arch Plast Surg. 2013 Sep;40(5):492-5\. doi: 10.5999/aps.2013.40.5.492\. Epub 2013 Sep 13\. PMID: 24086799; PMCID: PMC3785579. 14. Matsunaga, A., Ochiai, T., Abe, I., Kawamura, A., Muto, R., Tomita, Y., & Ogawa, M. (2007). [Subungual glomus tumour: evaluation of ultrasound imaging in preoperative assessment](https://doi.org/10.1684/ejd.2007.00190?ref=theplasticsfella.com). *European journal of dermatology : EJD*, *17*(1), 67–69\. https://doi.org/10.1684/ejd.2007.00190 15. Drapé, J. L., Idy-Peretti, I., Goettmann, S., Guérin-Surville, H., & Bittoun, J. (1996). [Standard and high resolution magnetic resonance imaging of glomus tumors of toes and fingertips](https://doi.org/10.1016/s0190-9622%2896%2990678-7?ref=theplasticsfella.com). *Journal of the American Academy of Dermatology*, *35*(4), 550–555\. https://doi.org/10.1016/s0190-9622(96)90678-7 16. Boon LM, Mulliken JB, Enjolras O, Vikkula M. [Glomuvenous malformation (glomangioma) and venous malformation: distinct clinicopathologic and genetic entities](https://pubmed.ncbi.nlm.nih.gov/15313813/?ref=theplasticsfella.com). Arch Dermatol. 2004 Aug;140(8):971-6\. doi: 10.1001/archderm.140.8.971\. PMID: 15313813. 17. Lee, H. J., Kim, P. T., Kyung, H. S., Kim, H. S., & Jeon, I. H. (2014). [Nail-preserving excision for subungual glomus tumour of the hand](https://doi.org/10.3109/2000656X.2013.861842?ref=theplasticsfella.com). *Journal of plastic surgery and hand surgery*, *48*(3), 201–204\. https://doi.org/10.3109/2000656X.2013.861842 18. Pahwa, M., Pahwa, P., & Kathuria, S. (2010). [Glomus tumour of the nail bed treated with the 'trap door' technique: a report of two patients](https://doi.org/10.3109/09546630903277610?ref=theplasticsfella.com). *The Journal of dermatological treatment*, *21*(5), 298–300\. https://doi.org/10.3109/09546630903277610 19. Gould E. P. (1991). [Sclerotherapy for multiple glomangiomata](https://pubmed.ncbi.nlm.nih.gov/1645758/?ref=theplasticsfella.com). *The Journal of dermatologic surgery and oncology*, *17*(4), 351–352\. https://doi.org/10.1111/j.1524-4725.1991.tb01710.x ### Congenital Brachial Plexus Palsy - Clinical Scenario URL: https://www.theplasticsfella.com/congenital-brachial-plexus-palsy-clinical-scenario/ Last updated: 2024-09-04T17:09:21.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Clinical-Case-Main-Image--7--1.png) #### Clinical Scenario ****You are working with the national brachial plexus service. A baby is referred to your clinic by the neonatologists as they have had a limp left arm since the time of delivery.** ****Objectives:** ****1\.** Take a history from parents of a baby with congenital brachial plexus palsy. ****2\.** Examine the baby and create a differential diagnosis. ****3\.** Plan appropriate investigations. ****4\.** Discuss your surgical management plan. ****5\.** Discuss longer-term follow-up and potential sequelae. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Sternal Wound Infections - Clinical Scenario URL: https://www.theplasticsfella.com/sternal-wound-infections-clinical-scenario/ Last updated: 2024-09-04T17:10:56.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Clinical-Case-Main-Image--5--1.png) #### Clinical Scenario ****A 57-year-old lady presents with a sternal wound sinus 4 weeks after a median sternotomy for a mitral valve replacement.** ****Objectives:** ****1\.** Identify and classify a DSWI. ****2\.** Diagnose a DSWI. ****3\.** Identify appropriate investigations for SWI. ****4\.** Treatment options for DSWI. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Dupuytren's Disease - Clinical Scenario URL: https://www.theplasticsfella.com/dupuytrens-disease-clinical-scenario/ Last updated: 2024-09-04T17:11:18.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Clinical-Case-Main-Image--14--1.png) #### Clinical Scenario A 65-year-old male farmer presents with stiffness in the middle finger of his right hand, affecting his ability to grip objects and shake hands. He has uncontrolled diabetes on insulin, benign prostatic hyperplasia, and a history of carpal tunnel release 5 years ago. His father had similar hand problems but did not seek medical attention. ****Objectives:** ****1\.** Outline the assessment of this patient. ****2\.** Knowledge of the fascial anatomy of the hand. ****3\.** Describe the management options available for Dupuytren’s disease. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Ulnar Tunnel Syndrome - Clinical Scenario URL: https://www.theplasticsfella.com/ulnar-tunnel-syndrome-clinical-scenario/ Last updated: 2024-09-04T17:11:43.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/AI-generated-image--2--1.png) #### Clinical Scenario ****A 65-year-old male presents with a history of progressive numbness and tingling in his right ring and little fingers. This is associated with clumsiness, dropping things, and ulnar-sided wrist pain on his right dominant hand.** ****Objectives:** ****1\.** Describe the clinical presentation of ulnar tunnel syndrome. ****2\.** Clinically assess and examine the hand. ****3\.** Provide a differential diagnosis. ****4\.** Describe which investigations you would arrange. ****5\.** Consent for surgical management. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Pronator Syndrome - Clinical Scenario URL: https://www.theplasticsfella.com/pronator-syndrome-clinical-case/ Last updated: 2024-09-04T17:12:07.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Clinical-Case-Main-Image--2--1.png) #### Clinical Scenario ****52-year-old lady presents with a 1-year history of progressively worsening numbness of the right thumb, index, and middle finger, associated with pain over the anterior forearm. The patient denies any weakness while performing daily hand functions.** ****Objectives:** ****1\.** Assess patients with suspected median nerve neuropathy. ****2\.** Discuss the aetiology of median nerve compressive neuropathies. ****3\.** Knowledge of specific clinical findings distinguishing pronator syndrome from other causes of median nerve neuropathy. ****4\.** Provide a management plan for patients suffering from pronator syndrome. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Poland Syndrome - Clinical Scenario URL: https://www.theplasticsfella.com/poland-syndrome-clinical-scenario/ Last updated: 2024-09-04T17:14:07.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Poland-Syndrome.png) #### Clinical Scenario ****You review a 2-month-old baby at your paediatric plastic surgery outpatient clinic who has been referred by the paediatric team. He has right-sided chest wall hypoplasia and syndactyly of the middle three digits.** ****Objectives:** ****1\.** Take a history from the family. ****2\.** Consider a differential diagnosis. ****3\.** Arrange appropriate investigations. ****4\.** Consent for surgery. ****5\.** Manage expectations. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Micro Focus: Venous Congestion, Breast Algorithms, & Chest Wall Recon URL: https://www.theplasticsfella.com/july-14th/ Last updated: 2024-07-14T10:33:02.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-14th/#a-letter-from-pfella) Is enhancing your CV the #1 research priority? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/july-14th/#the-sunday-quiz) **\+ Leaderboard** Check out the winners on our leaderboard! 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/july-14th/#behind-the-fella) Episode 03 is out now! 4. 🎓 [****theFellows' Corner**](https://www.theplasticsfella.com/july-14th/#the-fellows-corner) New in: Sternal wound infections diagnosis & treatment. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-14th/#what-does-the-evidence-say) Treatment of a congested free flap. 6. ****🔥** [****Recommended Articles of the Week**](https://www.theplasticsfella.com/july-14th/#articles-of-the-week) Microsurgical breast reconstruction, free flaps reconstruction for soft tissue defects, & immediate lymphatic reconstruction; with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/july-14th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Enhancing Your CV is Your #1 Research Priority (Apparently)* 👋 ****Hey Team!** Ever wondered why we really do research? I recently conducted a survey of 80 people in the plastics field about their research motivations and challenges, and the results were quite eye-opening. Here are the highlights 👇 I recently conducted a survey with over 240 votes in the plastics field, asking about your research motivations and challenges. The results were quite eye-opening. - Nearly half of you have fewer than five publications, while just over 10% have more than 20. - Only one in three believe their research has a significant clinical impact. - Half of you feel there isn’t enough time to conduct research in your current roles. - The top motivation for research is enhancing your CV, while contributing to science ranked the lowest. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Research-poster--1-.png) Motivations to do research It seems research has turned into a currency, adding career value regardless of its scientific impact. This focus on quantity over quality is understandable but somewhat disheartening. The incentive structure clearly favors volume, especially early in one’s career, often at the expense of quality. In the most recent episode of [Behind the 'Fella](https://www.theplasticsfella.com/july-14th/#behind-the-fella), we talk about the importance of collaborative research, leading to better results. Despite these changes, academia still largely values the sheer number of publications. Our system pushes us toward producing high volumes of publications, often overshadowing quality. Case reports and series, while clinically valuable, are not always considered rigorous research. This distinction needs to change in how we evaluate and reward research efforts. Love, P'Fella ****tl;dr** 👉 +240 votes from plastics professionals reveals research motivations. 👉 1 in 3 believe their research impacts clinical practice. 👉 50% feel they lack time for research in their current roles. 👉 Top motivation: enhancing CV 👉 Lowest motivation: contributing to science. 👉 Research is often valued for quantity over quality. ## The Sunday Quiz **\*Drumroll🥁\* We've Got New Winners!* ****Congratulations to the Winners** of The Weekly Quiz! We're thrilled to announce the winners of this edition's quiz. After six rounds of questions on plastic surgery, our top scorers are ****AL**, ****Maitumelo**, and ****Shehzadi**. With a tie at the top, we're planning on a live playoff on our podcast! We'll contact the finalists soon. Thank you to everyone who participated and stay tuned for more fun quizzes in future editions! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Leaderboard-Team-Post-Template.png) Here's the rest of the leaderboard. ## Behind the ‘Fella **Episode 03 Release* 🎧 ****Behind the Fella: Episode 04** In this week's episode, we explore plastic surgery research with our guest, [Justin Wormald](https://x.com/JCRWormald?ref=theplasticsfella.com)! Check out the latest episode on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /1:47 1× Listen now on [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) and [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)! ## the Fellows' Corner **This Week's Focus: Sternal Wound Infections* ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--43-.png) #### Sternal Wound Infections [****Definition**](https://www.theplasticsfella.com/sternal-wound-infections/#definition-of-sternal-wound-infections) Sternal wound infections are divided into superficial (skin subcutaneous tissue and fascia) and deep (extending down to sternal bone hardware and mediastinum). [****Classification**](https://www.theplasticsfella.com/sternal-wound-infections/#classification-of-sternal-wound-infections) SWIs are often classified according to timing from surgery; for example, the Palierolero classification. [****Risk Factors**](https://www.theplasticsfella.com/sternal-wound-infections/#risk-factors-for-sternal-wound-infections) Risk factors can be grouped into patient-related (e.g., diabetes and obesity), intraoperative (e.g., increased surgical time), and postoperative factors (e.g., prolonged ICU stay). [****Diagnosis**](https://www.theplasticsfella.com/sternal-wound-infections/#diagnosis-of-sternal-wound-infections) Diagnosis is clinical and can be supported by laboratory tests such as FBC, ESR, CRP, and blood culture and imaging such as CXR and CT. [****Treatment**](https://www.theplasticsfella.com/sternal-wound-infections/#treatment-of-sternal-wound-infections) Superficial infections can be treated with antibiotics and local wound care while DSWI requires debridement, hardware removal, and early closure including flap closure. [****Flap Reconstruction**](https://www.theplasticsfella.com/sternal-wound-infections/#flap-reconstruction-for-sternal-wound-infections) Pectoralis major, rectus abdominis, latissimus dorsi, and omental flaps are the main flaps used for soft tissue cover in SWIs. [****Complications**](https://www.theplasticsfella.com/sternal-wound-infections/#complications-of-sternal-wound-infections) Complications with sternal wound infections include recurrent wound infections and wound dehiscence flap donor site morbidity (e.g., hernia) post rectus abdominis harvest. [Read the Article](https://www.theplasticsfella.com/sternal-wound-infections/) ## What Does the Evidence Say? **Treatment of a Congested Free Flap* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. **Venous congestion** is a significant complication in **free flap surgery**. Various techniques have been proposed to manage this issue. Local subcutaneous injection of low molecular-weight heparin has shown effectiveness in salvaging congested flaps (Pérez et al., 2014). Medical leeches have also been successfully used to treat venous insufficiency (Soucacos et al., 1994; Pannucci et al., 2014). Vacuum-assisted closure therapy has been reported as a novel approach to alleviating venous congestion (Uygur et al., 2008). Venous catheterization can increase venous outflow (Gürsoy et al., 2008). The superficial inferior epigastric vein is commonly used to augment venous drainage when congestion occurs (Kim et al., 2015; Niranjan et al., 2001; Rohde & Keller, 2005). Preserving the opposite pedicle or superficial veins during flap harvest provides options for venous augmentation if needed postoperatively (Niranjan et al., 2001). ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* 1️⃣ ***The latest advancements in microsurgical breast reconstruction** ([Tanna](https://journals.lww.com/plasreconsurg/abstract/2024/07000/contemporary%5Fmicrosurgical%5Fbreast%5Freconstruction%5F.51.aspx?context=featuredarticles&collectionid=2&ref=theplasticsfella.com), 2024) Explore the evolution of techniques, preoperative planning, surgical steps, and enhanced recovery pathways to achieve optimal patient outcomes in microsurgical breast reconstruction with abdominally-based flaps. 2️⃣ ***Free flaps for reconstructing soft tissue defects in the lower extremity** ([Xiong](https://onlinelibrary.wiley.com/doi/full/10.1002/micr.30020?ref=theplasticsfella.com), 2016) A meta-analysis on the reliability and safety of free flaps, the procedure's evolution, complication rates, and the efficacy of various techniques over the last two decades. 3️⃣ ***Insights on immediate lymphatic reconstruction (ILR)** ([Friedman](https://www.jprasurg.com/article/S1748-6815%2824%2900250-X/abstract?ref=theplasticsfella.com#secsect0005), 2024) Discover evolving techniques, advanced imaging, strategic planning, and how these innovations have shaped safe and effective surgical approaches in reducing breast cancer-related lymphedema. ## Feedback ### I hope you enjoyed it 😄 --- ### Sternal Wound Infections: Classification, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/sternal-wound-infections/ Last updated: 2024-07-11T10:59:47.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/sternal-wound-infections/#definition-of-sternal-wound-infections) Sternal wound infections are divided into superficial (skin subcutaneous tissue and fascia) and deep (extending down to sternal bone hardware and mediastinum). [****Classification**](https://www.theplasticsfella.com/sternal-wound-infections/#classification-of-sternal-wound-infections) SWIs are often classified according to timing from surgery; for example, the Palierolero classification. [****Risk Factors**](https://www.theplasticsfella.com/sternal-wound-infections/#risk-factors-for-sternal-wound-infections) Risk factors can be grouped into patient-related (e.g., diabetes and obesity), intraoperative (e.g., increased surgical time), and postoperative factors (e.g., prolonged ICU stay). [****Diagnosis**](https://www.theplasticsfella.com/sternal-wound-infections/#diagnosis-of-sternal-wound-infections) Diagnosis is clinical and can be supported by laboratory tests such as FBC, ESR, CRP, and blood culture and imaging such as CXR and CT. [****Treatment**](https://www.theplasticsfella.com/sternal-wound-infections/#treatment-of-sternal-wound-infections) Superficial infections can be treated with antibiotics and local wound care while DSWI requires debridement, hardware removal, and early closure including flap closure. [****Flap Reconstruction**](https://www.theplasticsfella.com/sternal-wound-infections/#flap-reconstruction-for-sternal-wound-infections) Pectoralis major, rectus abdominis, latissimus dorsi, and omental flaps are the main flaps used for soft tissue cover in SWIs. [****Complications**](https://www.theplasticsfella.com/sternal-wound-infections/#complications-of-sternal-wound-infections) Complications with sternal wound infections include recurrent wound infections and wound dehiscence flap donor site morbidity (e.g., hernia) post rectus abdominis harvest. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Definition of Sternal Wound Infections ****Key Point** Sternal wound infections are divided into superficial (skin subcutaneous tissue and fascia) and deep (extending down to sternal bone hardware and mediastinum) Sternal wound infections are classified based on the **depth of the infection**. **Superficial** infections affect skin and subcutaneous layers, while **deep** infections extend to the sternal bone and beyond. **Superficial Sternal Wound Infections (SSWI)** - Involves the skin, subcutaneous tissue, and pectoralis fascia. - Defined as infections that do not extend beyond the pectoralis fascia ([Singh](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140234/?ref=theplasticsfella.com#r25025-8), 2011). SSWI generally has a lower mortality risk, ranging from **0.5% to 9%**, whereas DSWI has a significantly higher risk, reported between **10% and 47%** ([Singh](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140234/?ref=theplasticsfella.com#r25025-8), 2011). **Deep Sternal Wound Infections (DSWI)** A DSWI is characterized by ([Garner](https://pubmed.ncbi.nlm.nih.gov/2841893/?ref=theplasticsfella.com), 1988): 1. An organism isolated from the culture of mediastinal tissue or fluid. 2. Evidence of mediastinitis observed during surgical intervention. 3. Presence of symptoms such as chest pain, sternal instability, or fever over 38°C, alongside: - Purulent drainage from the mediastinum and the isolation of an organism present in a blood culture - Culture of the mediastinal area A DSWI can be considered as soft-tissue openings that extend down to the **sternal bone and hardware** ([Levy](https://pubmed.ncbi.nlm.nih.gov/31942289/?ref=theplasticsfella.com), 2019). DSWI can involve the **mediastinum, bone, or cartilage**, and infections beneath the subcutaneous tissue ([Yusuf](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6053175/?ref=theplasticsfella.com), 2018). 😎 ****Fun Fact:** Mediastinitis, a severe complication after coronary artery bypass surgery, doubles the mortality rate in patients with deep sternal wound infection (DSWI). ([Braxton](https://pubmed.ncbi.nlm.nih.gov/15366690/?ref=theplasticsfella.com), 2004). --- ## Classification of Sternal Wound Infections ****Key Point** SWIs can be classified according to timing from surgery according to the Palierolero classification. There are many classifications of SWI. [Greig](https://pubmed.ncbi.nlm.nih.gov/17349591/?ref=theplasticsfella.com) et al classified according to location (**upper, lower, or entire sternum**), which can be used to guide the best reconstructive option ([Hever](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027694/pdf/main.pdf?ref=theplasticsfella.com), 2021). SWIs can also be classified according to timing from surgery – the Palierolero classification which is detailed in the table below ([Palierolero](https://pubmed.ncbi.nlm.nih.gov/3729602/?ref=theplasticsfella.com), 1991 & [Singh](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140234/?ref=theplasticsfella.com#r25025-8), 2011). ![classification of sternal wound infections - the Palierolero classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--38-.png) The Palierolero classification of sternal wound infections [Kitano](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9634152/?ref=theplasticsfella.com) et al added a fourth classification which included **infection of aortic grafts** used to repair aortic arch aneurysms as exposure to grafts exacerbated infection and necessitated surgical replacement conferring higher mortality rates ([Kitano](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9634152/?ref=theplasticsfella.com), 2022). --- ## Risk Factors for Sternal Wound Infections ****Key Point** Risk factors can be grouped into patient-related (e.g., diabetes and obesity), intraoperative (e.g., increased surgical time), and postoperative factors (e.g., prolonged ICU stay). Major risk factors for the development of a DSWI following cardiac surgery can be grouped into **patient-related**, **intraoperative**, and **postoperative** factors as detailed in the table below ([Levy](https://pubmed.ncbi.nlm.nih.gov/31942289/?ref=theplasticsfella.com), 2019 & [Singh](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140234/?ref=theplasticsfella.com#r25025-8), 2011 & [Cutrell](https://pubmed.ncbi.nlm.nih.gov/27179393/?ref=theplasticsfella.com), 2016). ![Categorising major risk factors of a DSWI](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--46-.png) Major risk factors of a DSWI 😎 ****Fun Fact:** Patients undergoing a median sternotomy for coronary artery bypass grafting have the highest rate of sternal wound infections compared with those for other surgeries ([Singh](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140234/?ref=theplasticsfella.com#r25025-8), 2011). --- ## Diagnosis of Sternal Wound Infections ****Key Point** Diagnosis is clinical and can be supported by laboratory tests such as FBC, ESR, CRP, blood culture, and imaging such as CXR, CT, and MRI. ### Aetiology Sternal wound infections can be caused by **primary** or **secondary** infections. - **Primary:** **Staphylococcus aureus** is the most commonly isolated pathogen in DSWIs, followed by **Coagulase-Negative Staphylococci (CoNS)**. - **Secondary:** After initial surgical and antibiotic treatments, infections that persist tend to involve Gram-negative rods, particularly Enterobacteriaceae, with a decreasing proportion of Gram-positive cocci ([Chan](https://pubmed.ncbi.nlm.nih.gov/26707065/?ref=theplasticsfella.com), 2016). Rarely, DSWI can also occur by hematogenous route (mainly in children) and by contiguous extension from an adjacent infectious process (e.g., arthritis) ([De foe](https://pubmed.ncbi.nlm.nih.gov/11216770/?ref=theplasticsfella.com), 2001). 😎 ****Fun Fact:** Infections with Gram-negative rods are associated with a worse prognosis compared to those caused by Gram-positive organisms ([Yusuf](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6053175/?ref=theplasticsfella.com), 2018). ### Clinical Features The diagnosis of DSWI is clinical in nature. The **local**, **systematic**, and **chronic** presentation of a DSWI is detailed in the table below. ![Presentation of a DSWI, Signs of sternal wound infections](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--47-.png) Local, systematic, and chronic presentation of a DSWI ### ### Investigations A sternal wound infection requires comprehensive laboratory and radiology investigations. - **Laboratory Tests**: Infective and inflammatory markers, cultures. - **CXR:** Mediastinal widening, air-fluid level, pneumomediastinum, pleural effusion. - **CT chest:** Assess dehiscence depth and identify fluid collections, abscesses, air pockets, extension into adjacent structures, pleural or pericardial fluid, adenopathy, and parenchymal or sternal abnormalities. - **MRI:** Early osteomyelitis detection. Findings include hypointense signals on T1-weighted images and hyperintense signals on T2-weighted images. ![Mediastinitis on CT post-thoracotomy, Diagnosis of sternal wound infection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--42-.png) Mediastinitis on CT post-thoracotomy 💡 ****Tip:** PET combined with CT imaging is useful in localising the disease sites to guide adequate debridement. PET may also be used to monitor the response to therapy ([Zhang](https://pubmed.ncbi.nlm.nih.gov/30196022/?ref=theplasticsfella.com), 2018). --- ## Treatment of Sternal Wound Infections ****Key Point** Superficial infections can be treated with antibiotics and local wound care while DSWI requires debridement, hardware removal, negative pressure dressing, and closure. ### Principles Sternal wound infections should be treated by a multi-disciplinary team. Early administration of **targeted antibiotics** and **local wound care** is essential to prevent complications associated with DSWI/mediastinitis ([Levy](https://pubmed.ncbi.nlm.nih.gov/31942289/?ref=theplasticsfella.com), 2019). In relation to **deep sternal wound** infections, a recommended treatment approach ([Levy](https://pubmed.ncbi.nlm.nih.gov/31942289/?ref=theplasticsfella.com), 2019 & [Cauley](https://pubmed.ncbi.nlm.nih.gov/35253126/?ref=theplasticsfella.com#:~:text=Conclusion%3A%20Although%20sternal%20dehiscence%20remains,achieve%20good%20long%2Dterm%20outcomes.), 2022) includes: 1. **Debridement**: including hardware removal 2. **Sampling**: Aseptic tissue and bone culture collection for tailored antibiotics 3. **Antibiotics**: Start broad-spectrum antibiotics preoperatively and tailor them to cultures. Osteomyelitis typically requires a 6+ weeks regimen. 4. **Reconstruction**: Stabilisation of the thoracic skeleton (respiration) & soft tissue coverage with flap reconstruction (obliterate dead space, protect organs). 💡 ****Tip:** When foreign bodies cannot be removed (e.g., pacing wires, graft material), staged debridement and reconstruction should be considered for ongoing infection concerns. ([Levy](https://pubmed.ncbi.nlm.nih.gov/31942289/?ref=theplasticsfella.com), 2019) ### ### Wound Management Options After infection control, a flap can reconstruct the defect by eliminating dead space, providing vascularized tissue for healing and antibiotics, covering vital structures, and compressing sternal segments to promote bone healing. An **algorithm for sternal wound closures** can be found [here](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908337/?ref=theplasticsfella.com). Closure options include: - Closed suction antibiotic catheter irrigation systems - Vacuum-assisted closure (VAC) - Flap Reconstruction: discussed in more detail below VAC may be the only treatment for critically ill patients, especially with negative blood cultures, shallow wounds (<4 cm), low bony exposure, and sternal instability (Gladevitch, 2010). However, VAC use can increase bleeding risk and potentially damage underlying tissues, including rare right ventricular rupture. A skin graft with VAC dressing can enhance adherence and success ([Gladevitch](https://pubmed.ncbi.nlm.nih.gov/19028156/?ref=theplasticsfella.com), 2010). 😎 ****Fun Fact:** Immediate debridement and reconstruction reduce morbidity, mortality, and hospital stay compared to delayed procedures ([Cabbabe](https://pubmed.ncbi.nlm.nih.gov/19407620/?ref=theplasticsfella.com), 2009). Early reconstruction (< 4 days) also results in fewer infections, better flap survival, and shorter hospital stays ([Hever](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027694/pdf/main.pdf?ref=theplasticsfella.com), 2021). --- ## Flap Reconstruction for Sternal Wound Infections ****Key Point** Pectoralis major, rectus abdominis, latissimus dorsi, and omental flaps are the main flaps used for soft tissue cover in SWIs. The goal of flap reconstruction is to eliminate **dead space**, provide **vascularized** tissue for healing and antibiotics, **protect** vital structures, and compress sternal segments for osseous healing. **Workhorse flaps** for chest wall reconstruction include: - Pectoralis major: unilateral turnover or rotation advancement, bilateral. - Omental transposition - Rectus abdominis muscle - Latissimus dorsi muscle The table below details flap reconstruction considerations, advantages, and disadvantages for each flap. ![Flap reconstruction for sternal wound infections](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--88-.png) Flap reconstruction for sternal wound infections --- ## Complications of Sternal Wound Infections ****Key Point** Complications with sternal wound infections include recurrent wound infections, wound dehiscence, and flap donor site morbidity (e.g., hernia post rectus abdominis harvest). Complications include: - Recurrent wound infections - Hematoma - Wound dehiscence - Re-exploration for wound necrosis - Partial flap loss - Donor site complications from flap harvest such as abdominal hernia formation after rectus abdominis harvest Predictors of perioperative mortality after sternal debridement and muscle flap coverage ([Patel](https://pubmed.ncbi.nlm.nih.gov/19116546/?ref=theplasticsfella.com), 2009). - Presternotomy end-stage renal disease - Chronic obstructive lung disease - Mechanical ventilation 😎 ****Fun Fact:** Postoperative adhesions between the posterior sternum and cardiac structures can easily shear and lead to dreaded complications of ventricle laceration or arterial graft avulsion ([Levy](https://pubmed.ncbi.nlm.nih.gov/31942289/?ref=theplasticsfella.com), 2019). --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Sternal Wound Infections:** You have learned to distinguish between superficial and deep sternal wound infections, understanding their impact on patient health and the complexities. ****2\. Classification:** You are familiar with the Palierolero classification system, categorizing SWIs based on the timing of their occurrence post-surgery. ****3\. Risk Factors:** You have looked into risk factors that contribute to the development of SWIs, categorized into patient-related, intraoperative, and postoperative factors. ****4\. Diagnostic Proficiency:** You understand the clinical signs of SWIs and the role of laboratory tests and imaging in confirming the diagnosis and planning treatment. ****5\. Treatment Strategies:** You understand the differences in treatment approaches for superficial versus deep infections, including antibiotics, local wound care, and more aggressive interventions like debridement and flap reconstruction. ****6\. Flap Reconstruction Options:** You have learned about various flap options for reconstructing defects caused by SWIs. ****7\. Complications:** You understand the potential complications associated with SWIs and the importance of meticulous surgical technique and postoperative care to minimize these risks. --- ## Further Reading 1. Levy AS, Ascherman JA. [Sternal Wound Reconstruction Made Simple](https://pubmed.ncbi.nlm.nih.gov/31942289/?ref=theplasticsfella.com). Plast Reconstr Surg Glob Open. 2019 Nov 27;7(11):e2488\. doi: 10.1097/GOX.0000000000002488\. PMID: 31942289; PMCID: PMC6908337. 2. Pairolero PC, Arnold PG, Harris JB. [Long-term results of pectoralis major muscle transposition for infected sternotomy wounds](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1358581/?ref=theplasticsfella.com). Ann Surg. 1991 Jun;213(6):583-9; discussion 589-90\. doi: 10.1097/00000658-199106000-00008\. PMID: 2039289; PMCID: PMC1358581. 3. Singh K, Anderson E, Harper JG. [Overview and management of sternal wound infection](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140234/?ref=theplasticsfella.com#r25025-8). Semin Plast Surg. 2011 Feb;25(1):25-33\. doi: 10.1055/s-0031-1275168\. PMID: 22294940; PMCID: PMC3140234. 4. Braxton JH, Marrin CA, McGrath PD, Morton JR, Norotsky M, Charlesworth DC, Lahey SJ, Clough R, Ross CS, Olmstead EM, O'Connor GT. [10-year follow-up of patients with and without mediastinitis](https://pubmed.ncbi.nlm.nih.gov/15366690/?ref=theplasticsfella.com). Semin Thorac Cardiovasc Surg. 2004 Spring;16(1):70-6\. doi: 10.1053/j.semtcvs.2004.01.006\. PMID: 15366690. 5. Gdalevitch P, Afilalo J, Lee C. [Predictors of vacuum-assisted closure failure of sternotomy wounds](https://pubmed.ncbi.nlm.nih.gov/19028156/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2010 Jan;63(1):180-3\. doi: 10.1016/j.bjps.2008.08.020\. Epub 2008 Nov 22\. PMID: 19028156. 6. Jones G, Jurkiewicz MJ, Bostwick J, Wood R, Bried JT, Culbertson J, Howell R, Eaves F, Carlson G, Nahai F. [Management of the infected median sternotomy wound with muscle flaps](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1190886/?ref=theplasticsfella.com). The Emory 20-year experience. Ann Surg. 1997 Jun;225(6):766-76; discussion 776-8\. doi: 10.1097/00000658-199706000-00014\. PMID: 9230817; PMCID: PMC1190886. 7. Patel NV, Woznick AR, Welsh KS, Bendick PJ, Boura JA, Mucci SJ. [Predictors of mortality after muscle flap advancement for deep sternal wound infections](https://pubmed.ncbi.nlm.nih.gov/19116546/?ref=theplasticsfella.com). Plast Reconstr Surg. 2009 Jan;123(1):132-138\. doi: 10.1097/PRS.0b013e3181904b56\. PMID: 19116546. 8. De Feo M, Renzulli A, Ismeno G, Gregorio R, Della Corte A, Utili R, Cotrufo M. [Variables predicting adverse outcome in patients with deep sternal wound infection](https://pubmed.ncbi.nlm.nih.gov/11216770/?ref=theplasticsfella.com). Ann Thorac Surg. 2001 Jan;71(1):324-31\. doi: 10.1016/s0003-4975(00)02137-8\. PMID: 11216770. 9. Cutrell JB, Barros N, McBroom M, Luby J, Minhajuddin A, Ring WS, Greilich PE. [Risk factors for deep sternal wound infection after cardiac surgery: Influence of red blood cell transfusions and chronic infection](https://pubmed.ncbi.nlm.nih.gov/27179393/?ref=theplasticsfella.com). Am J Infect Control. 2016 Nov 1;44(11):1302-1309\. doi: 10.1016/j.ajic.2016.03.027\. Epub 2016 May 11\. PMID: 27179393. 10. Chan M, Yusuf E, Giulieri S, Perrottet N, Von Segesser L, Borens O, Trampuz A. [A retrospective study of deep sternal wound infections: clinical and microbiological characteristics, treatment, and risk factors for complications](https://pubmed.ncbi.nlm.nih.gov/26707065/?ref=theplasticsfella.com). Diagn Microbiol Infect Dis. 2016 Mar;84(3):261-5\. doi: 10.1016/j.diagmicrobio.2015.11.011\. Epub 2015 Nov 14\. PMID: 26707065. 11. Yusuf E, Chan M, Renz N, Trampuz A. [Current perspectives on diagnosis and management of sternal wound infections](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6053175/?ref=theplasticsfella.com). Infect Drug Resist. 2018 Jul 16;11:961-968\. doi: 10.2147/IDR.S130172\. PMID: 30038509; PMCID: PMC6053175. 12. Pairolero PC, Arnold PG. [Management of infected median sternotomy wounds.](https://pubmed.ncbi.nlm.nih.gov/3729602/?ref=theplasticsfella.com) Ann Thorac Surg. 1986 Jul;42(1):1-2\. doi: 10.1016/s0003-4975(10)61822-x. PMID: 3729602. 13. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. [CDC definitions for nosocomial infections, 1988](https://pubmed.ncbi.nlm.nih.gov/2841893/?ref=theplasticsfella.com). Am J Infect Control. 1988 Jun;16(3):128-40\. doi: 10.1016/0196-6553(88)90053-3\. Erratum in: Am J Infect Control 1988 Aug;16(4):177\. PMID: 2841893. 14. Bakri K, Mardini S, Evans KK, Carlsen BT, Arnold PG. [Workhorse flaps in chest wall reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis flaps](https://pubmed.ncbi.nlm.nih.gov/22294942/?ref=theplasticsfella.com). Semin Plast Surg. 2011 Feb;25(1):43-54\. doi: 10.1055/s-0031-1275170\. PMID: 22294942; PMCID: PMC3140231. 15. Kitano D, Takahashi H, Nomura T, Okada K, Terashi H, Sakakibara S. [A new clinical classification and reconstructive strategy for post-sternotomy surgical site infection](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9634152/?ref=theplasticsfella.com). Regen Ther. 2022 Oct 29;21:519-526\. doi: 10.1016/j.reth.2022.10.007\. PMID: 36382133; PMCID: PMC9634152. 16. Zhang R, Feng Z, Zhang Y, Tan H, Wang J, Qi F. [Diagnostic value of fluorine-18 deoxyglucose positron emission tomography/computed tomography in deep sternal wound infection](https://pubmed.ncbi.nlm.nih.gov/30196022/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2018 Dec;71(12):1768-1776\. doi: 10.1016/j.bjps.2018.07.017\. Epub 2018 Aug 2\. PMID: 30196022. 17. Pech T, Kania A, Fehlberg W, Kalff JC, Walgenbach KJ, Busch KH. [Therapie der Sternumosteomyelitis nach medianer Sternotomie bei 130 Patienten mittels gestielter myokutaner Latissimuslappenplastik \[Treatment of Sternal Osteomyelitis after Median Sternotomy in 130 Patients with Pedicled Myocutaneous Latissimus Flap\]](https://pubmed.ncbi.nlm.nih.gov/30184571/?ref=theplasticsfella.com). Zentralbl Chir. 2018 Aug;143(S 01):S51-S60\. German. doi: 10.1055/a-0624-9574\. Epub 2018 Sep 5\. PMID: 30184571. 18. Cauley RP, Barron S, Slatnick B, Maselli A, Kang C, Delvalle D, Chu L, Morris D. [An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience](https://pubmed.ncbi.nlm.nih.gov/35253126/?ref=theplasticsfella.com#:~:text=Conclusion%3A%20Although%20sternal%20dehiscence%20remains,achieve%20good%20long%2Dterm%20outcomes.). J Reconstr Microsurg. 2022 Oct;38(8):671-682\. doi: 10.1055/s-0042-1743167\. Epub 2022 Mar 4\. PMID: 35253126. 19. Hever P, Singh P, Eiben I, Eiben P, Nikkhah D. [The management of deep sternal wound infection: Literature review and reconstructive algorithm](https://pubmed.ncbi.nlm.nih.gov/33855148/?ref=theplasticsfella.com). JPRAS Open. 2021 Mar 6;28:77-89\. doi: 10.1016/j.jpra.2021.02.007\. PMID: 33855148; PMCID: PMC8027694. 20. Greig AV, Geh JL, Khanduja V, Shibu M. [Choice of flap for the management of deep sternal wound infection--an anatomical classification](https://pubmed.ncbi.nlm.nih.gov/17349591/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2007;60(4):372-8\. doi: 10.1016/j.bjps.2006.10.005\. Epub 2007 Jan 19\. PMID: 17349591. ### Dupuytren's Disease: Pathoanatomy, Clinical Assessment, & Management URL: https://www.theplasticsfella.com/dupuytrens-disease/ Last updated: 2024-08-03T13:57:41.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/dupuytrens-disease/#definition-of-dupuytrens-disease) Dupuytren’s disease is a benign fibroproliferative disorder affecting the fascia of the palm and fingers. [****Epidemiology**](https://www.theplasticsfella.com/dupuytrens-disease/#epidemiology-of-dupuytrens-disease) More common in older men of Northern European descent and is linked to family history, alcoholism, diabetes, epilepsy, & manual labour. [****Pathoanatomy**](https://www.theplasticsfella.com/dupuytrens-disease/#anatomy-of-dupuytrens-disease) Normal fascial anatomy becomes diseased with the formation of cords and nodules causing progressive contracture, usually on the ulnar hand. Cleland’s ligaments are not affected by the disease process. [****Clinical Assessment**](https://www.theplasticsfella.com/dupuytrens-disease/#clinical-assessment-of-dupuytrens-disease) A progressive history and clinically palpable disease with a fixed flexion deformity. It is a clinical diagnosis. [****Management**](https://www.theplasticsfella.com/dupuytrens-disease/#management-of-dupuytrens-disease) Treatment aims to release contractures using non-operative methods like Collagenase injections and needle aponeurotomy, or surgical release such as fasciotomy or fasciectomy. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Dupuytren's Disease ****Key Point** Dupuytren’s disease is a benign fibroproliferative disorder most commonly affecting the fascia of the palm and fingers. Dupuytren’s disease is a benign fibroproliferative disorder affecting the fascia of the palm and fingers. It begins with nodular formation, and progresses to longitudinal cord development. The image below further illustrates Dupuytren’s disease. ![Dupuytren’s disease, Dupuytren’s contracture, fibroproliferative disorder](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--53-.png) Presentation of Dupuytren’s disease in the left little finger --- ## Epidemiology of Dupuytren's Disease ****Key Point** Dupuytren’s disease is more common in older men of Northern European descent. It is linked to family history, alcoholism, diabetes, epilepsy, and manual labour. Dupuyten’s disease can affect any ethnic group but it is more common in individuals of **northern European** descent. The disease is more prevalent in **men**, with incidence rising with **age**. The disease is often linked with ([Ruettermann](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8864671/?ref=theplasticsfella.com), 2021): - Family history: autosomal dominant with variable penetrance - Medical Conditions: Alcohol Dependency, Diabetes, Epilepsy - Manual labour or repeated trauma is controversial. --- ## Anatomy of Dupuytren's Disease ****Key Point** The fascia develops pathological nodules and cords that progress to join contractures. Cleland’s ligaments are spared. The palmar fascia is a complex structure. To understand Dupuytren's disease effectively, it is crucial to distinguish between the anatomy of normal palmar fascia and its pathological changes. ### Normal Palmar Fascia Anatomy **Overview** The fascial anatomy of the palm is a complex structure. It originates at the wrist and extends towards the digits. It can be divided into **four main anatomic** components ([Rayan, 1999](https://pubmed.ncbi.nlm.nih.gov/10050245/?ref=theplasticsfella.com)) 1. **Palmar** (central) aponeurosis 2. **Thenar** (radial) aponeurosis 3. **Hypothenar** (ulnar) aponeurosis 4. **Fingers:** palmo-digital fascia & digital fascia The image below shows the fascial anatomy of the palm. ![Cleland’s and Grayson's ligaments of the hand, Diagnosing Dupuytren's Disease](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--70-.png) Cleland’s and Grayson's ligaments of the hand **Palmar Aponeurosis** The palmar aponeurosis is a triangular facial layer with its apex overlying the palmaris longus. It gives rise to the pretendinous bands, which subsequently further divide at the metacarpal heads into 3 layers: 1. **Superficial:** attaches to the skin at the palmar digital crease. 2. **Central:** produces 2 spiral bands which merge with lateral digital sheath. 3. **Deep:** insert on the interosseous muscle fascia and deep transverse metacarpal ligament. **Other structures** - **Spiral bands** travel distally and dorsally to form the web space coalescence. As they progress distally, they rotate 90° and pass from the coronal plane into the sagittal plane. - **The natatory ligament** is a 3-dimensional support system spanning all 4 web spaces. - **Cleland’s** and **Grayson's ligaments** surround the neurovascular bundle in a dorsal and volar manner, respectively. These ligaments are illustrated in the image below. 😎 ****Fun Fact:** The PL tendon fibres blend with the PA and fan toward the thenar fascia, making the PL tendon prominent when pinching or cupping the hand with the wrist flexed. ### Pathological Palmar Fascia Anatomy Dupuytren’s disease is characterised by the development of **nodules and cords** within the palmar fascia. Initially, pathological nodules develop in the palm, and progressive cord formation then extends to the fingers. It is described into 3 distinct phases: 1. **Proliferative:** Nodule formation 2. **Involutional:** Thickened nodules form cords 3. **Residual:** Acellular scarring causes signification contractures This usually affects the ulnar hand with the ring and little finger most commonly involved. Cord formation results in varying degrees of contracture pathognomic with Dupuytren’s disease as summarised in the table below ([Leibovic](https://europepmc.org/article/med/30012292?ref=theplasticsfella.com), 2018). ![Cord formation in varying degrees of contracture regarding Dupuytren’s disease](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--71-.png) Cord formation in varying degrees of contracture regarding Dupuytren’s disease 😎 ****Fun Fact:** ****Cleland's ligament** and the ****transverse ligament of the palmar aponeurosis** are not involved in Dupuytren's disease ([Leibovic](https://europepmc.org/article/med/30012292?ref=theplasticsfella.com), 2018). --- ## Clinical Assessment of Dupuytren's Disease ****Key Point** A history of progression from nodules to cord development, with clinically evident fixed flexion deformity is the cornerstone of the diagnosis. The diagnosis is clinical and based on a detailed history and examination findings. ### History - Palpable nodules start in the palm along the distal palmar crease. - Nodules progress into palpable cords. - Cords thicken & shorten, causing fixed flexion contractures MCPJ & PIPJ. - Pain rarely presents symptoms. - Decreased range of motion interferes with daily activities. The image below shows the presentation of Dupuytren's disease. ![Clinical presentation of Dupuytren's disease](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--72-.png) Clinical presentation of Dupuytren's disease ### Physical Exam In relation to the hand examination: - Non-tender nodule in the pretendinous bands of the palmar fascia. - Garrod pads (knuckle pads over PIPJ) may be tender. - Presence of pits and grooves in the palm. - Blanching of the skin with finger extension. - Hueston's Tabletop Test. 💡 ****Tip:** Hueston's Tabletop Test is positive if the patient cannot lay their palm flat on a table with straightened fingers. ([Fine](https://www.sciencedirect.com/science/article/abs/pii/S0263931919300468?ref=theplasticsfella.com), 2019). In some patients, a total body examination may reveal ([Karbowiak](https://pubmed.ncbi.nlm.nih.gov/34088710/?ref=theplasticsfella.com), 2021): - **Peyronie's disease:** Dartos fascia of the penis - **Ledderhose disease:** Plantar fascia ### Differential Diagnosis Dupuytren's disease is a relatively straightforward clinical diagnosis. However, it can occasionally be confused with, - **Trigger finger:** usually associated with pain and no cords - **Volkmann’s ischemic contracture:** history of trauma - **Ulnar claw hand:** passively correctable 😎 ****Fun Fact:** Dupuytren’s diathesis is a severe, early-onset form with bilateral involvement, family history, rapid progression, and frequent recurrences. ([Eberlin](https://www.sciencedirect.com/science/article/abs/pii/S0749071218300350?via%3Dihub&ref=theplasticsfella.com), 2018, [Hindocha](https://www.sciencedirect.com/science/article/abs/pii/S0749071218300301?via%3Dihub&ref=theplasticsfella.com), 2018). --- ## Management of Dupuytren's Disease ****Key Point** Treatment involves a multidisciplinary team of hand surgeons and therapists aiming to release contractures, reduce disease presence, and prevent progression. Dupuytren's disease cannot be completely cured, and recurrence is common with any treatment. **Goals** should be individualized for each patient by an MDT. General considerations include: - **Resection** of diseased tissue and release of contractures. - **Prevention** of progression and reduction of recurrence risk. - **Maintenance** of functional fingers and hand. ### Indications for Treatment Indications for treatment depend on disease progression, location, and patient factors. More specifically, - **History:** rapid progression, occupational considerations. - **Contractures:** PIPJ, or MCP joint > 30 degrees. - **Function:** reduction function or hygiene. ### Treatment Options Dupuytren's disease can be managed through non-operative or operative interventions ([Desai](https://www.sciencedirect.com/science/article/abs/pii/S0363502311002851?ref=theplasticsfella.com), 2011), including: - **Non-operative:** Conservative management and hand therapy - **Minimally invasive:** Collagenase injections, needle aponeurotomy - **Surgery:** Fasciectomy, dermofasciectomy The specific indications for these treatment options are detailed below. ![Management of Dupuytren's disease](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--49-.png) Operative and non-operative management methods for Dupuytren's disease 💡 ****Tip:** Fasciotomy divides the fascia to relieve tension, with less surgical morbidity but higher recurrence rates, suitable for minor contractures. Fasciectomy excises pathological fascia. ### Surgical Technique Different approaches have been described for treating Dupuytren's disease. Here is the general approach: - **Prepare:** Assemble the hand set, hand table, lead hand, and loupes. - **Design:** Use Brunner incisions or the Skoog approach, followed by [Z-plasties](https://www.theplasticsfella.com/z-plasty/). - **Dissect:** Raise adequate flaps before excising all diseased fascia, preserving the neurovascular bundle. - **Close:** Close without tension using interrupted sutures and splint the hand with fingers in extension. [Z-plasties](https://www.theplasticsfella.com/z-plasty/) may be needed. - **Post-Op:** Initiate early rehabilitation according to local protocols. The image below illustrates the post-operative view of Dupuytren's disease resected via Brunner incisions. ![Contracture release for Dupuytren's disease, surgical treatment for Dupuytren's disease](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--50-.png) Contracture release for Dupuytren's disease ### Complications Treatment for Dupuytren's disease can lead to several complications, including: - Neurovascular injury - Hematoma - Dupuytren’s flare response - Skin flap necrosis - Recurrence, with rates after surgery being highly variable ([Eberlin](https://www.sciencedirect.com/science/article/abs/pii/S0749071218300350?via%3Dihub&ref=theplasticsfella.com), 2018). 💡 ****Tip:** Finger ischemia from vessel spasm and shortening may occur on full extension. Flexion often restores circulation. Splint the finger slightly flexed, gradually increasing extension in future visits ([Black](https://journals.lww.com/jaaos/abstract/2011/12000/dupuytren%5Fdisease%5F%5Fan%5Fevolving%5Funderstanding%5Fof%5Fan.5.aspx?ref=theplasticsfella.com), 2011). --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Dupuytren’s Disease:** Dupuytren's disease is a benign fibroproliferative disorder primarily affecting the fascia of the palm and fingers, leading to progressive hand deformity. ****2\. Epidemiology:** Dupuytren’s disease predominantly affects older men of Northern European descent and is associated with factors such as family history, alcoholism, diabetes, and manual labor. ****3\. Pathoanatomy:** You understand the transformation of normal fascial anatomy into diseased cords and nodules, leading to contractures, specifically affecting the ulnar side of the hand. ****4\. Clinical Assessment:** You can identify Dupuytren's disease through its clinical presentation, which includes nodules and cords leading to fixed flexion deformities. ****5\. Management Strategies:** You're informed about the various treatment options ranging from non-operative methods such as collagenase injections and needle aponeurotomy to surgical interventions like fasciotomy and fasciectomy. ****6\. Potential Complications:** You are prepared to manage and anticipate potential complications arising from the treatment of Dupuytren’s disease, such as neurovascular injury, hematoma, or recurrence of the disease. --- ## Further Reading 1. Ruettermann M, Hermann RM, Khatib-Chahidi K, Werker PMN. [Dupuytren's Disease-Etiology and Treatment](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8864671/?ref=theplasticsfella.com). Dtsch Arztebl Int. 2021 Nov 19;118(46):781-788\. doi: 10.3238/arztebl.m2021.0325.PMID: 34702442; PMCID: PMC8864671. 2. Karbowiak, Marta, et al. "[Dupuytren’s disease](https://pubmed.ncbi.nlm.nih.gov/34088710/?ref=theplasticsfella.com)." *bmj* 373 (2021). 3. Leibovic, Stephen J. "[Normal and Pathologic Anatomy of Dupuytren Disease](https://europepmc.org/article/med/30012292?ref=theplasticsfella.com)." Hand Clinics 34.3 (2018): 315-329. 4. Eberlin, Kyle R., and Chaitanya S. Mudgal. "[Complications of treatment for Dupuytren disease](https://www.sciencedirect.com/science/article/abs/pii/S0749071218300350?via%3Dihub&ref=theplasticsfella.com)." Hand Clinics 34.3 (2018): 387-394. 5. Hindocha, Sandip. "[Risk factors, disease associations, and Dupuytren diathesis](https://www.sciencedirect.com/science/article/abs/pii/S0749071218300301?via%3Dihub&ref=theplasticsfella.com)." Hand Clinics 34.3 (2018): 307-314. 6. Fine, Nicola F., and Nadia Sciberras. "[Examination of the hand for MRCS](https://www.sciencedirect.com/science/article/abs/pii/S0263931919300468?ref=theplasticsfella.com)." Surgery (Oxford) 37.5 (2019): 265-269. 7. Desai, Shaunak S., and Vincent R. Hentz. "[The treatment of Dupuytren disease](https://www.sciencedirect.com/science/article/abs/pii/S0363502311002851?ref=theplasticsfella.com)." The Journal of hand surgery 36.5 (2011): 936-942. 8. Rodrigues, J. N., et al. "[Functional outcome and complications following surgery for Dupuytren’s disease: a multi-centre cross-sectional study](https://journals.sagepub.com/doi/abs/10.1177/1753193416660045?ref=theplasticsfella.com)." Journal of Hand Surgery (European Volume) 42.1 (2017): 7-17 9. Black, Eric M., and Philip E. Blazar. "[Dupuytren disease: an evolving understanding of an age-old disease](https://journals.lww.com/jaaos/abstract/2011/12000/dupuytren%5Fdisease%5F%5Fan%5Fevolving%5Funderstanding%5Fof%5Fan.5.aspx?ref=theplasticsfella.com)." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 19.12 (2011): 746-757. ### Gynaecomastia - Clinical Case URL: https://www.theplasticsfella.com/gynaecomastia-clinical-case-2/ Last updated: 2024-09-04T17:14:33.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Gynaecomastia-Clinical-Case.png) #### Clinical Scenario ****A 35-year-old man reports enlargement of his breasts for the last 6 months and is concerned about his appearance.** ****Objectives:** ****1\.** Take a relevant history for gynecomastia. ****2\.** Identify relevant investigations for gynecomastia. ****3\.** Consider treatment options for gynecomastia. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### FBI Stops Simultaneous Surgery, Final Week of the Sunday Quiz, & Melanomas URL: https://www.theplasticsfella.com/july-7th/ Last updated: 2024-07-07T12:29:30.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-7th/#a-letter-from-pfella) FBI stops simultaneous surgery. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/july-7th/#the-sunday-quiz) **\+ Leaderboard** How well do you know melanomas? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/july-7th/#behind-the-fella) Sneak peek from episode 03: All things research. 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/july-7th/#the-fellows-corner) Fresh drop: Gynaecomastia pathophysiology, diagnosis, & treatment. 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/july-7th/#what-does-the-evidence-say) Adjuvant therapies in melanoma. 6. ****🔥** [****Recommended Articles of the Week**](https://www.theplasticsfella.com/july-7th/#articles-of-the-week) Lymph node dissection, excision margins for thick cutaneous melanoma, & margins for primary cutaneous melanoma; with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/july-7th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **FBI Stops Simultaneous Surgery* 👋 ****Hey Team!** Big news: ****the FBI investigated a Medical Center**, accusing three heart surgeons of running two ORs at once and letting residents handle complex surgeries. Let's break it down: 👇 Experienced surgeons often differentiate between aspects of surgical procedures that require their expertise and those that can be managed by senior residents or fellows. **The practice of running multiple operating rooms simultaneously is usually designed to treat more patients efficiently**. **These "surgical trainees" are often not novices;** they are often fully trained fellows who require real surgical experience to refine their skills. However, the absence of hands-on practice could compromise future patient care. There is a significant debate surrounding this practice. Critics argue that entrusting complex parts of surgeries to residents could be risky, especially as modern medicine increasingly prioritizes safety and quality, **which makes this practice controversial**. Patients typically provide informed consent, acknowledging the involvement of trainees in their surgeries. However, questions remain about the actual qualifications of these residents and whether patients fully understand the extent of trainee involvement. The involvement of the **FBI** raises further questions. Typically, state medical boards are responsible for overseeing medical qualifications and practices, so why is a federal agency involved? This situation underscores the delicate balance between ensuring patient safety and providing necessary training to future surgeons—a balance that is crucial for the advancement and security of the medical field. Let’s keep the conversation going! ❤️, P'Fella ## The Sunday Quiz **How Well Do You Know* ***Melanoma** **s** *?* ****Are you ready for the last round of The Weekly Quiz?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Melanoma.png) Melanoma - Definition We're planning to discuss **melanomas** in an upcoming podcast episode. Subscribe on [**Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) or [**Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)to listen once it's out! ## Behind the ‘Fella **Sneak Peek from Episode 03* 🎧 ****Tune in Now: "Behind the Fella"** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. In this week's episode, we explore all things research! You can now listen on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com). 0:00 /1:14 1× Listen now on [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) and [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)! If there's any specific discussion you're interested in, let us know below. ## the Fellows' Corner **This Week's Focus: Gynaecomastia* In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques**. Read below for an overview of our article on Gynaecomastia. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Main-Article-Images--65-.png) #### Gynaecomastia [****Definition**](https://www.theplasticsfella.com/gynaecomastia/#definition-of-gynaecomastia) Gynaecomastia (GM) is characterized by enlargement of the male breast, caused by glandular proliferation and fat deposition. [****Pathophysiology**](https://www.theplasticsfella.com/gynaecomastia/#pathophysiology-of-gynaecomastia) Gynaecomastia is caused by an imbalance of androgenic and oestrogenic effects on the breast. [****Clinical Features**](https://www.theplasticsfella.com/gynaecomastia/#clinical-features-of-gynaecomastia) Gynaecomastia presents as bilateral, firm, concentric, and painless enlargement of the male breast. [****Classification**](https://www.theplasticsfella.com/gynaecomastia/#classification-of-gynaecomastia) Simon's classification is based on the degree of tissue and skin excess and Cordova is based on structural components of the breast. Gynaecomastia is staged using the Rohrich et al staging system. [****Investigations**](https://www.theplasticsfella.com/gynaecomastia/#investigations-for-gynaecomastia) Evaluation of gynaecomastia must include a detailed medical history, clinical examination, specific blood tests, imaging, and tissue sampling. [****Treatment**](https://www.theplasticsfella.com/gynaecomastia/#treatment-of-gynaecomastia) Treatment options include weight loss, reassurance, pharmacotherapy, and surgical resection or liposuction. [****Complications**](https://www.theplasticsfella.com/gynaecomastia/#complications-of-gynaecomastia) Complications of surgical excision include NAC loss, deformity, over/under resection, scarring, and recurrence. [Read the Article](www.theplasticsfella.com/gynaecomastia/) ## What Does the Evidence Say? **Adjuvant Therapies in Melanoma* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Major adjuvant trials have shown significant survival benefits for patients with **resected Stage III melanoma**. - **EORTC** **18,201** demonstrated that ipilimumab significantly improved 5-year recurrence-free (40.8% vs. 30.3%) and overall survival (65.4% vs. 54.4%) compared to placebo. - **CheckMate 238** found nivolumab more effective than ipilimumab, with a 24-month relapse-free survival rate of 70.5% versus 63.7%. - **Combi-AD** revealed that dabrafenib plus trametinib greatly reduced metastasis risk, achieving a 3-year relapse-free survival of 59% compared to 39% for placebo. - **EORTC 1325/KeyNote 054** showed pembrolizumab increased recurrence-free survival to 75.4% versus 61% for placebo. - **BRIM-8** indicated a modest effect of vemurafenib on disease-free survival in Stage IIC-III melanoma. These studies confirm the efficacy of adjuvant therapies in improving outcomes for this patient group. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* 1️⃣ ***Is lymph node dissection essential for melanoma with sentinel-node metastasis?** ([Faries](https://www.nejm.org/doi/full/10.1056/NEJMoa1613210?ref=theplasticsfella.com), 2017) Immediate completion lymph node dissection in melanoma patients with sentinel-node metastases did not enhance melanoma-specific survival compared to nodal observation, but improved regional disease control and offered valuable prognostic insights, albeit with a higher risk of lymphedema. 2️⃣ ***Which surgical excision margins are more effective for thick cutaneous melanoma?** ([Utjés](https://pubmed.ncbi.nlm.nih.gov/31280965/?ref=theplasticsfella.com), 2019) A long-term study comparing 2-cm and 4-cm surgical excision margins for thick cutaneous melanoma found that both margins provide similar overall and melanoma-specific survival rates, suggesting that the narrower 2-cm margin is sufficient for effective treatment. 3️⃣ ***Comparison of a 1-cm surgical margin and a 2-cm margin for treating primary cutaneous melanoma** ([Moncrieff](https://pubmed.ncbi.nlm.nih.gov/29850955/?ref=theplasticsfella.com), 2018) A pilot study (MelMarT) compared 1-cm and 2-cm surgical excision margins for primary cutaneous melanoma thicker than 1 mm, finding that both margins were feasible, with no significant differences in patient quality of life. ## Feedback ### I hope you enjoyed it 😄 --- ### Gynaecomastia: Pathophysiology, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/gynaecomastia/ Last updated: 2024-07-07T08:46:21.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/gynaecomastia/#definition-of-gynaecomastia) Gynaecomastia is enlargement of the male breast, caused by glandular proliferation and fat deposition. [****Pathophysiology**](https://www.theplasticsfella.com/gynaecomastia/#pathophysiology-of-gynaecomastia) An imbalance of androgenic and oestrogenic effects on the breast. [****Clinical Features**](https://www.theplasticsfella.com/gynaecomastia/#clinical-features-of-gynaecomastia) Bilateral, firm, concentric, and painless enlargement of the male breast. [****Classification**](https://www.theplasticsfella.com/gynaecomastia/#classification-of-gynaecomastia) Simon's classification is based on the degree of tissue and skin excess and Cordova is based on structural components of the breast. Gynaecomastia is staged using the Rohrich et al staging system. [****Investigations**](https://www.theplasticsfella.com/gynaecomastia/#investigations-for-gynaecomastia) Detailed medical history, clinical examination, specific blood tests, ± imaging ± tissue sampling. [****Treatment**](https://www.theplasticsfella.com/gynaecomastia/#treatment-of-gynaecomastia) Weight loss, reassurance, pharmacotherapy, and surgical resection or liposuction. [****Complications**](https://www.theplasticsfella.com/gynaecomastia/#complications-of-gynaecomastia) Complications of surgical excision include NAC loss, deformity, over/under resection, scarring, and recurrence. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Definition of Gynaecomastia ****Key Point** Gynaecomastia (GM) is characterised by enlargement of the male breast, caused by glandular proliferation and fat deposition. **Gynaecomastia** is defined as generalised enlargement of male breast tissue, with the presence of a rubbery or firm mass extending concentrically and symmetrically from the nipple. Histologically, it involves a benign proliferation of glandular tissue in the male breast ([Cuhaci](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987263/?ref=theplasticsfella.com), 2014). **Pseudogynaecomastia** is common in obese men, and consists of lipomastia alone, without glandular proliferation. 😎 ****Fun Fact:** At least 30% of males will be affected by gynaecomastia during their life ([Cuhaci](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987263/?ref=theplasticsfella.com), 2014). --- ## Pathophysiology of Gynaecomastia ****Key Point** Gynaecomastia arises from an imbalance between androgenic and oestrogenic effects on breast tissue. Gynaecomastia results from an imbalance in breast tissue, where oestrogenic effects outweigh androgenic effects. Causes include: - Elevated **estradiol** levels**.** - Increased local **oestrogen** production. - Excess **testosterone**. - Increased **aromatase** activity converting androgens to oestrogens. ### Increased Oestrogen Increased oestrogen levels contribute significantly to gynaecomastia. This can result from: - **Production:** High levels of free oestrogens secreted by testes or adrenal glands - **Metabolism:** Extraglandular aromatization of oestrogen precursors, reduced degradation of oestrogens. - **Exposure:** Oestrogen-like chemicals, exogenous oestrogens, or drugs displacing oestrogen more than androgen from SHBG. ### Decreased Testosterone Decreased testosterone levels contribute to gynaecomastia. This can result from: - **Production:** Decreased androgen production in the testes - **Metabolism:** Altered androgen metabolism, Increased binding of androgens (relative to oestrogens) by SHBG - **Exposure:** Drug-induced displacement of androgens from their receptors and androgen receptor defects --- ## Aetiology of Gynaecomastia ****Key Point** Gynaecomastia can be idiopathic, physiological (trimodal distribution) or pathological. The aetiology of gynaecomastia can be categorised into three main areas: **idiopathic**, **physiological**, and **pathological.** ### Physiological Physiological **gynaecomastia** has the classic **trimodal** distribution. The 3 time periods commonly affected are - **Newborns:** 60-90% affected by maternal oestrogen transfer; resolves within the first year. - **Puberty:** Up to 65% affected by temporary oestrogen elevation; 90% resolve spontaneously. - **Elderly:** declining testosterone levels, medications, & other factors. These 3 periods are explained in greater detail in the image below. ![Physiologic gynecomastia, pathophysiology of gynaecomastia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--66-.png) Physiologic gynaecomastia ### **Pathological** Pathological causes are **less common**, but thorough investigations should still be considered. In the clinical history, red flags: 1. **Medications** ([Barros](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10876201/?ref=theplasticsfella.com), 2012): Anti-androgens, Steroids, Psychiatric medications, Anti-hypertensives. 2. **Drugs**: Amphetamines, alcohol and marijuana The below table details other pathological causes of gynaecomastia. ![Pathological gynaecomastia, diagnosis of gynaecomastia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--68-.png) Pathological gynaecomastia 😎 ****Fun Fact:** Spironolactone causes gynaecomastia by several mechanisms, it blocks testosterone synthesis, blocks androgen action, and displaces oestrogen from SHBG ([Swerdloff](https://www.ncbi.nlm.nih.gov/books/NBK279105/?ref=theplasticsfella.com), 2023). --- ## Clinical Features of Gynaecomastia ****Key Point** Gynaecomastia presents as bilateral, firm, concentric, painless enlargement of the male breast The classic clinical feature of gynaecomastia is **bilateral**, **firm**, **concentric** breast enlargement in the **absence of skin changes**. It is important to differentiate true gynaecomastia from pseudo-gynaecomastia, and male breast cancer. Key points to consider in the **history** include: - **Patient Status:** Age, Medications, Drugs (Anabolic, Recreational) - **Symptoms:** Duration, tenderness/pain, weight changes - **Systemic:** liver disease, malnutrition, kidney failure, thyroid, adrenal disease. It is important to document the following on **examination**: - **Inspection:** ptosis, skin excess - **Palpation:** masses - **Specific:** fat versus glandular predominance via Pinch test - **Other areas:** genitals, thyroid, GI examination (liver disease) Key physical features of gynecomastia are detailed in the table below, adapted from [Swerdloff](https://www.ncbi.nlm.nih.gov/books/NBK279105/?ref=theplasticsfella.com), 2023\. ![Physical features of gynaecomastia, presentation of gynaecomastia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--63-.png) Physical features of gynaecomastia 😎 ****Fun Fact:** 30% to 60% of boys exhibit GM during adolescence ([Baros](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10876201/?ref=theplasticsfella.com), 2012). More than half of the patients with persistent pubertal gynaecomastia have a family history of the condition ([Baros](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10876201/?ref=theplasticsfella.com), 2012). --- ## Classification of Gynaecomastia ****Key Point** Simons grade is based on the degree of tissue and skin excess. Cordova considers structural components of the breast. Rohrich stages are based on the degree of hypertrophy and fibrosis. The staging and presentation of gynecomastia are crucial in determining the appropriate management options. The most commonly used classification system for this purpose is the Simon Classification, detailed below. ### Simon Classification **Simon classification** is based on the degree of tissue and skin excess. - **Type I:** minor breast enlargement without skin excess. - **Type IIa:** moderate breast enlargementwithout skin excess. - **Type IIb:** moderate breast enlargementwith minor skin redundancy. - **Type III:** gross breast enlargement with skin excess creating a pendulous breast. This classification can be visualised in the image below. ![Simon Classification of Gynaecomastia, Gynecomastia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/07/Gynaecomastia-Classificaiton.png) Simon Classification of Gynaecomastia ### Cordova Classification **Cordova and Moschella** classification takes into account the different **structural components** of the breast, the **relationship with the IMF,** and the **NAC**. - **Grade I:** increase in diameter and protrusion limited to the areola. - **Grade II:** hypertrophy of all the components of the breast; NAC is above the IMF. - **Grade III:** hypertrophy of all the components; NAC at the same height as or 1 cm below the IMF. - **Grade IV:** hypertrophy of all the components; NAC >1cm below the IMF. ### Rohrich Staging The Rohrich Classification system is used to stage gynecomastia based on the degree of hypertrophy and ptosis: - **Grade I: Minimal hypertrophy (<250g) with no ptosis** - Ia - primarily glandular - Ib - primarily fibrous - **Grade II: Moderate hypertrophy (250-500g) with no ptosis** - IIa - primarily glandular - IIb - primarily fibrous - **Grade III: Severe hypertrophy (>500g) with grade I ptosis** - **Grade IV: Severe hypertrophy with grade II or III ptosis** 😎 ****Fun Fact:** Gynecomastia does not increase the risk of male breast cancer. However, patients with Klinefelter syndrome have up to 50 times higher risk of developing breast cancer. --- ## Investigations for Gynaecomastia ****Key Point** Routine evaluation of gynaecomastia includes specific blood tests, imaging, and tissue sampling, often involving an endocrinologist. ### Laboratory Routine laboratory investigations focus on identifying any treatable endocrinological cause. - **Bloods**: Liver Profile, Testosterone, TSH/free thyroxine, LH, hCG, prolactin - If small, firm testes: Karyotyping for 47XXY - If abnormal testicular mass: ultrasound, beta-hCG, FSH, LH, serum testosterone, or oestradiol ### Imaging ### Imaging is not routinely performed in the pre-operative workup of gynecomastia. Typical breast ultrasound findings include hypoechoic retroareolar masses and increased anteroposterior depth at the nipple. Imaging considerations include: - **Mammography:** If malignancy is suspected ± histology - **Ultrasound:** Adrenal glands and testes, if indicated. ± histology --- ## Treatment of Gynaecomastia ****Key Point** Treatment options include weight loss, reassurance, medical pharmacotherapy, and surgical correction. Treatment for gynaecomastia varies based on **aetiology** and **severity**. Before any intervention, it is essential to stop causative medications or treat underlying endocrine or systemic conditions. **Mild** cases typically focus on reassurance, diet, and exercise, while more **severe** cases may require medical or surgical treatment. This is explained in more detail below. 😎 ****Fun Fact:** Most cases of pubertal gynecomastia resolve spontaneously within one to two years, but about 20% of patients have residual gynecomastia by age 20\. ### ### Medical Treatment Medical treatment for gynecomastia is considered in cases that are **severe**, **persistent**, or of **recent onset** (less than 6 months). If there is no treatable underlying cause, 3 classes of medical therapies can be considered 1. **Androgens**: testosterone, dihydrotestosterone, danazol. 2. **Anti-oestrogens**: clomiphene citrate, tamoxifen (up to 80% of patients report complete resolution, Bedognetti, 2009). 3. **Aromatase inhibitors**: letrozole, anastrozole (Braunstein, 2007). Prophylactic breast irradiation can reduce gynecomastia in patients on long-term antiandrogen therapy (e.g., prostate cancer), but it carries a theoretical risk of tumorigenesis and is not indicated for idiopathic gynecomastia. 💡 ****Tip:** Medical treatment is most effective when started before the glandular structure is replaced by stromal hyalinization and fibrosis. ### Surgical Treatment for Gynaecomastia ****Key Point** Surgery is useful in the management of patients with long-standing symptomatic gynaecomastia or when medical therapy is not successful. **Indications for Surgery** Surgery aims to reduce the size of the breast with minimal scars possible. It is indicated in: - **Symptomatic** patients - **Breast changes:** fibrosis, risk for carcinoma (e.g. Klinefelter's syndrome) - **Medical Therapy** has been ineffective - Interferes with the patient's **activities of daily living** ![Gynaecomastia pre- and post-surgery.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--65-.png) Gynaecomastia pre- and post-surgery. **Types of Surgery** The decision-making process for gynaecomastia should focus on: technique (liposuction vs resection vs combination), single vs two-stage, and timing. In relation to **liposuction**, options include: - Manual liposuction - Power-assisted liposuction: Reduces operative fatigue and improves control in chest wall contouring - Ultrasound-assisted liposuction (UAL): Associated with improved skin retraction - Laser-assisted liposuction In relation to surgical excision, design options include: - **Nipple Incisions**: Periareolar, Circumareolar - **Breast Incisions**: Wise pattern, IMF +/- free nipple graft In relation to **timing** of surgery, considerations include: - Delayed until the underlying cause of gynaecomastia has been treated. - Delayed in pubertal gynaecomastia til after completion of puberty when possible, to minimize the chance of recurrent gynaecomastia after surgery. Surgical approaches for gynaecomastia are detailed in the table below – adapted from ([Baros](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10876201/?ref=theplasticsfella.com), 2012). ![Surgical treatment approaches for gynaecomastia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--64-.png) Surgical treatment approaches for gynaecomastia 💡 ****Tip:** Two-stage surgery is indicated for significant excess skin and grade III Renault ptosis over hypertrophied pectoralis muscles, commonly seen in bodybuilders after steroid use. --- ## Complications of Gynaecomastia ****Key Point** Complications of surgical excision include NAC loss, deformity, over/under resection, scarring, and recurrence. Surgical excision for gynaecomastia can lead to several complications, including NAC (nipple-areolar complex) loss, deformity, over- or under-resection, scarring, and recurrence. - **Over-resection**: Over-correction can result in a sunken nipple, known as "saucer deformity," where the nipple adheres to the underlying muscle due to the lack of subcutaneous tissue. - **Scarring**: Noticeable scars may form, affecting the cosmetic outcome. - **Recurrence**: Gynecomastia can recur if the underlying cause is not addressed. - **Nipple-Areolar Complex**: Loss or compromise of the NAC can lead to significant deformity. - **Early Postoperative Complications**: These can include haematoma, seroma, infection, and wound healing problems, often related to the anaesthesia and surgical process. Effective surgical planning and careful postoperative care are essential to minimize these risks and achieve the best results for patients undergoing gynecomastia surgery. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding of Gynaecomastia:** This includes knowledge about its definition, pathophysiology, classification, and how it presents clinically. ****2\. Diagnostic Process:** Recognized the importance of a detailed medical history, clinical examination, specific blood tests, imaging, and potentially tissue sampling for the effective diagnosis of gynaecomastia. ****3\. Treatment Options:** Understood various treatment strategies from conservative approaches like reassurance and weight loss to pharmacological treatments and surgical interventions. ****4\. Surgical Techniques and Complications:** Familiarized with different surgical approaches for the management of gynaecomastia and learned about potential complications associated with these surgeries. --- ## Further Reading 1. Swerdloff RS, Ng JCM. [Gynecomastia: Etiology, Diagnosis, and Treatment](https://www.ncbi.nlm.nih.gov/books/NBK279105/?ref=theplasticsfella.com). \[Updated 2023 Jan 6\]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext \[Internet\]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279105/ 2. Cuhaci N, Polat SB, Evranos B, Ersoy R, Cakir B. [Gynecomastia: Clinical evaluation and management](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987263/?ref=theplasticsfella.com). Indian J Endocrinol Metab. 2014 Mar;18(2):150-8\. doi: 10.4103/2230-8210.129104\. PMID: 24741509; PMCID: PMC3987263. 3. Ali SN, Jayasena CN, Sam AH. [Which patients with gynaecomastia require more detailed investigation?](https://pubmed.ncbi.nlm.nih.gov/29193251/?ref=theplasticsfella.com) Clin Endocrinol (Oxf). 2018 Mar;88(3):360-363\. doi: 10.1111/cen.13526\. Epub 2017 Dec 21\. PMID: 29193251. 4. Narula HS, Carlson HE. [Gynecomastia](https://pubmed.ncbi.nlm.nih.gov/17543732/?ref=theplasticsfella.com). Endocrinol Metab Clin North Am. 2007 Jun;36(2):497-519\. doi: 10.1016/j.ecl.2007.03.013\. PMID: 17543732. 5. Barros AC, Sampaio Mde C. [Gynecomastia: physiopathology, evaluation and treatment](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10876201/?ref=theplasticsfella.com). Sao Paulo Med J. 2012;130(3):187-97\. doi: 10.1590/s1516-31802012000300009\. PMID: 22790552; PMCID: PMC10876201. 6. Braunstein GD. Clinical practice. [Gynecomastia](https://pubmed.ncbi.nlm.nih.gov/17881754/?ref=theplasticsfella.com). N Engl J Med. 2007 Sep 20;357(12):1229-37\. doi: 10.1056/NEJMcp070677\. PMID: 17881754. 7. Bedognetti D, Rubagotti A, Conti G, Francesca F, De Cobelli O, Canclini L, Gallucci M, Aragona F, Di Tonno P, Cortellini P, Martorana G, Lapini A, Boccardo F. [An open, randomised, multicentre, phase 3 trial comparing the efficacy of two tamoxifen schedules in preventing gynaecomastia induced by bicalutamide monotherapy in prostate cancer patients](https://pubmed.ncbi.nlm.nih.gov/19481335/?ref=theplasticsfella.com). Eur Urol. 2010 Feb;57(2):238-45\. doi: 10.1016/j.eururo.2009.05.019\. Epub 2009 May 19\. PMID: 19481335. 8. Godwin Y. [Correction of Tuberous Nipple Areolar Complex Deformity in Gynecomastia: The Deformity That Can Get Forgotten](https://pubmed.ncbi.nlm.nih.gov/29762454/?ref=theplasticsfella.com). Ann Plast Surg. 2018 Jul;81(1):3-6\. doi: 10.1097/SAP.0000000000001442\. PMID: 29762454. ### 🎈Special Edition: P'Fella's 5th B'day! Triumphs, Flops & a Bold Future! URL: https://www.theplasticsfella.com/june-30th/ Last updated: 2024-06-30T14:36:45.000Z #### 5 years of thePlasticsFella ****This isn't your usual edition of thePlasticsPaper.** This is a celebration – a joyous celebration of 5 incredible years! 🎉 It's a time to reflect, highlight some impressive stats, revisit our mission, and showcase the amazing resources we've built for you over this journey. Here’s what we’ll dive into together: 1. [****Proudest Success**:](https://www.theplasticsfella.com/june-30th/#proudest-success) +1 Million People Use Our Free Library! 2. [****Hardest Challenge**](https://www.theplasticsfella.com/june-30th/#hardest-challenge): Building a Universal Learning Environment! 3. [****Biggest Blunder**](https://www.theplasticsfella.com/june-30th/#biggest-blunder): Not Building a Team Sooner! 4. [****Best Decision**](https://www.theplasticsfella.com/june-30th/#best-decision): Our Sustainable Educational Model! 5. [****Bold Future Plans**](https://www.theplasticsfella.com/june-30th/#bold-future-plans): "Duolingo for Plastic Surgery" P.S. – Got more questions? [Ask it here](https://www.theplasticsfella.com/june-30th/#have-another-question), and it might get answered on the podcast ## ****Proudest Success** +1 Million People Use Our Free Library! When thePlasticsFella first started, it was niche. Super niche. We provided concise notes on specific aspects of plastic surgery. Never did I imagine that, 5 years later, over **1,000,000 people** would have used the platform to learn and understand plastic surgery. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/Zones-of-the-Hand-Journal-Club.png) In the last 12 months alone, we've welcomed **350,000 new users**. So who are these new users? - **Plastic Surgery Medical Students: 20%** - **Plastic Surgery Trainees/Residents: 65%** - **Consultants/Attendings: 10%** - **Other Professionals: 5%** ### And this is how they discover the platform? ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/thePlasticsPaper.png) # Once users get onto the platform, you dive into a wealth of resources. Over the past 12 months, certain articles have stood out as the most popular, reflecting key areas of interest and need within the plastic surgery community. ### Here are the top 10 articles that have captured the most attention ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/thePlasticsPaper-1.png) ### ## ****Hardest Challenge** Building a Universal Learning Environment! Developing a resource that caters to over 1 million people is no easy feat, especially considering the diverse learning styles among users. Some prefer **bullet points**, others **long sentences**, and many benefit from **images** and **videos**. ### The challenge is to cater to everyone without alienating anyone. Over time, we've fine-tuned our content to suit various preferences effectively. Here’s our simple yet effective approach: 1. **Super Concise Summaries:** At the top of every page, we provide a brief summary. This allows users to quickly find essential information, perfect for those needing a quick reference while at work. 2. **Key Points:** At the beginning of each section, we highlight key points. This helps users who need a bit more information but still prefer a concise format. 3. **Comprehensive Main Body:** The main content combines sentences, bullet points, and images/videos. This section is for users who want a more in-depth understanding, catering to all learning styles in a balanced manner. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/thePlasticsPaper-2.png) By structuring our content this way, we've managed to create a versatile learning environment that meets the needs of a diverse audience. ## ****Biggest Blunder** Not Building a Team Sooner! ### This one is easy to pinpoint. The biggest mistake? Going solo for too long. **For the first four years or so, it was just me**. As a full-time plastic surgery resident, I could only dedicate about \~**20 hours a week** on top of my normal job. This meant the platform progressed slowly and steadily rather than experiencing "overnight success" (which, in hindsight, has its benefits). Operating solo also taught me efficiency in managing all aspects of an educational platform. But now, I'm delighted (and so is my wife!) that I have a fantastic team to help out. Check them out below: ![Image](https://pbs.twimg.com/media/GKvhzouXQAEjkQ2?format=jpg&name=4096x4096) Our team is amazing. The content we produce each month far exceeds what I could ever have done alone. This is crucial for creating high-quality content for the community. All the revenue invested by you, the community, goes directly back into the platform. **We now have a super streamlined process, creating over +30 pieces of educational content every month for you all**. And the team is only going to get bigger & better. ## ****Best Decision** Our Sustainable Educational Model! ### The best decision at thePlasticsFella? our business model. This has never changed and never will. **Profiting from education is something I strongly oppose.** Some platforms charge exorbitant fees (often with random discounts) for a few hundred questions, or hefty amounts for short courses with no follow-up—information you'll likely forget within 48 hours. This creates barriers to education and misaligned incentives. Every dollar generated by thePlasticsFella goes directly back into the platform. The more users we have, the better the learning environment becomes, making our community stronger. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/About-Us---Ghost-1.png) **Our model has turned thePlasticsFella into a self-sustaining ecosystem**. Every penny is reinvested to enhance and expand our free educational library. This isn’t just a resource; it’s a vibrant community where quality education and engagement thrive together. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/About-Us---Ghost-2.png) By continuously reinvesting, we’ve created a virtuous cycle. More engagement leads to more resources, enabling us to produce even better content. ## ****Bold Future Plans** "Duolingo for Plastic Surgery" ### We have a pretty ambitious goal. So hear me out. **Right now, we have about 70% of the plastic surgery curriculum covered.** We aim to reach nearly 100% in the next 6 months (thanks ot the amazing team!) Then, it’s time to focus on the software. We'll be building a completely new learning environment that fully integrates with your day-to-day life. Almost like **Duolingo for plastic surgeons** (but you'll actually learn the language of plastic surgery). **Our vision is to build a single platform that covers every aspect of plastic surgery education**. From foundational knowledge to advanced techniques, this platform will be your go-to resource for learning, practice, and professional growth. ## This is all made possible by the amazing support from the amazing community (in particular thePlasticsPro users), so thank you 🙏 ## Have another question ### We'll answer it on an upcoming episode of Behind the 'Fella 🎙️ --- ### Poland Syndrome: Aetiology, Presentation, & Management URL: https://www.theplasticsfella.com/poland-syndrome/ Last updated: 2024-06-22T09:48:27.000Z #### Summary Card [****Definition** ](https://www.theplasticsfella.com/poland-syndrome/#definition-of-poland-syndrome)A spectrum of unilateral congenital chest wall deformities involving the ****sternal head of the pectoralis major.** It is associated with ****ipsilateral hand anomalies**. [****Aetiology**](https://www.theplasticsfella.com/poland-syndrome/#aetiology-of-poland-syndrome) Poland syndrome occurs predominantly on the right side and mostly in males. The precise aetiology remains uncertain but working theories include subclavian artery hypoplasia, genetic and teratogenic. [****Presentation**](https://www.theplasticsfella.com/poland-syndrome/#presentation-of-poland-syndrome) Poland syndrome is a constellation of phenotypes including the absence of hypoplasia of the sternal portion of the pectoralis major alongside predominantly ipsilateral chest wall and hand differences. [****Investigations**](https://www.theplasticsfella.com/poland-syndrome/#investigations-for-poland-syndrome) Poland syndrome is a clinical diagnosis. Imaging is useful to exclude rare associations and for pre-operative planning. [****Differential Diagnosis** ](https://www.theplasticsfella.com/poland-syndrome/#differential-diagnosis-of-poland-syndrome)The differential diagnosis of Poland syndrome depends on the structures involved - chest wall, shoulder, and hand. Rare syndromes and associations should be kept in mind. [****Management**](https://www.theplasticsfella.com/poland-syndrome/#management-of-poland-syndrome) Surgical management aims to create a stable and symmetrical thorax and chest wall while optimising hand function and appearance. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## Definition of Poland Syndrome ****Key Point** Poland syndrome is a unilateral congenital condition characterised by chest wall deformity, aplasia or hypoplasia of the pectoralis major and minor muscles, and ipsilateral hand anomalies among other features. Poland syndrome refers to a **spectrum of unilateral chest wall, shoulder and upper limb anomalies**. It is usually sporadic, although a few familial cases have been described ([Darian](https://pubmed.ncbi.nlm.nih.gov/2560355/?ref=theplasticsfella.com), 1989) and is more common in males. Initial case reports were provided in 1826 ([Moir](https://pubmed.ncbi.nlm.nih.gov/18582821/?ref=theplasticsfella.com), 2008), with the eponym being taken from Alfred Poland’s 1941 paper of an autopsy of a 27-year-old convict ([Poland](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410274/?ref=theplasticsfella.com), 1941 & [Ram](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410274/?ref=theplasticsfella.com) 2015). The image below further defines Poland syndrome. ![Definition and presentation of left-sided Poland syndrome.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--45-.png) Definition and presentation of left-sided Poland syndrome 😎 ****Fun Fact:** 75% of cases of Poland syndrome involve the right side. --- ## Aetiology of Poland Syndrome ****Key Point** Poland syndrome occurs predominantly on the right side and mostly in males. The precise aetiology remains uncertain but working theories include subclavian artery hypoplasia, genetic and teratogenic. Poland syndrome occurs in around **1:20,000 - 1:32,000** live births, with a male-to-female ratio of **3:1** ([Gupta](https://books.google.co.uk/books/about/The%5FGrowing%5FHand.html?id=rUB-QgAACAAJ&ref=theplasticsfella.com), 2000). The exact aetiology is unknown. It is generally considered to be: - **Sporadic** (genetic associations have been described by [Glass](https://pubmed.ncbi.nlm.nih.gov/36581828/?ref=theplasticsfella.com)) - “**Subclavian-artery steal syndrome**”: a unilateral reduction in blood supply due to a developmental difference in the subclavian artery. - **Drugs**: Teratogens ([Moir](https://pdf.sciencedirectassets.com/274153/1-s2.0-S1055858608X00034/1-s2.0-S1055858608000140/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjEMz%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJIMEYCIQDsKQyKW765bMqhccTUGWRsg%2FzxrV7VKtTEGbKHJqOGQQIhAIZVz7LLybU4yiQNmn%2FS%2BMLvIHEVCtu6xJudAyQRHgmBKrMFCFUQBRoMMDU5MDAzNTQ2ODY1IgwYi1B2vGT0ndqzufIqkAVZ6TfLxTzTEfUxXJckxm%2FPKiZI6Wr2FikNUSaDUTSbmDPI4gbWkMl7k2sdO4WehmLbdnSkM98gJ4M7qxjaceBhe%2Fq5iG38tciDw21vzmd4ohRd%2BaK37w%2BDLJANWAGhsp%2Bcelnyy2SXMd3CCjXe8lEfHIpuz6tRH0eJhW4U55c5p%2FOkE%2F2wJ%2Blwutnu3diJnyka3p0z1BMaBckWXp2iI5i4b0OxC9J%2BIZzkvwTPG9IOdDkTfprE019%2BHAIuIANCTlj4r6Eau8s5ivydMh4UwbZwO2laesF4liYg%2Btt%2Bzf2H%2FS2N4mvS03FPs73pUJZILqm0ekraaU%2BtRsZP3D2fBLs0cBloPySlXmEJ%2FW6jOdg7JWBmrBIlyWbKdzOKJnqNl0ta7J%2F8qzLXkfwFjJ%2B4eVnncXvSfaIesXTqFcjPHqMuzUei1ha184tpbtHNSeztju8DX4S8l%2BD%2F3NR4ensGZ5amZUNF6SZ7SdaLAOe7XB5tQS6tdEfY%2F88CoZFnahCRpII8ISLYLR%2BWtkOX%2F%2FEmfj9LXaNZX8pIrDJIhkDuKSmkOs%2BnHUcCecxxn%2F9OLynfSZxXu5VfMfhufdZbA3%2BL3YSNy01u1Fo5hrW8%2FdDMxExf5Ndjxv2dWwAZpanO%2BPdyzpqK1Tk9Wk23PzQYBnLl8x7kR%2B%2FK6XPzo05H%2BJcCf46Sa5ErxfOy%2FrQhgEdrB9hblT0Uz%2BNfX2rl22GsbsUcy0Mjlu3eaoANFOM6KygXZC3JHcXHAMv4UrqyaSb%2FYkqhAj5r8yRMa6iS%2FE3Bn4eG3Y0amKW3dA36v6cva42JrR2yQ1gFkxoSr%2FJ1Ikx%2Fc%2FNZwdK51aKhgV95rqn5FcU6FO%2FQ9aBJj0%2BqXgKN51QptoqsDjDSseqyBjqwARZHGBW5b6H%2BQh1aPbxnlo0%2F4syoSe2HeJRzs%2FtiZz6lj0TMsnq7oVO5T9rl2UoOTvrPJh9mbNv7iD9MveNWCXTKga%2F15EafXf47XLZfyNlNSEvJuli9rstM5DCzJzdIot2xhKUqH8quMcpOGqB1f7irJswwNaKOM8SywU9x7fS5jP%2BrA6a2bAn3ubzdinkBJLICNAXYq4Jypq1gbgEhQqpd1ysKHA9uOOX%2B56sA%2Bebg&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20240601T045955Z&X-Amz-SignedHeaders=host&X-Amz-Expires=300&X-Amz-Credential=ASIAQ3PHCVTYWQC7Z2EY%2F20240601%2Fus-east-1%2Fs3%2Faws4%5Frequest&X-Amz-Signature=76c903d050724368e9e17ac0838f38aa45310e1a04ebc549266ef68ac50112ee&hash=24c323e598b85ce3134cb1a57437e7eaf875e129b9c07f2e229a7bf9030001c8&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=S1055858608000140&tid=spdf-914d7b01-15ed-4824-81cf-1468a63861db&sid=99c486b2132e4043e028e7427b979b7e1391gxrqb&type=client&tsoh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&ua=0104585902020e5d555c&rr=88cca3188c2506e5&cc=gb&ref=theplasticsfella.com), 2008).Maternal smoking (doubles the risk), Cocaine, Misoprostol (prostaglandin analogue). 😎 ****Fun Fact:** There have been a handful of cases described in the literature of Poland syndrome presenting in conjunction with ****Moebius syndrome** (congenital hypoplasia of the 6th and 7th cranial nerves). Genetic studies have identified PLXND1 as a possible causative gene linking the two congenital differences ([Glass](https://pubmed.ncbi.nlm.nih.gov/36581828/?ref=theplasticsfella.com), 2022). --- ## Presentation of Poland Syndrome ****Key Point** Poland syndrome is a constellation of phenotypes including the absence of hypoplasia of the sternal portion of the pectoralis major, alongside predominantly ipsilateral chest wall and hand differences. Patients with Poland syndrome are most commonly referred for evaluation due to noticeable **deformities in the hand or chest wall**. ### Clinical Features The syndrome's most consistent feature across cases is the hypoplasia or aplasia of the sternal head of the pectoralis major. - **Chest wall:** Aplasia or hypoplasia of the breast, hypoplastic scapula, rib hypoplasia - **Shoulder:** Axillary bands, muscle hypoplasia - **Hand:** Brachydactyly (short digits), Symbrachydactyly (short, joined or webbed digits), Syndactyly (joined or webbed digits), Ectrodactyly (absence of digits) 💡 ****Tip:** Contralateral digit differences are very rare but have been reported (Powell, 1993 & [Gupta](https://books.google.co.uk/books/about/The%5FGrowing%5FHand.html?id=rUB-QgAACAAJ&ref=theplasticsfella.com), 2000). ### **Associated Anomalies** While extremely rare, some cases of Poland syndrome have been associated with the development of childhood **hematological** and **solid organ malignancies**, including: - Acute lymphoblastic leukemia - Acute myeloblastic leukemia - Chronic myelogenous leukemia - Non-Hodgkin's lymphoma There are also reports of Poland syndrome occurring alongside other congenital conditions such as: - Craniofrontonasal dysplasia - Pituitary anomalies - Dextrocardia ([Ozkok S](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593920/pdf/NCI-6-192.pdf?ref=theplasticsfella.com), 2018). 😎 ****Fun Fact:** Cardiorespiratory compromise secondary to deformity is uncommon. The image below illustrates right-hand symbrachydactyly in the presentation of Poland syndrome. ![Right-hand symbrachydactyly in the presentation of Poland syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--44-.png) Right-hand symbrachydactyly - Poland syndrome 💡 ****Tip:** Sprengel’s anomaly is the failure of the descent of the scapula. The scapula may also be hypoplastic and winged. --- ## Investigations for Poland Syndrome ****Key Point** Poland syndrome is a clinical diagnosis. Imaging is useful to exclude rare associations and for pre-operative planning. Poland syndrome is primarily diagnosed based on **clinical observations**. The role of diagnostic investigations is to confirm the extent of physical anomalies, exclude associated conditions, and assist in surgical planning. Investigations to consider include: - **X-ray:** Hands, chest wall, and shoulder girdle. - **US:** Chest wall, shoulder, cardiac, abdominal, & renal ([Baldelli I](https://ojrd.biomedcentral.com/articles/10.1186/s13023-020-01481-x?ref=theplasticsfella.com), 2020). - **CT or MRI:** For 3D reconstruction and surgical planning. - **Genetic** counselling and testing are not yet routine but may be offered. 💡 ****Tip:** 3D-printed bespoke implants can be generated from CT or MRI images ([Chavoin](https://pubmed.ncbi.nlm.nih.gov/30045173/?ref=theplasticsfella.com), 2018). --- ## Differential Diagnosis of Poland Syndrome ****Key Point** The diagnosis of Poland syndrome depends on the structures involved. Rare syndromes and associations should be kept in mind. Poland syndrome may be considered in 4 categories: - Unilateral - Bilateral (rare) - Associated upper limb anomalies - Complex These categories and their features are illustrated in the table below. ![This table categorises the differential diagnosis od Poland syndrome and their clinical features.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--36-.png) Differential diagnosis and clinical features of Poland syndrome --- ## Management of Poland Syndrome ****Key Point** Surgical management aims to create a stable and symmetrical thorax and chest wall, whilst optimising hand function and appearance. Management of Poland Syndrome involves a blend of surgical intervention and supportive therapies to address both the physical deformities and psychological impact of the condition: - **Non-progressive nature:** Patients and families are reassured about the non-progressive nature of the diagnosis. - **Supportive therapies:** Physiotherapy, occupational therapy, and psychological support are critical, particularly as children transition into young adulthood. - **Considerations for timing:** Surgical interventions are planned around key developmental stages to minimize impact on self-esteem and body image, typically intensifying around age 6 or 7 and into the teenage years. 💡 ****Tip:** ****Prenatal diagnosis** may occur, depending on local scanning policy and expertise ([Nguyen](https://pubmed.ncbi.nlm.nih.gov/37423914/?ref=theplasticsfella.com), 2023). ### Surgical Interventions Early surgical intervention is required in severe chest wall deformity that can be associated with lung herniation in around **7%** of cases ([Moir](https://pdf.sciencedirectassets.com/274153/1-s2.0-S1055858608X00034/1-s2.0-S1055858608000140/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjEMz%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJIMEYCIQDsKQyKW765bMqhccTUGWRsg%2FzxrV7VKtTEGbKHJqOGQQIhAIZVz7LLybU4yiQNmn%2FS%2BMLvIHEVCtu6xJudAyQRHgmBKrMFCFUQBRoMMDU5MDAzNTQ2ODY1IgwYi1B2vGT0ndqzufIqkAVZ6TfLxTzTEfUxXJckxm%2FPKiZI6Wr2FikNUSaDUTSbmDPI4gbWkMl7k2sdO4WehmLbdnSkM98gJ4M7qxjaceBhe%2Fq5iG38tciDw21vzmd4ohRd%2BaK37w%2BDLJANWAGhsp%2Bcelnyy2SXMd3CCjXe8lEfHIpuz6tRH0eJhW4U55c5p%2FOkE%2F2wJ%2Blwutnu3diJnyka3p0z1BMaBckWXp2iI5i4b0OxC9J%2BIZzkvwTPG9IOdDkTfprE019%2BHAIuIANCTlj4r6Eau8s5ivydMh4UwbZwO2laesF4liYg%2Btt%2Bzf2H%2FS2N4mvS03FPs73pUJZILqm0ekraaU%2BtRsZP3D2fBLs0cBloPySlXmEJ%2FW6jOdg7JWBmrBIlyWbKdzOKJnqNl0ta7J%2F8qzLXkfwFjJ%2B4eVnncXvSfaIesXTqFcjPHqMuzUei1ha184tpbtHNSeztju8DX4S8l%2BD%2F3NR4ensGZ5amZUNF6SZ7SdaLAOe7XB5tQS6tdEfY%2F88CoZFnahCRpII8ISLYLR%2BWtkOX%2F%2FEmfj9LXaNZX8pIrDJIhkDuKSmkOs%2BnHUcCecxxn%2F9OLynfSZxXu5VfMfhufdZbA3%2BL3YSNy01u1Fo5hrW8%2FdDMxExf5Ndjxv2dWwAZpanO%2BPdyzpqK1Tk9Wk23PzQYBnLl8x7kR%2B%2FK6XPzo05H%2BJcCf46Sa5ErxfOy%2FrQhgEdrB9hblT0Uz%2BNfX2rl22GsbsUcy0Mjlu3eaoANFOM6KygXZC3JHcXHAMv4UrqyaSb%2FYkqhAj5r8yRMa6iS%2FE3Bn4eG3Y0amKW3dA36v6cva42JrR2yQ1gFkxoSr%2FJ1Ikx%2Fc%2FNZwdK51aKhgV95rqn5FcU6FO%2FQ9aBJj0%2BqXgKN51QptoqsDjDSseqyBjqwARZHGBW5b6H%2BQh1aPbxnlo0%2F4syoSe2HeJRzs%2FtiZz6lj0TMsnq7oVO5T9rl2UoOTvrPJh9mbNv7iD9MveNWCXTKga%2F15EafXf47XLZfyNlNSEvJuli9rstM5DCzJzdIot2xhKUqH8quMcpOGqB1f7irJswwNaKOM8SywU9x7fS5jP%2BrA6a2bAn3ubzdinkBJLICNAXYq4Jypq1gbgEhQqpd1ysKHA9uOOX%2B56sA%2Bebg&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20240601T045955Z&X-Amz-SignedHeaders=host&X-Amz-Expires=300&X-Amz-Credential=ASIAQ3PHCVTYWQC7Z2EY%2F20240601%2Fus-east-1%2Fs3%2Faws4%5Frequest&X-Amz-Signature=76c903d050724368e9e17ac0838f38aa45310e1a04ebc549266ef68ac50112ee&hash=24c323e598b85ce3134cb1a57437e7eaf875e129b9c07f2e229a7bf9030001c8&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=S1055858608000140&tid=spdf-914d7b01-15ed-4824-81cf-1468a63861db&sid=99c486b2132e4043e028e7427b979b7e1391gxrqb&type=client&tsoh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&ua=0104585902020e5d555c&rr=88cca3188c2506e5&cc=gb&ref=theplasticsfella.com), 2008). Surgery may focus on the chest or upper limb and address functional and aesthetic concerns. Individuals with isolated, mild chest wall differences may not desire any intervention but options should be discussed. **Reconstruction of Rib and Sternum Defects** A multidisciplinary approach with cardiothoracic surgeons is warranted for large defects. Key principles include delaying surgery until after growth spurts and addressing all tissue layers. The objectives are to ensure thoracic stability, protect pulmonary and mediastinal structures, prevent paradoxical chest wall motion, and support soft tissue reconstruction (breast or pectoralis). - Goertex mesh +/- bone or cartilage graft - Sternal osteotomy - Nuss procedure for pectus excavatum **Reconstruction of the Shoulder Girdle, Anterior Axillary Fold, and Chest Wall** - **Reconstruction of anterior axillary fold and pectoralis muscle:** endoscopic/short incision pedicled latissimus dorsi – functional and aesthetic ([Ouyang](https://pdf.sciencedirectassets.com/273464/1-s2.0-S1748681521X00113/1-s2.0-S1748681521002217/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjEND%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJGMEQCIFFLD7Xt%2BNumfsDHJfsngC5LfHuwzHGw1FiIuLpVTlBmAiB2Okt0NfvZpRgH%2FE%2BYJOsAEWXeYrBqwuw5suXjLPEg7SqzBQhZEAUaDDA1OTAwMzU0Njg2NSIMuzXpuxyf7f5%2FwGGlKpAFuvgDu%2Fro5gYFogjsBFdi%2BbentJaRTKMqP9oP6LozCGHthRh3M3L%2FsG0JW3l1zID3JlJHsOoVyPa3R95%2BqqsA2gvEeLpgEpkMYvyYUod0XxiodImruL8xxPomF4W0l7ssu2HlAbbs4VHC4SKD4yoZDQP72UOp2uCY2MFZBg4BmVDrfj3ZCEUFudKu8xo2AH0ryvJxVnm1%2F1rVZ3dVlAXOhQkDIDMxcbEpIgS2P1W5zL1fuu%2BBE1g9hVJBj6nhz75Q5qNOunGRp9cWm08emhy2Y1oy%2Fjm1V5l%2Fo0aRVzxGGrsni5M3H0te5uxHR5zxYzKtu%2BK57ZAgldsHJvBcD%2FcbLvlGue8I8extn%2BCIrHuuO7fLeql3EQhAqYedsI0Nvqp9MzFgAW8haKR0mWqXpmydrQDsKUurQQy5B%2BJI6oUNXiW%2BYV6dCp%2FKlg9Ga9D4dEUI4mrPRCJnYKEzNHp04f1U6%2FOSgbUfM16RLfdTUrW2KG8qvFtisEiChUHsW2ttSqANFr7VyUImzsbDB%2FivRKHwr8zBdzDrFN2zOxVHPxzn6sjK%2Fa5KULMACps0cXN%2F0Td9B%2FjouvqddIa81r8KqzI65kxQKFIzXZwXVdYusUuI7XmjTbuMMn73uc05LADma6GVg%2FOu2mYcjmxOcKGCkmNuI0MRN83yD03FEShYhBeK3XSXO%2BXzM%2FLavjLgZKxucDBVMDqY83jdYvzzN2LMpOrDslh1iBtKPoqmqmnRt%2FVwVGkORu7xm22WWMg5ZZCr0YvsvsxWHyIhTAdzWcst1aVtJlsagMjaIO5LUbdrqaZ7t3Jx%2BTUCt3xl5P82SvvEt0g7DsHrqv3a7JRQAqBbO1uO3g%2BPhPHliKkLlSIikbLFcJUwsaDrsgY6sgEQ%2BqeUNDaNPqlJMNPYDlPBYCnbdiSm7IJaoE%2BZg94RoauZ9gwYkhTup9JXgPwA21uiX3etxkWI28GazGao%2BxmrvaYbo3nN%2FYEL3iZQRY6jMqwdYFpMlr03dh%2FSAViCCqRmWFl2x8%2Btm5B163oCvwFT%2FbJus%2Bdsc%2FyrGHrDfMnS%2B8KcIDPRU8l3UKIr6pWKK0Z8daDOqV%2FhmaPzGNfBsBfX0Pmz2H0aEt4MVxIFPmXUY995&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20240601T082818Z&X-Amz-SignedHeaders=host&X-Amz-Expires=300&X-Amz-Credential=ASIAQ3PHCVTY4B2LJ5PG%2F20240601%2Fus-east-1%2Fs3%2Faws4%5Frequest&X-Amz-Signature=5a4434ed0af1716f19306f6bda35d46fbad867ac8828320722b8ee5f9af83348&hash=709953997d70947cd97ada9f73eb5b26dbbeb0650af58c13cdd2221e3ee80309&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=S1748681521002217&tid=spdf-96c025ac-9e07-4f12-8ae1-bac11119879f&sid=99c486b2132e4043e028e7427b979b7e1391gxrqb&type=client&tsoh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&ua=0104585902050b5a5152&rr=88cdd4565df871d8&cc=gb&ref=theplasticsfella.com), 2021) - **Reconstruction of the breast:** extended latissimus dorsi +/- fat grafting/implant or free tissue transfer ([Pinsole](https://pubmed.ncbi.nlm.nih.gov/18178141/?ref=theplasticsfella.com), 2008). **Reconstruction of Hand Differences** Surgery is planned between 6 months and 3 years, depending on the digits involved. Ideal timing considers the child's size to avoid growth restriction from delayed operation (e.g., growth discrepancy in syndactyly), prioritization of associated anomalies requiring surgery, delays for safe general anesthesia, and avoiding conflicts with developmental milestones or significant life events. - **Symbrachydactyly:** Surgical distraction or toe interphalangeal joint transfer ([Lister](https://pubmed.ncbi.nlm.nih.gov/3420188/?ref=theplasticsfella.com), 1988, [Schenker](https://pubmed.ncbi.nlm.nih.gov/12706156/?ref=theplasticsfella.com), 2003, [Sabapathy](https://pubmed.ncbi.nlm.nih.gov/33966936/?ref=theplasticsfella.com) 2021). Free toe transfer([Van Holder](https://pubmed.ncbi.nlm.nih.gov/10473161/?ref=theplasticsfella.com), 1999). - **Syndactyly:** Surgical release of conjoined digits with or without skin graft ([Choong](https://pubmed.ncbi.nlm.nih.gov/38764415/?ref=theplasticsfella.com), 2024). 💡 ****Tip:** When the ipsilateral latissimus dorsi muscle is unavailable for anterior chest wall reconstruction, the contralateral latissimus can be used as a functional free flap. Powered by the intercostal nerve, it restores pectoralis function, anterior chest wall symmetry, and posterior axillary fold symmetry. ([Kelly](https://pubmed.ncbi.nlm.nih.gov/10673931/?ref=theplasticsfella.com), 1999). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Poland Syndrome:** You have understood Poland Syndrome, recognizing it as a complex congenial condition characterized by a spectrum of anomalies primarily affecting the chest wall and upper limbs. ****2\. Clinical Features:** You have identified the distinctive physical manifestations of Poland syndrome; hypoplasia or aplasia of the sternal head of the pectoralis major and minor muscles, and various hand anomalies. ****3\. Aetiology:** You are familiar with theories concerning the origin of Poland Syndrome, suggesting a vascular disruption due to subclavian artery supply issues, alongside potential genetic and teratogenic influences. ****4\. Diagnostic Approach:** You understand Poland Syndrome is primarily diagnosed through clinical evaluation, supported by imaging techniques in detailed assessment and pre-surgical planning. ****5\. Management Strategies:** You have a clear outline of the management options, emphasizing surgical intervention aimed at correcting deformities to achieve functional and aesthetic improvements. ****6\. Differentiation from Similar Conditions:** You can distinguish Poland Syndrome from other syndromes and anomalies based on the specific structures involved and its unique clinical presentations. --- ## Further Reading 1. Gupta A, Kay S, Sheker L. [The Growing Hand: Diagnosis and Management of the Upper Extremity in Children: Diagnosis and Management of the Child's Upper Extremity](https://books.google.co.uk/books/about/The%5FGrowing%5FHand.html?id=rUB-QgAACAAJ&ref=theplasticsfella.com) \- 2000 ISBN 10: 0723421331 2. Kelly EJ, O'Sullivan ST, Kay SP. [Microneurovascular transfer of contralateral latissimus dorsi in Poland's syndrome](https://pubmed.ncbi.nlm.nih.gov/10673931/?ref=theplasticsfella.com). Br J Plast Surg. 1999 Sep;52(6):503-4\. doi: 10.1054/bjps.1999.3156\. PMID: 10673931. 3. Glass GE, Mohammedali S, Sivakumar B, Stotland MA, Abdulkader F, Prosser DO, Love DR. [Poland-Möbius syndrome: a case report implicating a novel mutation of the PLXND1 gene and literature review](https://pubmed.ncbi.nlm.nih.gov/36581828/?ref=theplasticsfella.com). BMC Pediatr. 2022 Dec 30;22(1):745\. doi: 10.1186/s12887-022-03803-3\. PMID: 36581828; PMCID: PMC9801559. 4. Darian VB, Argenta LC, Pasyk KA. [Familial Poland's syndrome](https://pubmed.ncbi.nlm.nih.gov/2560355/?ref=theplasticsfella.com). Ann Plast Surg. 1989 Dec;23(6):531-7\. doi: 10.1097/00000637-198912000-00010\. PMID: 2560355. 5. Ozkok S, Erol N, Onal C, Yikilmaz A. [Left-sided Poland's syndrome associated with dextrocardia](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593920/pdf/NCI-6-192.pdf?ref=theplasticsfella.com). North Clin Istanb. 2018 Sep 3;6(2):192-195\. doi: 10.14744/nci.2018.82698\. PMID: 31297489; PMCID: PMC6593920. 6. Baldelli I, Baccarani A, Barone C, Bedeschi F, Bianca S, Calabrese O, Castori M, Catena N, Corain M, Costanzo S, Barbato GP, De Stefano S, Divizia MT, Feletti F, Formica M, Lando M, Lerone M, Lorenzetti F, Martinoli C, Mellini L, Nava MB, Porcellini G, Puliti A, Romanini MV, Rondoni F, Santi P, Sartini S, Senes F, Spada L, Tarani L, Valle M, Venturino C, Zaottini F, Torre M, Crimi M. [Consensus-based recommendations for diagnosis and medical management of Poland syndrome (sequence)](https://ojrd.biomedcentral.com/articles/10.1186/s13023-020-01481-x?ref=theplasticsfella.com). Orphanet J Rare Dis. 2020 Aug 5;15(1):201\. doi: 10.1186/s13023-020-01481-x. PMID: 32758259; PMCID: PMC7405453. 7. Nguyen GV, Goncalves LF, Vaughn J, Friedman N, Wickland J, Cornejo P. [Prenatal diagnosis of Poland-Möbius syndrome by multimodality fetal imaging](https://pubmed.ncbi.nlm.nih.gov/37423914/?ref=theplasticsfella.com). Pediatr Radiol. 2023 Sep;53(10):2144-2148\. doi: 10.1007/s00247-023-05712-8\. Epub 2023 Jul 10\. PMID: 37423914. 8. Moir CR, Johnson CH. [Poland's syndrome](https://pubmed.ncbi.nlm.nih.gov/18582821/?ref=theplasticsfella.com). Semin Pediatr Surg. 2008 Aug;17(3):161-6\. doi: 10.1053/j.sempedsurg.2008.03.005\. PMID: 18582821. 9. Poland A. [Deficiency of the pectoral muscles](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410274/?ref=theplasticsfella.com). Guy’s Hosp Rep 1841; 6:191 in Ram AN, Chung KC. Poland's syndrome: current thoughts in the setting of a controversy. Plast Reconstr Surg. 2009 Mar;123(3):949-953\. doi: 10.1097/PRS.0b013e318199f508\. PMID: 19319059; PMCID: PMC4410274. 10. Ouyang Y, Xu B, Luan J, Liu C. [Chest Wall Reconstruction in Male Poland Syndrome Patients with Endoscopic-Assisted Latissimus Dorsi Muscle Flap Transfer](https://www.jprasurg.com/article/S1748-6815%2821%2900221-7/abstract?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2021 Nov;74(11):3141-3149\. doi: 10.1016/j.bjps.2021.03.117\. Epub 2021 May 4\. PMID: 34039526. 11. Pinsolle V, Chichery A, Grolleau JL, Chavoin JP. [Autologous fat injection in Poland's syndrome](https://pubmed.ncbi.nlm.nih.gov/18178141/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2008 Jul;61(7):784-91\. doi: 10.1016/j.bjps.2007.11.033\. Epub 2008 Feb 21\. PMID: 18178141. 12. Lister G. [Microsurgical transfer of the second toe for congenital deficiency of the thumb](https://pubmed.ncbi.nlm.nih.gov/3420188/?ref=theplasticsfella.com). Plast Reconstr Surg. 1988 Oct;82(4):658-65\. doi: 10.1097/00006534-198810000-00017\. PMID: 3420188. 13. Choong J, Hadjiandreou M, McGee P, Lam WL. [Graftless Syndactyly Release](https://pubmed.ncbi.nlm.nih.gov/38764415/?ref=theplasticsfella.com). Tech Hand Up Extrem Surg. 2024 Jun 1;28(2):51-59\. doi: 10.1097/BTH.0000000000000472\. PMID: 38764415. 14. Sabapathy SR, Mohan M, Shanmugakrishnan RR. [Nonvascularized Free Toe Phalangeal Transfers in Congenital Hand Differences: Radiological, Functional, and Patient/Parent-Reported Outcomes](https://pubmed.ncbi.nlm.nih.gov/33966936/?ref=theplasticsfella.com). J Hand Surg Am. 2021 Dec;46(12):1124.e1-1124.e9\. doi: 10.1016/j.jhsa.2021.03.012\. Epub 2021 May 7\. PMID: 33966936. 15. Schenker M, Kelley SP, Kay SP. [Free hand-to-toe transfer: a method to minimise donor-site morbidity in free joint transfers](https://pubmed.ncbi.nlm.nih.gov/12706156/?ref=theplasticsfella.com). Br J Plast Surg. 2003 Jan;56(1):57-9\. doi: 10.1016/s0007-1226(03)00003-1\. PMID: 12706156. 16. Van Holder C, Giele H, Gilbert A. [Double second toe transfer in congenital hand anomalies](https://pubmed.ncbi.nlm.nih.gov/10473161/?ref=theplasticsfella.com). J Hand Surg Br. 1999 Aug;24(4):471-5\. doi: 10.1054/jhsb.1999.0162\. PMID: 10473161. 17. Chavoin JP, Taizou M, Moreno B, Leyx P, Grolleau JL, Chaput B. [Correcting Poland Syndrome with a Custom-Made Silicone Implant: Contribution of Three-Dimensional Computer-Aided Design Reconstruction](https://pubmed.ncbi.nlm.nih.gov/30045173/?ref=theplasticsfella.com). Plast Reconstr Surg. 2018 Aug;142(2):109e-119e. doi: 10.1097/PRS.0000000000004605\. PMID: 30045173. ### Pre-Rounding is overrated, burn complications & fluid resuscitation URL: https://www.theplasticsfella.com/june-23rd/ Last updated: 2024-06-22T09:45:45.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-23rd/#a-letter-from-pfella) What are your thoughts on pre-rounds? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-23rd/#the-sunday-quiz) How well do you know **burn complications*? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/june-23rd/#behind-the-fella) A snippet from "Flexor Teno, Sutures & Anki" 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/june-23rd/#what-does-the-evidence-say) Parkland’s formula for fluid resuscitation 5. ****🔥** [****Recommended Articles of the Week**](https://www.theplasticsfella.com/june-23rd/#articles-of-the-week) Burn Fluids, STSG donor-sites, & acute burn care \+ 1-sentence summaries. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/june-23rd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Pre-Rounding Is Overrated* 👋 ****Hey Team!** Let's talk about pre-rounding, something many plastic surgery residents/trainees do every morning across the globe. Waking up patients early, asking the same questions, and rushing through exams before rounds – it's a frustrating and often unnecessary ritual. 👇 Pre-rounds are like customer service saying "I’m still here, please continue to hold'”​. Not every patient needs to be woken up in the early hours of the morning. ### **The Case Against Pre-rounding** **Disrupting Patient Rest** One of the main issues with pre-rounding is the **disruption of patients' rest**. By waking patients up, we might be doing more harm than good, as they lose out on the restorative benefits of uninterrupted sleep. Another significant drawback of pre-rounding is **redundancy**. Information gathered during pre-rounds often gets repeated during the official rounds. This not only wastes time but also can frustrate patients who have to answer the same questions multiple times. ### ### **The Benefits of Pre-rounding** **Fostering Autonomy and Ownership** By making initial assessments and formulating preliminary care plans, junior trainees get hands-on experience in decision-making. This practice prepares them for future independent practice, making them more confident and competent physicians. **Enhanced Clinical Skills** Pre-rounding also offers interns the chance to enhance their clinical skills. Direct observation of patients enables interns to notice subtle changes that might not be captured in electronic health records. These real-time observations are crucial for developing sharp diagnostic skills. Pre-rounding is probably overrated in my opinion. By adopting a more patient-centered approach, ensuring efficient communication, and tailoring the process to each patient's needs, we can maintain the educational benefits for interns while prioritizing patient comfort and recovery. P'Fella ❤️ ****tl;dr** 👉 Pre-rounding disrupts patient rest & leads to redundant information. 👉 Can foster autonomy and enhance clinical skills for interns. 👉 Balancing educational benefits and patient comfort is crucial. 👉 Adopt a patient-centered approach. ## The Sunday Quiz **How Well Do You Know Burn Complications?* ****Are you ready for a new round of The Weekly Quiz?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week — the winner at the end of six rounds will earn you a $100 voucher. ![This image shows Ganglion Cysts of the hand](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/Main-Article-Images--55-.png) Burn Complications We're planning to discuss **burn complications** in an upcoming podcast episode. Subscribe on [**Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) or [**Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)to listen once it's out! ## Behind the ‘Fella Episode 2 is LIVE! 🎧 ****Tune in Now: "Behind the Fella" 🎧** Tune into our podcast for exclusive ****team meetings** where we uncover ****behind-the-scenes** details of the platform and discuss ****hot topics** in ****plastic surgery** with our fellows. In this week's episode: 💯 Live Sunday Quiz 😷 Flexor Tenosynovitis 🗂️ Anki Flaschards 💬 the Fellow's Debate! Listen on [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) & [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)! 0:00 /0:57 1× Listen here on [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) and [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)****.** If there's any specific discussion you're interested in, let us know below. ## the Fellows' Corner **This Week's Focus: Poland Syndrome* In case you've missed out, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques** focused on the Chest Wall. Here's an overview of our article on [Poland Syndrome](https://www.theplasticsfella.com/poland-syndrome/). #### Poland Syndrome [****Definition** ](https://www.theplasticsfella.com/poland-syndrome/#definition-of-poland-syndrome)A spectrum of unilateral congenital chest wall deformities involving the ****sternal head of the pectoralis major.** It is associated with ****ipsilateral hand anomalies**. [****Aetiology**](https://www.theplasticsfella.com/poland-syndrome/#aetiology-of-poland-syndrome) Poland syndrome occurs predominantly on the right side and mostly in males. The precise aetiology remains uncertain but working theories include subclavian artery hypoplasia, genetic and teratogenic. [****Presentation**](https://www.theplasticsfella.com/poland-syndrome/#presentation-of-poland-syndrome) Poland syndrome is a constellation of phenotypes including the absence of hypoplasia of the sternal portion of the pectoralis major alongside predominantly ipsilateral chest wall and hand differences. [****Investigations**](https://www.theplasticsfella.com/poland-syndrome/#investigations-for-poland-syndrome) Poland syndrome is a clinical diagnosis. Imaging is useful to exclude rare associations and for pre-operative planning. [****Differential Diagnosis** ](https://www.theplasticsfella.com/poland-syndrome/#differential-diagnosis-of-poland-syndrome)The differential diagnosis of Poland syndrome depends on the structures involved - chest wall, shoulder, and hand. Rare syndromes and associations should be kept in mind. [****Management**](https://www.theplasticsfella.com/poland-syndrome/#management-of-poland-syndrome) Surgical management aims to create a stable and symmetrical thorax and chest wall while optimising hand function and appearance. [Read the Article](https://www.theplasticsfella.com/poland-syndrome/) ## What Does the Evidence Say? **Fluid Resuscitation* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. ### Is Parkland’s formula the best for fluid resuscitation? The best formula for fluid resuscitation of burns remains a topic of debate, with various studies proposing different approaches. Blanco-Schweizer (2019) and Daniels (2020) both suggest that the Parkland formula, which estimates fluid resuscitation based on body surface area, may not be the most effective method. Blanco-Schweizer (2019) found that the BET formula, which uses high albumin concentration fluids, successfully resuscitated burn patients with less fluid administration. Similarly, Daniels (2020) found that a restrictive fluid regime was associated with higher survival compared to the Parkland formula. However, these findings are not universally accepted, and further research is needed to determine the most effective fluid resuscitation formula for burn patients. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries* 1️⃣ ***Use of c** **rystalloid resuscitation** **in treating burn shock** ([Baxter](https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1968.tb14738.x?ref=theplasticsfella.com), 1968) The study shows that maintaining ECF volume and circulatory response is vital, requiring more fluids at a faster rate than expected. Within the first 24–30 hours post-burn, circulatory hemodynamics are closely tied to ECF volume maintenance, and it diminishes afterward. 2️⃣ ***Split-thickness skin graft donor-site morbidity** ([Asuku](https://www.sciencedirect.com/science/article/pii/S0305417921000504?ref=theplasticsfella.com), 2021) This systematic review of split-thickness skin graft (STSG) donor-site morbidities found that the mean time to epithelialization ranged from 4.7 to 35 days, with significant variations in pain, infection rates, and scarring. It highlights the need for standardized assessment tools to evaluate and manage STSG donor-site complications. 3️⃣ ***The role of plastic surgeons in the multidisciplinary burn team** ([Davis](https://journals.lww.com/plasreconsurg/abstract/2024/04000/acute%5Fburn%5Fcare.41.aspx?ref=theplasticsfella.com), 2024) Explore the need for a systematic approach to assess burn wounds and manage major burns & inhalation injuries. Also covers emerging surgical techniques for debridement and methods for wound closure using autografts and skin substitutes. ## Feedback ### I hope you enjoyed it 😄 --- ### Basal Cell Carcinomas, New Monthly “Journal”, & 3 Trending Articles URL: https://www.theplasticsfella.com/june-16th/ Last updated: 2024-06-16T09:04:09.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-16th/#a-letter-from-pfella) A new monthly “journal” from the P'Fella. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-16th/#the-sunday-quiz) **\+ Leaderboard** How well do you know **basal cell carcinoma*? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/june-16th/#behind-the-fella) Episode 2 is out now! 4. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/june-16th/#what-does-the-evidence-say) What is the ideal margin for basal cell carcinoma? 5. ****🔥** [****Recommended Articles of the Week**](https://www.theplasticsfella.com/june-16th/#articles-of-the-week) BCC: The best surgical margin, margins in BCC of the face, & excision margins; with 1-sentence summaries. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/june-16th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Building in Public: A New Monthly “Journal”* 👋 ****Hey Team!** As you well know, ****our platform thrives on your contributions** — your feedback, ideas, and suggestions are integral to enhancing the entire educational experience. I'm excited to announce a new initiative we're building with your input: ****a monthly journal delivered directly to your inbox**. 👇 ### ### What’s the Big Idea? Every month, you’ll get an email packed with the latest from ThePlasticsFella — **think of it as ThePlasticsPaper on steroids**. We're talking deep dives into new publications, clinical cases, and prep materials, all centered around evidence-based plastic surgery. You'll get detailed explanations of new content on the platform, insights into the creation process, recommendations for further reading complete with concise summaries, and even a behind-the-scenes look at our growth — new member statistics, user activity, and more. Think of it as a more formal and in-depth version of ThePlasticsPaper, dedicated entirely to advancing your knowledge. **And don't worry, ThePlasticsPaper isn’t going anywhere; you'll continue to receive it every Sunday.** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/NEW-PUBLICATIONS.png) **I Need Your Help!** First, we need a name for this journal. Something that encapsulates its essence without sounding mundane — easier said than done, right? I’d love to hear your creative ideas. Second, I want to know what you'd like to see in this monthly edition. What topics, features, or types of content are you most interested in? This new publication represents a significant step forward, and for now, it will be available to ThePlasticsPro users as we fine-tune and develop the format. I’m eager to hear your suggestions and look forward to making this journal something truly special. With love, P'Fella ❤️ P.S. This is the 100th edition of thePlasticsPapaer, thank you all for reading it. ****tl;dr** 👉 Our new monthly publication will deep dive into plastic surgery articles, clinical cases, and prep materials. 👉 It'll include plastics content, recommended reads, and platform growth stats. 👉 This'll initially be available to ThePlasticsPro users. 👉 We're looking forward to your name suggestions and content ideas. ## The Sunday Quiz **How Well Do You Know Basal Cell Carcinomas?* ****Are you ready for a new round of The Weekly Quiz?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end of six rounds will earn you a $100 voucher. ## Behind the ‘Fella **Second Episode Released!* More exciting news: "Behind the Fella" Episode 02 is now live on[**Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com)and[**Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)**.** These podcast episodes explore behind-the-scenes of our practice, featuring exclusive insights from team meetings and trending discussions on plastic surgery with our fellows. 🎙️ What to expect in Episode 2: \- ****Live quiz session** with Sunday quiz winners \- ****Flashcards:** Anki, AI-generated flashcards or humans? ****\- Flexor Tenosynovitis:** Surgical approach, Washout, Closure. ****\- Fellows' Debate:** Absorbable sutures vs. non -absorbable sutures 0:00 /5:24 1× Listen here on [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) and [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)****.** ## What Does the Evidence Say? **What's the Ideal Margin for Basal Cell Carcinoma?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. The optimal surgical margins for basal cell carcinomas (BCCs) depend on various factors, including tumor size, location, and histological subtype. For small, well-defined primary BCCs, a 3mm margin is sufficient, while larger or high-risk BCCs may require a 4-6mm margin (Luz 2015, Quazi 2020). However, the accuracy of visual assessment of BCC margins can vary, with some studies suggesting a 2mm margin is adequate (Epstein 1973, Gulleth 2010). Recurrence rates for BCCs with 2-5mm margins range from 0.39-3.96% (Gulleth 2010). Factors associated with incomplete excision and higher recurrence rates include age, lesion size, BCC subtype, location, and infiltration depth (Codazzi 2014). Positive surgical margins, particularly in central facial locations, are associated with a higher risk of recurrence (Bozan 2015). This will be discussed and debated in more detail in our next episode****.** Tune in on [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) or [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) for a listen! ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries.* 1️⃣ ***What is the best surgical margin for basal cell carcinoma?** ([Gulleth](https://pubmed.ncbi.nlm.nih.gov/20885244/?ref=theplasticsfella.com), 2010) From systematically analyzed data encompassing 16,066 lesions, this article found that a 3-mm surgical margin is generally sufficient to achieve a 95% cure rate for nonmorpheaform BCCs that are 2 cm or smaller. 2️⃣ ***Surgical margins in basal cell carcinoma of the face** ([Bozan](https://pubmed.ncbi.nlm.nih.gov/26050215/?ref=theplasticsfella.com), 2015) Evaluates the outcomes of BCC of the head and neck, focusing on those with positive surgical margins. The study found that 14.9% of lesions had positive surgical margins, with a recurrence rate of 26.1% in these cases. 3️⃣ ***The excision margins used for basal cell carcinomas are too wide?** ([Bisson](https://pubmed.ncbi.nlm.nih.gov/12160534/?ref=theplasticsfella.com), 2002) The study compared marked surgical margins with histological margins on 100 BCCs. The findings show that current surgical practices maintain a balance between low rates of incomplete excision and minimal normal skin sacrifice. ## Feedback ### I hope you enjoyed it 😄 --- ### Hemifacial Microsomia: Definition, Classification, & Treatment URL: https://www.theplasticsfella.com/hemifacial-microsomia/ Last updated: 2024-06-12T18:27:07.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/hemifacial-microsomia/#definition-of-hemifacial-microsomia) The commonest craniofacial abnormality is characterised by a spectrum of underdeveloped congenital facial features. [****Clinical Picture**](https://www.theplasticsfella.com/hemifacial-microsomia/#clinical-features-of-hemifacial-microsomia) A variable phenotype of ear, bone, and muscle hypoplasia of differing severity. It is linked to cleft palate, facial nerve palsy, & macrostomia. [****Classification**](https://www.theplasticsfella.com/hemifacial-microsomia/#classification-of-hemifacial-microsomia) Multiple systems exist to overcome clinical heterogeneity. This includes OMENS, Pruzansky (Mandible), and Meurman (Ear). [****Management**](https://www.theplasticsfella.com/hemifacial-microsomia/#management-of-hemifacial-microsomia) A multi-disciplinary team to correct ocular, mandibular, ear, facial nerve, and soft tissue issues over staged treatments. --- ## Definition of Hemifacial Microsomia ****Key Point** Hemifacial microsomia is a congenital condition marked by a range of underdeveloped facial features, making it the most common craniofacial abnormality. **Hemifacial microsomia** is a congenital condition characterised by a spectrum of underdeveloped facial features. It is the most common craniofacial abnormality ([Grabb](https://www.theplasticsfella.com/hemifacial-microsomia/), 1965) and usually occurs from sporadic mutations ([Burck](https://doi.org/10.1007/bf00279415?ref=theplasticsfella.com), 1983) that affect the first and second branchial arches. The image below illustrates hemifacial microsomia. ![Presentation of hemifacial microsomia ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Hemifacial-microsomia.png) Presentation of hemifacial microsomia Other names for hemifacial microsomia include First and Second Brachial Arch Syndrome, Otomandibular Dysostosis, Craniofacial Microsomia, or the oculoauriculovertebral spectrum. It correlates with Tessier Craniofacial Cleft 7\. 😎 ****Fun Fact:** It is hypothesised that hemifacial microsomia may be due to a haemorrhage from an abnormal stapedial artery ([Poswillo](https://doi.org/10.1016/0030-4220%2873%2990070-4?ref=theplasticsfella.com), 1973) or mesodermal insufficiency ([Stark](https://doi.org/10.1097/00006534-196203000-00001?ref=theplasticsfella.com), 1962). --- ## Clinical Features of Hemifacial Microsomia ****Key Point** Hemifacial microsomia is a spectrum of clinical pathology that involves the ear, bone, and muscle. Each patient has a variable phenotypic appearance. Hemifacial microsomia is a clinical diagnosis. It is usually a unilateral condition but can be bilaterally asymmetric. There is a **variable** phenotype, which means the clinical features are part of a **spectrum** of severity. ### "Classic" Clinical Features - **Ear underdevelopment:** Microtia, anotia, atresia. - **Hypoplasia of the bone:** Mandible, zygoma, maxilla, temporal bone. - **Muscle underdevelopment:** Mastication, palatal, tongue. ### Associated pathologies - **Cleft Palate:** \~35% incidence in hemifacial microsomia ([Sokol](https://doi.org/10.1016/s0022-3468%2878%2980416-3?ref=theplasticsfella.com), 1978). - **Facial Nerve Dysfunction:** \~22% incidence​8​ ± absent parotid gland. - **Macrostomia:** \~23% incidence in hemifacial microsomia ([Fan](https://doi.org/10.1016/j.joms.2004.10.006?ref=theplasticsfella.com), 2005). 💡 ****Tip:** Goldenhar Syndrome is a variant of hemifacial microsomia (features of hemifacial microsomia + Tessier Cleft 8). --- ## Classification of Hemifacial Microsomia ****Key Point** The phenotypic variability makes it difficult to classify hemifacial microsomia. Options include OMENS, Pruzansky for Mandible, and Meurman for Ear. Multiple classification systems for hemifacial microsomia exist. This is to overcome the heterogeneity of clinical appearances from this condition. ### OMENS Classification for Hemifacial Microsomia This classifies deformities based on **O**rbits, **M**andible, **E**ar, **N**erve (Facial) and **S**oft Tissue ([Vento](https://doi.org/10.1597/1545-1569%5F1991%5F028%5F0068%5Ftomens%5F2.3.co%5F2?ref=theplasticsfella.com), 1991). Unlike other classifications, this encompasses the clinical spectrum of the condition. The image below illustrates the OMENS Classification. ![OMENS CLasssification of Hemifacial Microsomia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/OMENS-classification.png) OMENS Classification of Hemifacial Microsomia ### Pruzansky Classification of the Mandible The Pruzansky classification assesses the degree of mandibular involvement in hemifacial microsomia. Most commonly, there is an asymmetric mandible with only unilateral involvement. - **I:** Mild ramus hypoplasia; the body is minimally affected. - **IIa:** Ramus & condyle hypoplasia, the glenoid-condyle surface is normal. - **IIb:** Type IIa **and** a non-articulating TMJ. - **III:** Thin or absent ramus and no TMJ. The image below illustrates the Pruzansky classification. ![Pruzansky Classification of the Mandible, Classification of Hemifacial Microsomia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Pruzansky-Classification-2.png) Pruzansky Classification of the Mandible 💡 ****Tip:** The "glenoid" is an oval depression on the zygomatic process of the temporal bone that receives the condyle of the mandible. ### Meurman Classification of the Ear The Meurman classification assesses the degree of auricle involvement in hemifacial microsomia. There are 3 grades based on the presence or absence of structures. - **I:** Small ear with all structures present. - **II:** cartilage and skin remnant, atresia of the external meatus - **III:** total or near-total absence of the ear. The image below illustrates the Meurman classification. ![Meurman Classification of the Ear, Classification of Hemifacial Microsomia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Meurman-Classification.png) Meurman Classification of the Ear --- ## Management of Hemifacial Microsomia ****Key Point** The treatment should be individualised to the patient. Key aspects include oral competence, hearing, dentition, mandibular reconstruction, and facial palsy treatment, if present. There is no standardised treatment algorithm for hemifacial microsomia. This is primarily due to the phenotypic variation of patients. Current evidence-based practice promotes individualised patient care. ### Minor Interventions - **Skin Tags:** remove skin tags at an appropriate age. Pre-auricular skin tags with cartilage remnants may be near the facial nerve. - **Deafness**: fit hearing aids as an infant to ensure no speech delay. - **Teeth**: orthodontic treatment as a child and early adolescents. ### Microtia If microtia is present, ear reconstruction with autologous material should be delayed until the patient is age-appropriate, between 7 and 10 years, depending on the technique used ([Brent](https://www.ncbi.nlm.nih.gov/pubmed/1513882?ref=theplasticsfella.com), 1992 & [Nagata](https://www.ncbi.nlm.nih.gov/pubmed/8310017?ref=theplasticsfella.com), 1994). ### Mandibular Hypoplasia There is no standardised algorithm for the timing of surgical management of mandibular hypoplasia. Traditionally, surgeons have waited until skeletal maturity to correct malocclusion with orthognathic procedures ([Meazzini](https://doi.org/10.1016/j.jcms.2011.03.004?ref=theplasticsfella.com), 2012 & [Schreuder](https://doi.org/10.1016/j.ijom.2006.12.002?ref=theplasticsfella.com), 2007). - **In severe cases**, early mandibular distraction can be considered to allow for appropriate bone stock development ([Wan](https://doi.org/10.1097/PRS.0b013e31820cf4d6?ref=theplasticsfella.com), 2011). - **In Pruzansky III**, mandibular reconstruction may require a costochondral rib graft, bone grafts, and alloplastic implants. ### Facial Paralysis Management of these patients should be at centres that specialise in facial reanimation surgery. Ocular protection from corneal desiccation and ulceration is a priority. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Hemifacial Microsomia:** You’ve reviewed Hemifacial Microsomia, recognizing it as the most common craniofacial abnormality characterized by a spectrum of underdeveloped facial features. ****2\. Clinical Features:** You are aware of the variable clinical presentation of Hemifacial Microsomia, including ear, bone, and muscle hypoplasia, and its association with conditions such as cleft palate, facial nerve palsy, and macrostomia. ****3\. Classification Systems:** You have learned about various classification systems that describe the severity and specifics of Hemifacial Microsomia. ****4\. Management**: You've understood the multidisciplinary approach for managing Hemifacial Microsomia, focusing on corrective and reconstructive procedures for ocular, mandibular, ear, facial nerve, and soft tissue abnormalities. ****5\. Multi-stage Treatments:** You are prepared to guide patients through the potentially complex, staged treatments needed to address both functional and aesthetic concerns associated with Hemifacial Microsomia. --- ## References 1. Keogh IJ, Troulis MJ, Monroy AA, Eavey RD, Kaban LB. [Isolated Microtia as a Marker for Unsuspected Hemifacial Microsomia](https://doi.org/10.1001/archotol.133.10.997?ref=theplasticsfella.com). *Arch Otolaryngol Head Neck Surg*. October 2007:997\. doi:10.1001/archotol.133.10.997 2. Fawzy HAAR, Ghareeb F, Farghaly A-S, Al Barah A, El Sheikh Y. [Patterns and management of congenital nasal clefts](https://doi.org/10.4103/1110-2098.155960?ref=theplasticsfella.com). *Menoufia Med J*. 2015:99\. doi:10.4103/1110-2098.155960 3. Grabb W. [The first and second branchial arch syndrome](https://doi.org/10.1097/00006534-196511000-00001?ref=theplasticsfella.com). *Plast Reconstr Surg*. 1965;36(5):485-508\. doi:10.1097/00006534-196511000-00001 4. Burck U. [Genetic aspects of hemifacial microsomia](https://doi.org/10.1007/bf00279415?ref=theplasticsfella.com). *Hum Genet*. 1983;64(3):291-296\. doi:10.1007/bf00279415 5. STARK R, SAUNDERS D. [The first branchial syndrome. The oral-mandibular-auricular syndrome](https://doi.org/10.1097/00006534-196203000-00001?ref=theplasticsfella.com). *Plast Reconstr Surg Transplant Bull*. 1962;29:229-239\. doi:10.1097/00006534-196203000-00001 6. Poswillo D. [The pathogenesis of the first and second branchial arch syndrome](https://doi.org/10.1016/0030-4220%2873%2990070-4?ref=theplasticsfella.com). *Oral Surg Oral Med Oral Pathol*. 1973;35(3):302-328\. doi:10.1016/0030-4220(73)90070-4 7. Sokol AB. [Velopharyngeal insufficiency in hemifacial microsomia](https://doi.org/10.1016/s0022-3468%2878%2980416-3?ref=theplasticsfella.com). *Journal of Pediatric Surgery*. June 1978:344\. doi:10.1016/s0022-3468(78)80416-3 8. Carvalho G, Song C, Vargervik K, Lalwani A. [Auditory and facial nerve dysfunction in patients with hemifacial microsomia](https://doi.org/10.1001/archotol.125.2.209?ref=theplasticsfella.com). *Arch Otolaryngol Head Neck Surg*. 1999;125(2):209-212\. doi:10.1001/archotol.125.2.209 9. Fan W, Mulliken J, Padwa B. [An association between hemifacial microsomia and facial clefting](https://doi.org/10.1016/j.joms.2004.10.006?ref=theplasticsfella.com). *J Oral Maxillofac Surg*. 2005;63(3):330-334\. doi:10.1016/j.joms.2004.10.006 10. Vento A, LaBrie R, Mulliken J. [The O.M.E.N.S. classification of hemifacial microsomia](https://doi.org/10.1597/1545-1569%5F1991%5F028%5F0068%5Ftomens%5F2.3.co%5F2?ref=theplasticsfella.com). *Cleft Palate Craniofac J*. 1991;28(1):68-76; discussion 77\. doi:10.1597/1545-1569\_1991\_028\_0068\_tomens\_2.3.co\_2 11. Brent B. [Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases](https://www.ncbi.nlm.nih.gov/pubmed/1513882?ref=theplasticsfella.com). *Plast Reconstr Surg*. 1992;90(3):355-374; discussion 375-6\. 12. Nagata S. [Modification of the stages in total reconstruction of the auricle: Part IV](https://www.ncbi.nlm.nih.gov/pubmed/8310017?ref=theplasticsfella.com). Ear elevation for the constructed auricle. *Plast Reconstr Surg*. 1994;93(2):254-266; discussion 267-8. 13. Meazzini M, Mazzoleni F, Bozzetti A, Brusati R. [Comparison of mandibular vertical growth in hemifacial microsomia patients treated with early distraction or not treated: follow up till the completion of growth](https://doi.org/10.1016/j.jcms.2011.03.004?ref=theplasticsfella.com). *J Craniomaxillofac Surg*. 2012;40(2):105-111\. doi:10.1016/j.jcms.2011.03.004 14. Schreuder W, Jansma J, Bierman M, Vissink A. [Distraction osteogenesis versus bilateral sagittal split osteotomy for advancement of the retrognathic mandible: a review of the literature](https://doi.org/10.1016/j.ijom.2006.12.002?ref=theplasticsfella.com). *Int J Oral Maxillofac Surg*. 2007;36(2):103-110\. doi:10.1016/j.ijom.2006.12.002 15. Wan D, Taub P, Allam K, et al. [Distraction osteogenesis of costocartilaginous rib grafts and treatment algorithm for severely hypoplastic mandibles](https://doi.org/10.1097/PRS.0b013e31820cf4d6?ref=theplasticsfella.com). *Plast Reconstr Surg*. 2011;127(5):2005-2013\. doi:10.1097/PRS.0b013e31820cf4d6 ### Treacher Collins Syndrome: Clinical Features, Genetics, & Treatment URL: https://www.theplasticsfella.com/treacher-collins-syndrome/ Last updated: 2024-06-12T18:27:31.000Z ‌ #### Summary Card [****Definition**](https://www.theplasticsfella.com/treacher-collins-syndrome/#definition-of-treacher-collins-syndrome) A genetic syndrome with bilateral abnormalities of the first and second branchial arches combining Tessier cleft numbers 6-9. [****Aetiology**](https://www.theplasticsfella.com/treacher-collins-syndrome/#aetiology-of-treacher-collins) Sporadic or autosomal dominant inheritance of variable penetrance. TCOF1 is the commonest genetic mutation. [****Clinical Features**](https://www.theplasticsfella.com/treacher-collins-syndrome/#clinical-features-of-treacher-collins) Pathology of the first and second branchial arches results in deficiencies and excess in bone and soft tissue of the face. [****Management**](https://www.theplasticsfella.com/treacher-collins-syndrome/#management-of-treacher-collins) In the acute setting, airway and nutrition are the focus. Longer-term reconstruction focuses on ocular, auricular, and mandibular treatments. ‌ --- ## Definition of Treacher Collins Syndrome ****Key Point** Treacher Collins Syndrome, or mandibulofacial dysostosis, or Franceschetti Syndrome, is a genetic craniofacial disorder characterized by bilateral abnormalities in the first and second branchial arches Treacher Collins Syndrome is a genetic craniofacial syndrome characterised by bilateral abnormalities of the first and second branchial arches combining [Tessier](https://www.theplasticsfella.com/craniofacial-clefts/#tessier-classification-of-craniofacial-clefts) cleft numbers 6-9\. This condition was first described by Berry in 1889 and later by Treacher Collins in 1900, who was a British Ophthalmologist. The image below illustrates Treacher Collins syndrome. ![Treacher Collins syndrome example](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Treacher-Collins-Syndrome-1.png) Treacher Collins Syndrome It is also known as mandibulofacial dysostosis, Franceschetti Syndrome ([Franceschetti](https://www.ncbi.nlm.nih.gov/pubmed/18142195?ref=theplasticsfella.com), 1949) first and second branchial arch syndrome, or Tessier Cleft 6,7,8. --- ## Aetiology of Treacher Collins ****Key Point** The majority of Treacher Collins is the sporadic inheritance of variable penetrance. It can also be caused by autosomal dominant mutations with TCOF1. ## The incidence of Treacher Collins syndrome is approximately **\~1/50,000** live births. From a genetic perspective, it is linked to changes in genes on chromosome 5: - **Autosomal dominant** inheritance in 40% - **Sporadic** inheritance in 60% - **Variable** penetrance - **Linked** to TCOF1 ([Posnick](https://doi.org/10.1597/1545-1569%282000%29037%3C0434:TCSCET%3E2.0.CO;2?ref=theplasticsfella.com), 2000), PLORIC, POLR1D ([Fisher](https://doi.org/10.1111/j.1399-0004.2011.01632.x?ref=theplasticsfella.com), 2011) There is no general consensus on the pathophysiology of Treacher Collins Syndrome. There are two main theories: 1. **Failure** of the facial and mandibular facial processes to fuse ([van der](https://doi.org/10.1097/00006534-198304000-00022?ref=theplasticsfella.com), 1983). 2. **Manifestation** of a combined Tessier 6, 7, 8 facial clefts ([Hunt](https://doi.org/10.1097/01.PRS.0000033869.10382.91?ref=theplasticsfella.com), 2002)​. 😎 ****Fun Fact:** TCOF1 is the most common gene and is associated with the underproduction of treacle protein, a neural crest precursor. --- ## Clinical Features of Treacher Collins ****Key Point** Treacher Collins syndrome is a condition affecting first and second branchial arches. This results in deficiencies and excess bone and soft tissue of the face. Treacher Collins syndrome affects structures of the first and second branchial arches. This results in abnormalities in the eyes, face, mouth, facial bones, and ears. These clinical features are illustrated in the diagram below. ![Clinical Features of Treacher Collins Syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Treacher-Collins-Syndrome-Clinical-Features-1.png) Clinical Features of Treacher Collins Syndrome ### Bone - **Skull:** reduced cranial base angle (basilar kyphosis). - **Mandible:** hypoplasia, shortened ramus, class II malocclusion, - **Maxilla:** anterior open bite, absent or ankylosing TMJ. - **Zygoma:** hypoplastic, absent or clefted. - **Orbit:** absent lateral orbital walls cause downward palpebral fissures. 💡 ****Tip:** Synostosis is not a typical feature of Treacher Collins syndrome ### Soft Tissue - **Eyelashes:** Absent medially, lower eyelid colobomas. - **Eyelid:** The upper lateral half is redundant, which creates a "pseudoptosis". - **Tarsus:** Absent. - **Canthus:** Absent or medially displaced lateral canthus. - **Nose:** Wide nasal bridge, dorsal hump, and poor tip projection. - **Muscles:** Hypoplastic or absent masticators, hypoplastic temporalis. - **Palate:** 2° cleft palate (36%) and VPI, or high-arched ([Poswillo](https://doi.org/10.1016/0030-4220%2873%2990070-4?ref=theplasticsfella.com), 1973 & [Marsh](https://doi.org/10.1097/00006534-198610000-00003?ref=theplasticsfella.com), 1986). - **Ear:** Microtia or cryptotia, hypoplastic meatus, absent middle ear ossicle, extra auricle ([Amirhassankhani](https://doi.org/10.1097/SCS.0000000000004201?ref=theplasticsfella.com), 2018) The image below visualizes the facial abnormalities of Treacher Collins syndrome. ![Signs of Treacher Collins syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Treacher-Collins-Syndrome-Facial-Features.png) Facial abnormalities of Treacher Collins syndrome ### Function - **Vision:** loss, amblyopia, lateral canthal vertical dystopia. - **Hearing:** conductive hearing loss. - **Speech:** speech delay. - **Lacrimal system:** absent. 💡 ****Tip: Nager syndrome** is clinically similar to TCOS but there is an associated thumb and radial hypoplasia with impaired intelligence. --- ## Management of Treacher Collins ****Key Point** In the acute setting, airway and nutrition are the focus. Longer-term reconstruction focuses on ocular, auricular, and mandibular treatments. ### Acute Treatment In the acute setting, airway and nutrition are the primary goals. Airway compromise and poor feeding are issues relating to maxillary hypoplasia, mandibular hypoplasia, and narrow pharyngeal diameter. - Prone positioning or nasopharyngeal airway. - Tube feeding if failure to thrive. ### Reconstruction The reconstructive strategy should be individualised to the patient. The goal is to restore function, treat deficits or excesses, and improve cosmesis. Surgical techniques to consider include: - [**Bone graft**](https://www.theplasticsfella.com/bone-grafts/)**:** Orbital floor, zygomatic hypoplasia - **Costochondral graft:** TMJ reconstruction, mandibular deformities - **Mandible:** Advancements, distraction, Le Fort I osteotomy - **Oculoplastics:** Lateral Canthopexy - **Soft Tissue Flaps:** Ear reconstruction - **Rhinoplasty:** Dorsum hump and loss of nasal tip projection Each department has specific guidelines for its patient cohort. Generally speaking, the following timeline is recommended: - **Orbital Reconstruction:** \>7 years after bone development - **Mandible:** During early teenage years - **Middle ear:** After external ear reconstruction --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Treacher Collins Syndrome:** Treacher Collins Syndrome (TCS) is a genetic disorder primarily affecting the structure of the face due to abnormalities in the first and second branchial arches. ****2\. Recognition of Symptoms:** You are aware of the physical manifestations of TCS, which include facial asymmetry, ear abnormalities, and potential vision and hearing impairments. ****3\. Genetic Factors:** You understand that TCS can be sporadic or inherited in an autosomal dominant pattern with variable penetrance, with mutations in the TCOF1 gene being the most common genetic link. ****4\. Management:** Initial management focuses on critical functions such as airway stability and nutrition, with long-term management involving surgical interventions to improve facial structure and function. ****5\. Surgical Interventions**: You understand the various surgical techniques for managing TCS, including mandibular advancements, ear reconstruction, and rhinoplasty. ****6\. Treatment Challenges:** You recognize the complexities involved in treating TCS, including the timing of surgeries to coincide with facial growth and developmental stages. --- ## Further Reading 1. Collins ET. Cases of symmetrical congenital notches in the outer part of each lower lid and defective development of the malar bones. *Trans Ophthalmol Soc*. 1900:20: 190–192. 2. FRANCESCHETTI A, KLEIN D. [The mandibulofacial dysostosis; a new hereditary syndrome](https://www.ncbi.nlm.nih.gov/pubmed/18142195?ref=theplasticsfella.com). *Acta Ophthalmol (Copenh)*. 1949;27(2):143-224\. 3. Posnick J, Ruiz R. [Treacher Collins syndrome: current evaluation, treatment, and future directions](https://doi.org/10.1597/1545-1569%282000%29037<0434:TCSCET>2.0.CO;2?ref=theplasticsfella.com). *Cleft Palate Craniofac J*. 2000;37(5):434\. doi:10.1597/1545-1569(2000)037<0434:TCSCET>2.0.CO;2 4. Fisher E. [Exploring the genetic origins of Treacher Collins syndrome](https://doi.org/10.1111/j.1399-0004.2011.01632.x?ref=theplasticsfella.com). *Clin Genet*. 2011;79(4):330-332\. doi:10.1111/j.1399-0004.2011.01632.x 5. van der, Mazzola R, Vermey-Keers C, Stricker M, Raphael B. [A morphogenetic classification of craniofacial malformations](https://doi.org/10.1097/00006534-198304000-00022?ref=theplasticsfella.com). *Plast Reconstr Surg*. 1983;71(4):560-572\. doi:10.1097/00006534-198304000-00022 6. Hunt J, Hobar P. [Common craniofacial anomalies: the facial dysostoses](https://doi.org/10.1097/01.PRS.0000033869.10382.91?ref=theplasticsfella.com). *Plast Reconstr Surg*. 2002;110(7):1714-1725; quiz 1726; discussion 1727-8\. doi:10.1097/01.PRS.0000033869.10382.91 7. Poswillo D. [The pathogenesis of the first and second branchial arch syndrome](https://doi.org/10.1016/0030-4220%2873%2990070-4?ref=theplasticsfella.com). *Oral Surg Oral Med Oral Pathol*. 1973;35(3):302-328\. doi:10.1016/0030-4220(73)90070-4 8. Amirhassankhani S, Lloyd M. [Accessory Auricles: Systematic Review of Definition, Associated Conditions, and Recommendations for Clinical Practice](https://doi.org/10.1097/SCS.0000000000004201?ref=theplasticsfella.com). *J Craniofac Surg*. 2018;29(2):372-375\. doi:10.1097/SCS.0000000000004201 9. Hertle RW, Ziylan S, Katowitz JA. [Ophthalmic features and visual prognosis in the Treacher-Collins syndrome](https://doi.org/10.1136/bjo.77.10.642?ref=theplasticsfella.com). *British Journal of Ophthalmology*. October 1993:642-645\. doi:10.1136/bjo.77.10.642 10. Marsh J, Celin S, Vannier M, Gado M. [The skeletal anatomy of mandibulofacial dysostosis (Treacher Collins syndrome)](https://doi.org/10.1097/00006534-198610000-00003?ref=theplasticsfella.com). *Plast Reconstr Surg*. 1986;78(4):460-470\. doi:10.1097/00006534-198610000-00003 ### Pierre Robin Sequence: Causes, Pathophysiology, & Treatment URL: https://www.theplasticsfella.com/pierre-robin-sequence/ Last updated: 2024-06-12T18:05:28.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/pierre-robin-sequence/#definition-of-pierre-robin-sequence) Micrognathia, Glossoptosis, and U-shaped Palate result in upper airway obstruction and failure to thrive. [****Genetics**](https://www.theplasticsfella.com/pierre-robin-sequence/#genetics-of-pierre-robin-sequence) Rare and linked to Stickler, Nagar, and Treacher Collins Syndrome [****Treatment**](https://www.theplasticsfella.com/pierre-robin-sequence/#treatment-of-pierre-robin-sequence) Acute management for airway and feeding. Long-term patients will often outgrow issues with airway and feeding. --- ## Definition of Pierre Robin Sequence ****Key Point** Pierre Robin Sequence is a congenital condition characterized by a series of developmental defects leading to upper airway obstruction and failure to thrive, either as part of a syndrome or in isolation. Pierre Robin Sequence is a congenital group of defects resulting in upper airway obstruction and failure to thrive. It can be syndromic or occur in isolation. It is called a **"sequence"** because a single developmental defect results in a chain of secondary defects. More specifically: - **Defect 1:** Micrognathia due to mandibular hypoplasia. - **Defect 2:** Glossoptosis due to posterior displacement of the tongue. - **Defect 3:** U-shaped cleft palatedueto blocked closure of the palatal shelves. A small jaw results in the tongue occupying a more significant proportion of the oropharynx and falling back to cause airway obstruction. This sequence can be visualised in the illustration below. ![Pierre Robin Sequence](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Pierre-Robin-Sequence.png) Pierre Robin Sequence 💡 ****Tip:** The base of the tongue reliably follows the chin point because of the attachment of the genioglossus muscle --- ## Genetics of Pierre Robin Sequence ****Key Point** Pierre Robin Sequence has no specific identifiable genetic cause (yet). It is most commonly linked to Stickler Syndrome. The incidence of the Pierre Robin sequence is \~1 in 8500-20,000 live births ([Bush](https://doi.org/10.1016/0007-1226%2883%2990123-6?ref=theplasticsfella.com), 1983). To date, no specific human gene has been associated with the Pierre Robin sequence. There is a suggestion of a link to SOX9 and KCNJ2 mutations. Pierre Robin Sequence is associated with ([Marques](https://doi.org/10.1597/1545-1569%5F1998%5F035%5F0517%5Feoirs%5F2.3.co%5F2?ref=theplasticsfella.com), 1998)​: - **Stickler** Syndrome – the risk of retinal detachment - **Nager** Syndrome - [**Treacher Collins** Syndrome](https://www.theplasticsfella.com/treacher-collins-syndrome/) A patient with Treacher Collins Syndrome can be seen below. ![Treacher Collins syndrome example](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Treacher-Collins-Syndrome-Clinical-Features-1-1.png) Treacher Collins Syndrome 💡 ****Tip:** Genetic screening for Stickler Syndrome should be considered in patients with Pierre Robin Sequence --- ## Treatment of Pierre Robin Sequence ****Key Point** Acute management focuses on airway and feeding management. Considering longer term, patients can often outgrow their clinical issues. Treatment is focused on the specific needs of each patient, but may include surgery to assist with breathing and feeding modifications to prevent choking. Generally, syndromic PRS patients are much more challenging to treat than those that occur in isolation. ### Basic Airway Management 1. Turn to the newborn prone to relieve the glossoptosis. 2. A nasopharyngeal airway to bypass the obstruction caused by the tongue. ### Advanced Airway Management Advanced airway management options for the Pierre Robin Sequence include ([Flores](https://doi.org/10.1097/PRS.0000000000000225?ref=theplasticsfella.com), 2014)​: - **Glossopexy:** Tongue-lip adhesion for obstruction caused by glossoptosis ([Kirschner](https://doi.org/10.1597/1545-1569%5F2003%5F040%5F0013%5Fsamipr%5F2.0.co%5F2?ref=theplasticsfella.com), 2003)​. - **Tracheostomy** - **Subperiosteal release** of the floor of the mouth - **Distraction osteogenesis** of the mandible ([Cohen](https://www.ncbi.nlm.nih.gov/pubmed/10340643?ref=theplasticsfella.com), 1999 & [Tahiri](https://doi.org/10.1097/01.prs.0000438049.29258.a8?ref=theplasticsfella.com), 2014) is an alternative to tracheostomy. Prior to any surgical intervention, a nasoendoscopy is recommended. This is performed to rule out other anatomical sites or causes of airway obstruction The mortality associated with these symptoms is between 1.7 and 11.3% ([Smith](https://doi.org/10.1016/j.ijporl.2005.07.003?ref=theplasticsfella.com), 2006)​. 💡 ****Tip:** Most babies outgrow these difficulties by 6 months due to mandibular growth and improved control of the tongue. --- ## Conclusion ## Upon completing this article, you will have accomplished the following: ****1\. Basica of Pierre Robin Sequence:** Pierre Robin Sequence (PRS) is a congenital condition characterized by a series of developmental defects that result in upper airway obstruction and feeding challenges. ****2\. Recognition of Symptoms:** You are aware of the physical manifestations of PRS, which primarily include micrognathia, glossoptosis, and a U-shaped cleft palate, leading to difficulties in breathing and feeding. ****3\. Associated Conditions:** You understand that PRS can occur in isolation or as part of syndromes like Stickler, Treacher Collins, and Nager Syndromes. ****4\. Management:** You've learned that initial management focuses on securing the airway and ensuring adequate nutrition, with long-term management often seeing improvement as the child grows. ****5\. Potential Surgeries**: You are prepared to advise on possible future surgical interventions necessary if the child does not outgrow the breathing or feeding difficulties. ****6\. Treatment Challenges:** You recognize the complexities of treating PRS, including the timing of any surgical interventions and the multidisciplinary approach needed for optimal care. --- ## Further Reading 1. Resnick CM. [Precise osteotomies for mandibular distraction in infants with Robin sequence using virtual surgical planning](https://doi.org/10.1016/j.ijom.2017.07.020?ref=theplasticsfella.com). *International Journal of Oral and Maxillofacial Surgery*. January 2018:35-43\. doi:10.1016/j.ijom.2017.07.020 2. Robin P. [A fall of the base of the tongue considered as a new cause of nasopharyngeal respiratory impairment: Pierre Robin sequence, a translation](https://www.ncbi.nlm.nih.gov/pubmed/8171154?ref=theplasticsfella.com). 1923\. *Plast Reconstr Surg*. 1994;93(6):1301-1303\. 3. Bush P, Williams A. [Incidence of the Robin Anomalad (Pierre Robin syndrome)](https://doi.org/10.1016/0007-1226%2883%2990123-6?ref=theplasticsfella.com). *Br J Plast Surg*. 1983;36(4):434-437\. doi:10.1016/0007-1226(83)90123-6 4. Marques I, Barbieri M, Bettiol H. [Etiopathogenesis of isolated Robin sequence](https://doi.org/10.1597/1545-1569%5F1998%5F035%5F0517%5Feoirs%5F2.3.co%5F2?ref=theplasticsfella.com). *Cleft Palate Craniofac J*. 1998;35(6):517-525\. doi:10.1597/1545-1569\_1998\_035\_0517\_eoirs\_2.3.co\_2 5. Poswillo D. [The aetiology and pathogenesis of craniofacial deformity](https://www.ncbi.nlm.nih.gov/pubmed/3074909?ref=theplasticsfella.com). *Development*. 1988;103 Suppl:207-212\. 6. Sher A. [Mechanisms of airway obstruction in Robin sequence: implications for treatment](https://doi.org/10.1597/1545-1569%5F1992%5F029%5F0224%5Fmoaoir%5F2.3.co%5F2?ref=theplasticsfella.com). *Cleft Palate Craniofac J*. 1992;29(3):224-231\. doi:10.1597/1545-1569\_1992\_029\_0224\_moaoir\_2.3.co\_2 7. Cohen M. [Robin sequences and complexes: causal heterogeneity and pathogenetic/phenotypic variability](https://www.ncbi.nlm.nih.gov/pubmed/10340643?ref=theplasticsfella.com). *Am J Med Genet*. 1999;84(4):311-315\. 8. Flores R, Tholpady S, Sati S, et al. [The surgical correction of Pierre Robin sequence: mandibular distraction osteogenesis versus tongue-lip adhesion](https://doi.org/10.1097/PRS.0000000000000225?ref=theplasticsfella.com). *Plast Reconstr Surg*. 2014;133(6):1433-1439\. doi:10.1097/PRS.0000000000000225 9. Kirschner R, Low D, Randall P, et al. [Surgical airway management in Pierre Robin sequence: is there a role for tongue-lip adhesion?](https://doi.org/10.1597/1545-1569%5F2003%5F040%5F0013%5Fsamipr%5F2.0.co%5F2?ref=theplasticsfella.com) *Cleft Palate Craniofac J*. 2003;40(1):13-18\. doi:10.1597/1545-1569\_2003\_040\_0013\_samipr\_2.0.co\_2 10. Tahiri Y, Viezel-Mathieu A, Aldekhayel S, Lee J, Gilardino M. [The effectiveness of mandibular distraction in improving airway obstruction in the pediatric population](https://doi.org/10.1097/01.prs.0000438049.29258.a8?ref=theplasticsfella.com). *Plast Reconstr Surg*. 2014;133(3):352e-359e. doi:10.1097/01.prs.0000438049.29258.a8 11. Smith M, Senders C. [Prognosis of airway obstruction and feeding difficulty in the Robin sequence](https://doi.org/10.1016/j.ijporl.2005.07.003?ref=theplasticsfella.com). *Int J Pediatr Otorhinolaryngol*. 2006;70(2):319-324\. doi:10.1016/j.ijporl.2005.07.003 ### AIN Syndrome - Clinical Scenario URL: https://www.theplasticsfella.com/ain-syndrome-clinical-case/ Last updated: 2024-09-04T17:15:07.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/06/OK-Sign-for-AIN-Palsy.png) #### Clinical Scenario ****A 39-year-old woman presented with right forearm pain and reduce ability to flex her right thumb interphalangeal joint and index finger distal interphalangeal joint.** ****Objectives:** ****1\.** Identify the clinical features of AINS. ****2\.** Make a comprehensive diagnostic plan for AINS. ****3\.** Determine the treatment plan for AINS. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Special Edition: Everything Research (The Good, Bad & even worse) URL: https://www.theplasticsfella.com/june-9th/ Last updated: 2024-06-28T14:35:04.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-9th/#a-letter-from-pfella) Good research vs. CV research. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-9th/#the-sunday-quiz) **\+ Leaderboard** How well do you know **ganglion cysts*? 3. ****🎙️** [****Behind the 'Fella**](https://www.theplasticsfella.com/june-9th/#behind-the-fella) Announcing our upcoming guest appearance! 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/june-9th/#the-fellows-corner) What has our team been up to? 5. 📖 [****What Does the Evidence Say?**](https://www.theplasticsfella.com/june-9th/#what-does-the-evidence-say) Should research be mandatory during surgical training? 6. ****🔥** [****Recommended Articles of the Week**](https://www.theplasticsfella.com/june-9th/#articles-of-the-week) About academic publications, critical evaluation of studies, & LOE in plastic surgery research; with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/june-9th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Good Research vs. CV Research?* 👋 ****Hey Team!** ****Let's get real for a moment**. Have you ever wondered if the research we’re all pushing so hard to produce is actually moving the needle in plastic surgery? Is it driven by genuine curiosity and a desire to innovate, or are we just checking boxes to climb the career ladder? 👇 ### It’s time to have an **open conversation about the true state of research in our field**, and I need your input to make this discussion meaningful. Before we dive deeper, I’d love to get a quick sense of your research experience: ### What Motivates You to Do Research? First off, why are we doing this? Is your research motivated by a passion for discovery, or is it more about padding your CV? **Don’t worry, there are no wrong answers here—just honest ones**. I’m asking you to rank these motivations from most to least important: ### The Biggest Barrier to High-Quality Research Let’s face it—high-quality research is hard. But what makes it so difficult? Is it the lack of time, funding, or maybe something else? I want to hear from you: ### Part-Time vs. Full-Time Research Here’s a hot topic: should doctors juggle research with their clinical duties, or should research be a full-time gig? Let’s weigh the pros and cons together. Many believe that compulsory research doesn’t necessarily produce good science or encourage lifelong learning. It often wastes resources and creates avoidable problems. Offering two distinct career paths for training could better achieve objectives. In surgery and research, there are many right ways to succeed; insisting on only one approach is usually wrong. Moreover, assessing the "quality" of a surgical trainee should focus on their operational skills. That said, academic plastic surgery is vital, with high-quality trials like the Reconstructive Surgery Trials Network (RSTN) setting new standards and pushing boundaries in our field. Lots of love, P'Fella ❤️ ## The Sunday Quiz **How Well Do You Know Ganglion Cysts of the Hand & Wrist?* ****Are you ready for a new round of The Weekly Quiz?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end of six rounds will earn you a $100 voucher. ![This image shows Ganglion Cysts of the hand](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Ganglion-Cyst-of-the-Hand-2.png) Ganglion Cysts ****More exciting news!** You'll be seeing our top scorers of the last quiz battle for the crown on our next podcast episode! Tune in on [Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) or [Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) for a listen! 0:00 /0:57 1× Sunday Quiz Finale Snippet ## Behind the ‘Fella **First Guest Appearance! on* [**Apple*](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) *&* [**Spotify*](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) We’re excited to announce our first guest on the podcast: [Justin Wormald](https://x.com/JCRWormald?ref=theplasticsfella.com) 🥁 Justin has excelled in producing high-quality research in plastic surgery and has built an impressive network through the RSTN. As an academic clinical lecturer at [Oxford Trauma and Emergency Care](https://x.com/Oxford%5FTrauma?ref=theplasticsfella.com) and deputy director of the [Surgical Intervention Trials Unit at the University of Oxford](https://x.com/SITU%5FOxford?ref=theplasticsfella.com), he brings valuable insights. **This is a great chance to ask all your research-related questions.** If there's anything you want to hear from us or Justin in this upcoming **research episode**, drop your suggestions below. ## the Fellows' Corner **This Week's Focus: Ulnar Tunnel Syndrome* If you haven't got the chance yet, here's a reminder to check out our fresh **articles**, clinical **cases**, and surgical **techniques** focused on nerve compressions. Here's an overview of our article on Ulnar Tunnel Syndrome**.** #### Ulnar Tunnel Syndrome [****Definition** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#definition-of-ulnar-tunnel-syndrome)Ulnar tunnel syndrome or Guyon’s canal syndrome is compression of the ulnar nerve as it runs through the osseofibrous ulnar tunnel of the wrist. [****Anatomy** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#anatomy-of-the-ulnar-tunnel)The ulnar tunnel is formed by the ****hamate, pisiform, transverse carpal ligament, volar carpal ligaments,** and **hypothenar aponeurosis**. [****Aetiology** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#aetiology-of-ulnar-tunnel-syndrome)There are several causes of ulnar tunnel syndrome, of which ****ganglion** is the most common. [****Clinical Presentation** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#clinical-features-of-ulnar-tunnel-syndrome)Clinical features depend on location of compression and may be motor, sensory, or both. [****Investigations** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#investigations-for-ulnar-tunnel-syndrome)An ****X-ray** is the primary investigation. ****US** and ****MRI** can be used to look for soft tissue masses resulting in external compression. [****Management**](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#management-of-ulnar-tunnel-syndrome) Non-surgical treatment includes lifestyle advice, physiotherapy, and splinting. Surgery is indicated when these measures fail. [Read the Article](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/) ## What Does the Evidence Say? **Should Research Be Mandatory During Surgical Training?* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Our upcoming debate topic is **whether research should be mandatory during surgical training**! A range of studies have explored the role of mandatory surgical research during residency. Brochu (2018) and Papasavas (2013) both found that a structured research program can significantly increase academic productivity, with the latter reporting a three-fold increase in scientific presentations. Thakur (2000) and Sabir (2003) highlighted the positive impact of research training on career outcomes, with a higher likelihood of holding academic positions and increased scholarly activity. Atesok (2012) and Schultz (1996) emphasized the importance of integrating research into residency education, with the latter providing key elements for successful resident research. However, Benesch (2022) cautioned against viewing research as a one-time activity, instead advocating for a culture of scientific discovery. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries.* 1️⃣ ***Academic publications for career advancement and institutional reputation** ([Hong](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11081728/?ref=theplasticsfella.com), 2024) Should academic publishing focus on the dissemination of knowledge and improvement of patient care? What are the negative impacts of the "publish or perish" culture on individual well-being and the integrity of scientific research? 2️⃣ ***Evaluating the quality of evidence in research publications** ([Gabriel](https://journals.lww.com/prsgo/fulltext/2019/06000/reading%5Fbetween%5Fthe%5Flines%5F%5Fa%5Fplastic%5Fsurgeon%5Fs.27.aspx?ref=theplasticsfella.com), 2019) How to critically evaluate the methodology and results of studies, how different levels of evidence (LOE) grading scales are used, and the challenges of conducting high-quality randomized controlled trials (RCTs) in plastic surgery. 3️⃣ ***Levels of evidence in plastic surgery research** ([Rifkin](https://pubmed.ncbi.nlm.nih.gov/31119282/?ref=theplasticsfella.com), 2020) An analysis of trends in the quality of research published in plastic surgery literature over a decade which reveals an increase in higher-quality studies, specifically Level I and II evidence, although case series and retrospective cohort studies remain predominant. ## Feedback ### I hope you enjoyed it 😄 --- ### The Best Surgical Loupes, Nerve Nerds, & 3 Trending Articles URL: https://www.theplasticsfella.com/june-2nd/ Last updated: 2024-06-01T09:29:45.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-2nd/#a-letter-from-pfella) What makes the ‘best’ surgical loupe? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-2nd/#the-sunday-quiz) **\+ Leaderboard** How well do you know **AIN Syndrome*? 3. ****🎙️** [****Behind the 'Fella Sneak Peaks**](https://www.theplasticsfella.com/june-2nd/#behind-the-fella) Featuring the K-wires debate from our first episode. 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/june-2nd/#the-fellows-corner) What's new with the team? 5. 📖 [****What Does the Evidence Say?** ](https://www.theplasticsfella.com/june-2nd/#what-does-the-evidence-say) Nerve graft vs. vein graft for nerve repair. 6. ****🔥** [****Nerve Injuries Articles of the Week**](https://www.theplasticsfella.com/june-2nd/#articles-of-the-week) Managing 'long' nerve gaps, allografts vs. autografts vs. conduits, & treating neuromas; with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/june-2nd/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **What is the ‘Best’ Surgical Loupe?* 👋 ****Hey Team!** I hope you’re all doing fantastic! Today, I want to chat about something that’s right in our line of sight every day — surgical loupes. Have you ever wondered if there’s such a thing as the "perfect" surgical loupe? 👇 ### **Surgical loupes are like a trusted companion**—they need to be just right for each of us. What’s your ideal magnification level? Do you prefer a wide field of view or something more focused? And how about the weight? Do you like them featherlight or a bit more substantial? Lets find out 👇 ### A Few Consistent Themes Throughout the years there has always been some consistent "issues" with surgical loupes. - **Price Tag:** We all know that high-quality loupes can be quite an investment. One of the future goals of thePlasticsFella is to make resources, like surgical loupes, more accessible to the wider community. - **FOMO**: Even if you love your current loupes, do you ever catch yourself thinking they could be just a bit better? Maybe lighter, with clearer lenses, or even more comfortable. - **Sticking to What We Know:** Once we’ve found a pair we like, it can be tough to switch. The thought of adjusting to new loupes can be daunting. **Here's a fun Fact**, Loupes is just one aspect of thePlasticsFella Logo. ![](https://lh7-us.googleusercontent.com/docsz/AD_4nXdfZ-kmkNg3Zs5HfEaDple11wiaKohx1v10RC03MccGk4D5gPG0tCf7WZpjhumT-47bWCiRfuyvFwI3nzfGa88fdpV-hn3IVQSjGh9oiat5QZrZv4gPI6cM4ovEIAVUI-8REh62pg8CVexTJKP326OtAVs?key=VE6BXUZFwhQudikkPVwgwA) Lots of love, P'Fella ❤️ ****tl;dr** 👉 Surgical loupes need to fit each surgeon's personal preferences in magnification, field of view, and weight. 👉 High-quality loupes are expensive, and balancing value and affordability is important. 👉 Even your favorite loupes have room for improvement in weight, clarity, and comfort. 👉 Switching to new loupes can be tough because of your familiarity with the current ones. ## The Sunday Quiz **New Season is Starting!* ****Are you ready for a new round of The Weekly Quiz?** Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end of six rounds will earn you a $100 voucher. ![AIN as a branch of the median nerve](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--23--2.png) AIN as a branch of the median nerve ## Behind the ‘Fella **Episode One Sneak Peak!* We're excited for your feedback on "Behind the Fella," Episode 01, now live on[**Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) **or** [**Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)**.** These episodes explore behind-the-scenes of our practice, featuring exclusive insights from team meetings and trending discussions on plastic surgery with our fellows. Here's a sneak peak from the **K-wires debate!** 🩹 0:00 /4:17 1× Click here for [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) or [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)****.** Tune into the full episode to find out which side won: **Should K-wires be buried or left unburied?** [Subscribe on Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) [Subscribe on Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) ## the Fellows' Corner **This Week's Release: Nerve Compressions* Our team has been hard at work creating fantastic new content for our community, including fresh **articles**, clinical **cases**, and surgical **techniques** focused on nerve compressions. - [Ulnar Tunnel Syndrome](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/) - [AIN Syndrome](https://www.theplasticsfella.com/ain-syndrome/) - [Pronator Syndrome](https://www.theplasticsfella.com/pronator-syndrome/) Here's an overview of our article on Pronator Syndrome**.** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--26--1.png) #### Pronator Syndrome [****Definition**](https://www.theplasticsfella.com/pronator-syndrome/#definition-of-pronator-syndrome) Rare median nerve compression in the proximal forearm, mostly in middle-aged females​​. [****Anatomy**](https://www.theplasticsfella.com/pronator-syndrome/#anatomy-of-pronator-syndrome) Median nerve compression at five distinct locations causes pronator syndrome​​. [****Clinical Features**](https://www.theplasticsfella.com/pronator-syndrome/#clinical-features-of-pronator-syndrome) Typically presents with forearm pain, positive Tinel sign at the elbow, and no night symptoms​​. [****Management**](https://www.theplasticsfella.com/pronator-syndrome/#management-of-pronator-syndrome) Primarily conservative treatment with rest and splinting. Surgical decompression is reserved for cases that f​​ail to resolve with conservative measures. [Read the Article](https://www.theplasticsfella.com/pronator-syndrome/) ## What Does the Evidence Say? **Nerve Graft vs. Vein Graft for Nerve Repair* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. Our upcoming debate topic is ****Nerve Graft vs. Vein Graft for Nerve Repair**! ### Nerve Graft or Vein Graft for Nerve Repair? A range of studies have explored the use of **nerve grafts and vein conduits for nerve repair**, with varying outcomes. Katz (2011) and Ahmad (2014) both found positive results for vein grafts, with the latter reporting better sensory and motor recovery compared to isolated nerve grafts. However, Suematsu (1988) found that nerve grafts led to **higher re-innervation and shorter delay in myoelectrical response**, while Zabbia (2024) found **no significant difference in functional recovery between fibrin glue and microsurgical repair**. Hasegawa (2003) reported successful outcomes for vascularized nerve grafts in large nerve gaps, and Chiu (1990) found that autogenous vein grafts were effective for small nerve gaps. However, Papalia (2013) found that vein conduits filled with adipose tissue hindered nerve regeneration. Terzis (2010) suggested that vascularized nerve grafts could be beneficial for complex upper extremity nerve reconstruction. ## Articles of the Week **3 Interesting Articles with 1 Sentence Summaries.* 1️⃣ ***Practical tips for managing 'long' nerve gaps** ([Baek](https://www.jhsgo.org/article/S2589-5141%2824%2900021-5/fulltext?ref=theplasticsfella.com#%20), 2024) Strategies for treating long-gap nerve injuries; nerve autografts, processed nerve allografts, nerve transfers, and tendon transfers with pros and cons. 2️⃣ ***Nerve gap repair: Comparing the effectiveness of allografts, autografts, and conduits** ([Lans](https://journals.lww.com/plasreconsurg/fulltext/2023/05000/a%5Fsystematic%5Freview%5Fand%5Fmeta%5Fanalysis%5Fof%5Fnerve%5Fgap.24.aspx?ref=theplasticsfella.com), 2023) Findings show that autografts and allografts have similar meaningful recovery rates, both superior to conduits for sensory nerve repairs. 3️⃣ ***Causes, pathophysiology, and treatment for neuromas from nerve injuries in the hand** ([Watson](https://www.jhandsurg.org/article/S0363-5023%2809%2901121-6/abstract?ref=theplasticsfella.com), 2010) The debilitating nature of neuromas, individualized treatment plans, and various surgical and non-surgical approaches to manage and alleviate pain. ## Feedback ### I hope you enjoyed it 😄 --- ### Ulnar Tunnel Syndrome: Anatomy, Clinical Features, & Management URL: https://www.theplasticsfella.com/ulnar-tunnel-syndrome/ Last updated: 2024-06-11T23:01:27.000Z #### Summary Card [****Definition** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#definition-of-ulnar-tunnel-syndrome)Ulnar tunnel syndrome or Guyon’s canal syndrome is compression of the ulnar nerve as it runs through the osseofibrous ulnar tunnel of the wrist. [****Anatomy** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#anatomy-of-the-ulnar-tunnel)The ulnar tunnel is formed by the ****hamate, pisiform, transverse carpal ligament, volar carpal ligaments,** and **hypothenar aponeurosis**. [****Aetiology** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#aetiology-of-ulnar-tunnel-syndrome)There are several causes of ulnar tunnel syndrome, of which ****ganglion** is the most common. [****Clinical Presentation** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#clinical-features-of-ulnar-tunnel-syndrome)Clinical features depend on location of compression and may be motor, sensory, or both. [****Investigations** ](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#investigations-for-ulnar-tunnel-syndrome)An ****X-ray** is the primary investigation. ****US** and ****MRI** can be used to look for soft tissue masses resulting in external compression. [****Management**](https://www.theplasticsfella.com/ulnar-tunnel-syndrome/#management-of-ulnar-tunnel-syndrome) Non-surgical treatment includes lifestyle advice, physiotherapy, and splinting. Surgery is indicated when these measures fail. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## Definition of Ulnar Tunnel Syndrome ****Key Point** Ulnar tunnel syndrome or Guyon’s canal syndrome is a compression neuropathy of the ulnar nerve as it runs through the osseofibrous ulnar tunnel of the wrist. **Ulnar tunnel syndrome** or Guyon’s canal syndrome is a compression neuropathy of the ulnar nerve as it runs through the osseofibrous ulnar tunnel of the wrist. Key points to understand include: - It is also known as **Guyon’s canal**, named after the French surgeon who originally described it ([Guyon](https://franco.wiki/fr/F%C3%A9lix%5FGuyon.html?ref=theplasticsfella.com), 1861). - It is far less common compared to [cubital tunnel syndrome](https://www.theplasticsfella.com/cubital-tunnel-syndrome/). The image below further illustrates the ulnar nerve in the ulnar tunnel. ![Anatomy of the ulnar nerve through Guyon’s canal.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--22-.png) Anatomy of the ulnar nerve through Guyon’s canal. --- ## Anatomy of the Ulnar Tunnel ****Key Point** The ulnar tunnel is formed by the **hamate, pisiform, transverse carpal ligament, volar carpal ligaments,** and ****hypothenar aponeurosis.** It is considered in three zones (mixed, motor, and sensory) from proximal to distal. ### Anatomical Boundaries The ulnar tunnel is the osseofibrous tunnel that the ulnar nerve and artery pass through at the level of the carpus. The anatomical borders of Guyon’s Canal are: - **Radial Boundary:** Hook of the hamate - **Ulnar Boundary:** Pisiform - **Floor:** Formed by the Transverse Carpal Ligament - **Roof:** Consists of the Volar Carpal Ligament and Hypothenar Aponeurosis The anatomical positioning of the ulnar tunnel is illustrated in the image below. ![Anatomy of the ulnar tunnel, Ulnar Tunnel Syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--34-.png) Anatomy of the ulnar tunnel 😎 ****Fun Fact:** Fractures of the hook of the hamate typically lead to compression in Zone 2 of Guyon's canal. This compression primarily affects the deep motor branch of the ulnar nerve. ### Zones of the Canal The ulnar nerve and artery pass through it and the canal can be considered in **3 zones** based on the location and subsequent nerve fibres involve: 1. **Zone 1:** Mixed motor and sensory 2. **Zone 2:** Motor (most common) 3. **Zone 3:** Sensory 💡 ****Tip:** 'Sensory' has 3 syllables, hence is zone 3\. These zones are illustrated in the table below with their anatomical location. ![The 3 zones of Guyon’s canal, Anatomy of the Ulnar Tunnel](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--19-.png) The 3 zones of Guyon’s canal 💡 ****Tip:** The dorsal cutaneous nerve of the hand branches from the ulnar nerve before it enters Guyon's canal, ****preserving sensation** to the back of the hand in ulnar tunnel syndrome. --- ## Aetiology of Ulnar Tunnel Syndrome ****Key Point** There are several causes of ulnar tunnel syndrome, of which ganglion is the most common. The most common cause of ulnar tunnel syndrome/compression in Guyon's canal is a **ganglion** or **intra-neural cyst** ([Lee](https://pubmed.ncbi.nlm.nih.gov/35654688/?ref=theplasticsfella.com), 2022). Less common causes include: - **Trauma:** Hook of hamate fracture, repetitive external compression - **Anomalous muscles:** Palmaris duplicates, Hypothenar or FCU variants - **Vascular:** Ulnar artery thrombosis or aneurysm 😎 ****Fun Fact:** In Seddon’s original descriptions of surgical treatment for ulnar nerve compression, a ganglion caused compression in four of the first five cases of Guyon's canal that he explored. ([Listers The Hand](https://books.google.co.uk/books/about/Lister%5Fs%5FThe%5FHand.html?id=oIdsAAAAMAAJ&redir%5Fesc=y&ref=theplasticsfella.com)). --- ## Clinical Features of Ulnar Tunnel Syndrome ****Key Point** Clinical features may be motor, sensory, or both, depending on the location of compression. Symptoms include ulnar-sided wrist pain, muscle weakness, and sensory disturbance in the ulnar digits, with preservation of sensation on the dorsum. Ulnar Tunnel Syndrome can have motor, sensory, or mixed clinical features. These features are determined by the location of injury to the ulnar nerve ([Hoogvleit](https://pubmed.ncbi.nlm.nih.gov/23902776/?ref=theplasticsfella.com), 2013). ### Motor Symptoms **Motor symptoms** can occur with an ulnar nerve injury in zone 2, the most common location. They can also occur in Zone 1 injuries (mixed motor and sensory). **Classic features include:** - Dropping objects: loss of fine motor control. - Interosseous and hypothenar muscle wasting - Positive Froment's sign: Inability to adduct thumb to hold paper, compensated by flexing flexor pollicis longus due to weak adduction. ### Sensory Symptoms **Sensory symptoms** can occur with an ulnar nerve injury in zone 3\. They can also occur in Zone 1 injuries (mixed motor and sensory). **Classic features include:** - Pain at the wrist radiating to the ulnar two digits. - Sensory disturbance in ulnar digits. - Symptoms are exacerbated at night or by activity. Three types of ulnar tunnel syndrome are classified based on the level of nerve compression within Guyon’s canal, as outlined in the table below. ![types of ulnar tunnel syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--20-.png) Types of ulnar tunnel syndrome **Other tests to evaluate the cause:** - Pain over the hook of the hamate indicating fracture. - Ulnar artery aneurysm may be palpable. - Positive Tinel Hoffman percussion test. 😎 ****Fun Fact:** Keen cyclists are at risk of ulnar tunnel syndrome due to prolonged and repetitive compression of the ulnar nerve within Guyon’s canal when the hand is resting on the handlebars ([Hoogvleit](https://pubmed.ncbi.nlm.nih.gov/23902776/?ref=theplasticsfella.com), 2013). --- ## Investigations for Ulnar Tunnel Syndrome ****Key Point** ****Radiological** investigations can be used to look for soft tissue masses resulting in external compression. ****Nerve conduction studies** can delineate in which zone of the ulnar tunnel the ulnar nerve is compressed. ### Radiological Investigations Ulnar Tunnel Syndrome can have a bone or soft tissue aetiology. Clinical assessment will help guide the relevant imaging modality. Options include: - **X-ray:** Demonstrate hamate or pisiform fracture. - **US:** Demonstrate soft tissue lesions or ulnar artery anomalies, nerve elastography may be useful to demonstrate compression, depending on user experience. - **MRI:** Further delineate mass lesions and increasingly detailed anatomy. ### **Electrophysiology** Increased latency of sensory action potentials in zone I and zone III compressions while increased motor latency and decreased compound muscle action potentials in zone II compression. 😎 ****Fun Fact:** Diffusion tensor imaging (dTI) is a promising MRI technique that measures nerve alignment. It may become a standard, non-invasive method for diagnosing cubital tunnel syndrome and other nerve compression syndrome ([Griffiths](https://pubmed.ncbi.nlm.nih.gov/34294771/?ref=theplasticsfella.com), 2021). --- ## Management of Ulnar Tunnel Syndrome ****Key Point** Non-surgical treatment includes lifestyle advice, physiotherapy, and splinting. Surgical decompression is indicated if refractory to conservative management. ### Non-surgical For mild ulnar tunnel syndrome lasting **less than 3 months**, **lifestyle modifications** can be effective. Recommendations include avoiding ulnar compression, such as altering hand position on bicycle handlebars. - **Splinting:** The wrist should be splinted in a neutral position, with or without the inclusion of fingers. A Delphi study of expert opinions shows variation in the recommended duration of splinting, ranging from 1 to 12 weeks ([Hoogvleit](https://pubmed.ncbi.nlm.nih.gov/23902776/?ref=theplasticsfella.com), 2013) - **Nerve Gliding Exercises:** These can help alleviate symptoms. - **Medications:** NSAIDs and steroids are generally not effective for ulnar tunnel syndrome. ### Surgical Surgery is indicated for severe or persistent symptoms unresponsive to basic interventions. The goal is to release pressure on the ulnar nerve by dividing the roof of Guyon’s canal (volar carpal ligament). 1. **Incision:** Commonly, a carpal tunnel incision is used. 2. **Nerve Protection:** Identify and protect the cutaneous nerve in the distal wound (15% incidence). 3. **Ligament Division:** Divide the volar carpal ligament and possibly some palmaris brevis fibers. 4. **Identify Structures:** Locate the hook of the hamate. 5. **Nerve Exposure:** Expose the full length of the ulnar nerve. 6. **Hemostasis:** Use microcautery for bleeding vessels. 7. **Muscle Release:** Release the aponeurotic arch of the hypothenar muscles with tenotomy scissors. 8. **Decompression Extent:** Decompress up to the antebrachial fascia. 9. **Wound Closure:** Use simple interrupted sutures. This [5-minute video](https://www.youtube.com/watch?v=qnH3lXa74LY&ref=theplasticsfella.com) by Susan McKinnon demonstrates the key steps. 😎 ****Fun Fact:** At least 5 different surgical incisions are used to release the ulnar tunnel, the most widely used being the carpal tunnel incision ([Hoogvleit](https://pubmed.ncbi.nlm.nih.gov/23902776/?ref=theplasticsfella.com), 2013). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Ulnar Tunnel Syndrome:** You've learned about Ulnar Tunnel Syndrome and its definition as a compression neuropathy of the ulnar nerve at the wrist. ****2\. Anatomy:** You've gained insights into the anatomical features of the ulnar tunnel, including its formation by the hamate, pisiform, and surrounding ligaments and aponeuroses. ****3\. Identifying Causes:** You now understand the various aetiologies of ulnar tunnel syndrome, with ganglions being the most common cause among others such as anomalous muscles and hypothenar anomalies. ****4\. Clinical Presentation:** You've learned how the symptoms of ulnar tunnel syndrome can vary based on the exact location of nerve compression, affecting motor and/or sensory functions. ****5\. Diagnostic Tools:** You are now familiar with the primary and supplementary diagnostic tools for this condition, including X-ray, ultrasound, MRI, and electrophysiological studies. ****6\. Management Strategies:** You've understood the management options ranging from non-surgical approaches like physiotherapy and splinting to surgical interventions when necessary. --- ## Further Reading 1. Barton N. [Lister’s “the hand”: diagnosis and indications](https://books.google.co.uk/books/about/Lister%5Fs%5FThe%5FHand.html?id=oIdsAAAAMAAJ&redir%5Fesc=y&ref=theplasticsfella.com). J Bone Joint Surg Br. 2003;85-B(1):152-152\. doi:10.1302/0301-620X.85B1.0850152 2. Greens DP, Wolfe SW. [*Green’s Operative Hand Surgery*](https://www.uk.elsevierhealth.com/greens-operative-hand-surgery-9780323697934.html?ref=theplasticsfella.com). 6th ed. Elsevier/Churchill Livingstone; 2011\. Accessed May 22, 2024\. http://www.clinicalkey.com/dura/browse/bookChapter/3-s2.0-C20091589800 3. Guyon, Felix (1861). "[Note sur une disposition anatomique propere a la face anterieure de la region du poignet et non encore decrite](https://en.wikipedia.org/wiki/Ulnar%5Fcanal?ref=theplasticsfella.com)". *Bull Soc Anat Paris*. 6: 184–186. 4. Spinner RJ. [The longest intraneural ganglion cyst: it's not about size but principle(s)](https://pubmed.ncbi.nlm.nih.gov/24074634/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2014 Feb;67(2):e69-70\. doi: 10.1016/j.bjps.2013.09.002\. Epub 2013 Sep 11\. PMID: 24074634. 5. Bachoura A, Jacoby SM. [Ulnar tunnel syndrome](https://pubmed.ncbi.nlm.nih.gov/23026462/?ref=theplasticsfella.com). Orthop Clin North Am. 2012 Oct;43(4):467-74\. doi: 10.1016/j.ocl.2012.07.016\. PMID: 23026462. 6. Lee JH, Lee JK, Park JS, Kim DH, Baek JH, Yoon BN, Kim S, Ha C, Cho WM, Han SH. [Characteristics of surgically treated Guyon canal syndrome: A multicenter retrospective study](https://pubmed.ncbi.nlm.nih.gov/35654688/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2022 Sep;75(9):3269-3278\. doi: 10.1016/j.bjps.2022.04.049\. Epub 2022 Apr 27\. PMID: 35654688. 7. Hoogvliet P, Coert JH, Fridén J, Huisstede BM; European HANDGUIDE group. [How to treat Guyon's canal syndrome? Results from the European HANDGUIDE study: a multidisciplinary treatment guideline](https://pubmed.ncbi.nlm.nih.gov/23902776/?ref=theplasticsfella.com). Br J Sports Med. 2013 Nov;47(17):1063-70\. doi: 10.1136/bjsports-2013-092280\. Epub 2013 Jul 31\. PMID: 23902776. 8. Griffiths TT, Flather R, Teh I, Haroon HA, Shelley D, Plein S, Bourke G, Wade RG. [Diffusion tensor imaging in cubital tunnel syndrome](https://pubmed.ncbi.nlm.nih.gov/34294771/?ref=theplasticsfella.com). Sci Rep. 2021 Jul 22;11(1):14982\. doi: 10.1038/s41598-021-94211-7\. PMID: 34294771; PMCID: PMC8298404. 9. Sinha, S. Pinder, R. M., & Majumder, S. (2013). [The largest reported epineural ganglion of the ulnar nerve causing cubital tunnel syndrome: case report and review of the literature](https://www.sciencedirect.com/science/article/pii/S1748681512005840?ref=theplasticsfella.com). *Journal of Plastic, Reconstructive & Aesthetic Surgery*, *66*(1), e23-e25. ### Anterior Interosseous Nerve Syndrome: Pathophysiology, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/ain-syndrome/ Last updated: 2024-06-18T08:48:52.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/ain-syndrome/#definition-of-ain-syndrome) Anterior interosseous nerve syndrome (AINS) is a peripheral neuropathy that involves disruption of the anterior interosseous nerve. [****Anatomy**](https://www.theplasticsfella.com/ain-syndrome/#anatomy-of-ain-syndrome) The AIN is purely a motor branch of the median nerve arising distal to the elbow. [****Aetiology**](https://www.theplasticsfella.com/ain-syndrome/#aetiology-of-ain-syndrome) Initially thought to be caused by compression and entrapment, the currently proposed pathophysiology includes immune neuropathy. [****Presentation**](https://www.theplasticsfella.com/ain-syndrome/#presentation-of-ain-syndrome) AIN syndrome presents as an isolated paralysis of the AIN-supplied muscles (FPL, FDP, and PQ) and no sensory loss. [****Investigations**](https://www.theplasticsfella.com/ain-syndrome/#investigations-of-ain-syndrome) Diagnosis is based on a combination of physical exam and EMG. MRI and US can also be useful. [****Differential Diagnoses**](https://www.theplasticsfella.com/ain-syndrome/#differential-diagnoses-of-ain-syndrome) Flexor tendon rupture, proximal nerve compression, and other compressive neuropathies such as pronator syndrome or carpal tunnel syndrome. [****Treatment**](https://www.theplasticsfella.com/ain-syndrome/#treatment-of-ain-syndrome) Initially, a non-operative approach is recommended, followed by surgical decompression if symptoms persist. [****Complications**](https://www.theplasticsfella.com/ain-syndrome/#complications-of-ain-syndrome) Persistent AIN motor deficit can be treated by tendon or nerve transfer. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Definition of AIN syndrome ****Key Point** Anterior interosseous nerve syndrome (AINS) is a peripheral neuropathy that involves disruption of the anterior interosseous nerve. Anterior interosseous nerve syndrome (AINS) is a rare form of peripheral neuropathy that involves an isolated palsy of the anterior **interosseous nerve** – a branch of the median nerve ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022). It is also known as **Kiloh-Nevin's syndrome**.It refers to the constellation of signs and symptoms referable to the weakness of: - **pronator quadratus,** - **flexor pollicis longus,** and - **flexor digitorum profundus** to the index finger ([Chin](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Douglas+H.C.L+Chin%2C+Roy+A+Meals%2C+Anterior+interosseous+nerve+syndrome%2C+Journal+of+the+American+Society+for+Surgery+of+the+Hand%2C&btnG=&ref=theplasticsfella.com), 2001). This condition can present in a complete or incomplete form: ([Hill](https://pubmed.ncbi.nlm.nih.gov/3968404/?ref=theplasticsfella.com), 1985) - **Complete AINS:** All three muscles are affected, leading to notable functional impairments such as difficulty in pinching and gripping. - **Incomplete AINS:** Only one or two of the innervated muscles show symptoms, which may result in less apparent clinical signs. Recently selective compression of the AIN fascicles within the median nerve above the forearm has also been described as giving rise to this group of symptoms ([Krishnan](https://pubmed.ncbi.nlm.nih.gov/32890049/?ref=theplasticsfella.com), 2020). 😎 ****Fun Fact:** AINS is quite rare, comprising <1% of all upper limb nerve syndromes, affecting men and women, as well as dominant and nondominant upper extremities equally ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022). --- ## Anatomy of AIN Syndrome ****Key Point** The AIN is a purely motor branch of the median nerve arising \~4cm distal to the medial epicondyle. There is no sensory component. AIN is a **terminal motor branch** of the median nerve. It has the following characteristics: - Arises from the median nerve approximately **4cm** distal to the **medial epicondyle** (and **5-8 cm** distal to the **lateral epicondyle**). - Travels between FDS and FDP. - Continues between FPL and FDP. - Lies on the anterior surface of the **interosseous membrane** travelling with the anterior interosseous artery to the **pronator quadratus**. The image below illustrates the anatomy of AIN syndrome. ![Median nerve with AIN branch in forearm ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--23-.png) AIN as a branch of the median nerve It innervates **3 muscles** in the forearm. - **Flexor Digitorum Profundus (FDP):** Affects the index and middle fingers, facilitating flexion at the distal interphalangeal joints. - **Flexor Pollicis Longus (FPL**)**:** Enables flexion at the interphalangeal joint of the thumb. - **Pronator Quadratus (PQ):** Responsible for pronation of the forearm, allowing the palm to face downwards. The AIN has **no cutaneous sensory component**. 💡 ****Tip:** Terminal branches innervate the joint capsule and the intercarpal, radiocarpal, and distal radioulnar joints and can lead to wrist pain as a part of AIN syndrome presentations. --- ## Aetiology of AIN Syndrome ****Key Point** Initially thought to be caused by compression and entrapment, the currently proposed pathophysiology includes immune neuropathy. ### Pathophysiology Originally, compression and entrapment of the AIN were suspected to be the etiology of AINS. However, the pathophysiology of AINS is now widely debated and remains unclear. Current theories include: ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022; [Boeckstyns](https://pubmed.ncbi.nlm.nih.gov/35128983/?ref=theplasticsfella.com), 2022, [Krishnan](https://pubmed.ncbi.nlm.nih.gov/32890049/?ref=theplasticsfella.com), 2020) - Idiopathicimmune-mediated **neuritis**. - Intrinsic **compression** in the forearm or selective fascicular compression of the AIN fascicles above the forearm prior to branching. More recent evidence suggests that AINS may be a variation of **neuralgic amyotrophy** (NA), which is an idiopathic immune neuropathy ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022) ### Compression The **AIN** can be **internally** entrapped/compressed by muscles, tendons, blood vessels, and bones. More specifically: Muscles of the forearm: - **Pronator teres heads** muscle (The most common site of entrapment). - The proximal edge of the **flexor digitorum superficialis** (FDS) arch. - **Palmaris longus.** - An accessory head of the FPL (Gantzer’s muscle) ([Degreef](https://pubmed.ncbi.nlm.nih.gov/15587039/?ref=theplasticsfella.com), 2004). Other sites of compression include: - Bicipital aponeurosis and Tendinous bands. - Thrombosed radial or ulnar artery branch in the mid-forearm. - Osseous spurs. **External compressive** aetiology (e.g. supracondylar fracture) is not considered true AINS. Symptoms have consistently been shown to resolve once the external compression is eliminated. 😎 ****Fun Fact:** Direct traumatic injury to the AIN, either due to upper extremity trauma or extrinsic mass (i.e. tumour) is rare and not considered true AINS due to differing pathophysiology ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022). --- ## Presentation of AIN Syndrome ****Key Point** AIN syndrome presents as an isolated paralysis of the AIN-supplied muscles (FPL, FDP, and PQ) and no sensory loss. Wrist pain may be evident. Patients affected typically present in their 40s. A positive prognostic variable is a patient less than 40 as they are expected to have faster recovery. This may be after a trauma or spontaneous ([Sood](https://pubmed.ncbi.nlm.nih.gov/9061529/?ref=theplasticsfella.com), 1997). ### Pain - If present, there is prodrome pain that is transient and hours to 2-3 weeks. - It is usually acute, poorly localised in the proximal volar forearm and the cubital fossa, and worsened by repetitive action. 💡 ****Tip:** Risk Factors for AIN palsy include Diabetes, HIV, Nutritional Deficiencies, Rheumatoid Disease ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022). ### Motor Weakness - **FPL:** loss of thumb IPJ flexion. - **FDP Index:** loss of DIPJ flexion. - **PQ:** reduced forearm pronation. - **OK Sign:** struggle to bring the tips of the thumb and index finger together. - **Key Pinch:** unable to resist a paper pinch between the thumb and index finger or compensates by extending the thumb and index finger joints. ![Presentation of AIN syndrome, diagnosing AIN syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--32-.png) Patients with Ain syndrome struggle to make an 'OK' sign 🚨 These patients should have a normal sensory examination. [****Pronator syndrome**](https://www.theplasticsfella.com/pronator-syndrome/) also involves sensory changes in the median nerve. ### Provocative Tests - Pronator quadratus weakness presents as weak resisted pronation with the elbow fully flexed. - To distinguish from FPL attritional rupture (common in rheumatoid arthritis), passively flex and extend the wrist to check for the tenodesis effect in an intact tendon. 😎 ****Fun Fact:** The Martin-Gruber communicating branch, a unique connection between the median or AIN and ulnar nerves, may contribute to intrinsic muscle weakness in addition to the characteristic palsy triad of AINS ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022). --- ## Investigations of AIN Syndrome ****Key Point** Diagnosis is based on a combination of physical exam and EMG. MRI is increasingly useful. ### Neurophysiology Investigations This investigation can diagnose and assess the severity of AIN palsy, rule out more proximal lesions, and evaluate nerve recovery. Additionally, EMG helps differentiate idiopathic AIN syndrome (a part of neuralgic amyotrophy) from compression neuropathy. Findings include: - Abnormal activity and prolonged latency in the FPL, FDP, and PQ ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022). - It may also show fibrillations and sharp waves in the affected muscles. - Sensory nerve conduction studies of the median nerve should be normal, as the anterior interosseous nerve lacks sensory innervation ([Akhondi](https://www.ncbi.nlm.nih.gov/books/NBK525956/?ref=theplasticsfella.com#:~:text=Anterior%20interosseus%20syndrome%20is%20an,and%20thumb%20finger%20pincer%20movement.), 2023). 💡 ****Tip:** Sensory nerve conduction studies of the median nerve should be normal as there is no sensory innervation to the anterior interosseous nerve. ### ### MRI T2-weighted fat-saturated images show increased signal intensity within the muscles innervated by the AIN (FPL, FDP, and PQ). An MRI "bullseye" sign may be seen in the nerve proximal to the point of compression ([Park](https://pubmed.ncbi.nlm.nih.gov/38685735/?ref=theplasticsfella.com), 2024). The image below illustrates the MRI presentation of AIN syndrome. ![MRI for AINS- pronator quadratus edema](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--24-.png) Pronator quadratus edema in an MRI for AINS (T1 weighted) 💡 ****Tip:** The most reliable MRI finding is increased signal intensity within the PQ ([Dunn](https://pubmed.ncbi.nlm.nih.gov/17938918/?ref=theplasticsfella.com), 2007). ### **Ultrasound** The US can demonstrate anatomical causes of compression and the severity of compression (derived from calculating a ratio of nerve diameter proximal and distal to the lesion) ([Park](https://pubmed.ncbi.nlm.nih.gov/38685735/?ref=theplasticsfella.com), 2024). --- ## Differential Diagnoses of AIN Syndrome ****Key Point** Flexor tendon rupture, proximal nerve compression, and other compressive neuropathies such as pronator syndrome or carpal tunnel can all present similarly. It is important to be able to differentiate between AIN Syndrome, [Pronator Syndrome](https://www.theplasticsfella.com/pronator-syndrome/), and [Carpal Tunnel Syndrome](https://www.theplasticsfella.com/carpal-tunnel-syndrome/). Other differentials include an FDP index rupture, FPL rupture, or brachial neuritis. The differences in compressive neuropathies are detailed in the table below. ![Comparison of carpal tunnel syndrome, AIN syndrome, and pronator teres syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--33-.png) Comparative Overview of carpal tunnel syndrome, AIN syndrome, and pronator teres syndrome 💡 ****Tip:** To exclude FPL tendon rupture, the wrist is flexed passively and extended to confirm that the individual has an intact tenodesis effect. --- ## Treatment of AIN Syndrome ****Key Point** The non-operative approach initially, along with subsequent surgical decompression if symptoms persist. Due to the self-limiting nature of AINS, conservative and symptomatic management is the first line of treatment in the absence of a demonstrable acute external compressive cause. It includes: ([Li](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188), 2022) - Multimodal Analgesia. - **Hand Therapy:** contracture prevention, splinting of the elbow near 90 degrees of flexion (or position of most comfort for the patient). - **Other considerations**: Electrical stimulation therapy, Supplemental vitamin B12. Recovery generally begins **3 to 12 months** after onset of symptoms with full resolution taking up to **18 months**. ### Surgical intervention **Indications** ([Chin](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Douglas+H.C.L+Chin%2C+Roy+A+Meals%2C+Anterior+interosseous+nerve+syndrome%2C+Journal+of+the+American+Society+for+Surgery+of+the+Hand%2C&btnG=&ref=theplasticsfella.com), 2001; [Aljwader](https://pubmed.ncbi.nlm.nih.gov/26921536/?ref=theplasticsfella.com), 2016) - No improvement is noted within 6 to 12 months. - If the neurologic condition worsens, surgical exploration may be warranted. - Confirmed compression neuropathy. **Surgical treatment consists of:** - Exploration - Neurolysis - Decompression - including endoscopic decompression Endoscopic decompression can be performed, with advantages considered to be smaller scars, less blood loss, and improved recovery time. However, it is not suitable for all cases and has a learning curve. --- ## Complications of AIN Syndrome ****Key Point** Persistent AIN motor deficit can be treated by tendon transfer. Persistent AIN motor deficit may occur after conservative treatment or surgical decompression and can be treated by tendon transfer. - **Brachioradialis to FPL transfer.** - **FDP of 3rd and 4th finger to the index finger.** **Tendon transfer** would usually only be considered **\> 1 year** after onset of symptoms. For all tendon transfers, equivalent nerve transfers exist. The nerve to FDS or supinator nerves may be transferred to the AIN ([MacKinnon](https://surgicaleducation.wustl.edu/flexor-digitorum-superficialis-anterior-interosseous-nerve-transfer/?ref=theplasticsfella.com), 2011; [Hsiao](https://pubmed.ncbi.nlm.nih.gov/18807095/?ref=theplasticsfella.com), 2009). --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding AINS:** You've gained a comprehensive overview of Anterior Interosseous Nerve Syndrome (AINS), its definition, and its symptoms. ****2\. Anatomical Insights:** You've learned about the anatomy of the anterior interosseous nerve, including its origins, path, and the muscles it innervates. ****3\. Pathophysiology:** You understand the theories behind the causes of AINS, including immune neuropathy and mechanical compression, and how they contribute to the condition. ****4\. Clinical Presentation:** You've learned how AINS presents clinically, primarily affecting motor functions without sensory loss, impacting the ability to perform specific hand movements. ****5\. Diagnostic Processes:** You are now familiar with the diagnostic methods for AINS and various conditions that mimic AINS symptoms, helping in distinguishing AINS from other similar neuropathies. ****6\. Management Strategies:** You've understood both conservative and surgical management options for AINS, and the indications for each approach. ****7\. Complications and Interventions:** You've learned about the complications associated with persistent AINS and advanced surgical interventions such as nerve and tendon transfers. --- ## Further Reading 1. Aljawder A, Faqi MK, Mohamed A, Alkhalifa F. [Anterior interosseous nerve syndrome diagnosis and intraoperative findings: A case report](https://pubmed.ncbi.nlm.nih.gov/26921536/?ref=theplasticsfella.com). Int J Surg Case Rep. 2016;21:44-7\. doi: 10.1016/j.ijscr.2016.02.021\. Epub 2016 Feb 20\. PMID: 26921536; PMCID: PMC4802332. 2. Akhondi H, Varacallo M. [Anterior Interosseous Syndrome](https://www.ncbi.nlm.nih.gov/books/NBK525956/?ref=theplasticsfella.com#:~:text=Anterior%20interosseus%20syndrome%20is%20an,and%20thumb%20finger%20pincer%20movement.). \[Updated 2023 Aug 4\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525956/ accessed on 24th May 2024 3. Vincelet Y, Journeau P, Popkov D, Haumont T, Lascombes P. [The anatomical basis for anterior interosseous nerve palsy secondary to supracondylar humerus fractures in children](https://pubmed.ncbi.nlm.nih.gov/23916783/?ref=theplasticsfella.com). Orthop Traumatol Surg Res. 2013 Sep;99(5):543-7\. doi: 10.1016/j.otsr.2013.04.002\. Epub 2013 Aug 2\. PMID: 23916783. 4. Degreef I, De Smet L. [Anterior interosseous nerve paralysis due to Gantzer's muscle](https://pubmed.ncbi.nlm.nih.gov/15587039/?ref=theplasticsfella.com). Acta Orthop Belg. 2004 Oct;70(5):482-4\. PMID: 15587039. 5. Dunn AJ, Salonen DC, Anastakis DJ. [MR imaging findings of anterior interosseous nerve lesions](https://pubmed.ncbi.nlm.nih.gov/17938918/?ref=theplasticsfella.com). Skeletal Radiol. 2007 Dec;36(12):1155-62\. doi: 10.1007/s00256-007-0382-7\. Epub 2007 Oct 16\. PMID: 17938918. 6. Sood MK, Burke FD. [Anterior interosseous nerve palsy. A review of 16 cases](https://pubmed.ncbi.nlm.nih.gov/9061529/?ref=theplasticsfella.com). J Hand Surg Br. 1997 Feb;22(1):64-8\. doi: 10.1016/s0266-7681(97)80020-4\. PMID: 9061529. 7. Li N, Russo K, Rando L, Gulotta-Parrish L, Sherman W, Kaye AD. [Anterior Interosseous Nerve Syndrome](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9547755/?ref=theplasticsfella.com#ref-153188). Orthop Rev (Pavia). 2022 Oct 7;14(4):38678\. doi: 10.52965/001c.38678\. PMID: 36225171; PMCID: PMC9547755. 8. Krishnan KR, Sneag DB, Feinberg JH, Wolfe SW. [Anterior Interosseous Nerve Syndrome Reconsidered: A Critical Analysis Review](https://pubmed.ncbi.nlm.nih.gov/32890049/?ref=theplasticsfella.com). JBJS Rev. 2020 Sep;8(9):e2000011\. doi: 10.2106/JBJS.RVW.20.00011\. PMID: 32890049. 9. Boeckstyns M. [My current views on the anterior interosseous nerve syndrome](https://pubmed.ncbi.nlm.nih.gov/35128983/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2022 May;47(5):542-543\. doi: 10.1177/17531934221076268\. Epub 2022 Feb 6\. PMID: 35128983. 10. Joist A, Joosten U, Wetterkamp D, Neuber M, Probst A, Rieger H. [Anterior interosseous nerve compression after supracondylar fracture of the humerus: a metaanalysis](https://pubmed.ncbi.nlm.nih.gov/10350251/?ref=theplasticsfella.com). J Neurosurg. 1999 Jun;90(6):1053-6\. doi: 10.3171/jns.1999.90.6.1053\. PMID: 10350251. 11. Chin, Douglas HCL, and Roy A. Meals. "[Anterior interosseous nerve syndrome](https://scholar.google.com/scholar?hl=en&as%5Fsdt=0%2C5&q=Douglas+H.C.L+Chin%2C+Roy+A+Meals%2C+Anterior+interosseous+nerve+syndrome%2C+Journal+of+the+American+Society+for+Surgery+of+the+Hand%2C&btnG=&ref=theplasticsfella.com)." Journal of the American Society for Surgery of the Hand 1.4 (2001): 249-257. 12. Casey PJ, Moed BR. [Fractures of the forearm complicated by palsy of the anterior interosseous nerve caused by a constrictive dressing. A report of four cases](https://pubmed.ncbi.nlm.nih.gov/9010194/?ref=theplasticsfella.com). J Bone Joint Surg Am. 1997 Jan;79(1):122-4\. doi: 10.2106/00004623-199701000-00014\. PMID: 9010194. 13. Ikumi A, Yoshii Y, Nagashima K, Takeuchi Y, Tatsumura M, Mammoto T, Hirano A, Yamazaki M. [Anterior interosseous nerve syndrome following infection with COVID-19: a case report](https://pubmed.ncbi.nlm.nih.gov/37301873/?ref=theplasticsfella.com). J Med Case Rep. 2023 Jun 11;17(1):253\. doi: 10.1186/s13256-023-03952-8\. PMID: 37301873; PMCID: PMC10257534 14. Park JE, Sneag DB, Choi YS, Oh SH, Choi S. [Fascicular Involvement of the Median Nerve Trunk in the Upper Arm: Manifestation as Anterior Interosseous Nerve Syndrome With Unique Imaging Features](https://pubmed.ncbi.nlm.nih.gov/38685735/?ref=theplasticsfella.com). Korean J Radiol. 2024 May;25(5):449-458\. doi: 10.3348/kjr.2023.1218\. PMID: 38685735; PMCID: PMC11058432. 15. Hsiao EC, Fox IK, Tung TH, Mackinnon SE. [Motor nerve transfers to restore extrinsic median nerve function: case report](https://pubmed.ncbi.nlm.nih.gov/18807095/?ref=theplasticsfella.com). Hand (N Y). 2009 Mar;4(1):92-7\. doi: 10.1007/s11552-008-9128-9\. Epub 2008 Sep 19\. PMID: 18807095; PMCID: PMC2654949. 16. MacKinnon SE, Yee A. [Flexor digitorum superficialis to anterior interosseous nerve transfer](https://surgicaleducation.wustl.edu/flexor-digitorum-superficialis-anterior-interosseous-nerve-transfer/?ref=theplasticsfella.com). Online video. [https://surgicaleducation.wustl.edu/flexor-digitorum-superficialis-anterior-interosseous-nerve-transfer/](https://surgicaleducation.wustl.edu/flexor-digitorum-superficialis-anterior-interosseous-nerve-transfer/?ref=theplasticsfella.com) Accessed 26th May 2024. 17. Hill NA, Howard FM, Huffer BR. [The incomplete anterior interosseous nerve syndrome](https://pubmed.ncbi.nlm.nih.gov/3968404/?ref=theplasticsfella.com). J Hand Surg Am. 1985 Jan;10(1):4-16\. doi: 10.1016/s0363-5023(85)80240-9\. PMID: 3968404. 18. Unadkat J, Wollstein R. [Anti-retroviral drug induced partial anterior interosseous nerve palsy: a case report](https://pubmed.ncbi.nlm.nih.gov/18938121/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2009 Nov;62(11):e540-1\. doi: 10.1016/j.bjps.2008.06.055\. Epub 2008 Oct 19\. PMID: 18938121. ### Pronator Syndrome: Anatomy, Clinical Features, & Management URL: https://www.theplasticsfella.com/pronator-syndrome/ Last updated: 2024-05-29T21:09:20.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/pronator-syndrome/#definition-of-pronator-syndrome) Rare median nerve compression in the proximal forearm, mostly in middle-aged females​​. [****Anatomy**](https://www.theplasticsfella.com/pronator-syndrome/#anatomy-of-pronator-syndrome) Median nerve compression at five distinct locations causes pronator syndrome​​. [****Clinical Features**](https://www.theplasticsfella.com/pronator-syndrome/#clinical-features-of-pronator-syndrome) Typically presents with forearm pain, positive Tinel sign at the elbow, and no night symptoms​​. [****Management**](https://www.theplasticsfella.com/pronator-syndrome/#management-of-pronator-syndrome) Primarily conservative treatment with rest and splinting. Surgical decompression is reserved for cases that f​​ail to resolve with conservative measures. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Pronator Syndrome ****Key Point** Pronator Syndrome is a compressive neuropathy of the median nerve in the proximal forearm. Pronator Syndrome is a compressive neuropathy of the median nerve at the level of the elbow, as it passes from the arm to the forearm. It is a rare form of neuropathy of the median nerve. Key facts include: - An incidence of **<10%** of all median nerve entrapments. - Tends to affect **females** in the **5th decade of life** - Increased riskwith **well-developed arm muscles** ([Ruiz](https://docs.google.com/document/d/1IhY21NCJUW4FC%5FLp1Y1ENIdPCbDpY9iomKTm%5FwjwUfM/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2023). The basic anatomy of pronator syndrome is illustrated below. ![Median nerve, Upper limb, neuropathy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--25-.png) The course of the median nerve down the upper limb 😎 ****Fun Fact:** Pronator syndrome is commonly associated with ***medial epicondylitis** *.* --- ## Anatomy of Pronator Syndrome ****Key Point** The median nerve enters the forearm via the cubital fossa, with potential compression at five locations in the elbow leading to pronator syndrome. Median nerve is formed from the medial and lateral cords of the brachial plexus, representing **C6-T1 nerve roots**. Its course in the upper limb is: - Travels through the axilla and down the arm, **lateral to brachial artery**. - Enters forearm via the cubital fossa and comes to lie between FDS + FDP muscle bellies, after passing **between the two heads of pronator teres.** - Gives off anterior interosseous nerve in the forearm + palmar cutaneous branch before passing through the carpal tunnel terminating as the recurrent and palmar digital branches ([Drake](https://docs.google.com/document/d/1IhY21NCJUW4FC%5FLp1Y1ENIdPCbDpY9iomKTm%5FwjwUfM/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2020). Compression at the elbow, giving rise to pronator syndrome, may occur at **5 distinct locations**: 1. Between the **ulnar and humeral heads of pronator teres:** commonest aetiology. 2. **Supracondylar process:** a residual bony structure of the distal humerus present in 1% of the population. 3. **Ligament of Struthers:** connective tissue band extending from the supracondylar process to the medial epicondyle. 4. **Bicipital aponeurosis** (Lacertus fibrosus): thickened aponeurosis of the biceps brachii at the elbow. 5. **FDS aponeurotic arch** ([Balcerzak](https://docs.google.com/document/d/1IhY21NCJUW4FC%5FLp1Y1ENIdPCbDpY9iomKTm%5FwjwUfM/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2022). **Additional rarer sites of nerve compression:** - The accessory head of the flexor pollicis longus (Gantzer muscle) - Exostoses of the radius - The ulnar segment of the flexor carpi ulnaris muscle - The brachialis muscle and its fascial bands ([Balcerzak](https://docs.google.com/document/d/1IhY21NCJUW4FC%5FLp1Y1ENIdPCbDpY9iomKTm%5FwjwUfM/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2022). The anatomy of the upper limb concerning pronator syndrome is illustrated below. ![Median nerve neuropathy, compression neuropathy, pronator syndrome, carpal tunnel syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--26-.png) Sites of potential compression of the median nerve at the elbow. 💡 ****Tip:** Ligament of Struthers is not to be confused with ****Arcade of Struthers**, which is a thin aponeurotic band in the arm originating from the brachial fascia, that can cause an **ulnar nerve entrapment** ([Loukas](https://journals.lww.com/neurosurgery/abstract/2010/06000/sir%5Fjohn%5Fstruthers%5F%5F1823%5F1899%5F%5Fand%5Fhis%5Fligament.32.aspx?ref=theplasticsfella.com), 2010). --- ## Clinical Features of Pronator Syndrome ****Key Point** Pronator syndrome presents as median nerve distribution parestheisa, pain in the volar arm, and positive tinel signs in the volar forearm. The clinical features of pronator syndrome share similarities with other compressive neuropathies of the median nerve. However, distinct findings help in distinguishing pronator syndrome from its primary differential diagnosis, [carpal tunnel syndrome](https://www.theplasticsfella.com/carpal-tunnel-syndrome/) (CTS). Typical findings include: - **Paresthesia:** Tingling or numbness in the radial 3 ½ fingers, often exacerbated by repeated pronation and supination. - **Aching Pain:** Felt over the proximal volar forearm. - **Positive Tinel sign** in the proximal volar forearm 😎 ****Fun Fact:** The palmar cutaneous branch of the median nerve originates 4-5 cm proximal to the carpal tunnel, and is therefore spared in CTS. A summary of clinical findings of pronator syndrome vs [carpal tunnel syndrome](https://www.theplasticsfella.com/carpal-tunnel-syndrome/) is outlined in the table below ([Balcerzak](https://docs.google.com/document/d/1IhY21NCJUW4FC%5FLp1Y1ENIdPCbDpY9iomKTm%5FwjwUfM/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2022). ![Clinical findings of pronator syndrome vs carpal tunnel syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--27-.png) Clinical findings of pronator syndrome vs carpal tunnel syndrome Provocative tests for different entrapment sites can aid in the diagnosis, but lack specificity and sensitivity ([Adler](https://docs.google.com/document/d/1IhY21NCJUW4FC%5FLp1Y1ENIdPCbDpY9iomKTm%5FwjwUfM/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2020): - **Compression at Pronator Teres:** Resisted forearm pronation with the elbow extended. - **Compression at Bicipital aponeurosis:** Resisted elbow flexion with forearm supination. - **Compression at FDS aponeurotic arch:** Resisted contraction of the FDS to the middle finger. Investigations are performed as part of routine workup but diagnosis remains a clinical one. - **Radiographs:** Elbow X-rays may show a supracondylar process. - **EMG:** confirms diagnosis if positive, but is usually equivocal. 💡 ****Tip:** [****Anterior interosseous syndrome**](https://www.theplasticsfella.com/anterior-interosseous-syndrome/) **(AIN)** is another type of compressive median nerve neuropathy characterised by pure motor palsy without sensory symptoms. This key feature differentiates AIN from pronator syndrome, which often presents with predominantly sensory disturbances ([Krishnan](https://docs.google.com/document/d/1IhY21NCJUW4FC%5FLp1Y1ENIdPCbDpY9iomKTm%5FwjwUfM/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2020). --- ## Management of Pronator Syndrome ****Key Point** Treatment for pronator syndrome is primarily conservative, with surgery considered for persistent symptoms and significant functional impairment. Treatment is primarily conservative, with surgery being considered only for persistent symptoms and significant functional impairment. ### Non-operative Suitable for patients with **mild to moderate** symptoms. - **Rest, Splinting, and NSAIDs:** Administer for 3-6 months. - **Technique:** Splint should prevent forearm pronation/supination. ### Operative **Surgical decompression of the median nerve** is considered when nonoperative management fails after **3-6 months**. Important points include: - Involves decompression of the median nerve at all five potential compression sites. - Approach is usually open but endoscopic release has been described ([Sos](https://docs.google.com/document/d/1IhY21NCJUW4FC%5FLp1Y1ENIdPCbDpY9iomKTm%5FwjwUfM/edit?ref=theplasticsfella.com#heading=h.w0bdufc3d7hg), 2021). - **Complications** include scarring, contracture, infection, medial cutaneous nerve injury. --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Pronator Syndrome:** You've understood Pronator Syndrome and its clinical definition as a rare median nerve compression in the proximal forearm, affecting predominantly middle-aged females. ****2\. Anatomical Knowledge:** You've learned about the anatomy related to Pronator Syndrome, including the five potential compression sites of the median nerve in the proximal forearm. ****3\. Clinical Recognition:** You've explored the clinical features of Pronator Syndrome, such as forearm pain, a positive Tinel sign at the elbow, and the absence of night symptoms, and can differentiate it from other similar neuropathies. ****4\. Diagnostic Insight:** You are familiar with the diagnostic approach for Pronator Syndrome, emphasizing physical examinations, and supported by imaging and electrodiagnostic tests to confirm the diagnosis. ****5\. Management Strategies:** You've understood the primary conservative treatment approaches including rest and splinting, and the criteria for when surgical intervention may be necessary. --- ## Further Reading 1. Ruiz, Emmanuel Stephano Bracho. "[Pronator Syndrome and Other Nerve Compressions That Mimic Carpal Tunnel Syndrome a Case Report and Literature Review](https://sarpublication.com/media/articles/SARJS%5F43%5F31-35.pdf?ref=theplasticsfella.com)." SAR J Surg 4.3 (2023): 31-35. 2. Sos C, Roulet S, Lafon L, Corcia P, Laulan J, Bacle G. [Median nerve entrapment syndrome in the elbow and proximal forearm](https://pubmed.ncbi.nlm.nih.gov/33516890/?ref=theplasticsfella.com). Anatomic causes and results for a 55-case surgical series at a mean 7 years' follow-up. Orthop Traumatol Surg Res. 2021 Apr;107(2):102825\. doi: 10.1016/j.otsr.2021.102825\. Epub 2021 Jan 28\. PMID: 33516890. 3. Drake, Richard L., et al. [*Gray's Atlas of Anatomy E-Book*](https://books.google.com.mt/books?hl=en&lr=&id=Di%5FTDwAAQBAJ&oi=fnd&pg=PP1&dq=grays+anatomy&ots=1oMnh79fXs&sig=MSdnDWngUD0szWjKYyW0HrAN56A&redir%5Fesc=y&ref=theplasticsfella.com#v=onepage&q&f=false)*: Gray's Atlas of Anatomy E-Book*. Elsevier Health Sciences, 2020. 4. Balcerzak AA, Ruzik K, Tubbs RS, Konschake M, Podgórski M, Borowski A, Drobniewski M, Olewnik Ł. [How to Differentiate Pronator Syndrome from Carpal Tunnel Syndrome: A Comprehensive Clinical Comparison](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9600501/?ref=theplasticsfella.com). Diagnostics (Basel). 2022 Oct 8;12(10):2433\. doi: 10.3390/diagnostics12102433\. PMID: 36292122; PMCID: PMC9600501. 5. Loukas, Marios, et al. "[Sir John Struthers (1823–1899) and his ligament and arcade](https://journals.lww.com/neurosurgery/abstract/2010/06000/sir%5Fjohn%5Fstruthers%5F%5F1823%5F1899%5F%5Fand%5Fhis%5Fligament.32.aspx?ref=theplasticsfella.com)." Neurosurgery 66.6 (2010): 1170-1173\. 6. Adler, Jeremy A., and Jennifer Moriatis Wolf. "[Proximal median nerve compression: pronator syndrome](https://pubmed.ncbi.nlm.nih.gov/32893044/?ref=theplasticsfella.com#:~:text=Pronator%20syndrome%20%28PS%29%20is%20a,correct%20diagnosis%20can%20be%20challenging.)." The Journal of Hand Surgery 45.12 (2020): 1157-1165. 7. Krishnan KR, Sneag DB, Feinberg JH, Wolfe SW. [Anterior Interosseous Nerve Syndrome Reconsidered: A Critical Analysis Review](https://pubmed.ncbi.nlm.nih.gov/32890049/?ref=theplasticsfella.com). JBJS Rev. 2020 Sep;8(9):e2000011\. doi: 10.2106/JBJS.RVW.20.00011\. PMID: 32890049. ### Low Volume Surgeons = Hobbyists, Skin Cancer Guidelines & Episode 1. URL: https://www.theplasticsfella.com/may-26th/ Last updated: 2024-05-26T16:36:31.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-26th/#a-letter-from-pfella) Low-volume surgeons are hobbyists? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-26th/#the-sunday-quiz) **\+ Leaderboard** Start of a new season: Merkel cell carcinoma 3. ****🎙️** [****Behind the 'Fella Episode 1**](https://www.theplasticsfella.com/may-26th/#behind-the-fella) Listen to our first podcast episode! 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/may-26th/#the-fellows-corner) What's new with the team? 5. 📖 [****What does the evidence say?** ](https://www.theplasticsfella.com/may-26th/#what-does-the-evidence-say) What does the evidence say about burying K-wires? 6. ****🔥** [****Skin Cancer Articles of the Week**](https://www.theplasticsfella.com/may-26th/#articles-of-the-week) Merkel cell carcinoma, melanoma controversies, & basal cell carcinoma; with 1 sentence summaries. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/may-26th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Low-Volume Surgeons are Hobbyists?* 👋 ****Hey Team!** I've come across the argument that low-volume surgeons are hobbyists, but I disagree, especially in the context of plastic surgery. Let's dive into the details. 👇 ### ### **Defining "low volume" is tricky**. The "Take the Volume Pledge" campaign sets minimum annual procedure thresholds, like 10 per hospital and 5 per surgeon for carotid stenting, and 50 per hospital and 25 per surgeon for hip and knee replacements. However, these numbers can be arbitrary and not always evidence-based. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Screenshot-2024-05-26-at-15.16.12.png) [NEJM Publication](https://www.nejm.org/doi/abs/10.1056/NEJMp1508472?ref=theplasticsfella.com) ### But the Evidence is Clear? Higher-volume surgeons do generally have better outcomes. A systematic review by Chowdhury et al. found that high-volume hospitals had significantly better outcomes in 74% of studies, though the benefit was less pronounced in prospective studies (40%). Similarly, high-volume surgeons had better outcomes in 74% of studies. ### A Different Perspective In plastic surgery, many conditions are inherently low volume, making certain surgeries rare. Procedures like thumb pollicization or Gustilo-Anderson 3C fractures are seldom encountered, even by subspecialists. As plastic surgeons, we handle a wide range of complex cases, similar to general surgeons but without the focus on visceral organs. The "Take the Volume Pledge" doesn't address managing low-volume procedures in these specialties, which are critical for patient care. ### Potential Solutions High standards must be maintained across all types of surgeries, whether common or rare. - **Subspecialize Further:** Encourage focused subspecialization to develop deep expertise in specific areas. - **Travel to Other Departments:** Gain exposure to rare procedures by collaborating with high-volume centers. - **Centralize Surgeries:** Centralize low-volume surgeries in specialized centers to ensure patients receive care from experienced surgeons. I'm eager to hear your thoughts. What methods should we explore to maintain our low-volume skills? Just reply to this email and share your insights! P'Fella ❤️ ****tl;dr** 👉 I disagree with the idea that low-volume surgeons are hobbyists, especially in plastic surgery. 👉 Defining low volume is complex and often arbitrary. 👉 Many conditions in plastic surgery are already low volume, making surgeries even rarer. 👉 Let's discuss how to adapt our training to ensure optimal patient care. ## The Sunday Quiz **New Season is Starting!* ****Are you ready for a new round of The Weekly Quiz?** Welcome to ****the first round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end of six rounds will earn you a $100 voucher. PS: Our top scorers from the last season are joining us for a playoff, live on our upcoming podcast episode! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--13--3.png) Presentation of Merkel Cell Carcinoma ## Behind the ‘Fella **Episode One is Now Live!* Have you checked out the first episode of our podcast yet? "Behind the Fella," is now live on[**Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) **or** [**Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)**.** Join us for exclusive insights from our team meetings and engaging discussions on plastic surgery with our fellows. Get a unique, behind-the-scenes look at our practice! 0:00 /3:50 1× Click here for [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) or [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com)****.** **The first episode is out! 🌟** Have a listen to our discussion on: - Meet the team! - Seymour fractures - K-wire tips and tricks - Surgical video brainstorming debut on the platform [Subscribe on Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) [Subscribe on Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) ## the Fellows' Corner **What have the fellows been up to?* Our team has been hard at work creating fantastic new content for our community, including fresh **articles**, clinical **cases**, and surgical **techniques** focused on tumors. Don't miss our article on **Merkel cell carcinomas.** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--14--1.png) #### Merkel Cell Carcinoma [****Definition**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#definition-of-merkel-cell-carcinoma) Merkel cell carcinoma is a malignant skin lesion arising from neuroendocrine cells. [****Risk Factors** ](https://www.theplasticsfella.com/merkel-cell-carcinoma/#risk-factors-of-merkel-cell-carcinoma)Include sun exposure, older age, immunosuppression, being Caucasian, and being male. [****Pathogenesis**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#pathogenesis-of-merkel-cell-carcinoma) Merkel cell polyomavirus (MCPyV) is a recently discovered polyomavirus in MCC tumour tissue. [****Clinical Features**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-features-of-merkel-cell-carcinoma) A fast-growing, painless, firm, non-tender cutaneous nodule. It is reddish-purple with a shiny surface, most commonly in the head and neck region. [****Diagnosis**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#diagnosis-of-merkel-cell-carcinoma) Definitive diagnosis of MCC consists of histopathology with an immunohistochemistry panel. An SNLB should be performed on all patients who are diagnosed with MCC. [****Clinical Staging**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-staging-of-merkel-cell-carcinoma) MCC is classified and staged from the AJCC 8th edition of 2017. [****Treatment**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-staging-of-merkel-cell-carcinoma) Treatment of MCC involves wide local excision +/- radiotherapy as MCC is very radiosensitive. Chemotherapy is rarely used, except occasionally for palliative care. [Read the Article](https://www.theplasticsfella.com/seymour-fracture/) On top of that, we've also curated a clinical case of Merkel cell carcinoma – you can read it [here](https://www.theplasticsfella.com/merkel-cell-carcinoma-clinical-scenario/). ## **What does the Evidence say?* **A new section!* In this section, we dive deep into the latest research and evidence on medical practices and surgical techniques. For our first debate topic, we have ****Buried vs Non-Buried K-Wires in Hand Surgery!** ### Buried vs Non-Buried K-Wires in Hand Surgery "The decision to bury or leave Kirschner wires (K-wires) exposed in hand surgery is influenced by various factors, including ease of removal, perceived risk of infection, and patient preferences (Gardiner 2018). While some studies have found **no significant difference** in infection rates between buried and non-buried K-wires (Koç 2012), others have reported a **lower risk of pin site infection** with buried K-wires (Hidajat 2023). However, non-buried K-wires have been associated with a l**ower risk of adverse events** and may be more **cost-effective** (Wormald 2017). Similarly, percutaneous K-wires have been found to have a significantly greater infection rate than buried wires in treating hand fractures (Rafique 2006)". ## Articles of the Week **3 interesting articles with 1 sentence summaries.* 1️⃣ ***NCCN guidelines for Merkel cell carcinoma** ([Chrysalyne](https://www.nccn.org/professionals/physician%5Fgls/pdf/mcc.pdf?ref=theplasticsfella.com), 2024) The NCCN Guidelines for Merkel Cell Carcinoma highlight the importance of early detection through comprehensive skin exams and biopsy, with immunohistochemistry staining confirming the diagnosis. 2️⃣ ***What are some controversies in melanoma treatment?** ([Temple-Oberle](https://journals.lww.com/plasreconsurg/abstract/2023/03000/current%5Fcontroversies%5Fin%5Fmelanoma%5Ftreatment.42.aspx?ref=theplasticsfella.com), 2023) Controversies in melanoma treatment: Optimal margins for in situ and invasive disease, reconstructive options like the keystone flap for excision defects, and advancements in managing sentinel node biopsies. 3️⃣ ***NCCN guidelines on basal cell carcinoma** ([Chrysalyne](https://jnccn.org/configurable/content/journals$002fjnccn$002f21$002f11$002farticle-p1181.xml?t%3Aac=journals%24002fjnccn%24002f21%24002f11%24002farticle-p1181.xml&ArticleBodyColorStyles=full%20html&ref=theplasticsfella.com), 2024) Explore the latest NCCN guidelines on Basal Cell Skin Cancer, detailing diagnostic, treatment, and follow-up practices for this prevalent skin cancer. ## Feedback ### I hope you enjoyed it 😄 --- ### Schwannoma - Clinical Scenario URL: https://www.theplasticsfella.com/schwannoma-clinical-scenario/ Last updated: 2024-09-04T17:15:34.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/AI-generated-image.png) #### Clinical Scenario ****A 41-year-old female presents with a lump on the volar aspect of the right dominant index finger as seen in the image above. It has been slow-growing and is associated with numbness and tingling. She is otherwise fit and well. There is no history of trauma.** ****Objectives:** ****1\.** Consider the differential diagnosis of upper limb lesion with associated nerve symptoms. ****2\.** Take a pertinent history and perform a focused examination of someone with an upper limb nerve lesion. ****3\.** Select appropriate investigations. ****4\.** Describe the surgical management of the lesion to the patient and list potential complications. ****5\.** Describe post-operative care and prognosis. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Merkel Cell Carcinoma: Diagnosis, Classification, & Treatment URL: https://www.theplasticsfella.com/merkel-cell-carcinoma/ Last updated: 2024-05-23T09:35:19.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#definition-of-merkel-cell-carcinoma) Merkel cell carcinoma is a malignant skin lesion arising from neuroendocrine cells. [****Risk Factors** ](https://www.theplasticsfella.com/merkel-cell-carcinoma/#risk-factors-of-merkel-cell-carcinoma)Include sun exposure, older age, immunosuppression, being Caucasian, and being male. [****Pathogenesis**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#pathogenesis-of-merkel-cell-carcinoma) Merkel cell polyomavirus (MCPyV) is a recently discovered polyomavirus in MCC tumour tissue. [****Clinical Features**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-features-of-merkel-cell-carcinoma) A fast-growing, painless, firm, non-tender cutaneous nodule. It is reddish-purple with a shiny surface, most commonly in the head and neck region. [****Diagnosis**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#diagnosis-of-merkel-cell-carcinoma) Definitive diagnosis of MCC consists of histopathology with an immunohistochemistry panel. An SNLB should be performed on all patients who are diagnosed with MCC. [****Clinical Staging**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-staging-of-merkel-cell-carcinoma) MCC is classified and staged from the AJCC 8th edition of 2017. [****Treatment**](https://www.theplasticsfella.com/merkel-cell-carcinoma/#clinical-staging-of-merkel-cell-carcinoma) Treatment of MCC involves wide local excision +/- radiotherapy as MCC is very radiosensitive. Chemotherapy is rarely used, except occasionally for palliative care. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. --- ## Definition of Merkel Cell Carcinoma ****Key Point** Merkel cell carcinoma is a rare, but aggressive malignant skin lesion arising from neuroendocrine cells. Merkel cell carcinoma (MCC) is a rare but **aggressive** **neuroendocrine carcinoma** of the skin found at the **dermoepidermal junction**. It originates from Merkel cells, first identified in 1875 by Friedrich Sigmund Merkel. Initially thought to be non-keratinizing epidermal cells, Merkel cells are now understood to be primary neural cells located within the basal layer of the epidermis ([Goessling](https://pubmed.ncbi.nlm.nih.gov/11786590/?ref=theplasticsfella.com), 2002). MCC exhibits features of both epithelial and neuroendocrine origin. The image below visualizes Merkel cell carcinoma in the ear. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--13--1.png) Merkel Cell Carcinoma 😎 ****Fun Fact:** Merkel cells function as mechanoreceptors, essential for the body's touch-sensitivity response ([NCI](https://www.cancer.gov/types/skin/hp/merkel-cell-treatment-pdq?ref=theplasticsfella.com#%5F73), 2024) --- ## Risk Factors of Merkel Cell Carcinoma ****Key Point** Risk factors for MCC include sun exposure, age, immunosuppression, and being caucasian and male. As the incidence of Merkel cell carcinoma continues to rise globally, understanding the risk factors and epidemiological trends is essential for early detection and prevention. Recognised risk factors include: - Sun exposure - Increasing age - Being Caucasian - Immunosuppression - Being male - Infection with the Merkel cell polyomavirus (MCPyV) 💡 ****Memory Tip:** For risk factors, consider an elderly Caucasian male who is on immunosuppressive medications and has had extensive sun exposure. The table below categorizes favourable and unfavourable prognostic indicators of MCC. ![Favourable and unfavourable prognostic indicators of MCC, Categorization of MCC](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--16-.png) Favourable and unfavourable prognostic indicators of MCC 😎 ****Fun Fact:** More than 70% of patients are over the age of 70 at the time of diagnosis ([Zwijnenburg](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com), 2021). --- ## Pathogenesis of Merkel Cell Carcinoma ****Key Point** The discovery of the Merkel cell polyomavirus (MCPyV) in MCC tumor tissues has significantly advanced the pathogenesis of Merkel cell carcinoma. Merkel cell carcinoma can develop through two distinct pathways with similar clinical presentations and prognoses but differing in aetiology. ([Dellambra](https://pubmed.ncbi.nlm.nih.gov/34201709/?ref=theplasticsfella.com), 2021) - The integration in the patient DNA of Merkel cell polyomavirus (MCPyV). - Triggered by extensive DNA mutations due to **UV radiation** and as such MCC most often arise in sun-exposed areas of the body. ### Merkel cell polyomavirus (MCPyV) This is a recently discovered polyomavirus in MCC tumour tissues. The prognostic significance of **viral load**, **antibody titer levels**, and the role of underlying **immunosuppression** in hosts is yet to be determined ([NCI](https://www.cancer.gov/types/skin/hp/merkel-cell-treatment-pdq?ref=theplasticsfella.com#%5F73), 2024). MCPyV seroprevalence in the general population is high and increases with age from 50% in childhood to 80% above 50 years. 😎 ****Fun Fact:** MCPyV remains latent in immunocompetent hosts, but immunocompromise can lead to viral reactivation ([Zwijnenburg](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com), 2021). --- ## Clinical Features of Merkel Cell Carcinoma ****Key Point** MCC presents as a fast-growing, painless, firm cutaneous nodule. It is classically non-tender and reddish-purple in colour with a shiny surface. They are most commonly located in the head and neck region. ### Typical Presentation MCC presents as a fast-growing, painless, firm cutaneous nodule. It is classically non-tender and reddish-purple in colour with a shiny surface. It can present as a subcutaneous nodule without overlying skin changes ([Brady](https://pubmed.ncbi.nlm.nih.gov/29493954/?ref=theplasticsfella.com), 2023). **Common locations** include: 1. Head and neck 2. Upper limb and shoulder 3. Lower limb 4. Trunk There are reported cases in other anatomical regions. These are much l**ess common** and include: salivary glands, nasal cavity, oral mucosa, eyelids (mimics chalazia or basal cell carcinoma - [North](https://pubmed.ncbi.nlm.nih.gov/30871952/?ref=theplasticsfella.com), 2019) ### Metastasis MCC grows quickly and rapidly metastasises ([Zwijnenburg](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com), 2021). In some instances, MCC may first be detected as lymph node metastasis without an identifiable primary tumour ([Deneve](https://pubmed.ncbi.nlm.nih.gov/22271206/?ref=theplasticsfella.com), 2012). It can locally spread to other areas of the **skin**, infiltrating via dermal lymphatics and resulting in **multiple satellite lesions** ([Dellambra](https://pubmed.ncbi.nlm.nih.gov/34201709/?ref=theplasticsfella.com), 2021). Other locations include: - Lymph nodes - Liver - Lungs - Bones - Brain 💡 ****Tip:** A mnemonic for summarising typical clinical characteristics of MCC ([Heath](https://pubmed.ncbi.nlm.nih.gov/18280333/?ref=theplasticsfella.com), 2008): ****A** \- Asymptomatic ****E** \- Expanding rapidly ****I** \- Immunosuppressed ****O** \- Older than 50 years ****U** \- UV-exposed skin And 90% of patients present with 3 or more of these characteristics. **Association with Other Skin Cancers** MCC can coexist with other types of skin cancers, such as: ([Brady](https://pubmed.ncbi.nlm.nih.gov/29493954/?ref=theplasticsfella.com), 2023) - squamous cell carcinoma - basal cell carcinoma - sebaceous carcinoma MCC tumours can also be admixed or adjacent to other skin tumours ([NCCN](https://www.nccn.org/professionals/physician%5Fgls/pdf/mcc.pdf?ref=theplasticsfella.com), 2023). 😎 ****Fun Fact:** Although overall incidence is relatively rare MCC is the second cause of skin cancer death after melanoma ([Harms](https://pubmed.ncbi.nlm.nih.gov/28802497/?ref=theplasticsfella.com), 2017). --- ## Diagnosis of Merkel Cell Carcinoma ****Key Point** The definitive diagnosis of Merkel Cell Carcinoma relies on histopathology accompanied by an immunohistochemistry panel, and a sentinel lymph node biopsy (SLNB) is recommended for all diagnosed patients. Merkel Cell Carcinoma (MCC) is diagnosed **histopathologically** after a lesion raises **clinical suspicion**. Due to its nonspecific features, timely diagnosis requires a high index of suspicion. Histopathology is essential for confirming a diagnosis of Merkel Cell Carcinoma (MCC). The pathology report should include key features with prognostic value: - **Size:** Larger tumors (>2cm) are associated with poorer outcomes. - **Peripheral and Deep-Margin Status** - **Lymphovascular Invasion (LVI):** - **Extracutaneous Extension** - **Breslow Depth:** Measures tumor thickness from the top of the granular layer of the epidermis (or from the base of an ulcer). This correlates with sentinel lymph node (SLN) positivity, overall survival, and disease-free survival ([NCCN](https://www.nccn.org/professionals/physician%5Fgls/pdf/mcc.pdf?ref=theplasticsfella.com), 2023). 💡 ****Tip:** Histopathological factors such as increased depth of invasion, lymphovascular invasion, and T-cell infiltration are also linked to poorer outcomes ([Zwijnenburg](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com), 2021) ### **Immunohistochemistry** Histopathological diagnosis of Merkel Cell Carcinoma (MCC) requires immunohistochemistry to differentiate it from other small cell neoplasms ([Brady](https://pubmed.ncbi.nlm.nih.gov/29493954/?ref=theplasticsfella.com), 2023), such as: - **Lymphoma** - **Ewing Sarcoma** - **Neuroblastoma** - **Melanoma** - **Small Cell Lung Cancer** Once MCC is confirmed by biopsy, additional workup may include: - **Complete History** - **Physical Examination:** Including skin and lymph nodes. - **Imaging Studies:** As clinically indicated, including a CT scan of the chest and abdomen to rule out primary small cell lung cancer and to assess for distant and regional metastasis 😎 ****Fun Fact:** Benign Merkel cells are typically located in the basal layer of the epidermis whereas MCC is reported to originate from any layer of the skin ([Zwijnenburg](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com), 2021). --- ## Clinical Staging of Merkel Cell Carcinoma ****Key Point** MCC is classified and staged from the AJCC 8th edition of 2017. Merkel Cell Carcinoma (MCC) is classified and staged according to the American Joint Committee on Cancer (AJCC) 8th edition, published in 2017, assessing tumor extent and spread. ### **Primary Tumor (T)** The staging of the primary tumor in MCC is designated by the 'T' category and is based on the size and extent of the tumor: - **TX:** Primary tumor cannot be assessed (e.g., curetted). - **T0:** No evidence of primary tumor. - **Tis:** Carcinoma in situ (localized and not spread). - **T1:** ≤2 cm. - **T2:** \>2 cm but ≤5 cm. - **T3:** \>5 cm. - **T4:** invades fascia, muscle, cartilage, or bone. ### **Regional Lymph Nodes (N)** Lymph node involvement is categorized under the 'N' staging: - **NX:** Regional lymph nodes cannot be clinically assessed (e.g., previously removed for another reason, or because of body habitus). - **N0:** No regional lymph node metastasis detected on clinical and/or radiologic examination. - **N1:** Metastasis in regional lymph node(s). - **N2:** In-transit metastasis (discontinuous from primary tumor; located between the primary tumor and draining regional nodal basin, or distal to the primary tumor) without lymph node metastasis. - **N3:** In-transit metastasis (discontinuous from primary tumour; located between primary tumour and draining regional nodal basin, or distal to the primary tumour) *with* lymph node metastasis. ### **Distant Metastasis (M)** The presence of distant metastasis is described in the 'M' category: - **M0:** No distant metastasis detected on clinical and/or radiologic examination. - **M1:** Distant metastasis detected. - **M1a:** Metastasis to distant skin, subcutaneous tissue, or distant lymph nodes. - **M1b:** Metastasis to the lung. - **M1c:** Metastasis to all other visceral sites, representing the most advanced stage of disease spread. The table below illustrates [AJCC's 8th Edition Staging of Merkel cell carcinoma](https://merkelcell.org/news-and-publications/2016/8th-edition-mcc-staging-system-announced/?ref=theplasticsfella.com). ![Merkel cell carcinoma classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--14-.png) AJCC's 8th edition staging of Merkel cell carcinoma --- ## **Treatment** of Merkel Cell Carcinoma ****Key Point** Treatment of MCC involves excision, +/- SLNB +/- radiotherapy as MCC is very radiosensitive. Immunomodulators have shown promise in treating MCC. Treating Merkel Cell Carcinoma (MCC) requires a multidisciplinary team focused on patient care. This team typically includes surgeons, radiotherapists, and chemotherapists. Below is the standard treatment protocol according to [NCCN](https://www.nccn.org/professionals/physician%5Fgls/pdf/mcc.pdf?ref=theplasticsfella.com), 2023. ### Local Disease (Clinical N0) **Surgery** - **Excision**: Perform 1-2 cm wider local excision or Mohs surgery for precise margin control and tissue preservation ([Singh](https://pubmed.ncbi.nlm.nih.gov/29408552/?ref=theplasticsfella.com), 2018). - **Delayed Reconstruction** is recommended until negative histological margins and SLNB results are confirmed. Simple closures are preferred to facilitate early adjuvant radiotherapy. 😎 ****Fun Fact:** Spontaneous MCC regressions have been described after biopsy/complete excision. Likely due to injury leading to inflammation that activate immune anti-tumour responses ([Dellambra](https://pubmed.ncbi.nlm.nih.gov/34201709/?ref=theplasticsfella.com), 2021). **Sentinel Lymph Node Biopsy (SLNB):** - Recommended for **clinically node-negative disease.** - Perform **at the time of excision** or wider local excision ([NCCN](https://www.nccn.org/professionals/physician%5Fgls/pdf/mcc.pdf?ref=theplasticsfella.com), 2023). - If **negative**, regional recurrence is low, and lymph node region treatment is generally not recommended ([Zwijnenburg](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com), 2021). - If positive, adjuvant radiotherapy or completion lymph node clearance improves overall survival and disease-free survival ([Sims, 2018](https://pubmed.ncbi.nlm.nih.gov/29549898/?ref=theplasticsfella.com)). ⚠️ ****Variations in SLNB Practice** Especially for MCC of the ****head and neck**, indications may vary and the risk of false-negative results can be higher ([Milhailids,](https://pubmed.ncbi.nlm.nih.gov/34697002/?ref=theplasticsfella.com) 2021). **Radiotherapy (RT):** - Indicated if surgical margins are **positive**, if surgery is not feasible, or in cases with adverse features. - Indicated in a **negative SLNB** if there is an **increased recurrence risk** (e.g., unsuccessful SLNB, inappropriate IHC, large tumor, chronic immunosuppression) ([Dellambra](https://pubmed.ncbi.nlm.nih.gov/34201709/?ref=theplasticsfella.com), 2021). - If no SLNB is performed, elective treatment of at least the first draining lymph node level by surgery or radiotherapy is recommended ([Zwijnenburg](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com), 2021). ### Regional Disease (Clinical N+) - **Nodal Dissection:** Required following confirmation of positive clinical node. - **Adjuvant Therapy:** Consider radiotherapy and systemic therapy if multiple nodes are involved ([Zwijenburg](https://www.mdpi.com/2072-6694/13/7/1614?ref=theplasticsfella.com), 2021). ### **Metastatic Disease (Clinical M1)** For patients with metastatic disease systemic therapy, radiation therapy ± surgery may be considered alone or in combination ([Brady](https://pubmed.ncbi.nlm.nih.gov/29493954/?ref=theplasticsfella.com), 2023). General options to consider include: - **Immunotherapy:** Promising responses with PD-1 Pathway Inhibitors ([Zwijnenburg](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com), 2021). - **Systemic Therapy:** For distant metastases. - **Targeted Radiotherapy/Metastasectomy:** Based on MDT recommendations. - **Palliative Care:** Manages symptoms and improves quality of life. Immunotherapy treatments have shown promise and can cause long-lasting responses in a significant proportion of patients with recurrent or metastatic MCC. 😎 ****Fun Fact:** Clinical trials utilising immunomodulating agents such as anti-PD-1 and PD-L1 antibodies have shown great promise in providing improved progression-free survival ([Dasanu](https://pubmed.ncbi.nlm.nih.gov/29933728/?ref=theplasticsfella.com), 2019). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Merkel Cell Carcinoma:** You've gained insight into the definition, origin, and aggressive nature of MCC, a rare but fast-growing neuroendocrine carcinoma of the skin. ****2\. Risk Factors and Pathogenesis:** You've learned about the risk factors for MCC, the influence of Merkel cell polyomavirus (MCPyV), as well as the dual pathogenesis pathways of this cancer. ****3\. Clinical Presentation and Diagnosis:** You are now familiar with the typical presentation of MCC and the essential role of histopathology and immunohistochemistry in its diagnosis. ****4\. Staging and Treatment Options:** You've explored the AJCC 8th edition staging for MCC and understand the standard treatments along with the indications for the use of chemotherapy. ****5\. Prognostic Factors:** You've reviewed how factors such as tumor size, lymph node involvement, and patient's immune status influence the prognosis of MCC patients. --- ## Further Reading 1. National Cancer Institute Apr 2024\. [Merkel Cell Carcinoma Treatment](https://www.cancer.gov/types/skin/hp/merkel-cell-treatment-pdq?ref=theplasticsfella.com#section%5F1.8) (PDQ®)–Health Professional Version. Accessed on 5th May 2024 2. National Comprehensive Cancer Network [NCCN Clinical Practice Guidelines in Oncology Merkel Cell Carcinoma](https://www.nccn.org/professionals/physician%5Fgls/pdf/mcc.pdf?ref=theplasticsfella.com). Published November 2023\. Accessed 5th May 2024 3. Harms PW. [Update on Merkel Cell Carcinom](https://pubmed.ncbi.nlm.nih.gov/28802497/?ref=theplasticsfella.com)a. Clin Lab Med. 2017 Sep;37(3):485-501\. doi: 10.1016/j.cll.2017.05.004\. Epub 2017 Jun 13\. PMID: 28802497. 4. Dellambra E, Carbone ML, Ricci F, Ricci F, Di Pietro FR, Moretta G, Verkoskaia S, Feudi E, Failla CM, Abeni D, Fania L. [Merkel Cell Carcinoma](https://pubmed.ncbi.nlm.nih.gov/34201709/?ref=theplasticsfella.com). Biomedicines. 2021 Jun 23;9(7):718\. doi: 10.3390/biomedicines9070718\. PMID: 34201709; PMCID: PMC8301416. 5. Zwijnenburg EM, Lubeek SFK, Werner JEM, Amir AL, Weijs WLJ, Takes RP, Pegge SAH, van Herpen CML, Adema GJ, Kaanders JHAM. [Merkel Cell Carcinoma: New Trends](https://pubmed.ncbi.nlm.nih.gov/33807446/?ref=theplasticsfella.com). Cancers (Basel). 2021 Mar 31;13(7):1614\. doi: 10.3390/cancers13071614\. PMID: 33807446; PMCID: PMC8036880. 6. Goessling W, McKee PH, Mayer RJ. [Merkel cell carcinoma](https://pubmed.ncbi.nlm.nih.gov/11786590/?ref=theplasticsfella.com). J Clin Oncol. 2002 Jan 15;20(2):588-98\. doi: 10.1200/JCO.2002.20.2.588\. PMID: 11786590. 7. Harms, P.W.; Harms, K.L.; Moore, P.S.; DeCaprio, J.A.; Nghiem, P.; Wong, M.K.K.; Brownell, I.; on behalf of the International Workshop on Merkel Cell Carcinoma Research (IWMCC) Working Group. [The biology and treatment of Merkel cell carcinoma: Current understanding and research priorities](https://pubmed.ncbi.nlm.nih.gov/30287935/?ref=theplasticsfella.com). Nat. Rev. Clin. Oncol. 2018, 15, 763–776\. 8. Amin MB, Edge S, Greene F, et al., eds. [AJCC Cancer Staging Manual (ed 8th)](https://pubmed.ncbi.nlm.nih.gov/28094848/?ref=theplasticsfella.com). New York: Springer International Publishing; 2017. 9. Heath M, Jaimes N, Lemos B, Mostaghimi A, Wang LC, Peñas PF, Nghiem P. [Clinical characteristics of Merkel cell carcinoma at diagnosis in 195 patients: the AEIOU features](https://pubmed.ncbi.nlm.nih.gov/18280333/?ref=theplasticsfella.com). J Am Acad Dermatol. 2008 Mar;58(3):375-81\. doi: 10.1016/j.jaad.2007.11.020\. PMID: 18280333; PMCID: PMC2335370. 10. Brady M, Spiker AM. [Merkel Cell Carcinoma of the Skin](https://pubmed.ncbi.nlm.nih.gov/29493954/?ref=theplasticsfella.com). 2023 Jul 17\. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29493954. 11. Medina-Franco H, Urist MM, Fiveash J, Heslin MJ, Bland KI, Beenken SW. [Multimodality treatment of Merkel cell carcinoma: case series and literature review of 1024 case](https://pubmed.ncbi.nlm.nih.gov/11314935/?ref=theplasticsfella.com)s. Ann Surg Oncol. 2001 Apr;8(3):204-8\. doi: 10.1007/s10434-001-0204-4\. PMID: 11314935. 12. Mihailids TH, Dobbs T, Coelho J, Hemington-Gorse S, Cubitt JJ. [A letter to the editor: Sentinel lymph node biopsy for Merkel cell carcinoma - A UK-wide perspective](https://pubmed.ncbi.nlm.nih.gov/34697002/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2021 Dec;74(12):3443-3476\. doi: 10.1016/j.bjps.2021.09.013\. Epub 2021 Oct 7\. PMID: 34697002. 13. Dasanu CA, Del Rosario M, Codreanu I, Hyams DM, Plaxe SC. [Inferior outcomes in immunocompromised Merkel cell carcinoma patients: Can they be overcome by the use of PD1/PDL1 inhibitors?](https://pubmed.ncbi.nlm.nih.gov/29933728/?ref=theplasticsfella.com) J Oncol Pharm Pract. 2019 Jan;25(1):214-216\. doi: 10.1177/1078155218785002\. Epub 2018 Jun 22\. PMID: 29933728. 14. Ma KL, Sharon CE, Tortorello GN, Keele L, Lukens JN, Karakousis GC, Miura JT. [Delayed time to radiation and overall survival in Merkel cell carcinoma](https://pubmed.ncbi.nlm.nih.gov/37622232/?ref=theplasticsfella.com). J Surg Oncol. 2023 Dec;128(8):1385-1393\. doi: 10.1002/jso.27421\. Epub 2023 Aug 25\. PMID: 37622232. 15. Rotondo JC, Bononi I, Puozzo A, Govoni M, Foschi V, Lanza G, Gafà R, Gaboriaud P, Touzé FA, Selvatici R, Martini F, Tognon M. [Merkel Cell Carcinomas Arising in Autoimmune Disease Affected Patients Treated with Biologic Drugs, Including Anti-TNF](https://pubmed.ncbi.nlm.nih.gov/28174236/?ref=theplasticsfella.com). Clin Cancer Res. 2017 Jul 15;23(14):3929-3934\. doi: 10.1158/1078-0432.CCR-16-2899\. Epub 2017 Feb 7\. PMID: 28174236. 16. Deneve JL, Messina JL, Marzban SS, Gonzalez RJ, Walls BM, Fisher KJ, Chen YA, Cruse CW, Sondak VK, Zager JS. [Merkel cell carcinoma of unknown primary origin](https://pubmed.ncbi.nlm.nih.gov/22271206/?ref=theplasticsfella.com). Ann Surg Oncol. 2012 Jul;19(7):2360-6\. doi: 10.1245/s10434-011-2213-2\. Epub 2012 Jan 21\. PMID: 22271206; PMCID: PMC4504007. 17. Becker JC, Stang A, DeCaprio JA, Cerroni L, Lebbé C, Veness M, Nghiem P. [Merkel cell carcinoma](https://pubmed.ncbi.nlm.nih.gov/29072302/?ref=theplasticsfella.com). Nat Rev Dis Primers. 2017 Oct 26;3:17077\. doi: 10.1038/nrdp.2017.77\. PMID: 29072302; PMCID: PMC6054450. 18. Singh B, Qureshi MM, Truong MT, Sahni D. [Demographics and outcomes of stage I and II Merkel cell carcinoma treated with Mohs micrographic surgery compared with wide local excision in the National Cancer Database](https://pubmed.ncbi.nlm.nih.gov/29408552/?ref=theplasticsfella.com). J Am Acad Dermatol. 2018 Jul;79(1):126-134.e3\. doi: 10.1016/j.jaad.2018.01.041\. Epub 2018 Feb 3\. PMID: 29408552. 19. North VS, Habib LA, Yoon MK. [Merkel cell carcinoma of the eyelid: A review](https://pubmed.ncbi.nlm.nih.gov/30871952/?ref=theplasticsfella.com). Surv Ophthalmol. 2019 Sep-Oct;64(5):659-667\. doi: 10.1016/j.survophthal.2019.03.002\. Epub 2019 Mar 11\. PMID: 30871952. --- ### Merkel Cell Carcinoma - Clinical Scenario URL: https://www.theplasticsfella.com/merkel-cell-carcinoma-clinical-scenario/ Last updated: 2024-09-04T17:16:01.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Clinical-Case-Main-Image-1.png) #### Clinical Scenario A 70-year-old presents with the lesion pictured above. The lesion has been present for 5 months and has not increased in size. She is an avid fisherman and had a heart transplant 10 years ago. ****Objectives:** ****1\.** Identify the clinical features of Merkel Cell Carcinoma (MCC). ****2\.** Make a comprehensive diagnostic plan for MCC. ****3.** Determine the treatment plan for MCC. ****4.** Create a follow-up plan for MCC after treatment. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Progressive Hemifacial Atrophy: Parry Romberg Disease URL: https://www.theplasticsfella.com/progressive-hemifacial-atrophy/ Last updated: 2024-05-23T09:50:05.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/progressive-hemifacial-atrophy/#definition-of-progressive-hemifacial-atrophy) An acquired condition causing progressive wasting of skin, soft tissue and bone. [****Clinical Features**](https://www.theplasticsfella.com/progressive-hemifacial-atrophy/#clinical-features-of-progressive-hemifacial-atrophy) Progressive unilateral wasting in the trigeminal region begins in early adolescence and stabilises over time. [****Management**](https://www.theplasticsfella.com/progressive-hemifacial-atrophy/#management-of-progressive-hemifacial-atrophy) Radiological investigations help support the diagnosis and reconstruction to restore atrophied function and structures. --- ## Definition of Progressive Hemifacial Atrophy ****Key Point** Progressive hemifacial atrophy is a rare, acquired disorder marked by unilateral, sporadic wasting of the facial skin, soft tissues, and bone, with unknown aetiology and typically no family history. Progressive hemifacial atrophy is an acquired condition characterised by gradual wasting of facial skin, soft tissue and bone. The majority of cases are unilateral, sporadic and without a family history. The exact aetiology is relatively unknown. The image below further describes the definition and origin of progressive hemifacial atrophy. ![Definition and Origin of Progressive Hemifacial Atrophy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Progressive-Hemifacial-Atrophy-Definition.png) Definition and Origin 😎 ****Fun Fact:** It is also called Parry-Romberg Syndrome. German neurologist Albert Eulenburg was the first to use the descriptive title "progressive hemifacial atrophy" in 1871\. --- ## Clinical Features of Progressive Hemifacial Atrophy ****Key Point** Progressive hemifacial atrophy is the progressive wasting of skin, soft tissue, and one in the trigeminal regions. Other features include pigmentation, coup de sabre, and seizures. Progressive hemifacial atrophy is characterised by progressive soft tissue and bone wasting. General speaking, there are "rules of thumb", which include: - Distribution of the trigeminal nerve. - Gradually progresses and then gradually stops over time. - It is irreversible without intervention. - Signs begin to manifest in early adolescence and stop in adulthood. The image below illustrates the clinical features of progressive hemifacial atrophy. ![Clinical Features of Progressive Hemifacial Atrophy, Identifying Parry Romberg Disease](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Progressive-Hemifacial-Atrophy-Clinical-Features.png) Clinical Features of Progressive Hemifacial Atrophy Clinical features of progressive hemifacial atrophy include: - **Hair:** loss or change in colour - **Forehead:** 'coupe de sabre' (forehead depression extending into hairline) - **Eyes:** ptosis, enophthalmos, heterochromia irides (2 different eye colours) - **Cheek:** Zygomatic atrophy, atrophy of masticators - **Mandible:** Micrognathia - **Skin:** pigment changes - **Mouth:** Malocclusion, tongue or palate atrophy - **Non-physical signs:** seizures The image below illustrates coup de sabre of progressive hemifacial atrophy. ![coup de sabre of progressive hemifacial atrophy, Identifying Parry Romberg Disease](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/coupe-de-sabre.png) Coupe de Sabre --- ## Management of Progressive Hemifacial Atrophy ****Key Point** Progressive hemifacial atrophy is a clinical diagnosis supported by MRI and CT scans. Treatment focuses on the reconstruction of atrophied structures and restoration of structures. The management of progressive hemifacial microsomia is centred on a multi-disciplinary team. Treatment is generally not offered while the condition has not been stable for a period of time. ### Investigations Progressive hemifacial atrophy is a clinical diagnosis supported by radiological and histological investigations. - **MRI:** confirm atrophy of soft tissue and bony structures, display infarction, haemorrhage and white matter hyper-density, which can help guide treatment. - **Histology:** dermal sclerosis, fat atrophy, decrease in adnexal structures, and perivascular plasma cells and lymphocytes. This is not routine. - **Genetic counselling** is not recommended at this time. The radiological investigations can be visualised below. ![Radiological features of progressive hemifacial atrophy, Diagnosing progressive hemifacial atrophy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Progressive-Hemifacial-Atrophy-Radiology.png) Radiological features of progressive hemifacial atrophy ### Treatment Treatment is generally not offered while the condition has not been stable for a period of time. These options include: - **Grafts:** fat, dermatofat, cartilage - **Flaps:** free flaps, muscle transfers, adipofascial flaps - **Bone Reconstruction:** Le Fort 1 Osteotomy, Genioplasty - **Implants:** Alloplastic augmentation 💡 ****Tip:** Local or Regional flaps may also undergo atrophy. --- ## **Conclusion** Upon completing this article, you will have accomplished the following: ****1\. Definition and Epidemiology:** You've learned about Progressive Hemifacial Atrophy (PHA), a rare condition characterized by unilateral wasting of facial tissues including skin, soft tissue, and bone, often referred to as Parry-Romberg Syndrome. ****2\. Clinical Features:** You are familiar with the typical clinical manifestations of PHA such as the distinctive "coupe de sabre" appearance, and other symptoms affecting hair, eyes, skin, and facial structures. ****3\. Diagnostic Approaches:** You've explored how PHA is diagnosed primarily through clinical evaluation supported by imaging techniques like MRI and CT scans, which help in assessing the extent of tissue and bone atrophy. ****4\. Management Strategies:** You've gained insight into the treatment options for PHA, focusing on reconstructive techniques to restore facial symmetry and function. ****5\. Challenges in Management:** You understand the complexity of managing PHA due to its progressive nature and the need for treatment to be deferred until the disease stabilizes. ### Schwannoma: Anatomy, Clinical Characteristics, & Management URL: https://www.theplasticsfella.com/schwannoma/ Last updated: 2024-05-28T08:07:32.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/schwannoma/#definition-of-schwannomas) Schwannomas are benign tumors arising from Schwann cells, often causing pain, numbness, or weakness due to nerve compression. [****Clinical Features** ](https://www.theplasticsfella.com/schwannoma/#clinical-features-of-schwannomas)Schwannomas are encapsulated peripheral nerve tumours, within the epineurium and often associated with a single nerve fascicle. [****Investigations**](https://www.theplasticsfella.com/schwannoma/#investigations-for-schwannomas) Schwannomas are best characterised by T2 weighted MRI. [****Management** ](https://www.theplasticsfella.com/schwannoma/#management-of-schwannoma)Surgical excision is indicated for symptomatic lesions or uncertain diagnosis. The recurrence of a Schwannoma is extremely rare and the prognosis is excellent. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## Definition of Schwannomas ****Key Point** Schwannomas are benign tumors arising from Schwann cells, which form the myelin sheath around axons. A Schwannoma is a **benign**, isolated peripheral nerve lesion with no malignant potential. These benign tumors develop from **Schwann** **cells**, which form the **myelin sheath** around axons and are crucial for effective nerve signal transmission. These tumors typically originate from a **single nerve fascicle** within the protective endoneurium layer. ![Encapsulated benign peripheral nerve tumour, Gross histology of Schwannoma of peripheral nerve. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--8-.png) Encapsulated benign peripheral nerve tumour --- ## Clinical Features of Schwannomas ****Key Point** Schwannomas are typically solitary, painless, slow-growing lesions that can cause radiating pain upon palpation. Their growth may displace and compress adjacent nerves, causing pain, numbness, or weakness. ### **Typical Presentation** Schwannomas are benign tumors originating from Schwann cells, presenting with several distinct clinical features: - **Solitary Nature:** Typically appearing as solitary, painless, and slow-growing lesions. - **Palpation or compression** of the lesion can produce radiating pain in a specific nerve distribution. - **Mass Effect:** The tumor's growth can displace and compress adjacent nerves, leading to pain, numbness, or weakness, depending on its location. - **Location Variability:** These tumors are most commonly found in the retroperitoneal and abdominal wall areas, though they occur less frequently in the head, neck, and extremities. (Lam, 2019) 💡 ****Tip:** The lesion is often mobile in a transverse direction but not longitudinally. ![Schwannoma clinical presentation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--17-.png) Schwannoma presentation in the finger ### **Genetic Associations** Schwannomas frequently manifest in individuals with genetic disorders such as: - **Neurofibromatosis:** NF1 is Characterized by early childhood onset, presenting with café-au-lait spots, Lisch nodules, and other systemic symptoms. - **Schwannomatosis:** Often involves multiple schwannomas without the presence of vestibular tumors. 😎 ****Fun Fact:** There are 4 descriptions of nasal tip schwannoma in the literature (presumably associated with the anterior ethmoidal nerve) that can be managed with open rhinoplasty technique ([Fujita](https://pubmed.ncbi.nlm.nih.gov/17046644/?ref=theplasticsfella.com), 2006). ### **Differential Diagnosis** Differentiating schwannomas from other nerve tumors is crucial, as these can be benign or malignant: **Benign Tumors** - **Neurofibromas:** These are the most common peripheral nerve tumors. Specific types, such as plexiform, intraneural, and large nerve neurofibromas, are considered pre-malignant. - **Lipomas:** Occurring both intra- and extraneural, these tumors can cause compression neuropathies and displacement. Intraneural lipomas, encapsulated by the epineurium, may impair blood supply leading to atrophy of Schwann cells and axons. **Malignant Tumors:** - **Malignant Peripheral Nerve Sheath Tumors (MPNST):** These rare tumors account for less than 1% of all sarcomas and are notable for their rapid growth, pain, and poor prognosis. They typically respond poorly to chemoradiotherapy. 💡 ****Tip:** The plural form is Schwannomata, but Schwannomas is more commonly used. --- ## Investigations for Schwannomas ****Key Point** US and MRI are useful in characterising Schwannomas, hyperintense well-circumscribed lesions on T2 weighted MRI. Schwannomas are a radiological and histological diagnosis confirmed after a high index of clinical suspicion. ### Radiological MRI is the preferred imaging modality, providing detailed information on nerve structure and tumor biology ([Eraky](https://pubmed.ncbi.nlm.nih.gov/37258452/?ref=theplasticsfella.com) 2023). More specifically: - **T2-weighted MRI:** Schwannomas typically appear as hyperintense, well-circumscribed lesions. - **Ultrasound (US):** is useful in the initial characterisation of Schwannomas. Non-invasive and readily accessible. - **CT and X-ray** are not useful in the characterisation of Schwannoma due to their inability to provide detailed information about soft tissue structures. ### Histopathology Histological diagnosis can be obtained through excisional or tru-cut biopsies. - **Excision Biopsy:** Considered the diagnostic modality of choice. Provides definitive diagnosis through histopathological examination. - **Tru-Cut Biopsy:** Useful when resection is associated with significant morbidity or when malignancy is suspected. ([Hems](https://pubmed.ncbi.nlm.nih.gov/38534080/?ref=theplasticsfella.com), 2024). Minimally invasive and can help in preoperative planning. On anaylsis of these histology specimens: - Stain positively for S100 and SOX10 immunostains. - These tumors are encapsulated - Pathognomonic presence of Antoni A (spindle cells and eosinophilic cytoplasm) and Antoni B (relatively acellular) areas. Of note, several pathological subtypes such as "ancient type" schwannomas have been described, all strongly positive for S100 and Sox10 on immunostaining. 😎 ****Fun Fact:** Heterogeneity in T2 weighted MRI signal indicates Schwannoma and reflects the Antoni A (low signal) and B (high signal) areas within the lesion. The target sign is characteristic of neurofibroma. --- ## Management of Schwannoma ****Key Point** Schwannoma resection is indicated for pain and mass effect symptoms. Careful dissection allows these encapsulated tumours to be "shelled out". Schwannomas are generally considered to have no malignant potential, making the **primary indications** for excision: - Pain - Mass effect symptoms **Surgical management** of Schwannomas carefully dissects or "shells out" these encapsulated tumors from the surrounding nerve, often with excellent preservation of function. In the overwhelming majority of cases, the lesion can be completely removed, and any preoperative neurologic symptoms are likely to improve. **Practical tips for surgery include:** - Utilize optical magnification and microsurgical techniques to reduce the risk of postoperative neurologic deficit. - Be aware that interfascicular involvement may complicate dissection. - The incidence of postoperative neurologic deficit ranges from approximately 5% to 15%, with a significantly higher risk associated with procedures performed after incisional biopsy or in cases of recurrence. Recurrence of Schwannomas is uncommon, although multiple lesions in a single peripheral nerve have been described. 😎 ****Fun Fact:** Schwannoma surgery can be likened to peeling the layers of an onion skin. A microscope or a high-powered loupes and beaver blade allow meticulous dissection. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. The Anatomy of a Peripheral Nerve:** You've learned about the peripheral nervous system (PNS), including motor and sensory neurons, nerve axons, Schwann cells, and the protective layers (endoneurium, perineurium, and epineurium). ****2\. Clinical Characteristics and Histopathology of Nerve Tumors:** You understand the key features of benign and malignant nerve tumors, particularly Schwannomas, including their presentation, genetic associations, and histopathological characteristics. ****3\. Pathogenesis of Schwannomas:** You've explored how Schwannomas originate from Schwann cells, their growth patterns, and the symptoms they cause due to nerve compression. ****4\. Diagnostic Investigations for Schwannomas:** You are familiar with the imaging techniques used to characterize Schwannomas and the role of biopsy techniques in diagnosing these tumors. ****5\. Management and Prognosis of Schwannomas:** You've gained insight into the management strategies for Schwannomas, including indications for surgical excision, the typical excellent prognosis post-resection, and the rarity of recurrence. --- ## Further Reading 1. Hems T, Parafioriti A, Thomas BP, Di Bernardo A. [An algorithmic approach to the management of peripheral nerve tumours](https://pubmed.ncbi.nlm.nih.gov/38534080/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2024 Mar 27:17531934241238739\. doi: 10.1177/17531934241238739\. Epub ahead of print. PMID: 38534080. 2. Fujita K, Yuzuriha S, Noguchi M. ['Cyrano de Bergerac' nose deformity caused by the schwannoma of the nasal tip](https://pubmed.ncbi.nlm.nih.gov/17046644/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2006;59(11):1252-4\. doi: 10.1016/j.bjps.2006.03.059\. Epub 2006 Jun 6\. PMID: 17046644. 3. Lam R, Hunt BL, Arreola-Owen O. [Abdominal Wall Schwannoma](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453606/?ref=theplasticsfella.com). Fed Pract. 2019 Mar;36(3):129-133\. PMID: 30983853; PMCID: PMC6453606. 4. Graf A, Yang K, King D, Dzwierzynski W, Sanger J, Hettinger P. [Lipomas of the Brachial Plexus: A Case Series and Review of the Literature](https://pubmed.ncbi.nlm.nih.gov/29058949/?ref=theplasticsfella.com). Hand (N Y). 2019 May;14(3):333-338\. doi: 10.1177/1558944717735946\. Epub 2017 Oct 23\. PMID: 29058949; PMCID: PMC6535949. 5. Eraky AM, Beck RT, Treffy RW, Aaronson DM, Hedayat H. [Role of Advanced MR Imaging in Diagnosis of Neurological Malignancies: Current Status and Future Perspective](https://pubmed.ncbi.nlm.nih.gov/37258452/?ref=theplasticsfella.com). J Integr Neurosci. 2023 May 15;22(3):73\. doi: 10.31083/j.jin2203073\. PMID: 37258452. --- ### Craniofacial Clefts: Tessier Classification, Types, & Management URL: https://www.theplasticsfella.com/craniofacial-clefts/ Last updated: 2024-05-23T13:32:42.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/craniofacial-clefts/#definition-of-craniofacial-cleft) A skeletal and soft-tissue facial pathology that can be described as cleft numbers from 0-14 and can form part of syndromes. [****Pathogenesis**](https://www.theplasticsfella.com/craniofacial-clefts/#pathogenesis-of-craniofacial-cleft) Failure of fusion and dehiscence. They occur sporadically and have been linked to exposure and maternal risks. [****Tessier Classification**](https://www.theplasticsfella.com/craniofacial-clefts/#tessier-classification-of-craniofacial-clefts) Assigns a number to a craniofacial cleft based on its position relative to the midline. Clefts 0-7 are facial, and 8-14 are cranial. [****Types**](https://www.theplasticsfella.com/craniofacial-clefts/#types-of-craniofacial-clefts) Numbered 0-14 and can be grouped into oral-nasal, oral-ocular, lateral facial, and cranial clefts. [****Management**](https://www.theplasticsfella.com/craniofacial-clefts/#management-of-craniofacial-clefts) A multidisciplinary team to treat function, cosmesis, and reconstruct anatomical structures and cavities. --- ## Definition of Craniofacial Cleft ****Key Point** Craniofacial clefts encompass various soft-tissue and bone deformities, classified from 0-14 based on anatomical location. Craniofacial clefts is an umbrella term that encompasses a wide of soft-tissue and bone deformities. It is a type of craniofacial deformity defined by the American Society of Cleft Lip and Palate. They can be sub-defined based on the anatomical location: - **Oral-Nasal:** Clefts 0-3 - **Oral-Ocular:** Clefts 4-6 - **Lateral Facial:** Cleft 7-9 - **Cranial:** Clefts 10-14 ###### --- ## Craniofacial Cleft Pathogenesis ****Key Point** Craniofacial Clefts are caused by a failure of fusion and dehiscence. They occur sporadically and have been linked to exposure and maternal risks. Craniofacial clefts are "atypical clefts" that occur due to two theories: 1. **"Classic":** failure of fusions of the facial prominences. 2. **Mesodermal penetration:** failure of mesodermal penetration results in unsupported epithelial walls that dehisce. These occur sporadically, but specific environmental factors have been identified: - **Exposure:** radiation, vitamin A derivatives - **Maternal:** infection (CMV, toxoplasmosis), diabetes, weight, folic acid deficiency. 💡 ****Tip:** Facial development occurs during months 1 and 2\. The frontonasal prominence creates nasal and olfactory placodes that become medial and lateral processes. --- ## Tessier Classification of Craniofacial Clefts ****Key Point** Tessier Classification assigns a number to a craniofacial cleft based on its position relative to the midline. Clefts 0-7 are facial, and 8-14 are cranial. ### **Tessier Classification** is an **anatomical** classification of craniofacial clefts. A number is assigned to each malformation according to its **position relative to the midline.** Tessier classification is the most commonly used for Craniofacial clefts. - **Benefit:** easily correlate anatomical defects and required reconstruction. - **Limitation:** purely descriptive and does not denote causation. The image below further describes the Tessier classification for craniofacial clefts. ![Tessier Classification for Craniofacial Clefts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tessier-Classification.png) Tessier Classification for Craniofacial Clefts 1. **All clefts** are numbered from 0-14. 2. **Midline clefts** are number 0. 3. **Facial clefts** are numbered out laterally from 1-7 inferior to the orbit. 4. **Cranial clefts** are numbered in medially from 8-14 superior to the orbit. 5. **Facial** and **Cranial** clefts can be connected. The table below illustrates some tips to remember Tessier Classification. ![Tips for Tessier Classification, Classification for Craniofacial Clefts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tessier-Tips-Craniofacial-Clefts.png) Tips for Tessier Classification Craniofacial clefts can be grouped based on their location. There are 4 main groups: - **Oral-nasal clefts** are Tessier Clefts 0-3 between the midline and cupid's bow. This results in clefts involving the midline structures (lips and nose). - **Oral-Ocular clefts** are Tessier Clefts 4-6 that occur between oral and orbital cavities without disrupting the nose. - **Lateral Facial clefts** are Tessier Clefts 7-9, resulting in Treacher Collins Syndrome, hemifacial microsomal, and necrotic facial dysplasia. - **Cranial Clefts** are Tessier clefts 10-14 that occur in the frontal and cranial vault. 😎 ****Fun Fact:** Van der Meulen's embryological classification is less common: craniofacial skeleton develops along a helical course symbolised by the letter **S*. --- ## Types of Craniofacial Clefts ****Key Point** Craniofacial clefts are numbered 0-14 and involve soft tissue and bone. They can be grouped into oral-nasal, oral-ocular, lateral facial, and cranial clefts. **Cleft Number 0** - A cleft spectrum of **deficient** **or** **excess** midline structures. - Deficiency leads to **hypo**tolerism; excess leads to **hypertelorism**. - Can continue as cleft number 14. - Incomplete merging of the median nasal prominences in the midline. **Cleft Number 1** - Nasal dysplasia has a pattern similar to cleft lip and palate. - Lateral margin of cupid's bow and between the central and lateral incisors. - Can continue as cleft number 13. **Cleft Number 2 (Rare)** - Hypoplastic nasal ala, flattened nose, displaced medial canthus. - The lacrimal duct is not involved. - Can continue as cleft number 12. **Cleft Number 3 ("Common")** - Between the lateral incisors and canine. - Superiorly based alar and short nose. - The lacrimal system involved + **colobomas** of the lower eyelid. - Can continue as cleft 10 or 11. **Cleft Number 4** - Lateral to cupid's bowel and nasal ala. - Ascend **around** the alar base, along the nasomaxillary junction, and across the tear duct and medial orbital tissues. - Unilateral or bilateral. - **Colobomas** but intact medial canthal ligament. 😎 ****Fun Fact:** Coloboma is a ****congenital** ocular defect of the eyelid, iris, retina, choroid, or optic disk. The defects can range in size, from a small notch to a large structural cleft. **Cleft Number 5 (Rarest)** - Lateral to canine and infraorbital foramen. - Medial to the oral commissure. - Extends through the maxillary sinus to the orbital floor. - Abnormal **sphenoid wing** (**agenesis** linked to neurofibromatosis). **Cleft Number 6** - Forms part of **Treacher Collins Syndrome.** - **Normal Ear**. - Zygomaticomaxillary cleft. **Cleft Number 7 (Most Common)** - The middle ear, zygoma, maxilla, and mandible affected. - Variable expression of macrostomia and hypoplasia of the zygoma. - **Trigeminal** and **facial** nerves are involved. - Caused by disruption of the **stapedial artery** during embryogenesis. - Centred in the region of the zygomaticotemporal suture. - Associated with a duplicate maxilla, supernumerary teeth. - Occur in isolation or more commonly with craniofacial/[hemifacial microsomia](https://www.theplasticsfella.com/hemifacial-microsomia/). **Cleft 8 (Rare in Isolation)** - Primarily involves the orbital area. - Lateral commissure **coloboma** and lateral canthus **absence**. - Associated with **Goldenhaar Syndrome**. **Cleft Number 9 (Rare)** - Involves the upper eyelid and brow. - The temporal branch of facial nerve palsy. - Associated with encephaloceles. **Cleft Number 10** - Involvement of middle orbital area and cranial base. - Link to hypertelorism. - Proptosis with front-orbital encephalocele may be present. - Can be an extension of cleft number 4. **Cleft Number 11** - Involvement of upper medial eyelid (not cranial base). - Link to encephalocele & hypertelorism (pneumatisation of ethmoid cells). - Can be an extension of cleft number 4. **Cleft Number 12** - Laterally displaced medial canthus and frontal hairline projected downward. - Hypertelorism and telecanthus. - Involved frontal and sphenoid sinuses. **Cleft Number 13** - Paramedian frontal encephalocele. - V-shaped hair. - Dystopia and hypertelorism. **Cleft Number 14** - A spectrum of deficiency to excess. - Involves CNS abnormalities. - Can see herniation of intracranial contents. **Cleft Number 30** - Bifid tongue. - A notch on the lower lip. - Issues with hyoid bone and thyroid cartilage. 💡 ****Tip**: Clefts do not pass through bony foramina that are the site of neurovascular structures. --- ## Management of Craniofacial Clefts ****Key Point** The management is based on a multi-disciplinary team focusing on treatment function, cavity separation, and cosmesis. ### Principles The management of craniofacial clefts is centred on a multi-disciplinary team. The goal of treatment is to restore function, cosmesis, and normal anatomical alignment of structures and cavities. Critical aspects of the management focus on: 1. **Eyes:** Eyelid reconstruction to prevent globe exposure. 2. **Mouth**: functional correction of macrostoma. 3. **Cavities:** recreate separations between nose, mouth, and orbits. 💡 ****Tip:** Lateral clefts affect bone more, and medial clefts affect soft tissue more. ### Techniques To achieve these goals, a myriad of techniques is available. These include: - Distraction Osteogenesis - [Bone grafting ](https://www.theplasticsfella.com/bone-grafts/) - Alloplastic implants - [Tissue Expansion](https://www.theplasticsfella.com/tissue-expansion/) - [Flap Reconstruction](https://www.theplasticsfella.com/classification-of-flaps/) 💡 ****Tip**: Bilateral cases may present different clefts on each side. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Craniofacial Clefts:** You've understood the definition and classification of craniofacial clefts, ranging from numbers 0 to 14, based on the Tessier classification. ****2\. Pathogenesis:** You understand the developmental disruptions that lead to craniofacial clefts, including the failure of fusion and dehiscence, influenced by genetic and environmental factors. ****3\. Types of Clefts:** You've learned about the different types of craniofacial clefts categorized under oral-nasal, oral-ocular, lateral facial, and cranial groups, along with their specific anatomical impacts. ****4\. Management:** You have become familiar with the multidisciplinary approach to treating craniofacial clefts, focusing on restoring function and cosmesis through various surgical and non-surgical techniques. ****5\. Early Intervention:** You understand the importance of early and accurate diagnosis and intervention in managing craniofacial clefts to improve functional and aesthetic outcomes for patients. --- ### Fluid Resuscitation in Burns: Formulas, Indications, & Fluids URL: https://www.theplasticsfella.com/burns-fluid-resuscitation/ Last updated: 2024-05-23T09:15:29.000Z #### Summary Card [****Indications for Resuscitation**](https://www.theplasticsfella.com/burns-fluid-resuscitation/#indications-for-fluid-resuscitation) Fluid resuscitation is indicated in burns with < 15% TBSA in adults and >10% TBSA in children. [****Pathophysiology of "Burn Shock"**](https://www.theplasticsfella.com/burns-fluid-resuscitation/#pathophysiology-of-burn-shock) Fluid shifts from intravascular to interstitial spaces, intracellular sodium shifts, local vasoconstriction, and systemic vasodilation. [****Types of Fluids**](https://www.theplasticsfella.com/burns-fluid-resuscitation/#types-of-fluids) Crystalloids and colloids are the mainstays of fluids in burns resuscitation. Most formulas are based on Hartmans/Ringers Lactate. [****Formulas**](https://www.theplasticsfella.com/burns-fluid-resuscitation/#formulas-for-burn-resuscitation) The Parkland Formula (4mL x %TBSA x kg) is the most widely used formula for the first 24 hours of fluid resuscitation. [****Resuscitation in Children and the Elderly**](https://www.theplasticsfella.com/burns-fluid-resuscitation/#resuscitation-in-children-and-the-elderly) Maintenance with 5% dextrose & resuscitation fluid to overcome proportionally greater surface area & reduced hepatic glycogen stores. [****Complications**](https://www.theplasticsfella.com/burns-fluid-resuscitation/#complications-of-fluid-resuscitation) This can be due to under- or over-resuscitation. Too much fluid can result in oedema and cardiac and respiratory compromise. ‌ --- ## Indications for Fluid Resuscitation ****Key Point** Fluid resuscitation is indicated for adults with burns over 15% total body surface area (TBSA) and children over 10% TBSA. The American Burns Association state that "burns greater than 20% TBSA should undergo formal fluid resuscitation using estimates based on body size and surface area burned" ([Pham et al.](https://pubmed.ncbi.nlm.nih.gov/18182930/?ref=theplasticsfella.com), 2008). Globally speaking, the following two are recommended guidelines for fluid resuscitation in a burn based on [burn size](https://www.theplasticsfella.com/total-body-surface-area-in-burns/). 1. **Adults** \> 15% TBSA 2. **Children** \>10% TBSA The image below illustrates the Lund & Browder Chart for classifying burns. ![Lund & Browder Chart for classifying burns, Fluid Resuscitation in Burns](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Burns-TBSA-Calculator-1-1024x512-2.png) Lund & Browder Chart for classifying burns The goal of fluid resuscitation is to prevent rather than treat burn shock. This goal is achieved in the following ways: 1. Restore circulating **volume**. 2. Preserve tissue **perfusion**. 3. Avoid **ischemic** extension of the burn wound. 💡 ****Tip:** Adequate volume resuscitation can preserve the zone of stasis and prevent further fluid loss. --- ## Pathophysiology of Burn Shock ****Key Point** Burn shock occurs at the cellular level due to intracellular sodium shifts causing hypovolemia and cellular edema, local vasoconstriction paired with systemic vasodilation, and fluid shifts from intravascular to interstitial spaces. Burn shock begins at a cellular level ([Baxter](https://pubmed.ncbi.nlm.nih.gov/4973463/?ref=theplasticsfella.com), 1968 & [Moyer](https://pubmed.ncbi.nlm.nih.gov/14333526/?ref=theplasticsfella.com), 1965 & [Arturson](https://pubmed.ncbi.nlm.nih.gov/451475/?ref=theplasticsfella.com), 1979). It is a combination of distributive, cardiogenic, and hypovolemic shock. Key components of the physiological changes during a burn are: - **Intracellular sodium shift** contributes to hypovolemia and cellular oedema. - **Local vasoconstriction** and **systemic vasodilation** form inflammatory and vasoactive mediators. - **A fluid shift from intravascular to interstitial spaces** due to increased vascular permeability from disrupted capillaries. This pathophysiological response is compounded by a reduced cardiac output and increased systemic vascular resistance. It is also influenced by [burn depth](https://www.theplasticsfella.com/burn-depth/) and [total body surface area](https://www.theplasticsfella.com/total-body-surface-area-in-burns/). There are two main "**fluid compartments**". - **Intracellular:** fluid inside the cell (the majority of fluid in the body). - **Extracellular:** fluid outside the cell that consists of intravascular and interstitial fluid. --- ## Types of Fluids ****Key Point** Commonly used fluid formulas include Parkland and modified Brooke formulas. Most fluid regimes are crystalloids, colloids are used less regularly. **There is no absolute consensus on fluid formula or fluid type**. It is important to replace the fluid in the intravascular compartment to avoid end-organ hypoperfusion and ischemia. **Isotonic crystalloids**, **hypertonic solutions**, and **colloids** can all be used to effectively restore plasma volume, but every solution has advantages and disadvantages. The table below breaks down the pros and cons of crystalloids and colloids. ![A table comparing the differences in crystalloid and colloids for fluid resuscitation and their advantages and disadvantages](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Crystalloids-and-Colloids-Fluid-Rususcitaton-in-Burns.png) Crystalloid and Colloid Burn Fluid Resuscitation ### Crystalloids A crystalloid fluid is an aqueous solution of mineral salts and other small, water-soluble molecules. Most commercially available crystalloid solutions are **isotonic** to **human plasma**. Administration of large volumes of crystalloid during burn resuscitation decreases plasma protein concentration. Commonly used crystalloids include: - **Saline:** Normal Saline, Hypertonic Saline - **Ringer's Lactate** (also called Haartman's solution) - **5% Dextrose** (used in paediatric burns) 💡 ****Theory**: hypertonic saline's hyperosmolarity increases water shift into the intravascular space & reduces intracellular water volume. It is not routinely used. ([Monafo](https://pubmed.ncbi.nlm.nih.gov/5447485/?ref=theplasticsfella.com), 1970 & [Shimazaki](https://pubmed.ncbi.nlm.nih.gov/2030508/?ref=theplasticsfella.com), 1991). ### Colloids Several recent studies have suggested that colloid is useful in decreasing total fluid administration, thereby reducing the risk of “fluid creep”, and oedema formation. There is little consensus with respect to indications or dosing ([Eljaiek R et al](https://pubmed.ncbi.nlm.nih.gov/27613476/?ref=theplasticsfella.com), 2017). Colloid options available include: - **Albumin** - **Dextran** - **Hydroxyethyl** 💡 ****Tip:** Plasma sodium concentrations should be closely monitored to avoid excessive hypernatremia. ### Albumin Replacement Albumin should be replaced in a major burn. The **Muir and Barclay formula** calculates the volume of human albumin solution required in the **first 36 hours:** - 0.5mL X kg X TBSA% to be infused in each time period. - Time periods are 3 x 4 hours, 2 x 6 hours, 1 x 12 hours. --- ## Formulas for Burn Resuscitation ****Key Point** Burn resuscitation utilizes formulas to calculate fluid needs. They require ongoing adjustment based on physiological responses such as urine output, vital signs, and blood gas metrics to ensure effective treatment. There are different formulas used to calculate fluid requirements in burn resuscitation. These include the commonly used Parkland formula and modified Brooke formula. These formulas are classified in the table below. ![A table showing the correct formulas and calculations required for the Parkland Formula in burns fluid resuscitation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Burn-Fluid-Resuscitation-Formulas.png) Parkland Formula and Modified Brooke Formula for Burns ### Parkland Formula **4ml x %TBSA x kg** The Parkland formula (also known as the Baxter Formula) was developed in 1968 by Baxter and Shires. It remains one of the most widely used resuscitation **crystalloid-only** formulas. It is calculated as **4ml x %TBSA x kg**. The first half is given in the first 8 hours, the second half is given in the next 16 hours. **First 24 hours after burn:** - 4ml x %TBSA x kg in the first 24 hours. - 1st half is in the first 8 hours, and 2nd half is in the next 16 hours. - Increase fluids in [deeper burns](https://www.theplasticsfella.com/burn-depth/), delayed results, & inhalation ([Baxter](https://pubmed.ncbi.nlm.nih.gov/4609676/?ref=theplasticsfella.com), 1974 & 1978). **Second 24 hours after burn:** - There is less attention to colloid recommendations for the second 24 hours. - Colloids are given as 20–60% of calculated plasma volume. No crystalloids. - Glucose in water to maintain a urinary output of 0.5–1 ml/hr in adults & 1 ml/hr in children. **Variations:** - The rate of fluid infusion should be adjusted to the physiological response. - The volume of fluid should be titrated to maintain a urine output of approximately 0.5–1.0 ml/ kg/hr in adults and 1.0–1.5 ml/kg/hr in children. - Other variables, including the heart rate, blood pressure, lactate, base deficit, and mental status, must be considered simultaneously. 😎 ****Fun Fact:** The high dose of 4mL/kg rapidly corrects the extracellular sodium deficit. This was updated by the American Burns Association's "consensus" formula of 2-4mL/kg/TBSA%. ### Modified-Brooke Formula **2ml x %TBSA x kg:** The original Brooke formula proposed by Dr Artz at the Army Burn Center was composed of both crystalloid and colloid fluids. **Initial 24 hours:** - 2ml x %TBSA x kg in adults and 3ml x %TBSA x kg in children. - No colloids. - Ringer Lactate or Hartman's solution. **Next 24 hours:** - Colloids at 0.3–0.5 ml/kg/% burn and no crystalloids are given. - Glucose in water is added to maintain good urinary output. 😎 ****Fun Fact:** Plasma expansion is initially independent of crystalloids or colloids. At 24hrs, capillary integrity is restored to allow manipulation of intravascular oncotic pressure with colloids ([Pruitt et al](https://www.ncbi.nlm.nih.gov/pubmed/5099912?ref=theplasticsfella.com), 1971). ### Assessing Response to Fluids The rate and volume of fluid resuscitation should be titrated and adapted to specific physiological responses. Key parameters include: - **Urine Output:** \>0.5mL/kg/hr in adults, >1mL/kg/hr in children. - **Vital Signs:** pulse, blood pressure, respirator rate. - **Temperature** Core-peripheral temperature gradient. - **Urine osmolality**. - **Arterial Blood Gas:** Lactate and base excess. --- ## Resuscitation in Children and the Elderly ****Key Point** There are special considerations for fluid resuscitation in children and the elderly due to reduced physiological reserves and medical comorbidities. ### Paediatrics Maintenance fluid with **5% dextrose** in addition to resuscitation fluid is required in the paediatric population. This is because: - Reduced physiological reserves. - Proportionally greater surface area than adults. **Glucose homeostasis** is an important parameter in children. - Hepatic glycogen stores in young children are depleted after \~12 hours - Important to provide sufficient glucose substrates during the first 24 hours of re-suscitation. - Achieved by adding dextrose to the maintenance fluid or early enteral nutrition. ### Elderly The elderly population are compounded by **medical comorbidities** and a **decreased baseline cardiac and pulmonary function**. This results in an increased risk of volume overload complications. **Hemodynamic monitoring** should be used in concert with UOP to optimize perfusion and cardiac function‌. ‌ ## ‌ ‌ --- ## Complications of Fluid Resuscitation ****Key Point** Precise fluid titration in burn resuscitation is essential to avoid high morbidity from under-resuscitation, leading to burn shock, organ failure, inadequate perfusion, and over-resuscitation. Precise titration of fluid rate is critical due to the high morbidity of both under-resuscitation and over-resuscitation. ### Complications of Under-Resuscitation - Uncontrolled burn shock. - Inadequate organ perfusion. - Organ failure. ### Complications of Over-Resuscitation - Increases the risk of massive oedema formation. - Elevated compartment pressures including the abdominal, ocular, and extremity compartments. - Conversion of superficial to deep [burn depth](https://www.theplasticsfella.com/burn-depth/). - Acute respiratory distress syndrome (ARDS). 😎 ****Fun Fact:** Pruitt coined “fluid creep” to describe this phenomenon of increasing resuscitation volumes. Clinicians should “push the pendulum back" to reduce over-resuscitation ([Pruitt](https://pubmed.ncbi.nlm.nih.gov/11003341/?ref=theplasticsfella.com), 2000). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Fluid Resuscitation:** You've understoood the indications for fluid resuscitation in burn patients, recognizing the critical thresholds of total body surface area (TBSA) affected in adults and children. ****2\. Pathophysiology and Fluid Types:** You've explored the pathophysiology of burn shock and learned about the types of fluids used in resuscitation and their specific applications based on the burn severity. ****3\. Resuscitation Formulas:** You understand the application formulas like the Parkland and Modified-Brooke formulas for calculating initial fluid needs and adjusting treatment. ****4\. Addressing Special Populations:** You are familiar with the unique considerations required for fluid resuscitation in children and the elderly, acknowledging their distinct physiological and medical needs. ****5\. Complications and Management Strategies:** You've reviewed the potential complications associated with under- and over-resuscitation, learning how to balance fluid therapy to prevent complications. --- ## Further Reading 1. Pham TN, Cancio LC, Gibran NS; American Burn Association. [American Burn Association practice guidelines burn shock resuscitation](https://pubmed.ncbi.nlm.nih.gov/18182930/?ref=theplasticsfella.com). J Burn Care Res. 2008 Jan-Feb;29(1):257-66\. doi: 10.1097/BCR.0b013e31815f3876\. PMID: 18182930. 2. Baxter CR, Shires T. [Physiological response to crystalloid resuscitation of severe burns](https://pubmed.ncbi.nlm.nih.gov/4973463/?ref=theplasticsfella.com). Ann N Y Acad Sci. 1968 Aug 14;150(3):874-94\. doi: 10.1111/j.1749-6632.1968.tb14738.x. PMID: 4973463. 3. MOYER CA, MARGRAF HW, MONAFO WW Jr. [BURN SHOCK AND EXTRAVASCULAR SODIUM DEFICIENCY--TREATMENT WITH RINGER'S SOLUTION WITH LACTATE](https://pubmed.ncbi.nlm.nih.gov/14333526/?ref=theplasticsfella.com). Arch Surg. 1965 Jun;90:799-811\. doi: 10.1001/archsurg.1965.01320120001001\. PMID: 14333526. 4. Arturson G, Jonsson CE. [Transcapillary transport after thermal injury](https://pubmed.ncbi.nlm.nih.gov/451475/?ref=theplasticsfella.com). Scand J Plast Reconstr Surg. 1979;13(1):29-38\. doi: 10.3109/02844317909013016\. PMID: 451475. 5. Monafo WW. [The treatment of burn shock by the intravenous and oral administration of hypertonic lactated saline solution](https://pubmed.ncbi.nlm.nih.gov/5447485/?ref=theplasticsfella.com). J Trauma. 1970 Jul;10(7):575-86\. doi: 10.1097/00005373-197007000-00006\. PMID: 5447485. 6. Shimazaki S, Yukioka T, Matuda H. [Fluid distribution and pulmonary dysfunction following burn shock](https://pubmed.ncbi.nlm.nih.gov/2030508/?ref=theplasticsfella.com). J Trauma. 1991 May;31(5):623-6; discussion 626-8\. doi: 10.1097/00005373-199105000-00005\. PMID: 2030508. 7. Eljaiek R, Heylbroeck C, Dubois MJ. [Albumin administration for fluid resuscitation in burn patients: A systematic review and meta-analysis](https://pubmed.ncbi.nlm.nih.gov/27613476/?ref=theplasticsfella.com). Burns. 2017 Feb;43(1):17-24\. doi: 10.1016/j.burns.2016.08.001\. Epub 2016 Sep 6\. PMID: 27613476. 8. Baxter CR. [Fluid volume and electrolyte changes of the early postburn period](https://pubmed.ncbi.nlm.nih.gov/4609676/?ref=theplasticsfella.com). Clin Plast Surg. 1974 Oct;1(4):693-703\. PMID: 4609676. 9. Baxter CR. [Problems and complications of burn shock resuscitation](https://pubmed.ncbi.nlm.nih.gov/734611/?ref=theplasticsfella.com). Surg Clin North Am. 1978 Dec;58(6):1313-22\. doi: 10.1016/s0039-6109(16)41693-2\. PMID: 734611. 10. Pruitt BA Jr, Mason AD Jr, Moncrief JA. [Hemodynamic changes in the early postburn patient: the influence of fluid administration and of a vasodilator (hydralazine)](https://pubmed.ncbi.nlm.nih.gov/5099912/?ref=theplasticsfella.com). J Trauma. 1971 Jan;11(1):36-46\. doi: 10.1097/00005373-197101000-00003\. PMID: 5099912. 11. Pruitt BA Jr. [Protection from excessive resuscitation: "pushing the pendulum back"](https://pubmed.ncbi.nlm.nih.gov/11003341/?ref=theplasticsfella.com). J Trauma. 2000 Sep;49(3):567-8\. doi: 10.1097/00005373-200009000-00030\. PMID: 11003341. --- ### Spitz Naevus - Clinical Scenario URL: https://www.theplasticsfella.com/spitz-naevus-clinical-scenario/ Last updated: 2024-09-04T17:16:41.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/AI-generated-image--1--1.png) #### Clinical Scenario ****An 8-year-old girl is brought to the clinic due to a new mole on the child’s face which was first noticed a few months ago. Started as a small pale nodule and grew more noticeable over the past few months.** ****Objectives:** ****1\.** Describe the clinical and dermoscopy findings of Spitz Naevus. ****2\.** Describe the histopathological findings of Spitz Naevus. ****3\.** Appreciate the different types of Spitz naevi and their potential for malignant behaviour. ****4\.** Knowledge of the management of Spitz naevus in different age groups. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Spitz Naevus: Pathophysiology, Clinical Features, & Management URL: https://www.theplasticsfella.com/spitz-naevus/ Last updated: 2025-02-27T11:18:15.000Z #### Summary Card [****Definition** ](https://www.theplasticsfella.com/spitz-naevus/#definition-of-spitz-naevus)Spitz nevus is a rare, benign melanocytic nevus, representing about 1% of surgically removed childhood nevi. It mostly affects children. [****Pathophysiology**](https://www.theplasticsfella.com/spitz-naevus/#pathophysiology-of-spitz-naevus) Spitz naevi have unique histological traits, including larger melanocytes and Kamino bodies. Variants include classic, spindle cell, pigmented, and atypical forms [****Clinical Features** ](https://www.theplasticsfella.com/spitz-naevus/#clinical-features-of-spitz-naevus)Spitz nevi appear as single, dome-shaped papules with uniform pigmentation. They exhibit starburst or globular patterns on dermoscopy and undergo rapid growth, followed by long-term stability and potential spontaneous regression. [****Atypical Spitz Tumour and Spitzoid Melanoma** ](https://www.theplasticsfella.com/spitz-naevus/#atypical-spitz-tumour-and-spitzoid-melanoma)Atypical Spitz tumors have features between benign and malignant. Spitzoid melanoma resembles benign nevi but behaves like melanoma, with a generally better prognosis. [****Management**](https://www.theplasticsfella.com/spitz-naevus/#management-of-spitz-naevus) Management involves non-surgical monitoring for children under 12 and excision biopsy for older children, adults, or changing lesions. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Spitz Naevus ****Key Point** Spitz naevus is a benign melanocytic neoplasm that commonly presents in the paediatric population. Spitz naevus is a **distinct clinical and histological type of melanocytic nevus**, characterised by a **benign** tumour formation of **spindled** and/or **epithelioid** melanocytes. A spitz naevus represents about 1% of naevi surgically removed in childhood. - 50% of cases occur in children under 10 years old ([Gaspar](https://pubmed.ncbi.nlm.nih.gov/31787210/?ref=theplasticsfella.com), 2020). - 70% of cases are identified by the age of 20 ([Gaspar](https://pubmed.ncbi.nlm.nih.gov/31787210/?ref=theplasticsfella.com), 2020). - Affects both males and females equally ([Gaspar](https://pubmed.ncbi.nlm.nih.gov/31787210/?ref=theplasticsfella.com), 2020). Originally described as ‘melanomas of childhood’ by Spitz in 1948, it was later found that 12 of the original 13 cases were benign. Only one case was a true melanoma that spread and caused death ([Spitz](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637087/?ref=theplasticsfella.com), 2019). ![Spitz tumour, epithelioid/spindle-cell naevus, Spitz naevus](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--9--2.png) Classic Spitz Naevus 😎 ****Fun Fact:** Over the years multiple names have been used including Spitz naevus, Spitz tumour, spindle cell naevus, and epithelioid naevus. --- ## Pathophysiology of Spitz Naevus ****Key Point** Many variants of Spitz naevus exist, sharing common histological findings including spindled and epithelioid melanocytes and Kamino bodies. In Spitz naevi, like other types of naevi and melanoma, cell growth is mainly driven by mutations in genes within the **RAS-RAF-MEK-ERK-MAP** **kinase pathway.** Spitz naevus is a type of melanocytic naevus that meets all the key histological criteria for diagnosing a melanocytic naevus but has unique features that set it apart. Histologically, Spitz naevi consist of: - **Spindled** and/or epithelioid melanocytes - Larger **melanocytes** than those found in other types of naevi. - **Kamino** bodies (PAS-positive eosinophilic globules), which are unique to Spitz naevi ([Gaspar](https://pubmed.ncbi.nlm.nih.gov/31787210/?ref=theplasticsfella.com), 2020). --- ## Clinical Features of Spitz Naevus ****Key Point** Spitz naevus typically presents as a single, well-defined, non-ulcerated papule with varying pigmentation, showing characteristic patterns on dermoscopy. ### General Appearance Spitz naevus usually appears as a **single, soft, dome-shaped papule**, though it can sometimes be flat. The pigmentation is uniform and can range from pink, red, and tan to light or dark brown. Variants with ALK fusions may exhibit colors from amelanotic to darkly pigmented. Common clinical features of the subtypes include: - **Size:** Typically ranges from 0-2 cm in diameter. - **Location:** Commonly found on the face or limbs. - **Presentation:** Generally presents as solitary lesions, though multiple lesions can occur. - **Growth Pattern:** Rapid growth phase lasting a few months, followed by a static phase that may last for years. - **Regression:** Lesions may regress and disappear spontaneously over time. ([Argenziano](https://pubmed.ncbi.nlm.nih.gov/21494025/?ref=theplasticsfella.com), 2011). ![Appearance of Spitz naevus, Identifying Spitz naevus](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--15-.png) Appearance of Spitz naevus 💡 ****Tip:** In patients with ****severe solar elastosis and elderly individuals, diagnosis** of Spitz naevus should be made cautiously, as such lesions in this cohort of patients are more likely to be ****malignant** in nature. ### Types of Spitz Naevi - **Classic Spitz Naevus:** Symmetric, dome-shaped lesions with uniform pink or tan coloration and distinct borders. These are composed of spindle or epithelioid melanocytes. - **Spindle Cell Tumour of Reed:** Features elongated spindle-shaped melanocytes arranged in a nodular, fascicular pattern. - **Pigmented Spitz Naevus:** Displays varying pigmentation from light brown to black, potentially mimicking melanoma both clinically and histologically. - **Atypical Spitz Naevus/Tumour:** Shows atypical features that differ from typical Spitz naevi, often requiring careful evaluation. These types, their characteristics, and management options are summarized in the table below. ![Types of spitz naevi, their characteristics, and management options](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/02/Main-Article-Images---2025-02-27T165024.492.png) Types of spitz naevi, their characteristics, and management options 😎 ****Fun Fact:** ****Agminated Spitz naevus** is a rare entity that presents with multiple Spitz naevi in a segmental presentation. It is an example of [cutaneous mosaicism](https://dermnetnz.org/topics/cutaneous-mosaicism?ref=theplasticsfella.com) and is due to a genetic mutation. ### Dermoscopy Findings - **Starburst Pattern:** Radial streaks or lines extending from the periphery, highly indicative of Spitz nevi. - **Globular Pattern:** Round, oval, or cobblestone-like structures, uniformly distributed and colored. - **Symmetric Pigmentation:** Evenly distributed pigmentation within the lesion, giving it a benign appearance. - **Central Homogeneous Area:** A uniformly colored and textured area in the center of the lesion The dermoscopic findings of spitz naevi are summarised in this video below. --- ## Atypical Spitz Tumour and Spitzoid Melanoma ****Key Point** Atypical Spitz tumour is an intermediate entity that has features common to both benign Spitz naevi and melanoma. Spitzoid melanoma is a conventional melanoma that resembles Spitz tumours in histology. ### Atypical Spitz Tumour Atypical Spitz Tumour (AST) is a special type of Spitz naevus. While it has a higher risk of involving sentinel nodes, it usually behaves less aggressively ([Harms](https://doi.org/10.5858/arpa.2015-0207-RA?ref=theplasticsfella.com), 2015). These tumors consist of **epithelioid and spindled melanocytes**. They have enough atypical features to stand out from standard Spitz nevi but not enough to be classified as melanoma. ASTs are seen as an **intermediate stage** between typical Spitz naevus and Spitzoid melanoma - **Appearance:** ASTs are usually raised, dome-shaped, and have a smooth surface. They are often larger than common moles. - **Location:** Commonly found on the lower limbs, but they can appear anywhere on the body. - **Shape:** Typically symmetrical with well-defined borders, although they can sometimes have irregular edges. - **Color:** The color can vary widely, including pink, red, tan, brown, or black, and may have mixed pigmentation within the same lesion. - **Age:** Mostly seen in children and adolescents, but they can occur at any age ([Harms](https://doi.org/10.5858/arpa.2015-0207-RA?ref=theplasticsfella.com), 2015) - **Treatment:** ASTs should be conservatively excised if atypical features are noted ([Harms](https://doi.org/10.5858/arpa.2015-0207-RA?ref=theplasticsfella.com), 2015) ### Spitzoid Melanoma Spitzoid melanoma is a rare type of **malignant melanoma** that closely resembles the benign neoplasm Spitz naevus in its histology ([Batra](https://doi.org/10.2217/mmt.15.6?ref=theplasticsfella.com), 2015). Clinical Features of Spitzoid Melanoma: - **Appearance:** typically presents as a changing and enlarging papule or nodule. It may appear amelanotic or pigmented. Advanced stages of the condition might show crusting and ulceration. - **Location:** most commonly found on the head or extremities. - **Shape and Colour:** often appear round and uniform in colour without the classic [ABCDE](https://www.aad.org/public/diseases/skin-cancer/find/at-risk/abcdes?ref=theplasticsfella.com) characterisitics. - **Origin:** It can develop as a new lesion (de novo) or evolve from an existing Spitz naevus. Spitzoid Melanoma should be managed as any other cutaneous melanoma and staged accordingly. However, it carries a much better prognosis ([Paradela](https://pubmed.ncbi.nlm.nih.gov/22928628/?ref=theplasticsfella.com), 2013). 😎 ****Fun Fact:** When suspicious lesions are biopsied, histological analysis may yield uncertain results, and a diagnosis of Spitzoid Melanoma of Uncertain Malignant Potential (STUMP) may be considered. --- ## Management of Spitz Naevus ****Key Point** Management depends on the patient's age and characteristics of the lesion. It ranges from active observation to surgical excision to obtain a histological diagnosis. Spitz naevi represent a benign neoplasm and aggressive surgical management is not usually warranted if the diagnosis is certain, especially in the paediatric population or when cosmetic areas of the face are involved. ### Observation (Children <12 years) - monitored through digital dermatoscopic surveillance. - tracking changes in the lesion's dermatoscopic appearance with serial photographs. - 3 monthly follow-up appointments until growth ceases. - 6 monthly or yearly follow-ups until resolution. - Excision biopsy if changes are observed on follow-up ([Lallas](https://doi.org/10.1111/bjd.15339?ref=theplasticsfella.com), 2017). ### Surgical Management This method is used for children above 12 years and adults, in case of an evolving lesion. - **Incision biopsy** in large lesions in cosmetically sensitive areas. - **Punch biopsy** (not recommended in view of diagnostic inaccuracy). - **Excision biopsy with 2-3 mm margin** for histological evaluation (preferred). - **Wide excision with a further margin** of confirmed *atypical Spitz tumours* (regardless of complete excision at biopsy) ([Ludgate](https://doi.org/10.1002/cncr.24047?ref=theplasticsfella.com), 2009). 😎 ****Fun Fact:** There is ongoing controversy over the margins recommended for ASTs, with 1 cm being advocated in view of the malignant potential ([Situm](https://pubmed.ncbi.nlm.nih.gov/19140279/?ref=theplasticsfella.com), 2008 & [Ludgate](https://doi.org/10.1002/cncr.24047?ref=theplasticsfella.com), 2009). Sentinel node biopsy may have a role but till now no studies have shown its prognostic benefit ([Metzger](https://pubmed.ncbi.nlm.nih.gov/24026360/?ref=theplasticsfella.com), 2013). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding of Spitz Nevus:** You've gained insights into the nature and characteristics of Spitz nevus, including its definition, epidemiology, and the typical demographic affected. ****2\. Histopathological Features:** You've learned about the unique histological traits of Spitz nevi, such as larger melanocytes and the presence of Kamino bodies, and how these features differentiate various subtypes. ****3\. Clinical Presentation:** You are now familiar with the clinical appearance of Spitz nevi, how they present as dome-shaped papules with uniform pigmentation, and their behavior through growth phases. ****4\. Atypical Spitz Tumors and Spitzoid Melanoma:** You've explored atypical Spitz tumors and Spitzoid melanoma, understanding their intermediate and malignant behaviors respectively, and how they compare to benign Spitz nevi. ****5\. Comprehensive Management:** You understand the varied management strategies for Spitz nevi, ranging from non-surgical monitoring in younger patients to surgical excision in older children and adults based on lesion changes. --- ## Further Reading 1. Sainz-Gaspar L, Sánchez-Bernal J, Noguera-Morel L, Hernández-Martín A, Colmenero I, Torrelo A. S[pitz Nevus and Other Spitzoid Tumors in Children -Part 1: Clinical, Histopathologic, and Immunohistochemical Features](https://pubmed.ncbi.nlm.nih.gov/31787210/?ref=theplasticsfella.com). Actas Dermosifiliogr (Engl Ed). 2020 Jan 2;111(1):7-19\. English, Spanish. doi: 10.1016/j.ad.2019.02.011\. Epub 2019 Nov 28\. PMID: 31787210\. 2. [What to look for: ABCDEs of melanoma](https://www.aad.org/public/diseases/skin-cancer/find/at-risk/abcdes?ref=theplasticsfella.com). American Academy of Dermatology www.aad.org Accessed on 11th May 2024 3. Spitz K, Piliang M, Mostow E. [Sophie Spitz: A woman ahead of her time](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637087/?ref=theplasticsfella.com). Int J Womens Dermatol. 2019 Mar 11;5(3):190-191\. doi: 10.1016/j.ijwd.2019.02.002\. PMID: 31360758; PMCID: PMC6637087. 4. Argenziano G, Agozzino M, Bonifazi E, Broganelli P, Brunetti B, Ferrara G, Fulgione E, Garrone A, Zalaudek I. [Natural evolution of Spitz nevi](https://pubmed.ncbi.nlm.nih.gov/21494025/?ref=theplasticsfella.com). Dermatology. 2011;222(3):256-60\. doi: 10.1159/000326109\. Epub 2011 Apr 13\. PMID: 21494025. 5. A. Lallas, Z. Apalla, D. Ioannides, E. Lazaridou, A. Kyrgidis, P. Broganelli, R. Alfano, I. Zalaudek, G. Argenziano, on behalf of the International Dermoscopy Society, Renato Bakos, Andreas Blum, Ralph Braun, Horacio Cabo, Allan Halpern, Rainer Hofmann‐Wellenhof, Harald Kittler, Josep Malvehy, Ashfaq Marghoob, Scott Menzies, Elvira Moscarella, John Paoli, Giovanni Pellacani, Susana Puig, Harold Rabinovitz, Alon Scope, Peter Soyer, Wilhelm Stolz, Masaru Tanaka, Luc Thomas, Philipp Tschandl, [Update on dermoscopy of Spitz/Reed naevi and management guidelines by the International Dermoscopy Society](https://doi.org/10.1111/bjd.15339?ref=theplasticsfella.com), *British Journal of Dermatology*, Volume 177, Issue 3, 1 September 2017, Pages 645–655, https://doi.org/10.1111/bjd.15339 6. Harms, K. L., Lowe, L., Fullen, D. R., & Harms, P. W. (2015). [Atypical Spitz Tumors: A Diagnostic Challenge](https://doi.org/10.5858/arpa.2015-0207-RA?ref=theplasticsfella.com). *Archives of pathology & laboratory medicine*, *139*(10), 1263–1270\. https://doi.org/10.5858/arpa.2015-0207-RA 7. Batra S. (2015). [Spitzoid melanoma of childhood: a case series and review](https://doi.org/10.2217/mmt.15.6?ref=theplasticsfella.com). *Melanoma management*, *2*(2), 121–125\. https://doi.org/10.2217/mmt.15.6 8. Paradela S, Fonseca E, Pita-Fernández S, Prieto VG. [Spitzoid and non-spitzoid melanoma in children: a prognostic comparative study](https://pubmed.ncbi.nlm.nih.gov/22928628/?ref=theplasticsfella.com). J Eur Acad Dermatol Venereol. 2013 Oct;27(10):1214-21\. doi: 10.1111/j.1468-3083.2012.04686.x. Epub 2012 Aug 29\. PMID: 22928628. 9. Ludgate, M. W., Fullen, D. R., Lee, J., Lowe, L., Bradford, C., Geiger, J., Schwartz, J., & Johnson, T. M. (2009). [The atypical Spitz tumor of uncertain biologic potential: a series of 67 patients from a single institution](https://doi.org/10.1002/cncr.24047?ref=theplasticsfella.com). *Cancer*, *115*(3), 631–641\. https://doi.org/10.1002/cncr.24047 10. Situm, M., Bolanca, Z., Buljan, M., Tomas, D., & Ivancić, M. (2008). [Nevus Spitz--everlasting diagnostic difficulties--the review](https://pubmed.ncbi.nlm.nih.gov/19140279/?ref=theplasticsfella.com). Collegium antropologicum, 32 Suppl 2, 171–176. 11. Metzger AT, Kane AA, Bayliss SJ. [Differences in treatment of Spitz nevi and atypical Spitz tumors in pediatric patients among dermatologists and plastic surgeons](https://pubmed.ncbi.nlm.nih.gov/24026360/?ref=theplasticsfella.com). JAMA Dermatol. 2013 Nov;149(11):1348-50\. doi: 10.1001/jamadermatol.2013.4947\. PMID: 24026360. --- ### Bury K-wires? Sunday Quiz Winners, Trending Cosmetic Articles. URL: https://www.theplasticsfella.com/may-19th/ Last updated: 2024-05-18T09:59:16.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-19th/#a-letter-from-pfella) The Buried K-Wire Paradox 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-19th/#the-sunday-quiz) **\+ Leaderboard** Winners announced! And we got a tie! 3. ****🎙️** [****Trailer Release!**](https://www.theplasticsfella.com/may-19th/#behind-the-fella) Listen to Behind the 'Fella trailer! 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/may-19th/#the-fellows-corner) What's new with the team? 5. ****🔥** [****Cosmetic Articles of the Week**](https://www.theplasticsfella.com/may-19th/#articles-of-the-week) Soft-tissue fillers, WAMs, & cosmetic tourism With 1 sentence summaries! 6. 💕 [****Feedback**](https://www.theplasticsfella.com/may-19th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **The Buried K-wire Paradox.* 👋 ****Hey Team!** Ever notice how a simple surgical decision can spark deeper debates in our field? This week, we dug into whether K-wires should be left exposed or buried—a topic that really highlights a fundamental paradox in plastic surgery. 👇 ### Should we bury our K-wires or keep them exposed? Our Fellows debated this in an upcoming episode of [Behind the 'Fella](https://www.theplasticsfella.com/may-19th/#behind-the-fella). One side argued that exposed K-wires, if managed well, avoid additional surgeries and reduce hospital stays. The other side said buried K-wires reduce infections and increase comfort. We ran a Twitter poll, and nearly 80% of you prefer keeping K-wires exposed. > I like not burying k-wires because they are easy to take out. > But patients don't like metal sticking out of their fingers. > > What are your thoughts? > > — thePlasticsFella (@PlasticsFella) [November 23, 2021](https://twitter.com/PlasticsFella/status/1463224271266885636?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) So, what’s the deal with the "Buried K-wire paradox"? It’s all about balancing short-term surgical efficiency with potential long-term patient outcomes: - **Exposing K-wires:** This method avoids another surgery, saving operating room time and hospital stays. It allows for quick, easy removal in a clinical setting without extra intervention. It’s practical and resource-efficient. - **Burying K-wires:** This method reduces pin-site infections and increases patient comfort. While it requires another procedure to remove the wires, it eliminates the discomfort and appearance of exposed metal. The paradox is that each approach's potential benefits have the potential to undermine the other's, making it difficult to determine which method provides the best overall outcome. This inherent conflict between immediate efficiency and potential long-term benefits creates a genuine paradox in surgical decision-making This debate isn't just about K-wires; it highlights broader issues in surgical practices that are hard to prove in trials but impact our work. It raises questions like dissolvable vs. non-dissolvable sutures, showing how we balance evidence-based practices with real-world experience and resource limits. P'Fella ❤️ ****tl;dr** The "Buried K-wire paradox" highlights a conflict in plastic surgery: exposed K-wires save time and reduce hospital stays, while buried K-wires has the potential to lower infection risk and increase comfort, with 80% favouring exposed K-wires ## The Sunday Quiz **\*Drumroll*🥁**\* We've got winners!* ****Congratulations to the Winners** of The Weekly Quiz! We're thrilled to announce the winners of this edition's quiz. After six rounds of questions on plastic surgery, our top scorers are ****Alex**, ****Maitumelo**, ****Hatan**, and ****Paul**. With a tie at the top, we're considering a playoff, possibly live on our podcast! We'll contact the finalists soon. Thank you to everyone who participated. Stay tuned for more fun quizzes in future editions ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Leaderboard-Team-Post-Template.png) Here's the rest of the leaderboard ## Behind the ‘Fella **The Trailer is here!* 🎉 Exciting News! Our new podcast, "Behind the Fella," is now live on Apple Podcasts and Spotify! Join us for exclusive insights from our team meetings and engaging discussions on plastic surgery with our fellows. Get a unique, behind-the-scenes look at our practice! ****Subscribe on** [****Spotify**](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) **or** [****Apple**](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) **🌟 The first episode drops tomorrow! 🌟** We’ll explore Ring Avulsion Injury, AI Image Creation, Writing Op-Notes, Reading Patterns, and debate whether Steri-Strips should be applied longitudinally or transversely. [Subscribe on Apple](https://podcasts.apple.com/ie/podcast/behind-the-fella/id1746377600?ref=theplasticsfella.com) [Subscribe on Spotify](https://open.spotify.com/show/46pGp957C6aXCUKSqe03qR?ref=theplasticsfella.com) ## the Fellows' Corner **What have the fellows been up to?* Our team has been hard at work creating fantastic new content for our community, including fresh **articles**, clinical **cases**, and surgical **techniques** focused on tumors. Don't miss our recent article on **Seymour Fractures** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--5--1.png) #### Seymour Fractures [****Definition** ](https://www.theplasticsfella.com/seymour-fracture/#definition-of-seymour-fracture)A Seymour fracture is an open, displaced distal phalangeal physeal fracture with an associated nailbed injury. [****Anatomy** ](https://www.theplasticsfella.com/seymour-fracture/#anatomy-of-seymour-fracture)They present as mallet fingers with a flexion deformity due to the level of flexor and extensor tendons at the distal phalanx. [****Clinical Features** ](https://www.theplasticsfella.com/seymour-fracture/#clinical-features-of-seymour-fracture)Crush injuries associated with a nail plate avulsion and proximal nail bed interposition at the fracture site. [****Investigations** ](https://www.theplasticsfella.com/seymour-fracture/#investigations-for-seymour-fracture)X-rays are required for adequate diagnosis with distinct features seen on the lateral view. [****Treatment** ](https://www.theplasticsfella.com/seymour-fracture/#treatment-of-seymour-fracture)Treatment is multimodal and involves irrigation, debridement, reduction, fixation, and antibiotics. [****Complications** ](https://www.theplasticsfella.com/seymour-fracture/#complications-of-seymour-fracture)Include osteomyelitis, nail dystrophy, non-union or malunion, and growth disturbances of the distal phalanx. [Read the Article](https://www.theplasticsfella.com/seymour-fracture/) ## Articles of the Week **3 interesting articles with 1 sentence summaries.* 1️⃣ ***What are the possible complications of injecting soft-tissue fillers?** ([Ozturk](https://academic.oup.com/asj/article/33/6/862/2801380?searchresult=1&ref=theplasticsfella.com), 2013) Explore the risks associated with soft-tissue fillers such as necrosis and blindness, along with high-risk injection sites. 2️⃣ ***Wearable Activity Monitors (WAMs) in tracking postoperative recovery** ([Kwasnicki](https://www.jprasurg.com/article/S1748-6815%2824%2900232-8/fulltext?ref=theplasticsfella.com), 2024) Discover how WAMs help track gradual improvement in patients' functional mobility over six months after abdominal wall surgery. 3️⃣ ***The financial impact of cosmetic surgery tourism** ([Roberts](https://www.sciencedirect.com/science/article/abs/pii/S1479666X24000441?dgcid=author&ref=theplasticsfella.com), 2024) A five-year look back at Canniesburn Plastic Surgery Unit highlights the high costs and common complications, showing the importance of better patient awareness and stronger global policies. ## Feedback ### I hope you enjoyed it 😄 --- ### Electrical Burns: Causes, Complications, & Management URL: https://www.theplasticsfella.com/electrical-burns/ Last updated: 2024-05-17T16:09:53.000Z #### Summary Card [****Pathophysiology of Electrical Burns**](https://www.theplasticsfella.com/electrical-burns/#pathophysiology-of-electrical-burns) Electrical burns lead to thermal heating, electroporation, and protein denaturation, with severity determined by the current, voltage, and resistance formula. [****Types of Electrical Burns**](https://www.theplasticsfella.com/electrical-burns/#types-of-electrical-burns) Electrical burns can be classified as high or low voltage, direct or alternating current. [****Lightning Strike Burn**](https://www.theplasticsfella.com/electrical-burns/#lightning-strike-burn) Lightning is an extremely high voltage, high amperage, ultra-short duration electrical discharge of direct current. [****Severity of Injury**](https://www.theplasticsfella.com/electrical-burns/#severity-of-electrical-burn-injuries) This is influenced by voltage & resistance. Bone is the most resistant and its slow heat escape results in more thermal injury (Joule Effect). [****Management of an Electrical Burn**](https://www.theplasticsfella.com/electrical-burns/#management-of-an-electrical-burn) Switch off the power source, ATLS surveys, cardiac monitoring and standard burn management. It may increase urine output or fasciotomy. --- ## Pathophysiology of Electrical Burns ****Key Point** Electrical burns result in thermal heating, electroporation, and protein denaturation. An electrical burn can occur by direct contact or indirectly via an arc, flash, or flame. This results in three pathophysiological effects: 1. **Thermal** burn via carbonation and joule heating. 2. **Electroportation** (pors in cell membranes to allow free passage of fluid and electrolytes). 3. Protein **denaturation**. The degree of these mechanisms is influenced by the current, voltage and resistance. More specifically, **current = voltage/resistance**. --- ## Types of Electrical Burns ****Key Point** Electrical burns can be classified as high or low voltage, direct or alternating current. Electrical burns can be classified by their voltage and their type of current. In terms of voltage, this can be a low voltage, high voltage, or lightning strike electrical burn. Currents can be described as direct (DC) or alternating (AC). This is illustrated in the diagram below. ![This a labelled table showing the differences in direct current, alternating current, high voltage and low voltage electrical burn injuries](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Types-of-Electrical-Burns.png) Types of Electrical Burns ### ### Low Voltage Electrical Burn A low-voltage electrical injury is defined as **less than 1000 volts**. The patients will have entrance and exit wounds but generally no deep tissue damage. For example: - Standard single-phase household electrical supply. - Industrial power supplies are often three-phase and commonly 415 volts. - Common car battery. - Surgical diathermy. 😎 ****Fun Fact:** Entry and exit wounds are created because the current is concentrated at points of contact with the source and the ground. ### High Voltage Electrical Burn A high-voltage electrical injury is defined as **more than 1000 volts.** It can cause an injury through the current transmission and also flash burns. These patients are less likely to have direct contact with the source. Instead, they are injured indirectly through an arc of flash flame. **Flash burns** - Skin burns **without** deep tissue damage or entrance/exit wounds. - Current isn't transmitted through the patient. - A high-tension discharge creates an arc or “flash over” that can ignite clothing. **Transmission Burns** - Skin burns **with** deep tissue damage and entrance/exit wounds. - This is the mechanism of electroporation. - Compartmental swelling, tenderness and pain are a sign of muscle damage that fasciotomies should be strongly considered for. - Haemochromgens released from muscle can result in [acute kidney injury](https://www.theplasticsfella.com/burn-complications/#kidney-injury-in-burns). 😎 ****Fun Fact:** Electroporation is the mechanism of injury in high-voltage burns. Protein is converted to 'pores', resulting in unfiltered fluid shifts, apoptosis, and muscle necrosis. ### Direct and Alternating Current There are two types of current; direct currents (DC) and alternating currents (AC). **Direct Current** - Usually a single shock. - The patient is thrown away from the electrical source. - The main complication is blunt trauma but an arrhythmia may occur. **Alternating Current** - Can cause continuous muscle tetany. - Prevents the patient from releasing their touch on the source. - High complication rate compared to direct current injuries. --- ## Lightning Strike Burn ****Key Point** Lightning is an extremely high voltage, high amperage, ultra-short duration electrical discharge of direct current. **Pattern of Injury** Lightning strikes can occur as a direct strike (high mortality), a "side flash" or "step voltage". - Side flash occurs when lightning strikes an object of high resistance such as a tree. The current is then deflected through a victim on its way to the ground. - Step voltage occurs when the discharge flowing through the ground may pass up one leg and down the other. A lightning strike is illustrated in the image below. ![Lightning Strike, electrical burn injuries](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Lightning-Strike.png) Lightning Strike **Complications** - Lichtenberg flowers are pathognomonic of a lightning strike. - Burns and deep muscle damage are less common than other electrical burns. - Respiratory (discharge affecting the medullary respiratory centre). - Cardiac arrest. - Perforated tympanic membrane. - Corneal damage. --- ## Severity of Electrical Burn Injuries ****Key Point** The severity of electrical burn injuries depends on the electrical current's characteristics such as voltage, resistance, and contact duration, and the path electricity takes through the body. The severity of an electrical burn is multifactorial. It is strongly influenced by the characteristics of the electrical current and the direction of the electricity travelling through the body. ### Characteristics of the Electricity The important electrical characteristics that influence the degree of injury are: - **Current:** voltage x resistance. - **Resistance:** more resistant anatomy creates more thermal energy. - **Duration** of contact. Different tissues exhibit characteristic electrical resistance according to their electrolyte content. The **most resistan**t are ordered below. 1. **Bone:** slow heat escape can cause secondary thermal damage (Joule Effect). 2. **Skin:** increased in thick, dry skin. 3. **Fat:** once the skin is breached, fat receives an increased current. 4. **Nerve:** can be secondary thermal damage as heat is slow to escape from bone. 5. **Muscle:** will result in oedema, myoglobinuria and hyperkalemia. 6. **Blood and fluid:** the least resistance anatomical structure. Entry and exit wounds of electrical burns are illustrated below. ![Exit and Entry Points of an Electrical Burn](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Exit-and-Entry-Points-electrical-burn.png) Exit and Entry Points of an Electrical Burn ### Direction of Electricity The direction of the electrical conduction provides a guide for the type of burn injury. For example: - **Chest:** cardiac arrest, myocardial damage, ventricular fibrillation, or delayed arrhythmias. - **Brain:** respiratory arrest, neurological (seizures). - **Ears:** tympanic membrane. - **Eyes:** corneal injury, cataracts. 😎 ****Fun Fact:** Electricity can increase the temperature of its conducting structure even after the current has finished. This phenomenon is known as the Joule effect. --- ## Management of an Electrical Burn ****Key Point** Management of electrical burns involves immediate power source disconnection, adherence to ATLS protocols, and referral to burn centers. Management of electrical burns involves immediate power source disconnection, adherence to ATLS protocols, and referral to burn centers. Treatment focuses on specialized fluid resuscitation, cardiac monitoring, potential fasciotomies for high-voltage injuries, and aggressive management of myoglobinuria with diuretics to prevent renal complications from rhabdomyolysis. ### Basic Management 1. Switch off the power source and avoid personal injury. 2. ATLS guidelines with a primary survey, secondary survey, AMPLE history. 3. Referral to Specialist Burn Centre to treat burns. ### Specific to Electrical Burns **Fluid Resuscitation** - Standard burns [resuscitation formula](https://www.theplasticsfella.com/burns-fluid-resuscitation/#formulas-for-burn-resuscitation) may be inadequate. - Haemochromogenuria requires a urine output of 75–100ml/hr in adults, and 2ml/kg/hr in children until urine is clear. **Cardiac** - Treat cardiac and respiratory arrest. - 24 hours of ECG monitoring may be required for high voltage injury, loss of consciousness, or abnormal ECG on arrival. **Fasciotomy** - High voltage injury involving limbs may require fasciotomy. - Resuscitate prior to fasciotomy so that haemochromogens from the newly perfused muscle are flushed rapidly through the kidneys. - Intra-operative hypotension can result in delayed haemorrhage. **Myoglobinuria** - Haemochromogens suggestive of rhabdomyolysis - Intratubular deposition results in renal failure - Increase urine output to 75-100 ml/hr in adults, 2ml/kg/hr in children - Consider adding in mannitol, furosemide or sodium bicarbonate The image below illustrates Myoglobinuria. ![Myoglobinuria, Electrical burn characteristics, renal failure](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Haemglobinuria-red-urine.png) Myoglobinuria ### --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Electrical Burn Pathophysiology:** You've gained insight into how electrical burns result from thermal heating, electroporation, and protein denaturation, influenced by the voltage, current, and resistance encountered. ****2\. Types of Electrical Burns:** You understand the classification of electrical burns into high or low voltage, and direct or alternating current, which helps in anticipating the injury pattern and guiding treatment. ****3\. Recognizing Lightning Strike Burns:** You've learned about the unique characteristics of lightning strike burns, which are high voltage and direct current events with specific injury patterns and complications. ****4\. Assessing the Severity of Electrical Burn Injuries:** You are familiar with the factors that determine the severity of electrical burns, including the electrical current's characteristics and the path it takes through the body. ****5\. Management for Electrical Burns:** You have explored the essential management steps for electrical burns, including immediate care, the importance of continuous monitoring, and specific interventions. ### Neck Dissection: Types, Anatomy, Indications, & Complications URL: https://www.theplasticsfella.com/neck-dissection/ Last updated: 2024-05-16T08:39:40.000Z #### Summary Card [****Types of Neck Dissections**](https://www.theplasticsfella.com/neck-dissection/#types-of-neck-dissections) "Type" refers to the location of ****nodes** and ****secondary structures** removed or preserved during the neck dissection. [****Radical Neck Dissection**](https://www.theplasticsfella.com/neck-dissection/#radical-neck-dissection) Removal of lymph nodes in levels I-V, sternocleidomastoid muscle, spinal accessory nerve, and internal jugular vein. [****Modified Radical Neck Dissection**](https://www.theplasticsfella.com/neck-dissection/#modified-radical-neck-dissection) Removal of levels I-V but preserve the spinal accessory nerve and/or internal jugular vein and/or sternocleidomastoid muscle. [****Selective Neck Dissection**](https://www.theplasticsfella.com/neck-dissection/#selective-neck-dissection) Preserve one or more lymph node levels based on specific drainage patterns from the primary tumour site. [****Indications for Neck Dissection**](https://www.theplasticsfella.com/neck-dissection/#indications-for-neck-dissection) Selective neck dissection is indicated for node-positive cases based on N staging and node-negative cases with a high risk (>20%) of occult metastases. [****Anatomy of a Neck Dissection**](https://www.theplasticsfella.com/neck-dissection/#anatomy-of-a-neck-dissection) In a neck dissection, critical structures include the spinal accessory, marginal mandibular, vagus, hypoglossal, and more. [****Neck Dissection Complications**](https://www.theplasticsfella.com/neck-dissection/#neck-dissection-complications) Intra-operative and post-operative complications relating to skin, arteries, veins, nerves, and thoracic duct. --- ## Types of Neck Dissections ****Key Point** Neck dissections are categorized as radical, extended, modified, or selective, based on the extent and location of lymph node removal. Neck dissections are described as radical, extended, modified and selective. These different types of neck dissections refer to the amount and location of **nodes** removed or the **secondary structures** removed or preserved. Types of neck dissections are illustrated in the table below. ![The different types of neck dissections include radical, modified, extended or selective. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Types-of-Neck-Dissections.png) Types of Neck Dissections Neck dissections can be therapeutic or prophylactic. Their indications should be discussed at a multidisciplinary meeting based on their nodal status (N1-3). Even if clinically node-negative necks (N0), there is a risk of microscopic nodal spread. --- ## Radical Neck Dissection ****Key Point** A radical neck dissection involves the removal of lymph nodes in levels I-V in addition to the sternocleidomastoid muscle, spinal accessory nerve, and internal jugular vein. The radical neck dissection was first described in 1906 by Crile, based on the Halstedian concept of en bloc resection. A radical neck dissection involves the removal of lymph nodes in levels I-V in addition to: - Sternocleidomastoid Muscle - Internal Jugular Vein - Spinal Accessory Nerve The image below illustrates the anatomy of a radical neck dissection. ![A diagram showing the anatomy of a radical neck dissection which involves removing levels 1-5 of the nodes, sternocleidomastoid muscle and spinal accessory nerve.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Radical-Neck-Dissection.png) Radical Neck Dissection An extended radical neck dissection is the resection of lymph node groups and/or additional structures not included in the classic neck dissection. Here is a video of a radical neck dissection (not the best audio quality, sorry!). --- ## Modified Radical Neck Dissection ****Key Point** Modified radical neck dissections remove levels I-V but preserve the spinal accessory nerve and/or internal jugular vein and/or sternocleidomastoid muscle. Modified radical neck dissections remove levels I-V (similar to a radical neck dissection). It is modified in the structures it preserves. These modifications are described in relation to which structures are **preserved:** 1. **Type I:** Spinal accessory nerve is preserved. 2. **Type II:** Spinal accessory **&** internal jugular vein **or** sternocleidomastoid. 3. **Type III:** Spinal accessory **&** internal jugular vein **&** sternocleidomastoid. Modified radical neck dissection classification can be visualised below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Modified-Radical-Neck-Dissection.png) Modified Radical Neck Dissection Below is an intra-operative video of a modified radical neck dissection. --- ## Selective Neck Dissection ****Key Point** Selective neck dissections preserve one or more lymph node levels based on specific drainage patterns from the primary tumour site. Selective neck dissections preserve one or more lymph node levels. Specific lymph node regions are **selected** based on the lymphatic drainage patterns from the primary tumour site. Other structures are preserved (similar to a Type III modified radical neck dissection). As illustrated in the table below, there are different types of selective neck dissections based on nodal levels removed: - **Supraomohyoid**: SND I-III - **Lateral**: SND II-IV - **Posterolateral**: SND II-V - **Central**: SND VI The table below shows the different types of selective neck dissections. ![There are different types of selective neck dissections based on the lymphatic drainage of the neck](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Selective-Neck-Dissections.png) Selective Neck Dissections Below is a video by the Mayo Clinic showing a selective neck dissection. --- ## Indications for Neck Dissection ****Key Point** Indications for neck dissection include node-positive cases (N1-N3) and node-negative necks with >20% risk of occult metastasis. The specific indications for a selective neck dissection should be discussed at an MDT. This operation should be considered in: - **Node-positive necks:** N1 (SND), N2 (MRND III/SND), N3 (MRNDI/RND) - **Node-negative necks:** risk of occult metastasis >20% (oral cavity, pharynx) - T2 disease (varies per department and is an ongoing discussion) 😎 ****Fun Fact:** Generally speaking, lip, sinus, and glottis tumours often have a risk of <20% of occult metastasis. This is an important consideration for neck dissection in node-negative necks. Generally speaking for **aerodigestive tumours:** - **Oral Cavity:** SND I-III (consider SND I-IV for invasive oral tumour) - **Larynx and Pharynx:** SND II-IV - **Oropharyngeal:** SND II-IV - **Hypopharyngeal:** SND II-IV Generally speaking for **cutaneous tumours**: - **Post. scalp & upper neck:** SND II-V, post-auricular, suboccipital ("posterolateral SND") - **Pre-auricular, anterior scalp, temporal:** SND parotid, II, III, Va and external jugular nodes ("posterolateral SND"). - **Anterior and lateral face:** SND parotid and facial nodes I-III 💡 ****Tip:** Bilateral neck dissections should be considered for midline structures. --- ## Anatomy of a Neck Dissection ****Key Point** Key structures in a neck dissection include the spinal accessory nerve, digastric muscle, marginal mandibular nerve, internal jugular vein, vagus nerve, hypoglossal nerve, phrenic nerve, brachial plexus, and thoracic duct. Important structures to be aware of in a neck dissection include (and are not limited to!) the following: - **Spinal accessory nerve:** travels anterior to IJV, medial to posterior digastric and stylohyoid muscles, enters SCM and exits near Erb's point (posterior border of SCM). - **Digastric muscle:** travels from hyoid to mastoid tip anterior to the external and internal carotid artery, hypoglossal nerve, and internal jugular vein. The marginal mandibular nerve is lateral to the posterior belly. - **Marginal mandibular nerve:** deep to the superficial layer of the deep cervical fascia and superficial to the anterior facial vein. - **Internal Jugular Vein:** deep to the anterior belly of the omohyoid muscle. - **Vagus Nerve:** deep to the internal jugular vein in the carotid sheath. - **Hypoglossal nerve:** deep to the internal jugular vein, anterior to the internal and external carotid arteries, and continues inferior to the posterior belly of the digastric muscle to enter the tongue musculature. - **Phrenic nerve:** superficial to anterior scalene muscle and deep to the transverse cervical artery. - **Brachial plexus:** passes between the anterior and middle scalene muscles. - **Thoracic duct:** posterior to the internal jugular vein and anterior to the phrenic and transverse cervical artery. --- ## Neck Dissection Complications ****Key Point** Neck dissection complications can be intra-operative and post-operative issues relating to skin, arteries, veins, nerves, and thoracic duct. There can be intra-operative and post-operative complications relating to the anaesthetic and the surgery itself. Specific surgical complications relevant to neck dissections include, but are not limited to: - **Soft Tissue:** flap necrosis, wound breakdowns, fistula, oedema, scar contracture. - **Vessels**: bleeding, embolus, stroke. - **Nerves**: spinal Accessory, hypoglossal, glossopharyngeal, phrenic, plexus. - **Other**: Pneumothorax, chyle leak/fistula, infections. - **Perioperatively**: DVT, PE, transfusions, death. - **Radiotherapy** complications (indicated in N2/N3 or extracapsular spread). 💡 ****Tip:** the sympathetic trunk is posterior to the carotid sheath, and the phrenic nerve is anterior to the scalenus anterior muscle. ### Chyle Leak in Neck Dissections A chyle leak or fistula is a very challenging condition to treat. It is the result of damage to the left thoracic duct or the right lymphatic duct. It presents as a collection or milky discharge. **Diagnosis** can be made by testing drain triglyceride levels greater than serum levels, absolute drain triglyceride levels greater than 100 mg/dL, or with the presence of chylomicrons. **Treatment** options include: - Fat-free diet or medium-chain diet to reduce the volume of the leak. - Total Parenteral Nutrition may be required. - Consider octreotide. - Gradually reduce suction off the drain. - If exploration is required (rare), consider a sternocleidomastoid flap turnover. - Thoracoscopic ligation of ductal tissue as it travels through the diaphragmatic hiatus between the azygous vein and the aorta. There are some significant anatomical variations in the left thoracic duct, but generally speaking: - Starts from the cisterna chyli at the level of lumbar vertebrae. - Via aortic hiatus, posterior mediastinum, oesophagus, over the subclavian artery. - Finishes at the left subclavian vein near the internal jugular vein. The image below illustrates the thoracic duct. ![Thoracic Duct Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Thorcic-Duct-Injury-Chyle-Leak.png) Thoracic Duct --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Types of Neck Dissections:** You've gained knowledge about the various types of neck dissections — radical, modified radical, and selective — and their specific applications based on the extent of lymph node removal and the preservation of key anatomical structures. ****2\. Neck Dissection Indications:** You are now familiar with the criteria for selecting the appropriate type of neck dissection based on nodal involvement and the likelihood of occult metastases for surgical planning. ****3\. Anatomical Considerations:** You've learned about the critical anatomical landmarks and structures involved in neck dissections, vital for minimizing complications and ensuring effective surgical outcomes. ****4\. Awareness of Complications:** You understand the potential intra-operative and post-operative complications associated with neck dissections, including risks to specific nerves, vascular structures, and other tissues for patient management and counseling. ****5\. Management Strategies for Complications:** You've explored the management strategies for specific complications such as chyle leaks to optimize patient recovery and outcomes. --- ### Tumours of the Oral Cavity: Types, Staging, Treatment, & Anatomy URL: https://www.theplasticsfella.com/tumours-of-the-oral-cavity/ Last updated: 2024-10-09T22:01:10.000Z #### Summary Card [****Anatomy**](https://www.theplasticsfella.com/tumours-of-the-oral-cavity/#anatomy-of-oral-cavity-tumours) Bordered by lips, hard-soft palate junction, circumvallate papillae of the tongue and anterior pillars of the tonsils. [****Clinical Picture**](https://www.theplasticsfella.com/tumours-of-the-oral-cavity/#clinical-picture-of-oral-cavity-tumours) Typically present with a non-healing ulcer or growth. Secondary symptoms include loose teeth, trismus, and otalgia. [****Pre-Malignant Lesions**](https://www.theplasticsfella.com/tumours-of-the-oral-cavity/#premalignant-lesions) Tumours may arise **de novo* or from pre-malignant lesions such as leukoplakia or erythroplakia. [****Types of Tumours**](https://www.theplasticsfella.com/tumours-of-the-oral-cavity/#types-of-oral-cavity-tumours) Squamous cell carcinoma is the most common. Other considerations are sarcoma, ameloblastoma, and metastasis of unknown primary. [****Treatment Options**](https://www.theplasticsfella.com/tumours-of-the-oral-cavity/#treatment-of-oral-cavity-tumours) Surgical resection, reconstruction, neck dissection and chemo/radiotherapy. These can be curative or palliative. [****Oral Cavity Cancer Staging**](https://www.theplasticsfella.com/tumours-of-the-oral-cavity/#oral-cavity-cancer-staging) 8th AJCC Edition includes depth of invasion and extranodal extension to upstage disease. --- ## Anatomy of Oral Cavity Tumours ****Key Point** The oral cavity is bordered by the lips, hard-soft palate junction, circumvallate papillae of the tongue, and anterior pillars of the tonsils. ### Borders - **Anterior:** wet-dry border of the lips. - **Posterosuperior:** hard-soft palate junction. - **Posteroinferior:** tongue's circumvallate papillae, tonsil's anterior pillars (created by the palatoglossus muscle). 😎 ****Fun Fact:** The tongue, in particular the lateral aspect of the middle third, is the commonest site of oral cancer. The image below illustrates oral cavity anatomy. ![A labelled diagram of the oral cavity anatomy which contains the hard palate, buccal mucosa, retromolar trigone, floor of mouth, anterior 2/3 of tongue and inferior alveolar ridge.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Oral-Cavity-Anatomy.png) Oral Cavity Anatomy ### Contents of the Oral Cavity There are 7 key anatomical structures in the oral cavity. They can be remembered by the mnemonic **FRAMPAL**, which is explained below. - **F**loor of the mouth: bounded by inferior alveolar ridges and tongue. - **R**etromolar trigone: mucosa over the anterior aspect of ascending ramus formed by oropharynx, nasopharynx, buccinator, floor of mouth and parapharyngeal space. - **A**lveolar ridges: superior and inferior. - **M**ucosa (Buccal): inner cheeks & lips anterior to pterygomandibular raphe. - **P**alate (Hard): between the superior alveolar ridge and soft palate junction. - **A**nterior 2/3 of the tongue: anterior to circumvallate papillae. - **L**ips: inner aspect. 💡 ****Tip:** In the 8th AJCC Edition, dry vermilion lip tumours are now considered ****cutaneous** tumours. They were previously included in the oral cavity classification. --- ## Clinical Picture of Oral Cavity Tumours ****Key Point** Patients typically present with a non-healing ulcer or growth. These may arise spontaneously or from a pre-existing lesion. Secondary symptoms include loose teeth, trismus, and otalgia. ### History Patients' symptoms can be a nonhealing ulcer or mass growth. In more advanced stages, a patient may have local and regional symptoms such as: - **Teeth:** unexplained tooth loss. - **Trismus:** tonic contraction of the muscles of mastication reducing mouth opening. This can be due to oedema, pain, invasion of muscles, or radiotherapy-induced fibrosis. - **Referred otalgia:** convergence theory suggests there are common sensory pathways between ear and cranial nerves that result in patients being unable to correctly pinpoint the location of pathology ([Chen](https://pubmed.ncbi.nlm.nih.gov/19797791/?ref=theplasticsfella.com), 2009) . It is linked to innervation by cranial nerve IV. - [**Nodes**](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/)**:** usually submandibular (Level I), upper/middle jugular (Level II, III) 💡 ****Tip:** palpation can provide more information than visual inspection (especially in those difficult-to-see and submucosal areas) ### Risk Factors Patients with oral cavity tumours may also have the following **risk factors:** - **Toxins:** tobacco, alcohol, betel nut (causes fibrosis) - **Infections:** oral HPV-16 infection (different staging system due to better prognosis), AIDS (hairy leukoplakia) - **Patient Status:** poor nutrition, immunosuppressed or immunocompromised - **Genetics:** Fanconi's Anaemia (recessive), Li-Fraumeni syndrome (p53 gene) - **Pre-malignant lesions:** leukoplakia, erythroplakia 💡 ****Tip:** HPV virus is associated with ****oropharyngeal** tumours, and EBV is associated with ****nasopharyngeal** tumours. ### Radiological Findings MRI is the modality of choice for oropharyngeal tumours. T1-weighted images show fat as white and water as black. The opposite is true for T2\. - **CT Neck/Chest with Contrast:** gold standard, bone invasion. - **PET/CT:** metabolic FDG-avidity for staging and useful if dental artefact. - **MRI:** good for soft-tissue definition, assess nerve involvement. - **Pandendoscopy:** looking for synchronous tumours. --- ## Premalignant Lesions ****Key Point** Tumours of the oral cavity may arise **de novo* or from pre-malignant lesions such as leukoplakia or erythroplakia. Premalignant lesions in the oral cavity can develop into tumours either de novo or from conditions like leukoplakia and erythroplakia. Both conditions necessitate a cautious approach with biopsy and possible excision due to their significant transformation risks. The image below illustrates pre-malignant lesions for oral cavity tumours. ![Leukoplakia and Erythroplakia are premalignant lesions for oral cavity tumours, SCCs and squamous cell cancers](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/2.png) Leukoplakia and Erythroplakia **Leukoplakia** - A white patch that cannot be easily removed or scraped off. - It cannot be explained by another condition, therefore a diagnosis of exclusion. - A biopsy may show non-dysplastic or dysplastic epithelium (\~25%). - Dysplastic leukoplakia should be excised due to risk of malignant transformation (\~20%). **Erythroplakia** - A red patch that is soft with a velvety texture. - Higher risk of dysplasia and malignancy on biopsy compared to leukoplakia. - Hairy leukoplakia can be seen in immunosuppressed or compromised patients, such as HIV/AIDS. - It is also a diagnosis of exclusion and should be excised. **Other pathologies** to consider are: - Actinic Cheilitis (Sailor's Lip) - Proliferative Verrucous Leukoplakia - Tobacco Pouch Keratosis - Lichen Planus --- ## Types of Oral Cavity Tumours ****Key Point** Squamous cell carcinoma is the most common. Other considerations are sarcoma, ameloblastoma, metastasis, or unknown primary. ### Squamous Cell Carcinoma Squamous cell carcinoma of the head and neck arises from epithelial cells and occurs in the oral cavity, pharynx and larynx. This is the most common pathology in the oral cavity. It should be distinguished from [cutaneous squamous cell carcinoma](http://theplasticsfella.com/?ref=theplasticsfella.com). ### Other Pathologies - **Salivary gland:** mucoepidermoid, adenocarcinoma, adenoid cystic carcinoma. - **Mucosal melanomas:** rare but usually present as locally aggressive tumours, mainly of the hard palate and gingiva. - **Sarcomas**: including osteosarcoma of the mandible or maxilla. - **Odontogenic tumours:** such as ameloblastoma. - **Haematological:** including lymphoma and leukaemia. - Metastasis to the Mouth or Cancer of Unkown Primary. --- ## Treatment of Oral Cavity Tumours ****Key Point** Treatment is based on surgical resection, reconstruction, neck dissection, and chemo/radiotherapy. It is individualised at the MDM meetings. After a discussion at a multidisciplinary meeting, treatment options for oral cavity tumours depend on the tumour characteristics, the extent of the disease and patient status. Treatment options include: - Surgical Resection (5-10mm margins) ± Reconstruction ± Neck Dissection. - Chemotherapy. - Radiotherapy: nodal disease, T2, palliative or no surgical option. - Multimodal: surgery with adjuvant chemoradiotherapy. - Immunotherapy: experimental. ### Surgery Generally speaking, oral cavity tumours require surgical Resection (5-10mm margins) ± reconstruction ± neck dissection. There are different approaches to an oral cavity tumour, which can include: - **Transoral:** consider if the tumour is 1/3 tongue is resected or with a significant floor of mouth defect. ### Radiotherapy Radiotherapy should be considered for oral cavity primary tumours. In particular, if these tumours are: - T3 or T4 lesions - Close or positive surgical margins - Perineural or lymphovascular invasion - Extracapsular spread --- ## Oral Cavity Cancer Staging ****Key Point** 8th AJCC Edition includes depth of invasion and extranodal extension to upstage disease. **Oral cavity carcinoma staging** is outlined in the AJCC 8th Edition Staging Guidelines ([Zanoni](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528815/?ref=theplasticsfella.com), 2019). This staging criterion refers to squamous cell carcinomas as well as less common epithelial and minor salivary gland cancers. ### Primary tumour (T) - **Tx:** primary tumour cannot be assessed. - **Tis:** carcinoma in situ (dysplastic lesions with intact basement membrane). - **T1:** ≤2 cm **+** DOI ≤5 mm. - **T2:** ≤2 cm **+** DOI 5-10 mm, **or** 2-4 cm **+** DOI ≤10 mm. - **T3:** \>4cm **or** any size + DOI 10-20mm. - **T4a:** DOI>20 mm, **or** invade mandible, inferior alveolar nerve, maxilla bone or sinus, skin. - **T4b:** invade masticator space, pterygoid plates, skull base, and carotid artery. Superficial erosion alone of bone/tooth is not T4 disease. 💡 ****Depth of Invasion (DOI)** is not the tumour thickness. It is the depth from the basement membrane. It is greater than tumour thickness in ulcerations and less than tumour thickness in exophytic tumours. ### Regional lymph node (N) Regional nodal status can be clinical (no lymph node dissection) and pathological (lymph node dissection). It is similar to most other head and neck cancers (HPV-negative oropharyngeal, hypopharynx, larynx). **Clinical nodal status (cN)** Clinical nodal status arises from examination, imaging, and fine-needle aspiration. It depends on the number, size, location and extranodal extension (ENE status). - **Nx:** nodes cannot be assessed. - **N0:** no regional node metastases. - **N1:** single ipsilateral node ≤3 cm & ENE\-. - **N2a:** ipsilateral node ≤3 cm & ENE+ **or** ipsilateral node 3-6 cm & ENE\-. - **N2b:** multiple ipsilateral nodes ≤6 cm & ENE\-. - **N2c:** bilateral or contralateral nodes ≤6 cm & ENE\-. - **N3a:** single node >6 cm & ENE\-. - **N3b:** single node with **clinically** overt ENE+, or multiple nodes and ENE+, single contralateral nodes and ENE+, or single node >3cm and ENE+. 💡 ****Tip:** a midline node is considered ipsilateral. It can be difficult to remember, so here are some tips! - **Multiple nodes:** N2b is the *lowest* nodal status. - **Contralateral or bilateral:** N2c is the *lowest* nodal status. - **Node >6cm:** N3a is the *lowest* nodal status. - **If ENE+:** N2a if ≤3 cm or N3b if >3cm. - **If N3b:** the node *must* be ENE+. 💡 ****Extranodal Extension** is a radiological and clinical finding. The node is adherent or "stuck" to nearby structures. It is used as a poor prognostic indicator and upstaging of disease in the 8th AJCC Edition. ### Distant metastases (M) - **cM0:** no evidence of metastases. - **cM1:** distant metastasis. - **pM1:** distant metastasis, microscopically confirmed. 💡 ****Tip:** Lungs are the most common site of distant metastasis for oral cavity tumours. Radiological workup should include this area. ### Stage groups The prognostic stage groups are defined the same as for most other cancers of the head and neck: - **Stage 0:** Tis, N0, M0 - **Stage I:** T1, N0, M0 - **Stage II:** T2, N0, M0 - **Stage III:** T3, N0, M0 or \[T1, T2, T3\], N1, M0 - **Stage IVA:** T4a, \[N0, N1\], M0 or \[T1, T2, T3, T4a\], N2, M0 - **Stage IVB:** \[Any T\], N3, M0 or T4b, \[Any N\], M0 - **Stage IVC:** \[Any T\], \[Any N\], M1 💡 ****Tip:** Rigid head and neck endoscopy, head and neck CE-CT and/or MRI and chest imaging (with CT and/or FGD-PET) are strongly recommended. ([Machiels](https://pubmed.ncbi.nlm.nih.gov/33239190/?ref=theplasticsfella.com), 2020) --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Oral Cavity Anatomy:** You've gained a detailed understanding of the borders and contents of the oral cavity, vital for recognizing the areas commonly affected by oral cancers. ****2\. Clinical Presentation:** You are now familiar with the typical clinical presentations of oral cavity tumors, including their symptoms and risk factors, which is crucial for early diagnosis and intervention. ****3\. Pre-malignant Conditions:** You've learned about pre-malignant lesions such as leukoplakia and erythroplakia, their implications for cancer development, and the importance of vigilant monitoring and management. ****4\. Tumor Types and Staging:** You now understand the different types of tumors that can occur in the oral cavity and the staging criteria based on the latest AJCC guidelines, aiding in accurate diagnosis and treatment planning. ****5\. Treatment Strategies:** You've explored the comprehensive treatment options for oral cavity tumors, including surgical approaches, radiation, and chemotherapy, tailored to the stage and specific characteristics of the tumor. --- ## Further Reading 1. Chen RC, Khorsandi AS, Shatzkes DR, Holliday RA. [The radiology of referred otalgia](https://pubmed.ncbi.nlm.nih.gov/19797791/?ref=theplasticsfella.com). AJNR Am J Neuroradiol. 2009 Nov;30(10):1817-23\. doi: 10.3174/ajnr.A1605\. Epub 2009 Oct 1\. PMID: 19797791; PMCID: PMC7051282 2. Zanoni DK, Patel SG, Shah JP. [Changes in the 8th Edition of the American Joint Committee on Cancer (AJCC) Staging of Head and Neck Cancer: Rationale and Implications](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528815/?ref=theplasticsfella.com). Curr Oncol Rep. 2019 Apr 17;21(6):52\. doi: 10.1007/s11912-019-0799-x. PMID: 30997577 3. Machiels JP, René Leemans C, Golusinski W, Grau C, Licitra L, Gregoire V; EHNS Executive Board. Electronic address: secretariat@ehns.org; ESMO Guidelines Committee. Electronic address: clinicalguidelines@esmo.org; ESTRO Executive Board. Electronic address: info@estro.org. [Squamous cell carcinoma of the oral cavity, larynx, oropharynx and hypopharynx: EHNS-ESMO-ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up](https://pubmed.ncbi.nlm.nih.gov/33239190/?ref=theplasticsfella.com). Ann Oncol. 2020 Nov;31(11):1462-1475\. doi: 10.1016/j.annonc.2020.07.011\. Epub 2020 Oct 23\. PMID: 33239190. --- ### Chemical Burns: Types, Complications, & Management URL: https://www.theplasticsfella.com/chemical-burns/ Last updated: 2024-05-16T22:24:24.000Z #### Summary Card [****Overview**](https://www.theplasticsfella.com/chemical-burns/#overview-of-chemical-burns) There are 4 main groups: acids, burns, organic solvents, and inorganic solvents. [****Features**](https://www.theplasticsfella.com/chemical-burns/#features-of-chemical-burns) The degree of chemical burn is dependent on the chemical, its concentration, and the extent of exposure. [****Complications**](https://www.theplasticsfella.com/chemical-burns/#complications-of-chemical-burns) Each chemical has specific secondary effects. For example, hydrofluoric acid has severe pain, low calcium, and raised potassium. [****Management**](https://www.theplasticsfella.com/chemical-burns/#management-of-chemical-burns) Treat with prompt & constant water irrigation (some exceptions!). After neutralisation, manage similar to a thermal burn. ‌ ‌ --- ## Overview of Chemical Burns ****Key Point** The 4 main groups are acids, burns, organic solvents, and inorganic solvents. Chemical burns can be broadly categorised into 4 main groups: acids, burns, organic solvents, and inorganic solvents. They differ in their pathophysiology, clinical progression, and potential complications. Chemical burns are categorised in the table below. ![This is a labelled table showing the chemicals, mechanisms, clinical features and treatment options for common acid and alkali chemical burns.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Chemical-Burns.png) Summary of Chemical Burns 😎 ****Fun Fact:** hydrofluoric acid has soluble free fluoride ions that bind to calcium ions, which causes soft tissue necrosis & severe hypocalcemia. --- ## Features of Chemical Burns ****Key Point** The degree of a chemical burn is dependent on the type of chemical, the extent of exposure, and first aid management. Each chemical has a specific set of secondary features or complications. The degree of a chemical burn can vary based on the **type of chemical**, the **extent of exposur**e, and any **first aid management**. ### Degree of Burn The degree of chemical burn is dependent upon the following variables: 1. Type and extent of exposure (skin, mucosa, inhalation) 2. Type of chemical agent and its mechanism of action 3. Quantity, strength, or concentration of agent The image below illustrates chemical burns on skin. ![Chemical Burn on Skin](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Chemical-Burns-on-SKin.png) Chemical Burn on Skin Unlike thermal burns, chemical burns will continue their tissue destruction until inactivated by a neutralising agent. Because of this, the initial estimation of a [burn depth](https://www.theplasticsfella.com/burn-depth/) and [total body surface](https://www.theplasticsfella.com/total-body-surface-area-in-burns/) area is often inaccurate. --- ## Complications of Chemical Burns ****Key Point** Each chemical has specific secondary effects. For example, hydrofluoric acid has severe pain, low calcium, and raised potassium. Each chemical has its own mechanism of burn. As a result, each chemical can often have a specific set of secondary clinical presentations. This can help guide the type of chemical involved and can also help treat the patient. Below is a visual summary of complications of chemical burns. ![A visual summary labelling the complications and effects of chemical burns on lungs, heart, liver, kindey and electrolytes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Complications-of-Chemical-Burns.png) Complications of Chemical Burns - **Acute pain:** hydrofluoric acid - **Hypocalcaemia:** hydrofluoric acid, phosphorous - **Hypomagnesaemia:** hydrofluoric acid - **Hyperkalaemia:** hydrofluoric acid - **Prolonged Q-T Interval:** hydrofluoric acid - **Hepatorenal injury:** tannic, formic acid, phosphorous, petroleum - **Particles embedded in the skin:** phosphorus - **Inhalation injuries:** ammonia - **Methaemoglobinaemia and hemolysis:** cresol - **Perforated nasal septum:** chromic acid --- ## Management of Chemical Burns ****Key Point** Chemical burns are typically treated with prompt and constant water irrigation (some exceptions!). After neutralisation of the chemical, treat complications and manage similar to a thermal burn. Chemical burns are generally treated with prompt and constant water irrigation with some exceptions. ### General Management 1. Remove causative agent and any contaminated clothing. 2. Constant water irrigation whilst monitoring for pH. 3. Monitor systemic toxicity or complications. 4. Assess for specific injuries: eyes, airway, hair, nails, heart, kidneys. 5. Discuss or contact toxicology experts. 6. Once neutralised, treat similarly to a thermal burn. There are specific exceptions to the "constant irrigation with water". These are: - Sodium, potassium, and lithium may ignite. - Phenol is not water-soluble (apply polyethylene glycol). - Hydrochloric acid + H20 may cause exothermic reactions (neutralise by soap). - Diphoterine binds to acids, alkalis, vesicants, and many more substances. ### Hydrofluoric Acid In addition to the above management, hydrofluoric acid requires neutralisation with calcium gluconate to inactivate free fluoride ions. - **Topical** calcium gluconate burn gel (10% with DMSO). - **Injection** with 10% calcium gluconate (multiple 0.1–0.2 ml via 30G needle). - **Intra-arterial** infusion of calcium gluconate. - **Intravenous** ischaemic retrograde infusion (Biers block). - **Early excision** is sometimes required. ### Secondary Injuries - **GI Tract:** endoscopy and CT may show extra-luminal damage. - **Lungs:** fibre-optic bronchoscopy, bronchodilators. - **Eyes**: ophthalmology referral. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Chemical Burn Categories:** You've gained insight into the four main categories of chemical burns, including acids, burns, organic solvents, and inorganic solvents, and how they differ in their pathophysiology and clinical progression. ****2\. Burn Severity Factors:** You now understand how the type of chemical, its concentration, and the duration of exposure influence the severity of chemical burns and their initial management. ****3\. Identifying Complications:** You've learned about specific secondary effects and complications associated with different chemicals, crucial for effective emergency response and treatment planning. ****4\. Management Techniques:** You are now familiar with the initial management of chemical burns, including the importance of prompt and constant water irrigation and the exceptions where different treatments are required. ****5\. Treatment Protocols:** You've explored detailed protocols for managing complex cases and the necessary steps for addressing systemic and local injuries caused by chemical exposures. ### Burn Complications: Organ Failure, Metabolism, & Nutrition URL: https://www.theplasticsfella.com/burn-complications/ Last updated: 2024-05-17T16:32:54.000Z #### Summary Card [****Overview of Burn Complications**](https://www.theplasticsfella.com/burn-complications/#overview-of-burn-complications) A burn has a multi-organ effect on a patient. A release of inflammatory mediators and neural stimulation results in both local and systemic effects. [****Jackson's Burn Wound Model**](https://www.theplasticsfella.com/burn-complications/#jacksons-burn-wound-model) This describes zones of ****coagulation** (cell death), ****stasis**(damage to microcirculation), and ****hyperaemia** (inflammatory response). [****Hypovolaemia**](https://www.theplasticsfella.com/burn-complications/#hypovolemia-in-burns) Hypovolemia from a shift in protein and fluid from the intravascular to the interstitial space due to an increase in capillary permeability. [****Hypermetabolic Response In Burns**](https://www.theplasticsfella.com/burn-complications/#hypermetabolic-response-in-burns) A burn results in changes to metabolism, hormones, cardiorespiratory function, gastrointestinal function, and immunity. [****Nutrition in Burn Patients**](https://www.theplasticsfella.com/burn-complications/#nutrition-in-burn-patients) Nutrition maintains a patient's body mass and reduces the risk of bowel ileus, bacterial translocation, and long-term immunity issues. [****Gastrointestinal System in Burns**](https://www.theplasticsfella.com/burn-complications/#gastrointestinal-system-in-burns) There are three main concerns: gastric ulceration, ileus, and mucosal damage. It is closely linked to nutrition and enteral feeding. [****Kidney Injury in Burns**](https://www.theplasticsfella.com/burn-complications/#kidney-injury-in-burns) Renal failure is linked to hypovolemia, medications, cardiac dysfunction, and sepsis. It's exacerbated by haemochromogens. [****Electrolyte Imbalance in Burns**](https://www.theplasticsfella.com/burn-complications/#electrolyte-imbalance-in-burns) Sodium, potassium, and glucose are most commonly affected. Their imbalances change over time as the burn evolves. ‌ --- #### ## Overview Burn Complications ****Key Point** A burn has a multi-organ effect on a patient. A release of inflammatory mediators and neural stimulation results in both local and systemic effects. The local effectsof a burn are based onJackson's burn model, which describes zones of coagulation, stasis, and hyperaemia. The systemic effectsof a burn include: - **Fluid and electrolytes:** hypovolemia, sodium and potassium imbalance. - **Metabolism:** hypermetabolism, nutrition. - **Organs:** cardiorespiratory, liver dysfunction, renal. - **Infection:** sepsis, toxic shock system. The below flow-chart illustrates the effects of a burn. ![Complications of a Burn can be local or systemic. This is a labell drawing showing the complications](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Complications-of-a-Burn.png) Complications of a Burn --- ‌ ‌ ## Jackson's Burn Wound Model ‌ ****Key Point** Jackson's burn wound model describes zones of ****coagulation** (cell death), ****stasis** (damage to microcirculation), and ****hyperaemia** (inflammatory response). Jackson's Burn Wound model states there are 3 zones to a thermal burn injury: coagulation, stasis, and hyperaemia. This is based on the work by [Jackson](https://pubmed.ncbi.nlm.nih.gov/13059343/?ref=theplasticsfella.com) in the 1950s. The image below shows the 3 zones of a thermal burn injury according to Jackson's burn wound model. ![Jackson's Burn Wound Model, Classification of burns, burn injuries](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Jackson-s-Burn-Wound-Model-3.png) Jackson's Burn Wound Model ### Zone of Coagulation (Cell Death) - Inner zone (nearest the burn source). - Heat cannot be conducted away rapidly enough. - There is immediate coagulation of cellular proteins, there is rapid cell death. ### Zone of Stasis (Circulation) - The intermediate zone surrounding the zone of Coagulative Necrosis. - Less direct damage to tissue but more damage to the microcirculation. - If untreated, inflammatory response results in necrosis & [burn depth](https://www.theplasticsfella.com/burn-depth/) evolve. - The extent of progress is influenced by the effectiveness of resuscitation. ### Zone of Hyperaemia (Inflammation) - The outermost zone surrounding the region of compromised vasculature. - Inflammatory mediators result in vasodilation and increased permeability. - Results in the fluid shift into the interstitial space. - After this initial response, this zone should return to normal. - Examples of inflammatory mediators are free oxygen radicals and histamine. 💡 ****Tip:** The [depth](https://www.theplasticsfella.com/burn-depth/) degree of tissue necrosis is influenced by the burn (temperature, duration) and its management (initial first aid, and [fluid resuscitation](https://www.theplasticsfella.com/burns-fluid-resuscitation/)). --- ‌ ‌ ## Hypovolemia in Burns ‌ ****Key Point** Hypovolemia is the most profound and direct effect of a burn. It is primarily due to a shift in protein and fluid from the intravascular to the interstitial space caused by an increase in capillary permeability. Hypovolemia results in "burn shock". It begins at a cellular level ([Baxter](https://pubmed.ncbi.nlm.nih.gov/4973463/?ref=theplasticsfella.com), 1968 & [Moyer](https://pubmed.ncbi.nlm.nih.gov/14333526/?ref=theplasticsfella.com), 1965 & [Arturson](https://pubmed.ncbi.nlm.nih.gov/451475/?ref=theplasticsfella.com), 1979) and is a combination of distributive, cardiogenic, and hypovolemic shock. Key components of the physiological changes during a burn are: - **Intracellular sodium shift** contributes to hypovolemia and cellular oedema. - **Local vasoconstriction** and **systemic vasodilation** form inflammatory and vasoactive mediators. - **A fluid shift from intravascular to interstitial spaces** due to Increased vascular permeability from disrupted capillaries. An accurate assessment of [burn depth](https://www.theplasticsfella.com/burn-depth/) and [total body surface area](https://www.theplasticsfella.com/total-body-surface-area-in-burns/) will allow effective [fluid resuscitation](https://www.theplasticsfella.com/burns-fluid-resuscitation/) of hypovolemia. 😎 ****Fun Fact:** This pathophysiological response is compounded by a reduced cardiac output and increased systemic vascular resistance. --- ## Hypermetabolic Response in Burns ‌ ****Key Point** Following a hypodynamic period, a hypermetabolic response occurs at a cellular and humoral level resulting in changes to metabolism, hormones, cardiorespiratory function, gastrointestinal function, and immunity. The response to a burn can be described as an "ebb and flow". The ebb is a **hypo**dynamic period that occurs \~48 hours after a burn, which is then followed by a **hyper**metabolic flow phase. This response does not return to "normal" until wound remodeling is complete. Clinically, these patients have tachycardia, hyperthermia & protein wasting. ### Physiology At a physiological level, the hypermetabolic response occurs due to: - **Hyperdynamic circulation:** increased cardiac output, increased oxygen consumption and C02 production. - **Hyperthermia:** core temperature can be chronically elevated. - **Hormone shift:** increased stress hormones cortisol, catecholamine and reduced anabolic hormones (growth hormone, insulin, and anabolic steroids). - **Glucose increase:** Increased glycogenolysis causes hyperglycemia (excess glucose is metabolised anaerobically resulting in lactate production) to create a diabetic-like state. - **Lactate increase:** Anaerobic metabolism resulting in carbohydrate cycling (less energy than aerobic metabolism) with reduced nitrogen balance. ### Effect of Response This results in a series of complications and morbidities: - **Reduced immunity** at a cellular and humoral level results in increased infections and decreased healing. Circulating levels of immunoglobulins are reduced. - **Loss of body mass** from the breakdown of muscle protein impairs wound healing and rehabilitation. There is an increased central deposition of fat, decreased bone mineralization, and decreased longitudinal growth of the body. - **GI disturbances:** increase in bacterial translocation that can be minimized by beginning very early enteral nutrition. 😎 ****Fun Fact:** "Ebb and Flow" was first described by Cuthbertson in 1942. --- ## Nutrition in Burn Patients ****Key Point** The role of nutrition is to maintain the patient's body mass and reduce the risk of bowel ileus, bacterial translocation, and long-term immunity issues. Nutrition is a key aspect of burn management due to the hypermetabolic response affecting lean body mass, and large shifts in fluids and electrolytes. ### Aims Normal gastric feeding as soon as possible after burn injury. - Maintain a patient's body weight. - Maintain protein. - [Stabilise fluids](https://www.theplasticsfella.com/burns-fluid-resuscitation/) and electrolyte disturbances. During this time, patients should be weighed daily, bowel movements recorded, and documentation of extra eating habits or requests. ### Nutritional Formulas The nutritional requirements in burn patients are related to the **Resting Energy Expenditure (REE).** This can be calculated in different ways by: 1. Calorimetric testing of oxygen consumption and C02 production. 2. [Schofield equation](https://en.wikipedia.org/wiki/Schofield%5Fequation?ref=theplasticsfella.com) (for basal metabolic rate). 3. [Harris-Benedict Equation](https://en.wikipedia.org/wiki/Harris%E2%80%93Benedict%5Fequation?ref=theplasticsfella.com) (for resting energy expenditure). The number of calories required in a burn patient can be calculated by: 1. **Adults:** Curreri Formula: 25kcl/kg + 40kcal/[%TBSA](https://www.theplasticsfella.com/total-body-surface-area-in-burns/) every 24 hours. 2. **Children:** Galveston Formula: 1500kcal/m2 \+ 1500kcal/m2 BSA burn. The Galveston formula requires the calculation of BSA via the Du Boi Formula: BSA \[m2\] = Weight \[kg\]0.425 × height (cm)0.725 × 0.007184. ### Route of Nutrition Burns patients can receive their nutrition through 3 routes: oral, enteral, or parenteral. Here are the key points regarding different options. - **Oral:** recommended if clinically feasible. - **Enteral** via nasogastric or nasojejunal feeding to help maintain mucosa, reduce bacterial translocation (gram-negative), and prevent intestinal ileus. - **Parenteral:** *not* routinely used due to effects on fatty liver infiltration, reduced immune function, and sepsis. It is associated with impaired mucosal immunity and enhanced endotoxin translocation. ### Paediatric Patients - Children are more prone to gastric dilatation. This can be overcome through a nasogastric tube on free drainage. - A high metabolic rate results in less tolerance to nutritional deprivation. - Very early enteral feeding should be established as soon as they arrive at the definitive treatment centre. 💡 ****Tip:** Nutrition should be a coordinated response with departmental dieticians. --- ## Gastrointestinal System in Burns ****Key Point** The gastrointestinal system and genitourinary system are commonly affected by a burn. The both relate to a lack of flow (water or food) in patients. ### Gastrointestinal complications are closely linked to nutrition in the previous section. There are three main concerns: **gastric ulceration**, **ileus**, and **mucosal damage**. - **Ileus:** an adynamic bowel can occur & is prevented by early enteral nutrition. - **Mucosa:** mucosa damage occurs due to inadequate nutrition. This results in bacterial translocation (bowel circulation) & subsequent gram-negative sepsis. - **Ulceration:** high risk of acute gastric ulceration that can be reduced by proton-pump inhibitors, H2 antagonists, and enteral feeding. 😎 ****Fun Fact:** Curling's ulcers are the eponymous description of duodenal ulcers in burns. --- ## Kidney Injury in Burns ****Key Point** Renal failure in burns has a multifactorial aetiology often linked to hypovolemia, medications, cardiac dysfunction, and sepsis. It is exacerbated by haemochromogens in the urine. ### Acute Kidney Injury Renal failure in burns has a multifactorial aetiology that is often related to hypovolemia, medications, cardiac dysfunction, and sepsis. It can be treated by: 1. [Fluid resuscitation](https://www.theplasticsfella.com/burns-fluid-resuscitation/) 2. **Monitoring urine output:** normal is 0.5–1.0 ml/ kg/hr in adults, 1.0–1.5 ml/kg/hr in children. This should be increased in AKIs or myoglobinuria. 3. **Mannitol:** renoprotective osmotic diuretic. ### Hemoglobinuria Myoglobin and haemoglobin are haemochromogens that colour the urine a dirty red. They are released by tissue injury, especially muscle, and deposition in the proximal tubules of the kidney. This can lead to acute renal failure. This is treated in a similar method to acute kidney injury as discussed above. 1. Increase urine output to 2mL/kg/hr. 2. Consider mannitol. 3. Consider performing a fasciotomy (as opposed to an escharotomy which doesn’t release deep muscle fascia). ### Oliguria Oliguria is low urine output. It is closely linked to inadequate fluid resuscitation. Its management is to increase the rate of infusion, monitor urine output, and titrate accordingly. Diuretics are not routinely recommended for isolating oliguria. Patients at high risk of requiring more fluids are ([Maybauer et al](https://pubmed.ncbi.nlm.nih.gov/16715001/?ref=theplasticsfella.com), 2009): - Children - Delayed resuscitation - Inhalation or electrical injury 💡 ****Tip:** Urine output should be considered an "extra vital sign". It is an excellent marker of the patient's medical stability. --- ## Electrolyte Imbalance in Burns ****Key Point** Sodium, potassium and glucose are the commonly affected electrolytes in burn patients. Their imbalances change over time as the burn evolves. A burn patient is the victim of major fluid and electrolyte shifts. The two common electrolyte disturbances are sodium and potassium. Other affected electrolytes include calcium, magnesium, and phosphate. This is illustrated in the diagram below. ![A labelled table showing imbalances of Sodium and Potassium in Burns patients. Two columns comparing their changes and reasons for their change ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Electrolytes-in-Burns.png) Sodium and Potassium in Burns ### Sodium - Initially **low** as sodium exits the extracellular space due to increased vessel permeability. Paediatrics are at increased risk of dilutional hyponatremia. - After resuscitation, it can be **high** due to fluids (contains sodium) and sodium returning to the extracellular space. This is compounded by an acute kidney injury, resolution of oedema (concentrates the sodium), and a free water deficit. ### Potassium - Initially **high** due to potassium leaks from cell lysis and tissue necrosis. - Common in electrical burns. - Bicarbonate and glucose plus insulin may be required to correct this problem. ### Glucose - Children are prone to **hypoglycemia** due to limited glycogen stores. - Blood glucose and electrolyte levels should be measured regularly. - Early enteral feeding or addition of dextrose to the electrolyte solution. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Pathophysiology of Burns:** You've learned how burns result in multi-organ effects, involving the release of inflammatory mediators and neural stimulation. ****2\. Burn Complications:** You now understand the complex complications associated with burns, including hypovolemic shock, hypermetabolic response, and specific organ system impacts. ****3\. Burn Severity and Zones:** You've gained knowledge on Jackson's Burn Wound Model which describes the three zones of damage in a burn area. ****4\. Nutritional Needs in Burn Patients:** You are familiar with the crucial role of nutrition in managing burn patients, addressing the hypermetabolic state, and preventing complications. ****5\. Electrolyte Management:** You've explored the management of common electrolyte imbalances in burn patients, understanding how shifts in sodium, potassium, and glucose can impact patient recovery. ## ### Ring Avulsion Injury - Clinical Scenario URL: https://www.theplasticsfella.com/ring-avulsion-injury-clinical-scenario/ Last updated: 2024-09-04T17:17:11.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Clinical-Case-of-Ring-Avulsion-Injury.png) #### Clinical Scenario 37 y/o male, construction worker presented to the Emergency Department with injury to his right middle finger. He slipped whilst climbing a fence. The primary survey excluded any other injuries. ****Objectives:** ****1\.** Classify ring avulsion injuries using the Urbaniak classification. ****2\.** Clinically assess and examine the injured hand for injuries. ****3\.** Different management options in ring avulsion injuries. ****4\.** Knowledge of rehabilitation protocols following revascularization. ****5\.** Counsel patients effectively regarding possible complications. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Can Surgery be a Recipe? AI Clinical Cases, Final Round Quiz. URL: https://www.theplasticsfella.com/may-12th/ Last updated: 2024-05-12T12:50:28.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-12th/#a-letter-from-pfella) Can surgery be a recipe? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-12th/#the-sunday-quiz) **\+ Leaderboard** How well do you know **Salivary Gland Tumours?* 3. ****🆕** [****New Feature**](https://www.theplasticsfella.com/may-12th/#new-feature) AI images for Clinical Cases & more! 4. 🎓 [****theFellow's Corner**](https://www.theplasticsfella.com/may-12th/#the-fellows-corner) Meet the Team and their content 5. ****🔥** [****Articles of the Week**](https://www.theplasticsfella.com/may-12th/#articles-of-the-week) Limb Salvage, Amputations, & Flap Techniques With 1 sentence summaries!. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/may-12th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Can surgery be a recipe?* 👋 ****Hey Team!** Imagine if understanding a surgical procedure was as straightforward as following a well-crafted recipe. This might sound simple, yet it has the potential to improve how we prepare for our surgical cases. ****👇** Over the next few months, the team will be building a unique "surgical recipe book" tailored for plastic surgery. This will be more than a static manual— it’s a dynamic document that will evolve through our collective expertise and experiences. **Example Insight: MPCJ UCL Repair** This is just a glimpse of what we're aiming to achieve—a practical, accessible guide that enhances both learning and application. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Screenshot-2024-05-11-at-20.03.10.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Thumb-MCPJ-UCL-Incision.png) Read the complete [surgical technique](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/) **What's the motivation?** - **Clarity:** Our 'recipes' will simplify complex procedures into clear, actionable steps. There is a a balance thought between oversimplification and understanding the nuances of a surgical technique - **Confidence:** Confidence in preparation is key. These surgical checklists will be evidence-based and intregated with main articles in the library to help streamline preparation. - **Community:** This is the exiciting part. Your input is invaluable. Over time, each surgical "recipe" will have the infrastructure so you can share your insights and modifications to help us refine these techniques. Every contribution enriches our collective knowledge. **Join Us on This Journey** What methods work best for you when learning surgical techniques? Checklists? Visual aids? Let us know your preferences and help us shape this tool to better suit your needs. Best, P'Fella ❤️ ## The Sunday Quiz **Final Week! How well do you know Salivary Gland Tumours?* Welcome to ****the final round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end six rounds will earn you a $100 voucher. Good luck! ![A labelled anatomical drawing showing Salivary Gland Tumours involve the parotid gland, submandibular gland, sublingual gland, and small glands throughout the head and neck region.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Types-of-Salivary-Gland-Tumours-.png) ## New Feature [Clinical Scenarios](https://www.theplasticsfella.com/tag/clinical-cases/) Update One of the most requested educational tools from thePlasticsFella is to create a "viva-style" oral examination designed for postgraduate exams. These [c](https://www.theplasticsfella.com/tag/clinical-cases/)[linical scenarios](https://www.theplasticsfella.com/tag/clinical-cases/) can be quite challenging to develop online, but here are some strategies we're implementing to overcome this: - **AI-Generated Images**: These are an excellent way to create images that avoid issues related to patient confidentiality and consent. We can tailor images specifically to each required case. - **Scenario Updates**: As the case progresses, the examiner provides updates with a new image to reflect the latest developments. Check it out below! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/1-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/2.png) Check out all [Clinical Cases](https://www.theplasticsfella.com/tag/clinical-cases/) ### ## the Fellows' Corner What have the fellows been up to? We're excited to announce that three educational fellows and a full-time editor joined thePlasticsFella team over a month ago. They've been working hard to produce valuable content for our community. **Meet the Team 👇** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Meet-the-Team.png) The Team! We've recently published new articles and clinical case studies. Amidst managing complex patient cases, our team has been diligently drafting new articles, developing fresh content, and incorporating your feedback to enhance what we share. Explore our latest content: - [Seymour Fractures](https://www.theplasticsfella.com/seymour-fracture/): When is it best to insert a K-wire? - [Thumb MCPJ UCL Repair](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/): What's the optimal surgical approach? - [Ring Avulsion Injuries](https://www.theplasticsfella.com/ring-avulsion-injury/#urbaniak-classification-of-ring-avulsion-injuries): Understanding the Urbaniak Classification. Have a question for them? We'll answer it on the next episode of Behind the 'Fella (launching soon). ## Articles of the Week 3 Interesting Articles with 1 sentence summaries. 1️⃣ ***How to get Aesthetic Outcomes in Extremity Salvage and Reconstruction** ([Govshievich](https://journals.lww.com/plasreconsurg/abstract/2023/04000/aesthetic%5Fconsiderations%5Fin%5Fextremity%5Fsalvage%5Fand.38.aspx?ref=theplasticsfella.com), 2023) Find out how to acquire aesthetic results with thoughtful flap selection, primary thinning, and strategic secondary revisions in extremity salvage and reconstruction. 2️⃣ ***What are the Current Concepts in Lower Extremity Amputation?** ([Hanwright](https://journals.lww.com/plasreconsurg/abstract/2023/10000/current%5Fconcepts%5Fin%5Flower%5Fextremity%5Famputation%5F%5Fa.43.aspx?ref=theplasticsfella.com), 2023) What's the latest in lower extremity amputation care? Review soft-tissue considerations, nerve management strategies, and emerging osseointegration techniques for best functional outcomes. 3️⃣ ***Crucial Flap Techniques for Surgeons: A Guide** ([Neligan](https://journals.lww.com/plasreconsurg/abstract/2023/01000/useful%5Fflaps%5Ffor%5Fplastic%5Fsurgeons%5Fto%5Fknow.40.aspx?ref=theplasticsfella.com), 2023) Explore useful flaps, identify potential pitfalls, and get tips on enhancing your plastic surgery skills. ## Feedback ### I hope you enjoyed it 😄 --- ### Seymour Fracture - Clinical Scenario URL: https://www.theplasticsfella.com/seymour-fracture-clinical-scenario-copy/ Last updated: 2024-09-04T17:22:45.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Seymour-Fracture.png) #### Clinical Scenario A 5-year-old presents with avulsion of the nail of the ring finger after being hit with a ball while playing with his friend 18 hours ago. ****Objectives:** ****1\.** Recognise a Seymour fracture. ****2\.** Request relevant investigations. ****3.** Treatment plan; including closed and open options. ****4\.** Identify & treat potential complications. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Thumb MCPJ UCL Injury: Thumb Anatomy, Diagnosis, & Management URL: https://www.theplasticsfella.com/thumb-mcpj-ucl-injury/ Last updated: 2024-06-27T20:39:52.000Z #### Summary Card [****UCL Anatomy of the Thumb** ](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury/#ucl-anatomy-of-the-thumb)The ulnar collateral ligaments is a thumb MCPJ stabiliser. It is most commonly injured following forced abduction. [****Aetiology**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury/#aetiology-of-thumb-mpcj-ucl-injury) UCL injuries can be acute (“Skier’s thumb”) or chronic (“Gamekeeper’s thumb”). [****Assessment** ](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury/#assessment-of-thumb-mcpj-ucl-injury)Pain, swelling, and bruising, diagnosed with valgus stress tests. Imaging to bony involvement and MCPJ arthritis. [****Management** ](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury/#management-of-thumb-mcpj-ucl-injury)Conservative methods for acute partial tears. Surgery (repair, reinforce, or reconstruct) for complete tears, chronic, Stener Lesion. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. --- ## UCL Anatomy of the Thumb ****Key Point** The UCL provides stability to the thumb MCPJ, particularly to valgus stress/radial deviation. The joint is also supported by radial collateral ligaments, volar plate, sesamoid bones, and flexor tendons. The ulnar collateral ligament (UCL) runs obliquely from the lateral condyles of the metacarpal to insert on the volar distal phalanx. This dorsal-volar course enables this structure to be **taut in flexion and loose in extension.** The UCL anatomy can be visualised below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Thumb-MCPJ-UCL-3.png) Thumb MCPJ UCL Anatomy The thumb MCPJ is a condyloid joint that relies predominantly on the strong ulnar and radial collateral ligaments for stability. Further stability is provided by: - Accessory collateral ligaments - Volar plate - Sesamoid bones - Flexor tendons. 💡 ****Tip:** The ****ulnar collateral ligament** is a thick band approximately, ****4-8mm** wide ****12-14mm** long. --- ## Aetiology of Thumb MCPJ UCL Injury ****Key Point** Acute ulnar collateral ligament injuries of the thumb are common in skiers and often involve avulsion fractures. These are typically managed based on injury severity, with surgery recommended for severe cases. ### Acute UCL Injury Acute ulnar collateral ligament injuries are caused by forced radial abduction of the thumb. They are more common than radial collateral injuries and often seen in skiers. An UCL injury may be associated with an avulsion fracture. Many fracture patterns exist but important points are: - It can occur at ulnar base of the proximal phalanx - The size of the avulsion fracture has been used to guide management; with a fragment **\>2mm** being used as an indication for surgery ### **Chronic** Chronic UCL injuries are commonly referred to as Gamekeeper's thumb due to the chronic stretching of the UCL after repeated abduction movements. This was described by Scottish surgeon, Campbell, in gamekeepers who broke rabbits necks between their thumb and index finger, the force being transmitted over a fulcrum formed by the ulnar aspect of their thumb. --- ## Assessment of Thumb MCPJ UCL Injury ****Key Point** Thumb MCPJ UCL injuries, characterized by pain, swelling, and bruising from forced abduction, require valgus stress tests and imaging to assess ligament damage. The diagnosis a thumb MCPJ UCL injury requires clinical and radiological investigations. In terms of the patient's **history**, common findings include: - History of forced **abduction** accompanied - **Pain**, bruising, and swelling at the base of the thumb ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Thumb-MCPJ-UCL-Stress-Test.png) Valgus Stress Test In relation to **clinical examination**, common findings include: - **Weakness** of pinch grip. - Increase **angle** on valgus stress of the MCPJ: **30 degrees** or >15% compared the other hand ([Avery](https://pubmed.ncbi.nlm.nih.gov/25771322/?ref=theplasticsfella.com), 2015). - Discrete (partial) or loss of **endpoint** (complete) on valgus stress. 💡 ****Tip:** It is important to examine the MP joint in extension and flexion and compare the opposite side under valgus stress to determine if there is ****increased laxity** (indicative of a partial injury) or ****lack of an “end point”** on passive movement (indicative of a complete tear or avulsion). ### Classification of MCPJ UCL Injuries Thumb MCPJ UCL injuries can be classified by the degree of tenderness and laxity. - **Grade 1:** tenderness of UCL, no laxity - **Grade 2:** tenderness and demonstrable but mild laxity, **with clear endpoint** - **Grade 3:** tenderness, laxity, and no clear endpoint on valgus stress This classification guides the management of **Grade 1 and 2** injuries. These can be managed conservatively in a thumb spica whilst open reduction and fixation is the mainstay of management for **Grade 3** injuries. This classification is explained in the table below. ![Classification of Thumb MCPJ UCL Injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Basal-Thumb-Osteoarthritis.png) Classification of Thumb MCPJ UCL Injury 💡 ****Tip:** In children, isolated rupture of the UCL without salter harris fracture is rare. ### **Investigations Thumb MCPJ UCL** Radiological investigations are commonly performed in suspected thumb UCL MPCJ injuries. These are usually X-rays, MRI, or Ultrasound. **Xray:** - AP/oblique and lateral X-rays should be taken to identify associated fractures. - Stress X-rays may be obtained and dynamic fluoroscopy can be used to assess the range of motion and joint opening. A typical fracture pattern associated with a thumb MCPJ UCL injury is illustrated in the image below. ![X-ray ulnar collateral avulsion fragment, Thumb MCPJ UCL Injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Necrotising-Fasciitis-Definition--10-.png) AP X-ray of Ulnar collateral ligament avulsion with bony fragment. **Other Radiological Investigations:** - **Ultrasound**: high diagnostic accuracy for Stener Lesions ([Qamhawi,](https://pubmed.ncbi.nlm.nih.gov/33596684/?ref=theplasticsfella.com) 2021), more user dependent. - **MRI**: demonstrate high diagnostic accuracy for Stener lesions ([Qamhawi,](https://pubmed.ncbi.nlm.nih.gov/33596684/?ref=theplasticsfella.com) 2021), more expensive, can result in false positives due the difficulty to distinguish thumb MPCJ UCL with fibrous scar tissue. The image below shows the anatomy of the thumb injury in investigations. ![Investigations for Thumb MCPJ UCL Injury, Thumb MCPJ UCL Injury Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Basal-Thumb-Osteoarthritis--1-.png) Investigations for Thumb MCPJ UCL Injury 😎 ****Fun Fact:** A Stener lesion occurs when the adductor aponeurosis is interposed between the UCL and MCP joint and prevents a completely avulsed UCL from approximating to its insertion. This requires surgical fixation to regain function. --- ## Management of Thumb MCPJ UCL Injury ****Key Point** Conservative immobilisation is indication for partial thumb ligament tears. Chronic or complete tears require reinforcement (bone anchors, internal brace) or reconstruction (tendon graft). Thumb MCPJ UCL injuries can be treated **conservatively** or **surgically**. This is influenced by the degree of laxity, presence of an endpoint and a Stener Lesion. ### **Conservative treatment** **Conservative options** includes **4 weeks of immobilisation**, followed by 2 weeks in a lightweight splint. This is a common treatment protocol for acute partial tear injuries 1. **Initial Phase:** 4 weeks of immobilization using a short arm thumb spica cast, leaving the interphalangeal joint free. 2. **Follow-up Phase:** 2 weeks in a lightweight splint. The indication for conservative treatment is a Grade 1 injury. Controversy remains regarding the most appropriate management of Grade 2 partial and complete tears with some surgeons opting for conservative management when a US and clinical examination do not detect a Stener lesion. ### Surgical Repair Techniques ### The surgical options available for the thumb MCPJ UCL injury include: - **Repair**: primary repair in the acute setting - **Reinforce**: Bone Anchors, Internal Brace/Suspension Tape - **Reconstruction**: Chronic Injuries with Tendon graft (eg PL, FCR - Littler Technique) 💡 The key surgical steps are described in **“*[**Surgical Technique - Thumb MCP UCL injury*](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/)**”* Additional points to note on surgical interventions: - **Contraindication** to surgical management is the presence of MCPJ osteoarthritis. This can occur in the chronic injury. - **Avulsed fragments** greater than 2mm may be reduced and fixed using surgical screws. However, this is a matter of debate. 💡 ****Tip:** Early active movement facilitates good return of function and range of movement ([Crowely](https://journals.lww.com/techhandsurg/abstract/2013/09000/early%5Factive%5Fmobilization%5Ffollowing%5Fucl%5Frepair.2.aspx?ref=theplasticsfella.com), 2013). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Thumb MCPJ UCL Injury:** You've gained a comprehensive understanding of the functional anatomy of the thumb, specifically focusing on the ulnar collateral ligament. ****2\. Identifying Injury Causes and Types:** You've learned about the causes of thumb MCPJ UCL injuries, distinguishing between acute injuries often seen in sports (Skier’s thumb) and chronic conditions (Gamekeeper’s thumb), and how these conditions influence treatment decisions. ****3\. Diagnostic Strategies:** You're now familiar with the diagnostic process for UCL injuries of the thumb, including clinical examination techniques to assess ligament damage and the presence of any associated avulsion fractures. ****4\. Thumb Injury Treatment Options:** You now understand the management strategies for thumb MCPJ UCL injuries, ranging from conservative treatment for partial tears to surgical interventions for complete tears and certain avulsion fractures. ****5\. Surgical Techniques:** You've reviewed various surgical techniques and their indications, which can help in planning the appropriate intervention based on the severity of the injury and the specific patient needs. --- ## Further Reading 1. Qamhawi Z, Shah K, Kiernan G, Furniss D, Teh J, Azzopardi C. [Diagnostic accuracy of ultrasound and magnetic resonance imaging in detecting Stener lesions of the thumb: systematic review and meta-analysis](https://journals.sagepub.com/doi/abs/10.1177/1753193421993015?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2021 Nov;46(9):946-953\. doi: 10.1177/1753193421993015. Epub 2021 Feb 17\. PMID: 33596684. 2. Avery DM 3rd, Caggiano NM, Matullo KS. [Ulnar collateral ligament injuries of the thumb: a comprehensive review](https://pubmed.ncbi.nlm.nih.gov/25771322/?ref=theplasticsfella.com). Orthop Clin North Am. 2015 Apr;46(2):281-92\. doi: 10.1016/j.ocl.2014.11.007. Epub 2014 Dec 30\. PMID: 25771322. 3. Sircar K, Dargel J, Scaal M, Eysel P, Müller LP, Wegmann K. [Thumb metacarpophalangeal joint morphology and reconstruction of the ruptured ulnar collateral ligament](https://pubmed.ncbi.nlm.nih.gov/37005740/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2023 Sep;48(8):768-772\. doi: 10.1177/17531934231164260. Epub 2023 Apr 2\. PMID: 37005740. 4. Crowley, Timothy P. MBChB, MRCS(Glasg); Stevenson, Susan MBChB, PhD, FRCS(Plast); Taghizadeh, Reika MBChB, FRCS(Plast); Addison, Patrick MBChB, MD, FRCS(Plast); Milner, Richard H. MD, FRCS(Plast). [Early Active Mobilization Following UCL Repair With Mitek Bone Anchor](https://journals.lww.com/techhandsurg/abstract/2013/09000/early%5Factive%5Fmobilization%5Ffollowing%5Fucl%5Frepair.2.aspx?ref=theplasticsfella.com). Techniques in Hand & Upper Extremity Surgery 17(3):p 124-127, September 2013\. | DOI: 10.1097/BTH.0b013e318284dbd7 5. Gluck JS, Balutis EC, Glickel SZ. [Thumb ligament injuries](https://pubmed.ncbi.nlm.nih.gov/25813924/?ref=theplasticsfella.com). J Hand Surg Am. 2015 Apr;40(4):835-42\. doi: 10.1016/j.jhsa.2014.11.009\. PMID: 25813924. --- ### Seymour Fracture: Causes, Clinical Features, & Treatment URL: https://www.theplasticsfella.com/seymour-fracture/ Last updated: 2024-05-11T09:56:43.000Z #### Summary Card [****Definition** ](https://www.theplasticsfella.com/seymour-fracture/#definition-of-seymour-fracture)A Seymour fracture is an open, displaced distal phalangeal physeal fracture with an associated nailbed injury. [****Anatomy** ](https://www.theplasticsfella.com/seymour-fracture/#anatomy-of-seymour-fracture)They present as mallet fingers with a flexion deformity due to the level of flexor and extensor tendons at the distal phalanx. [****Clinical Features** ](https://www.theplasticsfella.com/seymour-fracture/#clinical-features-of-seymour-fracture)Crush injuries associated with a nail plate avulsion and proximal nail bed interposition at the fracture site. [****Investigations** ](https://www.theplasticsfella.com/seymour-fracture/#investigations-for-seymour-fracture)X-rays are required for adequate diagnosis with distinct features seen on the lateral view. [****Treatment** ](https://www.theplasticsfella.com/seymour-fracture/#treatment-of-seymour-fracture)Treatment is multimodal and involves irrigation, debridement, reduction, fixation, and antibiotics. [****Complications** ](https://www.theplasticsfella.com/seymour-fracture/#complications-of-seymour-fracture)Include osteomyelitis, nail dystrophy, non-union or malunion, and growth disturbances of the distal phalanx. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow, South Africa. ****Reviewer:** Dr Suzanne Thomson, Educational Fellow, Scotland. --- ## Definition of Seymour Fracture ****Key Point** A Seymour fracture is an open, displaced distal phalangeal physeal fracture with an associated nailbed injury. A **Seymour fracture** is a displaced, open fracture of the juxta-epiphyseal region of the distal phalanx, with an overlying nail bed injury that occurs in skeletally immature individuals. The image below illustrates a Seymour fracture. ![Seymour fracture, Nailbed Injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--4-.png) Seymour fracture It is associated with the avulsion of the **nail plate** and a concomitant laceration of the **nail bed** due to the proximity of the nail bed to the fracture site. It presents as either: - Salter-Harris Type I - Salter-Harris Type II - "Juxta-epiphyseal" occurs at the metaphysis, slightly distal to the physis 💡 ****Tip:** Seymour Fractures are often mis-diagnosed. Always be careful of a proximal nail bed injury! --- ## Anatomy of Seymour Fracture ****Key Point** Seymour fractures are caused by crushing injuries and present as mallet fingers with a flexion deformity. The Seymour Fracture is considered a **bony** and **soft tissue injury**. In relation to the bone, there is a predisposition for this fracture in the distal phalanx [(Krusche-Mandl](https://pubmed.ncbi.nlm.nih.gov/23351909/?ref=theplasticsfella.com), 2013) due to: - Weakness of the **epiphyseal-metaphyseal** junction. - Angulation of the **diaphysis** on the **epiphysis**. - Insertion sites of the flexor and extensor tendons into the distal phalanx. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--5-.png) The injury presents as a **pseudomallet**, characterized by a flexion deformity of the distal phalanx, due to asymmetric tendon insertions. - **Extensor** tendon attaches to the **epiphysis** of the proximal fracture fragment. - **FDP** tendon attaches to the **metaphysis** of the distal fragment. This configuration results in opposing forces at the fracture site, which hinders proper healing. The image below illustrates the anatomy of the Seymour Fracture. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Seymour-Fracturee-Anatomy.png) Seymour Fracture Anatomy 😎 ****Fun Fact:** Extensor tendon rupture is uncommon in children because the epiphyseal plate is weaker than the tendon ([Krushe-Manndl,](https://pubmed.ncbi.nlm.nih.gov/23351909/?ref=theplasticsfella.com) 2013). --- ## Clinical Features of Seymour Fracture ****Key Point** Seymour fractures have a variety of presentations from subtle nailbed injuries to grossly displaced and exposed fractures. It can be commonly misdiagnosed. A Seymour Fracture has a typical **history** of a crush injury. In terms of **clinical examination**, common findings include: - Nail bed injury with an avulsed nail plate (often lying superficial to the eponychial fold) - Skin laceration - 'Pseudomallet' deformity due to flexion forces > extensor forces. - Elongation of the lunula. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Seymour-Fractures.png) Clinical Features of a Seymour Fracture 😎 ****Fun Fact:** The middle finger is the most commonly involved finger ([Lopez](https://pubmed.ncbi.nlm.nih.gov/34842086/?ref=theplasticsfella.com), 2021). --- ## Investigations for Seymour Fracture ****Key Point** X-rays, especially the ****lateral view** are key to identifying Seymour fractures. The identification of Seymour fractures is key to ensuring adequate and appropriate treatment. X-ray is the imaging modality of choice, key radiological findings are: - **Posteroanterior**: may appear normal. - **Lateral**: widened physis or displacement between epiphysis and metaphysis. They may also be a flexion deformity at the fracture site. The image below illustrates Seymour fracture on the lateral view of an X-ray. ![Seymour fracture on the lateral view of an X-ray, Diagnosing Seymour Fracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images.png) Seymour fracture on the lateral view of an X-ray 💡 ****Tip:** A lateral x-ray distinguishes between an extensor tendon rupture and a juxta-epiphyseal Seymour fracture. --- ## Treatment of Seymour Fracture ****Key Point** Treatment is multimodal and involves irrigation, debridement, reduction, fixation, and antibiotics. Treatment is multimodal and involves irrigation, debridement, reduction, fixation, and antibiotics ([Krushe-Manndl,](https://pubmed.ncbi.nlm.nih.gov/23351909/?ref=theplasticsfella.com) 2013). The recommended management of Seymour fractures can be looked at from both a soft tissue and bone perspective ([Lin](https://pubmed.ncbi.nlm.nih.gov/30358692/?ref=theplasticsfella.com), 2019): **Soft Tissue** **Repair:** - Nail plate removal. - Extraction of the germinal matrix entrapped at the fracture site through hyperflexion of the digit or distal fragment retraction - Irrigation and selective debridement **Fracture reduction.** - **K-wire** if the fracture is **unstable** or concern of patient non-compliance. - **Splinting** the DIPJ if stable fracture after reduction and compliant patient. - **Tip**: The nail aids in stable reduction by acting like a splint ![K-wire fixation of Seymour fracture](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--3-.png) K-wire fixation of Seymour Fracture It is worth noting, other techniques have been described. For example, late infected Seymour fractures can be treated by a one-suture technique that holds the distal phalanx in place. This technique avoids the need for K-wires in the setting of infection ([Englert](https://pubmed.ncbi.nlm.nih.gov/36974281/?ref=theplasticsfella.com), 2022). 💡 ****Tip:** The absence of fracture healing can be seen on radiographs - by trabecular bone or callus bridging across the fracture site ([Samade](https://pubmed.ncbi.nlm.nih.gov/31597480/?ref=theplasticsfella.com), 2021). --- ## Complications of Seymour Fracture ****Key Point** Complications include osteomyelitis, nail dystrophy, non-union or malunion, and growth disturbances of the distal phalanx. The primary concern regarding Seymour Fractures is the **interposition of the germinal matrix is between fracture fragments -** resulting in Osteomyelitis, Non-union, or Malunion. Factors that lead to increase complications include: - Delayed Treatment - Insufficient debridement. - Incomplete fracture reduction. - Inadequate antibiotic treatment. A Seymour fracture presenting after 24 hours is considered a delayed fracture and has a greater risk of infection ([Samade](https://pubmed.ncbi.nlm.nih.gov/31597480/?ref=theplasticsfella.com), 2021). An algorithm for the approach for delayed Seymour fractures can be found [here](https://pubmed.ncbi.nlm.nih.gov/31597480/?ref=theplasticsfella.com). 😎 ****Fun Fact:** Premature physeal closure is usually due to infection rather than direct injury to the growth plate ([Lin](https://pubmed.ncbi.nlm.nih.gov/30358692/?ref=theplasticsfella.com), 2019). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition and Anatomy of Seymour Fractures:** You've learned that a Seymour fracture is an open, displaced distal phalangeal physeal fracture with an associated nail bed injury, commonly occurring in children. ****2\. Causes and Presentation of Seymour Fractures:** You now understand that these fractures often result from crushing injuries and are characterized by symptoms such as mallet fingers with a flexion deformity at the distal phalanx. ****3\. Seymour Fracture Diagnostic Approaches:** You're aware that X-rays, particularly lateral views, are crucial in diagnosing Seymour fractures. ****4\. Treatment Modalities for Seymour Fractures:** You've learned about treatment approaches for Seymour fractures, which includes irrigation, debridement, reduction, fixation, and antibiotics. ****5\. Potential Complications of Seymour Fractures:** You understand possible complications such as osteomyelitis, nail dystrophy, non-union or malunion, and growth disturbances. --- ## Further Reading 1. Perez-Lopez LM, Parada-Avendaño I, Cabrera-Gonzalez M, Fontecha CG. [Seymour fracture: Better do not underestimate it](https://pubmed.ncbi.nlm.nih.gov/34842086/?ref=theplasticsfella.com). Jt Dis Relat Surg. 2021;32(3):569-574\. doi: 10.52312/jdrs.2021.330\. Epub 2021 Nov 19\. PMID: 34842086; PMCID: PMC8650660. 2. Kiely AL, Nolan GS, Cooper LRL. [The optimal management of Seymour fractures in children and adolescents: a systematic review protocol](https://pubmed.ncbi.nlm.nih.gov/32576259/?ref=theplasticsfella.com). Syst Rev. 2020 Jun 23;9(1):150\. doi: 10.1186/s13643-020-01407-5\. PMID: 32576259; PMCID: PMC7313162. 3. Krusche-Mandl I, Köttstorfer J, Thalhammer G, Aldrian S, Erhart J, Platzer P. [Seymour fractures: retrospective analysis and therapeutic considerations](https://pubmed.ncbi.nlm.nih.gov/23351909/?ref=theplasticsfella.com). J Hand Surg Am. 2013 Feb;38(2):258-64\. doi: 10.1016/j.jhsa.2012.11.015\. PMID: 23351909. 4. Seymour N. [Juxta-epiphysial fracture of the terminal phalanx of the finger](https://pubmed.ncbi.nlm.nih.gov/5939484/?ref=theplasticsfella.com). J Bone Joint Surg Br. 1966 May;48(2):347-9\. PMID: 5939484. 5. Lin JS, Popp JE, Balch Samora J. [Treatment of Acute Seymour Fractures](https://pubmed.ncbi.nlm.nih.gov/30358692/?ref=theplasticsfella.com). J Pediatr Orthop. 2019 Jan;39(1):e23-e27\. doi: 10.1097/BPO.0000000000001275\. PMID: 30358692. 6. Samade R, Lin JS, Popp JE, Samora JB. [Delayed Presentation of Seymour Fractures: A Single Institution Experience and Management Recommendations](https://pubmed.ncbi.nlm.nih.gov/31597480/?ref=theplasticsfella.com). Hand (N Y). 2021 Sep;16(5):686-693\. doi: 10.1177/1558944719878846\. Epub 2019 Oct 9\. PMID: 31597480; PMCID: PMC8461200. 7. Reyes BA, Ho CA. [The High Risk of Infection With Delayed Treatment of Open Seymour Fractures: Salter-Harris I/II or Juxta-epiphyseal Fractures of the Distal Phalanx With Associated Nailbed Laceration](https://pubmed.ncbi.nlm.nih.gov/26327401/?ref=theplasticsfella.com). J Pediatr Orthop. 2017 Jun;37(4):247-253\. doi: 10.1097/BPO.0000000000000638\. PMID: 26327401. 8. Farid M, Shibu M. [A rare case of Seymour fracture in an adult with non-fused growth plates](https://pubmed.ncbi.nlm.nih.gov/34104672/?ref=theplasticsfella.com). Case Reports Plast Surg Hand Surg. 2021 May 19;8(1):72-75\. doi: 10.1080/23320885.2021.1927738\. PMID: 34104672; PMCID: PMC8143599. 9. Englert EG, Tooley T, Weisz K, Shapiro P. [Suture Fixation of Subacute Pediatric Seymour Fractures](https://pubmed.ncbi.nlm.nih.gov/36974281/?ref=theplasticsfella.com). J Hand Surg Glob Online. 2022 Dec 7;5(2):231-233\. doi: 10.1016/j.jhsg.2022.10.013\. PMID: 36974281; PMCID: PMC10039310. 10. Abzug JM, Kozin SH. [Seymour fractures](https://pubmed.ncbi.nlm.nih.gov/24206995/?ref=theplasticsfella.com). J Hand Surg Am. 2013 Nov;38(11):2267-70; quiz 2270\. doi: 10.1016/j.jhsa.2013.08.104\. PMID: 24206995. --- ### Ring Avulsion Injury: Mechanisms, Classification, & Management URL: https://www.theplasticsfella.com/ring-avulsion-injury/ Last updated: 2024-12-27T13:11:43.000Z #### Summary Card [****Definition** ](https://www.theplasticsfella.com/ring-avulsion-injury/#definition-of-ring-avulsion-injury)Ring avulsion injuries occur from sudden traction on a digit, causing damage ranging from circumferential lacerations to complete amputation, with possible vascular compromise. [****Mechanisms**](https://www.theplasticsfella.com/ring-avulsion-injury/#mechanisms-of-ring-avulsion-injury) Ring avulsion injuries typically occur when rings catch on machinery or stationary objects during everyday activities. [****Anatomy** ](https://www.theplasticsfella.com/ring-avulsion-injury/#anatomy-of-ring-avulsion-injury)Neurovascular bundle location makes vessels and nerves particularly prone to ring traction injury. [****Classification**](https://www.theplasticsfella.com/ring-avulsion-injury/#urbaniak-classification-of-ring-avulsion-injuries) A circulatory status-based classification such as the Urbaniak classification is useful in guiding treatment options. [****Assessment**](https://www.theplasticsfella.com/ring-avulsion-injury/#assessment-of-ring-avulsion-injuries) A thorough assessment should identify all damaged structures, by examining neurovascular status, ROM, and bone injury. [****Management**](https://www.theplasticsfella.com/ring-avulsion-injury/#management-of-ring-avulsion-injuries) Treatment varies depending on the structures injured ranging from simple suturing and wound care to revascularization, replantation, or amputation of the affected digit. ****Primary Contributor:** Dr Kurt Lee Chircop, Educational Fellow. ****Reviewer:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Ring Avulsion Injury ****Key Point** Ring avulsion injuries, often caused by sudden force on a finger ring, can range from lacerations with associated soft tissue injuries to total amputation. Ring avulsion injuries are typically caused by a sudden pull on a finger ring, resulting in extensive soft tissue damage due to the traction force exerted on the digit. There is a clinical spectrum of severity dependent on the force of injury. More specifically: - **Skin:** ranges from a circumferential laceration to complete finger amputation. - **Associated damage:** Injury to vessels, nerves, bone and tendons. The image below illustrates a Class 3 ring avulsion injury. ![Avulsion injury, ring degloving, traction injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition--6-.png) Class 3 ring avulsion injury of the right ring finger. --- ## Mechanisms of Ring Avulsion Injury ****Key Point** Ring avulsion injuries occur when a ring gets caught, causing forceful traction, with multiple factors affecting the degree of injury. Ring avulsion injuries happen when a finger ring gets caught on an object, causing a sudden, forceful pull. This can result in various injuries, from minor abrasions to severe degloving or even amputation. The severity of the injury depends on three main factors, - **Traction Force:** A force of 80 newtons can cause injury, additional force associated can cause degloving or complete amputation. - **Duration and Resistance:** The length of time and resistance of the ring during the pull also influences the severity of the injury. - **Ring material:** Strong alloys are unlikely to buckle from the force applied, leading to more severe injury. --- ## Anatomy of Ring Avulsion Injury ****Key Point** Ring Avulsions can affect bone and soft tissue. In particular, arteries, veins and nerves. Ring avulsion injuries can affect both **soft tissue** and **bone**. In relation to the soft tissue, important anatomical structures to be aware of are the artery and vein. 1. **Digital Arteries:** each digit contains a radial and ulnar digital artery arising from common digital arteries. 2. **Digital Veins:** there is no well defined venous network in the finger. The veins on the dorsal side are larger than those on the palmar side. 3. **Digital Nerves**: each digit contains a radial and ulnar digital nerves arising from common digital nerves. Neurovascular bundle location makes vessels and nerves particularly prone to ring traction injury. The proper digital arteries communicate with each other at 3 locations: C1 pulley, C3 pulley, FDP insertion. This is anatomy of the blood supply to the finger is illustrated below. ![Digital arteries, digital nerves, hand anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition--7-.png) Venous and Ligamentous Anatomy of Ring Avulsion Injuries --- ## Urbaniak Classification of Ring Avulsion Injuries ****Key Point** Modified Urbaniak classification is the most widely used, based on circulatory status. Urbaniak classifies ring avulsion injuries into three categories based on the finger's circulatory status, with Nissenbaum refining Class 2 to reflect skeletal or other soft tissue injuries. Urbaniak classifies ring avulsion injuries into **Class I** (Adequate circulation), **Class II** (inadequate circulation) and **class III** (complete degloving). This is illustrated in more detail in the table below. ![Classification of Ring Avulsion Injuries, Severity of Ring Avulsion Injuries](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--6-.png) Urbaniak Classification of Ring Avulsion Injuries Please note, other classifications exist. These are less commonly used - for exmaple: Kay, Wentz, and Wolf classification ([Jones,](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753839/?ref=theplasticsfella.com) 2016). 😎 ****Fun Fact:** Traditionally, ****Class** ****III** injuries were treated with amputation, but with advancements in microsurgical techniques, successful replantations with satisfactory functional outcomes have been reported ([Gardiner,](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8517313/?ref=theplasticsfella.com) 2021). --- ## Assessment of Ring Avulsion Injuries ****Key Point** Assess ring avulsion injuries for their vascular status and level of injury. Patient factors should also be considered and supported by radiological investigations. A thorough **examination** and classification are vital for determining the appropriate treatment for ring avulsion injuries. The focus should be on these clinical findings: - **Circulation:** blood flow to determine vascular damage - **Range of Motion:** intact FDS/FDP and extensors - **Nerve Function:** degree of sensory disturbance - **Injury Patterns:** staggered injury with varying levels of tissue damage Plain radiographs of the injured digit, including the amputated stump (if available) are useful in identifying the level of injury and any associated fractures. The image below illustrates a ring avulsion injury. ![Assessing a Ring Avulsion Injury, ring avulsion injury signs](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Main-Article-Images--7-.png) Assessing a Ring Avulsion Injury 💡 ****Tip:** Digital circulation can be assessed clinically by checking the ****capillary refill time**, or by utilising imaging studies using ****Doppler US** or ****Hand angiography** [(Balas,](https://pubmed.ncbi.nlm.nih.gov/7419562/?ref=theplasticsfella.com) 1980). --- ## Management of Ring Avulsion Injuries ****Key Point** Management is based on severity of injury and involves standard wound care, microsurgical repair, or completion of amputation. Surgical management of ring avulsion injuries depends on the severity, level of injury, and classification. ### **Class I Treatment** These patients have **adequate circulation** without extensive soft tissue damage. These patients should receive: - Standard wound care - Delayed skin closure helps prevent constriction and oedema. - Regular monitoring is critical to detect any signs of deteriorating circulation. ### **Class II Treatment** These patients have **inadequate circulation** involving the arteries (IIa) or bones (IIB). These patients should receive - **Microvascular repair:** direct end-to-end arterial repair or vein grafts, aiming to repair one artery and two veins. - Bone Fixation/Tendon reconstruction - Immobilization to reduce tension on the repairs. 😎 ****Fun Fact:** The red line and ribbon signs suggest artery avulsion from a traction injury, indicating that direct repair is inadvisable due to vessel damage. A vein graft is the recommended treatment. ([Maricevich,](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213257/?ref=theplasticsfella.com) 2011). ### **Class III Treatment** These patients have **complete degloving/amputation**. - Assess suitability for replantation or progress to completion amputation. - Usually involves vein grafts, venous flaps, and other reconstructive procedures. Replantation outcomes vary based on the degree of damage, requiring thorough patient counseling and managing expectations ([Bamba,](https://journals.sagepub.com/doi/10.1177/1558944717692094?ref=theplasticsfella.com) 2018). Below is a summary table of treatment of ring avulsion injuries. ![Surgical treatment for ring avulsion injuries, Classification of ring avulsion injuries.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition--9-.png) Surgical treatment for ring avulsion injuries. 💡 ****Tip:** Intimal damage is best assessed under high magnification, allowing resection until healthy vessel tissue is found. The arterial vessel's quality is evaluated with the spurt test. ([Gardiner](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8517313/?ref=theplasticsfella.com), 2021). --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Ring Avulsion Injuries:** You have gained a comprehensive understanding of ring avulsion injuries, which occur due to sudden traction on a digit, often from a ring catching on an object, leading to varying degrees of damage from lacerations to amputation. ****2\. Ring Avulsion Injury Mechanisms:** You now understand the mechanisms that contribute to these injuries, including the forces involved and how they can affect the severity of the injury. ****3\. The Anatomy of Ring Avulsion Injuries:** The article provided insights into the specific anatomical structures at risk during a ring avulsion injury, particularly highlighting the vulnerability of the neurovascular bundle and the structural anatomy that can influence the injury outcome. ****4\. Classification of Ring Avulsion Injuries:** You are familiar with the Urbaniak classification system, which is based on circulatory status and helps guide treatment decisions by categorizing the injuries into three main classes. ****5\. Assessment Techniques of Ring Avulsion Injuries:** You've learned about the comprehensive assessment needed for these injuries, including checking neurovascular status, range of motion, and the use of radiographs to understand the extent of damage. ****6\. Treatment of Ring Avulsion Injuries**: Various management strategies for ring avulsion injuries, ranging from conservative treatment with standard wound care to more complex procedures like microsurgical repair, revascularization, replantation, or amputation depending on the severity of the injury. --- ## Further Reading 1. Kupfer, David & Eaton, Charles & Swanson, Stephen & Mccarter, M. & Lee, Gilbert. (1999). [Ring avulsion injuries: A biomechanical study](https://www.researchgate.net/publication/12716263%5FRing%5Favulsion%5Finjuries%5FA%5Fbiomechanical%5Fstudy?ref=theplasticsfella.com). The Journal of hand surgery. 24\. 1249-53\. 10.1053/jhsu.1999.1249. 2. Maw, Jonathan, Kai Yuen Wong, and Patrick Gillespie. ["Hand anatomy."](https://doi.org/10.12968/hmed.2016.77.3.C34?ref=theplasticsfella.com) *British Journal of Hospital Medicine* 77.3 (2016): C34-C40\. https://doi.org/10.12968/hmed.2016.77.3.C34 3. Jones M, Gujral S. [Ring Avulsion Injuries](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753839/?ref=theplasticsfella.com). Eplasty. 2016 Feb 10;16:ic5\. PMID: 26933469; PMCID: PMC4753839. 4. Gardiner S, Friebel TR, Bray J, Anadkat M, Nikkhah D. [Practical Techniques to Ensure Success in Digital Ring Avulsion Injuries](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8517313/?ref=theplasticsfella.com). Plast Reconstr Surg Glob Open. 2021 Aug 19;9(8):e3771\. doi: 10.1097/GOX.0000000000003771. PMID: 34667701; PMCID: PMC8517313. 5. Balas P, Katsogiannis A, Katsiotis P, Karaitianos J. [Comparative study of evaluation of digital arterial circulation by doppler ultrasonic tracing and hand arteriography](https://pubmed.ncbi.nlm.nih.gov/7419562/?ref=theplasticsfella.com). J Cardiovasc Surg (Torino). 1980 Jul-Aug;21(4):455-62\. PMID: 7419562. 6. Bamba R, Malhotra G, Bueno RA Jr, Thayer WP, Shack RB. [Ring Avulsion Injuries: A Systematic Review](https://journals.sagepub.com/doi/10.1177/1558944717692094?ref=theplasticsfella.com). Hand (N Y). 2018 Jan;13(1):15-22\. doi: 10.1177/1558944717692094. Epub 2017 Feb 16\. PMID: 28720047; PMCID: PMC5755869. 7. Maricevich M, Carlsen B, Mardini S, Moran S. [Upper extremity and digital replantation](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213257/?ref=theplasticsfella.com). Hand (N Y). 2011 Dec;6(4):356-63\. doi: 10.1007/s11552-011-9353-5. Epub 2011 Aug 4\. PMID: 23204960; PMCID: PMC3213257. ### Thumb MCPJ UCL Injury - Clinical Scenario URL: https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-clinical-scenario/ Last updated: 2024-09-04T17:23:32.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Thumb-MCPJ-UCL-Clinical-case.png) #### Clinical Scenario ****A 30-year-old professional skier presents to the emergency department after a fall during training, landing on her outstretched hand with her thumb in extension. She reports severe pain at the base of the thumb, swelling, and limited mobility.** ****Objectives:** ****1\.** Differential diagnosis of ulnar collateral ligament injury. ****2\.** Patho-anatomy of the mechanism of injury described. ****3\.** Clinical examination and investigations. ****4\.** Treatment options you would provide. ****5\.** Post-operative care following UCL repair. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Salivary Gland Tumours: Classifying, Anatomy, & Treatment URL: https://www.theplasticsfella.com/salivary-gland-tumours/ Last updated: 2024-05-09T06:20:48.000Z #### Summary Card [****Anatomy of Salivary Gland Tumours**](https://www.theplasticsfella.com/salivary-gland-tumours/#anatomy-of-salivary-gland-tumours) The parotid, submandibular, sublingual, and minor salivary glands have unique anatomy and duct systems. [****Classification of Salivary Gland Tumours**](https://www.theplasticsfella.com/salivary-gland-tumours/#classification-of-salivary-gland-tumours) By location (parotid, submandibular, sublingual or minor glands) and by pathology (benign or malignant). [****Benign Salivary Gland Tumours**](https://www.theplasticsfella.com/salivary-gland-tumours/#benign-salivary-gland-tumours) The commonest type of salivary gland tumours. Pleomorphic adenoma is the most common, followed by Warthin's Tumour. [****Malignant Salivary Gland Tumours**](https://www.theplasticsfella.com/salivary-gland-tumours/#malignant-salivary-gland-tumours) They can be primary or secondary. The most common is mucoepidermoid carcinoma in the parotid gland. [****Investigations of Salivary Gland Tumours**](https://www.theplasticsfella.com/salivary-gland-tumours/#investigations-of-salivary-gland-tumours) Ultrasound with fine-needle aspiration for cytology. CT or MRI can be considered for anatomical delineation and staging. --- ## Anatomy of Salivary Gland Tumours ****Key Point** The salivary glands consist of parotid, submandibular, sublingual and minor salivary glands. The "salivary glands" develop during weeks 6-8 of gestation to form the parotid, submandibular, sublingual and minor salivary glands. **Parotid:** - *Serous* acini primarily. - deep and superficial lobes separated by the facial nerve, and tail. - Surrounding fascia is a continuation of deep cervical fascia. - **Stensen's duct:** anterior border to 2nd maxillary molar. **Submandibular** - In submandibular triangle. - *Mucous* & *Serous* Acini. - **Wharton’s Duct** into the anterior floor of the mouth. **Sublingual** - In the anterior floor of the mouth. - Multiple ducts of Rivinus form Bartholin's duct, which empties into Wharton's duct. **Minor glands** - Common locations include labial, buccal, palatine, anterior and posterior lingual. There are over 600 - 1000\. - Mainly mucous secreting. 😎 ****Fun Fact:** The submandibular and parotid glands are responsible for the majority of salivary production in an unstimulated state and stimulated state, respectively. Total salivary flow is \~1.5L/day. --- ## Classification of Salivary Gland Tumours ****Key Point** Salivary gland tumours can be classified by their location (parotid, submandibular, sublingual, or minor glands) and by their pathology (benign or malignant). Salivary gland tumours can arise from epithelial, mesenchymal and lymphoid tissue. The major and minor salivary glands are associated with a remarkable diversity of neoplasms. WHO histologic classification for salivary gland tumours has over 40 different types of tumours as they can arise from epithelial, mesenchymal and lymphoid tissues. There were recent updates in their [8th edition](https://publications.iarc.fr/?ref=theplasticsfella.com) publication on Salivary Gland Tumours. The image below illustrates major and minor salivary glands and the location of salivary gland tumours. ![A labelled anatomical drawing showing Salivary Gland Tumours involve the parotid gland, submandibular gland, sublingual gland, and small glands throughout the head and neck region.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Types-of-Salivary-Gland-Tumours-.png) Location of Salivary Gland Tumours From a clinical perspective, salivary gland tumours can be classified by the type of gland and their degree of malignancy. ### Type of Gland The most common location of a salivary gland tumour is the parotid gland but it does have the least risk of malignancy. - **Major salivary gland:** parotid, submandibular, sublingual. - **Minor salivary gland:** small glands throughout the head and neck region. 💡 ****Tip:** The location of the mass **can* be a clue. For example, the neck is submandibular, and the floor of the mouth is sublingual. ### Disease These are just some examples of the 40+ different types of salivary gland tumours. - **Benign:** pleomorphic adenoma, adenolymphoma, oncocytoma, sebaceous neoplasms, intraductal papilloma. - **Benign Soft Tissue:** Haemangioma (commonest paediatric salivary gland tumours), Lipoma, sialolipoma, nodular fasciitis. - **Malignant:** mucoepidermoid, adenoid cystic, acinic cell, mixed, adenocarcinoma (from myoepithelium), primary SCC, sebaceous, lymphoma. - **Non-neoplastic epithelial:** sclerosing polycystic adenosis, nodular oncocytic hyperplasia, lymphoepithelial sialadenitis, intercalated duct hyperplasia. - **Hematolymphoid:** mucosa-associated lymphoid tissue (MALT lymphoma). 💡 ****Tip:** the smaller the gland, the higher the risk of malignancy. --- ## Benign Salivary Gland Tumours ****Key Point** Benign tumours are the most common type of salivary gland tumours. Pleomorphic adenoma is the most common in adults and children, followed by Warthin's Tumour. **Benign tumours are the most common type of salivary gland tumours.** The two most frequently diagnosed are pleomorphic adenoma (commonest solid tumour in children) and adenolymphoma. Less common benign tumours include intraductal papilloma, sebaceous neoplasms and oncocytoma. Typically, they present as a painless, slow-growing mass. There are several different types, and here are some examples below. ### Pleomorphic Adenoma - **Incidence:** most common salivary tumour & often in middle-aged **females**. - **Pathology:** benign mixed tumour with a low malignant potential (\~10%). - **Location:** often parotid (esp. superficial lobe tail), less likely submandibular. - **Surgery:** superficial parotidectomy or total parotidectomy if deep lobe with facial nerve preservation or total resection of a non-parotid salivary gland resection. Tumour is not encapsulated, which means simple enucleation would result in high recurrence rates. - **Radiotherapy:** No role for radiotherapy. 😎 ****Fun Fact:** pleomorphic adenoma has myoepithelial, epithelial and stromal histological components with stellate and spindle cells interspersed with a myxoid background. ### Adenolymphoma (Warthin's Tumour) This condition can also be referred to as papillary cystadenoma lymphomatosum. - **Incidence:** \~20% of salivary tumours & often in middle-aged smoking **males**. - **Pathology:** epithelial and lymphoid components with abundant cystic spaces. - **Location:** nearly always in the parotid, \~10% are bilateral & multicentric. - **Treatment:** superficial or deep parotidectomy with facial nerve preservation. 💡 ****Tip:** pleomorphic adenomas are most commonly found in middle-aged females, whilst adenolymphomas can be bilaterally found in smoking males. --- ## Malignant Salivary Gland Tumours ****Key Point** Malignant salivary gland tumours can be primary or secondary. The commonest is mucoepidermoid carcinoma in the parotid gland. Malignant salivary gland tumours can be primary or secondary malignancies (less common) with different histopathological grades (high, low or mixed). They are most commonly found in the parotid gland and less so in the submandibular gland. **Clinical features** of salivary gland malignancy include pain, facial nerve palsy, rapid growth, obstructive symptoms or local invasion. The **most common** salivary gland tumours are mucoepidermoid carcinoma (also in children), followed by adenoid cystic carcinoma and acinic cell carcinoma. Less common malignancies include adenocarcinoma, primary SCC, sebaceous carcinoma and lymphoma. ### Mucoepidermoid Carcinoma - **Incidence:** commonest parotid malignancy, middle-aged males **&** females. - **Pathology:** variable malignant potential based on histological grade, contains mucus-secreting cells, and epithelial cells of the epidermoid variety. It arises from the excretory duct. - **Location:** usually in the superficial lobe of the parotid. - **Treatment:** consider adjuvant radiotherapy, parotidectomy, [neck dissection](https://www.theplasticsfella.com/neck-dissection/). 😎 ****Fun Fact:** low-grade mucoepidermoid carcinomas can have an indolent presentation, and high-grade have a poor prognosis. ### Adenoid Cystic Carcinoma This is the most common malignancy of the sublingual, submandibular and minor salivary glands (mucoepidermoid carcinoma is the second most common). - **Incidence:** in middle-aged and **elderly** males **and** females. - **Pathology:** cribriform (Swiss-cheese, better prognosis), tubular (low grade), solid (high grade). It arises from the intercalated duct. - **Location:** usually in the submandibular gland. - **Treatment:** adjuvant radiotherapy, resection, high recurrence risk. 😎 ****Fun Fact:** adenoid cystic carcinomas spread perineurally with facial nerve skip lesions and invade local tissue but are less likely to travel to the cervical nodes. ### Acinic Cell Carcinoma - **Incidence:** in middle-aged patients. - **Pathology:** usually a **low-grade** multifocal tumour (once considered benign!) arising from the acinus. - **Location:** occurs most often in the parotid gland. - **Treatment:** Total parotidectomy; radiotherapy has no role. --- ## Investigations of Salivary Gland Tumours ****Key Point** After a history and examination, an ultrasound with fine-needle aspiration for cytology should be performed. CT or MRI should be considered for anatomical delineation and staging. The diagnosis of salivary gland tumours is based on history, examination findings and investigative results. Investigations to consider are: 1. **Fine Needle Aspiration for Cytology:** benign vs malignant. 2. **Ultrasound:** guides FNAC, assess location and lymph nodes. 3. **CT or MRI:** anatomical location, staging for metastasis. 4. **Open Biopsy:** can cause tumour seeding. A differential diagnosis for a parotid gland swelling can include the aforementioned benign and malignant tumours, and also: - **Sialadenitis:** chronic swelling independent of eating. - **Sialolithiasis:** recurrent pain and swelling with eating. It is the most common cause of submandibular swelling and can be diagnosed with a Sialogram. - **Granulomatous disease:** sarcoid, actinomycosis, mycobacterium. - Transient glandular hypertrophy (bulimics). ### AJCC Staging - **T1:** <2 cm without extraparenchymal extension. - **T2:** 2-4 cm without extraparenchymal extension. - **T3:** \>4 cm and/or having extraparenchymal extension. - **T4: >**6 cm or extension into extraglandular tissues. - **T4a:** Invades skin, mandible, ear canal, or facial nerve. - **T4b:** Invades skull base, pterygoid plates, carotid artery. [Neck dissection](https://www.theplasticsfella.com/neck-dissection/) is indicated for malignant salivary gland tumours with clinically positive nodes detected either on physical examination or with preoperative imaging workup. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Anatomy of Salivary Glands:** You've learned about the structural intricacies of the major and minor salivary glands, including their acini types, ductal systems, and anatomical positions, essential for understanding disease processes and surgical approaches. ****2\. Salivary Gland Tumour Classifications:** You now have insight into how salivary gland tumours are classified based on their location and pathology, aiding in accurate diagnosis and tailored treatment planning. ****3\. Benign Salivary Gland Tumours:** You've explored the most common types of benign tumours, such as pleomorphic adenoma and Warthin's tumour, including their typical presentations and treatment options, enhancing your ability to manage these conditions effectively. ****4\. Malignant Salivary Gland Tumours:** You've examined the characteristics of malignant salivary gland tumours, including common types like mucoepidermoid carcinoma, and their implications for prognosis and therapy. ****5\. Diagnostic Investigations for Salivary Gland Tumours:** You are now familiar with the key investigative techniques used in the diagnosis of salivary gland tumours, such as ultrasound-guided fine-needle aspiration, CT, MRI, and the importance of staging in treatment planning. ### Facial Nerve Anatomy: Course, Branches, & Variations URL: https://www.theplasticsfella.com/facial-nerve/ Last updated: 2024-05-08T23:09:40.000Z #### Summary Card [****Overview of Facial Nerve Anatomy**](https://www.theplasticsfella.com/facial-nerve/#overview-of-facial-nerve-anatomy) Cranial nerve VII is a motor and sensory nerve with intracranial, intratemporal, and extratemporal anatomical sections. [****Intracranial Facial Nerve Anatomy**](https://www.theplasticsfella.com/facial-nerve/#intracranial-facial-nerve-anatomy) Originates at the medullopontine angle of the brain stem from the facial nerve proper and nervus intermedius. [****Intratemporal Facial Nerve Anatomy**](https://www.theplasticsfella.com/facial-nerve/#intratemporal-facial-nerve-anatomy) The intratemporal facial nerve enters the internal auditory canal and provides motor, sensory, and secretomotor branches. [****Extracranial Facial Nerve Anatomy**](https://www.theplasticsfella.com/facial-nerve/#extracranial-facial-nerve-anatomy) Begins at the stylomastoid foramen, provides branches to nearby muscles, enters the parotid, and divides into the 5 terminal branches. [****Terminal Branches of the Facial Nerve**](https://www.theplasticsfella.com/facial-nerve/#terminal-branches-of-the-facia-nerve) Mnemonic: ****T**o **Z**anzibar ****B**y ****M**otor ****C**ar: ****T**emporal, ****Z**ygomatic, ****B**uccal, ****M**arginal Mandibular, ****C**ervical. --- ## Overview of Facial Nerve Anatomy ****Key Point** The facial nerve (cranial nerve VII) is a motor and sensory nerve that has 3 distinct intracranial, intratemporal, and extratemporal anatomical sections. The facial nerve (cranial nerve VII) is a motor and sensory nerve that has 3 distinct intracranial, intratemporal, and extratemporal anatomical sections. 1. **Intracranial:** arises from the precentral gyrus & travels via dorsolateral pons. 2. **Intratemporal:** fallopian canal's labyrinthine, tympanic & mastoid segments. 3. **Extra-temporal:** from stylomastoid foramen to 5 branches via the parotid. These three sections of the facial nerve are visualised in the illustration below. ![An illustrated diagram showing the facial nerve in yellow travel through its intracranial, extracranial and intratemporal anatomical sections](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Facial-Nerve-Anatomy-1.png) Facial Nerve Anatomy 😎 ****Fun Fact:** Ipsilateral supranuclear lesions cause contralateral facial paralysis with preserved frontalis because the temporal branch receives ****bicortical input** (unlike other branches). --- ## Intracranial Facial Nerve Anatomy ****Key Point** The facial nerve arises from the medullopontine angle of the brain stem from the facial nerve proper (motor) and nervus intermedius (parasympathetic and sensory fibres). ### **Origin** The facial nerve is formed by the facial nerve proper and the nervous intermedius. 1. **Facial Nerve Proper:** motor fibres exiting from the cerebellopontine angle. 2. **Nervus Intermedius:** parasympathetic and sensory fibres. ### **Intracranial Course** The intracranial section has 3 important anatomical landmarks: 1. Arises from the **medullopontine angle** of the brain stem. 2. Travels with cranial nerve VIII at the **internal auditory meatus**. 3. Enters the **petrous temporal bone**. This intracranial course of the facial nerve is visualised in the illustration below. ![Intracranial Facial Nerve Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Intracranial-Facial-Nerve-.png) Intracranial Facial Nerve Anatomy --- ## Intratemporal Facial Nerve Anatomy ****Key Point** The intratemporal facial nerve enters the internal auditory canal, has 5 main segments, and provides motor, sensory, and secretomotor branches. ### Intratemporal Course - Enters the **internal auditory canal** with the acoustic and vestibular nerves. - Travels the **fallopian canal** by itself through the segments. - **Segments:** cisternal, intracanlicular, labyrinthine, tympanic, mastoid. ### Intratemporal Branches Three clinically significant branches from this segment are: **Greater Petrosal:** - Innervates lacrimal gland & soft palate taste via geniculate ganglion. - Arises in the tympanic segment. **Nerve to Stapedius:** - Dampens loud noises (unaffected in Möbius Syndrome). - Arises from the mastoid segment. **Chorda Tympani:** - Innervates salivary glands, anterior 2/3 tongue taste via lingual. - Arises from the mastoid segment. 💡 ****Tip:** intracranial facial nerve injury results in loss of taste (ageusia) to the anterior 2/3 tongue and hyperacusia (nerve to stapedius). --- ## Extracranial Facial Nerve Anatomy ****Key Point** The extracranial facial nerve arises from the stylomastoid foramen, provides branches to nearby muscles, enters the parotid, and divides into the 5 terminal branches. ### **Extracranial Course** The facial nerve becomes extracranial after the **stylomastoid foramen,** where it is protected by the mastoid tip, tympanic ring, and mandibular ramus. It then travels past bone, muscle, and cartilage before reaching the parotid gland. - Anterior to the **posterior belly of the digastric muscle.** - Lateral to the **styloid process of the temporal bone**. - Inferomedially (\~1cm3) to the tip of the **tragal pointer of the ear**. - Posteriomedially enters the **parotid gland.** - Forms temprozygomatic and cervicofacial trunks in the **pes anserinus**. - Divides into terminal branches that innervate **facial muscles**. 💡 ****Tip:** Arborization begins in the parotid gland between the major terminal branches in the majority of patients. ### **Extracranial Branches** The facial nerve provides motor branches to the structures it passes by on its way to the parotid gland. - **Postauricular nerve:** occipitalis and posterior auricular muscles - **Branch** to the posterior belly of digastric and stylohyoid - **Terminal branches:** this is discussed in more detail below. 💡 ****Tip:** Extra-temporal injuries result in motor weakness ****only.** There is no sensory innervation after the stylomastoid foramen. --- ## Terminal Branches of the Facial Nerve ****Key Point** Facial nerve branches can be remembered by the mnemonic: ****T**o ****Z**anzibar ****B**y ****M**otor ****C**ar: ****T**emporal, ****Z**ygomatic, ****B**uccal, ****M**arginal Mandibular, ****C**ervical. ### **Terminal Branches of Facial Nerve** Facial nerve branches can be remembered by the mnemonic: **T**o **Z**anzibar **B**y **M**otor **C**ar: **T**emporal, **Z**ygomatic, **B**uccal, **M**arginal Mandibular, **C**ervical. - **Temporal:** innervates the frontalis muscle. - **Zygomatic:** innervates the orbicularis oculi and upper lip elevators. - **Buccal:** innervates buccinator and upper lip muscles. - **Marginal:** innervates lower lip mouths. - **Cervical branch:** platysma. ### **Course of Branches** The terminal branches of the facial nerve exit the parotid gland deep into the subcutaneous musculoaponeurotic system (SMAS) layer. Some branches of the facial nerve have vital landmarks: - **Temporal nerve:** Pitanguy's Line (0.5cm below tragus to 1.5cm above lateral brow) in temporoparietal fascia near the superficial temporal artery. - **Buccal branch:** travels with the parotid duct (Stenson's duct), Zucker's point. - **Marginal mandibular:** inferior border of the mandible, deep to the platysma and superficial to the facial artery and anterior facial vein. **Variations in Facial Nerve** Six distinctive anastomotic patterns were initially classified by [Davis](https://www.ncbi.nlm.nih.gov/pubmed/13311719?ref=theplasticsfella.com) et al. in 1956, but there is significant variation in the facial nerve due to: - No consistent spatial or topographic orientation. - Variations in branching patterns and anastomoses between branches ([Lineaweaver](https://www.ncbi.nlm.nih.gov/pubmed/10332290?ref=theplasticsfella.com) et al., 1997 & [Kwak](https://doi.org/10.1007/s00276-004-0259-6?ref=theplasticsfella.com) et al., 2004). - The temporal branch and marginal mandibular nerve have less arborization than other facial nerve branches. These branching pattern variations and cross-innervation clinically correlate to unexplained facial muscle strength in the presence of a known injury to the facial nerve. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Facial Nerve Anatomy:** You have gained comprehensive knowledge of the facial nerve's structure, functions, and three main anatomical sections (intracranial, intratemporal, and extratemporal), along with the variations in its branching patterns. ****2\. Intracranial Facial Nerve Anatomy:** You now understand the intracranial portion, which originates from the medullopontine angle, and includes both the motor facial nerve proper and the sensory/parasympathetic nervus intermedius. ****3\. Intratemporal Facial Nerve Anatomy:** You learned the path and branches of the facial nerve as it travels through the intratemporal segment, supplying motor, sensory, and secretomotor functions through key branches like the greater petrosal, nerve to stapedius, and chorda tympani. ****4\. Extracranial Facial Nerve Anatomy:** You explored the course and branches of the nerve after emerging from the stylomastoid foramen, including the five terminal branches (temporal, zygomatic, buccal, marginal mandibular, and cervical) that control facial muscles. ****5\. Terminal Branches Mnemonic and Landmarks:** You mastered the mnemonic "To Zanzibar By Motor Car" to remember the terminal branches and identify their landmarks to ensure precise clinical identification and intervention. ****6\. Variations in Branching Patterns:** You understand the distinctive anastomotic patterns and variations that influence facial nerve structure, which correlate with facial muscle function even in the presence of nerve injury. --- ## Further Reading 1. Greyling L, Glanvill R, Boon J, et al. [Bony landmarks as an aid for intraoperative facial nerve identification](https://doi.org/10.1002/ca.20508?ref=theplasticsfella.com). *Clin Anat*. 2007;20(7):739-744\. doi:10.1002/ca.20508 2. D’Antoni AV. [Gray’s Anatomy, the Anatomical Basis of Clinical Practice](https://doi.org/10.1002/ca.22677?ref=theplasticsfella.com), Forty-First Edition, by Susan Standring, Editor-in-Chief, Elsevier Limited, 2016, 1,562 Pages, Hardcover, $228.99 ($171.74), ISBN: 978-0-7020-5230-9\. *Clin Anat*. January 2016:264-265\. doi:10.1002/ca.22677 3. Westphal M. [Cranial Neuroimaging and Clinical Neuroanatomy](https://doi.org/10.1215/s1152851704200035?ref=theplasticsfella.com), Third Ed. *Neuro-Oncology*. July 2004:267-268\. doi:10.1215/s1152851704200035 4. DAVIS R, ANSON B, BUDINGER J, KURTH L. [Surgical anatomy of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves](https://www.ncbi.nlm.nih.gov/pubmed/13311719?ref=theplasticsfella.com). *Surg Gynecol Obstet*. 1956;102(4):385-412\. https://www.ncbi.nlm.nih.gov/pubmed/13311719. 5. Lineaweaver W, Rhoton A, Habal M. [Microsurgical anatomy of the facial nerve](https://www.ncbi.nlm.nih.gov/pubmed/10332290?ref=theplasticsfella.com). *J Craniofac Surg*. 1997;8(1):6-10\. https://www.ncbi.nlm.nih.gov/pubmed/10332290. 6. Kwak H, Park H, Youn K, et al. [Branching patterns of the facial nerve and its communication with the auriculotemporal nerve](https://doi.org/10.1007/s00276-004-0259-6?ref=theplasticsfella.com). *Surg Radiol Anat*. 2004;26(6):494-500\. doi:10.1007/s00276-004-0259-6 --- ### Mandibular Defects: Classification & Reconstruction URL: https://www.theplasticsfella.com/mandibular-defects/ Last updated: 2024-05-09T05:52:00.000Z #### Summary Card [****Classification of Mandibular Defects**](https://www.theplasticsfella.com/mandibular-defects/#classification-of-mandibular-defects) Jewer-Boyd classification is used to describe hemi-mandibular, central, and lateral defects. It guides the therapeutic algorithm. [****Pathophysiology of Mandibular Invasion**](https://www.theplasticsfella.com/mandibular-defects/#pathophysiology-of-mandibular-invasion) Directly in lymphatics or via nerves. Periosteum and teeth provide relative resistance to invasion. [****Types of Mandibular Resections**](https://www.theplasticsfella.com/mandibular-defects/#types-of-mandibular-resections) 3 types based on their width and length of resection: marginal (rim), segmental, and hemimandile. [****Types of Mandibular Reconstruction**](https://www.theplasticsfella.com/mandibular-defects/#types-of-mandibular-reconstruction) No reconstruction, plates, non-vascularised bone grafts, and vascularized bone flaps. --- ## Classification of Mandibular Defects ****Key Point** The Jewer-Boyd classification is most commonly used to describe hemi-mandibular, central and lateral defects. It guides the therapeutic algorithm. The classification of mandibular defects provides a standardised communication tool and guides the therapeutic algorithm for the reconstruction. There are several classification systems, but Jewer-Boyd is the most widely accepted in clinical practice ([Boyd](https://pubmed.ncbi.nlm.nih.gov/8248401/?ref=theplasticsfella.com) et al., 1993). ### Jewer-Boyd Mandibular Classification (H-C-L) In 1989, Jewer and Boyd described the HCL classification for hemimandibular (H), central (C), and lateral (L) defects of the mandible. Boyd modified this classification to include mucous (M) and/or skin (S) involvement. - **H**emimandibular: lateral and horizontal segments including the condyle of any length and not significantly crossing the midline. - **C**entral: segment between the incisive foramen (2 canines and 4 incisors). - **L**ateral: segment not including the condyles. This HCL mandible classification is seen in the image below. ![A labelled image showing the HCL classification for mandibular defects](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Jewer-Boyd-Classification--HCL-.png) Jewer-Boyd HCL Classification The length of the defect is not included in this mandibular classification. In reality, many mandibular defects are a combination — for example, LCL. 😎 ****Fun Fact:** a central resection can result in an Andy-Gump deformity, whilst the condyles are generally considered the least important. ### Other Mandibular Classifications - **CRBS by** [**Urken**](https://pubmed.ncbi.nlm.nih.gov/1863438/?ref=theplasticsfella.com) (1991) assessed the bone (condyle, ramus, body, and symphysis), soft tissue (lip, buccal, soft palate, floor of the mouth, tongue, and skin), and nerve (inferior alveolar, lingual, hypoglossal nerve, and facial nerve). - [**Schultz**](https://pubmed.ncbi.nlm.nih.gov/25811586/?ref=theplasticsfella.com)(2015)assesses a defect's dentate nature of alveolus and ramus, unilateral or bilateral, laterality of the donor's vessels, and condylar involvement. - [**Brown**](https://pubmed.ncbi.nlm.nih.gov/26758757/?ref=theplasticsfella.com) **(2016)** defines four classes of segmental mandibulectomy: lateral, hemimandibulectomy, anterior, and extensive ± condylectomy. There is no "perfect" mandibular classification system, and its complexities can make it challenging to apply in routine practice. 😎 ****Fun Fact:** an anterior defect has greater functional (eg, swallowing, mastication, phonation, and breathing) and esthetic morbidity ([Kakarala](https://pubmed.ncbi.nlm.nih.gov/29362116/?ref=theplasticsfella.com) et al., 2018) --- ## Pathophysiology of Mandibular Invasion ****Key Point** Invasion of the mandible can occur directly, in lymphatics or via nerves. Periosteum and teeth to provide relatively resistant to invasion. ### Mechanisms Generally speaking, mone invasion occurs via: 1. **Soft tissues:** infiltrative spread 2. **Lymphatic:** embolic spread 3. **Nerves:** permeative spread 4. **Occlusal surfaces:** directafter tooth extraction ### Role of Teeth The mechanism of tumour invasion is different for dentate and edentulous mandibles. - **Dentate mandible:** invasion occurs via tooth sockets. - **Edentulous mandible:** invasion via occlusal surface and alveolar bone resorption provide a shorter route. 😎 ****Fun Fact:** Non-irradiated mandibular periosteum and teeth are relatively resistant to tumour spread. --- ## Types of Mandibular Resections ****Key Point** 3 types of mandibular resections based on their width and length of resection: marginal (rim), segmental, and hemimandible. Mandibular resections can be classified into 3 different types of mandibulectomies based on their width and length of resection: marginal (rim), segmental, and hemi-mandible. Their relative indications are determined by physical examination and radiographic imaging after discussion at a multidisciplinary meeting. The types of mandibular resections can be seen in the image below. ![Mandibular resections can be classified into 3 different types of mandibulectomies based on their width and length of resection: marginal (rim), segmental and hemimandile](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Types-of-Mandibular-Resections.png) Margin, Segmental and Hemi-mandibulectomies ### Factors to Consider The management options for mandibular resection should take into consideration the following variables: - **Tumour:** location in relation to the mandible. - **Mandible:** dentate or edentulous, atrophy, radiotherapy. - **Patient:** comorbidities and outcome expectations. 💡 ****Tip:** If the tumour is adjacent but not involving the mandible, then a soft tissue resection with a periosteal resection can be considered. ### Marginal (Rim) A marginal rim resection of the alveolus ± lingual plate with body and inferior alveolar nerve preservation. It can be considered in the following patients after discussion at a multidisciplinary meeting. - Mandibular **adjacent**. - Mandibular **periosteum** invasion only with no involvement inferior dental canal. - Dentition **adjacent** with no periodontal ligament involvement. This is not suitable for: - Edentulous mandibles have alveolar bone resorption as the remaining bone is weakened and at high risk of fracture. - Irradiated bone because the patterns of tumour spread are less predictable. 💡 ****Tip:** an intraoperative finding of an adherent periosteum should raise suspicion for invasion. ### Segmental mandibulectomy Segmental mandibulectomy isa full-thickness resection of a mandibular segmental. It can be considered in the following patients after discussion at a multidisciplinary meeting. - Mandibular **invasion** regardless of patient dentition. - Mandibular **fixation** in an edentulous patient. - Mandibular **hypoplasia** restricts a safe rim resection. - Carious dentition **adjacent** with periodontal ligament involvement. - After radiation (radiotherapy disrupts periosteal resistance to tumour spread). If there is an invasion of the inferior dental canal, the assumption is that there is involvement of the inferior alveolar nerve. This requires resection lateral to the lingula to medial to the mental foramen. 😎 ****Fun Fact:** According to ****Brown's Thesis,** tumours invade at points of the abutment. It is feasible to perform a rim resection, leave teeth, and preserve the inferior alveolar nerve if uninvolved ([Brown](https://pubmed.ncbi.nlm.nih.gov/11933179/?ref=theplasticsfella.com) et al., 2002). --- ## Types of Mandibular Reconstruction ****Key Point** This is guided by the defect's location and size, soft tissue loss, and dental rehabilitation. Options include no reconstruction, plates, non-vascularised bone grafts, and vascularised bone flaps. ### Overview The type of mandibular reconstruction is primarily determined by the location and size of the mandibular defect, soft tissue loss, and goals for dental rehabilitation. Options for mandible reconstruction include no reconstruction, plates, non-vascularised bone grafts, and vascularised bone flaps. The **goals** of the reconstruction should be to provide: - **Stability** - **Function:** opening, mastication, swallow - **Structure:** dental occlusion, articulation - **Aesthetic:** lower facial height and contour ![A table comparing the role of plates, bone grafts and bone flaps in mandibular reconstruction are resection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Types-of-Mandibular-Reconstruction.png) Types of Mandible Reconstructions ### No Mandible Reconstruction No mandible reconstruction can be considered in a select number of patients. For example: - **Indications:** posterior defects with intact anterior segment, ascending ramus or lateral defects, condylar head resected from the TMJ, patient not suitable for extended operation, poor prognosis. - **Advantages:** quicker operation, can usually maintain speech and swallowing. - **Disadvantages:** crossbite and malocclusion. These patients can receive soft tissue reconstruction with similar aesthetic and functional outcomes. The goal is to provide vascularized tissue bulk, obliterate dead space, and coverage of essential structures. For example, major pectoralis flap, anterolateral thigh flap, and radial artery forearm flap. 😎 ****Fun Fact:** Posterior mandibular defects are less prone to an Andy-Gump deformity. ### Reconstruction Plates The operation is faster than other reconstructive options with no donor site morbidities. Mandibular plates can be considered in patients: - Not suitable for prolonged operation. - With a poor prognosis. - Good soft tissue coverage. - Not receiving radiotherapy. This option is often complicated in the long term by: - **Plate Fracture:** increased risk with radiotherapy. - **Plate Extrusion:** increased risk with anterior mandible and radiotherapy. - **Stress shielding:** leads to load bearing, bony resorption, and osteopenia. - Secondary procedures to manage plate complications. - Dental reconstruction is not possible. - Loosening of screws. *Potential* **benefits** include: - Less technical. - Shorter operation. - No donor morbidity. 😎 ****Fun Fact:** "Foreign implant" options include titanium, silicone, celluloid, ivory, rubber, and acrylic. ### Non-Vascularised Bone Grafts This technique requires a healthy vascularized wound bed. The graft can be taken from the rib, iliac crest, or an allograft. Non-vascularised bone grafts can be considered for mandibular reconstruction in more minor defects (<6cm) and: - No radiotherapy - Not an anterior mandible defect This reconstructive option has reduced survival with scarring, irradiation, and infection. It can be technically challenging due to inadequate skin or mucosal cover. There is evidence to suggest this is best performed in a delayed fashion ([Pogrel](https://pubmed.ncbi.nlm.nih.gov/9371107/?ref=theplasticsfella.com) et al., 1997) ### Vascularised Bone Flaps Vascularised bone flaps are generally considered the gold standard in mandible reconstruction. - **Indications:** Large defects (>6cm) or irradiated defects. - **Advantages:** more strength and stiffness, higher arthrodesis, and superior functional outcomes compared to other reconstruction options, allowing osseointegration. - **Disadvantages:** more extended operation, donor site morbidities. Reconstruction options include: - Free fibula flap - **DCIA flap:** osteotomy possible leaving periosteum and iliacus intact, AIIS to ASIS can be used for ramus. Good vessel calibre, length, and bone height. Limited by bulkiness. - **Scapular osteocutaenous flap:** low donor site morbidity, versatile as skin and bone have separate pedicles, thin bone for orbit, and hard palate. Limited by the volume of bone available and positioning. - **Radial forearm with radius:** long pedicle, technically easier, thin skin can conform to any defect. Limited by quality of bone, fracture risk, and donor site problems at the wrist. More suitable for orbital reconstruction. - **MUCH less** commonly used pedicled bone flaps, such as pectoralis major with 5th and 6th ribs or lateral sternum; trapezius with clavicle. Free fibula reconstruction is improved with pre-operative mandible computer-animated drawing and modelling. Osseointegration can be planned at the same time with ProPlan 3D software - ossteintegration scews are inserted prior to elevation. 😎 ****Fun Fact:** The "success" of the mandibular reconstruction can be assessed by oral competence, diet (soft, solid, tube dependence), and quality of speech. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Mandibular Defect Classifications:** You've gained insight into the Jewer-Boyd classification and other systems that help delineate mandibular defects, facilitating precise communication and therapeutic planning. ****2\. Pathophysiology of Mandibular Invasion:** You now understand the mechanisms of tumor invasion of the mandible, highlighting the role of lymphatics, nerves, and the relative resistance provided by periosteum and teeth. ****3\. Mandibular Resections:** You have become familiar with the types of mandibular resections—marginal, segmental, and hemimandibular—each with specific indications based on the extent of tumor involvement and mandibular anatomy. ****4\. Mandibular Reconstruction Options:** You've explored various mandibular reconstruction strategies including the use of no reconstruction, reconstruction plates, non-vascularised and vascularised bone grafts, each suited to different extents of defects and patient conditions. --- ## References 1. Boyd JB, Gullane PJ, Rotstein LE, Brown DH, Irish JC. [Classification of mandibular defects](https://pubmed.ncbi.nlm.nih.gov/8248401/?ref=theplasticsfella.com). Plast Reconstr Surg. 1993 Dec;92(7):1266-75\. PMID: 8248401. 2. Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF. [Oromandibular reconstruction using microvascular composite free flaps. Report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects](https://pubmed.ncbi.nlm.nih.gov/1863438/?ref=theplasticsfella.com). Arch Otolaryngol Head Neck Surg. 1991 Jul;117(7):733-44\. doi: 10.1001/archotol.1991.01870190045010\. PMID: 1863438. 3. Schultz BD, Sosin M, Nam A, Mohan R, Zhang P, Khalifian S, Vranis N, Manson PN, Bojovic B, Rodriguez ED. [Classification of mandible defects and algorithm for microvascular reconstruction](https://pubmed.ncbi.nlm.nih.gov/25811586/?ref=theplasticsfella.com). Plast Reconstr Surg. 2015 Apr;135(4):743e-754e. doi: 10.1097/PRS.0000000000001106\. PMID: 25811586. 4. Brown JS, Barry C, Ho M, Shaw R. [A new classification for mandibular defects after oncological resection](https://pubmed.ncbi.nlm.nih.gov/26758757/?ref=theplasticsfella.com). Lancet Oncol. 2016 Jan;17(1):e23-30\. doi: 10.1016/S1470-2045(15)00310-1\. Epub 2015 Dec 23\. PMID: 26758757. 5. Kakarala K, Shnayder Y, Tsue TT, Girod DA. [Mandibular reconstruction.](https://pubmed.ncbi.nlm.nih.gov/29362116/?ref=theplasticsfella.com) Oral Oncol. 2018 Feb;77:111-117\. doi: 10.1016/j.oraloncology.2017.12.020\. Epub 2018 Jan 4\. PMID: 29362116. 6. Pogrel MA, Podlesh S, Anthony JP, Alexander J. [A comparison of vascularised and nonvascularised bone grafts for reconstruction of mandibular continuity defects](https://pubmed.ncbi.nlm.nih.gov/9371107/?ref=theplasticsfella.com). J Oral Maxillofac Surg. 1997 Nov;55(11):1200-6\. doi: 10.1016/s0278-2391(97)90165-8\. PMID: 9371107. 7. Brown JS, Lowe D, Kalavrezos N, D'Souza J, Magennis P, Woolgar J. [Patterns of invasion and routes of tumor entry into the mandible by oral squamous cell carcinoma](https://pubmed.ncbi.nlm.nih.gov/11933179/?ref=theplasticsfella.com). Head Neck. 2002 Apr;24(4):370-83\. doi: 10.1002/hed.10062\. PMID: 11933179. ### Anatomy of the Lip: Muscles, Nerves, Arteries, & Function URL: https://www.theplasticsfella.com/anatomy-of-the-lip/ Last updated: 2024-05-08T16:18:05.000Z #### Summary Card [****Lip Neurovascular Anatomy**](https://www.theplasticsfella.com/anatomy-of-the-lip/#lip-neurovascular-anatomy) A composite soft tissue structure innervated by branches of the facial nerve and trigeminal nerve, supplied by labial arteries. [****Anatomical Lip Landmarks**](https://www.theplasticsfella.com/anatomy-of-the-lip/#anatomical-lip-landmarks) A specific set of landmarks includes the vermillion border, cupid's bow, philtrum, wet-dry mucosa, white roll, tubercle, and commissure. [****Aesthetic Units of the Lip**](https://www.theplasticsfella.com/anatomy-of-the-lip/#aesthetic-units-of-the-lip) The aesthetic subunits of the lip can be described as upper lateral, philtrum, lower lip, chin, and cheek. [****Muscles of the Lip**](https://www.theplasticsfella.com/anatomy-of-the-lip/#muscles-of-the-lip) Act as depressors & elevators. Most insert into the modiolus and are innervated by buccal & mandibular branches of the facial nerve. --- ## Lip Neurovascular Anatomy ****Key Point** The lip is a composite soft tissue structure that receives motor innervation from branches of the facial nerve and sensation from trigeminal nerve branches. The lip is a structure composed of skin, fat, muscle, and mucosa. The lip plays a vital role in oral competence, sensation, speech, and cosmesis. The neurovascular anatomy of the lip is detailed below. - **Motor:** buccal and mandibular branches of the facial nerve. - **Sensory:** infraorbital (upper) & mental (lower) branches of trigeminal nerve. - **Blood supply:** superior and inferior labial branches of the facial artery. - **Lymph:** ipsilateral [submandibular nodes](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-1-cervical-lymph-nodes); the middle can drain to [submental](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-1-cervical-lymph-nodes). The image below illustrates the blood supply to the lip. ![Blood supply to the lip. Lip anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Lip-Anatomy.png) Blood Supply to the Lip 💡 ****Tip**: the superior and inferior labial arteries are usually deep to the orbicularis at the level of the wet-dry mucosa. --- ## Anatomical Lip Landmarks ****Key Point** The lip has specific anatomical landmarks that should be respected during the reconstructive process. This includes the vermillion border, cupid's bow, philtrum, wet-dry mucosa, white roll, tubercle, and commissure. During the reconstruction of the lip in both elective and non-elective cases, it's important to identify key landmarks. This includes commissure, cupid's bow, tubercle and the red line (wet-dry vermillion line). These anatomical landmarks of the lip can be visualised below. ![A labelled diagram of a lip showing cupids bow, white roll, mucosa, vermillion border](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/1.png) Anatomical Landmarks of the Lip 💡 ****Tip:** the philtrum is formed by decussation of orbicularis oris, the orbicularis ridge forms the white roll. --- ## Aesthetic Units of the Lip ****Key Point** The aesthetic subunits of the lip can be described as upper lateral, philtrum, lower lip, chin, and cheek. The face has several areas of subunits to help with treatment algorithms and reconstructive options – the lip is no different. There are 5 aesthetic units directly relevant to the lip (six if you include the cheek). These aesthetic subunits can be visualised in the diagram below. ![Aesthetic Units of the Lip, Lip Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/2-1.png) Aesthetic Units of the Lip --- ## Muscles of the Lip ****Key Point** The muscles of the lip act as depressors and elevators. The majority of the muscles insert into the modiolus and are innervated by the buccal and mandibular branches of the facial nerve. The muscles of the lip can be classified into elevators and depressors. Their primary innervation is through the buccal and mandibular branches. These muscles may be damaged during trauma, localised for botox or reconstructed in dynamic facial nerve surgeries. The image below illustrates the facial expression muscles. ![A labelled drawing of the lip and it's muscles that have a role in depression and elevation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/3.png) Muscles of the Lip These muscles have specific origins and insertion points on the face. This clues the type of function (elevation or depression) and nerve innervation (buccal or mandibular branch). These lip muscle origin and insertion points can be seen in the table below. ![A table of lip muscles that shows their origin, insertion, action and nerve innervation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/4.png) Table of Lip Muscles 💡 ****Tip:** the modiolus is a site lateral to the commissure, which is the site of multiple muscle insertions. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Lip Neurovascular Anatomy:** You have a comprehensive grasp of the lip's neurovascular anatomy, including the motor innervation from the facial nerve branches, sensory input from trigeminal branches, and blood supply from the labial arteries. ****2\. Anatomical Landmarks:** You know the key anatomical landmarks of the lip, such as the vermillion border, cupid's bow, philtrum, wet-dry mucosa, white roll, tubercle, and commissure, essential for reconstructive and aesthetic procedures. ****3\. Aesthetic Units:** You understand the aesthetic units of the lip, including upper lateral, philtrum, lower lip, chin, and cheek, to guide reconstructive and cosmetic planning. ****4\. Muscle Function and Innervation:** You have detailed knowledge of the muscles of the lip, their role as elevators and depressors, and their innervation through the buccal and mandibular branches. ****5\. Clinical Tips and Techniques:** You have acquired practical tips on the anatomical structures and their importance in cosmetic and reconstructive surgery, like the significance of the philtrum and modiolus for facial muscle function. --- ### Radial Artery Forearm Flap: Anatomy, Elevation, & Complications URL: https://www.theplasticsfella.com/radial-artery-forearm-flap/ Last updated: 2024-05-07T08:17:15.000Z #### Radial Artery Forearm Flap [****Anatomy of the Radial Artery Forearm Flap**](https://www.theplasticsfella.com/radial-artery-forearm-flap/#anatomy-of-the-radial-artery-forearm-flap) A fasciocutaneous flap is supplied by the radial artery and drained by the superficial (cephalic) and deep (vena comitans) venous system. [****Design of the Radial Artery Forearm Flap**](https://www.theplasticsfella.com/radial-artery-forearm-flap/#design-of-the-radial-artery-forearm-flap) It is designed to fit the defect. Identify cephalic vein, lateral intermuscular septum, FCR, and brachioradialis. [****Elevation of the Radial Artery Forearm Flap**](https://www.theplasticsfella.com/radial-artery-forearm-flap/#elevation-of-the-radial-artery-forearm-flap) From proximal to distal between the antebrachial fascia and the muscle belly fascia/paratenon. Retract brachioradialis laterally to identify vascular pedicle in the lateral intermuscular septum. [****Discussion on the Radial Artery Forearm Flap**](https://www.theplasticsfella.com/radial-artery-forearm-flap/#discussion-on-the-radial-artery-forearm-flap) A versatile and reproducible flap with relatively constant anatomy. It's limited by sacrificing a major vessel in the arm and donor site wound healing issues. --- ## Anatomy of the Radial Artery Forearm Flap ****Key Point** The radial artery forearm flap is a fasciocutaneous flap supplied by the radial artery and drained by the superficial (cephalic) and deep (vena comitans) venous system. ### Flap Composition **The radial artery forearm flap is a fasciocutaneous flap that can be harvested with different compositions.** This flexibility is because theradial artery provides perforators that pierce antebrachial fascia and supply skin, fat, fascia, muscles, tendons, nerves, and bone. Composition options include: - Suprafascial cutaneous flaps - Adipofascial cutaneous flaps - Osteofasciocutaenous (distal radius segment leaving dorsal & radial cortices) - ± tendons of palmaris longus, brachioradialis, flexor carpi radialis ### Arterial Supply ‌**The radial artery forearm flap is supplied by the radial artery.** The radial artery originates from the brachial artery, deep to the bicipital aponeurosis to give a pedicle length of \~20cm long and \~3mm wide. Key landmarks during its distal course down the lateral intermuscular septum include: - **Proximal forearm:** between brachioradialis & pronator teres. - **Distal forearm:** between brachioradialis & flexor carpi radialis. - **Wrist:** posterior to APL and EPB to enter snuffbox. - **Hand:** between 1st/2nd metacarpals to form the deep palmar arch. 💡 ****Tip:** The radial artery travels in the lateral intermuscular septum which is a line 1cm below the antecubital fossa to the scaphoid tubercle. Most perforators arise \~12-20cm from the origin of the radial artery. ### Venous Drainage ‌The radial artery forearm flap's main venous drainage is through the superficial system (cephalic) and the deep system (venae comitans). A decision has to be made on whether to preserve the cephalic vein or use it as part of the venous drainage of the flap. In relation to the **venae comitantes:** - 2 vessels parallel to the radial artery. - \~2mm in diameter, \~16cm in length, and contain valves. - Joins with superficial vessels (cephalic & basilic) via the median cubital vein. In relation to the **cephalic vein:** - Superficial vein. - Similar in length but slightly wider in diameter than venae comitantes. - Located between the brachioradialis and biceps at the elbow. 💡 ****Tip:** Communications exist between venae comintantes and the superficial venous system that allow bypassing, shunting, and retrograde flow. ### Flap Innervation ‌The radial artery forearm flap is innervated by cutaneous nerves. Motor innervation is generally not required as it is not typically used for a muscle flap. - **Lateral antebrachial nerve:** lateral half of the volar forearm. - **Medial antebrachial nerve:** medial half of the volar forearm. --- ‌ ‌ ## Design of the Radial Artery Forearm Flap ****Key Point** The skin paddle is designed to fit the defect. Consider arm protection and Allen's test. Identify cephalic vein, lateral intermuscular septum, FCR, and brachioradialis. 1. **Avoid** intravenous or arterial lines that may impact the flap vascularity. 2. **Allen's test** to determine the continuity of the palmar arch and any potential radial-sided vascular insufficiency. 3. **Identify** lateral intermuscular Septum, cephalic vein, and brachioradialis. 4. **Palpate** or Doppler the Radial Artery. 5. **Visualise** superficial veins: cephalic may be needed for venous anastomosis and also identifies the location of the lateral cutaneous nerve. 6. **Design** your skin paddle: avoid the ulnar subcutaneous border as the radial artery supplies this area the least. 😎 ****Fun Fact:** The skin at the wrist is thinner than the proximal skin but has more perforators. The ulnar aspect has less hair. --- ‌ ‌ ## Elevation of the Radial Artery Forearm Flap ****Key Point** From proximal to distal between the antebrachial fascia and the muscle belly fascia/paratenon. Retract brachioradialis laterally to identify vascular pedicle in the lateral intermuscular septum. ‌ Here's the process of elevating the radial artery forearm flap. 1. **Inflate** the tourniquet after insanguination. 2. **Incise** the skin paddle. Starting radial or ulnar is a surgical preference. 3. **Proximal extension** of the incision should dermis-only to allow a subcutaneous elevation of forearm and preservation of the superficial venous system. 4. **Elevate** between the antebrachial fascia and muscle belly fascia or paratenon of the FCR & palmaris longus. 5. **Identify** the cephalic vein and superficial branch radial nerve distally. 6. **Ligate** the radial artery and venae comitans distally. 7. **Retract** the brachioradialis laterally to access the lateral intermuscular septum. Be careful to preserve the more proximal fasciocutaneous perforators. 8. **Dissect** flap from its deep structures but keep attached to its pedicle and surrounding tissue. The pedicle dissection along the intermuscular septum is continued to the level of the brachial artery. 9. **Release the tourniquet** to perform hemostasis and inspect the vascularity of the hand. 10. **Perform** a donor site closure, usually with a split-thickness skin graft. The video below illustrates Radial Forearm Elevation. Mayo Clinic Radial Forearm Elevation 💡 ****Tip:** For elevation, the vascular bundle is located in the groove between the brachioradialis and flexor carpi radialis muscles. ### ‌ ‌ --- ## Discussion on the Radial Artery Forearm Flap ****Key Point** The radial artery forearm flap is a versatile and reproducible flap with relatively constant anatomy. It's limited by sacrificing a major vessel in the arm and donor site wound healing issues. Below is the evaluation of the radial artery forearm flap. ### **Advantages** - Relatively constant and reproducible vascular anatomy based on large vessels. - Versatile flap composition (skin, fat, fascia, bone, and tendon). - Versatile in shape and design due to thinness and pliability. - Can easily be used as a free, pedicled, or flow-through flap.‌‌ - Venous anastomosis options as superficial and deep venous systems communicate. - The radial artery provides a long pedicle. ### **Disadvantages** - Poor donor site healing with potential functional and cosmetic issues - Bone harvesting can result in fracture - Sacrifices major artery of the arm. ### ‌ ‌ --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Anatomy:** You will have a thorough grasp of the radial artery forearm flap's anatomy, including its fasciocutaneous composition and arterial, venous, and nerve structures. ****2\. Flap Design:** You will know how to design the radial artery forearm flap to fit specific defects while considering arm protection, Allen's test, and identifying critical structures like the cephalic vein and lateral intermuscular septum. ****3\. Elevation Techniques:** You will understand the procedural steps for elevating the flap, including incision, vascular pedicle identification, and proper dissection techniques between fascia layers. ****4\. Procedure Evaluation:** You will be able to evaluate the radial artery forearm flap's use in surgical practice, balancing its versatility against potential complications like functional impairment and bone fracture. ### Ectropion: Causes, Assessment, & Treatment URL: https://www.theplasticsfella.com/ectropion/ Last updated: 2024-05-06T20:18:53.000Z #### Summary Card [****Definition of an Ectropion**](https://www.theplasticsfella.com/ectropion/#definition-of-an-ectropion) Lower eyelid eversion causes globe, conjunctiva and corneal exposure. [****Classification of an Ectropion**](https://www.theplasticsfella.com/ectropion/#classification-of-an-ectropion) Involutional (common), paralytic, cicatricial, mechanical and congenital (rare) aetiology. [****Assessment of an Ectropion**](https://www.theplasticsfella.com/ectropion/#assessment-of-an-ectropion) Determine aetiology, degree of horizontal lid laxity, canthal tendon integrity [****Treatment of Ectropion**](https://www.theplasticsfella.com/ectropion/#treatment-of-ectropion) Options include canthopexy, canthoplasty, tarsal strip, wedge excision, and other specific procedures. --- ## Definition of an Ectropion Ectropion is the eversion of the lower eyelid resulting in exposure of the globe, conjunctiva and sometimes the cornea. It may have paralytic, involutional, cicatricial, mechanical and congenital (rare) aetiology. The image below clarifies the definition of an ectropion. ![A labelled drawing of an eye with a blue arrow pointing to the ectropion of the lower eyelid. The box at the bottom of the image has the definition of an ectropion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Eyelid-Ectropian-1.png) Definition of an Ectropion Initially, there is lacrimal punctum ectropion and epiphora. With the evolution there is the exposure of the conjunctiva, inflammation, keratinization, and further thinning of the tarsus, worsening the ectropion. --- ## Classification of an Ectropion ****Key Point** The majority of ectropions are involutional. Other causes to consider are cicatricial (scarring), paralytic (facial nerve palsy), and mechanical (eyelid tumour). ### Involutional Involutional ectropion is the most common cause of lower eyelid eversion. It results from abnormal laxity in the lid support system. More specifically: - **Laxity of the medial** canthal tendon displaces the punctum laterally. - **Laxity of lateral** canthal tendon displaces the lateral canthus medially. - **Atrophy** of skin, fat, tarsal plates, and orbital septum. - **Weakening** of the pretarsal orbicularis causes tarsal plate eversion. - **Dehiscence** of capsulopalpebral fascia and Muller muscle destabilises tarsus. ### Other types of ectropion: - **Paralytic:** orbicularis muscle tone is weak or absent due to facial nerve palsy. - **Cicatricial:** anterior or middle lamellae are shortened due to scarring. - **Congenital:** associated with tarsal plate abnormalities, conjunctival oedema post-birth trauma, epicanthus inversus, and blepharophimosis syndrome. The video below showcases the practical approach of an ectropion. A guide to lower eyelid ectropion --- ## Assessment of an Ectropion ****Key Point** The clinical assessment should determine type of ectropion, functional impact, degree of horizontal lid laxity, and integrity of the canthal tendons. ### History The purpose of this history is to determine if the ectropion is cosmetic and/or functional and clues for any potential causes. Functional symptoms include: - Irritation, foreign body sensation due to corneal exposure. - Excessive tearing (epiphora) due to punctum eversion. ### ### Inspection 1. **Eyelid Position:** lid margin and degree of scleral show. 2. **Position of the puncta:** normally located lateral to the caruncle & inverted towards the lacrimal lake. Medial canthal laxity causes it to rotate away and lose contact with the ocular surface and tear lake. 3. **Position of lateral canthus:** normally forms an acute angle and a rounded shape is indicative of lateral tendon elongation. 4. **Eyelid Pathology:** primary (tumour as a mechanical cause) or secondary (epiphora, corneal irritation or epithelial changes secondary to exposure, chronic blepharitis, palpebral conjunctival hypertrophy and keratinization, conjunctival scarring, and to rule out suspicious changes such as loss of lashes (madarosis), ulceration, or infiltration). 5. **Skin quality:** scars, upper and lower lids, any wrinkles, static and dynamic. 6. **Facial Architecture:** patients with hypoplastic midface, also known as hemiproptosis, will have an inferior orbital rim located posteriorly relative to the globe. 7. **Signs of facial nerve palsy:** paralytic ectropion. ### Provocative Tests 1. **Look up & open mouth:** exacerbates cicatricial ectropion by placing the anterior lamella on the maximum stretch. 2. **Pull anterior** to test for horizontal lid laxity: a >10mm gap between the cornea and posterior lid margin is considered abnormal. 3. **Pull inferior** to test the "snap-back": an immediate snap-back of the eyelid when pulled down is considered normal. 4. **Pull superior** to test vertical skin laxity: the lower eyelid should reach 2mm below the limbus when pushed laterally and superiorly. Lack of movement suggests shortening of the anterior lamella, lack of return to position suggests cicatricial, and improvement in eversion suggests involutional. 5. **Pull lateral** to test canthal tendons. Normal lateral movement of punctum (medial canthal) and lateral canthus (lateral canthal) tendons is <2mm. 💡 ****Tip:** other causes of the scleral show include canthal tendon laxity, shortening of the posterior lamella, proptosis, shallow orbit, or large globe. --- ## Treatment of Ectropion ****Key Point** Surgery is the definitive management of an ectropion. The type of procedure depends on aetiology, degree of lid laxity, and integrity of the canthal tendons. Definitive management is surgical. Medical management is temporizing but can improve symptoms. This includes lubrication of the ocular surface and horizontal taping of the eyelid. ### Paralytic Ectropion This usually requires a correction of both the medial and lateral aspects of the lower eyelid. A treatment algorithm to consider is: 1. Correct medial aspect with a medial canthoplasty if canthal tendon intact. 2. Correct medial aspect with a medial canthopexy if unstable medial canthus. 3. Tighten ectropion with a lateral canthal sling or Kuhnt-Szymanowski procedure. 💡 ****Tip:** A canthopexy tightens the canthal tendon without opening the canthal angle. A canthoplasty is indicated if the canthal tendon is intact and a canthotomy-cantholysis followed by resuspending the lower eyelid to the orbital rim. ### Involutional Ectropion Involutional ectropion is treated by reducing the horizontal lid laxity. The specific procedure depends on the region's main laxity and stability of the canthal tendons. - **Medial Laxity + stable medial canthus:** medial wedge excision (pentagon) - **Medial laxity + unstable canthus:** medial canthopexy ± wedge - **Lateral laxity + stable lateral canthus:** lateral wedge - **Lateral laxity + excess skin:** Kuhnt-Szymanowski - **Lateral laxity + unstable lateral canthus:** lateral canthal sling via a lateral canthotomy by securing a tarsal strip to the lateral orbital rim (2mm above the level of medial canthus). The video below illustrates the intra-operative process of a lateral tarsal strip. Intra-operative video of a lateral tarsal strip. 😎 ****Fun Fact:** A Kuhnt-Szymanowski procedure is a wedge resection of the lateral posterior lamella and excision of excess skin via a subciliary blepharoplasty incision. ### Cicatricial Ectropian This focuses on graft or flap reconstruction to lengthen the anterior lamella or release scars. Options include: - Z-plasty - Flaps - Grafts ### Specific Treatments: - **Lower eyelid retractor disinsertion:** the Jones procedure reattached retractors to the tarsus. - **Punctal ectropion:** the medial spindle procedure apposes the everted punctum. - **Paralytic ectropion** with facial nerve paralysis may also require brow ptosis. - Mechanical ectropion from facial ptosis may often require surgical elevation of the mid-face (such as a suborbicularis oculi fat lift), or a facelift in conjunction with lower lid tightening. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Ectropion**: You have gained a comprehensive understanding of ectropion and the various types such as involutional, paralytic, cicatricial, mechanical, and congenital ectropions. ****2\. Assessment Skills**: You are now familiar with how to conduct a detailed clinical assessment of ectropion, focusing on determining its etiology, evaluating the degree of horizontal lid laxity, and assessing the integrity of the canthal tendons. ****3\. Knowledge of Treatment Options**: You've learned about the multiple surgical and non-surgical treatment options available for managing ectropion, tailored according to the specific cause and severity of the condition. ****4\. Complication Awareness**: The article has equipped you with the knowledge to identify potential complications associated with ectropion, enhancing your ability to manage these effectively. ****5\. Practical Application**: Through the exploration of various case studies and treatment methodologies, you have enhanced your practical skills in addressing ectropion, preparing you to apply these techniques in clinical settings. --- ### Congenital Melanocytic Naevus: Features & Management URL: https://www.theplasticsfella.com/congenital-melanocytic-naevus/ Last updated: 2024-05-06T19:50:55.000Z #### Summary Card [****Definition of a Congenital Melanocytic Naevus**](https://www.theplasticsfella.com/congenital-melanocytic-naevus/#definition-of-a-congenital-melanocytic-naevus) A brown or black lesion is present at birth, which can be considered "giant" if >20cm. [****Features of Congenital Melanocytic Naevu**](https://www.theplasticsfella.com/congenital-melanocytic-naevus/#features-of-congenital-melanocytic-naevus)[****s**](https://www.theplasticsfella.com/congenital-melanocytic-naevus/#features-of-congenital-melanocytic-naevus) A congenital lesion with pigmentation changes, risk of malignant transformation, and extracutaneous complications. [****Management of Congenital Melanocytic Naevus**](https://www.theplasticsfella.com/congenital-melanocytic-naevus/#management-of-congenital-melanocytic-naevus) A multi-disciplinary team for active surveillance or surgical resection if indicated. --- ## Definition of a Congenital Melanocytic Naevus A congenital melanocytic lesion is a black or brown lesion present at birth. A “giant” congenital melanocytic nevus is >20 cm in adults or predicted to reach that size by adulthood ([Bittencourt](https://pubmed.ncbi.nlm.nih.gov/11015516/?ref=theplasticsfella.com) et al., 2000). The image below illustrates the signs of Congenital Melanocytic Naevus. ![Giant Congenital Melanocytic Naevus Signs](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Giant-Congenital-Melanocytic-Naevus.png) Giant Congenital Melanocytic Naevus 😎 ****Fun Fact:** A melanocytic nevus is an abnormal collection of melanocytes of neuroectodermal origin in an ectopic location. --- ## Features of Congenital Melanocytic Naevus ****Key Point** A congenital melanocytic naevus is a pigmented lesion present at birth that has a risk of malignant transformation and extracutaneous deposition. A congenital melanocytic naevus presents as a brown or black lesion at birth. It is most commonly found on the trunk and changes appearance over time with multiple satellite lesions. ### **Natural History** The natural history of giant congenital melanocytic nevi is one of expansion in proportion to the body’s growth. - **At birth:** hairless, pale brown, flat lesion. - **Colour:** hyperpigmentation and colour variegation, the surface pigment may fade. - **Texture:** hypertrichosis, verrucous, nodularity (neurotisation of the lesion). - **Malignant Transformation**: focal growths, ulceration, pruritus, pain, or bleeding. The image below illustrates the natural growth of a congenital melanocytic naevus. ![The presentation of a congenital melanocytic naevus](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Congenital-Melanocytic-Naevus.png) The presentation of a congenital melanocytic naevus ### **Complications** Complications of giant congenital melanocytic nevi include irritating symptoms (pruritus, ulceration), psychosocial dysfunction related to the aesthetic appearance, and prolonged treatment. Less common complications include: - **Melanoma:** malignant transformation is discussed more below. - **Extracutaneous deposits:** mucosal, retroperitoneal, and leptomeningeal. - **Neurocutaneous melanosis:** benign or malignant CNS proliferation in patients with giant CMN, multiple satellite lesions, and location of trunk or calvarium. - **MSK associations:** scoliosis, spinal dysraphism, limb abnormalities. ### **Melanoma Transformation** Malignant transformation in patients with giant congenital melanocytic nevi can result in **cutaneous** or **noncutaneous** melanoma. The reported risk of melanoma in patients with giant congenital melanocytic nevi ranges from 3-9% ([Watt](https://pubmed.ncbi.nlm.nih.gov/15253185/?ref=theplasticsfella.com) et al., 2004) with a lifetime risk of approximately 6% (\~ 17-fold increased risk of melanoma compared with the general population) ([Rhodes](https://pubmed.ncbi.nlm.nih.gov/7243980/?ref=theplasticsfella.com) et al., 1981). In relation to the rate of malignant transformation ([Trozak](https://pubmed.ncbi.nlm.nih.gov/1090894/?ref=theplasticsfella.com) et al., 1975 & [Kaplan](https://pubmed.ncbi.nlm.nih.gov/4815697/?ref=theplasticsfella.com), 1974): - 50% by age 3 - 60% by childhood - 70% by puberty For this reason, surgical excision of high-risk cutaneous lesions is best performed in early childhood rather than delaying treatment until a later age. --- ## Management of Congenital Melanocytic Naevus ****Key Point** A congenital melanocytic naevus is managed through a multi-disciplinary team. The majority of lesions are treated through active surveillance or surgical resection if indicated. A multidisciplinary approach involving paediatricians, dermatologists, psychologists, plastic surgeons, neurologists, neurosurgeons, and radiologists. ### Active Surveillance - Regular examination with photography by a dermatologist and plastic surgeons. - Patient education on the natural history and potential for pigment fading. The image below illustrates the complications of giant congenital melanocytic naevus. ![This illustrates the complications of giant congenital melanocytic naevus. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Complications-Congenital-Melanocytic-Naevus.png) Giant Congenital Melanocytic Naevus ### Surgical Excision **Indications** for surgical excision of congenital melanocytic nevi include ([Gosain](https://pubmed.ncbi.nlm.nih.gov/11698832/?ref=theplasticsfella.com) et al. 2001 & [Bauer](https://pubmed.ncbi.nlm.nih.gov/15636760/?ref=theplasticsfella.com) et al., 2005): - Melanoma transformation - Symptom control - Maintain function - Aesthetic improvement 😎 ****Fun Fact:** Routine surgery with current techniques has not been shown to reduce the risk of malignancy in CMNs and is therefore for cosmetic reasons only ([Kinsler & Bulstrode](https://www.researchgate.net/publication/24041287%5FThe%5Frole%5Fof%5Fsurgery%5Fin%5Fthe%5Fmanagement%5Fof%5Fcongenital%5Fmelanocytic%5Fnaevi%5Fin%5Fchildren%5Fa%5Fperspective%5Ffrom%5FGreat%5FOrmond%5FStreet%5FHospital?ref=theplasticsfella.com), 2009). Surgical **options** include: - **Direct Excision:** the most accepted treatment option. - **Serial excision:** ideally, if amenable to an excision in three stages or less. - **Reconstruction:** skin graft, expansion, skin substitutes, free tissue transfer. After surgical treatment, regular follow-up for recurrence and monitoring of satellite lesions. **Timing of Surgery** Early surgery has not been shown to be advantageous and carries increased anaesthetic risk. Surgery can be considered in patients after 1 year when anaesthetic risks are lower. Traditionally, it was thought that early surgery for CMNs was preferable. This was based on the theory that pigment deepens after birth (‘Abtropfung’) (Unna, 1893). This has now been refuted, and the current theory is that the depth of the naevus correlates best with its size ([Worret](https://pubmed.ncbi.nlm.nih.gov/9557780/?ref=theplasticsfella.com) et al., 1893 & [Barnhill](https://pubmed.ncbi.nlm.nih.gov/7593778/?ref=theplasticsfella.com) et al., 1995 & [Cass](https://pubmed.ncbi.nlm.nih.gov/9094005/?ref=theplasticsfella.com) et al., 1997). ### Non-Surgical Options Many nonsurgical options for the treatment of giant congenital melanocytic nevi have been described, including **dermabrasion**, **laser** ablation, **curettage**, and **chemical peel**. Limitations with these treatments include: - Decrease the burden of nevus cells but do **not** result in complete cell removal. - No histologic diagnosis. - Difficult postoperative monitoring. 💡 ****Tip:** Consider an MRI and neurodevelopmental assessment if a giant with multiple satellite lesions. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Congenital Melanocytic Naevus:** Gained a comprehensive understanding of what a congenital melanocytic naevus is, including the differentiation between common and giant types based on size criteria. ****2\. Features and Complications:** Learned about the distinct features of congenital melanocytic naevi, such as pigmentation changes, and the risk factors associated with malignant transformation and extracutaneous manifestations. ****3\. Management Strategies:** Explored the various management strategies for congenital melanocytic naevi, including the roles of active surveillance and surgical resection. ****4\. Treatment Options:** Familiarized yourself with the specific treatment options available for congenital melanocytic naevi, from non-surgical approaches like dermabrasion and laser therapy to surgical interventions such as excision and reconstructive techniques. ****5\. Preventive and Monitoring Measures:** Understood regular monitoring and patient education in managing congenital melanocytic naevi to monitor for signs of malignant transformation and to manage cosmetic concerns. ****6\. Potential for Malignant Transformation:** Developed an awareness of the potential for malignant transformation within these naevi and the implications this has for long-term patient management and surveillance protocols. ## --- ## References 1. Bittencourt, F. V., Marghoob, A. A., Kopf, A. W., et al. [Large congenital melanocytic nevi and the risk for development of malignant melanoma and neurocutaneous melanocytosis](https://pubmed.ncbi.nlm.nih.gov/11015516/?ref=theplasticsfella.com). *Pediatrics* 106: 736, 2000. 2. Watt, A. J., Kotsis, S. V., and Chung, K. C. [Risk of melanoma arising in large congenital melanocytic nevi: A systematic review](https://pubmed.ncbi.nlm.nih.gov/15253185/?ref=theplasticsfella.com). *Plast. Reconstr. Surg.* 113: 1968, 2004. 3. Rhodes, A.R., Wood, W.C., Sober, A.J.et al. [Nonepidermal origin of malignant melanoma associated with a giant congenital nevocellular nevus](https://pubmed.ncbi.nlm.nih.gov/7243980/?ref=theplasticsfella.com). *Plast. Reconstr. Surg.* 67: 782, 1981. 4. Trozak, D. J., Rowland, W. R., and Hu, F. [Metastatic malignant melanoma in prepubertal children](https://pubmed.ncbi.nlm.nih.gov/1090894/?ref=theplasticsfella.com). *Pediatrics* 55: 191, 1975. 5. Kaplan, E. N. [The risk of malignancy in large congenital nevi](https://pubmed.ncbi.nlm.nih.gov/4815697/?ref=theplasticsfella.com). *Plast. Reconstr. Surg.* 53: 421, 1974. 6. Gosain, A. K., Santoro, T. D., Larson, D. L., et al. [Giant congenital nevi: A 20-year experience and an algorithm fortheir management](https://pubmed.ncbi.nlm.nih.gov/11698832/?ref=theplasticsfella.com). *Plast. Reconstr. Surg.* 108: 622, 2001. 7. Bauer, B. S., and Corcoran, J. [Treatment of large and giant nevi](https://pubmed.ncbi.nlm.nih.gov/15636760/?ref=theplasticsfella.com). *Clin. Plast. Surg.* 32: 11, 2005. 8. Unna PG. Naevi und Naevocarcinome. Berl Klin Wochenschr 1893;30:14e6. 9. Worret WI, Burgdorf WH. [Which direction do nevus cells move?Abtropfung reexamined](https://pubmed.ncbi.nlm.nih.gov/9557780/?ref=theplasticsfella.com). Am J Dermatopathol 1998;20:135e9 10. Barnhill RL, Fleischli M. [Histological features of congenital melanocytic nevi in infants one year of age or younger](https://pubmed.ncbi.nlm.nih.gov/7593778/?ref=theplasticsfella.com). J Am AcadDermatol 1981;33:780e5. 11. Cass DL, Bullard KM, Sylvester KG, et al. [Wound size and gestational age modulate scar formation in fetal wound repair](https://pubmed.ncbi.nlm.nih.gov/9094005/?ref=theplasticsfella.com). J Pediatr Surg 1997;32:411e5. 12. Kinsler, V., & Bulstrode, N. (2009). [The role of surgery in the management of congenital melanocytic naevi in children: a perspective from Great Ormond Street Hospital](https://www.researchgate.net/publication/24041287%5FThe%5Frole%5Fof%5Fsurgery%5Fin%5Fthe%5Fmanagement%5Fof%5Fcongenital%5Fmelanocytic%5Fnaevi%5Fin%5Fchildren%5Fa%5Fperspective%5Ffrom%5FGreat%5FOrmond%5FStreet%5FHospital?ref=theplasticsfella.com). Journal of Plastic, Reconstructive & Aesthetic Surgery, 62(5), 595–601.doi:10.1016/j.bjps.2008.12.016 10.1016/j.bjps.2008.12.016 --- ### Skills > Ethics (apparently), Podcast Teaser, New Surgical Techniques Collection. URL: https://www.theplasticsfella.com/may-5th/ Last updated: 2024-05-04T19:38:37.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/may-5th/#a-letter-from-pfella) Technical Skills trump ethics (apparently) 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/may-5th/#the-sunday-quiz) **\+ Leaderboard** How well do you know **Syndactyly?* 3. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/may-5th/#upcoming-events) 9 events in next 6 months. 4. ****🍴 New:** [****Surgical Techniques** ](https://www.theplasticsfella.com/may-5th/#new-feature)Incisions, Designs, Dissections, Repairs & more 5. ****🔥** [****3 New Articles**](https://www.theplasticsfella.com/may-5th/#articles-of-the-week) **with summaries!** Ring Avulsions, Thumb UCL Repair, Seymour Fracture. 6. 💕 [****Feedback**](https://www.theplasticsfella.com/may-5th/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **Technical Skills trump ethics (apparently)* 👋 ****Hey Team!** ****What Qualities Do You Value Most in a Consultant or Attending?** It's easy to focus on what leaders expect from us, but what do we really look for in them? Here’s a dive into the traits that make a consultant stand out: ****👇** ### Before you read on, take a quick second: What qualities do you really value in your consultant or attending? We often think about what **consultants and attendings** expect from us, **but let's flip the script**: What makes us really trust and value their leadership? To get some solid insights, I dove into the latest research. I found a compelling study in PRS Global Open (Sendek et al, 2023) that gives us a clear picture ![An external file that holds a picture, illustration, etc. Object name is gox-11-e5460-g002.jpg](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10721122/bin/gox-11-e5460-g002.jpg) Essential traits for plastic surgeons by group: faculty (123), residents (21), students (43) The chart really lays out how priorities shift in plastic surgery training from students to faculty: 1. **Faculty**: They really zero in on being "Technically Sound" (65%) and "Ethical" (55%). This was surprising? When you're leading surgeries and making big decisions, you've got to have the skills followed by integrity (apparently). 2. **Residents**: These are kind of in the middle ground. They still care a lot about technical skills (53%), but there's also a big nod towards being "Emotionally Intelligent" (42%) and "Adaptable" (37%). It’s about handling the pressures of surgery and adapting to whatever the OR throws at you. 3. **Students**: Here it’s all about being a "Collaborative/team player" (54%) and "Compassionate/empathetic" (39%). When you’re just starting out, the focus is really on getting along well with others and understanding patients’ needs. Also, "Culturally Competent" popping up (29%) shows they're tuning into the broader world's diversity, which is pretty crucial. As careers progress, the emphasis shifts from mastering interpersonal skills to honing technical and ethical expertise. It’s intriguing to see how the valued traits evolve with increasing responsibilities in plastic surgery. P'Fella ❤️ ****tl;dr** Essential traits valued in plastic surgery vary by training level—faculty focus on technical skill and ethics, residents balance technical skills with emotional intelligence and adaptability, while students emphasize teamwork, empathy, and cultural competence ## The Sunday Quiz **How well do you know syndactyly?* Welcome to ****the next round** of The Weekly Quiz. Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end six rounds will earn you a $100 voucher. Good luck! ## Upcoming Events A Curated List of Webinars, Courses & Conferences ## Behind the ‘Fella Launching in 2 weeks We're excited to take you behind the scenes at ThePlasticsFella with our brand-new podcast! We'll share exclusive insights from our team meetings and dive into complex topics with top experts in the field. Just last week, you helped choose our new logo.. **and here is the winner!** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/behind-the--fella-logo.png) The new logo as voted by you! ### Get Notified Early ## New Feature Surgical Techniques are now live! ### Explore our new feature: a guide to plastic surgery techniques! This comprehensive resource covers surgical preparation, execution, and post-operative care. Designed for surgeons and medical students alike, it includes detailed steps, visual aids, and expert insights. **Currently in the experimentation phase, we welcome your feedback to enhance its utility.** **This collection will be growing over time!** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/05/Thumb-MCPJ-UCL-Incision-1.png) #### Surgical Checklist ✅ [****Prepare**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#preparation)****:** Regional or general anaesthesia, tourniquet, loupes. ✅ [****Design**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#design): ulnar mid-axial side distal to dorsal-ulnar border proximal. ✅ [****Dissect**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#dissection)****:** Protect dorsal nerve, incise aponeurosis, capsulotomy. ****✅** [****Primary Repair**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#primary-repair-of-ucl): ligament-ligament, ligament-periosteum. ****✅** [****Close**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#closure)****:** Layered closure of capsule, aponeurosis & skin. ****✅** [****Post-Op**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#post-operative)****:** Elevation, analgesia, immobilization, hand Therapy. [Read the Full Article](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/) ## Articles of the Week 3 Interesting Articles with 1 sentence summaries. 1️⃣ ***A New way to treat finger degloving injuries** ([Shiyu](https://www.jhandsurg.org/article/S0363-5023%2823%2900649-4/abstract?ref=theplasticsfella.com), 2024) This new surgical technique repairs fingertip degloving injuries effectively using artificial dermis combined with a medial flap from the second toe. This preserves toenail integrity, finger length, and function. 2️⃣ ***How to treat a Thumb UCL injuries** ([Legerstee](https://journals.sagepub.com/doi/10.1177/17531934241235556?ref=theplasticsfella.com), 2024) Find out how regardless of the method used, effective postoperative results can be achieved for thumb ulnar collateral ligament ruptures. 3️⃣ ***Best practices for Seymour fractures** ([Kiely](https://pubmed.ncbi.nlm.nih.gov/34810026/?ref=theplasticsfella.com), 2022) How does early debridement within 48 hours and prophylactic antibiotics significantly reduce infection risks in pediatric Seymour fractures? ## Feedback ### I hope you enjoyed it 😄 --- ### Primary Repair Thumb MCPJ UCL Injury - Surgical Technique URL: https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/ Last updated: 2024-05-20T19:39:59.000Z #### Surgical Checklist ✅ [****Prepare**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#preparation)****:** Regional or general anaesthesia, tourniquet, and loupes. ✅ [****Design**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#design): ulnar mid-axial side distal to dorsal-ulnar border proximal. ✅ [****Dissect**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#dissection)****:** Protect dorsal nerve, incise aponeurosis, capsulotomy. ****✅** [****Primary Repair**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#primary-repair-of-ucl): ligament-ligament, ligament-periosteum. ****✅** [****Close**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#closure)****:** Layered closure of capsule, aponeurosis & skin. ****✅** [****Post-Op**](https://www.theplasticsfella.com/thumb-mcpj-ucl-injury-surgical-technique/#post-operative)****:** Elevation, analgesia, immobilization, hand Therapy. ****Primary Contributor:** Dr Suzanne Thomson, Educational Fellow. ****Reviewer:** Dr Kurt Lee Chircop, Educational Fellow. _This post is for subscribers on the thePlastics Pro tier only._ ### Lip Reconstruction: Anatomy, Indications, & Algorithm URL: https://www.theplasticsfella.com/lip-reconstruction/ Last updated: 2025-05-21T10:16:34.000Z #### Summary Card [****Anatomy of Lip Reconstruction**](https://www.theplasticsfella.com/lip-reconstruction/#anatomy-of-lip-reconstruction) The lip is composed of skin, muscle, and mucosa. Its blood supply is the labial arteries. [****Principles of Lip Reconstruction**](https://www.theplasticsfella.com/lip-reconstruction/#principles-of-lip-reconstruction) Restore the layers of the lip. Key landmarks to preserve include the philtrum, modiolus, cupid's bow, and vermillion. [****Lip Reconstruction Options**](https://www.theplasticsfella.com/lip-reconstruction/#lip-reconstruction-options) The lip can be reconstructed by primary closure, local flap, or free flap. This depends on the patient and the lip defect (size and location). [****Primary Lip Closure in Lip Reconstruction**](https://www.theplasticsfella.com/lip-reconstruction/#primary-lip-closure-in-lip-reconstruction) Defects <1/3 of the lip and appropriate soft tissue laxity. [****Abbe Lip Switch Flap**](https://www.theplasticsfella.com/lip-reconstruction/#abbe-lip-switch-flap) Defects <1/3 of the lip and an ****intact commissure.** [****Abbe-Estlander Flap**](https://www.theplasticsfella.com/lip-reconstruction/#abbe-estlander-flap) Defects <1/3 of the lip and an ****involved commissure.** [****Karapandzic Flap**](https://www.theplasticsfella.com/lip-reconstruction/#karapandzic-flap) Central defects <2/3 of the upper and lower lip. [****Bernard-Burow Cheiloplasty**](https://www.theplasticsfella.com/lip-reconstruction/#bernard-burow-cheiloplasty) Central defect >2/3 of the lower lip, causes incompetence & microstomia. [****Free Flap Reconstruction**](https://www.theplasticsfella.com/lip-reconstruction/#free-flap-reconstruction) Radial forearm flap to reconstruct the entire lip. There is no motor innervation, and cosmesis can be poor. --- ## Anatomy of Lip Reconstruction ****Key Point** The lip is composed of skin, muscle, and mucosa. It is supplied by the labial arteries. Key landmarks include modiolus, cupid's bow, vermillion, and philtrum. Lip reconstruction recreates the skin, muscle, and mucosa elements of the lip to maintain oral competence, speech, and cosmesis. The neurovascular anatomy of the lip is detailed below. - **Motor:** buccal and mandibular branches of the facial nerve. - **Sensory:** infraorbital (upper), mental (lower) branches of trigeminal nerve. - **Blood supply:** superior and inferior labial branches of the facial artery. The landmarks of the lip are illustrated below. ![Landmarks of the Lip, Lip Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/1-2.png) Landmarks of the Lip [Read more on Lip Anatomy](https://www.theplasticsfella.com/anatomy-of-the-lip/) --- ## Principles of Lip Reconstruction ****Key Point** Lip reconstruction should restore the layers of the lip. There are key anatomical landmarks that should also be preserved. "Restoration is designed from within.... the mucosal lining should be considered first, then the supporting structures, and then finally the skin covering". This was outlined in Sir Harold Gilles's seminal publication, as illustrated below. ![Principles of Lip Reconstruction, Plastic Surgery of the Face by Sir Harold Gilles](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Principles-in-Lip-Reconstrucitn.png) Principles of Lip Reconstruction --- ## Lip Reconstruction Options ****Key Point** Lip reconstruction is guided by the location, size, and depth of the defect. Reconstructive options include primary closure, local flap, or free flap. Landmarks, competence, and function should be preserved when possible. Lip reconstruction should aim to restore "like with like". The reconstruction is dependent on the following factors: - **Location:** upper lip vs lower lip, central vs lateral vs commissural. - **Size and depth:** <1/3 vs <2/3, skin vs mucosal vs muscle, vermillion. - **Goals:** function vs cosmesis vs maintaining oral aperture (important for dentures). The lip reconstructive options are illustrated in the table below. ![A table explaining the different types of lip reconstructions available to the upper and lower lip. Columns discuss their indications, limitations and benefits](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Types-of-Lip-Reconstructions.png) Lip Reconstruction Options ### 💡 ****Tip:** the size of the lip defect (e.g. "<1/3") should be considered as a guide only. Each patient is different with different degrees of soft tissue laxity. --- ## Primary Lip Closure in Lip Reconstruction ****Key Point** Primary lip closure is used for defects less than one-third of the lip, following wedge excision of lesions. It maintains muscle continuity and innervation in a single stage. This is indicated in patients with defects <1/3 of the lip and appropriate soft tissue laxity. It is commonly used after wedge excision of lip lesions, such as [squamous cell carcinoma](https://www.theplasticsfella.com/squamous-cell-carcinoma/). - **Indications:** defect <1/3 of the lip and appropriate soft tissue laxity. - **Benefit:** single-stage, innervated, muscle continuity. - **Limitations:** small defects, can remove cupid's bow/philtrum. - **Design:** Realign all layers of the lip (skin, muscle, and mucosa). Primary lip closure is better illustrated in the image below. ![A labelled drawing of a red lip with a cancer. The lip is reconstruced with a blue dotted line to show a primary closure reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/3-2.png) Primary Lip Closure 💡 ****Tip:** the wedge resection of the lip can be designed as a "W", "V", pentagonal, rectangular ± burrow's triangles. --- ## Abbe Lip Switch Flap ****Key Point** This is indicated in compliant patients with defects <1/3 of the lip and an intact commissure. The second-stage release should be performed in 2-3 weeks. Abbe Lip Switch Flap is a refined surgical technique designed for patients with specific lip defects. This is ideal for defects that are less than one-third of the lip's length and when the commissure remains intact. - **Indications:** defect <1/3 of the lip + intact commissure + compliant patient. - **Benefit:** muscle continuity, preserves landmarks (cupid's bow, philtrum, modiolus). - **Limitations:** two-stage, insensate. - **Design:** full thickness, half the defect width, based on ipsilateral labial artery. - **Tip:** protect the labial artery with a cuff of muscle and ensure adequate mouth opening during the 2-week period between the first and second stages. The anatomy of the Abbe Lip Switch Flap is illustrated below. ![A labelled drawing of a red lip with a cancer. The lip is reconstruced with a blue dotted line to show a lip switch. Arrows show the arteries and incisions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2025/05/Lip-Reconstruction.png) Abbe Lip Switch in Lip Reconstruction 💡 ****Tip:** The Abbe-Lip switch can be combined with a perialar crescentic advancement for central defects. --- ## Abbe-Estlander Flap ****Key Point** This is indicated in compliant patients with defects <1/3 of the lip and an involved commissure. The second-stage release should be performed in 2-3 weeks. This surgical approach is ideal for patients with lip defects under two-thirds and involving the commissure, allowing for a potential single-stage process. - **Indications:** defect <2/3 of upper and lower lip + commissure affected. - **Benefit:** single-stage is possible. - **Limitations:** insensate, can distort oral animation as modiolus altered. - **Design:** full thickness, third-half defect width, contralateral labial artery. - **Tip:** protect the labial artery with a cuff of muscle; it may require secondary commissuroplasty. The image below illustrates the mechanism of the Abbe-Estlander Flap. ![A labelled drawing of a red lip with a cancer. The lip is reconstruced with a blue dotted line to show a Abbe-Estlander flap. Arrows show the arteries and incisions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/5-1.png) Abbe-Estlander Flap 💡 ****Tip:** The Abbe-Estlander flap can technically be used for lower lip defects. Just consider that the upper lip is a less forgiving donor site. --- ## Karapandzic Flap ****Key Point** This is indicated in central defects <2/3 of the upper and lower lip. This single-stage procedure is based on the bilateral labial arteries. It can lead to microstomia. The karapandzic flap is an orbicularis oris myocutaneous flap with an axial blood supply. - **Indications**: central defect <2/3 of upper and lower lip. - **Benefit:** single-stage, sensate, preserves oral competence and landmarks (philtrum and modioulus). - **Limitations:** can lead to microstomia. - **Design:** rotational, circumoral flaps based on the bilateral labial arteries. - **Tip**: preserve the vascular pedicles and buccal branches by performing intramuscular dissection. Karapandzic Flap lip reconstruction is illustrated below. ![A labelled drawing of a red lip with a cancer. The lip is reconstruced with a blue dotted line to show a Karapandzic Flap. Arrows show the arteries and incisions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/6.png) Karapandzic Flap 💡 ****Tip:** In a karapandzic flap, the width of the circumoral incision must be equal to the height of the defect at all points of the flap. --- ## Bernard-Burow Cheiloplasty ****Key Point** This is indicated in central defects >2/3 of the lower lip. This single-stage procedure is based on the subdermal plexus and can result in oral incompetence and microstomia. This procedure, efficient in its single-stage approach, utilizes the subdermal plexus for the medial advancement of the cheek with innovative Burow's triangles. - **Indications:** central defect >2/3 of the lower lip. - **Benefit:** single-stage. - **Limitations:** insensate, can lead to oral incompetence and microstomia. - **Design:** medial advancement of the cheek with Burow's triangles. - **Tip:** based on facial subunits and the dermal plexus. The Bernard-Burow Flap is illustrated in the image below. ![A labelled drawing of a red lip with a cancer. The lip is reconstruced with a blue dotted line to show a Bernard-Burow lip flap. Arrows show the arteries and incisions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/7.png) Bernard-Burow Flap (Webster Modification) 💡 ****Tip:** The Webster modification preserves muscular innervation by not incorporating muscle in Burow's triangles. --- ## Free Flap Reconstruction ****Key Point** The radial forearm flap can be considered for reconstructing the entire lip in patients with irradiated tissue (post-tumour resection). There is no motor innervation, and cosmesis can be poor. The Radial Forearm Flap is a choice for reconstructing the entire lip, particularly in patients with tissue damage from radiation post-tumor resection. - **Indications:** total or near total loss of the lip. - **Benefit:** good soft tissue coverage with potential for sensation with lateral antebrachial cutaneous nerve. - **Limitations:** no motor innervation, poor cosmesis (colour and lip landmarks). - **Design:** radial forearm and palmaris longus. - **Tip:** consider in patients after tumour resection and radiotherapy to local tissues. There are currently published case reports on the role of an innervated gracilis muscle in providing a functional lower lip. The radial forearm and palmaris longus is illustrated below. ![An intra-operative picture of a radial forearm flap being raised. The surgeons are in green and the patient has blood on their arm. This is for a lip reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/8.png) Radial Forearm Lip Reconstruction 💡 ****Tip:** Lower lip height can be maintained by incorporating the palmaris longus into the radial forearm flap. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Lip Anatomy and Landmarks:** You've gained a detailed understanding of the functional and aesthetic components that make up the lip, including the skin, muscle, mucosa, and critical vascular supply. ****2\. Lip Reconstruction Principles:** You've learned about the principles of lip reconstruction which emphasize restoring the lip's three layers while preserving key anatomical landmarks like the philtrum, modiolus, cupid's bow, and vermillion for both functional and cosmetic purposes. ****3\. Reconstruction Techniques Overview:** You've gained knowledge on various surgical techniques for lip reconstruction, tailored to the extent and location of the defect. ****4\. Specific Surgical Options:** You've reviewed surgical options including the Abbe Flap, Karapandzic Flap, Bernard-Burow Cheiloplasty, and others, understanding their indications, benefits, and limitations. ****5\. Decision Making in Lip Reconstruction:** Finally, you've learned how to apply these concepts in clinical practice, considering factors such as the size of the defect, the involvement of key structures, patient-specific factors, and desired outcomes to select the most appropriate reconstructive strategy. --- ### Dynamic Facial Palsy Reconstruction: Grafts, Transfers, & Muscle Flaps URL: https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/ Last updated: 2024-04-30T21:01:30.000Z ‌ #### Summary Card [****Overview of Dynamic Reconstruction**](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#overview-of-dynamic-reconstruction) Dynamic reconstruction includes nerve grafts, nerve transfers, muscle transfers, muscle flaps or a combination. [****Primary Facial Nerve Repair** ](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#primary-facial-nerve-repair)Indicated in acute extra-cranial facial nerve injury with proximal and distal nerve stumps that can be repaired under minimal tension. [****Ipsilateral Nerve Grafting** ](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#ipsilateral-nerve-grafting)Indicated in acute extra-cranial nerve injuries with a wide neural gap that is not amenable to a tension-free direct repair. [****Cross-Facial Nerve Graft** ](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#cross-facial-nerve-graft)Indicated if distal branches present but ****no proximal stump** ± ****muscle transfer** if no viable facial muscle or babysitter procedure. [****Nerve Transfers** ](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#nerve-transfers)Indicated if distal branches present but ****no proximal stump** ± ****muscle transfer** if there is no viable facial muscle ± CFNG****.** [****Regional Muscle Transfer** ](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#regional-muscle-transfer)Indicated when no viable muscles in long-standing palsy. The temporalis muscle is a commonly used option. [****Free Muscle Transfer** ](https://www.theplasticsfella.com/dynamic-facial-nerve-palsy-reconstruction/#free-muscle-transfer)Indicated if facial muscles will not provide useful function after motor reinnervation ± CFNG or babysitter procedure. Gracilis is the most commonly used. --- ## Overview of Dynamic Reconstruction ****Key Point** Dynamic reconstruction options include nerve grafts, nerve transfers, muscle transfers, muscle flaps, or a combination of the above. This is guided by the patient, aetiology, timing, and location of facial nerve palsy. ### Overview Traditionally, there have been two ways to categorise operative techniques for facial nerve palsy: 1. **Non-operative:** "conservative". 2. **Operative:** static and dynamic reconstruction. The **aim** of the treatment is: - Symmetry at rest - Dynamic, spontaneous movements - Ocular, nasal and oral competence - Corneal protection - Reduce surgical morbidities ### Reconstructive Strategy The treatment options for facial nerve palsy can be simplified by looking at 3 key factors – **aetiology**, **time,** and **location**. - **Patient:** what is their current status, and what is the aetiology of their facial nerve palsy. This will guide the expected clinical course and potential recovery. - **Time** reflects the trophic status of the facial muscles. After 18 months, treatment options should include new muscle. - **Location** reflects the viability of a proximal stump or distal branches. There is no proximal stump present in intra-cranial/intra-temporal palsy. Based on these factors, a facial palsy patient will require nerve, muscle or a combination of both for successful dynamic reconstruction. This is illustrated in the diagram below. ![Dynamic Facial Palsy Reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Dynamic-Facial-Palsy-Options.png) Dynamic Facial Palsy Reconstruction 💡 ****Tip:** muscle recruitment is required after 18 months of injury due to motor end-plate atrophy, neuromuscular fibrosis and muscle atrophy. --- ‌ ‌‌ ‌ ## Primary Facial Nerve Repair ‌ ****Key Point** ****Indication:** Acute extra-cranial facial nerve injury with proximal and distal nerve stumps that can be repaired under minimal tension. ‌ Primary facial nerve repair provides the best chance of nerve function recovery ([Humphrey](https://doi.org/10.1055/s-2008-1075832?ref=theplasticsfella.com) et al., 2008). It is the treatment of choice for acute extra-cranial facial nerve injuries ([Humphrey](https://doi.org/10.1055/s-2008-1075832?ref=theplasticsfella.com) et al., 2008) when there is a proximal and distal stump. In terms of the surgical technique: 1. Tension-free nerve coaptation with minimal anatomical displacement ([Gordin](https://doi.org/10.1055/s-0034-1372522?ref=theplasticsfella.com) et al., 2015). 2. Patient must have viable facial muscle fibres and functional motor endplates. 3. Within 72 hours, allow identification with a nerve stimulator. 4. Epineural vs perineural is adequate ([Gordin](https://doi.org/10.1055/s-0034-1372522?ref=theplasticsfella.com) et al., 2015). 5. Suture or fibrin glue – with no convincing superiority outcomes currently ([Bozorg](https://doi.org/10.1007/s00405-004-0829-6?ref=theplasticsfella.com) et al., 2004) --- ‌ ‌ ## Ipsilateral Nerve Grafting ‌ ****Key Point** ****Indication:** Acute extra-cranial nerve injuries with a wide neural gap that is not amenable to a tension-free direct repair. Autologous ipsilateral nerve grafting is indicated in patients with facial palsy and a wide neural gap. Nerve grafting should go beyond the zone of injury. Donor nerves for this technique include: - **Greater auricular nerve:** 10 cm length, proximity to the operative field - **Sural nerve:** 35cm length that can be neurolysed as segments ([Chu & Byrne](https://doi.org/10.1055/s-2008-1075831?ref=theplasticsfella.com), 2008) and allows a two-team approach with minimal donor-site morbidity. - **Antebrachial cutaneous nerves​​:** arm donor site morbidity ([Myckatyn](https://doi.org/10.1016/s0094-1298%2802%2900102-5?ref=theplasticsfella.com) et al., 2003) - **Cervical Plexus:** proximity to the operative field. **Advantages** - Donor nerves have a suitable length for reconstruction. - Proximity to the operative field. - Some donor nerves allow a two-team approach (sural nerve). **Disadvantages** of this nerve grafting include: - **Numbness at donor site** – sural nerve and lateral foot paraesthesia. - Inadequate **size** match of donor and recipient nerves. - Linked to **synkinesis** if performed in the intraosseous part of the facial nerve. --- ## Cross-Facial Nerve Graft ****Key Point** ****Indication:** Facial Palsy with ****no proximal stump** but distal branches are present. This may be supplemented with a ****muscle transfer** if there is no viable facial muscle in injuries in long-standing paralysis. ### Overview The VII-VII cross facial nerve graft (CFNG) was first described by Scaramella. It provides cross-innervation from the non-paralysed contralateral side to the paralysed ipsilateral side. ### Technique The CFNG can be performed as a one- or two-stage procedure. The growth of axons is assessed by an advancing Tinel's sign. - **Donor Graft:** reverse sural nerve graft. - **Donor Nerve:** a facial nerve branch that produces a smile without eye closure. - **Coaptation:** distal nerve stumps or neurotisation directly into the muscle. - **Variations**: followed by a free muscle transfer (after motor axonal growth) or combined with a "babysitter procedure" (partial hypoglossal to facial). In a **single-stage** operation, both ends of the sural nerve graft are repaired. In a **two-stage**, repair the intact side. The graft is successful if a neuroma needs to be resected and an advancing positive Tinels sign. ### Discussion - **Advantages:** symmetrical spontaneous motion because of the fibres from the unaffected facial nerve acting as "pacemakers” for the affectedside. - **Disadvantages:** prolonged denervation period during the regenerative period can lead to irreversible muscle atrophy. --- ## Nerve Transfers ****Key Point** ****Indication:** Facial Palsy with ****no proximal stump** and ****intact distal nerves.** This may be supplemented with a muscle transfer if there is no viable facial muscle in injuries. ### Overview Nerve transfers are suitable for patients with an intact distal nerve but no proximal stump. In rarer cases, it can also be used in Mobius Syndrome, where a cross-facial nerve graft is contraindicated or as a babysitter procedure, as described above. ### Technique The **donor nerves** include nerve to masseter, glossopharyngeal, accessory, phenic and hypoglossal. In a **hypoglossal** (XII) to the facial nerve (VII) nerve transfer: - The hypoglossal is near the extratemporal facial nerve. - XII is divided distally and reflected up to VII. - Can consider a "jump graft": end-to-side coaptation of a nerve graft to XII and the other end of the graft is sutured to the distal stumps of VII (preserves ipsilateral tongue function). In a **“babysitter procedure”** described by Terzis**:** - A cranial nerve transfer acting as a *babysitter* to the musculature by providing a faster route to re-innervation. - It preserves the musculature and possibly the denervated stump while the axons grow across the cross-face nerve graft. - For example: the motor nerve to masseter. ### Discussion - **Advantages:** provide good muscle tone, powerful excursion. - **Disadvantage:** sacrifice a donor cranial nerve and can produce synkinesis. 💡 ****Fun Fact:** if the hypoglossal nerve is used, it results in ipsilateral atrophy of tongue musculature, which affects speech and swallowing. --- ## Regional Muscle Transfer ****Key Point** ****Indication:** When there is ****no viable musculature**. When there is no viable musculature, then muscle should be imported. This occurs after long-standing atrophy. Local muscle flaps have been described to dynamize the face by utilising the functional trigeminal nerve on the paralysed side. **Temporalis Muscle Transfer** - **Origin**: As described by Gilles, Labbé, Hault and many other variations. - **Anatomy:** fan-shaped muscle from temporal fossa to coronoid process supplied by temporal artery & innervated by the trigeminal nerve. - **Procedure:** the strip of muscle is folded over the zygomatic arch and inserted into the eye or oral commissure ± detached from coronoid insertion. **Masseter Muscle Transfer** - **Indication:** restore motion to the lower part of the face. - **Technique**: released from the mandible and attached to orbicularis. **Digastric Muscle Transfer**: - **Indication**: restore lower lip depressor function in mandibular branch nerve injuries. - **Technique**: anterior digastric tendon is inserted into the orbicularis at the lower vermillion, central to the commisure. **Disadvantages**: - Muscle transpositions are usually unable to recreate a spontaneous dynamic smile as activation of the muscle requires a specific manoeuvre (such as clenching the teeth). - Most donor muscles are innervated by the trigeminal nerve, so they don't produce true mimetic function. ‌ --- ## Free Muscle Transfer ****Key Point** ****Indication:** Facial muscles will not provide useful function after motor reinnervation. Facial re-animation with free muscle transfer is indicated when facial muscles will not provide useful function after reinnervation. It requires both neural control and muscle recruitment. It can be a one-stage operation if a masseteric nerve transfer is possible. It is typically a two-stage operation requiring a CFNG followed by a microneurovascular muscle transfer. **General Principles** 1. Match the size of donor and recipient nerves. 2. Leave the donor short to minimize re-innervation time. 3. Allow for 50% loss of power following transfer. 4. Match size and shape of donor's muscle to available pocket. **Donor Muscle Options:** - [Gracilis](https://www.theplasticsfella.com/gracilis-flap/): most commonly used - Latissimus Dorsi - Pectoralis Minor - Extensor digitorum brevis --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Dynamic Facial Palsy Reconstruction:** You have gained a thorough understanding of dynamic reconstruction options for facial palsy, including nerve grafts, nerve transfers, muscle transfers, and muscle flaps. This knowledge will help in identifying the appropriate intervention based on patient-specific factors such as the aetiology, timing, and location of the facial nerve palsy. ****2\. Exploring Specific Treatments:** You've explored detailed treatment modalities for various scenarios of facial nerve injury. These include primary facial nerve repair for acute injuries with available nerve stumps, ipsilateral nerve grafting for wide neural gaps, and cross-facial nerve grafting for cases with distal branches but no proximal stump. ****3\. Learning Surgical Techniques:** The article has introduced you to advanced surgical techniques and considerations, such as the use of regional muscle and free muscle transfers to restore facial function, especially in long-standing cases where muscle reinnervation is unlikely. ****4\. Appreciating Complex Decision-Making:** You've learned how the choice of surgical intervention is influenced by multiple factors, including the duration of the palsy, the presence or absence of nerve stumps, and the viability of facial musculature, which requires a nuanced understanding for effective treatment planning. --- ## Further Reading 1. Humphrey C, Kriet J. [Nerve repair and cable grafting for facial paralysis](https://doi.org/10.1055/s-2008-1075832?ref=theplasticsfella.com). *Facial Plast Surg*. 2008;24(2):170-176\. doi:10.1055/s-2008-1075832 2. Gordin E, Lee T, Ducic Y, Arnaoutakis D. [Facial nerve trauma: evaluation and considerations in management](https://doi.org/10.1055/s-0034-1372522?ref=theplasticsfella.com). *Craniomaxillofac Trauma Reconstr*. 2015;8(1):1-13\. doi:10.1055/s-0034-1372522 3. Bozorg Grayeli A, Mosnier I, Julien N, Garem H, Bouccara D, Sterkers O. [Long-term functional outcome in facial nerve graft by fibrin glue in the temporal bone and cerebellopontine angle](https://doi.org/10.1007/s00405-004-0829-6?ref=theplasticsfella.com). *Eur Arch Otorhinolaryngol*. September 2004:404-407\. doi:10.1007/s00405-004-0829-6 4. Millesi H. [The nerve gap](https://www.ncbi.nlm.nih.gov/pubmed/3539948?ref=theplasticsfella.com). Theory and clinical practice. *Hand Clin*. 1986;2(4):651-663. 5. Chu E, Byrne P. [Treatment considerations in facial paralysis](https://doi.org/10.1055/s-2008-1075831?ref=theplasticsfella.com). *Facial Plast Surg*. 2008;24(2):164-169\. doi:10.1055/s-2008-1075831 6. Myckatyn T, Mackinnon S. [The surgical management of facial nerve injury](https://doi.org/10.1016/s0094-1298%2802%2900102-5?ref=theplasticsfella.com). *Clin Plast Surg*. 2003;30(2):307-318\. doi:10.1016/s0094-1298(02)00102-5 7. Darrouzet V, Duclos J, Liguoro D, Truilhe Y, De B, Bebear J. [Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases](https://doi.org/10.1067/mhn.2001.116182?ref=theplasticsfella.com). *Otolaryngol Head Neck Surg*. 2001;125(1):77-84\. doi:10.1067/mhn.2001.116182 8. Liu Y, Han J, Zhou X, et al. [Surgical management of facial paralysis resulting from temporal bone fractures](https://doi.org/10.3109/00016489.2014.892214?ref=theplasticsfella.com). *Acta Otolaryngol*. 2014;134(6):656-660\. doi:10.3109/00016489.2014.892214 9. Nash J, Friedland D, Boorsma K, Rhee J. [Management and outcomes of facial paralysis from intratemporal blunt trauma: a systematic review](https://doi.org/10.1002/lary.21681?ref=theplasticsfella.com). *Laryngoscope*. 2010;120 Suppl 4:S214\. doi:10.1002/lary.21681 ‌‌‌‌ --- ### Hypertelorism: Definition, Classifying, Causes, & Treatment URL: https://www.theplasticsfella.com/hypertelorism/ Last updated: 2024-04-30T20:33:38.000Z #### Summary Card [****Definition of Hypertelorism**](https://www.theplasticsfella.com/hypertelorism/#definition-of-hypertelorism) An increase in the interorbital distance between the dacryons. [****Classification of Hypertelorism**](https://www.theplasticsfella.com/hypertelorism/#classification-of-hypertelorism) Tessier classification is based on interorbital distance. The standard is 20-30mm. [****Causes of Hypertelorism**](https://www.theplasticsfella.com/hypertelorism/#causes-of-hypertelorism) Syndromic (Apert's, Crouzens, Edwards) or non-syndromic (facial clefts, midline tumours). [****Treatment of Hypertelorism**](https://www.theplasticsfella.com/hypertelorism/#treatment-of-hypertelorism) An MDT to restore orbital dystopia and cosmesis through box osteotomy, facial bipartition, and medial canthopexy. --- ## Definition of Hypertelorism Hypertelorism is an increase in the interorbital distance as measured between the dacryons. It results in true lateralization of the orbit where the inner canthal distance (ICD), the outer canthal distance (OCD), and interpupillary distance (IPD) are all increased. It is a congenital condition caused by overexpansion of ethmoid sinuses. See image below for further clarification. ![Definition of Hypertelorism, Signs of Hypertelorism](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Definition-of-Hyperterlorism.png) Definition of Hypertelorism --- ## Classification of Hypertelorism ****Key Point** Hypertelorism is defined radiologically by the distance between the dacryons, with classifications provided by Tessier, and is distinct from similar conditions like telecanthus and pseudo-hypertelorism. Hypertelorism is a measurement from the dacryon. This is the junction between the maxillary, frontal, and lacrimal bones. It is a **radiological measurement**, not a clinical measurement. The average adult interorbital distance can range from 20-30mm. Tessier provides a classification of this, as detailed below in the illustration. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Hypertelorism-Classification.png) Classification of Hypertelorism It is important to be aware of two other similar conditions: - **Telecanthus:** increases the intercanthal distance with the normal distance between the bony orbits. - **Pseudo-hypertelorism**: 'illusion' of telecanthus in patients with a flat nasal bridge or prominent epicanthal folds. This is linked to Down Syndrome, Fetal Alcohol Syndrome, and Klinefelter Syndrome. --- ## Causes of Hypertelorism ****Key Point** Hypertelorism, characterized by an increased distance between the eyes, can be caused by syndromic conditions like Apert's syndrome or non-syndromic factors such as sincipital encephaloceles. Hypertelorism can be syndromic or non-syndromic: - **Syndromic:** Apert's, Craniofrontonasal dysplasia, Crouzens, Edwards. - **Non-syndromic:** Sincipital encephaloceles, facial [clefts](https://www.theplasticsfella.com/craniofacial-clefts/), midline tumours. An example of hypertelorism is seen in the illustration below of a patient with craniofrontonasal dysplasia. ![Causes of Hypertelorism, patient with craniofrontonasal dysplasia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Causes-of-Hypertelorism.png) Causes of Hypertelorism 💡 ****Tip**: Hypertelorism can prevent the development of binocular vision and result in cosmetic concerns for the patient. --- ## Treatment of Hypertelorism ****Key Point** Treatment of hypertelorism involves a multi-disciplinary approach focused on restoring function and normal appearance through surgical techniques such as box osteotomy, facial bipartition, and medial canthopexy. The management of hypertelorism is centred on a multi-disciplinary team. The goal of treatment is to restore function, normal orbital dystopia, cosmesis, and normal anatomical alignment. Surgical techniques that can be considered are: 1. **Box Osteotomy:** normal midface width and hypertelorism 2. **Facial Bipartition:** an inverted V deformity of maxillary occlusion. 3. **Medial Canthopexy:** reattach the medial canthal ligament after osteotomies. Surgery is often indicated between the ages of 5 - 7\. This is to reduce the risk of damage to unerupted teeth or maxillary growth. These surgical treatments for hypertelorism are visualised below. ![surgical treatments for hypertelorism](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Treatment-of-Hypertelorism.png) Treatment of Hypertelorism 💡 ****Tip**: Perform a CT and ophthalmic assessment prior to any surgical intervention. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding Hypertelorism:** You have gained a comprehensive understanding of what hypertelorism is, including its definition as an increase in the interorbital distance measured between the dacryons. ****2\. Learning the Classification System:** You are now familiar with the Tessier classification system, which categorizes hypertelorism based on interorbital distance, providing a standard measurement range. ****3\. Identifying the Causes:** You've learned about the various causes of hypertelorism, distinguishing between syndromic causes like Apert's, Crouzen's, and Edwards syndromes, and non-syndromic causes such as facial clefts and midline tumors. ****4\. Treatment for Hypertelorism:** You've explored the multi-disciplinary treatment approaches for hypertelorism, including surgical techniques like box osteotomy, facial bipartition, and medial canthopexy, aimed at restoring orbital dystopia and improving cosmesis. ### Squamous Cell Carcinoma (SCC) of the Skin: Guidelines, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/squamous-cell-carcinoma/ Last updated: 2024-04-30T20:14:32.000Z #### Summary Card [****Definition of Squamous Cell Carcinoma**](https://www.theplasticsfella.com/squamous-cell-carcinoma/#definition-of-squamous-cell-carcinoma) Malignant tumour from epidermal keratinocytes or hair follicles. [****Diagnosis of Squamous Cell Carcinoma**](https://www.theplasticsfella.com/squamous-cell-carcinoma/#diagnosis-of-squamous-cell-carcinoma) Indurated nodular keratinizing or crusted tumour that may ulcerate. It may also present as an ulcer without keratinization. [****Risk Factors for Squamous Cell Carcinoma**](https://www.theplasticsfella.com/squamous-cell-carcinoma/#risk-factors-for-squamous-cell-carcinoma) Sun exposure, pale skin, and medical conditions causing immunosuppression or immunocompromised. [****Surgical Treatment of Squamous Cell Carcinoma**](https://www.theplasticsfella.com/squamous-cell-carcinoma/#surgical-treatment-of-squamous-cell-carcinoma) First-line standard of care. A biopsy can be considered if clinical uncertainty and margins depend on the risk group. [****Radiotherapy for Squamous Cell Carcinoma**](https://www.theplasticsfella.com/squamous-cell-carcinoma/#radiotherapy-for-squamous-cell-carcinoma) Primarily an adjuvant treatment for specific high-risk tumours. It can be considered the first line if surgery is not feasible. [****Medical Treatments for Squamous Cell Carcinoma** ](https://www.theplasticsfella.com/squamous-cell-carcinoma/#medical-treatments-for-squamous-cell-carcinoma)Medical treatment for Squamous Cell Carcinoma include immune checkpoint inhibitors, chemotherapy, EGFR inhibitors, and electrochemotherapy. [****Risk Groups for Squamous Cell Carcinoma**](https://www.theplasticsfella.com/squamous-cell-carcinoma/#risk-groups-for-squamous-cell-carcinoma) It is a spectrum from low to very high risk based on TNM staging, patient status, and margin criteria. [****TNM Staging for Squamous Cell Carcinoma**](https://www.theplasticsfella.com/squamous-cell-carcinoma/#tnm-staging-for-squamous-cell-carcinoma) TNM (Tumour, Node and Metastasis) is used to classify and stage patients. [****Follow-Up for Squamous Cell Carcinoma**](https://www.theplasticsfella.com/squamous-cell-carcinoma/#follow-up-for-squamous-cell-carcinoma) All patients have post-operative visits to confirm the diagnosis and education. Long-term follow-up is based on tumour & patient risk status. This article is based on the British Association of Dermatology Guidelines, NCCN Guidelines, AJCC and Brigham and Women’s Hospital guidelines. --- ## Definition of Squamous Cell Carcinoma Primary cutaneous squamous cell carcinoma (SCC) is a malignant tumour that arises from the keratinocytes of the epidermis or its hair follicles. Aggressive histologic subtypes include adenoid (acantholytic), adenosquamous, desmoplastic or metaplastic. 0:00 /0:11 1× Definition of Squamous Cell Carcinomas 😎 ****Fun Fact:** It is the second most common skin malignancy (behind BCC) with a lifetime risk of \~5-15% ([Wu](https://doi.org/10.1158/1055-9965.EPI-13-0821?ref=theplasticsfella.com) et al., 2014). --- ## Diagnosis of Squamous Cell Carcinoma ****Key Point** Cutaneous squamous cell carcinoma is a clinical diagnosis confirmed by histology. Patients may require radiological investigations to staging or depth of invasion into bone. ### Clinical Diagnosis Cutaneous squamous cell carcinoma is generally a clinical diagnosis based on a history of rapid growth and specific features on examination. Squamous cell carcinomas are **indurated,** **nodular,** **keratinizing,** or crusted tumours that may **ulcerate** ([Keohane](https://onlinelibrary.wiley.com/doi/10.1111/bjd.19621?ref=theplasticsfella.com) et al., 2021). ![Squamous cell carcinoma usually presents as an indurated nodular keratinizing or crusted tumour that may ulcerate, or it may present as an ulcer without evidence of keratinization](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Squamous-Cell-Carcionoma-appearance.png) Clinical Features of a Squamous Cell Carcinoma ### Histological Diagnosis If there is clinical uncertainty, a **biopsy** can be performed. Biopsy should include deep reticular dermis because infiltration may only be present at deeper margins. The histological appearance is: - Dysplastic epidermal keratinocytes invading the basement membrane into the dermis - Keratin pearls - The degree of keratinisation can be variable ![A micrograph showing cells of the epidermis that are important to skin or cutaneous squamous cell carcinoma (SCC(](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Squamous-Cell-Carcionoma-Skin-Cells.png) Squamous Cell Carcinoma Histology 😎 ****Fun Fact:** under-assessment of aggressive histology subtypes can occur with shave or punch biopsies in 11-19% of cases ([Haws](https://doi.org/10.1016/j.jaad.2011.02.042?ref=theplasticsfella.com) et al., 2012 & [Griffiths](https://doi.org/10.1054/bjps.2002.3833?ref=theplasticsfella.com) et al., 2002). ### Radiology Radiological workup for SCC is not indicated for all patients. It can be used for staging, depth of invasion, or perineural invasion. The current recommendations for radiology ([Keohane](https://onlinelibrary.wiley.com/doi/10.1111/bjd.19621?ref=theplasticsfella.com) et al., 2021): - **Staging** if clinically concerned for local, regional or distant spread. Ultrasound-guided fine-needle aspiration or core biopsy of suspicious nodes. Contrast-enhanced CT scan or PET/CT should be considered to assess the extent of regional disease and for distant metastases. ([Lansbury](https://doi.org/10.1136/bmj.f6153?ref=theplasticsfella.com) et al., 2013) - **Depth of invasion** into underlying structures. If perineural or deep soft tissue, consider MRI. If there is bone involvement, CT with contrast is preferred if there are no contraindications​20–22. ([Rowe](https://doi.org/10.1016/0190-9622%2892%2970144-5?ref=theplasticsfella.com) et al., 1992 & [Chren](https://doi.org/10.1038/jid.2012.403?ref=theplasticsfella.com) et al., 2013) --- ## Risk Factors for Squamous Cell Carcinoma ****Key Point** The main risk factors for developing squamous cell carcinoma are ****sun exposure**, ****pale skin,** and medical conditions resulting in ****immunosuppression** or ****immunocompromise**. ### Sun Exposure The risk of SCC increases with age from natural cumulative sun exposure. There is a strong correlation with the following ([Juzeniene](https://doi.org/10.1016/j.ijheh.2014.06.002?ref=theplasticsfella.com) et al., 2014 & [Box](https://doi.org/10.1046/j.1523-1747.2001.01224.x?ref=theplasticsfella.com) et al., 2001): - **Chronic** sun exposure - **Total site-specific** exposure - **Number of site-specific** sunburns 😎 ****Fun Fact:** Any exposure to indoor tanning increases the risk of cSCC by 67% ([Senet](https://doi.org/10.1001/archdermatol.2011.3362?ref=theplasticsfella.com) et al., 2012). ### Fitzpatrick Type I + II - Individuals with fair skin, hair, and eye colour. - Susceptibility to oncogenic UV damage in genes linked with pigmentation​. ([Box](https://doi.org/10.1046/j.1523-1747.2001.01224.x?ref=theplasticsfella.com) et al., 2001) 😎 ****Fun Fact:** Cutaneous SCC 5-year survival is ≥90%​37,38​. ### Co-Morbidities - **Skin Cancers:** up to 50% of skin cancer in 5 years ([Wu](https://doi.org/10.1158/1055-9965.EPI-13-0821?ref=theplasticsfella.com) et al., 2014). - **Chronic ulcers:** Marjolin’s Ulcer8​ or Burn Scars ([Das](https://doi.org/10.1016/j.burns.2015.02.008?ref=theplasticsfella.com) et al., 2015). - **Organ** transplantation/immunosuppression ([Kim](https://doi.org/10.1053/j.seminoncol.2016.02.019?ref=theplasticsfella.com) et al., 2016). - **Pre-existing lesions:** Actinic Keratosis​11​ or Bowen’s Disease ([Glogau](https://doi.org/10.1067/mjd.2000.103339?ref=theplasticsfella.com), 2000 & [Eimpunth](https://doi.org/10.1097/DSS.0000000000001028?ref=theplasticsfella.com) et al., 2017). - **Genetic syndromes:** Albinism​14​ or Xeroderma Pigmentosum ([Bradford](https://doi.org/10.1136/jmg.2010.083022?ref=theplasticsfella.com) et al., 2011). - **Haematological** **conditions:** Lymphoma or Leukemia. ### Less Common - Exposure to chemicals: pesticides, herbicides or arsenic. - Recessive dystrophic epidermolysis bullosa (RDEB). 💡 ****Tip:** the prophylactic use of systemic retinoids and/or nicotinamide can be considered in high-risk patients ([Bradford](https://doi.org/10.1136/jmg.2010.083022?ref=theplasticsfella.com) et al., 2011 & [ijsten](https://pubmed.ncbi.nlm.nih.gov/14512910/?ref=theplasticsfella.com) et al., 2015). --- ## Surgical Treatment of Squamous Cell Carcinoma ****Key Point** Surgical resection is the standard of care. A biopsy can be considered if clinical uncertainty and margins depend on the risk group. ### Standard Surgical Excision This is the first-line treatment option for resectable primary cutaneous SCC. The following **peripheral** margins are recommended ([Keohane](https://onlinelibrary.wiley.com/doi/10.1111/bjd.19621?ref=theplasticsfella.com) et al., 2021): - ≥ 4 mm for a low-risk cSCC tumour. - ≥ 6 mm for a high-risk cSCC tumour. - ≥ 10 mm for a very high-risk cSCC tumour. These surgical margins achieve a 5-year disease-free rate of >91%​26 ([Karagas](https://www.ncbi.nlm.nih.gov/pubmed/1597912?ref=theplasticsfella.com) et al., 1992). The following **deep** margins are recommended ([Keohane](https://onlinelibrary.wiley.com/doi/10.1111/bjd.19621?ref=theplasticsfella.com) et al., 2021): - Mobile lesions should be excised in the next clear surgical plane. - Scalp lesions should be excised with the galea. - Deeply infiltrating or fixed lesions excised with underlying structure (determined clinically, or by imaging, or both). ![A labelled diagram showing the recommended peripheral margins for squamous cell carcinoma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Squamous-Cell-Carcionoma-Margins.png) Peripheral Margins for SCC 💡 ****Fun Fact:** 4-6mm margins achieve 5-year disease-free rates >91%​19,20. ([Griffiths](https://doi.org/10.1054/bjps.2002.3833?ref=theplasticsfella.com) et al., 2002 & [Rowe](https://doi.org/10.1016/0190-9622%2892%2970144-5?ref=theplasticsfella.com) et al., 1992) ### Other Surgical Options 1. **Moh’s Micrographic Surgery** *can* be considered for **high-risk** lesions, poorly defined tumour margins, or in sites where tissue conservation is important for function. This has 96% cure rates of 96% for primary cSCCs and 77% for recurrent cSCCs. ([Turner](https://doi.org/10.1046/j.1365-2133.2000.03422.x?ref=theplasticsfella.com) et al., 2000) 2. **Curettage and electrodesiccation** *can* be considered for **low-risk** lesions and patients. Surgical resection is required if adipose is reached. Lower-quality data shows cure rates \~95% at 5 years ([Chren](https://doi.org/10.1038/jid.2012.403?ref=theplasticsfella.com) et al., 2013 & [Lansbury](https://doi.org/10.1136/bmj.f6153?ref=theplasticsfella.com) et al., 2013). This does not allow for margin assessment, but histology should be reviewed for any high-risk features. ### Positive or Near-Margins in SCC Additional treatment options should be offered if margins are positive after excision or narrowly excised in high-risk patients. - **Observation:** low-risk tumour, low-risk patient & narrow margins (<1mm). - **Wider Excision, Mohs or Adjuvant Radiotherapy** in high-risk patients with positive or close margins (<1 mm). ### Lymph Nodes The nodal status of patients with squamous cell carcinoma is guided by clinical examination. The criteria for selecting patients and survival benefits for Sentinel lymph node biopsy (SLNB) is unclear. The current recommendations for sentinel node biopsy to consider high-risk cases of primary cSCC in a clinical trial or after MDT discussion ([Keohane](https://onlinelibrary.wiley.com/doi/10.1111/bjd.19621?ref=theplasticsfella.com) et al., 2021). Lymph node clearance is for patients suitable for surgery with clinical or radiological lymph node involvement. --- ## Radiotherapy for Squamous Cell Carcinoma ****Key Point** Radiotherapy is primarily used as an adjuvant treatment for specific high-risk tumors and patients. It can be considered first-line if surgery is not feasible. **Radiotherapy** can be considered as primary treatment for **non-surgical** candidates or as **adjuvant therapy** for certain types of squamous cell carcinomas. This should be discussed as an MDT. This improves local control and disease-free survival, but there is likely no survival benefit​30,31. ### Primary Radiotherapy Primary radiotherapy can be considered in the following patients: 1. Surgery is not feasible, challenging or results in an unacceptable functional or aesthetic outcome. 2. Patient preference. ### Adjuvant Radiotherapy Consider adjuvant radiotherapy after MDT discussion in patients with: 1. **Narrow** excised tumour margins (<1mm). 2. **Completely** excised T3 tumours. 3. **Incompletely** excised if further surgery is not possible, high risk of local recurrence, perineural invasion (multifocal, named nerve, diameter >0.1mm, below dermis), recurrent disease, immunocompromised. Radiotherapy should **not** be offered to completely excise T1 or T2 cutaneous squamous cell carcinoma with microscopic, dermal-only, nerve diameter<0.1mm perineural invasion. If the perineural invasion is present, **conformal radiotherapy** is an option for the entire course of the involved nerve when surgery is inappropriate. This can be considered in SCCs with perineural invasion and symptomatic perineural invasion and/or radiological evidence of perineural invasion --- ## Medical Treatments for Squamous Cell Carcinoma ****Key Point** Treatment options for metastatic or locally advanced squamous cell carcinoma include immune checkpoint inhibitors, systemic chemotherapy, EGFR inhibitors, and electrochemotherapy, depending on the patient's specific situation and the suitability of other therapies. These options are generally considered for patients with metastatic SCC. - **Immune checkpoint inhibitor** treatment in people with locally advanced cSCC where curative surgery or radiotherapy is not reasonable. - **Systemic chemotherapy** or epidermal growth factor receptor (EGFR) inhibitors in people with metastatic cSCC with contraindications to immune checkpoint inhibitors. - **Electrochemotherapy** in people with locally advanced cSCC in palliative settings if other local or systemic therapies are not appropriate. --- ## Risk Groups for Squamous Cell Carcinoma ****Key Point** Risk Groups for Squamous Cell Carcinoma is a spectrum from low to very high risk based on TNM staging, patient status, and margin criteria. Risk assessment of the primary tumour guides treatment plan and follow-up for patients. NCCN, AJCC, and Brigham & Women’s Guidelines are commonly used ([Marcil](https://doi.org/10.1001/archderm.136.12.1524?ref=theplasticsfella.com) et al., 2000). ### British Association of Dermatology 2021 The British Association of Dermatologies stratifies SCC into low-risk, high-risk, and very high-risk. These risk categories are determined by the patient, macroscopic and microscopic findings, as explained below ([Keohane](https://onlinelibrary.wiley.com/doi/10.1111/bjd.19621?ref=theplasticsfella.com) et al., 2021). - **Patient:** immune status - **Macroscopic:** site, size - **Microscopic:** thickness, depth, PNI, LVI, differentiation, subtype ![Risk Groups for Squamous Cell Carcinoma Diagnosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Risk-Groups-Squamous-Cell-Carcionoma.png) Risk Groups for Squamous Cell Carcinoma ### NCCN Risk Stratification ![NCCN 2020 Risk Stratification Guidelines for Non-Melanoma Skin Cancers](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Screenshot-2020-03-30-at-13.09.20-2.png) NCCN 2020 Risk Stratification Guidelines for Non-Melanoma Skin Cancers 💡 ****Tip:** If any high-risk feature is present, the patient should be managed according to the high-risk treatment pathway for local cSCC. --- ## TNM Staging for Squamous Cell Carcinoma ****Key Point** The TNM staging system is the internationally accepted classification of squamous cell carcinoma. It is based on tumour size, nodal status, and metastasis. The stage can be used to stratify risk, guide management, and predict outcomes. ![TNM Classification Squamous Cell Carcinoma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/TNM-Staging-Squamous-Cell-Carcionoma-of-the-Skin.png) TNM Classification for Squamous Cell Carcinoma ![TNM Staging for Squamous Cell Carcinoma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/TNM-Staging-Squamous-Cell-Carcionoma.png) TNM Staging for Squamous Cell Carcinoma --- ## Follow-Up for Squamous Cell Carcinoma ****Key Point** All patients have post-operative visits to confirm the diagnosis and education. Long-term follow-up based on tumour & patient risk status. This is guided by the BAD and NCCN guidelines. Follow-up of patients with squamous cell carcinoma is based on the risk group and extent of the disease. 30%-50% of these patients will develop another SCC within 5 years and 70% of SCC recurrences occur within 2 years ([Marcil](https://doi.org/10.1001/archderm.136.12.1524?ref=theplasticsfella.com) et al., 2000 & [Karagas](https://www.ncbi.nlm.nih.gov/pubmed/1597912?ref=theplasticsfella.com) et al., 1992). All patients should have: - An initial follow-up for education on the disease, self-examination, and sun protection. - Involved a clinical nurse specialist. - Discussion at the MDT if indicated. - Examination of skin and lymph node basins. ### British Association of Dermatology Guidelines: - **Low-Risk:** one post-treatment review, safety net. - **High Risk:** 4-monthly intervals for year 1, 6-monthly intervals for year 2. - **Very High Risk**: 4-monthly for 2 years, 6-monthly for year 3\. - **Metastatic:** 3-monthly for 2 years, 6 monthly for years 3-5 (minimum). Consider lifelong skin surveillance if likely to develop further high-risk SCCs (such as organ transplant recipients). ### NCCN Guidelines - **Local:** 3-12 months for 2 years, 6-12 months for 3 years, then annually. - **Regional:**1-3 months in year 1, 2-4 months in year 2, 4-6 months in year 3, then 6-12 months for life. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding of Squamous Cell Carcinoma:** You now have a detailed understanding of the definition, classification, and anatomy of SCC, a common and potentially serious skin cancer. ****2\. Diagnostic Criteria for SCC:** The article has equipped you with knowledge about the clinical and histological features that define SCC, aiding in its identification and distinction from other skin conditions. ****3\. Identified Risk Factors:** You are now aware of the primary risk factors for SCC, including sun exposure, skin type, and immune status, which are crucial for assessing patient risk and tailoring prevention strategies. ****4\. Treatment Options for Squamous Cell Carcinoma:** You have learned about the various treatment modalities for SCC, ranging from surgical interventions to radiation therapy and medical treatments, depending on the stage and severity of the disease. ****5\. Follow-Up Care:** The article highlighted the importance of post-treatment follow-up, which is essential for managing recurrence risks and maintaining patient health. --- ## Further Reading 1. Keohane et al; British Association of Dermatologists’ Clinical Standards Unit. [British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma 2020](https://onlinelibrary.wiley.com/doi/10.1111/bjd.19621?ref=theplasticsfella.com). Br J Dermatol. 2021 Mar;184(3):401-414\. doi: 10.1111/bjd.19621\. PMID: 33150585\. 2. Xiang F, Lucas R, Hales S, Neale R. [Incidence of nonmelanoma skin cancer in relation to ambient UV radiation in white populations](https://doi.org/10.1001/jamadermatol.2014.762?ref=theplasticsfella.com), 1978-2012: empirical relationships. *JAMA Dermatol*. 2014;150(10):1063-1071\. doi:10.1001/jamadermatol.2014.762 3. Wu S, Han J, Laden F, Qureshi A. [Long-term ultraviolet flux, other potential risk factors, and skin cancer risk: a cohort study](https://doi.org/10.1158/1055-9965.EPI-13-0821?ref=theplasticsfella.com). *Cancer Epidemiol Biomarkers Prev*. 2014;23(6):1080-1089\. doi:10.1158/1055-9965.EPI-13-0821 4. Juzeniene A, Grigalavicius M, Baturaite Z, Moan J. [Minimal and maximal incidence rates of skin cancer in Caucasians estimated by use of sigmoidal UV dose-incidence curves](https://doi.org/10.1016/j.ijheh.2014.06.002?ref=theplasticsfella.com). *Int J Hyg Environ Health*. 2014;217(8):839-844\. doi:10.1016/j.ijheh.2014.06.002 5. Gallagher R, Hill G, Bajdik C, et al. [Sunlight exposure, pigmentation factors, and risk of nonmelanocytic skin cancer](https://www.ncbi.nlm.nih.gov/pubmed/7857112?ref=theplasticsfella.com). II. Squamous cell carcinoma. *Arch Dermatol*. 1995;131(2):164-169\. https://www.ncbi.nlm.nih.gov/pubmed/7857112. 6. Wehner M, Shive M, Chren M, Han J, Qureshi A, Linos E. [Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis](https://doi.org/10.1136/bmj.e5909?ref=theplasticsfella.com). *BMJ*. 2012;345:e5909\. doi:10.1136/bmj.e5909 7. Box N, Duffy D, Irving R, et al. [Melanocortin-1 receptor genotype is a risk factor for basal and squamous cell carcinoma](https://doi.org/10.1046/j.1523-1747.2001.01224.x?ref=theplasticsfella.com). *J Invest Dermatol*. 2001;116(2):224-229\. doi:10.1046/j.1523-1747.2001.01224.x 8. Senet P, Combemale P, Debure C, et al. [Malignancy and chronic leg ulcers: the value of systematic wound biopsies: a prospective, multicenter, cross-sectional study](https://doi.org/10.1001/archdermatol.2011.3362?ref=theplasticsfella.com). *Arch Dermatol*. 2012;148(6):704-708\. doi:10.1001/archdermatol.2011.3362 9. Das K, Chakaraborty A, Rahman A, Khandkar S. [Incidences of malignancy in chronic burn scar ulcers: experience from Bangladesh](https://doi.org/10.1016/j.burns.2015.02.008?ref=theplasticsfella.com). *Burns*. 2015;41(6):1315-1321\. doi:10.1016/j.burns.2015.02.008 10. Kim C, Cheng J, Colegio O. [Cutaneous squamous cell carcinomas in solid organ transplant recipients: emerging strategies for surveillance, staging, and treatment](https://doi.org/10.1053/j.seminoncol.2016.02.019?ref=theplasticsfella.com). *Semin Oncol*. 2016;43(3):390-394\. doi:10.1053/j.seminoncol.2016.02.019 11. Dika E, Fanti P, Misciali C, et al. [Risk of skin cancer development in 672 patients affected by actinic keratosis](https://www.ncbi.nlm.nih.gov/pubmed/26381460?ref=theplasticsfella.com). *G Ital Dermatol Venereol*. 2016;151(6):628-633\. 12. Glogau R. [The risk of progression to invasive disease](https://doi.org/10.1067/mjd.2000.103339?ref=theplasticsfella.com). *J Am Acad Dermatol*. 2000;42(1 Pt 2):23-24\. doi:10.1067/mjd.2000.103339 13. Eimpunth S, Goldenberg A, Hamman M, et al. [Squamous Cell Carcinoma In Situ Upstaged to Invasive Squamous Cell Carcinoma: A 5-Year, Single Institution Retrospective Review](https://doi.org/10.1097/DSS.0000000000001028?ref=theplasticsfella.com). *Dermatol Surg*. 2017;43(5):698-703\. doi:10.1097/DSS.0000000000001028 14. Kiprono S, Chaula B, Beltraminelli H. [Histological review of skin cancers in African Albinos: a 10-year retrospective review](https://doi.org/10.1186/1471-2407-14-157?ref=theplasticsfella.com). *BMC Cancer*. 2014;14:157\. doi:10.1186/1471-2407-14-157 15. Bradford P, Goldstein A, Tamura D, et al. [Cancer and neurologic degeneration in xeroderma pigmentosum: long term follow-up characterises the role of DNA repair](https://doi.org/10.1136/jmg.2010.083022?ref=theplasticsfella.com). *J Med Genet*. 2011;48(3):168-176\. doi:10.1136/jmg.2010.083022 16. ijsten TE, Stern RS. [Oral retinoid use reduces cutaneous squamouscell carcinoma risk in patients with psoriasis treated with psoralen-UVA: a nested cohort study](https://pubmed.ncbi.nlm.nih.gov/14512910/?ref=theplasticsfella.com). JAmAcadDermatol2003;49:644–50.40 Chen AC, Martin AJ, Choy Bet al. A phase 3 randomized trial ofnicotinamide for skin-cancer chemoprevention.N Engl J Med2015;373:1618–26 17. Wolberink E, Pasch M, Zeiler M, van E, Gerritsen M. [High discordance between punch biopsy and excision in establishing basal cell carcinoma subtype: analysis of 500 cases](https://doi.org/10.1111/j.1468-3083.2012.04628.x?ref=theplasticsfella.com). *J Eur Acad Dermatol Venereol*. 2013;27(8):985-989\. doi:10.1111/j.1468-3083.2012.04628.x 18. Haws A, Rojano R, Tahan S, Phung T. [Accuracy of biopsy sampling for subtyping basal cell carcinoma](https://doi.org/10.1016/j.jaad.2011.02.042?ref=theplasticsfella.com). *J Am Acad Dermatol*. 2012;66(1):106-111\. doi:10.1016/j.jaad.2011.02.042 19. Griffiths R, Feeley K, Suvarna S. [Audit of clinical and histological prognostic factors in primary invasive squamous cell carcinoma of the skin: assessment in a minimum 5 year follow-up study after conventional excisional surgery](https://doi.org/10.1054/bjps.2002.3833?ref=theplasticsfella.com). *Br J Plast Surg*. 2002;55(4):287-292\. doi:10.1054/bjps.2002.3833 20. Rowe D, Carroll R, Day C. [Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip](https://doi.org/10.1016/0190-9622%2892%2970144-5?ref=theplasticsfella.com). Implications for treatment modality selection. *J Am Acad Dermatol*. 1992;26(6):976-990\. doi:10.1016/0190-9622(92)70144-5 21. Turner R, Leonard N, Malcolm A, Lawrence C, Dahl M. [A retrospective study of outcome of Mohs’ micrographic surgery for cutaneous squamous cell carcinoma using formalin fixed sections](https://doi.org/10.1046/j.1365-2133.2000.03422.x?ref=theplasticsfella.com). *Br J Dermatol*. 2000;142(4):752-757\. doi:10.1046/j.1365-2133.2000.03422.x 22. Chren M, Linos E, Torres J, Stuart S, Parvataneni R, Boscardin W. [Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma](https://doi.org/10.1038/jid.2012.403?ref=theplasticsfella.com). *J Invest Dermatol*. 2013;133(5):1188-1196\. doi:10.1038/jid.2012.403 23. Lansbury L, Bath-Hextall F, Perkins W, Stanton W, Leonardi-Bee J. [Interventions for non-metastatic squamous cell carcinoma of the skin: systematic review and pooled analysis of observational studies](https://doi.org/10.1136/bmj.f6153?ref=theplasticsfella.com). *BMJ*. 2013;347:f6153\. doi:10.1136/bmj.f6153 24. Marcil I, Stern R. [Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis](https://doi.org/10.1001/archderm.136.12.1524?ref=theplasticsfella.com). *Arch Dermatol*. 2000;136(12):1524-1530\. doi:10.1001/archderm.136.12.1524 25. Karagas M, Stukel T, Greenberg E, Baron J, Mott L, Stern R. [Risk of subsequent basal cell carcinoma and squamous cell carcinoma of the skin among patients with prior skin cancer](https://www.ncbi.nlm.nih.gov/pubmed/1597912?ref=theplasticsfella.com). Skin Cancer Prevention Study Group. *JAMA*. 1992;267(24):3305-3310\. --- ### The 6-year Rule in Surgery, Recorded Team Meetings, Infections +++. URL: https://www.theplasticsfella.com/april-27th/ Last updated: 2024-04-28T19:38:23.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/april-27th/#a-letter-from-pfella) 6-year performance rule for plastic surgeons. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/april-27th/#the-sunday-quiz) **\+ Leaderboard** How well do you know **Microtia?* 3. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-27th/#upcoming-events) 10 number of events in next 6 months. 4. ****🚀** [****New Updates**](https://www.theplasticsfella.com/april-27th/#new-features) Recorded team meetings soon! 5. ****🎭** [****The Fellows' Corner** ](https://www.theplasticsfella.com/april-27th/#the-fellows-corner) Infections +++ (new articles + scenarios) 6. ****🔥** [****3 Articles**](https://www.theplasticsfella.com/april-27th/#articles-of-the-week) **\+ 1 sentence summaries** Imposter Syndrome, Fat Injections, chatGPT. 7. 💕 [****Feedback**](https://www.theplasticsfella.com/april-27th/#feedback) Suggest ideas & give feedback! ****ps - what do you think of this new** [****logo**](https://www.theplasticsfella.com/april-27th/#new-features)****?** ## A Letter from P'Fella **The 6 Year Performance Rule* 👋 ****Hey Friends!** I’ve been mulling over a concept that’s been floating around—what I call the '6-year performance rule.' It’s not necessarily a new or original idea, but it’s intriguing and I thought it was worth sharing with you. ****👇** **The idea here is pretty straightforward**. It suggests that our surgical performance goes through a **cycle**: starting strong, peaking, and then potentially declining. It's like **after six years**, we hit our stride and then face a shift—whether that’s changing how we operate or adapting new roles. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/6-year-performance-rule-thePlasticsPaper.png) **Is There Any Evidence?** I’ve looked into whether there’s any hard evidence to back this up, but so far, nothing concrete. Studies do show that experience impacts patient outcomes in various ways, but they don’t specifically confirm or deny this six-year cycle. For instance: - **Young Surgeons:** Studies like Waljee's in 2017 indicate that younger surgeons can perform just as well as their more seasoned counterparts. - **Veteran Surgeons:** On the flip side, Chaudhry's 2009 study points out that surgeons with more experience tend to handle complex procedures better. - **Long-term Practice:** However, there's also data suggesting that outcomes might decline after many years, as highlighted by Sultana et al. in 2022. **What Do You Think?** So, what’s your take on this? Have you noticed any patterns in your own career, or do you think the concept doesn’t hold up? I’d love to hear your thoughts and experiences on this topic. Looking forward to hearing from you, P'Fella ❤️ ## The Sunday Quiz **Microtia* Welcome to the ****next round** of The Weekly Quiz Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end of six rounds will earn you a $100 voucher. Good luck! ![microtia, Tanzer, ear reconstruction, auricl, Brent, Nagata, surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/Microtia-4.png) Clinical Spectrum of Microtia ## Upcoming Events A Curated List of Webinars, Courses & Conferences. ## New Features Recorded Team Meetings coming soon! **Exciting news from the PlasticsFella Team!** We're kicking off fortnightly chats about **all things plastic surgery** and taking you **behind the scenes at thePlasticsFella**. We’ll also have expert guests joining us to tackle some of the trickier topics. Plus, we're publishing these sessions so we can all learn together. What do you think about these logos? Vote for your favorite below! ### What do you think of these logos? Vote below! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/1-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/2.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/3.png) ## The Fellows' Corner Infection +++ We’re really excited to share what we’ve been up to over the last couple of weeks. Our team of fellows have put together educational articles and clinical scenarios on infections of the hand. **Here’s what went live this week:** ![Pain on passive extension, fusiform swelling, held in passive flexion, pain along flexor sheath.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition--3-.jpg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Septic-Arthritis-of-thE-WRIST.png) ![Necrosis, Necrotizing fasciitis, oedema](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Clinical-Features.png) You can check on the articles below: - **Flexor Tenosynovitis**: [Main Article ](https://www.theplasticsfella.com/flexor-tenosynovitis/)and [Clinical Case ](https://www.theplasticsfella.com/flexor-tenosynovitis-clinical-scenario/) - **Necrotising Fasciitis**: [Main Article](https://www.theplasticsfella.com/necrotising-fasciitis/) and [Clinical Case](https://www.theplasticsfella.com/necrotising-fasciitis-clinical-scenario/) - **Septic Arthritis**: [Main Article](https://www.theplasticsfella.com/septic-arthritis/) and [Clinical Case ](https://www.theplasticsfella.com/septic-arthritis-clinical-scenario/) **What’s for Our Next Cycle?** Looking forward, we’re going to focus on Hand Trauma, and here's what to expect in our upcoming content: - Thumb MCPJ UCL Injury - Ring Avulsion Injury - Seymour Fracture ## Articles of the Week 3 Interesting Articles with 1 sentence summaries. 1️⃣ ****High Rates of Impostor Phenomenon in Academic Plastic Surgery** ([Sergesketter](https://journals.lww.com/plasreconsurg/fulltext/2024/05000/defining%5Fthe%5Fincidence%5Fof%5Fthe%5Fimpostor%5Fphenomenon.43.aspx?ref=theplasticsfella.com), 2024) Explore the high rates of impostor phenomenon among plastic surgery residents and faculty, especially in women, impacting professional confidence and career progression. 2️⃣ ****ChatGPT's is not smarter than Hand Surgeons** ([Yuri](https://www.jhsgo.org/article/S2589-5141%2823%2900199-8/fulltext?ref=theplasticsfella.com), 2024) This study scrutinizes ChatGPT's performance across 1,583 self-assessment questions, revealing a 36.2% success rate, with better results on text-only versus image-based questions. 3️⃣ ****Fat Injection Techniques: Tips and Tricks for Best Outcomes** ([Emmanuel](https://academic.oup.com/asj/article/29/5/360/199587?searchresult=1&ref=theplasticsfella.com), 2009) A study on how fat injection is transforming breast augmentation: 880 procedures over 10 years reveal stable, safe results with minimal complications, perfect for both cosmetic and reconstructive enhancements. ## Feedback ### I hope you enjoyed it 😄 --- ### Polydactyly: Classification & Treatment URL: https://www.theplasticsfella.com/polydactyly/ Last updated: 2024-04-24T19:13:16.000Z #### Summary Card [****Definition of Polydactyly**](https://www.theplasticsfella.com/polydactyly/#definition-of-polydactyly) Congenital duplication of digits that can be radial, ulnar, or central. [****Overview of Radial Polydactyly**](https://www.theplasticsfella.com/polydactyly/#overview-of-radial-polydactyly) A pre-axial duplication of the thumb classified by Wassell. [****Overview of Ulnar Polydactyly**](https://www.theplasticsfella.com/polydactyly/#overview-of-ulnar-polydactyly) Post-axial duplication of little finger classified by Stelling. --- ## Definition of Polydactyly Polydactyly is a congenital duplication of a finger. It can be pre-axial (radial), central and post-axial (ulnar) and is caused by disruption at the ZPE and AER [embryological](https://www.theplasticsfella.com/upper-limb-embryology/) signalling zones. The image below shows the congenital duplication of a finger. ![congenital duplication of a finger, Polydactyly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Polydactyly-Definition.png) Definition of Polydactyly 💡 ****Tip:** Polydactyly is classified by Swanson's congenital hand anomalies as "duplication". --- ## Overview of Radial Polydactyly ****Key Point** A pre-axial duplication of the thumb classified by Wassell. Radial (pre-axial) polydactyly is an isolated thumb duplication that is *generally* unilateral and non-syndromic. From a demographic perspective, it is different from ulnar polydactyly because: - It is usually sporadic. - It primarily affects Caucasians. - Patients should be screened for Fanconi anaemia. The image below shows an overview of radial polydactyly. ![Radial Polydactyly Signs](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Radial-Polydactyly.png) Radial Polydactyly ### ### Classification of Radial Polydactyly Radial polydactyly is a duplication of the thumb. It is classified by Wassell into 7 groups based on the degree of bony duplication. Type IV is the most common radial polydactyly. - **Type I:** Bifid Distal Phalanx - **Type II:** Duplicate Distal Phalanx - **Type III:** Bifid Proximal Phalanx + Duplicate Distal Phalanx - **Type IV:** Duplicate Distal Phalanx + Duplicate Distal Phalanx - **Type V:** Bifid 1st metacarpal + Duplicate Distal and Proximal Phalanx - **Type VI:** Duplicate 1st metacarpal + Distal Phalanx + Proximal Phalanx - **Type VII:** Triphalangeal thumb (triangular or rectangular extra middle phalanx) + normal thumb Diagnose triphalangeal thumb by excluding a five-finger hand. Look at the nail position (not in normal pronation) and x-ray (extra finger metacarpal). Surgery includes pollicisation and web space creation. 💡 ****Tip:** Radial duplicate usually receives the thenar muscles and is median nerve innervated. Ulnar duplicate receives the adductor pollicis, 1st dorsal intraosseous muscle and ulnar innervated. This Wassell classification of radial polydactyly is illustrated below. ![Wassell Classification for Radial Polydactyly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Wassell-Classification.png) Wassell Classification for Radial Polydactyly 😎 ****Fun Fact:** There is often a degree of hypoplasia in both digits. A subtle type I or II duplications may show signs of a widened nail plate. ### Management of Radial Polydactyly ***Key Principles*** Surgery aims to create an anatomically aligned thumb with joint stability that enables function. Ideally, it is performed prior to developing the thumb-pinch index at age 1\. A decision should be made on which duplicate to retain. This can be guided by: - **Size:** one duplicate is usually hypoplastic or rudimentary. - **Function:** ulnar collateral ligament is important for pinch. - **Movement:** passive and active range of movement. - **Radiology:** location of duplication. The Wassell classification notes "equal parts" or "spare parts" surgery. ***"Equal parts surgery"*** The Bilhaut-Cloquet Technique is indicated in **Types I + II** or convergent and symmetrical **type IV polydactyly.** Excise adjacent inner halves of each duplicate and fuse the remaining outer segments. - **Standard Technique:** simple wedge excision of structures. - **Modified Technique:** preservation of one nail complex and physics of one of the duplicates. Nail problems, epiphysiodesis and reduced range of movement limit this technique. Pre-axial polydactyly is illustrated in the image below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Bilhaut-Cloquet-Technique.png) ***"Spare Parts Surgery"*** This is indicated in types III and IV or asymmetrical I and II. Excise one duplicate and reconstruct the other using "spare parts surgery" in a single operation. This should be done before the patient turns 1 year of age before they develop the thumb-index pinch. The key steps to my operation are: - **Incision:** avoid straight lines to prevent full extension/flexion, and the nail bed to reduce the risk of nail plate ridging. - **Excision**: excise radial duplicate (proximal and smaller than ulnar digit). - **Ligaments:** reconstructradial collateral ligament of IPJ with a periosteal slave from the excised digit (Manske), preserve RCL of thumb MCPJ. - **Tendons:** realign EPL insertion to form a single tendon, centralise FPL by reconstructing the pulley, and transfer APB insertion from the radial duplicate. - **Bone**: excise asymmetric joint surfaces, closed wedge osteotomy of proximal phalanx, trans-articular 0.6 or 0.7mm K-wire for 4 weeks. These patients can be discharged same day if the patient is well and followed up in a specialist hand therapy clinic. ***Additional Techniques*** - **Types V + VI** *also* requires web space reconstruction, intrinsic reconstruction, basal joints and metacarpal osteotomies. - **Type VII** requires treatment of the extra interphalangeal joint. If a d*elta phalanx* is present, it is excised, and soft tissue is reconstructed. If the extra phalanx is *rectangular*, chrondresis of the least mobile joint. 💡 ****Tip:** Ideally, the ulnar thumb should be preserved as the ulnar collateral ligament is required for pinch stability. The surgical correction of radial polydactyly is shown in the video below. 😎 ****Fun Fact:** The radial duplicate is usually more hypoplastic and smaller than the ulnar. --- ## Overview of Ulnar Polydactyly ****Key Point** Post-axial duplication of little finger classified by Stelling. Ulnar post-axial polydactyly is a congenital duplication of the little finger digits. Unlike radial polydactyly, it is commoner in African American males and is more often bilateral. It is usually autosomal dominant with variable penetrance. The image below shows an overview of Ulnar Polydactyly. ![Ulnar Polydactyly Signs, Little Finger Duplication](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Ulnar-Polydactyly.png) Overview of Ulnar Polydactyly 😎 ****Fun Fact:** Polydactyly is linked to a HOX and Gli3 gene mutation resulting in the disruption of the AER and APZ signalling pathways. This is discussed in more detail in the [upper limb embryology](https://www.theplasticsfella.com/upper-limb-embryology/) article. ### Classification of Ulnar Polydactyly Ulnar polydactyly can be described using Stelling's classification. It also guides management. - **I:** "Nubbin" - soft tissue without bone excised or ligated as a neonate. - **II:** extra digit is structurally complete and articulates with normal or bifid metacarpal or phalanx. - **III:** extra digit is structurally complete and has its metacarpal. Types II and III patients require resection and reconstruction. This involves the abductor digit minimi and ulnar collateral ligament attachments to be transferred to the adjacent finger. An **alternative** classification can be **Type A** (well-developed supernumerary digit) or **Type B** (digit is rudimentary and pedunculated). The image below illustrates an X-ray representation of type II Selling Classification. ![X-ray representation of type II Stelling Classification.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Ulnar-Polydactyly-Xray.png) Ulnar Poydactyly X-Ray 😎 ****Fun Fact:** Central poyldactyly does exist, but it is rare. It usually involves the ring finger and can occur with syndactyly to create a 'synopolydactyly'. It has been linked to a gene mutation (HOXD13 gene) on Chromosome 2. --- ## ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basic Understanding of Polydactyly:** You have learned that polydactyly involves the congenital duplication of digits and can occur as radial, central, or ulnar types, each with unique characteristics and genetic implications. ****2\. Polydactyly Classification Systems:** You now understand the classifications for radial and ulnar polydactyly, which include the Wassel classification for radial polydactyly and the Stelling classification for ulnar polydactyly. ****3\. Surgical Management Approaches:** The article has provided insights into the surgical techniques for correcting radial and ulnar polydactyly, highlighting the importance of choosing the appropriate procedure based on the type and severity of the duplication. ****4\. Genetic and Embryological Aspects:** You have become familiar with the genetic mutations and embryological disruptions that lead to polydactyly, deepening your understanding of its developmental origins and the associated syndromes. --- ### Upper Limb Embryology: Development Milestones & Mechanisms URL: https://www.theplasticsfella.com/upper-limb-embryology/ Last updated: 2024-04-25T22:41:11.000Z #### Summary Card [****Overview of Upper Limb Embryology**](https://www.theplasticsfella.com/upper-limb-embryology/#overview-of-upper-limb-embryology) Upper limb development occurs during weeks 4-8 of gestation from the mesoderm and ectoderm. [****Developmental Milestones**](https://www.theplasticsfella.com/upper-limb-embryology/#developmental-milestones) The limb bud appears on day 26 and differentiates into a limb by day 58. [****Mechanisms of Development**](https://www.theplasticsfella.com/upper-limb-embryology/#mechanisms-of-development) Upper limb embryogenesis is based on 3 axes, 3 signalling zones, and 3 proteins. --- ## Overview of Upper Limb Embryology The upper limb develops during weeks 4-8 of gestation from mesoderm and ectoderm. More specifically, - **3 axis:** proximodistal, anteroposterior, dorsoventral - **3 centres:** apical ectodermal ridge, zone of polarizing activity, and dorsal ectoderm. - **3 proteins:** fibroblast growth centre, sonic hedgehog protein, WNT7a. These critical elements of embryological development are illustrated below. ![Upper Limb Embryology](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Upper-Limb-Embryology-Overview.png) Upper Limb Embryology 😎 ****Fun Fact:** The lateral plate of the mesoderm forms bone, cartilage and tendon. The somatic mesoderm differentiates into myofibroblasts that form muscle. --- ## Developmental Milestones ****Key Point** These are general guidelines for the development milestones of limb embryogenesis. ### The upper limb differentiates into a 'human-appearing' limb during 4-8 weeks of gestation. Here are some general timelines to consider: - **\~ Day 26:** Limb bud is present. - \~ **Day 30:** Blood vessels. - **\~ Day 33:** Paddle-shaped hand. - **\~ Day 36:** Nerves appear and myofibroblasts become muscle. - **\~ Day 42:** Webbed-shaped hand as digital rays become present. - \~ **Day 45**: muscles, ligmanets and carpals appear. - **\~ Day 48:** Palms move anteriorly and elbows flex. - **\~ Day 50:** Digits separate. - **\~ Day 56:** Digits ossify secondary to apoptosis. - **\~ Day 58**: Human limb. The below image contains a 9-week human embryo and you can observe the upper limb development. ![9-week human embryo illustrated, upper limb development](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Upper-Limb-Embryology.png) Upper limb embryology 💡 ****Tip:** **Tetramelia* is the term used to describe the failure of limb induction. ### Formation of a Blood Supply In the 4th week, the limb bud is supplied by a capillary network. This coalesces into a main stem artery that drains into a marginal vein. These structures then allow for the following to occur: - Subclavian-axillary brachial **arterial** axis is formed. - Basilic-axillary-subclavian **venous** axis is formed. The brachial artery branches into interosseous and median arteries. The median artery is the main blood supply to the hand, which is then replaced by the ulnar and radial arteries around day 44\. The median artery eventually supplies blood to the median nerve. - Ulnar and radial arteries replaced median artery (now supplies median nerve). --- ## Mechanisms of Development ****Key Point** Upper limb embryology occurs via 3 axes, 3 signalling centres and 3 proteins. The three axes of of limb development are proximodistal, anteroposterior, and dorsoventral. ### Proximodistal Axis - **Role:** "distalises" the limb by differentiating limb from the shoulder to finger. - **Signalling centre:** Apical Ectodermal Ridge (AER). - **Proteins:** Fibroblast growth factors (FGFR 2, 4, 8) influence SHH expression. 😎 ****Fun Fact:** AER is an ectodermal thickening at the leading bud edge. Its removal will result in a truncated limb. ### Anteroposterior - **Role:** "ulnarises" the limb by controlling ulnar and radial growth. - **Signalling centre:** Zone of Polarising Activity (ZPA). - **Proteins:** Sonic Hedgehog (SHH), which also influences FGFR expression. 😎 ****Fun Fact:** ZPA contains mesenchymal cells in the posterior limb bud margin. Its removal will result in an ulnar longitudinal deficiency. ### Dorsoventral Axis - **Role:** "dorsalises" the limb by differentiating a dorsal and palmar surface. - **Signalling centre:** Dorsal ectoderm. - **Proteins:** WNT7A, which activates LMX1. 😎 ****Fun Fact:** WNT7A is restricted to the dorsum by the volar-acting en-1\. Its removal will result in abnormal dorsalisation, such as nail-patella syndrome. Importantly, AER and ZPA are "symbitoic" which results in many conditions affected by the anterioposterior and proximodistal axes: - SHH signal is required to maintain AER integrity. - FGFs from the AER are required to express SHH. There is more information in this webinar below, by Pulvertarft: Pulvertaft Webinar --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Upper Limb Development:** You've learned about the embryological processes that occur from weeks 4 to 8 of gestation, involving the mesoderm and ectoderm, leading to the formation of the upper limb. ****2\. Developmental Milestones:** You now know the key developmental milestones, from the initial appearance of the limb bud to the differentiation into a human-appearing limb. ****3\. Mechanisms of Limb Development:** You've explored the three axes of development (proximodistal, anteroposterior, dorsoventral), the three signaling zones (AER, ZPA, dorsal ectoderm), and the three critical proteins (FGFs, SHH, WNT7a) in the process of limb development. ****4\. Clinical Applications:** You have gained a foundational understanding of recognizing developmental anomalies and their potential clinical implications. --- ### Septic Arthritis - Clinical Scenario URL: https://www.theplasticsfella.com/septic-arthritis-clinical-scenario/ Last updated: 2024-09-04T17:29:17.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/theplasticsfella_httpss.mj.runBI2YFVcSIHM_4k_clinical_photogr_f46f9fd1-f57a-4a1c-96d3-8d411b2cbd45_3.png) #### Clinical Scenario A 65-year-old lady presents with a 5-day history of a single swollen painful joint of her left hand. She enjoys gardening. She is clinically well. ****Objectives:** ****1\.** Obtain a relevant history of septic arthritis. ****2\.** Examination of a joint. ****3\.** Order relevant investigations. ****4\.** Create a relevant treatment plan. ****5\.** Identify complications of septic arthritis. ****Primary Contributor:** Dr Waruguru Wanjau, Plastic Surgery Trainee, South Africa. ****Reviewer:** Dr Suzanne Thomson, Plastic Surgeon, Scotland. _This post is for subscribers on the thePlastics Pro tier only._ ### Septic Arthritis of the Hand: Causes, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/septic-arthritis/ Last updated: 2024-04-23T21:53:17.000Z #### Summary Card [****Causes of Septic Arthritis**](https://www.theplasticsfella.com/septic-arthritis/#causes-of-septic-arthritis) Septic arthritis of the hand is caused by direct inoculation into the joint space, spread from surrounding infection, or hematogenous spread. [****Clinical Presentation of Septic Arthritis**](https://www.theplasticsfella.com/septic-arthritis/#clinical-presentation-of-septic-arthritis) Clinically septic arthritis of the hand presents as a swollen, warm, erythematous, and painful joint. [****Septic Arthritis Diagnosis**](https://www.theplasticsfella.com/septic-arthritis/#septic-arthritis-diagnosis) Diagnosis is based on clinical, radiological (X-rays, ultrasound, and MRI), and laboratory findings (bloodwork WBC, CRP, ESR, and arthrocentesis when possible). [****Treating Septic Arthritis**](https://www.theplasticsfella.com/septic-arthritis/#treating-septic-arthritis) Treatment of septic arthritis requires a combination of surgical debridement, antibiotics, and rehabilitation. [****Complications**](https://www.theplasticsfella.com/septic-arthritis/#complications) Septic Arthritis can result in joint stiffness, chronic infections, and persistent pain. ****Primary Contributor:** Dr Waruguru Wanjau, Plastic Surgery Trainee, South Africa. ****Reviewer:** Dr Suzanne Thomson, Plastic Surgeon, Scotland. --- ## Causes of Septic Arthritis ****Key Point** Septic arthritis of the hand can arise from direct inoculation through trauma or medical procedures, local spread, or less commonly through hematogenous spread. Septic arthritis of the hand can originate from several sources. It may develop from an infection spreading locally from surrounding tissues, or through hematogenous spread from distant sites. Direct inoculation can occur due to trauma or as a complication following surgical procedures. In regards to the specific joints involved in septic arthritis and their aetiology: - **DIPJ:** flexor tenosynovitis, felon, mucous cyst, or paronychia. - **PIPJ:** flexor tenosynovitis. - **MCPJ:** human bite during a fight (fight bite). - **Haematogenous:** rare, usually immunocompromised adults. Patient risk factors for septic arthritis include advanced age, rheumatoid arthritis, diabetes, and immunosuppression ([Earwood,](https://pubmed.ncbi.nlm.nih.gov/34913662/?ref=theplasticsfella.com) 2021). 😎 ****Fun Fact:** Cat bites are more likely than dog bites to cause septic arthritis due to the sharp teeth of cats, piercing tissues, leaving behind a trail of bacteria. --- ## Clinical Presentation of Septic Arthritis ****Key Point** Clinically septic arthritis of the hand presents as a swollen, warm, erythematous, painful joint. Septic Arthritis can present with local and systemic signs and symptoms. **Local** signs include: - **Skin changes:** swelling, warmth, erythema - **Pain:** pain during active motion, passive motion, and rest **Systemic** symptoms suggest **haematogenous spread.** These symptoms include: - Fevers, chills, malaise - Sepsis These signs and symptoms may not be present in patients with immunosuppressed patients or those with prosthetic joints - they may present with loosening in prosthetic joints. 😎 ****Fun Fact:** The joints of the index and middle fingers are most often affected ([Lipatov,](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9302027/?ref=theplasticsfella.com) 2022). --- ## Septic Arthritis Diagnosis ****Key Point** Diagnosis is based on clinical, radiological (X-rays, ultrasound, and MRI), and laboratory findings (bloodwork WBC, CRP, ESR ± arthrocentesis). The diagnosis of septic arthritis of the hand is based on clinical observations, laboratory investigations, and imaging ([Chenoweth,](https://pubmed.ncbi.nlm.nih.gov/32586459/?ref=theplasticsfella.com) 2020). ### Bloods Laboratory blood work includes: - **Inflammatory Markers:** WBC, CRP, and ESR. The trend in inflammatory markers can be used to monitor treatment response, with CRP often lagging a little behind WBC. - **Blood cultures** are indicated in the event of pyrexia, and may be indicative of sepsis or haematogenous spread. 😎 ****Fun Fact:** ****Staphylococcus aureus** is the most common causative factor in blood cultures. ### **Imaging** The imaging modalities that can be used to evaluate septic arthritis are **X-Ray**, **ultrasound**, and **MRI**. **X-rays** Obtain 2 or more views of the affected joint. - Can be used to evaluate for a retained foreign object, osteomyelitis. - Two to three weeks post onset one may see signs characteristic of osteomyelitis, such as osteolysis osteopenia, osteosclerosis, periosteal reaction, and sequestration ([Lipatov,](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9302027/?ref=theplasticsfella.com) 2022). This can be visualised in the image below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Septic-Arthritis-1.png) **Ultrasound:** - Can detect intra-articular effusion. - If joint aspiration, request gram stain and culture, cell count, crystal analysis, protein level, and glucose level. 😎 ****Fun Fact:** Septic arthritis can coexist with crystalline arthropathy; therefore, the presence of crystals on analysis does not rule out septic arthritis. Retained foreign objects can induce chemical synovitis that resembles an infectious process. **MRI:** When necessary can visualize joint effusion, its distribution, and the destruction of soft tissues and osteochondral structures of the joint. This can be visualised in the image below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Septic-Arthritis-of-thE-WRIST.png) The below figure illustrates the algorithm for the workup of patients with acute onset of joint pain ([Chenoweth,](https://pubmed.ncbi.nlm.nih.gov/32586459/?ref=theplasticsfella.com) 2020). 💡 ****Tip:** For a detailed algorithmic approach to the investigatons/work of septic arthritis, please read this article by [Chenoweth](https://pubmed.ncbi.nlm.nih.gov/32586459/?ref=theplasticsfella.com), 2020\. --- ## Treating Septic Arthritis ****Key Point** Treatment of septic arthritis is a combination of surgical treatment, antibiotics, and rehabilitation. Septic arthritis requires a **multi-modal treatment** approach of **surgical washout/debridement**, **antibiotics**, and **rehabilitation**. ### **Surgical Washout** Septic Arthritis is a surgical emergency that requires an urgent washout of the affected joint. Each joint has a particular surgical approach. General principles include: - Large volume **irrigation** of the affected joint. - **Debridement** of infection/non-viable tissue. - Delayed treatment of other injuries (eg: An extensor tendon/sagittal band injury in an MCPJ septic arthritis post fight-bite). - Tissue/Pus sent for microbiology, culture and sensitivity. 💡 ****Tip:** If signs of infection continue and inflammatory markers do not show a downward trend then repeat debridement is recommended within 24-48 hours after the index procedure. ### **Adjuncts to Surgical Treatment** Surgery is the primary treatment. Additional adjuncts can include: - **Antibiotics** for 2-4 weeks based on the sensitivities of the cultures. - **Hand Therapy**: early active mobilisation to attempt to restore of the function of the affected joint. 😎 ****Fun Fact:** Starting rehabilitation for a range of motion exercises following surgery is shown to reduce this stiffness. ([Chenoweth,](https://pubmed.ncbi.nlm.nih.gov/32586459/?ref=theplasticsfella.com) 2020). --- ## Complications ****Key Point** Septic arthritis can cause joint stiffness, chronic infections, and persistent pain, potentially requiring surgical intervention Complications of septic arthritis relate to the range of movement, chronic infections, and pain. More specifically: - **Stiffness**: this is the most common complication. This can relate to soft tissues (eg collateral ligament contractures) or from the articular destruction of the joint (arthritis) - **Chronic/Persistent Infections**: osteomyelitis, abscess, multiple surgeries. - **Chronic Pain**: this primarily relates to arthritic changes in the joint. In these patients, arthrodesis or arthroplasty of the specific joint may be required. Treatment of these complications depends on the specific issue. For example, if the **articular cartilage** is damaged, arthrodesis can be primarily or as a secondary arthrodesis 4−6 wk after the primary revision. Arthrodesis and amputation are significantly higher in diabetic and immunosuppressed individuals ([Giuffre,](https://pubmed.ncbi.nlm.nih.gov/21705153/?ref=theplasticsfella.com) 2011). 😎 ****Fun Fact:** Paediatric patients can have an associated growth plate injury. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Septic Arthritis:** You have acquired a detailed understanding of the causes, clinical presentation, and diagnostic methods for septic arthritis of the hand, essential for recognizing this condition in clinical settings. ****2\. Treatment Approaches:** You are now familiar with the current treatment strategies for septic arthritis, including the importance of prompt surgical debridement, the appropriate use of antibiotics, and the role of rehabilitation in recovery. ****3\. Recognized Importance of Early Intervention:** The article emphasized the critical nature of early diagnosis and intervention to prevent the progression of the infection and minimize long-term damage to the joint and function. ****4\. The Role of Rehabilitation:** You understand that rehabilitation is crucial in restoring function and range of motion in the affected joint after the initial acute management. ****5\. Awareness of Complications**: You have learned about the potential complications associated with septic arthritis. --- ## Further Reading 1. Earwood JS, Walker TR, Sue GJC. [Septic Arthritis: Diagnosis and Treatment](https://pubmed.ncbi.nlm.nih.gov/34913662/?ref=theplasticsfella.com). Am Fam Physician. 2021 Dec 1;104(6):589-597\. PMID: 34913662. 2. Lipatov KV, Asatryan A, Melkonyan G, Kazantcev AD, Solov'eva EI, Cherkasov UE. [Septic arthritis of the hand: Current issues of etiology, pathogenesis, diagnosis, treatment](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9302027/?ref=theplasticsfella.com). World J Orthop. 2022 Jul 18;13(7):622-630\. doi: 10.5312/wjo.v13.i7.622\. PMID: 36051375; PMCID: PMC9302027. 3. Giuffre JL, Jacobson NA, Rizzo M, Shin AY. [Pyarthrosis of the small joints of the hand resulting in arthrodesis or amputation](https://pubmed.ncbi.nlm.nih.gov/21705153/?ref=theplasticsfella.com). J Hand Surg Am. 2011 Aug;36(8):1273-81\. doi: 10.1016/j.jhsa.2011.05.022\. Epub 2011 Jun 25\. PMID: 21705153. 4. Chenoweth B. [Septic Joints: Finger and Wrist](https://pubmed.ncbi.nlm.nih.gov/32586459/?ref=theplasticsfella.com). Hand Clin. 2020 Aug;36(3):331-338\. doi: 10.1016/j.hcl.2020.03.006\. PMID: 32586459. ### Flexor Tenosynovitis: Anatomy, Clinical Features, & Treatment URL: https://www.theplasticsfella.com/flexor-tenosynovitis/ Last updated: 2024-04-29T09:14:42.000Z #### Summary Card [****Anatomy of Flexor Tenosynovitis**](https://www.theplasticsfella.com/flexor-tenosynovitis/#anatomy-of-flexor-tenosynovitis) The fibrous flexor sheath surrounds the flexor tendons and facilitates tendon gliding within a small volume of synovial fluid [****Diagnosis of Flexor Tenosynovitis**](https://www.theplasticsfella.com/flexor-tenosynovitis/#diagnosis-of-flexor-tenosynovitis) The four pathognomonic signs according to Kanavel are fusiform swelling, pain along the flexor sheath, digit held in slight flexion, and pain on passive extension. [****Flexor Tenosynovitis Treatment** ](https://www.theplasticsfella.com/flexor-tenosynovitis/#flexor-tenosynovitis-treatment)A surgical emergency requiring admission, elevation, and IV antibiotics. A closed washout through a limited incision may be used, although it is prudent to keep a low threshold for subsequent open washout. [****Complications of Flexor Tenosynovitis**](https://www.theplasticsfella.com/flexor-tenosynovitis/#complications-of-flexor-tenosynovitis) Stiffness, adhesions, amputation, and skin loss are the primary complications. ****Primary Contributor:** Dr Suzanne Thomson, Plastic Surgeon, Scotland. ****Reviewer:** Dr Kurt Lee Chircop, Plastic Surgery Trainee, Malta. --- ## Anatomy of Flexor Tenosynovitis ****Key Point** The fibrous flexor sheath surrounds the flexor tendons and facilitates tendon gliding within a small volume of synovial fluid. Infection can rapidly and proximally spread within these restricted spaces. The flexor sheaths are a **double-walled structure** beginning at the metacarpal neck in the palm and extending just proximal to the distal interphalangeal joint. The thumb and little finger have bursae extensions, providing a route for proximal spread of infection, as illustrated below. ![Volar hand anatomy of flexor tendons, flexor sheaths, and bursae.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition--1-.jpg) Flexor sheath anatomy with ulnar and radial bursa, thenar, and hypothenar muscles. An anatomical study of 367 hands by Scheldrup, 1951 demonstrated that in the majority of cases these connect via the potential space of Parona (the space between pronator quadratus and FDP tendon sheath). Read more about the anatomy of the flexor tendons and deep spaces of the hand in our [zones of the hand article](https://www.theplasticsfella.com/zones-of-the-hand/). The image below illustrates the anatomy of the flexor sheath of the right hand. ![Flexor Sheath Anatomy of the right hand, including annular & cruciate pulleys, and radial & ulnar bursae. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition--7-.jpg) Flexor Sheath Anatomy of the right hand. 😎 ****Fun Fact:** Infections in the little finger or thumb can spread to the wrist via the radial and ulnar bursa, potentially causing a "****horseshoe abscess**" that may compromise the median nerve and require surgical decompression. --- ## Diagnosis of Flexor Tenosynovitis ****Key Point** The classic presentation of pyogenic flexor tenosynovitis is Kanavel's signs: pain exacerbated on passive flexion, fusiform swelling & fixed position. Bloods (WCC, CRP, cultures) and imaging may support this diagnosis. ### Signs and Symptoms A **classical history** of penetrating trauma followed by increasing **pain** over the flexor aspect of the digit, **swelling** and **reduced function** in the days following are all red flags for potential pyogenic flexor tenosynovitis. These features are commonly described as Kanavel's cardinal signs: - **Pain** along the volar aspect of the digit - Fusiform **swelling** - Digit held in **flexed** position - **Pain** on passive extension Importantly, Kanavel’s signs are not uniformly present in children. Semiflexion of the digit being the least commonly observed sign ([Brusalis,](https://pubmed.ncbi.nlm.nih.gov/28341068/?ref=theplasticsfella.com) 2017). 😎 ****Fun Fact:** Diagnosis may be complicated by co-morbid conditions, such as ****carpal tunnel syndrome** or ****peripheral neuropathy**, masking the classical symptoms and signs ([Clements,](https://pubmed.ncbi.nlm.nih.gov/30871940/?ref=theplasticsfella.com) 2019). These clinical features of flexor tenosynovitis are illustrated in the image below. ![Pain on passive extension, fusiform swelling, held in passive flexion, pain along flexor sheath.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition--3-.jpg) Kanavel’s cardinal signs Increasing age, polymicrobial infection, poorly controlled diabetes, immunosuppression, and peripheral vascular disease are risk factors for flexor tenosynovitis. 😎 ****Fun Fact:** There may be no preceding traumatic injury, as cases of spontaneous PFT have been described. ### Grading There is a 3-point pre-operative severity grading system. The higher the grade of PFT, the worse the outcome ([Pang](https://pubmed.ncbi.nlm.nih.gov/17671013/?ref=theplasticsfella.com), 2007). This is described below: - **Grade One:** the presence of Kanavel’s signs - **Grade Two:** Kanavel’s signs & subcutaneous purulence - **Grade Three:** digital ischaemia. ### Investigations Pyogenic flexor tenosynovitis is primarily a clinical diagnosis. The following investigations may support the diagnosis: - **Inflammatory markers**: raised CRP and WCC are suggestive of bacterial infection - **Blood cultures:** the most common organisms are Staphylococcus & Strep. Vibrio species and anaerobes from **animal** bites, polymicrobial infection, or tetanus from **human** bites - **X-Ray:** 3 views, excluding foreign bodies, soft tissue oedemia. Osteomyelitis/bone changes are not routinely seen in an acute presentation. - **Ultrasound:** may demonstrate fluid in the flexor sheath and tendon changes and exclude other pathologies (eg: septic arthritis). ### Differential Diagnosis Flexor tenosynovitis has a classic presentation. If an atypical presentation, then please consider: - Felon - Paronychia - Septic Arthritis - Subcutaneous/Soft Tissue collection - Collar button abscesses. 😎 ****Fun Fact:** A Lund study indicated that purulent flexor tenosynovitis often suggests diabetes, as 23% of 39 patients had abnormal glucose tolerance, compared to 5% generally ([Leden,](https://pubmed.ncbi.nlm.nih.gov/4048877/?ref=theplasticsfella.com) 2009). --- ## Flexor Tenosynovitis Treatment ****Key Point** Flexor tenosynovitis is a **surgical emergency** requiring admission, elevation, and IV antibiotics. Early aggressive surgical management is standard. ### **Pre-Operative** Early diagnosis should be made and the patient admitted for hand elevation, splinting in a safe position to reduce pain and stiffness, and empirical antibiotics. - **Antibiotics:** Staphylococcus and streptococcus species should be covered in all cases, with the addition of gram-negative rods and anaerobes in immunocompromised patients ([BSSH trauma guidance,](https://www.bssh.ac.uk/%5Fuserfiles/pages/files/professionals/Trauma%20standards/10%20Flexor%20sheath%20infection.pdf?ref=theplasticsfella.com) 2024). - **Consent** for subsequent washouts and also the potential for complications. Please note: early presentations or where there is diagnostic uncertainty a trial of antibiotics may be used, however, early (within 24 hours) surgical washout is recommended in most cases. 💡 ****Tip:** With timely antibiotics and surgery 80% - 90% of individuals will recover full range of movement. ### **Intra-Operative** **Prep**: - General, regional, and local anaesthetic techniques have been described for surgical decompression and washout. - Tourniquet and Loupes are recommended. **Incisions**: - **Open** access via a Bruner's or midlateral incision **or** - **Limited incisions**, like a chevron at the A1 pulley and a horizontal cut at the distal interphalangeal crease, should be designed for possible enlargement. This intra-operative treatment strategy for Flexor Tenosynovitis is illustrated below. ![Image of mid-lateral incision and markings of various incision options.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition--5-.jpg) Incisions for Flexor Tenosynovitis 💡 ****Tip:** Extending the incision in a mid-lateral pattern protects the neurovascular bundles in the dorsal flap, provides complete access to the flexor sheath, and prevents tip necrosis associated with other flap pattern. **Washout and Cultures** - **Cultures**: Wound swabs should be sent for microbiology tests. - **Washout:** large volume irrigation in a proximal to distal fashion. 💡 ****Tip:** Decompression of the carpal tunnel and washout of deep space of Parona is required in horseshoe abscesses. **Severity** Severity can be assessed during surgery using the **Michon Classification** system, which determines the necessary extent of surgical washout—limited washout for grade one—and predicts postoperative function, with higher scores indicating worse outcome). The **Michon Classification** is as follows: - **Grade 1:** increased serous fluid in the flexor sheath - **Grade 2:** purulent fluid - **Grade 3:** frank pus +/- tendon necrosis ### **Post-Operative** - **Dressings**: loosely dressed, and a resting splint may be used for comfort for the first 24 hours. - **Microbiology**: targeted IV antibiotics should be provided. - **Hand Therapy:** early physiotherapy to improve post-operative range of movement. **Please note:** elevation may be combined with a closed irrigation catheter under the A1 pulley with a small drain sutured to the distal incision. The results of a randomized control trial assessing the utility of this are awaited ([Göransson,](https://pubmed.ncbi.nlm.nih.gov/26671952/?ref=theplasticsfella.com) 2015). --- ## Complications of Flexor Tenosynovitis ****Key Point** Complications and post-operative function are related to severity at presentation, co-morbidity, and time from onset to surgical management, and should be discussed pre-operatively. Flexor Tenosynovitis results in major soft tissue complications. Albeit, reports of outcomes are varied [(Bolton,](https://pubmed.ncbi.nlm.nih.gov/30387044/?ref=theplasticsfella.com) 2019). This can range from skin loss, fat necrosis to tendon adhesions, and collateral ligament contractures. These are detailed below: - **Skin Loss:** Major soft tissue infection can result in volar skin loss. This may require delayed skin graft or flap reconstruction - **Range of Movement**: Tendon damage, adhesions, and inflammation. Secondary Tenolysis may be required following intensive physiotherapy. - **Amputation**: Purulence and ischaemia in addition to Kanavel’s signs is associated with a **59%** amputation rate (Pang, [2007](https://pubmed.ncbi.nlm.nih.gov/17671013/?ref=theplasticsfella.com)) In severe cases, it can also result in deep abscesses, septic arthritis, and osteomyelitis ([Canella](https://pubmed.ncbi.nlm.nih.gov/23728188/?ref=theplasticsfella.com), 2013). 😎 ****Fun Fact:** Delayed presentation or management results in increased morbidity due to interruption of tendon gliding, tendon necrosis, and adhesion formation. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Anatomical Complexity:** Understanding the detailed anatomy of the flexor sheath to recognize the pathways an infection can spread and complicate, underscoring the necessity for timely and precise interventions. ****2\. Clinical Presentations:** Identifying the four Kanavel’s signs pathognomonic of PFT, thereby facilitating early diagnosis and management to prevent severe outcomes. ****3\. Management Strategies:** Recognizing PFT as a surgical emergency that necessitates hospital admission, initiation of IV antibiotics, and often surgical intervention to prevent irreversible damage to the flexor tendons. ****4\. Treatment Modalities:** Familiarity with surgical approaches from closed to open washouts, and recognizing the scenarios where each is applicable based on the severity and progression of the infection. ****5\. Potential Complications:** Knowing the potential complications such as stiffness, adhesions, and even amputation, and understanding how these are influenced by the severity at presentation, co-morbidities, and timeliness of surgical intervention. --- ## Further Reading 1. [Flexor Sheath Infection](https://www.bssh.ac.uk/%5Fuserfiles/pages/files/professionals/Trauma%20standards/10%20Flexor%20sheath%20infection.pdf?ref=theplasticsfella.com). The British Society for Surgery of the Hand. Accessed 23/4/2024\. 2. SCHELDRUP EW. [Tendon sheath patterns in the hand; an anatomical study based on 367 hand dissections](https://pubmed.ncbi.nlm.nih.gov/14855245/?ref=theplasticsfella.com). Surg Gynecol Obstet. 1951 Jul;93(1):16-22\. PMID: 14855245. 3. Bolton LE, Bainbridge C. [Current opinions regarding the management of pyogenic flexor tenosynovitis: a survey of Pulvertaft Hand Trauma Symposium attendees](https://pubmed.ncbi.nlm.nih.gov/30387044/?ref=theplasticsfella.com). Infection. 2019 Apr;47(2):225-231\. doi: 10.1007/s15010-018-1236-z. Epub 2018 Nov 1\. PMID: 30387044. 4. Pang HN, Teoh LC, Yam AK, Lee JY, Puhaindran ME, Tan AB. [Factors affecting the prognosis of pyogenic flexor tenosynovitis](https://pubmed.ncbi.nlm.nih.gov/17671013/?ref=theplasticsfella.com). J Bone Joint Surg Am. 2007 Aug;89(8):1742-8\. doi: 10.2106/JBJS.F.01356\. PMID: 17671013. 5. Clements JM, O'Neill T, Hill C. [Challenging Kanavel's cardinal signs of pyogenic flexor tenosynovitis of the hand](https://pubmed.ncbi.nlm.nih.gov/30871940/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2019 Jul;72(7):1219-1243\. doi: 10.1016/j.bjps.2019.02.011\. Epub 2019 Mar 2\. PMID: 30871940. 6. Brusalis CM, Thibaudeau S, Carrigan RB, Lin IC, Chang B, Shah AS. [Clinical Characteristics of Pyogenic Flexor Tenosynovitis in Pediatric Patients](https://pubmed.ncbi.nlm.nih.gov/28341068/?ref=theplasticsfella.com). J Hand Surg Am. 2017 May;42(5):388.e1-388.e5\. doi: 10.1016/j.jhsa.2017.02.007\. Epub 2017 Mar 22\. PMID: 28341068. 7. Rico AA, Holguín PH, González IG, Coba JM. [Flexor tendon synovial sheath haemangioma mimicking subacute tenosynovitis](https://pubmed.ncbi.nlm.nih.gov/7706868/?ref=theplasticsfella.com). J Hand Surg Br. 1994 Dec;19(6):704-5\. doi: 10.1016/0266-7681(94)90239-9\. PMID: 7706868. 8. Leden I, Jonsson G, Larsen S, Rank F, Scherstén B, Svensson B, Thorngren KG. [Flexor tenosynovitis (FTS): a risk indicator of abnormal glucose tolerance](https://pubmed.ncbi.nlm.nih.gov/4048877/?ref=theplasticsfella.com). Scand J Rheumatol. 1985;14(3):293-7\. doi: 10.3109/03009748509100409\. PMID: 4048877. 9. Leppänen OV, Jokihaara J, Kaivorinne A, Havulinna J, Göransson H. [Protocol for an investigator-blinded, randomized, 3-month, parallel-group study to compare the efficacy of intraoperative tendon sheath irrigation only with both intraoperative and postoperative irrigation in the treatment of purulent flexor tenosynovitis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679920/?ref=theplasticsfella.com). BMJ Open. 2015 Dec 15;5(12):e008824\. doi: 10.1136/bmjopen-2015-008824\. PMID: 26671952; PMCID: PMC4679920. 10. Michon J. Le phlegmon des gaines [\[Phlegmon of the tendon sheaths\]](https://pubmed.ncbi.nlm.nih.gov/4839194/?ref=theplasticsfella.com). Ann Chir. 1974 Apr;28(4):277-80\. French. PMID: 4839194. 11. Kanavel A: [Infections of the hand](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6540949/?ref=theplasticsfella.com), 7th ed. Philadelphia, Lea & Febiger, 1939. 12. Grinnell RS. [ACUTE SUPPURATIVE TENOSYNOVITIS OF THE FLEXOR TENDON SHEATHS OF THE HAND: A REVIEW OF ONE HUNDRED AND TWENTY-FIVE CASES](https://pubmed.ncbi.nlm.nih.gov/17856913/?ref=theplasticsfella.com). Ann Surg. 1937 Jan;105(1):97-119\. doi: 10.1097/00000658-193701000-00010\. PMID: 17856913; PMCID: PMC1390296. 13. Sharma KS, Rao K, Hobson MI. [Space of Parona infections: experience in management and outcomes in a regional hand centre](https://pubmed.ncbi.nlm.nih.gov/23571016/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2013 Jul;66(7):968-72\. doi: 10.1016/j.bjps.2013.03.020\. Epub 2013 Apr 6\. PMID: 23571016. 14. Stevanovic, M. V., and F. Sharpe. "Acute infections in the hand." *Green’s operative hand surgery* 1 (2005): 77-81. 15. Canella C, Pacheco M, Costa F, Marchiori E. [Infectious tenosynovitis in a patient with dermatopolymyositis and vasculitis](https://pubmed.ncbi.nlm.nih.gov/23728188/?ref=theplasticsfella.com). J Rheumatol. 2013 Jun;40(6):949\. doi: 10.3899/jrheum.121434\. PMID: 23728188. ## ### Camptodactyly: Features, Classification, & Management URL: https://www.theplasticsfella.com/camptodactyly/ Last updated: 2024-04-24T18:34:36.000Z #### Summary Card [****Definition of Camptodactyly**](https://www.theplasticsfella.com/camptodactyly/#definition-of-camptodactyly) Progressive flexion deformity of the PIPJ. [****Features of Camptodactyly**](https://www.theplasticsfella.com/camptodactyly/#features-of-camptodactyly) Often bilateral and little finger. An X-Ray may show secondary complications. [****Classification of Camptodactyly**](https://www.theplasticsfella.com/camptodactyly/#classification-of-camptodactyly) Classified based on onset of deformity and severity of the flexion. [****Management of Camptodactyly**](https://www.theplasticsfella.com/camptodactyly/#management-of-camptodactyly) Serial splinting and education for most patients. Surgery has a low success rate. --- ## Definition of Camptodactyly Camptodactyly is the *progressive* flexion deformity of the [proximal interphalangeal joint](https://www.theplasticsfella.com/pipj-anatomy/). Swanson classifies it as a 'failure of differentiation'. The image below illustrates the definition of Camptodactyly. ![Definition of Camptodactyly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Camptodactyly-Definition.png) Definition of Camptodactyly 💡 ****Tip:** the progressive nature of this condition is a key differentiator to arthrogryposis. --- ## Features of Camptodactyly ****Key Point** Camptodactlyly is a flexion deformity of the PIPJ that is usually the little finger and bilaterally. Radiology may show secondary sequelae. It is classified based on the onset of deformity. ### Clinical Features Camptodactyly is characterised by the progressive flexion deformity of the [proximal interphalangeal joint](https://www.theplasticsfella.com/pipj-anatomy/). It affects females more than males. Some key points include: - Abnormal flexion posture of PIPJ. - Painless without swelling. - Often bilateral and involves the little finger. Often **caused** by abnormal lumbrical insertion (HINT: pain on passive extension), short FDS tendon, and abnormal extensor mechanism. The **differential diagnosis** includes: - Traumatic PIPJ injury. - **Arthrogryposis**: congenital, ulnar deviation, multiple joints. - **Symphalangism** (failure of joint formation) if no skin creases. - Kirner’s deformity is not a differential diagnosis. This is a skeletal deformity characterised by progressive palmar and radial curvature of the **DIPJ**. 💡 ****Tip:** Examining PIPJ extension with MCPJ flexed can differentiate between intrinsic and extrinsic causes. The image below illustrates this failure of differentiation of Camptodactyly. ![Camptodactyly classification, Failure of Differentiation in Camptodactyly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Camptodactyly-features.png) Failure of Differentiation in Camptodactyly ### Radiological Signs Generally speaking, an X-Ray will not show any primary cause for the camptodactyly as its aetiology is of soft tissue origin. It can show some secondary changes, such as: - Morphological changes to the proximal phalanx. - Decrease in proximal phalanx head convexity. - Flattening at the base of the middle phalanx. - Loss of [PIPJ](https://www.theplasticsfella.com/pipj-anatomy/) joint space with volar subluxation. Check out the below image for the X-ray view of Camptodactyly. ![Camptodactyly X-ray view](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Xray-of-Camptodactyly.png) X-ray representation of Camptodactyly 💡 ****Tip:** a flattened dorsal phalanx is often not surgically correctable. --- ## Classification of Camptodactyly ****Key Point** Camptodactyly is classified based on onset of deformity and severity of the flexion. Camptodactyly classification is based on the **onset** of flexion deformities. - **Type I:** occurs during infancy (the most common type). - **Type II:** occurs during pre-teenage years. - **Type III:** severe, multiple digits, associated with syndromes. 😎 ****Fun Fact:** Type II camptodactyly can progress to Type III. --- ## Management of Camptodactyly ****Key Point** The majority of the patients with camptodactyly can be treated conservatively with splinting and education. Surgery is unlikely to achieve a successful outcome. Patients with camptodactyly can be treated by conservative or surgical options. This depends on the extent of their severity. The majority of patients can be managed in an **outpatient setting** by: - Education - Physiotherapy - Serial Splinting or casting In a select number of patients with severe disease, **surgical** considerations can include: - FDS transfer to extensor surface - Angulation osteotomy - Fusion Surgery should be performed in a step-wise manner to release and reconstruct structures until the flexion deformity is corrected. --- ## Conclusion ## Upon completing this article, you will have accomplished the following: ****1\. Pathophysiology of Camptodactyly:** You have learned that camptodactyly is characterized by a progressive flexion deformity of the proximal interphalangeal joint (PIPJ), predominantly affecting the little finger and often presenting bilaterally. ****2\. Clinical and Radiological Features:** You are now familiar with the clinical presentation of camptodactyly, which typically includes a painless, abnormal flexion posture of the PIPJ without swelling, and how radiology can show secondary changes but not the primary cause due to its soft tissue origins. ****3\. The Classification System:** You understand the classification of camptodactyly based on the onset of the deformity and the severity of the flexion for predicting the progression and planning the management strategy. ****4\. Management Strategies:** You have understood the conservative management approaches such as education, physiotherapy, and serial splinting, and understand when surgical intervention might be considered, and its generally low success rate. --- ### Syndactyly: Causes, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/syndactyly/ Last updated: 2024-04-24T16:37:59.000Z #### Summary Card [****Definition of Syndactyly**](https://www.theplasticsfella.com/syndactyly/#definition-of-syndactyly) A failure of differentiation fuses soft tissue ± bone of the finger [****Classification of Syndactyly**](https://www.theplasticsfella.com/syndactyly/#classification-of-syndactyly) This can be classified as incomplete or complex, simple or complex. [****Diagnosis of Syndactyly**](https://www.theplasticsfella.com/syndactyly/#diagnosis-of-syndactyly) A clinical diagnosis. Bony involvement is confirmed on the X-Ray. [****Management of Syndactyly**](https://www.theplasticsfella.com/syndactyly/#management-of-syndactyly) Before the age of 2\. Earlier if length discrepancy or border digits. --- ## Definition of Syndactyly Syndactyly is a congenital hand malformation defined as a "failure of differentiation" by Swanson or a "malformation of unspecific axis" according to OMT classification. It can be classified as simple (soft tissue), complex (soft tissue and bone), complete (fusion of adjacent nails), or incomplete. The image below illustrates a case of Syndactyly. ![Definition and visual representation of Syndactyly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Syndactyly-Definition.png) Definition and visual representation of Syndactyly A failure in apoptosis results in the fusion of interdigital soft tissue and bones during weeks 6-8 of gestation. This is the result of activation, suppression, and overexpression. 1. **WNT** is activated. 2. **BMP** and Retinoic acid suppression. 3. **FGF-8** is overexpressed in the [AER](https://www.theplasticsfella.com/upper-limb-embryology/). 😎 ****Fun Fact:** Isolated syndactyly is an autosomal dominant condition with variable penetrance. --- ## Classification of Syndactyly ****Key Point** Syndactyly is classified as complete or incomplete, simple or complex. This is related to the extent of fusion and structures involved. Syndactyly is classified by the extent of the fusion (entire finger or partial) and the structures (bone or soft tissue) involved. - **Simple:** no synostosis (soft tissue only). - **Incomplete:** fusion does not involve distal phalanx or overlying soft tissue. - **Complete:** fusion involves the distal phalanx and/or overlying soft tissue. - **Complex:** soft tissue with adjacent phalangeal fusion (synostosis). - **Complicated:** accessory digits or phalanges, additional cleft hand. - **Acrosyndactyly**: shortened digits fused distally with proximal fenestration. This classification is illustrated in the diagram below. ![This flow chart shows the classification of Syndactyly.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Classification-Syndactyly.png) Classification of Syndactyly 😎 ****Fun Fact:** Acrosyndactyly is a re-fusion of the distal tips that is thought to occur due to constriction ring syndrome. Several phenotypic subtypes can result in synopolydactyly, a fusion of border digits, and even polydactyly of all digits. --- ## Diagnosis of Syndactyly ****Key Point** Syndactyly is a clinical diagnosis that can occur in isolation or with an association syndrome. A plain X-ray will confirm synostosis. ### Clinical Findings Syndactyly is a clinical diagnosis. It most commonly occurs in the middle-ring fingers and can be associated with other structural abnormalities. It typically occurs in caucasian males with a family history and can be bilateral in \~50% of cases. The below image illustrates the clinical features of Syndactyly. ![Clinical features of Syndactyly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Features-of-Syndactyly.png) Features of Syndactyly The important **pathological features** of Syndactyly include: - **Bone**: degrees of synostosis, joints usually preserved unless symphalangism. - **Ligaments**: Cleland's and Grayson's ligaments thickened and coalesced. - **Tendons**: duplicated or shared flexor and extensor tendons and sheaths. - **Neurovascular**: duplicate or shared vessels and nerves. - **Skin**: short of skin. 💡 ****Tip:** Synonychia (nail fusion) is a clinical sign suggestive of distal phalanx fusion. ### Radiological Findings Check the image below for the radiological features of Syndactyly. ![Radiological Features of Syndactyly, Syndactyly Diagnosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Radiological-features-of-Syndactyly.png) Radiological View of Syndactyly ### Associated Features Syndactyly can be associated with other structural and craniofacial conditions including, - **Poland Syndrome:** chest wall abnormalities and symbrachydactyly. - [**Apert Syndrome**](https://www.theplasticsfella.com/craniosynostosis/#syndromic-craniosynostosis)**:** craniosynostosis and complex, bilateral syndactyly with symphalangism. - [**Carpenter syndrome**](https://www.theplasticsfella.com/craniosynostosis/#syndromic-craniosynostosis)**.** - **Acrocephalopolysyndactyly** - **Constriction ring syndrome** (distal digital fusion, proximal digit fenestrations). - **Familial syndactyly** is associated with syndactyly of the second and third toes. - **Timothy Syndrome:** long Q-T can lead to sudden cardiac arrest. --- ## Management of Syndactyly ****Key Point** Syndactyly is generally treated in the first 24 months. This is influenced by the finger(s), webspace, and length discrepancies. Patient care for Syndactyly should be individualised. In the immediate setting, patient education and family counselling are essential. This should all be managed by a multi-disciplinary team. ### Timing of surgery Syndactyly release should be performed by after the age of 1 and ideally before age 2\. The exact timing is influenced by the type of finger and webspace involvement. - *Earlier* surgery if border digits are involved or a length discrepancy (\~6 months). - *Later* surgery if "similar" digits are involved (e.g. ring-long, long-index) as a larger hand enables a technically more straightforward operation with more predictable results. 😎 ****Fun Fact:** Tethering from a length discrepancy leads to flexion contractures and rotational deformities of the longer digit. ### Principles of Surgery Techniques Surgery aims to separate digits, create minimal scarring, and respect the web space. This is performed through a combination of flaps and grafts adhering to the following principles: **Timings** 1. **Age:** between 1-2 years or \~6 months if fusion of unequal digits. 2. **Length:** release digits with length discrepancy first. 3. **Location:** release border digits first (ring-little, thumb-index). 4. **Multiple digits:** staged release to avoid vascular issues \~3-6 months apart. 5. **Bilateral:** simultaneously if < 18 months (less active) or staged if older. 💡 ****Tip:** If syndactyly of index-middle-ring-small digits, release index-middle and ring-small first, and do central syndactyly (middle-ring) 6 months later. **Technique** 1. **Incisions:** dorsal and volar interdigitating zigzag 60° flaps to the midline whilst preserving the paratenon. 2. **Flaps:** dorsal and volar random-pattern proximal flaps for webspace. 3. **Graft:** FTSG from wrist crease for colour, no hair, less contracture. Incomplete syndactyly can often be closed with local flaps only. 4. **Nailfold:** "stilleto flap" is a hyponychial interdigitating flap described by Buck-Gramcko or Hentz's "pulp plasty" with a composite graft. 5. **Sutures:** use absorbable sutures. 6. **Defatting:** reducse tension and graft requirements, and increases vascular injury. The management plan is similar for complex syndactyly except that flaps not grafts should cover any bone or joints. In patients with syndromic syndactyly, for example, Aperts Syndrome, symphalangism can also be present. As a result, a zig-zag incision can be replaced with a straight-line incision. 💡 ****Tip:** A skin graft is required because the circumference of two separated digits measured separately is nearly 20% greater than the circumference of two conjoined digits. ### Commisure Flap Design There are a large number of flap designs for syndactyly reconstruction. This is one technique: **Dorsal:** - A "dorsal **commisure** flap". - Aim: reconstruct the **commisure**. - Design: metacarpal head to distal 2/3 proximal phalanx. **Volar:** - A "volar **resurfacing** rectangular flap". - Aim: **resurface** proximal end of the digit that is adjacent to the commissure. - Design: a proximal transverse incision that represents the level of commissure reconstruction, and the distal transverse edge equals the length of the dorsal commissure flap. - This can also be performed as a "T-shaped" flap. 💡 ****Tip:** The width of these flaps does ****not** cross the midline (similar to the zig-zag incisions) **In the thumb-index webspace:** - **Mild**: four-flap Z-plasty (120 degrees) to access to adductor & first dorsal interosseous muscles (may require a partial release for adequate web-space breadth). - **Complete:** modified dorsal rotation advancement flap by Abdel Ghani. 💡 ****Tip:** Dorsal skin is thinner and easier to mobilize than the glabrous palmar skin. The dorsal flap also recreates the normal dorsal-to-palmar commissure slope. ### Contraindications for Syndactyly Release Each patient should be managed as an individual. Generally speaking, relative contradindications include: - Systemic comorbidities that make surgery unsafe. - A severe complex or complicated syndactyly that could result in a poor functional status. - Abnormal vasculatur that could compromise finger viability. - Mild syndactyly that has no functional deficit. - A hypoplastic digit that would become functionless if separated from a functional digit it is fused to. ### Complications Complications of syndactyly release can be intra-operative or post-operative and relate to the surgery or the anaesthetic. - **Peri-operative:** nerve, tendon, artery, or vein injury; haematoma - **Wound**: infection, dehiscence - **Scarring**: hypertrophy, contracture, web creep (commissure pulled distally) - **Bone**: joint instability due to insufficient collateral ligaments - **Nail**: nail deformities Venous complications are more common and often related to too tight a closure. 😎 ****Fun Fact:** Early ****web creep** is a wound issue (flap or graft loss). ****Latecreep** is caused by discrepant growth between scar/skin graft and surrounding tissue during the growth spurt. Mild migration does not require treatment, whereas substantial creep requires revision surgery. --- ## Conclusion ## Upon completing this article, you will have accomplished the following: ****1\. Basics of Syndactyly:** You've gained a comprehensive understanding of syndactyly, a congenital hand malformation characterized by the fusion of two or more digits. ****2\. Classification Systems:** You are now familiar with the classification of syndactyly, which distinguishes between simple and complex forms, as well as complete and incomplete types. ****3\. Diagnostic Approaches:** You have learned that the diagnosis of syndactyly is primarily clinical, supported by radiological findings that confirm the presence of bone involvement and the extent of the fusion. ****4\. Management Strategies:** You understand the management options for syndactyly, which range from surgical separation of fused digits to more complex reconstructive procedures depending on the severity of the condition. ****5\. Associated Conditions:** You are aware that syndactyly can occur as an isolated condition or in association with various syndromes, and recognizing these associations is important for comprehensive patient care. ****6\. Surgical Techniques:** You have an understanding of the specific surgical interventions used in the treatment of syndactyly, such as webspace creation, tendon and ligament reconstruction, and the use of skin grafts and flaps to achieve optimal functional and cosmetic outcomes. --- ### Flexor Tenosynovitis - Clinical Scenario URL: https://www.theplasticsfella.com/flexor-tenosynovitis-clinical-scenario/ Last updated: 2024-09-04T17:30:54.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis---Clinical-Case--1--2-1.jpg) #### Clinical Scenario A 40-year-old, right-hand dominant, tree surgeon with left index finger pain that is exacerbated by passive extension. He received a direct puncture wound 24 hours prior to presentation. No medical history of note, with the patient being otherwise fit and well. ****Objectives:** ****1\.** Early recognition of flexor sheath infection. ****2\.** Anatomy of the flexor sheath and radioulnar bursa of the hand. ****3\.** Describe emergent nonoperative and operative management. ****4\.** Understand the microbiology of flexor sheath infections. ****Primary Contributor:** Dr Suzanne Thomson, Plastic Surgeon, Scotland. ****Reviewer:** Dr Kurt Lee Chircop, Plastic Surgery Trainee, Malta. _This post is for subscribers on the thePlastics Pro tier only._ ### Necrotising Fasciitis - Clinical Scenario URL: https://www.theplasticsfella.com/necrotising-fasciitis-clinical-scenario/ Last updated: 2024-09-04T17:32:02.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis---Clinical-Case.png) #### Clinical Scenario A 45-year-old male arrives at the emergency department with severe pain in his right leg, which has increased in intensity over the past 24 hours. The leg is swollen, erythematous, and warm to the touch. There are also some dark, blistering areas on the skin. The patient mentions a minor cut on his leg from gardening a few days ago. He has a history of poorly controlled diabetes mellitus type 2. Parameters: Heart rate 145 bpm, Blood pressure 85/60, Temperature 38.4, Confused. ****Objectives:** ****1\.** Identify the pathognomonic signs of necrotising fasciitis. ****2\.** Identify the risk factors for necrotising fasciitis. ****3\.** Knowledge of relevant tests to help in making a diagnosis. ****4\.** Management plan for patients with suspected necrotising fasciitis. ****5\.** Identify and discuss any adjunctive therapies. ****Primary Contributor:** Dr Kurt Lee Chircop, Plastic Surgery Trainee, Malta. ****Reviewer**: Dr Waraguru Wanjau, Plastic Surgery Trainee, South Africa. _This post is for subscribers on the thePlastics Pro tier only._ ### Necrotising Fasciitis: Classification, Diagnosis, & Treatment. URL: https://www.theplasticsfella.com/necrotising-fasciitis/ Last updated: 2024-04-23T10:22:52.000Z #### Summary Card [****Definition of Necrotising Fasciitis**](https://www.theplasticsfella.com/necrotising-fasciitis/#definition-of-necrotising-fasciitis) Necrotising fasciitis is a rare, fast-spreading deep tissue infection causing extensive necrosis, with high morbidity and mortality rates. [****Classification of Necrotising Fasciitis** ](https://www.theplasticsfella.com/necrotising-fasciitis/#classification-of-necrotising-fasciitis)Classification is based on the causative organism: Type 1 is polymicrobial, while Types 2, 3, and 4 are monomicrobial. [****Necrotising Fasciitis Risk Factors**](https://www.theplasticsfella.com/necrotising-fasciitis/#necrotising-fasciitis-risk-factors) Immunocompromised individuals and those with recent surgery, trauma, or skin injuries are at higher risk, which can also affect healthy individuals. [****Pathophysiology of Necrotising Fasciitis**](https://www.theplasticsfella.com/necrotising-fasciitis/#pathophysiology-of-necrotising-fasciitis) Necrotising fasciitis involves a complex interplay between bacterial virulence, host immune response, and systemic toxicity. [****Clinical Features of Necrotising Fasciitis**](https://www.theplasticsfella.com/necrotising-fasciitis/#clinical-features-of-necrotising-fasciitis) Initial symptoms are erythema, pain, blistering, and fever are non-specific. Late signs like crepitus and patchy necrosis. [****Diagnostic Workup of Necrotising Fasciitis**](https://www.theplasticsfella.com/necrotising-fasciitis/#diagnostic-workup-of-necrotising-fasciitis) Clinical evaluation and suspicion, although routine blood work and CT imaging can be supportive. [****Treatment of Necrotising Fasciitis** ](https://www.theplasticsfella.com/necrotising-fasciitis/#treatment-of-necrotising-fasciitis)Broad-spectrum antibiotics and urgent surgical debridement are the mainstay of treatment. Multiple debridements may be required. ****Primary Contributor:** Kurt Lee Chircop, Educational Fellow, Malta. ****Reviewer:** Waruguru Wanjau, Educational Fellow, South Africa. --- ## Definition of Necrotising Fasciitis ****Key Point** Necrotising fasciitis is a rare but severe infection of deep soft tissues characterized by rapid progression and extensive necrosis. Necrotising fasciitis (NF) is a rare, rapidly progressing inflammatory infection of the deep soft tissues with relative sparing of the muscles and overlying skin in the first instance. It is characterized by **extensive necrosis across fascial planes**, leading to severe soft tissue destruction with high rates of morbidity and mortality. ![Necrosis, Necrotizing fasciitis, oedema](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Clinical-Features.png) Clinical Features of Necrotising Fasciitis --- ## **Classification of Necrotising Fasciitis** ****Key Point** Necrotising fasciitis may be polymicrobial or monomicrobial and is classified into 4 main subtypes. In necrotising fasciitis, infection spreads through subcutaneous tissues along superficial and deep fascial planes. It is usually classified into 4 subtypes based on the insulting organisms. - **Type 1 Polymicrobial:** a mixture of aerobic and anaerobic bacteria - **Type 2 Monomicrobial:** commonly Group A Streptococcus, Staphylococcus spp 2nd most common - **Type 3 Monomicrobial:** Gram-negative infection eg: Vibrio and Aeromonas spp - **Type 4 Fungal Infection:** Zygomycetes and Candida Type 1 infections account for **70%** of all documented NF followed by Type 2 infections, accounting for **20-30%** of cases. Type 3 infections are typically seen after marine exposure. Fungal infections are a rare cause of NF ([Fontes,](https://pubmed.ncbi.nlm.nih.gov/10874222/?ref=theplasticsfella.com) 2000). 😎 ****Fun Fact:** Necrotising fasciitis (NF) has historically been categorized by anatomical regions, each named after their initial describers: \- ****Fournier’s gangrene** affects the scrotum, penis, or perineum. \- ****Ludwig’s angina** targets the submandibular and sublingual spaces. \- ****Lemierre syndrome** is a rare outcome of pharyngeal infections involving the internal jugular vein. --- ## **Necrotising Fasciitis Risk Factors** ****Key Point** Immunocompromised individuals are at higher risk for developing Necrotising fasciitis. Necrotising fasciitis is typically seen in immunocompromised individuals, with other associated comorbidities, but can also affect previously healthy patients ([Puvanendran,](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762295/?ref=theplasticsfella.com) 2009). These risk factors can be broadly categorised into immunosuppression and trauma. More specifically: - Diabetes & Obesity - Chronic Disease: HIV/AIDS, Liver cirrhosis, Chronic Kidney disease - Malignancy and Chemotherapeutic drugs - Intravenous drug use - Penetrating Trauma - Abdominal or perineal surgery 😎 ****Fun Fact:** ****Type 1** infections are typically seen in immunocompromised individuals, commonly affecting the abdominal and perineal areas. ****Type 2** infection is seen in healthy individuals with a predilection to the extremities. --- ## Pathophysiology of Necrotising Fasciitis ****Key Point** Necrotising fasciitis involves bacterial invasion, rapid growth, tissue destruction, and systemic inflammation, potentially causing multi-organ failure. The pathophysiology of NF is a complicated interplay between **bacterial virulence**, host **immune response**, and **systemic toxicity**. The processes in disease progression are outlined below: 1. **Bacterial entry:** Pathogenic bacteria gain penetrate the natural skin barrier. 2. **Bacterial proliferation:** Rapid proliferation and exotoxin release contribute to soft tissue destruction and the activation of the inflammatory cascade. 3. **Tissue destruction:** The release of collagenases and proteases by bacteria causes the breakdown of the extracellular matrix and connective tissue components, initially limited to the fascial planes. 4. **Vascular compromise:** Ongoing infection results in inflammation and thrombosis of cutaneous perforators, compromising blood flow and causing ischaemia and patchy necrosis. 5. **Systemic effects:** Specific bacterial endotoxins cause a systemic inflammatory response (SIRS) with increased cytokine release, which may lead to multi-organ failure ([Peer,](https://pubmed.ncbi.nlm.nih.gov/17553320/?ref=theplasticsfella.com) 2007). --- ## Clinical Features of Necrotising Fasciitis ****Key Point** The patient is acutely & critically unwell. Initial clinical presentation is non-specific & requires a high index of suspicion. The **symptoms** and **signs** of necrotising fasciitis are non-specific, especially in the early stages of the disease, and given its rarity and high mortality a high index of suspicion is vital for prompt diagnosis ([Chen,](https://pubmed.ncbi.nlm.nih.gov/32826674/?ref=theplasticsfella.com) 2020). **Symptoms:** - **Pain out of proportion to clinical findings** - Rapid clinical deterioration - **Skin changes**: blistering, swelling, redness, bluish discoloration **Local signs:** - **Pain** extending beyond the affected area of demarcated erythema - **Skin changes:** eedema, erythema, hemorrhagic bullae, patchy necrosis (late) - **Subcutaneous:** emphysema and crepitus - **Discharge**: foul-smelling, **‘dishwater fluid’** appearance - **Rapidly progressing** **Systemic signs:** - **Febrile**: rigors, generalised malaise, and fatigue - Decreased mental capacity - Septic shock (hypotension, tachycardia) - Multiorgan failure 💡 ****Tip:** Crepitus, skin anaesthesia, and necrosis are late signs and are pathognomonic for necrotising fasciitis. --- ## Diagnostic Workup of Necrotising Fasciitis ****Key Point** Necrotising fasciitis is a clinical diagnosis confirmed intra-operatively. Diagnosis is based on clinical findings, aided by lab results and radiological investigations. ### Bloods Routine lab tests are required (eg CBC, Renal Function, CRP). Additional Important investigations to consider include: - **Signs of Ischaemia:** Lactate, Creatine kinase (muscle damage) - **Microbiology:** Blood cultures, wound swabs, and tissue specimen (for Gram stain and culture) These investigations will assist in the diagnosis and also the calculation of the **LRINEC score.** This stratifies patients into **low**, **medium**, or **high** probability for necrotising fasciitis diagnosis based on the below laboratory results: ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-LRINEC-Score.png) **A score >6 increases the likelihood of a necrotising infection, rather than other cutaneous manifestations** ([Lee,](https://www.sciencedirect.com/science/article/pii/S1016319012000110?ref=theplasticsfella.com) 2012). 💡 ****Tip:** ****LRINEC** ****score -** should not replace clinical acumen as it has been heavily criticized for its low specificity and sensitivity. Cases have been reported of confirmed NF with a LRINEC score of 0 ([Wilson,](https://pubmed.ncbi.nlm.nih.gov/23287745/?ref=theplasticsfella.com) 2013). ### **Imaging** Radiological investigations **may** aid the diagnosis of necrotising fasciitis. However, treatment should not be delayed while awaiting such investigations if a high index of clinical suspicion exists. - **Ultrasound:** rapidly accessible modality to assess for subcutaneous fluid collections and air - **X-rays:** reveal subcutaneous gas - **CT:** non-enhancing deep fascia in contrast studies, thickened deep fascia - **MRI: m**ost sensitive modality for identifying fascial involvement ([Malghem,](https://pubmed.ncbi.nlm.nih.gov/23043899/?ref=theplasticsfella.com) 2013) ### **Differential diagnosis** Other pathologies may resemble NF in both the early and late stages ([Okhunov,](https://ejournals.id/index.php/bmj/article/view/772?ref=theplasticsfella.com) 2023). These are listed below. **Early-stage disease** This is usually presents with erythema and oedema - Cellulitis - Erysipelas - Vasculitis: Lupus myofascitis, Churg Strauss syndrome) **Late-stage disease** This usually presentswith bullae, vesicles, and necrosis - Necrotising sweet syndrome**:** a rare type of neutrophilic dermatosis without an infective component. - Necrotising pyoderma gangrenosum. 💡 ****Tip:** ****Finger sweep test** assesses fascia integrity by making an incision, sweeping the index finger across the fascia, and checking for easy dissection and ‘dishwater’ discharge; a positive result indicates compromised fascia. --- ## **Treatment of Necrotising Fasciitis** ****Key Point** Management involves prompt broad-spectrum antibiotic therapy and urgent surgical debridement of necrotic tissue as needed. Necrotising fasciitis requires prompt diagnosis, and urgent surgical and medical management to decrease the morbidity and mortality associated with this infection. ### **Medical Management** - Early anaesthetic involvement for Fluid and Cardiac Support - Immediate broad spectrum Antibiotics as per local antibiotic guidelines (adjusted later according to culture & sensitivity). Suggestions for antibitoic regimen *mayinclude:* - Piperacillin/Tazobactam in combination with Clindamycin (1st line)\* or - Ceftriaxone in combination with Metronidazole (once Strep pyogenes has been ruled out). In the case of suspected MRSA Vancomycin is added to any of the above options ([Elkhoury,](https://pubmed.ncbi.nlm.nih.gov/37193468/?ref=theplasticsfella.com) 2023). ### **Surgical Management** There should be no delay in urgent surgical debridement. The **aims** of surgical debridement are: - Excision of necrotic and non-viable tissue - Washout of the involved cavity with 3-6L of 0.9% saline - Achieving a healthy wound bed - Stabilisation of the patient. The surgical wound should then be packed, with planned relook +/- further debridement within 24 hours. Multiple debridements may be required to achieve a healthy wound void of infection, depending on the clinical picture. In situations of severe infection impacting the extremities, there may be a need to amputate the affected limb to mitigate the spread of infection ([Cocanour,](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393412/?ref=theplasticsfella.com) 2017). The extent of surgical debridement can be appreciated in the image below. ![Debridement, Necrotizing Fasciitis Surgery, reconstruction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Necrotising-Fasciitis-Definition.jpg) Surgical Management of Necrotising Fasciitis. 😎 ****Fun Fact:** Hyperbaric oxygen therapy (HBOT) is suggested as a beneficial adjunct for treating Necrotising Fasciitis, potentially reducing tissue loss and enhancing survival when used with surgery and antibiotics, though its efficacy lacks robust evidence ([Levett,](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516968/?ref=theplasticsfella.com) 2015). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Recognizing Necrotising Fasciitis**: You are now familiar with the fundamental characteristics of necrotising fasciitis. The four main types determine the complexity of the condition. ****2\. Identifying Risk Factors:** You have learned about the high-risk groups for developing necrotising fasciitis and how certain conditions like diabetes and chronic kidney disease can predispose individuals to this infection. ****3\. Understanding Pathophysiology:** Pathophysiological mechanisms explain how the disease progresses and the systemic impact it can have. ****4\. Clinical Presentation:** You've gained insights into the clinical presentation of NF, including the critical Kanavel’s signs and other symptoms that might initially mimic less severe conditions. ****5\. Diagnosing Necrotising Fasciitis:** The essential diagnostic steps, the role of the LRINEC score, and imaging techniques in the diagnosis are important in management strategies. ****6\. Managing Complications:** You're now aware of the potential complications associated with necrotising fasciitis and the factors that influence these outcomes. --- ## Further Reading 1. Fontes RA Jr, Ogilvie CM, Miclau T. [Necrotizing soft-tissue infection](https://pubmed.ncbi.nlm.nih.gov/10874222/?ref=theplasticsfella.com)s. J Am Acad Orthop Surg. 2000 May-Jun;8(3):151-8\. doi: 10.5435/00124635-200005000-00002\. PMID: 10874222. 2. Puvanendran R, Huey JC, Pasupathy S. [Necrotizing fasciitis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762295/?ref=theplasticsfella.com). Can Fam Physician. 2009 Oct;55(10):981-7\. PMID: 19826154; PMCID: PMC2762295. 3. Peer SM, Rodrigues G, Kumar S, Khan SA. [A clinicopathological study of necrotizing fasciitis--an institutional experience](https://pubmed.ncbi.nlm.nih.gov/17553320/?ref=theplasticsfella.com). Journal of the College of Physicians and Surgeons--pakistan: JCPSP. 2007 May;17(5):257-260\. DOI: 05.2007/jcpsp.257260\. PMID: 17553320. 4. Chen, Leon L. DNP, AGACNP-BC, FCCP, FAANP, FNYAM; Fasolka, Brian PhD, RN, CEN; Treacy, Caitlin MS, AGACNP-BC. [Necrotizing fasciitis: A comprehensive review](https://pubmed.ncbi.nlm.nih.gov/32826674/?ref=theplasticsfella.com). Nursing 50(9):p 34-40, September 2020\. | DOI: 10.1097/01.NURSE.0000694752.85118.62 5. Sun X, Xie T. [Management of Necrotizing Fasciitis and Its Surgical Aspects](https://journals.sagepub.com/doi/abs/10.1177/1534734615606522?ref=theplasticsfella.com). The International Journal of Lower Extremity Wounds. 2015;14(4):328-334\. doi:10.1177/1534734615606522 6. Liao C, Lee Y, Su Y, Chuang C, Wong C. [Validation of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for early diagnosis of necrotizing fasciitis](https://www.sciencedirect.com/science/article/pii/S1016319012000110?ref=theplasticsfella.com). Tzu Chi Medical Journal. 2012;24(2):73-76\. doi: 10.1016/j.tcmj.2012.02.009. 7. Malghem J, Lecouvet FE, Omoumi P, Maldague BE, Vande Berg BC. [Necrotizing fasciitis: Contribution and limitations of diagnostic imaging](https://pubmed.ncbi.nlm.nih.gov/23043899/?ref=theplasticsfella.com). Joint Bone Spine. 2013;80(2):146-154\. doi: 10.1016/j.jbspin.2012.08.009. 8. Okhunov, A. O., and D. N. Korikhonov. "[Differential diagnosis of necrotizing fasciitis](https://ejournals.id/index.php/bmj/article/view/772?ref=theplasticsfella.com)." British Medical Journal 3.1 (2023). 9. Wilson MP, Schneir AB. [A case of necrotizing fasciitis with a LRINEC score of zero: Clinical suspicion should trump scoring systems](https://pubmed.ncbi.nlm.nih.gov/23287745/?ref=theplasticsfella.com). J Emerg Med. 2013;44(5):928-931\. doi: 10.1016/j.jemermed.2012.09.039 10. Elkhoury D, Quick S, Kalloo A E, et al. (April 14, 2023) [Necrotizing Fasciitis Secondary to Mycotic Femoral Aneurysm: A Narrative Review of Diagnosis and Management Strategies](https://pubmed.ncbi.nlm.nih.gov/37193468/?ref=theplasticsfella.com). Cureus 15(4): e37586\. doi:10.7759/cureus.37586 11. Cocanour CS, Chang P, Huston JM, Adams CA Jr, Diaz JJ, Wessel CB, Falcione BA, Bauza GM, Forsythe RA, Rosengart MR. [Management and Novel Adjuncts of Necrotizing Soft Tissue Infections](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393412/?ref=theplasticsfella.com). Surg Infect (Larchmt). 2017 Apr;18(3):250-272\. doi: 10.1089/sur.2016.200\. Epub 2017 Apr 4\. PMID: 28375805; PMCID: PMC5393412. 12. Levett DZ, Bennett MH, Millar I. [Adjunctive hyperbaric oxygen for necrotizing fasciitis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516968/?ref=theplasticsfella.com). Cochrane Database of Systematic Reviews 2015, Issue 1\. Art. No.: CD007937\. DOI: 10.1002/14651858.CD007937.pub2. ### Perfecting Op Notes, $200 Logo competition & Consent in Cosmetic Surgery. URL: https://www.theplasticsfella.com/april-21st/ Last updated: 2024-04-20T15:36:57.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/april-21st/#a-letter-from-pfella) Design the perfect operation note. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/april-21st/#the-sunday-quiz) (+ Leaderboard) How well do you know craniosynostosis**?* 3. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-21st/#upcoming-events) 10 number of events in next 6 months. 4. ****🚀** [****New Updates** ](https://www.theplasticsfella.com/april-21st/#new-features) $200 Podcast Logo Competition 5. ****🔥** [****3 New Articles**](https://www.theplasticsfella.com/april-21st/#articles-of-the-week) **with summaries!** Cosmetic Consent, Oncoplastic and Nerves! 6. 💕 [****Feedback**](https://www.theplasticsfella.com/april-21st/#feedback) Suggest ideas & give feedback! ## A Letter from P'Fella **What is the 'perfect' operation note?* 👋 ****Hey Team!** Dive into a crucial but often overlooked part of our surgical practice—perfecting the operation note. Let's turn this routine document into an art form of clarity and precision! ****👇** **Why Operation Notes Matter** An operation note isn't just routine paperwork; it's a crucial narrative that guides post-operative care and communicates important decisions. By refining our approach, we can ensure that these notes serve as effective, comprehensive guides. What do **you** think of this template below? ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Operation-note.png) **What Did People on** [**Twitter**](https://x.com/PlasticsFella/status/1779921705378463746?ref=theplasticsfella.com) **Say?** I put out a tweet during the week asking for the most important aspect to an operation note. Here were the key themes: - **Promptness**: Document details on the day for maximum accuracy. - **Clear Plans**: Ensure post-op plans are straightforward and executable by anyone. - **Honest Reporting**: Accurately describe the OR events without embellishment. - **Optimal Detail**: Aim for notes that are informative yet succinct. **What's your preference??** Let’s elevate our standard for operation notes together. The team are building surgical technique templates and your feedback is key! ****tl;dr** \- Operation notes guide detailed, accurate post-op care. \- Community feedback highlights clarity, directness, and practicality. \- Give feedback to help design the ideal surgical op note. ## The Sunday Quiz **Craniosynostosis* Welcome to the ****next round** of The Weekly Quiz Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end of six rounds will earn you a $100 voucher. Good luck! ![Craniosynostosis Definition ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Definition-of-Craniosynostosis.png) ## Upcoming Events A Curated List of Webinars, Courses & Conferences ### ## New Features Behind the Scenes Podcast coming soon! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Behind-the--fella.png) #### Behind the 'Fella Podcast $200 Logo Design Competition We're super excited to let you know about "Behind the 'Fella," our brand new podcast that takes you behind the scenes of our educational platform. Join us as we dive into the ways we build our team, enhance various skills, and chat with some top experts to broaden our horizons and spark creativity. ****Help Us Design Our Logo!** We'd love to see your creative ideas for our ****podcast logo**! Send your designs to support@theplasticsfella.com, and if yours is the one we go with, ****you'll snag $200**. Can't wait to see what you come up with! ****Deadline Sunday 28th April.** **Be notified when the 1st episode drops? input your email below 😄** ## Articles of the Week 3 Interesting Articles with 1 sentence summaries. 1️⃣ ****Oncoplastic Techniques and Tricks** ([PRS](https://journals.lww.com/plasreconsurg/pages/articleviewer.aspx?year=2024&issue=04000&article=00005&type=Fulltext&ref=theplasticsfella.com), 2024) Oncoplastic breast reconstruction combines oncologic and aesthetic techniques to optimize outcomes in breast-conserving surgery, using a variety of methods for volume displacement or replacement based on patient and tumor characteristics. 2️⃣ ****The best way to repair a nerve?** ([J Hand Surg](https://journals.sagepub.com/doi/10.1177/17531934241242002?ref=theplasticsfella.com), 2024) A practical guide for peripheral nerve repair advancements. Review your techniques for autografting, nerve transfers, and implants to effectively manage nerve transections and gaps. 3️⃣ ****How to properly Consent a Breast Augmentation** ([PRS Open](https://journals.lww.com/prsgo/fulltext/2023/11000/developing%5Fan%5Finternational%5Fframework%5Ffor%5Finformed.16.aspx?ref=theplasticsfella.com), 2023) This creates a standardized guideline for cosmetic breast augmentation, focusing on structured preoperative consultations, cooling-off periods, and consistent postoperative management based on extensive global survey data. ## Feedback ### I hope you enjoyed it 😄 --- ### Thumb Hypoplasia: Blauth Classification, Diagnosis, & Treatment URL: https://www.theplasticsfella.com/thumb-hypoplasia/ Last updated: 2025-06-18T13:09:37.000Z #### Summary Card [****Definition of Thumb Hypoplasia**](https://www.theplasticsfella.com/thumb-hypoplasia/#definition-of-thumb-hypoplasia) Congenital thumb "undergrowth" due to a radial longitudinal deficiency. [****Diagnosis of Thumb Hypoplasia**](https://www.theplasticsfella.com/thumb-hypoplasia/#diagnosis-of-thumb-hypoplasia) A clinical diagnosis supported by radiology and specific investigations for associated anomalies. [****Classification of Thumb Hypoplasia**](https://www.theplasticsfella.com/thumb-hypoplasia/#classification-of-thumb-hypoplasia) Blath Classification from I (functional small thumb) to V (absent thumb). This guides management. [****Staged Reconstruction of Thumb Hypoplasia**](https://www.theplasticsfella.com/thumb-hypoplasia/#staged-reconstruction-of-thumb-hypoplasia) Indicated in Blauth II and IUIa for webspace release, UCL reconstruction, opponensplasty, and tendon reconstruction. [****Index Pollicisation for Thumb Hypoplasia**](https://www.theplasticsfella.com/thumb-hypoplasia/#index-pollicisation-for-thumb-hypoplasia) Indicated for Blauth IIIb, IV, or V. --- ## Definition of Thumb Hypoplasia Thumb Hypoplasia is the congenital underdevelopment of the thumb due to a radial longitudinal deficiency. It is classified as "undergrowth" as per the Swanson classification. This is illustrated below. ![Definition of Thumb Hypoplasia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Thumb-Hypoplasia-Definition.png) Definition of Thumb Hypoplasia --- ## Diagnosis of Thumb Hypoplasia ****Key Point** Thumb hypoplasia is a clinical diagnosis supported by radiological investigations. Further investigations may be required for associated conditions. ### Clinical Diagnosis Thumb hypoplasia is a clinical diagnosis based on findings during clinical inspection and assessment of the range of motion. It can be supported by radiological findings. - **Skin:** Absent skin creases, web-space tightness. - **Ligaments:** Excessive abduction of MCP joint in UCL insufficiency. - **Muscles:** Hypoplasia of thenar musculature. - **Tendons:** Pollex abductus (FPL has extra insertion onto extensor tendon). - **Movement:** UCL laxity, absence of motion at joints (Blauth III). These clinical features of thumb hypoplasia are illustrated below. ![Clinical Features of Thumb Hypoplasia, Thumb Hypoplasia signs](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Thumb-Hypoplasia-Clinical-Features-1.png) Clinical Features of Thumb Hypoplasia ### Radiological Findings It is recommended to request bilateral films of the hand, wrist, and forearm. - Can help determine musculotendinous versus osseous deficiencies. - Type III B Basal metacarpal aplasia with deficient CMC joint. - Any associated hypoplastic radius. ![Radiological Features of Thumb Hypoplasia, Diagnosing Thumb Hypoplasia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Radiological-Thumb-Hypoplasia.png) Radiological View of Thumb Hypoplasia ### Associated Conditions Thumb hypoplasia can be associated with a diverse group of genetic conditions and syndromes. These include: - **VACTERL:** **V**ertebral anomalies, **A**nal atresia, **C**ardiac defects, **T**racheal anomalies, **E**sophageal atresia, **R**enal and radial abnormalities, **L**imb abnormalities. - **Holt-Oram:** Autosomal dominant, upper-limb defects, congenital heart malformation, cardiac conduction disease. Common cardiac defects include atrial or ventricular septal defects and conduction abnormalities or blocks. - **Thrombocytopenia-absent radius:** Bilateral absence of the radii with the presence of both thumbs and thrombocytopenia. It can be distinguished from Fanconi anemia by the neonatal onset of thrombocytopenia, which is typically seen later in life with Fanconi anemia, and the absence of pancytopenia. - **Fanconi anaemia:** Autosomal recessive condiciton characterized by bone marrow failure and radial limb abnormalities. Other common anomalies include café au lait spots, short stature, genital abnormalities, and microcephaly. Patients usually die of complications from pancytopenia, with a life expectancy of 20-30 years. It can be diagnosed on peripheral blood smear, complete blood count, and chromosomal challenge test. 😎 ****Fun Fact:** In the slight majority of patients, thumb hypoplasia is bilateral. --- ## Classification of Thumb Hypoplasia ****Key Point** The Blauth classification is used in thumb hypoplasia to describe the severity of the condition and structures involved. It can be used as a template to guide management. The **Blauth Classification** is used in thumb hypoplasia. It stratifies patients based on the degree of hypoplasia, collateral ligament, muscle, and tendon pathology. 1. **Blauth I:** Functional hypoplastic thumb, normal neurovascular bundles, 2. **Blauth II:** UCL insufficiency, webspace contracted, thenar hypoplasia. 3. **Blauth IIIa:** Type II + abnormal extrinsic tendons + *stable* CMCJ. 4. **Blauth IIIb:** Type II + abnormal extrinsic tendons + *unstable* CMCJ. 5. **Blauth IV:** Floating thumb (*pouce flottant)* attached by a soft tissue bridge. 6. **Blauth V:** Absent thumb. ![Blauth Classification of thumb hypoplasia](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Blauth-Classification-for-Thumb-Hypoplasia.png) Blauth Classification of Thumb Hypoplasia This classification subsequently guides the reconstructive pathway for conservative, staged procedures or index pollicisation. Here are some general principles. 1. **Blauth I:** if good function then does not require surgery 2. **Blauth II + IIIA:** staged procedure for each abnormality 3. **Blauth IIIb:** Pollicisation 😎 ****Fun Fact:** Thumb hypoplasia can be associated with partial or complete absence of the radius, and patients should be screened for Fanconi's anaemia. --- ## Staged Reconstruction of Thumb Hypoplasia ****Key Point** Staged reconstruction is indicated in patients with a stable MCPJ (Blauth II, IIIa). It involves first web space release, UCL reconstruction, opponensplasty, and tendon reconstruction. Thumb hypoplasia is usually surgically corrected by age 2 when indicated. A staged correction is indicated for Type II and IIIB thumb hypoplasia. This involves reconstruction of the webspace, MCPJ UCL insufficiency, hypothenar hypoplasia, and extrinsic tendons. **First Webspace Release** - This can be performed through a [Z-plasty](https://www.theplasticsfella.com/z-plasty/) (e.g. a four-flap Z-plasty). **UCL Reconstruction** UCL deficiency may be primary or secondary to a pollex abductus (FPL inserts into the distal phalanx and the EPL). This can be treated by, - Fusion - UCL reconstruction with a tendon graft (if UCL remnant present) - UCL reconstruction with FDS opponensplasty **Opponensplasty** This stage aims to augment the hypoplastic hypothenar muscles. Options for this opponensplasty include, - Ring Finger FDS transfer (can also help reconstruct the UCL) - Huber transfer (ADM to APB) **Tendon Reconstruction** Type III thumb hypoplasia has abnormal extrinsic tendons with a stable MCPJ. These patients can receive, - EIP to EPL tendon transfer - Pulley reconstruction --- ## Index Pollicisation for Thumb Hypoplasia ****Key Point** Index pollicisation is indicated in Blauth IIIb, IV, and V thumb hypoplasia. Index pollicisation is indicated in Blauth IIIB, IV, and V thumb hypoplasia. The fundamental goal is to recreate a functional thumb by utilizing a shortened and rotated index finger. **Incisions** - Radial palmer incision to create skin flaps at the base of the index finger that can be used to create a first webspace. - Dorsal incisions should preserve dorsal draining veins. **Dissection** - Ulnar digital nerve is mobilisation by interfasciular dissection of the common digital nerve to the index-middle finger web. - The radial digital artery to the middle finger is ligated and divided. - Interossei are elevated from the index finger metacarpal. **Resections** - Index metacarpal is removed with its head preserved to form a trapezium. - Epiphysis excised to prevent subsequent growth. **Stability** - The metacarpal head is rotated and secured with K-wires. - 120-160° rotation, 40° palmar abduction with the MCPJ hyperextended. **Intrinsic and Extrinsic Rebalance** - Extrinsic shortened: FPL and EPL are trimmed to the length of the metacarpal**.** - First dorsal interosseous to radial lateral band = APB. - First palmar interosseous to ulnar lateral band = Adductor pollicis. - EIP acts as EPL. - EDC to index acts as APL. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding of Thumb Hypoplasia:** You have understood thumb hypoplasia, a congenital condition characterized by the underdevelopment of the thumb due to radial longitudinal deficiency. ****2\. Diagnostic Techniques:** You now know how thumb hypoplasia is diagnosed, combining clinical examination with radiological investigations to assess the extent of the underdevelopment and any associated anomalies. ****3\. Classification Systems:** You are familiar with the Blauth Classification. This classification aids in guiding the management strategies for each specific type. ****4\. Management Options:** You have learned about management strategies for thumb hypoplasia. These treatments are tailored based on the severity of the hypoplasia as defined by the Blauth Classification. ****5\. Associated Conditions:** You are aware that thumb hypoplasia can be associated with several genetic conditions and syndromes, prompting the need for a comprehensive evaluation of associated anomalies. ****6\. Surgical Techniques:** You have been introduced to specific surgical interventions such as webspace release, UCL reconstruction, opponensplasty, and tendon reconstruction, as well as the complex procedure of index pollicisation. --- ### Craniosynostosis: Anatomy, Classification, & Investigations URL: https://www.theplasticsfella.com/craniosynostosis/ Last updated: 2024-04-17T20:11:52.000Z #### Summary Card [****Definition of Craniosynostosis**](https://www.theplasticsfella.com/craniosynostosis/#definition-of-craniosynostosis) The premature fusion of one or more cranial sutures. It can be isolated or part of a syndrome. [****Virchow's Law in Craniosynostosis**](https://www.theplasticsfella.com/craniosynostosis/#virchows-law-of-craniosynostosis) Virchow's Law states that premature suture fusion results in cranial growth predominantly parallel to sutures. [****Anatomy of Craniosynostosis**](https://www.theplasticsfella.com/craniosynostosis/#anatomy-of-craniosynostosis) 5 sutures fuse over a period of time: ****metopic** (6-8 months), ****sagittal** (22 years), ****coronal** (24 years), ****lambdoidal** (26 years), ****squamosal** (60 years). [****Classification of Craniosynostosis**](https://www.theplasticsfella.com/craniosynostosis/#classification-of-craniosynostosis) By the affected suture(s) or head shape. [****Secondary Features of Craniosynostosis**](https://www.theplasticsfella.com/craniosynostosis/#secondary-features-of-craniosynostosis) Facial dysmorphology, associated limb abnormalities, and potentially raised intracranial pressure. [****Syndromic Craniosynostosis**](https://www.theplasticsfella.com/craniosynostosis/#syndromic-craniosynostosis) ****Majority** are autosomal dominant FGFR mutations with abnormal facies and limb abnormalities. [****Positional Plagiocephaly**](https://www.theplasticsfella.com/craniosynostosis/#postitional-plagiocephaly) External pressure resulting in a rhomboid-shaped head, flat occiput with ipsilateral prominence of cheeks and brows. [****Investigations**](https://www.theplasticsfella.com/craniosynostosis/#investigations) X-ray, CT, or MRI can help confirm the clinical diagnosis, identify sutures, assess for complications, and plan for surgery. Primary Contributor: Dr Abdulrahman Abdulaziz Alghamdi, King Fahad University Hospital. --- ## Definition of Craniosynostosis Craniosynostosis is the premature fusion of one or more cranial sutures. It can be an isolated abnormality or part of a syndrome. It occurs in \~1 per 2500 births. This is illustrated in the image below. ![Craniosynostosis Definition ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Definition-of-Craniosynostosis.png) Definition of Craniosynostosis ### Risk Factors There are **specific risk factors** for developing craniosynostosis. These include: - Family history - Advanced maternal age - Use of clomiphene citrate for infertility - Pregnancy-related issues: smoking, hydrocephalus, hypothyroidism - Male gender --- ## Virchow's Law in Craniosynostosis ****Key Point** Virchow's Law states that premature suture fusion results in cranial growth predominantly parallel to sutures. **Virchow's Law states that premature suture fusion results in cranial growth predominantly parallel to sutures. It does not occur perpendicularly.** This means that each fusion pattern has a characteristic skull shape, as illustrated below. ![Virchow's Law for Craniosynostosis, Virchow's Law, Craniosynostosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/11/Virchows-law-.png) Virchow's Law for Craniosynostosis Other theories are published in regard to the pathophysiology and pathoanatomy of craniosynostosis. These include: 1. **Dural abnormality:** suture abnormality relating to the osteoinductive properties of the dura mater (McCarthy). 2. **Skull base abnormality:** abnormalities in the skull base result in abnormal tension on the cranial base exerted through the dura mater (Moss). 💡 ****Tip**: As the brain and CSF volume increases, the cranium grows through apposition (bone deposition from inner to outer surface) and sutural. --- ## Anatomy of Craniosynostosis ****Key Point** ****Metopic** suture is first to fuse at \~6-8 months, followed by ****sagittal** (22 years), ****coronal** (24 years), ****lambdoidal** (26 years) & finally ****squamosal** (60 years). The skull is constructed of 2 **frontal** bones, 2 **parietal** bones, and one **occipital** bone. In newborns, these bones are separated by patent sutures and fontanelles. The function of these fontanelles and patent sutures: - Allow for brain growth - Overlapping of skull bones during labor The normal cranial suture anatomy can be visualized below. ![Cranial Sutures, Skull Anatomy, Anatomy, Skull, Sutures, Fontanelles, Metopic Suture, Coronal Suture, Saggital Suture, Squamosal Suture, Lambdoidal Suture, Posterior Fontanelle, Anterior Fontanelle](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/11/Cranial-Suture-Anatomy-1.png) Anatomy of Craniosynostosis The premature fusion of one or more sutures leads to craniosynostosis. The normal timeline of cranial suture and fontanelle fusion is depicted below. ![Cranial Sutures, Skull Anatomy, Anatomy, Skull, Sutures, Fontanelles, Metopic Suture, Coronal Suture, Saggital Suture, Squamosal Suture, Lambdoidal Suture, Posterior Fontanelle, Anterior Fontanelle](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/11/Timeline-of-Cranial-Suture-Fusion-1.png) Timeline of Cranial Suture Fusion Craniosynostosis usually begins during pregnancy or the first year of life. It's usually completed by 3 years of age. Important dates in "normal" fusions and closures. - **Posterior Fontanelle:** 3-6 months - **Metopic**: 6-8 months - **Anterior Fontanelle:** 9-12 months - **Sagittal:** 22 years (most commonly involved) - **Coronal:** 24 years - **Lambdoidal:** 26 years - **Squamosal**: approximately 60 years --- ## Classification of Craniosynostosis ****Key Point** Craniosynostosis can be classified based on sutural involvement or head shape. These descriptions are correlated, as per Virchow Law. ### **Craniosynostosis can be classified by the affected suture(s) or head shape**. This is because each pattern of fusion has a characteristic skull shape, as per Virchow's Law. This classification is illustrated in the image detail below. ![Clinical Features of Craniosynostosis, Scaphocephaly, Plagiocephaly, Trigonocephaly, Bracycephaly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/11/Clinical-Features.png) Clinical Features of Craniosynostosis 😎 ****Fun Fact:** Key features of a metopic synostosis include trigonocephaly, metopic ridge, flare in the supraorbital rim, hypotelorism, and compensatory biparietal widening. It can be difficult to remember the shapes of each condition. The best way is to understand Virchow's Law and use the following image. ![Abnormal Skull Shapes in Craniosynostosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/11/Virchows-law---2-.png) Abnormal Skull Shapes in Craniosynostosis, Scaphocephaly, Plagiocephaly, Trigonocephaly, Bracycephaly Another way is also to understand the translations of the words. These are detailed below. ![Abnormal skull shapes classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/11/Translation-of-Craniosynostosis.png) Make it easier to remember! 💡 ****Tip:** an abnormal head shape can be craniosynostosis, primary microcephaly, hydrocephalus, or positional plagiocephaly. --- ## Secondary Features of Craniosynostosis ****Key Point** The premature fusion of sutures results in facial dysmorphology, associated limb abnormalities, and potentially raised intracranial pressure. Craniosynostosis has a direct effect on nearby intracranial and extracranial structures. - **Midface Hypoplasia** causing sleep apnea. - **Front-orbital rim recession** causing exorbitism and exposure keratitis. - **Flare in the supraorbital rim** found in trigonocephaly. - **Palpable ridges** from the thickness of closed sutures. A metopic ridge can occur in trigonocephaly - it is benign and often self-resolving. - **Limb abnormalities** are caused by a common molecular pathway. - **Raised intracranial pressure**, which is discussed in more detail below. ![Secondary Features of Craniosynostosis, Craniosynostosis Diagnosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Secondary-Features-Craniosynostosis.png) Secondary Features of Craniosynostosis 💡 ****Tip:** Exorbitism is eyeball protrusion from the decreased size of the orbit (exophthalmos is due to increased contents of a normal-sized orbit). ### Raised Intracranial Pressure Craniosynostosis can result in raised intracranial pressures >15mmHg. This can often be linked to aqueductal stenosis. These patients can have clinical features of: - **Head:** headaches, irritability, seizures, bulging fontanelles (Volcano sign) - **Eyes:** papilloedema, optic atrophy - **Abdomen:** Vomiting - **Other:** Developmental Delay There is an increased risk when multiple suture synostosis. It can be the result of: - **Cephalocranial disproportion:** decreased intracranial volume and restricted brain growth - **Vascular:** Chiari Malformation, intracranial venous congestion - **Other:** Hydrocephalus, upper Airway obstruction **Treatment** considerations include a shunt, ventriculostomy, and craniovault remodeling. --- ## Syndromic craniosynostosis ****Key Point** The ****majority** of syndromic synostoses are autosomal dominant, caused by FGFR mutations, and have abnormal faces and limb abnormalities. ### Overview The majority are **non-syndromic or isolated** craniosynostosis. Only \~20% have genetic aetiology, which includes mutations in: - **Most common:** FGFR mutations - **Less common:** TWIST, TCF12, ERF, EFNB1, RAB23, POR, IL11RA. This is described in the table below. ![Genetic Mutations of Craniosynostosis, Features of Craniosynostosis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/11/Genetic-Mutations-1.png) Genetic Mutations of Craniosynostosis ### Features Generally speaking, the syndromic conditions have similar features, which include: - Autosomal dominant (except Carpenter and Antley-Bixter) - Abnormal Facies - Limb Abnormalities **Crouzon Syndrome (Most Common)** - **Genetics:** Autosomal dominant FGFR2 mutation (can occur sporadically). - **Synostosis**: Bicoronal (other sutures can be involved). - **Features:** Exorbitism, midface hypoplasia, high arched or cleft palate, conductive hearing loss, class III malocclusion. - **Sequelae**: Progressive hydrocephalus. 💡 ****Tip:** Crouzon's syndrome has normal hands **Apert Syndrome** - **Genetics:** Autosomal dominant (although most cases are sporadic) - **Synostosis**: Bicoronal - **Features:** Parrot-beak, midface hypoplasia, cleft palate,syndactyly, class III malocclusion - **Sequelae:** Raised ICP, nonprogressive ventriculomegaly, conductive loss 💡 ****Tip:** Apert's syndrome has abnormal hands. **Carpenter's Syndrome (Rare)** - **Genetics**: Autosomal recessive RAB23 - **Synostosis**: usually sagittal or coronal, but many can be affected - **Features**: cardiac issues, partial finger syndactyl, preaxial feet polydactyly - **Sequelae**: obesity and intelligence 💡 ****Tip:** Carpenter's Syndrome is an ****autosomal recessive** condition. **Pfeiffer Syndrome (Rare)** - **Genetics:** Autosomal dominant FGFR2 (most common & severe) or FGFR1\. - **Clinical features:** obstructive sleep apnea, broad thumbs/toes. - **Sequelae:** can lead to Kleeblattschadel deformity. 💡 ****Tip:** Pfieffer syndrome has broad thumbs and toes. **Saethre-Chotzen Syndrome:** - **Genetics:** Autosomal dominant mutation in TWIST-1 gene - **Synostosis**: Bicoronal - **Clinical features:** low hairline, ptosis, prominent crus helicis, partial syndactyly, midface hypoplasia is less common 💡 ****Tip:** Saethre-Chotzen syndrome has ear and eye involvement. **Muenke Syndrome:** - **Genetics:** Autosomal dominant FGFR3 mutation with variable expression - **Synostosis:** coronal - **Clinical Features:** developmental delay and sensorineural hearing loss - **NB:** not all patients with Muenke syndrome suffer from craniosynostosis 💡 ****Tip:** Meunke Syndrome has more psychological than physical issues. --- ## Positional Plagiocephaly ****Key Point** Positional plagiocephaly is external pressure resulting in a rhomboid-shaped head, and flat occiput with ipsilateral prominence of cheeks and brows. Positional plagiocephaly is the distortion of the skull due to external pressure. Pathological "true" plagiocephaly is unilateral coronal or lambdoid synostosis. These differences are illustrated in the table below. ![Positional vs True Plagiocephaly, Positional Plagiocephaly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Positional-Plagiocephaly-1.png) Positional vs True Plagiocephaly --- ## Investigations ****Key Point** Radiological investigations such as X-ray, CT, or MRI can help confirm the clinical diagnosis, identify sutures, assess for complications, and plan for surgery. Craniosynostosis is primarily a **clinical diagnosis** based on abnormal head shapes during the first year of life and secondary features. Investigations are used for diagnosis, pre-operative planning, and monitoring. ### Radiology There are different radiological investigations at the clinician's disposal. **Skull X-ray** This is an AP, lateral, Townes projection, and C-spine. Features include: - Abnormal skull shape - Suture sclerosis, loss of lucency, "lipping", or interdigitations - Normal sutures widen to compensate - Harlequin sign on the lateral orbit (coronal synostoses superiorly displacing the lesser wing of sphenoid) - Copper-beaten skull from raised ICP - "Thumb printing" from gyri pressure on the inner table **Cranial CT with 3D Reconstruction** - Assess each individual suture fusion, intracranial volume, and morphology. - Useful for planning for surgery. - Can assess for the presence of hydrocephalus. - Raised ICP will result in reduced ventricle size and paracortical spaces, herniation through the foramen magnum. The below image shows the radiological features of Craniosynostosis. ![Radiological Features of Craniosynostosis, Scaphocephaly, Plagiocephaly, Trigonocephaly, Bracycephaly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/11/Craniosynostosis-10.png) Radiological features of Craniosynostosis on CT with 3D reconstructions **Transorbital Ultrasound** - Measure the diameter of the optic nerve sheath. - Increased ICP in cases such as craniosynostosis usually leads to the increased diameter of the optic nerve sheath. **MRI** - Not routinely used. - Can be considered for specific syndromes or concerns for specific pathologies, such as anomalous venous drainage. ### Additional Investigations Adjunctive investigations can help in certain circumstances. These include: - **Fundoscopy**: assess for papilledema - **Direct Intraparenchymal monitoring:** ICP monitoring --- ## Managment of Craniosynostosis ****Key Point** Craniosyonotsis management focuses on the correction of shapes, treating complications, and maintaining functional status. ### Overview The treatment of craniosynostosis is centred on a multidisciplinary team involving a plastic surgeon, ENT, orthodontist, speech therapist, child psychologist, and nurses. The **goals of treatment** should be to: - To correct abnormal head shape/skull deformity. - Treat or prevent raised intracranial pressure. - Expand the intracranial volume. - Protect the airway and cornea. ### Surgical Options A myriad of surgical options is available to treat craniosynostosis. The is no general consensus on the "best" time to perform surgery but generally is recommended in infancy between the ages of 3-12 months. Options to consider include: - **Vault Remodelling and Reconstruction** via distraction osteogenesis. This expansion technique can be performed at 6 months for Aperts, Crouzon's, Saethre-Chozen, and Meunke. TCVR can be performed via the 'Melbourne Technique' for *sagittal synostosis* via a wavy incision. - **Strip Craniectomy:** strip excision of bone over suture. *This can be considered in metopic synostosis* or early *sagittal synostosis*. - **Fronto-orbital advancement** increases AP dimension & reduces exorbitism. *This can be performed in unicoronal synostosis*. - **Monobloc advancement** of Le Fort III and fronto-orbital section. This can be performed in extreme cases of raised ICP, exposure kerattis, and airway problems. - **Le Fort III** to correct midface retrusion and secondary airway issues to become independent of tracheostomy and reduce sleep apnoea. - **Le Fort I** for midface hypoplasia, class III malocclusion, and anterior open bite. - **Spring-assisted cranioplasty** can be performed after a sagittal strip. It is a lower-risk and technically easier procedure but it doesn't fix frontal bossing. - **Skeletal distraction** via internal or external devices \~1mm/day and usually for \~ 2-3 weeks. Regrowth primarily from the dura. Ifhydrocephalus is present, shunting procedures are generally performed first, prior to bone remodeling. 💡 ****Tip:** In delayed synostosis presentations, the frontal sinus will be formed. This means a cranialisation procedure may also be required. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding of Craniosynostosis:** You've gained a comprehensive understanding of the definition, causes, and Virchow's Law related to craniosynostosis. ****2\. Suture Anatomy:** You've learned about the typical timeline and significance of the fusion of different cranial sutures, crucial for diagnosing and understanding the progression of craniosynostosis. ****3\. Classification Systems:** You are now familiar with the different classifications of craniosynostosis based on affected sutures and resulting head shapes for the clinical assessment. ****4\. Secondary Features and Syndromic Variations:** You've explored the secondary features associated with craniosynostosis, such as facial dysmorphology and limb abnormalities, as well as the distinctions between syndromic and nonsyndromic forms. ****5\. Diagnostic and Management Strategies:** You've learned about the various diagnostic tools such as X-ray, CT, and MRI that confirm the diagnosis and assist in surgical planning, alongside a multidisciplinary approach to management, correcting deformities, and preventing complications. --- ## Further Reading 1. Kajdic N, Spazzapan P, Velnar T. [Craniosynostosis - Recognition, clinical characteristics, and treatment.](https://www.bjbms.org/ojs/index.php/bjbms/article/view/2083?ref=theplasticsfella.com) Bosn J Basic Med Sci. 2018 May 20;18(2):110-116\. doi: 10.17305/bjbms.2017.2083\. PMID: 28623672; PMCID: PMC5988529. 2. Brah TK, Thind R, Abel DE. [Craniosynostosis: Clinical Presentation, Genetics, and Prenatal Diagnosis.](https://pubmed.ncbi.nlm.nih.gov/33111964/?ref=theplasticsfella.com) Obstet Gynecol Surv. 2020 Oct;75(10):636-644\. doi: 10.1097/OGX.0000000000000830\. PMID: 33111964. 3. Kirmi O, Lo SJ, Johnson D, Anslow P. [Craniosynostosis: a radiological and surgical perspective](https://pubmed.ncbi.nlm.nih.gov/20099636/?ref=theplasticsfella.com). Semin Ultrasound CT MR. 2009 Dec;30(6):492-512\. doi: 10.1053/j.sult.2009.08.002\. PMID: 20099636. 4. Dempsey RF, Monson LA, Maricevich RS, Truong TA, Olarunnipa S, Lam SK, Dauser RC, Hollier LH Jr, Buchanan EP. [Nonsyndromic Craniosynostosis](https://pubmed.ncbi.nlm.nih.gov/30851746/?ref=theplasticsfella.com). Clin Plast Surg. 2019 Apr;46(2):123-139\. doi: 10.1016/j.cps.2018.11.001\. Epub 2019 Jan 30\. PMID: 30851746. 5. Sawh-Martinez R, Steinbacher DM. [Syndromic Craniosynostosis.](https://pubmed.ncbi.nlm.nih.gov/30851747/?ref=theplasticsfella.com) Clin Plast Surg. 2019 Apr;46(2):141-155\. doi: 10.1016/j.cps.2018.11.009\. PMID: 30851747. ### Microtia: Causes, Classifications, & Surgery URL: https://www.theplasticsfella.com/microtia/ Last updated: 2025-06-27T18:16:43.000Z #### Summary Card [****Definition of Microtia**](https://www.theplasticsfella.com/microtia/#definition-of-microtia) A syndromic or isolated congenital hypoplastic deformity that presents in a clinical spectrum from minor to complete absence. [****Embryology of Microtia**](https://www.theplasticsfella.com/microtia/#embryology-of-microtia) The first and second branchial arches develop into six Hillocks of His. These develop the ear during the 5th to 9th weeks of gestation. [****Clinical Features of Microtia**](https://www.theplasticsfella.com/microtia/#clinical-features-of-microtia) Classified by the number of vestigial ear structures present. [****Secondary Features of Microtia**](https://www.theplasticsfella.com/microtia/#secondary-features-of-microtia) Hearing loss, bone hypoplasia, systemic soft tissue pathology, and craniofacial syndromes. [****Investigations for Microtia**](https://www.theplasticsfella.com/microtia/#investigations-for-microtia) Radiological and audiological evaluation guided management. [****Management of Microtia**](https://www.theplasticsfella.com/microtia/#management-of-microtia) Autologous, alloplastic, or prosthetic materials through two common techniques: Brent or Nagata. --- ## Definition of Microtia Microtia is a congenital hypoplastic deformity that can occur in isolation or in a syndrome. It presents a clinical spectrum of minor deficiencies to the complete absence of the auricle Major research and surgical development was performed by Tanzer in the second half of the 20th century. See image below. ![microtia, Tanzer, ear reconstruction, auricl, Brent, Nagata, surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/Microtia-3.png) Tanzer's 1959 Publication on Auricular Reconstruction ([Tanzer](https://pubmed.ncbi.nlm.nih.gov/13633474/?ref=theplasticsfella.com), 1959) Multiple causes have been suggested. These include genetics, teratogens, and vascular abnormalities/ischemia ([Llano-Rivas](https://pubmed.ncbi.nlm.nih.gov/10372445/?ref=theplasticsfella.com), 1999). These embryological abnormalities are relatively rare. - **Prevalence** is approximately 1-2 per 10,0000 births ([Figueroa](https://pubmed.ncbi.nlm.nih.gov/3877093/?ref=theplasticsfella.com), 1985 & [Bennun](https://pubmed.ncbi.nlm.nih.gov/4070453/?ref=theplasticsfella.com), 1985 & [Harris](https://pubmed.ncbi.nlm.nih.gov/8933331/?ref=theplasticsfella.com), 1996). - **Male** predominance. - **Ratio** of right/left/bilateral is 5:3:1 ([Harris](https://pubmed.ncbi.nlm.nih.gov/8933331/?ref=theplasticsfella.com), 1996). --- ## Embryology of Microtia ****Key Point** The first and second branchial arches develop into six Hillocks of His. This leads to ear development during the 5th to 9th weeks of gestation. Microtia occurs during the embryological development of the first (mandibular) and second (hyoid) [pharyngeal](https://www.theplasticsfella.com/pharyngeal-arches/) (branchial) arches. More specifically, the *six hillocks of His*. This is illustrated below. ![microtia, Tanzer, ear reconstruction, auricl, Brent, Nagata, surgery, embryology of the ear](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/Microtia-2.png) Embryology of the Ear in Microtia Important embryology **structures** to consider are: - **Ectoderm:** helps differentiate mesoderm into cartilage & forms the inner ear. - **1st** [**pharyngeal**](https://www.theplasticsfella.com/pharyngeal-arches/#pharyngeal-arches)[ **arch**](https://www.theplasticsfella.com/pharyngeal-arches/#pharyngeal-arches)**:** 3 anterior hillocks. - **2nd** [**pharyngeal**](https://www.theplasticsfella.com/pharyngeal-arches/) **arch:** 3 posterior hillocks. - **1st** [**pharyngeal**](https://www.theplasticsfella.com/pharyngeal-arches/) **cleft:** forms the external auditory meatus. - **1st** [**pharyngeal pouch**](https://www.theplasticsfella.com/pharyngeal-arches/#pharyngeal-pouches-and-grooves)**:** develops into the middle ear and Eustachian tube. - **Otic placode** in the ectoderm invaginates to form the inner ear. 💡 ****Tip:** The inner ear develops from the otic placode and ****not** the pharyngeal apparatus. This explains why the inner ear is often not involved. More specifically: - **Hillocks 1 to 3:** tragus, helical root, and helical crus. - **Hillocks 4 to 6:** antihelix, antitragus, and lobule. ****Important**: Textbooks and references cite variations in the Hillocks' derivatives. This description is from [Moore](https://books.google.lk/books/about/The%5FDeveloping%5FHuman%5FE%5FBook.html?id=pmKGBwAAQBAJ&redir%5Fesc=y&ref=theplasticsfella.com) et al, *Developing Human*, 10th Edition from 2015. The other parts of the ear (remaining helix, superior crus, scaphoid fossa) are derived from the 'free ear fold' posterior to the posterior hillocks. Microtia severity depends on the timing. An earlier embryological issue results in a more severe presentation. Important **dates** to consider are: - **Week 5:** External ear begins to form. - **Week 6:** anterior and posterior hillocks form. - **Week 9:** ear becomes recognizable. 😎 ****Fun Fact:** the lobule is the last part of the external ear to form. --- ## Clinical Features of Microtia ****Key Point** Microtia is a clinical spectrum that is classified based on the number of vestigial ear structures present. Microtia is a clinical spectrum of severity that can be syndromic or occur in isolation (more common) ([Llano-Rivas](https://pubmed.ncbi.nlm.nih.gov/10372445/?ref=theplasticsfella.com), 1999). It is graded in accordance with the number of vestigial ear structures present. - **Anotia**: the complete absence of the external ear. - **Lobule-type:** remnant ear & lobule without concha, acoustic meatus & tragus. - **Concha-type:** lobule, concha, acoustic meatus, tragus & incisura tragica are present to variable degrees. - **Small concha-type**: remnant lobule, small indentation representing concha. - **Atypical microtia:** patients who cannot be classified above. This is illustrated in the diagram below. ![microtia, Tanzer, ear reconstruction, auricl, Brent, Nagata, surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/Microtia-4.png) Clinical Spectrum of Microtia ([Beahm](https://pubmed.ncbi.nlm.nih.gov/12045579/?ref=theplasticsfella.com), 2002) Microtia is just one aspect of congenital ear deformities. The entire spectrum of "congenital ear deformities" (which includes microtia) was published by Tanzer. - **Type 1:** Anotia - **Type 2:** *Complete* hypoplasia (microtia) - **Type 2A:** Microtia *with* atresia of the external auditory meatus - **Type 2B:** Microtia *without* atresia of the external auditory meatus - **Type 3:** Hypoplasia of the *middle-third* of the ear - **Type 4:** Hypoplasia of the *superior-third* of the ear. - **Type 4A:** Constricted ear – lop/cup - **Type 4B:** Cryptotia - **Type 4C:** Hypoplasia of the entire upper third of the ear - **Type 5:** [Prominent Ear](https://www.theplasticsfella.com/otoplasty-overview-of-techniques/) 💡 ****Fun Fact:** The inner ear is not usually involved in microtia (unlike the middle ear) due to its different embryological origin. --- ## Secondary Features of Microtia ****Key Point** Microtia is associated with hearing loss, bone hypoplasia, systemic soft tissue pathology, and craniofacial syndromes. ### Hearing Loss Hearing loss in microtia is \~15% sensorineural and \~85% conductive. There can also be mixed (sensorineural and conductive) ([Carvalho](https://pubmed.ncbi.nlm.nih.gov/10037288/?ref=theplasticsfella.com), 1999). It is associated with: - **Ossicles**: disrupted or absent - **External Auditory Canal**:stenosis (mixed hearing loss and risk of cholesteatoma) or atresia (conductive hearing loss) ([Gill](https://pubmed.ncbi.nlm.nih.gov/5785652/?ref=theplasticsfella.com), 1969). - **Loss of tympanic cavity** 😎 ****Fun Fact:** The external auditory meatus and internal ear have different embryological origins. The internal ear is usually well constructed in patients with microtia. ### Bone The severity of external deformities correlates with the severity of temporal bone abnormalities ([Llano-Rivas](https://pubmed.ncbi.nlm.nih.gov/10372445/?ref=theplasticsfella.com), 1999). Bone pathology can include: - Mandibular hypoplasia (commonly the condyle) - Temporal bone - Vertebra - Limb reduction defects ### Other - **Head and Neck:** Facial nerve pathology, Cleft lip and palate - **Cardiac:** Defects - **Eye:** Anophthalmia and microphthalmia - **Renal:** syndromic ear anomalies are associated with brachio-oto-renal syndrome and Townes-Brocks syndrome. Ultrasound of the kidneys should be considered. ### Syndromes It is suggested to be the mildest form of hemifacial microsomia ([Figueroa](https://pubmed.ncbi.nlm.nih.gov/3877093/?ref=theplasticsfella.com), 1985 & [Bennun](https://pubmed.ncbi.nlm.nih.gov/4070453/?ref=theplasticsfella.com), 1985). It is also linked to other syndromes such as: - [Treacher Collins Syndrome](https://www.theplasticsfella.com/treacher-collins-syndrome/) - [Craniofacial (Hemifacial) Microsomia](https://www.theplasticsfella.com/hemifacial-microsomia/) - Goldenhar Syndrome 💡 ****Tip:** the presence of a tragus has been considered an indication of middle ear function ([Calzolari](https://pubmed.ncbi.nlm.nih.gov/10890145/?ref=theplasticsfella.com), 1999) --- ## Investigations for Microtia ****Key Point** All microtia patients should undergo complete radiological and audiological evaluation, regardless of presentation. ### Radiology - **CT:** shows temporal bone & middle ear, ossicles, cholesteatoma (squamous epithelium trapped in the middle ear) - **MRI**: shows facial nerve (often displaced in middle ear malformations) ([Calzolari](https://pubmed.ncbi.nlm.nih.gov/10890145/?ref=theplasticsfella.com), 1999 & [Carvalho](https://pubmed.ncbi.nlm.nih.gov/10037288/?ref=theplasticsfella.com), 1999). This can be seen in the images below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/microtia1-2-1.jpg) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/05/microtia1-1.jpg) Grade III Microtia on the Left - Case courtesy of Assoc [Prof Frank Gillard](about:blank) 😎 ****Fun Fact:** the potential to surgically improve hearing improvement is determined by CT-calculated **Jahrsdorfer Criteria,* which analyses middle ear structures. Middle ear reconstruction is contraindicated for a score <5/10. ### Audiology In terms of audiometric testing, this will determine conductive vs sensorineural hearing loss. --- ## Management of Microtia ****Key Point** The surgical treatment of microtia is centred on ****autologous**, ****alloplastic,** or ****prosthetic** materials through two common techniques: Brent or Nagata. The number one goal is to restore hearing, followed by reconstruction. The management of microtia should focus on the patient's goals, the timing of intervention, and surgical options in a multi-disciplinary team. Reconstruction is *usually* around the age of 7 - at this stage, the patient's ear size is suitable, donor site cartilage is suitable and the patient can often help make an informed decision. The primary goal of microtia management is to improve acoustic function. Other goals to consider are: - Preservation of the normal ear. - Improve the affected one. - Enable speech development. - Improve aesthetics. ### Timing of Microtia Surgery The exact time for microtia surgery is reflective of the patient and surgical preference. Issues to take into consideration are: - **Is the ear developed?** Most ears are developed by the age of 4 or 5\. The width of the ear continues to grow until 10\. It's also important to consider if there is adequate donor-site rib cartilage. - **What surgery is required?** This is discussed in more detail in the next section. The Brent Technique is performed earlier than the Nagata Technique. - **Is the kid being bullied?** Emotion and psychological factors, particularly in young school kids, are important considerations. - **Is Middle Ear Surgery required?** Ideally, the external ear should be treated first. Middle ear reconstruction is not indicated for unilateral microtia with normal hearing in the contralateral ear ([Moore](https://www.tandfonline.com/doi/abs/10.3109/00016488609122730?ref=theplasticsfella.com), 2009). There is a risk of injury to the facial nerve, but it can improve hearing by 70% in some cases ([Declau](https://pubmed.ncbi.nlm.nih.gov/10890146/?ref=theplasticsfella.com), 1999 & [Chang](https://pubmed.ncbi.nlm.nih.gov/8189991/?ref=theplasticsfella.com), 1994). ### Hearing Hearing loss and atresia can be treated through different techniques. The majority of hearing issues are conductive hearing loss. Patients with stenosis of EAM can have mixed sensorineural and conductive; atresia patients have conductive hearing loss. **Bone-anchored hearing aid (BAHA)** - Two-stage radiologically-guided osseointegration, discovered by Brånemark. - Abutment placed >65mm posterior to the external auditory meatus to avoid scars on the non-hair-bearing mastoid skin. - It can be placed after external ear reconstruction in unilateral cases. - Ideally performed by the age of 4 or 5\. **Other considerations:** - **Meatoplasty/Canaloplasty:** not routinely performed due to mild hearing improvement and risk of facial nerve injury. - Middle ear implants. ### External Ear Reconstruction Staged autogenous cartilage reconstruction remains the gold standard for correcting microtia. Two techniques that have popularised autologous rib cartilage graft frameworks are **Brent (4 stages)** and **Nagata (2 stages)**. **Brent Technique** ([Brent](https://pubmed.ncbi.nlm.nih.gov/1513882/?ref=theplasticsfella.com), 1992) This technique can be performed earlier than the Nagata technique as less rib cartilage is required. It is usually performed by the age of 6\. - **Stage I:** Plan, harvest from the contralateral chest, and create a subcutaneous pocket by incising anterior to the auricular vestige and removing any residual cartilage. - **Stage II:** Lobule created - **Stage III:** Post-auricular sulcus is created by incising outside the helical rim, advancing a post-auricular flap, and resurfacing with a split-thickness skin graft. - **Stage IV:** Tragus created by using normal ear conchal cartilage. After a 5-year follow-up, Brent concluded11 that 48% grow at the same rate as normal ears, 46% grow slightly bigger, and 10% grow slightly smaller. 💡 ****Tip:** The helical rim is formed by the 8th rib and the base of ear can be formed by a synchondrosis of the 6th and 8th rib. **Nagata Technique** ([Nagata](https://pubmed.ncbi.nlm.nih.gov/8337267/?ref=theplasticsfella.com), 1993) This technique is usually performed by the age of 9\. Its main difference from the Brent technique is that the creation and elevation are done at the same time. - **Stage I:** cartilage framework with a tragal component and lobule are inset into a subcutaneous pocket created by a posterior incision. - **Stage II**: The post-auricular sulcus is created by a cartilage wedge, a local flap (temporoparietal fascial flap or galeal flap), and a split-thickness skin graft. 💡 ****Tip:** In Nagata, the rib cartilage framework is created by ribs 6-9\. **Alloplastic Reconstruction:** - Single-stage subcutaneous implantation, often Medpor. - Reinisch technique. - Less commonly used due to the higher rates of extrusion. Tissue expansion is less commonly used because expanded skin is less supple than unexpanded skin. It is less able to conform to the anatomic details of an autologous or prosthetic ear cartilage framework. 💡 ****Tip:** No reconstruction is also an option for patients who have normal acoustic function and minimal psychological discomfort. ### --- ## Other Auricular Abnormalities ****Key Point** Other auricular abnormalities to consider include Stahl's ear, cryptotia, and constricted ear. **Stahl Ear** - An abnormal third crus traverses the superior third of the ear (from the crus antihelix to the edge of the helix). - The appearance of a "flattened" helix. - It can be treated with neonatal molding. **Cryptotia** - The upper pole of the helix is buried beneath the temporal skin. - Less common findings can include missing upper sulcus, underdeveloped scapha, or antihelical crura. - Reconstruction aims to create a posterior sulcus with a skin graft or flap. - The cause is due to an anomaly of intrinsic oblique and transverse auricular muscles. **Constricted Ear** - A deficiency in the "circumference of the helix". - Lop ear: folding of the superior aspect of the helix. - Cup ear: folding of the superior aspect of the helix **and** a [prominent ear](https://www.theplasticsfella.com/otoplasty-overview-of-techniques/). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding of Microtia:** You've gained insights into the congenital condition of microtia, including its definitions and classifications based on the severity and presence of vestigial ear structures. ****2\. Embryological Development:** You've learned about the crucial stages of ear development from the 5th to the 9th week of gestation, how disruptions in these stages lead to microtia, and the specific contributions of the first and second branchial arches. ****3\. Associated Conditions:** You've gained an understanding of the secondary features associated with microtia, such as hearing loss, bone hypoplasia, and their linkage to systemic and craniofacial syndromes, enhancing your ability to identify related complications. ****4\. Diagnostic and Management Practices:** You now know the appropriate investigations required for a comprehensive evaluation of microtia and the modern surgical techniques for its management, preparing you to handle such cases with a multidisciplinary approach. ****5\. Clinical Spectrum:** Through this article, you've explored the clinical presentation spectrum of microtia, from minor deformities to complete absence, and how these variations impact surgical planning and patient outcomes. ### --- ## Further Reading 1. Llano-Rivas I, González-del Angel A, del Castillo V, Reyes R, Carnevale A. [Microtia: a clinical and genetic study at the National Institute of Pediatrics in Mexico City](https://pubmed.ncbi.nlm.nih.gov/10372445/?ref=theplasticsfella.com). Arch Med Res. 1999 Mar-Apr;30(2):120-4\. doi: 10.1016/s0188-0128(98)00023-2\. PMID: 10372445. 2. Figueroa AA, Friede H. [Craniovertebral malformations in hemifacial microsomia](https://pubmed.ncbi.nlm.nih.gov/3877093/?ref=theplasticsfella.com). J Craniofac Genet Dev Biol Suppl. 1985;1:167-78\. PMID: 3877093. 3. Bennun RD, Mulliken JB, Kaban LB, Murray JE. [Microtia: a microform of hemifacial microsomia](https://pubmed.ncbi.nlm.nih.gov/4070453/?ref=theplasticsfella.com). Plast Reconstr Surg. 1985 Dec;76(6):859-65\. PMID: 4070453. 4. Harris J, Källén B, Robert E. [The epidemiology of anotia and microtia](https://pubmed.ncbi.nlm.nih.gov/8933331/?ref=theplasticsfella.com). J Med Genet. 1996 Oct;33(10):809-13\. doi: 10.1136/jmg.33.10.809\. PMID: 8933331; PMCID: PMC1050757. 5. Gill NW. [Congenital atresia of the ear. A review of the surgical findings in 83 cases](https://pubmed.ncbi.nlm.nih.gov/5785652/?ref=theplasticsfella.com). J Laryngol Otol. 1969 Jun;83(6):551-87\. doi: 10.1017/s0022215100070687\. PMID: 5785652. 6. Calzolari F, Garani G, Sensi A, Martini A. [Clinical and radiological evaluation in children with microtia](https://pubmed.ncbi.nlm.nih.gov/10890145/?ref=theplasticsfella.com). Br J Audiol. 1999 Oct;33(5):303-12\. doi: 10.3109/03005369909090114\. PMID: 10890145. 7. Carvalho GJ, Song CS, Vargervik K, Lalwani AK. [Auditory and facial nerve dysfunction in patients with hemifacial microsomia](https://pubmed.ncbi.nlm.nih.gov/10037288/?ref=theplasticsfella.com). Arch Otolaryngol Head Neck Surg. 1999 Feb;125(2):209-12\. doi: 10.1001/archotol.125.2.209\. PMID: 10037288. 8. David R. Moore (1986) [Critical Periods for Binaural Interaction and Spatial Representation](https://www.tandfonline.com/doi/abs/10.3109/00016488609122730?ref=theplasticsfella.com), Acta Oto-Laryngologica, 101:sup429,51-55, DOI: 10.3109/00016488609122730 9. Declau F, Cremers C, Van de Heyning P. [Diagnosis and management strategies in congenital atresia of the external auditory canal. Study Group on Otological Malformations and Hearing Impairment](https://pubmed.ncbi.nlm.nih.gov/10890146/?ref=theplasticsfella.com). Br J Audiol. 1999 Oct;33(5):313-27\. doi: 10.3109/03005369909090115\. PMID: 10890146. 10. Chang SO, Min YG, Kim CS, Koh TY. [Surgical management of congenital aural atresia](https://pubmed.ncbi.nlm.nih.gov/8189991/?ref=theplasticsfella.com). Laryngoscope. 1994 May;104(5 Pt 1):606-11\. doi: 10.1002/lary.5541040514\. PMID: 8189991. 11. Brent B. [Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases](https://pubmed.ncbi.nlm.nih.gov/1513882/?ref=theplasticsfella.com). Plast Reconstr Surg. 1992 Sep;90(3):355-74; discussion 375-6\. PMID: 1513882. 12. Nagata S. [A new method of total reconstruction of the auricle for microtia](https://pubmed.ncbi.nlm.nih.gov/8337267/?ref=theplasticsfella.com). Plast Reconstr Surg. 1993 Aug;92(2):187-201. 13. TANZER, R. C. (1959). *TOTAL RECONSTRUCTION OF THE EXTERNAL EAR. Plastic and Reconstructive Surgery, 23(1), 1–15.* doi:10.1097/00006534-195901000-00001 14. Beahm, E. K., & Walton, R. L. (2002). [*Auricular Reconstruction for Microtia: Part I. Anatomy, Embryology, and Clinical Evaluation*](https://pubmed.ncbi.nlm.nih.gov/12045579/?ref=theplasticsfella.com)*. Plastic and Reconstructive Surgery, 109(7), 2473–2482.*doi:10.1097/00006534-200206000-00046 ### This dogma in Plastic Surgery should stop, Quick Anaesthesia Tips & New Events URL: https://www.theplasticsfella.com/april-14th/ Last updated: 2024-04-20T15:08:18.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/april-14th/#a-letter-from-pfella) The biggest dogma in plastic surgery. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/april-14th/#the-sunday-quiz) **\+ Leaderboard** How well do you know Local Anaesthetic**?* 3. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-14th/#upcoming-events) 10 number of events in next 6 months. 4. ****🚀** [****New Updates** ](https://www.theplasticsfella.com/april-14th/#new-features) **You will love the Fellows' Corner* 5. ****🔥** [****3 New Articles**](https://www.theplasticsfella.com/april-14th/#articles-of-the-week) **with summaries!** **Local Anaesthetic Injection & Calculation Tips* 6. 💕 [****Feedback**](https://www.theplasticsfella.com/april-14th/#thanks-for-reading-this) Suggest ideas & give feedback! ## A Letter from P'Fella **What's the Biggest Dogma in Plastic Surgery?* 👋 ****Hey Friends!** Today, I'm excited to discuss a topic that often ignites lively debate among plastic surgery professionals: What's the biggest dogma in plastic surgery? Let's challenge conventional wisdom and reconsider long-held beliefs. ****👇** ### **Lemme start…** A prominent dogma in our field involves the use of **adrenaline** in finger local anaesthesia. Traditionally shunned due to fears of gangrene, this practice is rooted in teachings passed down through generations. Back in **1903**, **Heinrich Braun** introduced epinephrine into cocaine solutions to extend anaesthesia effects, acting as a 'chemical tourniquet.' Despite its benefits, Braun urged caution, particularly in digits, due to potential risks if the epinephrine action was too intense or prolonged—especially when blood supply was already compromised. **This caution dated from a time when adrenaline was manually diluted.** ### **Why the Persistence of this Dogma?** Why does this caution still hold sway? It stems from a medical culture that prioritises "**do no harm**," leading us to opt for what seems safest—typically plain lidocaine or bupivacaine—due to historical concerns. **Textbook influence** is also profound. Titles like 'Green's Operative Hand Surgery' have consistently cautioned against using epinephrine in digital blocks, reinforcing this cautious approach for decades. ![](https://lh7-us.googleusercontent.com/t2bLIAQPVHGJA-EM20f3NoYhhUL3UpbAnnCdHYr6YoyEJ07KPxR4ywhPNUuumMefTa4FrWoqQHg0QGzurDwmkU5qAzJ797iBqt0sBWVpRHeRfsmwCe3Zr1Kcp9eh4gubP5ealu3tpogTAHvjgtBdnkk) ****Caption: An Ischaemic Finger in a Vasculitis Patient (not from LA injection) (**[****Source**](https://doi.org/10.3346/jkms.2006.21.2.371?ref=theplasticsfella.com)****)** ### **What does the evidence say?** PlasticsFella [Twitter](https://twitter.com/PlasticsFella/status/1272973292136280064?ref=theplasticsfella.com) polls show that over **75% of practitioners now safely use adrenaline in finger procedures**, with no complications reported, challenging these fears. Historical data from a 1967 study with 421 cases using lidocaine and epinephrine, which reported zero digital gangrene incidents, supports this shift. Moreover, the 2005 Dalhousie Project by Donald Lalonde, which documented **adrenaline's safe use in thousands of cases without any finger infarction** or tissue loss, further confirms its safety in controlled settings, questioning traditional prohibitions. As we reassess medical dogmas, I encourage you to share: **What's your biggest dogma in plastic surgery?** Post your thoughts below, and let's explore these topics in this week's edition of ***Behind the 'Fella***. ****tl;dr** \- Outdated dogma against using adrenaline in finger anesthesia, citing historical fears of gangrene. \- Modern studies and surveys show adrenaline is safe, challenging old beliefs. \- Encourages reevaluation of longstanding practices in plastic surgery. ## The Sunday Quiz **How well do you know Local Anaesthetic?* Welcome to ****next round** of The Weekly Quiz, presented by thePlasticsPaper! Each edition of thePlasticsPaper includes a quiz question designed to challenge and engage our readers. Keep your wits about you and join in every week—the winner at the end six rounds will earn you a $100 voucher. Good luck! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Local-Anaesthetic--1-.png) ## Upcoming Events A Curated List of Webinars, Courses & Conferences ### ## New Features Introducing "The Fellow's Corner" 🌟 #### The Fellow's Corner We're thrilled to unveil an exciting ****new** section in your favorite plastic surgery newsletter — ****The Fellow's Corner!** This ****unique** space is designed to bring ****fresh** perspectives and deep insights directly from the frontlines of plastic surgery, shared by our esteemed educational fellows from ****Scotland, Malta, and South Africa**. ****Got a topic or question for our fellows?** Send your suggestions below and be a part of the conversation shaping the future of "The Fellow's Corner." 👇 ## Articles of the Week 3 Interesting Articles with 1 sentence summaries. 1️⃣ ****Calculate your LA Quickly (**[****JPRAS**](https://www.jprasurg.com/article/S1748-6815%2823%2900288-7/abstract?ref=theplasticsfella.com)****, 2023)** Surgeons can easily calculate safe local anesthetic volumes by dividing the patient's weight in kg by 10 and multiplying by the maximum safe dose in mg/kg, adjusting for solution concentration as needed. 2️⃣ ****The Best Technique for Injectons (**[****PRS Open**](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8337068/?ref=theplasticsfella.com)****, 2021)** The article provides 13 tips for minimizing pain during local anesthesia injections, including using buffered solutions, smaller needles, strategic syringe handling, and careful injection techniques to enhance patient comfort and effectiveness 3️⃣ ****Reducing Pain from Local Anesthetic (**[****PRS**](https://journals.lww.com/plasreconsurg/abstract/2014/10002/local%5Fanesthetics%5F%5Fwhat%5Fs%5Fnew%5Fin%5Fminimal%5Fpain.9.aspx?ref=theplasticsfella.com)****, 2014)** The article highlights a revolution in local anesthesia techniques in plastic surgery over the past decade, detailing advances like painless blunt-tipped cannula use, sharper needle injections with less pain, and long-lasting anesthetics via liposomal encapsulation, all contributing to safer, more comfortable procedures without sedation ## Thanks for reading this... ### I hope you enjoyed it 😄 --- ### Pharyngeal (Branchial) Arches: Grooves & Pouches URL: https://www.theplasticsfella.com/pharyngeal-arches/ Last updated: 2024-04-12T19:42:08.000Z Pharyngeal arches (branchial arches) provide nerve, artery, bone and muscle to the craniofacial development. This article explores arches, pouches and grooves. _This post is for subscribers on the thePlastics Pro tier only._ ### Breast Anatomy: Landmarks, Arteries, Nerves, & Illustrations URL: https://www.theplasticsfella.com/breast-anatomy/ Last updated: 2024-04-12T19:12:00.000Z The breast is a composition of alveoli, lobules and lobes. It receives blood and sensory supply from a diverse number of arteries and nerves. _This post is for subscribers on the thePlastics Pro tier only._ ### Infantile Haemagioma: Aetiology, Clinical Presentation, & Management URL: https://www.theplasticsfella.com/infantile-haemagioma/ Last updated: 2024-04-11T20:17:23.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/infantile-haemagioma/#definition-of-infantile-haemangioma) A benign vascular tumour of proliferative endothelium. [****Aetiology**](https://www.theplasticsfella.com/infantile-haemagioma/#aetiology-of-infantile-haemangioma) Premature Caucasian females with low birth weight and somatic mutations. [****Clinical Features**](https://www.theplasticsfella.com/infantile-haemagioma/#clinical-features-of-infantile-haemangioma) Superficial red, deep blue, focal or segmental lesions appear after birth or as a 'herald patch' and grow faster than the patient. [****Phases of Infantile Haemangioma Growth**](https://www.theplasticsfella.com/infantile-haemagioma/#phases-of-infantile-haemangioma) An infantile hemangioma exhibits 3 phases of growth: proliferating, involuting and involuted. [****Complications of Infantile Haemangioma**](https://www.theplasticsfella.com/infantile-haemagioma/#complications-of-infantile-haemangioma) Ulceration, infection, and obstruction to the eye, ear and airway. It is associated with PHACES. [****Investigations**](https://www.theplasticsfella.com/infantile-haemagioma/#investigations) MRI and ultrasound are common imaging modalities to assess infantile hemangioma. [****Management**](https://www.theplasticsfella.com/infantile-haemagioma/#management-of-infantile-haemangioma) Active surveillance, symptomatic management, medications, laser and surgery can all be considered. --- ## Definition of Infantile Haemangioma ****Key Point** An infantile haemangioma is a benign vascular tumour that is classified by its depth and pattern and undergoes proliferation and involution. An infantile haemangioma is a benign vascular tumour of proliferative endothelium. It exhibits proliferating, involuting, and involuted phases. They are classified based on two facts: - **Depth**: superficial, deep, mixed - **Pattern**: Focal, multifocal, segmental Below image visualizes infantile haemangioma. ![Infantile Haemangioma Definition](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Infantile-Haemangioma.png) Definition of Infantile Haemangioma 💡 ****Tip:** Focal is defined as one cutaneous region. Segmental tumours have “geographic patterning”. --- ## Aetiology of Infantile Haemangioma ****Key Point** Infantile haemangiomas, more common in premature Caucasian females with low birth weight, arise from either a somatic mutation in a progenitor cell or from endothelial cells responding to VEGF or Interferon B. Infantile haemangiomas generally occur in premature Caucasian females with low birth weight. Current genetic theories are based on intrinsic and extrinsic theories. - **Intrinsic**: somatic mutation in one progenitor cell. - **Extrinsic**: haemangioma endothelial cells respond to VEGF or Interferon B. See image below for a visualization of this. ![Infantile Haemangiomas](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Infantile-Haemangiomas-1.png) Aetiology of Infantile Haemangioma 😎 ****Fun Fact:** Infantile haemangiomas are GLUT1+. This is differs them from congenital haemangiomas. --- ## Clinical Features of Infantile Haemangioma ****Key Point** Infantile Haemangiomas can be superficial red, deep blue, focal or segmental. They generally appear after birth or as a 'herald patch' and grow faster than the patient. Parents may notice a ‘herald patch’ at birth. But the majority of tumours appear within 1 month of birth. They do not grow in proportion to the patient. The clinical appearance of an infantile haemangioma is dependent on its depth and pattern. **Depth** In reality, infantile haemangiomas over have a mixed components. - **Superficial**: bright red, well-demarcated, elevated, non-compressible - **Deep**: blue hue, poorly defined, warm **Pattern** - **Focal**: one cutaneous region - **Segmental**: geographic patterning, such as the “bearded appearance” - **Multifocal** - **Indeterminate** These appearances of infantile haemangiomas are illustrated below. ![How does infantile haemangiomas look](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Appearance-of-Infantile-Haemangioma.png) Appearances of infantile haemangioma 💡 ****Tip:** Infantile haemangiomas are not fully formed at birth and are GLUT1 negative, which distinguishes them from congenital haemangiomas. --- ## Phases of Infantile Haemangioma ****Key Point** An infantile hemangioma exhibits 3 phases of growth: proliferating, involuting and involuted. **Proliferating Phase** - *Increased* endothelial activity and angiogenesis due to VEGF and bFGF. - Usually lasts for <1 year (on average, starts 6 weeks and finishes 6 months). - Superficial tumours are red and raised; deep tumours become bluer. **Involuting Phase** - *Reduced* endothelial activity and angiogenesis due to TIMP1. - Spontaneous involution occurs in the majority of patients (\~90%). - Colours become paler with a "matte-like finish". **Involuted Phase** - The skin attempts to return to normal due to sparse capillaries and veins. - 1/3 by age 3, 50% by 5 years and nearly all by age 10. - There may be residual telangiectasia, atrophy and a “fibrofatty residuum”. These phases of infantile hemangioma can be visualised in the illustration below. ![Phases of Infantile Haemangioma, Identifying Infantile Haemangioma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Infantile-Haemangioma-Phases.png) Phases of Infantile Haemangioma 💡 ****Tip:** A proliferating haemangioma will often have a shiny, bright appearance with smaller exophytic growths/satellite lesions****.** --- ## Complications of Infantile Haemangioma ****Key Point** The main concerns with infantile haemangiomas are ulceration, infection, and appearance; they can also cause obstructive complications with the eye, ear, and airway. The most common complication of infantile haemangiomas is ulceration. These can result in subsequent pain, infection, bleeding and scarring. Other complications to be aware of are related to obstruction and PHACES. ### Obstruction - **Eye:** amblyopia (lazy eye), anisometropia (unequal refraction), strabismus (cross-eyed). - **Ear:** deformation, conductive hearing loss due to blockage of the external acoustic meatus. - **Airway:** can occur in “beard” facial haemangioma or subglottic lesions. Consider an endoscopy! - **Nose**: "Cyrano" nose deformity caused by soft tissue hemangioma infiltrating the alar cartilage. This is visualized below. ![Beard distribution in infantile haemangioma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Beard-Distribution-Infantile-Haemangioma.png) Beard distribution in infantile haemangiomas ### PHACES Association Infantile haemangiomas can be associated with other anomalies. These include: - **Posterior Cranial Fossa:** Dandy-Walker Complex, hypoplasia, microcephaly - **Haemangiomas**: segmental, cervicofacial region - **Arterial** - **Cardiac:** coarctation, aneurysm, patent ductus arteriosus - **Eye:** “morning glory” discs, retinal vascular issues, Horner Syndrome - **Sternal defects or supraumbilical raphe** See the below visualization of the Dandy-Walker complex. ![Dandy-Walker Complex](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Infantile-Haemangioma-complications.png) Dandy-Walker Complex of infantile haemangioma 😎 ****Fun Fact:** Dandy-Walker syndrome is a congenital brain underdevelopment of the cerebellar vermis, leading to an accumulation of cerebrospinal fluid in the fourth ventricle and posterior fossa. --- ## Investigations ****Key Point** MRI and ultrasound are common imaging modalities to assess infantile hemangioma. ### Radiology: - **MRI:** differentiate slow-flow and fast-flow malformations, brain in PHACES, well-delineated tumour with flow voids. - **X-Ray:** skeletal growth disturbances and phleboliths in venous malformations. - **Colour Doppler:** assess superficial lesions and blood flow velocity. - **Liver ultrasound ± Biopsy:** hepatic haemangiomas if >5 skin lesions. - **Angiography**: therapeutic embolization after initial workup. Below is a 3D illustration of radiology investigations. ![Doppler of Vascular Anomaly](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Radiology-of-Infantile-Haemangioma.png) Doppler of Vascular Anomaly ### Bedside Investigations - **Airway** evaluation with Endoscopy. - **Cardiac**: ECHO, ECG. - **Eyes**: Ophthalmic Exam (PHACES). - **Blood**: Full Blood Count + other baseline blood. --- ## Management of Infantile Haemangioma ****Key Point** Through an MDT approach, infantile haemangiomas can be treated with medications (eg. B-blockers, steroids), Laser, surgical debulking, or active surveillance. The management of infantile haemangiomas involves a multi-disciplinary team of surgeons, dermatologists, haematologists and interventional radiologists, focusing on patient education and supportive care for complications. All patients should undergo active surveillance. Treatment options include: - **Local Treatments:** analgesics, dressings, topical mupirocin - **Medical:** Beta-blockers, steroids, chemotherapeutic agents - **Intervention**: steroids, laser, surgical debulking, post-involution correct ### Systemic B-Blockers (Propranolol) This beta-blocker has been used as an ‘off-label’ treatment option for infantile haemangiomas since the 2008 NEJM publication. Important points about this treatment option: - **Dose**: 1-2mg/kg for 12 months. It is important to consult local guidelines. For example, 1mg/kg in 2 divided doses, doubling to 2mg/kg after 1 week and taper to avoid rebound growth. - **Pre-investigations**: Vital Signs, ECG, glucose, ECHO. - **Contraindications:** Sick sinus syndrome, Heart block (2nd or 3rd degree). If used in PHACES, it should be part of an MDT surveillance and lower dose. - **Side effects:** sleep disturbance, cold, wheezing**,** hypotension, hypoglycaemia, bronchospasm, hypothermia. ### Topical B-Blockers (Timolol) 0.5% Timolo can be considered if a select group of patients: - Early diagnosis of infantile haemangioma (thin and small lesion) - Whilst awaiting starting the systemic treatment (workup phase) 💡 ****Tip:** Topical B-blockers or oral prednisolone are an option if the patient is not suitable for oral propranolol. ### Steroids Oral Prednisolone is another option to be used instead or in conjunction with B-blockers. Important points about this treatment option include: - **Dose**: 12 months; consult local guidelines. - **Side effects**: GI upset, behavioural changes, immunosuppression, adrenal suppression. - **Tapering**: there can be “rebound growth” during steroid tapering. 💡 ****Tip:** Intralesional steroid injections (triamcinilone) can be considered in localised superficial haemangiomas. ### Chemotherapeutic Agents These are less commonly used and reserved for life-threatening haemangiomas that are resistant to propanolol and steroids. - **Vincristine**: as per the oncology team - **Interferon alpha-2a**: can cause spastic diplegia ### Laser Lasers are generally reserved for flat, superficial lesions with residual telangiectasia that have undergone involution. They generally do not penetrate deep infantile haemangiomas. - **Argon**: 488nm - **Pulse dye**: 585nm ### Surgery This is **not** a first-line treatment. There is a *potential* role for surgery in the acute or involuted phase. - **Acute**: a large haemangioma may require debulking. - **Involuted**: scar correction, removal of fibrofatty residuum. - **Nasal haemangiomas** often don't reduce in size and can require surgery to debulk the Cyrano nose. ## --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Aetiology and Risk Factors:** Learned about the factors contributing to the development of infantile haemangiomas, including premature birth, low birth weight, and genetic mutations. ****2\. Clinical Presentation and Diagnosis:** Gained an understanding of how infantile haemangiomas present, from superficial red or deep blue lesions to the use of imaging modalities like MRI and ultrasound for accurate diagnosis. ****3\. Management Strategies:** Explored management options for infantile haemangiomas, from observation and symptomatic management to the use of medications like beta-blockers, steroids, and in some cases, surgery or laser treatment, emphasizing the role of a multidisciplinary team approach. ****4\. Complications of Infantile Haemangioma:** Acknowledged the potential complications associated with infantile haemangiomas, including ulceration, infection, and obstruction of vital structures, as well as their association with PHACES syndrome. --- ### Basal Cell Carcinoma (BCC): Aetiology, Diagnosis, Treatment, & Follow-up URL: https://www.theplasticsfella.com/basal-cell-carcinoma/ Last updated: 2024-04-17T07:54:17.000Z Basal cell carcinomas are the most common skin cancer. This article details their aetiology, diagnosis and treatment options. _This post is for subscribers on the thePlastics Pro tier only._ ### Scaphoid Anatomy: Clinical, Radiological & Surgical URL: https://www.theplasticsfella.com/scaphoid-anatomy/ Last updated: 2024-04-11T19:35:22.000Z #### Summary Card [****Scaphoid Bone Anatomy**](https://www.theplasticsfella.com/scaphoid-anatomy/#scaphoid-bone-anatomy) The scaphoid has three regions: proximal pole, waist (corresponding to the anatomical snuffbox), and distal pole. [****Scaphoid Ligament Anatomy** ](https://www.theplasticsfella.com/scaphoid-anatomy/#scaphoid-ligament-anatomy) Key ligaments include Scapholunate Interosseous and Radioscaphocapitate, with volar ligaments being stronger. [****Blood Supply to the Scaphoid**](https://www.theplasticsfella.com/scaphoid-anatomy/#blood-supply-to-the-scaphoid) Radial artery provides 70-80% of blood supply. Dorsal blood enters via dorsal ridge foraminae; volar supply is 20-30% of internal vascularity, mainly in the distal pole. [****Imaging the Scaphoid Anatomy**](https://www.theplasticsfella.com/scaphoid-anatomy/#imaging-the-scaphoid-anatomy) Multiple angles needed, including PA view in ulnar deviation, 60° pronation, and 60° supination. Lateral view detects DISI or VISI deformities. 😎 ****Fun Fact:** The scaphoid was originally termed "Naviculare" based on the Latin "navis" (ship). It is now referred to as the "Scaphoid," derived from the Greek word "skaphe" meaning a skiff or boat. ### --- ### ## Scaphoid Bone Anatomy ****Key Point** The scaphoid has a proximal pole, waist, distal pole. Unique curvatures and angles allows articulation to radial, lunate, trapezoid, and trapezium bones. **Anatomical Regions** The scaphoid forms a mechanical linkage between the carpal rows. It serves as the lateral column in the proximal carpal row arch and can be divided into three basic regions: 1. Proximal pole 2. Waist 3. Distal pole The below video visalizes the anatomy of scaphoid bone. 0:00 /0:07 1× Scaphoid Bone Anatomy It possesses both a palmar concave and medial (ulnar) concave curvature. The angle from the proximal to distal pole (ie the intrascaphoid angle) is 40°± 3° in the coronal plane and 32°± 5° in the sagittal plane ([Berger](Berger RA. The anatomy of the scaphoid. Hand Clin. 2001 Nov;17%284%29:525-32. PMID: 11775465.), 2001). 😎 ****Fun Fact:** The "waist" corresponds to the anatomical snuffbox. The scaphoid tubercle is found at the proximal aspect of the thenar eminence's base in line with the radial border of the long finger. #### **Anatomical Surfaces** The scaphoid's surfaces are often described as proximal, lateral, distal, and medial surfaces. Each surface has a specific feature and articulation. - **Proximal surface**: hemispheric, articulates with scaphoid fossa of radius. - **Medial surface:** flat and crescentic, articulates with the lateral lunate surface - **Distal surface**: slightly convex, articulates with the trapezoid and trapezium. This scaphoid anatomy is described in the image below. ![Location of the Scaphoid Bone, Scaphoid Bone Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/Scaphoid-Bone-Anatomy.png) Location of the Scaphoid Bone 😎 ****Fun Fact:** The scaphoid bone is the largest carpal bone in the proximal carpal row. --- ## **Scaphoid Ligament Anatomy** ****Key Point** The scaphoid's ligaments, including the Scapholunate Interosseous, Radioscapholunate, Radioscaphocapitate, and Scaphotrapezium Ligaments, play a critical role in the stability of fractured fragments, with the carpal capsule being reinforced by stiffer volar ligaments. The scaphoid's fracture serves to highlight the importance of its ligaments, which govern the stability of the fractured fragments. The carpal capsule receives reinforcement from both dorsal and volar ligaments, with the volar ligaments being notably stronger. Some ligaments to mention include: - **Scapholunate**: C-shaped structure connecting the scaphoid and lunate bones, with a thicker dorsal fiber that provides the primary constraint to their translation, while its proximal fibers possess minimal mechanical strength. - **Radioscapholunate:** "ligament of Testut and Kuentz" is not a true ligament, functioning only as a neurovascular conduit without adding mechanical strength. - **Radioscaphocapitate:** ligament from the radial styloid to the capitate acts as a sling to support the waist of the scaphoid. This image visualizes ligament anatomy as discussed above. ![Ligament Anatomy, Scaphoid bone anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/Scaphoid-Bone-Ligament.png) Ligament anatomy - Original illustration from 1742 The scaphoid is also acted on by flexor and extensor tendons. More specifically: - **Flexor Carpi Radialis Tendon**: a fibro-osseous tunnel on its distal pole. - **Extensor Carpi Radialis Brevis and Longus**: bolster the posterior wrist joint capsule covering the scaphoid. The scaphoid serves as a focus of ligamentous attachment and represents one of two areas in the proximal carpal row, the other being the pisiform, that are dynamically influenced by extrinsic musculotendinous structures. ****Please Note:** the ligamentous anatomy of the scaphoid/wrist is an incredibly complex topic. This is section just a overview. --- ## **Blood Supply to the Scaphoid** ****Key Point** The scaphoid primarily receives blood from the radial artery, accounting for 70-80% of its intraosseous supply, with vessels accessing both externally via dorsal and volar routes and internally, chiefly through dorsal ridge foraminae. The scaphoid's vascular supply is predominantly retrograde, intricately moving from distal to proximal. It primarily receives its blood supply from the **radial artery** (70-80%), which further bifurcates into the **dorsal carpal branch** and the **superficial palmar/volar branch**. These vessels enter the scaphoid through **distal** half of the bone. 😎 ****Fun Fact:** The vessels enter the scaphoid through ****non-articular surfaces** at ligamentous attachments****.** **Dorsal carpal branch** - Supplies \~70%, especially its distal two-thirds. - Enters via the foramina on the dorsum oblique ridged between the articular surfaces for the radius and for the trapezium and trapezoid. **Superficial palmar/volar branch** - Supplies \~30%, especially the distal tuberosity. - Enters via the tubercle, which is concave volar aspected with a rounded elevation. [Gelberman](https://pubmed.ncbi.nlm.nih.gov/7430591/?ref=theplasticsfella.com)'s landmark paper in the 1980s showed: - The ulnar artery doesn't contribute to the scaphoid's vascularity. - The anterior interosseous artery makes a significant contribution. - There are no significant intra-osseous anastomoses between the dorsal and volar branches of the scaphoid, a result of the scaphoid emerging from the fusion of two chondrification zones. --- ### ## **Imaging the Scaphoid Anatomy** ## ****Key Point** Multiple imaging angles, including PA view in ulnar deviation, 60° pronation, and 60° supination, are essential for the scaphoid's detailed assessment, while the lateral view helps detect DISI or VISI deformities. The scaphoid's complex anatomy demands multifaceted imaging for a comprehensive assessment. More than two views are required due to its intricate shape and alignment. **PA View in Ulnar Deviation**: - This extends the scaphoid to provide a clear image of all scaphoid regions. - Minimal overlap of adjacent bones. **Oblique View** - 60° Pronation: focuses the distal pole and tubercle. - 60° Supination: focuses the scaphoid's proximal pole. **Lateral View**: - A difficult view to assess the scaphoid itself due to overlapping structures. - Useful for assess any DISI or VISI deformity. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Scaphoid Anatomy:** Acquired detailed insights on the scaphoid bone's structure, including its three distinct regions (proximal pole, waist, and distal pole), and its unique curvatures and angles that allow for articulation with surrounding carpal and radial bones. ****2\. Ligament Anatomy:** Learned about key ligaments associated with the scaphoid, such as the Scapholunate Interosseous and Radioscaphocapitate ligaments, and their significance in maintaining the stability of the wrist and scaphoid fractures. ****3\. Vascular Anatomy of the Scaphoid:** Gained an understanding of the scaphoid's blood supply, predominantly from the radial artery, and how its unique vascular anatomy influences healing and the risk of avascular necrosis. ****4\. Imaging in Scaphoid Evaluation:** Explored the critical role of various imaging techniques, including PA views in ulnar deviation, pronation, and supination, in diagnosing scaphoid fractures and assessing anatomical details crucial for treatment planning. --- ## Further Reading 1. Berger RA. [The gross and histologic anatomy of the scapholunate interosseous ligament](https://pubmed.ncbi.nlm.nih.gov/8683042/?ref=theplasticsfella.com). J Hand Surg \[Am\]. 1996;21:170-178. 2. Berger RA, Landsmeer JMF. [The palmar radiocarpal ligaments: A study of adult and fetal human wrist joints](https://pubmed.ncbi.nlm.nih.gov/2269772/?ref=theplasticsfella.com). J Hand Surg \[Am\]. 1990;15:847-854. 3. Berger RA, Crowninshield RD, Flatt AE. [The three-dimensional rotational behaviors of the carpal bones](https://pubmed.ncbi.nlm.nih.gov/7094476/?ref=theplasticsfella.com). Clin Orthop Rel Res. 1982;167:303-310. 4. Bettinger PC, Linscheid RL, Berger RA, et al. [An anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint](https://pubmed.ncbi.nlm.nih.gov/10447171/?ref=theplasticsfella.com). J Hand Surg \[Am\]. 1999;24:786-798. 5. Gelberman RH, Menon J. [The vascularity of the scaphoid bone](https://pubmed.ncbi.nlm.nih.gov/7430591/?ref=theplasticsfella.com). J Hand Surg. 1980;5:508-513. 6. Gelberman RB, Panagis JS, Taleisnik J, et al. [The arterial anatomy of the human carpus](https://pubmed.ncbi.nlm.nih.gov/6886330/?ref=theplasticsfella.com). Part I. The extraosseous vascularity. J Hand Surg \[Am\]. 1983;8:367-375. 7. Kobayashi M, Berger RA, Linscheid RL, et al. [Intercarpal kinematics during wrist motion](https://pubmed.ncbi.nlm.nih.gov/9048189/?ref=theplasticsfella.com). Hand Clin. 1997;13:143-149. 8. Kobayashi M, Berger RA, Nagy L, et al. [Normal kinematics of carpal bones: A three-dimensional analysis of carpal bone motion relative to the radius](https://www.sciencedirect.com/science/article/abs/pii/S0021929097000262?ref=theplasticsfella.com). J Biomech. 1997;30:787-793. 9. Panagis JS, Gelberman RB, Taleisnik J, et al. [The arterial anatomy of the human carpus](https://pubmed.ncbi.nlm.nih.gov/6886331/?ref=theplasticsfella.com). Part II: The intraosseous vascularity. J Hand Surg \[Am\]. 1983;8:375-382. 10. Smith DK, Linscheid RL, Amadio PC, et al. [Scaphoid anatomy: Evaluation with complex motion tomography](https://pubmed.ncbi.nlm.nih.gov/2781005/?ref=theplasticsfella.com). Radiology. 1989;173:177-180. 11. Taleisnik J, Kelly PJ. [The extraosseous and intraosseous blood supply of the scaphoid bone](https://pubmed.ncbi.nlm.nih.gov/5917699/?ref=theplasticsfella.com). J Bone Joint Surg \[Am\]. 1966;48:1125-1137. 12. Viegas SF, Yamaguchi S, Boyd NL, et al. [The dorsal ligaments of the wrist: Anatomy, mechanical properties, and function](https://pubmed.ncbi.nlm.nih.gov/10357522/?ref=theplasticsfella.com). J Hand Surg \[Am\]. 1999;24:456-468. 13. Cave EF. The carpus with reference to fractured navicular bone. Arch Surg. 1940;40:54-76. 14. Mazet R Jr, et al. [Fractures of the carpal navicular, analysis of 91 cases and review of the literature](https://pubmed.ncbi.nlm.nih.gov/19994475/?ref=theplasticsfella.com). J Bone Joint Surg \[Am\]. 1963;45:82-112. 15. Rockwood CA, et al. Fractures, vol 1\. Philadelphia: JB Lippincott Co; 1975. 16. Barber H. The intraosseous arterial anatomy of the adult human carpus, in Orthopedics, vol 5\. Oxford: Donald Parson; 1972\. p. 20. 17. Grettve S. [Arterial anatomy of the carpal bones](https://pubmed.ncbi.nlm.nih.gov/13353897/?ref=theplasticsfella.com). Acta Anat (Scand). 1955-6;25:331-45. 18. Lutzeler H. [Die entstehungsursache der pseudarthrose nach bruch des kahnbeins der hand](https://journals.scholarsportal.info/details/03670023/v235i5-6/450%5Fdedpnbdkdh.xml?ref=theplasticsfella.com). Dtsch Z Chir. 1932;235:450-67. 19. Travaglini F. [Arterial circulation of the carpal bones](https://pubmed.ncbi.nlm.nih.gov/13839218/?ref=theplasticsfella.com). Bull Hosp Joint Dis NY. 1959;20:19-36. 20. Obletz BE, et al. Non-union of fractures of the carpal navicular. J Bone Joint Surg \[Am\]. 1938;20:424-8. 21. Russe O. [Fracture of the carpal navicular: diagnosis, non-operative treatment, and operative treatment](https://pubmed.ncbi.nlm.nih.gov/13854612/?ref=theplasticsfella.com). J Bone Joint Surg \[Am\]. 1960;42:759-68. 22. Bohler L. [The treatment of fractures, vol 1](https://journals.lww.com/jbjsjournal/citation/1957/39010/the%5Ftreatment%5Fof%5Ffractures%5F%5Florenz%5Fbohler,%5Fm%5Fd%5F.33.aspx?ref=theplasticsfella.com). New York: Grune & Stratton, Inc; 1956. 23. Roolker W, Maas M, Broekhuizen AH. [Diagnosis and treatment of scaphoid fractures, can non-union be prevented](https://pubmed.ncbi.nlm.nih.gov/10613233/?ref=theplasticsfella.com). Arch Orthop Trauma Surg. 1999;119(7–8):428–31. 24. Trojan E. Der Kahnbeinbruch der Hand. In: Habilitationschrift. Wien: Eigenverlag & Bruck Bru ̈der Hollinek; 1961. 25. Zolczer L, Glanz J. A sajkacsontto ̈re ́s. In: A ke ́zto ̋ fedett se ́ru ̈le ́sei, elva ́ltoza ́sai. Budapest: Medicina; 1995. 26. Roolker L, Tiel-van Buul MM, Bossuyt PP, Dijkstra PF, van Grieken HJ, Broekhuizen TH. [The value of additional carpal box radiographs in suspected scaphoid fracture](https://pubmed.ncbi.nlm.nih.gov/9055127/?ref=theplasticsfella.com). Invest Radiol. 1997;32(3):149–53. 27. Roolker W, Tiel-van Buul MM, Bossuyt PM, et al. [Carpal Box radiography in suspected scaphoid fracture](https://pubmed.ncbi.nlm.nih.gov/8682815/?ref=theplasticsfella.com). J Bone Joint Surg \[Br\]. 1996;78(4):535–9. 28. Roolker W, Tiel-van Buul MM, Ritt MJ, Verbeeten Jr B, Griffioen FM, Broekhuizen AH. [Experimental evaluation of scaphoid X-series, carpal box radiographs, planar tomography, computed tomography and magnetic resonance imaging in the diagnosis of scaphoid fracture](https://pubmed.ncbi.nlm.nih.gov/9042876/?ref=theplasticsfella.com). J Trauma. 1997;42(2):247–53. 29. Tiel-van Buul MM, van Beek EJ, Broekhuizen AH, Nooitgedacht EA, Davids PH, Bakker AJ. [Diagnosing scaphoid fractures: radiographs cannot be used as a gold standard!](https://pubmed.ncbi.nlm.nih.gov/1572718/?ref=theplasticsfella.com) Injury. 1992;23(2):77–9. 30. Tiel-van Buul MM, van Beek EJ, Dijkstra PF, Bakker AD, Griffioen FM, Broekhuizen TH. [Radiography of the carpal scaphoid. Experimental evaluation of “the carpal box” and first clinical results](https://pubmed.ncbi.nlm.nih.gov/1464516/?ref=theplasticsfella.com). Invest Radiol. 1992;27(11):954–9. --- ### Melanoma: Diagnosis, Features, Sentinel Node, & Staging URL: https://www.theplasticsfella.com/melanoma/ Last updated: 2024-06-27T20:41:32.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/melanoma/#definition-of-melanoma) A malignant tumour of melanocytes. [****Risk Factors for Melanoma**](https://www.theplasticsfella.com/melanoma/#risk-factors-for-melanoma) Environment (radiation), genetic (BRAF) and patient-related factors (skin type and medical history). [****Diagnosis**](https://www.theplasticsfella.com/melanoma/#diagnosis-of-melanoma) Clinical suspicion is confirmed with a histological diagnosis. [****Types of Melanoma**](https://www.theplasticsfella.com/melanoma/#types-of-melanoma) Superficial spreading, nodular, lentigo, acral, subungual, amelanocytic and desmoplastic. [****Wide Local Excision of Melanoma**](https://www.theplasticsfella.com/melanoma/#wide-local-excision-of-melanoma) Margins are dependent on the Breslow thickness. [****Sentinel Lymph Node Biopsy**](https://www.theplasticsfella.com/melanoma/#sentinel-lymph-node-biopsy) Indicated ****≥ pT2a** or ≥ ****pT1b** with high-risk features. Techniques include ****radioactive isotop**e, ****blue dye** and ****indocyanine green**. [****Management of a +SLNB**](https://www.theplasticsfella.com/melanoma/#positive-sentinel-node-in-melanoma) Three options: ****complete lymph node dissection**, ****observation**, and ****adjuvant therapies**. [****Staging Melanoma**](https://www.theplasticsfella.com/melanoma/#staging-melanoma) TNM classification from the AJCC 8th Edition. --- ## Definition of Melanoma Melanoma is a malignant tumour of melanocytes. Melanocytes are derived from the neural crest and synthesise melanin. ![Melanoma Definition](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Melanoma-Definition.png) Definition of Melanoma 💡 ****Tip:** The "Glasgow 7-point checklist" looks at size, shape, colour, inflammation, crusting, bleeding, and sensation. --- ## Risk Factors for Melanoma ****Key Point** The risk of melanoma is dependent on the environment (radiation), genetic (BRAF) and patient-related factors (skin type and medical history). ### Ultraviolet Radiation The risk of melanoma increases with age from natural cumulative sun exposure. There is a strong correlation with the following: - **UVA (315-400nm):** sunbeds, DNA damaged by oxygen radicals - **UVB (280-315nm):** sunburn, absorbed by DNA, chromosomal damage - **UVC (200-280nm):** filters by ozone ### Fitzpatrick Type I + II - Individuals with fair skin, hair, and eye colour - Susceptibility to oncogenic UV damage in genes linked with pigmentation ### Co-Morbidities - **Skin Lesions:** previous melanoma, dysplastic lesions, giant CMNs - **Organ** transplantation/immunosuppression - **Genetic syndromes:** FAMM Syndrome 😎 ****Fun Fact:** FAMM syndrome is a family history of melanoma and a large number of dysplastic naevi. They have a nearly 100% lifetime risk of melanoma. --- ## Diagnosis of Melanoma ****Key Point** Melanoma is a clinical suspicion confirmed with a histological diagnosis. ### Clinical Suspicion Cutaneous melanoma can be clinically suspected based on a history of lesion evolution and specific features on examination. The classic feature is an asymmetrically pigmented lesion of variegated colour with an irregular border that is evolving. The ABCDE provides a diameter >6mm. Below image illustrates the clinical features of melanoma. ![This image shows Clinical Features of Melanoma.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Melanoma-features-1.png) Clinical Features of Melanoma ### Histological Diagnosis **Melanoma is a histological diagnosis.** This is a key differentiator to [basal cell](https://www.theplasticsfella.com/basal-cell-carcinoma/) and [squamous cell carcinomas](https://www.theplasticsfella.com/squamous-cell-carcinoma/), which can be resected based on a confident clinical examination. Initial histology can be obtained by: 1. **Excisional Biopsy** with a 2mm margin and cuff of fat. 2. **Incisional biopsy** if primary closure is not possible and reconstruction required. 3. **Punch Biopsy** can be considered but can affect Breslow thickness. 4. **Shave or curettage** is not recommended. See image below for a visualization of the excisional biopsy of melanoma. ![2mm Excisional Biopsy of a Melanoma, Diagnosis of Melanoma](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Melanoma-Biopsy.png) 2mm Excisional Biopsy of a Melanoma A melanoma histology report will provide the following information: 1. **Relevant** clinical information 2. **Type of surgery**: excisional, incisional, punch 3. **Location:** most commonly on the trunk 4. **Macroscopic**: vertical and depth dimensions 5. **Subtype**: superficial, nodular, acral, lentigo, amelanocytic, desmoplastic 6. **Margins**: margins excised if excisional biopsy performed 7. **Ulceration**: full thickness loss of epidermis, a poor prognostic sign 8. **Mitosis**: a marker for tumour activity, a poor prognostic sign 9. **Breslow Thickness**: status granulosum to the deepest part of the lesion 10. **BRAF status:** if requested, can decide suitability for immunotherapy 11. **Clarkes Level:** level of dermal invasion 12. **Growth**: radial or vertical, regression, LVI, PNI, microsatellites 😎 ****Fun Fact:** BRAF is a component of the MAPK cell signalling pathway. When activated, it results in uncontrolled cell proliferation. --- ## Types of Melanoma ****Key Point** The most common histological subtype is superficial spreading. Other subtypes include nodular, lentigo, acral, subungual, amelanocytic and desmoplastic. There are several different histological melanoma subtypes. These subtypes have specific clinical features and prognoses. The most common melanomas are superficial spreading. - **Superficial spreading:** radial then vertical growth phases. - **Nodular:** is more aggressive because it lacks a radial growth phase. - **Lentigo Maligna Melanoma:** arising from a lentigo maligna. - **Acral Lentiginous:** usually occurs on palms, soles and nails. - **Amelanocytic:** a melanoma without pigment. - **Desmoplastic:** high local recurrence rates. Below image visualizes different types of melanomas. ![Melanoma types classification](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Types-ofMelanoma.png) Types of Melanoma --- ## Wide Local Excision of Melanoma ****Key Point** The margins on a wide local excision are dependent on the Breslow thickness. ### Wide Local Excision The current guidelines for the excision of a histological-confirmed melanoma are based on the Breslow thickness of the lesion. - **Lentigo Maligna (in-situ):** 0.5mm with a cuff of fat - **Breslow ≤ 1mm:** 1cm peripheral margin, down to fascia deep margin - **Breslow 1-2mm:** 1-2cm peripheral margin, down to fascia deep margin - **Breslow >2mm:** 2 cm peripheral margin, down to fascia deep margin See image below for layers of the Dermis and Epidermis. ![Breslow Thickness, Layers of the Dermis and Epidermis ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Brewslow-Thickness.png) Breslow Thickness is measured from the Stratum Granulosum. --- ## Sentinel Lymph Node Biopsy ****Key Point** A sentinel node biopsy is ****indicated** in melanoma ****≥ pT2a** or ≥ ****pT1b** with high-risk features. Techniques include ****radioactive isotop**e, ****blue dye** and ****indocyanine green**. A sentinel node is the first lymph node receiving lymphatic drainage from a specific area and is representative of that nodal basin1. The sentinel node has a role in **prognosis, treatment pathways and staging.** It should be performed at the time of wide local excision, if indicated. ### Indications for SLNB The primary role of sentinel node biopsy is changing from that of a prognostic indicator to one that now influences access to adjuvant therapy​6​. - Primary Cutaneous Melanoma **≥ pT2a** - Primary Cutaneous Melanoma **≥ pT1b** considered if LVI or Mitotis ≥ 2mm It is not currently indicated for pT1a melanomas because the frequency of sentinel lymph node metastasis is <5% 8,9 compared to 4-12% for pT1b6 and 30% for BT>4mm8.10. 💡 ****Tip:** a false-negative case is a recurrence following a negative sentinel lymph node biopsy. This requires > 2 years of follow-up. ### Effect of SLNB on Treatment For those with a positive sentinel node, upstaging the disease allows earlier identification for adjuvant therapies. It also allows them to be categorized in a “high-risk follow-up group”​7​. A patient with **pT1b** melanoma has 2 options: - **No SLNB =** clinical **Stage 1B** with a 5-year survival of **97%**​3. - **Negative SLNB =** pathological **Stage 1A** witha 5-year survival of **99%**​3. - **Positive SLNB =** pathological **Stage 1B.** The below image conceptualizes the role of sentinel node biopsy in treating melanoma. ![The below image conceptualizes the role of sentinel node biopsy in treating melanoma.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Sentinel-Node-Melanoma.png) Role of Sentinel Node Biopsy ### Techniques The 3 commonly used techniques for sentinel node biopsies are radioactive isotope, blue dye or indocyanine green. **Radioactive Isotope** - Intradermal injection of a radiotracer at the tumour site & lymphoscintigraphy. - A handheld gamma probe guides dissection. - Usually, Technetium-99m–labelled radiocolloids. **Blue Dyes** (initially used by [Morton](https://pubmed.ncbi.nlm.nih.gov/1558490/?ref=theplasticsfella.com) et al) - Blue dye alone sensitivity of 81% (Silvestri, 2019). - Patent Blue V, isosulfan blue and methylene blue are commonly used. - Anaphylaxis, obscured dissection, tattooing, interferes with pulse oximetry. **Indocyanine Green** - Indocyanine green is a fluorescent tricarbocyanine dye. - Sensitivity: 91- 98%, with a specificity of 100% (Clloyd, 2014). - It cannot be used in patients with iodine or shellfish allergies. 💡 ****Tip:** a "n**on-sentinel node"* is the presence of an involved non-sentinel node (false negative SNB or an involved node on CLND). It's a significantly poor prognostic factor for melanoma-specific survival​3​. --- ## Positive Sentinel Node in Melanoma ****Key Point** Following a positive sentinel node, patients and doctors have three options: ****complete lymph node dissection**, ****observation**, and ****adjuvant therapies**. These patients are now Stage III disease. ### Completion Lymph Node Dissection in Melanoma Complete lymph node dissection should not be routinely recommended for patients who have a positive sentinel node biopsy​6​. Consider this treatment option in patients who are high risk of regional relapse based on their sentinel node results: - Extra-capsular spread - 3 or more sentinel nodes - Dewar Criteria​12​ (multifocal and extensive) - Node-only recurrence having failed first-line systemic treatment The [MSLT-2](https://www.theplasticsfella.com/mslt-ii-trial-journal-club/)​13​ and DeCOG​14​ Trials reported on the outcome of patients with a positive sentinel node randomised into observation and surgery. Key results include: - No survival advantage over radiological observation - Increase risk of nodal recurrence in those patients with observation Patients undergoing immediate lymph node dissection have: - Increased rate of regional disease control​13​ - Prognostic information​13​ - No increase in melanoma-specific survival​13​ - An increased risk of morbidity in nodal dissection patients​15​ With head and neck melanomas, adjuvant therapy is preferred to neck dissection​3​. 💡 ****Tip:** **Nodal Tumour Burden* is an important factor in determining prognosis. Microscopic deposits >2–4 mm, >4–15 mm, and 15 mm have a respective 5-year survival of 86%, 72% and 66%​3​. ### Adjuvant Therapy in Melanoma Discussed in more detail: [Oncological Adjuvant Therapies in Melanoma](https://www.theplasticsfella.com/oncological-adjuvant-trials-in-melanoma/) Current guidelines state adjuvant therapy should be available to Stage 3 patients. Generally speaking, patients deemed at high risk with a positive sentinel node should be considered for melanoma adjuvant therapy. A lymph node dissection could be considered if they have a node-only recurrence post-adjuvant treatment. ### Radiological Observation in Melanoma There is currently no consensus for ideal imaging in melanoma​7​ Current options include: - **Ultrasound:** MLST and DeCOG Trials but does have operator dependability​5​ - **CT/PET:** more sensitive to picking up recurrences​5​ - **MRI** is used in some UK centres​6​ Imaging surveillance will differ for those on adjuvant systemic therapy. --- ## Staging Melanoma ****Key Point** Melanoma is classified and stages using the TNM system from the AJCC 8th Edition. The image below details TNM Classification in staging melanoma. ![The image details TNM Classification in staging melanoma.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Staging-Melanoma.png) AJCC 8th Edition Staging Melanoma ### AJCC Version 8 Updates This article is written with the most recent version of AJCC and other publications, as referenced below. The following is a list of V8 updates​3​. **Histology Reports** - **Tumour thickness:** record to the nearest 0.1 mm, not 0.01 mm. - **Mitotic** rate no longer a T category criterion (increased mitotic rate decreases melanoma-specific survival​3). **Pathological Staging** - **pT1a** <0.8 mm without ulceration. - **pT1b** 0.8‐1.0 mm with or without ulceration or <0.8 mm with ulceration. - Pathological stage IA is revised to include T1b N0 M0 (formerly stage IB). **Metastatic disease** - **N:** “microscopic” and “macroscopic” is now clinically "occult" and "apparent". - **M1** subcategory designation for LDH (no longer upstages to M1c). - **M1d** designation is added for central nervous system metastases. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview of Melanoma:** Understood melanoma as a malignant tumor arising from melanocytes, with a complex interaction between genetic predispositions and environmental factors such as UV radiation. ****2\. Melanoma Risk Factors:** Identified key risk factors for developing melanoma, which include exposure to UV radiation, genetic mutations (such as BRAF), and personal characteristics like skin type and medical history. ****3\. Diagnostic Procedures:** Learned about the critical steps for diagnosing melanoma, emphasizing the necessity of histological examination to confirm clinical suspicions and detailed pathological analysis. ****4\. Surgical Management:** Gained insights into the surgical management of melanoma, particularly the importance of wide local excision tailored by the Breslow thickness of the tumor and the role of sentinel lymph node biopsy in staging and treatment planning. ****5\. Other Management Strategies:** Reviewed the management options available following a positive sentinel lymph node biopsy, ranging from complete lymph node dissection to observation and adjuvant therapies. ****6\. Staging and Prognostication:** Familiarized with the TNM classification system for melanoma, which helps in staging the disease and guiding treatment decisions based on tumor depth and nodal involvement. --- ## Further Reading 1. Morton DL. [Technical Details of Intraoperative Lymphatic Mapping for Early Stage Melanoma](https://pubmed.ncbi.nlm.nih.gov/1558490/?ref=theplasticsfella.com). *Arch Surg*. Published online April 1, 1992:392\. doi:10.1001/archsurg.1992.01420040034005 2. Dhakal S, Biswas T, Liesveld J, Friedberg J, Phillips G, Constine L. [Patterns and timing of initial relapse in patients subsequently undergoing transplantation for Hodgkin’s lymphoma](https://pubmed.ncbi.nlm.nih.gov/19250770/?ref=theplasticsfella.com). *Int J Radiat Oncol Biol Phys*. 2009;75(1):188-192\. doi:10.1016/j.ijrobp.2008.10.048 3. Gershenwald JE, Scolyer RA, Hess KR, et al. [Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual](https://pubmed.ncbi.nlm.nih.gov/29028110/?ref=theplasticsfella.com). *CA: A Cancer Journal for Clinicians*. Published online October 13, 2017:472-492\. doi:10.3322/caac.21409 4. Lee JH, Park HS, Wei Q, Kim MN, Cho J-H. [Difference of auditory brainstem responses by stimulating to round and oval window in animal experiments](https://www.tandfonline.com/doi/full/10.1080/21655979.2016.1226662?ref=theplasticsfella.com). *Bioengineered*. Published online September 30, 2016:8-13\. doi:10.1080/21655979.2016.1226662 5. Lee A, Droppelmann N, Panageas K, et al. [Patterns and Timing of Initial Relapse in Pathologic Stage II Melanoma Patients](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5505631/?ref=theplasticsfella.com). *Ann Surg Oncol*. 2017;24(4):939-946\. doi:10.1245/s10434-016-5642-0 6. Peach H, Board R, Cook M, et al. [Current role of sentinel lymph node biopsy in the management of cutaneous melanoma: A UK consensus statement](https://pubmed.ncbi.nlm.nih.gov/31477493/?ref=theplasticsfella.com). *J Plast Reconstr Aesthet Surg*. 2020;73(1):36-42\. doi:10.1016/j.bjps.2019.06.020 7. National Collaborating Centre for Cancer (UK). [Melanoma: Assessment and Management](https://pubmed.ncbi.nlm.nih.gov/26334080/?ref=theplasticsfella.com). Published online July 1, 2015\. 8. Kachare SD, Singla P, Vohra NA, Zervos EE, Wong JH, Fitzgerald TL. [Sentinel lymph node biopsy is prognostic but not therapeutic for thick melanoma](https://pubmed.ncbi.nlm.nih.gov/26096561/?ref=theplasticsfella.com). *Surgery*. Published online September 2015:662-668\. doi:10.1016/j.surg.2015.05.012 9. Wat H, Senthilselvan A, Salopek TG. [A retrospective, multicenter analysis of the predictive value of mitotic rate for sentinel lymph node (SLN) positivity in thin melanomas](https://pubmed.ncbi.nlm.nih.gov/26542815/?ref=theplasticsfella.com). *Journal of the American Academy of Dermatology*. Published online January 2016:94-101\. doi:10.1016/j.jaad.2015.09.014 10. Ribero S, Osella-Abate S, Sanlorenzo M, et al. [Sentinel Lymph Node Biopsy in Thick-Melanoma Patients (N=350): What is Its Prognostic Role?](https://pubmed.ncbi.nlm.nih.gov/25388059/?ref=theplasticsfella.com) *Ann Surg Oncol*. Published online November 12, 2014:1967-1973\. doi:10.1245/s10434-014-4211-7 11. Madu MF, Wouters MWJM, van Akkooi ACJ. [Sentinel node biopsy in melanoma: Current controversies addressed](https://www.ejso.com/article/S0748-7983%2816%2930852-6/abstract?ref=theplasticsfella.com). *European Journal of Surgical Oncology (EJSO)*. Published online March 2017:517-533\. doi:10.1016/j.ejso.2016.08.007 12. Dewar D, Newell B, Green M, Topping A, Powell B, Cook M. [The microanatomic location of metastatic melanoma in sentinel lymph nodes predicts nonsentinel lymph node involvement.](https://pubmed.ncbi.nlm.nih.gov/15310779/?ref=theplasticsfella.com) *J Clin Oncol*. 2004;22(16):3345-3349\. doi:10.1200/JCO.2004.12.177 13. Faries MB, Thompson JF, Cochran AJ, et al. [Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma](https://pubmed.ncbi.nlm.nih.gov/28591523/?ref=theplasticsfella.com). *N Engl J Med*. Published online June 8, 2017:2211-2222\. doi:10.1056/nejmoa1613210 14. Leiter UM, Stadler R, Mauch C, et al. [Final analysis of DECOG-SLT trial: Survival outcomes of complete lymph node dissection in melanoma patients with positive sentinel node](https://pubmed.ncbi.nlm.nih.gov/31557067/?ref=theplasticsfella.com). *JCO*. Published online May 20, 2018:9501-9501\. doi:10.1200/jco.2018.36.15\_suppl.9501 15. Faries MB, Thompson JF, et al. [The Impact on Morbidity and Length of Stay of Early Versus Delayed Complete Lymphadenectomy in Melanoma: Results of the Multicenter Selective Lymphadenectomy Trial (I)](https://pubmed.ncbi.nlm.nih.gov/20614193/?ref=theplasticsfella.com). *Ann Surg Oncol*. Published online July 8, 2010:3324-3329\. doi:10.1245/s10434-010-1203-0 16. Leong SP, Thelmo MC, Kim RP, et al. [Delayed harvesting of sentinel lymph nodes after previous wide local excision of extremity melanoma](https://pubmed.ncbi.nlm.nih.gov/12620917/?ref=theplasticsfella.com). *Ann Surg Oncol.* 2003;10:196–200. 17. Leong WL, Ghazarian DM, McCready DR. [Previous wide local excision of primary melanoma is not a contraindication for sentinel lymph node biopsy of the trunk and extremity](https://pubmed.ncbi.nlm.nih.gov/12619055/?ref=theplasticsfella.com). *J Surg Oncol.* 2003;82:143–146. 18. Kelemen PR, Essner R, Foshag LJ, Morton DL. [Lymphatic mapping and sentinel lymphadenectomy after wide local excision of primary melanoma](https://pubmed.ncbi.nlm.nih.gov/10472924/?ref=theplasticsfella.com). *J Am Coll Surg.* 1999;189:247–252. 19. Karakousis CP, Grigoropoulos P. [Sentinel node biopsy before and after wide excision of the primary melanoma](https://pubmed.ncbi.nlm.nih.gov/10622508/?ref=theplasticsfella.com). *Ann Surg Oncol.* 1999;6:785–789. 20. McCready DR, Ghazarian DM, Hershkop MS, Walker JA, Ambus U, Quirt IC. S[entinel lymph-node biopsy after previous wide local excision for melanoma](https://pubmed.ncbi.nlm.nih.gov/11764876/?ref=theplasticsfella.com). *Can J Surg.* 2001;44:432–434. 21. May MM, Lohse CM, Moore EJ, et al. [Wide local excision prior to sentinel lymph node biopsy for primary melanoma of the head and neck](https://pubmed.ncbi.nlm.nih.gov/30968948/?ref=theplasticsfella.com). *Int J Dermatol.* 2019;58:1184–1190. --- ### Ganglion Cysts of the Hand & Wrist: Diagnosis and Treatment URL: https://www.theplasticsfella.com/ganglion-cysts/ Last updated: 2024-04-11T18:47:28.000Z #### Summary Card [****Definition of Ganglion Cysts**](https://www.theplasticsfella.com/ganglion-cysts/#definition-of-ganglion-cysts) The most common soft tissue tumours in the hand, mostly arise from joint capsules or tendons. Main sites: dorsal wrist (60-70%) and volar wrist (15-20%). [****Pathophysiology of a Ganglion**](https://www.theplasticsfella.com/ganglion-cysts/#pathophysiology-of-a-ganglion) Resulting from repetitive microtrauma, containing a viscous fluid from hyaluronic acid production—theories related to mucoid and synovium. [****Clinical Picture of Ganglions**](https://www.theplasticsfella.com/ganglion-cysts/#clinical-picture-of-ganglions) Soft-tissue swellings vary in size and symptoms based on location. [****Investigations for Ganglions**](https://www.theplasticsfella.com/ganglion-cysts/#investigations-for-ganglions) Ultrasound and MRI can refine diagnosis and pinpoint location. MRIs have \~95% accuracy. [****Treatment of Ganglions & Outcomes**](https://www.theplasticsfella.com/ganglion-cysts/#treatment-of-ganglions) Observation, aspiration ± injection, and excision. Aspiration has the highest recurrence rate, and open surgical excision has the highest complication rate. [****Further Reading**](https://www.theplasticsfella.com/ganglion-cysts/#further-reading) Recommendations by P'Fella. [****Clinical Scenario**](https://www.theplasticsfella.com/ganglion-cysts-clinical-case/) Diagnose, manage ganglion cysts, & make decisions. --- ## Definition of Ganglion Cysts ****Key Point** Ganglions are the most common soft tissue tumours in the hand, often arising from joint capsules or tendons. Predominant sites include the dorsal wrist (60-70%) and volar wrist (15-20%). Ganglions are cysts filled with mucin. They represent the most prevalent soft tissue tumour in the hand. These cysts typically originate from neighbouring or underlying structures, including joint capsules, tendons, or tendon sheaths. The below image visualizes ganglion cysts of the hand. ![This image shows Ganglion Cysts of the hand](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Ganglion-Cyst-of-the-Hand-2.png) Definition of Ganglion Cysts Ganglion cysts commonly occur in specific sites of the hand and wrist, but not always. These are detailed below. - **Dorsal wrist:** 60-70%, originating from the scapholunate ligament. - **Volar wrist:** 15-20%, associated with the STT joint. - **Volar Retinacular:** 5-10%, arising from the A1 pulley. - **Distal Interphalangeal Joint:** Typically referred to as mucous cysts. These types of ganglion cysts are visualised below. ![This image shows the locations of Ganglion Cysts or different types of Ganglion Cysts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Locatons-of-Ganglion-Cyst-of-the-Hand-2.png) Locations of Ganglion Cysts Less frequently, ganglions are observed in the carpal tunnel, Guyon's canal, or intraosseous. 💡 ****Tip:** The location of the ganglion cyst significantly influences the clinical presentation. This is discussed in further detail below. . --- ## Pathophysiology of a Ganglion ****Key Point** Ganglions arise from repetitive trauma to joint structures, leading to fluid accumulation, and are characterized by interconnected ducts, compressed collagen, and a jelly-like substance. There is debate regarding the cyst's origin: whether it's due to mucoid degeneration or synovial growth/rupture. ### Origin & Composition Ganglions are believed to form due to repetitive microtrauma to a joint's capsular and ligamentous structures. This trauma stimulates fibroblasts at the synovial-capsule interface, leading them to produce hyaluronic acid. The outcome is a clear and highly viscous fluid, which accumulates, giving rise to the ganglion. ### **Characteristics of Ganglions** 1. Interconnected with nearby structures through continuous, intricate ducts. 2. Compressed collagen fibers. 3. Lacks an epithelial or synovial lining. 4. Filled with a high-viscosity, clear, jelly-like substance. Here's a visualization of the pathophysiology of ganglion cysts. ![This image visualizes the pathophysiology of ganglion cysts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Causes-of-Ganglion-Cyst-of-the-Hand.png) Pathophysiology of ganglion cysts ### **Debate on the Aetiology** There are two main theories regarding the formation of the ganglion cyst: 1. **Mucoid Theory:** This theory suggests that the cyst results from mucoid degeneration. This degeneration is marked by an increase in mucin and a decrease in fibrillated collagen fibers. However, this theory does not explain the recurrence of fluid after aspiration or incomplete resection. 2. **Synovium Theory:** This theory proposes that the cysts arise from herniation, rupture, or growth of the synovium. 😎 ****Fun Fact:** A one-way valvular mechanism has been suggested for the cyst and wrist joint. As communications are evidenced on arthrograms but not cystograms. --- ## Clinical Picture of Ganglions ****Key Point** Ganglion cysts appear as soft-tissue swellings in the hand with varying symptoms based on location and can change in size, cause pain, or compress nerves. Ganglion cysts, generally speaking, present as a soft-tissue swelling in a specific location in the hand. Key points identified in history: - **Timeline**: can be acute or slowly progressive. - **Size**: can fluctuate in size or self-resolve. - **Pain**: present if the cyst originates from a degenerated or arthritic joint. Typically non-tender upon palpation. - **Compression** symptoms if adjacent to a nerve (parasethesia, weakness). - **Transillumination**. There are more specific clinical pictures based on the location of the ganglion cyst. This is detailed in the table below. ![specific clinical pictures based on the location of the ganglion cyst](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Clinical-Features-of-Ganglion-Cysts-1.png) Clinical Features of Ganglions 💡 ****Tip:** Volar ganglions may appear small clinically but multiloculated cysts can extender under thenar muscles. --- ## Investigations for Ganglions ****Key Point** Ganglions are primarily clinically diagnosed; radiology refines diagnosis and location. Radiographs miss cysts, ultrasounds show hypoechoic structures and MRIs (95% accuracy) depict multiloculated lesions. Radiological investigations, although not imperative, serve to validate the diagnosis, ascertain the precise location, and identify any concomitant degenerative joint disease. - **Plain radiograph:** Ganglion cysts are invisible, but key differential diagnoses or joint disease. may be evident. - **Ultrasound**: Hypoechoic to anechoic with smooth walls; may have internal septations and exhibit acoustic enhancement. - **MRI**: \~95% accuracy, shows distinct multiloculated lesions with a stalk. T1 is typically hypointense, T2 and PDFS/T2FS are hyperintense ([Mckeon](https://pubmed.ncbi.nlm.nih.gov/26078505/?ref=theplasticsfella.com), 2015). The below image shows the ultrasound investigation view of hand and wrist ganglions. ![ultrasound view of hand and wrist ganglions.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Investifations-for-Ganglion-Cyst-of-the-Hand.png) Investigations of Ganglions 💡 ****Tip:** ****Occult ganglions** are not clinically palpable but a potential source of pain. They are identified on imaging. --- ## Treatment of Ganglions ****Key Point** Treatment options include observation (40% self-resolve), surgical excision (21% recurrence), or aspiration (59% recurrence). Open excision has higher risks, including wrist weakness, while long-term arthroscopic data is limited. The three main treatments for ganglions are observation, aspiration, and excision. - **Observation**: reassurance with education on change of self-resolution. - **Excision**: open or arthroscopic. - **Aspiration ± injection** (commonlycorticosteroids). ### Observation Interventions for dorsal wrist ganglia should offer better symptom relief, fewer recurrences, and reduced risks compared to non-treatment. Approximately 40% of untreated ganglia self-resolve ([Dias](https://pubmed.ncbi.nlm.nih.gov/17950209/?ref=theplasticsfella.com), 2007). However, this treatment option is limited by: - Longer time for symptom resolution compared to surgery. - Less patient satisfaction in this cohort of patients ([Dias](https://pubmed.ncbi.nlm.nih.gov/17950209/?ref=theplasticsfella.com), 2007). 😎 ****Fun Fact:** Historically, non-surgical treatment consisted of a sharp blow to the ganglion cyst with a mallet, dictionary, or Bible. ### Surgical Excision Ganglions can be excised through the standard open surgical approach or arthroscopic. The specific surgical technique varies based on the specific location. However, there are some key themes as detailed below: - **Incision**: Transverse or longitudinal incision can be advocated. - **Dissection**: preserve capsule and neurovascular bundles, identify the pedicle. - **Resection:** capsule, cyst and soft tissue attachment excised. - **Post-op**: There's no agreed-upon post-operative immobilisation strategy, and no data indicates one method as superior ([Wong](https://pubmed.ncbi.nlm.nih.gov/34096351/?ref=theplasticsfella.com), 2023). An in-depth review of each surgical technique based on anatomical location is outside the scope of this article. Below is a video of a dorsum wrist ganglion excision. Excision of a Dorsum Wrist Ganglion ### Aspiration ± Injection Each surgeon has their own specific technique for aspiration and injection. It is generally accepted the benefits of this treatment option includes: - Low-resource courses - Low risk of complications - Definitive confirmation of the diagnosis In 2010, [Paramhans](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890133/?ref=theplasticsfella.com) introduced the double dart technique: using concurrent 16-gauge (for aspiration) and 24-gauge needles (for triamcinolone acetonide injection) in the ganglion. This is visualised below. ![Aspiration and injection of Ganglion Cysts, double dart technique](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Treatment-of-Ganglions-1.png) Double dart technique - aspiration of Ganglion Cysts ### Outcomes The two commonly assessed outcomes in current literature relates to **recurrence** and **complications**. **Recurrence:** As detailed in a recent systematic review ([Head](https://pubmed.ncbi.nlm.nih.gov/25708437/?ref=theplasticsfella.com), 2015), - **Aspiration:** 59% (limited improvement vs. observation). - **Open Excision:** 21% (noteworthy for a higher complication rate). - **Arthroscopic:** 6% (limited comparative data; not clearly superior). The below image visualizes these recurrence percentages. ![Recurrence Rates for Ganglion Treatment](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Recurrence-rates-Ganglion-Cyst-of-the-Hand.png) Recurrence Rates for Ganglion Treatment 😎 ****Fun Fact:** Surgical excision may necessitate up to 2 weeks off work, while aspiration typically requires 3-4 days ([Dias](https://pubmed.ncbi.nlm.nih.gov/17950209/?ref=theplasticsfella.com), 2007). **Complications** Complications reported in surgical excision were comparatively more serious than those reported with aspiration and included radial artery damage and neurapraxia. The literature suggests the following mean complication rate ([Head](https://pubmed.ncbi.nlm.nih.gov/25708437/?ref=theplasticsfella.com), 2015). - **Open Excision:** 14% complication rate, with risks including radial artery damage and neurapraxia. - **Aspiration:** 2% complication rate. - **Arthroscopic:** 2% complication rate. Open excision has a higher rate of post-operative wrist weakness ([Dias](https://pubmed.ncbi.nlm.nih.gov/17950209/?ref=theplasticsfella.com), 2007). The exact reason for this weakness has not been established and this observation may be a consequence of surgery, the possible severity of any underlying intercarpal laxity. Below table depicts the recurrence and complication rates of these treatments. ![Recurrence and complication rates of ganglion treatments.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Outcomes-Ganglion-Cyst-of-the-Hand.png) Recurrence and complication rates of ganglion treatments. ### 💡 ****Tip:** The long-term data is currently limited on arthroscopic treatment. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Basics of Ganglion Cysts:** Gained a thorough understanding of ganglion cysts as the most common soft tissue tumors in the hand, often arising from joint capsules or tendons, and predominantly located on the dorsal and volar wrist. ****2\. Ganglion Cyst Pathophysiology:** Learned about the pathophysiological aspects of ganglion cysts, including theories regarding their origin either from mucoid degeneration or synovial growth/rupture, and the role of repetitive microtrauma in their development. ****3\. Clinical Presentation:** Gained knowledge on the clinical presentation of ganglion cysts, how they can vary in size, and the symptoms they may cause depending on their location, including potential nerve compression. ****4\. Diagnostic Approaches:** Understood the importance of ultrasound and MRI in refining the diagnosis of ganglion cysts, helping to pinpoint their location and structure with high accuracy. ****5\. Treatment Options and Outcomes:** Explored the various treatment options for ganglion cysts, from observation and aspiration to surgical excision, along with the associated recurrence rates and potential complications of each method. --- ## Further Reading 1. Dias JJ, Dhukaram V, Kumar P. [The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention](https://pubmed.ncbi.nlm.nih.gov/17950209/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2007 Oct;32(5):502-8\. doi: 10.1016/J.JHSE.2007.05.007\. Epub 2007 Aug 6\. PMID: 17950209. 2. Head L, Gencarelli JR, Allen M, Boyd KU. [Wrist ganglion treatment: systematic review and meta-analysis](https://pubmed.ncbi.nlm.nih.gov/25708437/?ref=theplasticsfella.com). J Hand Surg Am. 2015 Mar;40(3):546-53.e8\. doi: 10.1016/j.jhsa.2014.12.014\. PMID: 25708437. 3. McKeon KE, Wright BT, Lee DH. [Accuracy of MRI-based Diagnoses for Distal Upper Extremity Soft Tissue Masses](https://pubmed.ncbi.nlm.nih.gov/26078505/?ref=theplasticsfella.com). J Hand Microsurg. 2015 Jun;7(1):61-6\. doi: 10.1007/s12593-015-0174-6\. Epub 2015 Jan 15\. PMID: 26078505; PMCID: PMC4461636. 4. Paramhans D, Nayak D, Mathur RK, Kushwah K. [Double dart technique of instillation of triamcinolone in ganglion over the wrist](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890133/?ref=theplasticsfella.com). J Cutan Aesthet Surg. 2010 Jan;3(1):29-31\. doi: 10.4103/0974-2077.63286\. PMID: 20606991; PMCID: PMC2890133. 5. Wong CR, Karpinski M, Hatchell AC, McRae MH, Murphy J, McRae MC. [Immobilization of the Wrist After Dorsal Wrist Ganglion Excision: A Systematic Review and Survey of Current Practice](https://pubmed.ncbi.nlm.nih.gov/34096351/?ref=theplasticsfella.com). Hand (N Y). 2023 Mar;18(2):254-263\. doi: 10.1177/15589447211014631\. Epub 2021 Jun 6\. PMID: 34096351; PMCID: PMC10035098. --- ### Cubital Tunnel Syndrome: Anatomy, Clinical Diagnosis, and Treatment Options URL: https://www.theplasticsfella.com/cubital-tunnel-syndrome/ Last updated: 2024-04-11T10:09:50.000Z #### Summary Card [****Definition of Cubital Tunnel Syndrome**](https://www.theplasticsfella.com/cubital-tunnel-syndrome/#definition-of-cubital-tunnel-syndrome) Cubital Tunnel Syndrome arises from ulnar nerve compression within the cubital tunnel, leading to motor and sensory deficits. [****Anatomy of the Cubital Tunnel**](https://www.theplasticsfella.com/cubital-tunnel-syndrome/#anatomy-of-the-cubital-tunnel) The ulnar nerve originates from C8-T1\. The tunnel is formed by FCU fascia, Osborne’s ligament, medial epicondyle and olecranon. [****Diagnosis of Cubital Tunnel Syndrome**](https://www.theplasticsfella.com/cubital-tunnel-syndrome/#diagnosis-of-cubital-tunnel-syndrome) Little & ulnar-sided ring finger paresthesia, reduced grip strength, clawing & Fromen sign. Tinel’s and elbow flexion tests positive. [****Investigations of Cubital Tunnel Syndrome**](https://www.theplasticsfella.com/cubital-tunnel-syndrome/#investigations-of-cubital-tunnel-syndrome) Diagnosis is clinical, supported by nerve conduction studies. In specific cases, ultrasound, MRI, or X-rays might be needed. [****Treatment of Cubital Tunnel Syndrome**](https://www.theplasticsfella.com/cubital-tunnel-syndrome/#treatment-of-cubital-tunnel-syndrome) Involves therapy, analgesics, and surgical options: simple decompression, anterior transposition, and medial epicondylectomy. Non-surgical approaches are effective in mild cases. Contributors: Bryce Stash, MD, Monika Martinek, MS3, Natalie Gaio, MD --- ## Definition of Cubital Tunnel Syndrome ****Key Point** Cubital Tunnel Syndrome is an ulnar nerve compression within the cubital tunnel. This can occur anywhere from the medial intermuscular septum and the common flexor mass. Cubital Tunnel Syndrome arises from the **compression** of the **ulnar** nerve within the cubital tunnel, manifesting as **motor** and **sensory** deficits. It ranks as the second most common compressive neuropathy ([Andrews](https://pubmed.ncbi.nlm.nih.gov/30140129/?ref=theplasticsfella.com), 2018). The below image gives an overview of the Cubital Tunnel Syndrome. ![This image is an overview of Cubital Tunnel Syndrome in Upper Limb Surgery.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Cubital-Tunnel-Syndrome-1.png) Cubital Tunnel Syndrome **Common sites of compression are:** 1. **FCU Fascia:** forms the arcuate ligament with Osborne Ligament. 2. **Ligament of Osborne:** roof of the cubital tunnel. 3. **Arcade of Struthers:** band from intermuscular septum to medial triceps. 4. **Medial Intermuscle Septum** 5. **Epicondyle** 💡 ****Tip:** A memory hook for compression sites = FLAME. --- ‌ ‌ ## Anatomy of the Cubital Tunnel ****Key Point** The ulnar nerve, originating from C8-T1, navigates the cubital tunnel with boundaries defined by FCU fascia, Osborne’s ligament, medial epicondyle, olecranon, and surrounding ligaments. The ulnar nerve, originating from **C8-T1**, is a branch of the medial cord of the brachial plexus. **Before the cubital tunnel,** the ulnar nerve's course transitions from the anterior compartment(posteromedially to the brachial artery) to the posterior compartment (adjacent to the medial head of the triceps). **In the cubital tunnel, t**he ulnar nerve travels within well-defined anatomical boundaries. This is visualised in the image below. - **Roof**: FCU fascia and Osborne’s ligament - **Floor**: collateral ligament, joint capsule - **Medial Wall**: Medial epicondyle - **Lateral Wall**: Olecranon 😎 ****Fun Fact:** Osborne's ligament is a transverse fibrous band bridging the two heads of the flexor carpi ulnaris muscle ([Osborne](https://journals.sagepub.com/doi/10.1016/0072-968X%2870%2990027-6?ref=theplasticsfella.com), 1959) Below image visualizes the anatomical boundaries of Cubital Tunnel Syndrome. ![This image shows the Anatomical Boundaries of the Cubital Tunnel.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Cubital-Tunnel-Syndrome-2.png) Cubital Tunnel Anatomical Boundaries Other important landmarks include: - **Arcade of Struthers:** tendinous band between intermuscular septum and triceps. It arises \~8cm proximal to the medial humeral condyle. - **Intermuscular Septum**: continuous from the humeral medial epicondyle to the coracobrachialis muscle. - **FCU muscle**: the nerve exits the cubital tunnel under Osborne's ligament and enters the forearm through the two heads of the FCU muscle. 😎 ****Fun Fact:** The cubital tunnel area decreases by 55% during flexion ([Apfelberg](https://pubmed.ncbi.nlm.nih.gov/4347108/?ref=theplasticsfella.com), 1973) --- ## Diagnosis of Cubital Tunnel Syndrome ****Key Point** Cubital Tunnel Syndrome manifests with finger paresthesia and decreased grip strength. Physical exams reveal clawing and finger abduction, with Tinel’s and elbow flexion tests assisting the diagnosis. ### History Cubital Tunnel Syndrome is a progressively worsening condition marked by both motor and sensory deficiencies. It is characterized by: - **Sensory**: paresthesia of little and ulnar side of ring finger, worse at night. - **Motor**: reduced grip strength. A summary of the clinical features is visualised below. ![This image contains a table summarizing Clinical Features of cubital tunnel syndrome.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Cubital-Tunnel-Syndrome-8.png) Summary of Clinical Features ### Physical Exam **Inspection** On inspection, common observations are **clawing**, **little finger abduction** (Wartenberg Sign), and **1st webspace** **wasting** - **Clawing** is caused by intrinsic muscle denervation, leading to an unopposed pull by EDC and FDP tendons. - **Little finger abduction** is due to weakened ulnar nerve-innervated 3rd palmar interosseous and small finger lumbrical. - **Wasting** of 1st webspace is due to adductor pollicis atrophy. This can be visualised in the images below. ![This image shows the Clinical Features for cubital tunnel syndrome on Inspection](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Cubital-Tunnel-Syndrome-6.png) Clinical Features on Inspection Less frequently observed during examination are: - **Jeanne Sign**: Thumb MCP hyperextension and adduction due to radial nerve-innervated EPL, countering the loss of IP extension and thumb adduction from the ulnar nerve-regulated adductor pollicis. - **Masse Sign**: A flattened palmar arch and reduced ulnar hand elevation, attributed to weakened opponens digiti quinti and diminished small finger MCP flexion. **Feel** The sensory examination is typically straightforward, focusing on disturbances in the ulnar nerve distribution. Specifically: - Diminished sensation in the little finger and the ulnar side of the ring finger. - Decreased sensation on the dorsal aspect of the wrist, corresponding to the dorsal branch of the ulnar nerve. This sensory disturbance is visualized below. ![This image shows the Sensory Disturbance in the symptoms of Cubital Tunnel syndrome.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/a-Cubital-Tunnel-Syndrome.png) Cubital Tunnel Sensory Disturbance 💡 ****Tip:** Abnormal two-point discrimination is a sign of late disease. **Move** Cubital tunnel syndrome patients characteristically have reduced power in muscles innervated by the ulnar nerve. More specifically: - **Intrinsic muscle** weakness reduces fine motor. - **Adductor Pollicis** weakness reduces grip, pinch strength and enables Froment's sign. - **Subluxation** of ulnar nerve over medial epicondyle with elbow flexion. **The Froment Sign** is visualised below.Thumb's IPJ flexes (via AIN-innervated FPL) compensating for reduced thumb adduction (ulnar nerve-innervated). ![Froment's Sign in Ulnar Nerve Palsy in Cubital Tunnel Syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Cubital-Tunnel-Syndrome-4.png) Froment's Sign in Ulnar Nerve Palsy **Provocation Tests** Successful provocation tests will reproduce symptoms like paresthesias and/or numbness in the ring finger, little finger, or ulnar section of the dorsum hand. - **Tinel’s positive** at cubital tunnel: 70% sensitive, 98% specific ([Pandey](https://europepmc.org/article/med/24617698?ref=theplasticsfella.com), 2014). - **Elbow flexion** for 60 seconds: 75% sensitive, 99% specific ([Pandey](https://europepmc.org/article/med/24617698?ref=theplasticsfella.com), 2014). - **Pressure positive** at cubital tunnel ([Goldman](https://pubmed.ncbi.nlm.nih.gov/19887207/?ref=theplasticsfella.com) et al, 2008). ### Differential Diagnosis Cubital tunnel syndrome should be clinically differentiated from other ulnar nerve pathology. For example: **Ulnar Tunnel Syndrome** is the compression of the nerve in Guyon's canal. - **Sensation**: No dorsum hand sensory disturbance. - **Motor**: No extrinsic muscle motor issues. - **Provocative**: Positive Tinel's at Guyon's Canal. **C8 radiculopathy** is compression at the spine. - **Sensation**: Paresthesias in the small finger and ring finger. - **Motor**: deficits in extrinsic and intrinsic motor movements. - Differentiated by ordering cervical spine radiographs ([Andrews](https://pubmed.ncbi.nlm.nih.gov/30140129/?ref=theplasticsfella.com) et al, 2018). 💡 ****Tip:** Rare conditions, such as Guillain-Barre Syndrome and motor neuron disease, can mimic cubital tunnel syndrome. The main differences between the common differentials are visualised below: ![This image shows the Differential Diagnosis for Cubital Tunnel Syndrome.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Cubital-Tunnel-Syndrome-9.png) Differential Diagnosis for Cubital Tunnel 💡 ****Tip:** There is a ****classification system** proposed by ****McGowan**: ****· Grade 1:** Neuropathies with no weakness ****· Grade 2**: Neuropathies with muscle weakness ****· Grade 3**: Neuropathies with atrophy. --- ## Investigations‌‌ of Cubital Tunnel Syndrome ****Key Point** Cubital tunnel syndrome is a clinical diagnosis which can be supported by nerve conduction studies. In select cases, imaging may be required. ### Nerve Conduction Studies Nerve conduction studies can be used for the diagnosis and prognosis of nerve compression ([Tang](https://pubmed.ncbi.nlm.nih.gov/25539328/?ref=theplasticsfella.com), 2015). Key points for interpretation are: - **Amplitude:** CMAP (motor nerves) and SNAPS (sensory nerves) represent the number of functional axons. If reduced, velocity is less reliable. - **Conduction Velocity** represents the degree of delamination and localises the site of compression (less accurate if CMAPS are reduced). This is considered significant if <50 m/s across the elbow ([Landeau](https://pubmed.ncbi.nlm.nih.gov/23177030/?ref=theplasticsfella.com) et al, 2013). These create an **injury pattern** that can help predict postoperative outcomes. - **Demelyination** has a *favourable* recovery: reduced velocity, normal CMAP. - **Axonal** has an *unfavourable* recovery: reduced velocity, reduced CMAP - **Conduction** **block** has *favourable* recovery: CMAP 50% at elbow compared to the wrist. 💡 ****Tip:** Patients with a normal CMAP and no conduction block can often be [treated](https://www.theplasticsfella.com/cubital-tunnel-syndrome/#treatment-of-cubital-tunnel-syndrome) conservatively. ### Imaging - **Ultrasound**: high-frequency ultrasound of 14 Hz, ulnar nerve cross-sectional area of 0.065 squared cm ([Landeau](https://pubmed.ncbi.nlm.nih.gov/23177030/?ref=theplasticsfella.com) et al, 2013). - **MRI**: aids in the visualization of the ulnar nerve ([Landeau](https://pubmed.ncbi.nlm.nih.gov/23177030/?ref=theplasticsfella.com) et al, 2013). - **X-ray:** helps in the diagnosis of ulnar nerve compression caused by the presence of bone spurs, fractures, or arthritis ([Landeau](https://pubmed.ncbi.nlm.nih.gov/23177030/?ref=theplasticsfella.com) et al, 2013). --- ## Treatment of Cubital Tunnel Syndrome ****Key Point** Treatment involves upper limb therapy, analgesics, and surgical methods like simple decompression, anterior transposition (with subcutaneous, intramuscular, and submuscular variations), and medial epicondylectomy. Cubital Tunnel Syndrome treatment integrates the expertise of upper limb therapists, analgesics, and surgical interventions. The three primary surgical techniques have been found to produce satisfactory outcomes ([Boone](https://pubmed.ncbi.nlm.nih.gov/26243318/?ref=theplasticsfella.com), 2015). 1. Simple decompression 2. Anterior transposition: subcutaneous, intramuscular, submuscular 3. Medial epicondylectomy 💡 ****Tip:** For mild to moderate cubital tunnel syndrome, a non-surgical approach yields a 50% success rate (Dellon 2016). This involves elbow flexion limitation, triceps strengthening, night splints, and NSAIDs. ### ‌‌Simple Decompression ### - **Incision**: 8-10 cm behind medial epicondyle in the ulnar groove. - **Dissection**: Be cautious of the MABC located \~3 cm distal to the medial epicondyle in the subcutaneous plane. - **Release:** Medial intramuscular septum, Arcade of Struthers, Osbourne’s ligament, Arcuate ligament, Deep flexor/pronator aponeurosis. ### ‌‌Anterior Transposition This technique is combined with a simple decompression. It places the ulnar nerve anterior to the medial epicondyle, eliminating tension on the nerve with elbow flexion. Variations of this transposition include: - **Subcutaneous**: transposition within subcutaneous tissue. - **Submuscular**: transposition by detaching & reattaching flexor-pronator mass from the medial epicondyle. - **Intramuscular:** transposition with a fascial sling. This can be visualised in the video below by Dr Susan McKinnon. Submuscular Ulnar Nerve Transposition - Standard (Feat. Dr. Mackinnon) **Medial Epicondylectomy** This is a less common performance variation. It involves an oblique osteotomy in a plane midway between the coronal and sagittal planes.18 It is important to preserve the insertion of the MCL and repair the periosteum. - **Benefits**: limited nerve dissection is required - **Risks**: destabilizing the elbow by damaging the MCL. 😎 ****Fun Fact:** A recent systematic review concluded that there was insufficient evidence to identify a preferred operative treatment, and suggested that simple decompression and decompression with transposition were equally effective ([Caliandro](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6734129/?ref=theplasticsfella.com) et al, 2019) ‌ ## --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Overview of Cubital Tunnel Syndrome:** Gained insight into Cubital Tunnel Syndrome as a condition arising from ulnar nerve compression within the cubital tunnel, leading to motor and sensory deficits. ****2\. Anatomy and Pathophysiology:** Acquired knowledge on the anatomy of the cubital tunnel, including its formation by the FCU fascia, Osborne’s ligament, and the medial epicondyle and olecranon, and how these structures relate to ulnar nerve compression. ****3\. Diagnostic Techniques:** Learned the clinical presentation and diagnostic techniques for Cubital Tunnel Syndrome, including the significance of little and ulnar-sided ring finger paresthesia, reduced grip strength, and the utility of Tinel’s and elbow flexion tests. ****4\. Investigative Approaches:** Understood the role of nerve conduction studies in diagnosing Cubital Tunnel Syndrome and when additional imaging like ultrasound, MRI, or X-rays might be beneficial. ****5\. Treatment Modalities:** Explored treatment options ranging from therapy and analgesics to surgical interventions such as simple decompression, anterior transposition, and medial epicondylectomy, and the considerations for choosing each based on the severity of the condition. --- ## Further Reading 1. Andrews K, Rowland A, Pranjal A, Ebraheim N. [Cubital tunnel syndrome: Anatomy, clinical presentation, and management](https://pubmed.ncbi.nlm.nih.gov/30140129/?ref=theplasticsfella.com). J Orthop. 2018 Aug 16;15(3):832-836\. doi: 10.1016/j.jor.2018.08.010\. Erratum in: J Orthop. 2020 Dec 14;23:275\. PMID: 30140129; PMCID: PMC6104141. 2. Apfelberg DB, Larson SJ. [Dynamic anatomy of the ulnar nerve at the elbow](https://pubmed.ncbi.nlm.nih.gov/4347108/?ref=theplasticsfella.com). Plast Reconstr Surg. 1973 Jan;51(1):76-81\. PMID: 4347108. 3. Boone S, Gelberman RH, Calfee RP. [The Management of Cubital Tunnel Syndrome](https://pubmed.ncbi.nlm.nih.gov/26243318/?ref=theplasticsfella.com). J Hand Surg Am. 2015 Sep;40(9):1897-904; quiz 1904\. doi: 10.1016/j.jhsa.2015.03.011\. Epub 2015 Aug 1\. PMID: 26243318. 4. Caliandro P, La Torre G, Padua R, Giannini F, Padua L. [Treatment for ulnar neuropathy at the elbow](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6734129/?ref=theplasticsfella.com). Cochrane Database Syst Rev. 2016 Nov 15;11(11):CD006839\. doi: 10.1002/14651858.CD006839.pub4\. PMID: 27845501; PMCID: PMC6734129. 5. Landau ME, Campbell WW. [Clinical features and electrodiagnosis of ulnar neuropathies](https://pubmed.ncbi.nlm.nih.gov/23177030/?ref=theplasticsfella.com). Phys Med Rehabil Clin N Am. 2013 Feb;24(1):49-66\. doi: 10.1016/j.pmr.2012.08.019\. Epub 2012 Oct 25\. PMID: 23177030. 6. OSBORNE G. [Compression Neuritis of the Ulnar Nerve at the Elbow](https://journals.sagepub.com/doi/10.1016/0072-968X%2870%2990027-6?ref=theplasticsfella.com). Hand. 1970;2(1):10-13\. doi:10.1016/0072-968X(70)90027-6 7. Pandey T, Slaughter AJ, Reynolds KA, et al. [Clinical orthopedic examination findings in the upper extremity: correlation with imaging studies and diagnostic efficacy](https://europepmc.org/article/med/24617698?ref=theplasticsfella.com). Radiographics : a Review Publication of the Radiological Society of North America, Inc. 2014 Mar-Apr;34(2):e24-40\. DOI: 10.1148/rg.342125061\. PMID: 24617698. 8. Tang DT, Barbour JR, Davidge KM, Yee A, Mackinnon SE. [Nerve entrapment: update](https://pubmed.ncbi.nlm.nih.gov/25539328/?ref=theplasticsfella.com). Plast Reconstr Surg. 2015 Jan;135(1):199e-215e. doi: 10.1097/PRS.0000000000000828\. PMID: 25539328. ### Intrinsic "Plus" Hand: Anatomy, Aetiology, and Management URL: https://www.theplasticsfella.com/intrinsic-plus/ Last updated: 2024-06-23T10:00:05.000Z #### Summary Card [****Definition of Intrinsic Plus**](https://www.theplasticsfella.com/intrinsic-plus/#definition-of-intrinsic-plus) Intrinsic Plus condition is marked by tight interossei and lumbricals muscles causing MCPJ hyperflexion and PIPJ hyperextension, initially identified by Finochietto in 1920 and elaborated by Bunnell in 1946. [****Intrinsic Muscle Anatomy**](https://www.theplasticsfella.com/intrinsic-plus/#intrinsic-muscle-anatomy) Interossei and lumbricals contribute to MCPJ flexion, IPJ extension, grip, and pinch strength in hands. [****Intrinsic Plus Aetiology**](https://www.theplasticsfella.com/intrinsic-plus/#intrinsic-plus-aetiology) Intrinsic tightness can stem from local issues like fractures or systemic conditions like Rheumatoid Arthritis, affecting the interosseous muscles. [****Intrinsic Plus Clinical Picture**](https://www.theplasticsfella.com/intrinsic-plus/#intrinsic-plus-clinical-picture) Diagnosis involves identifying reduced PIPJ flexion in MCPJ extension (Bunnell's Test), with severe cases leading to non-correctible contractures and swan-neck deformities. [****Non-Surgical Management of the Intrinsic Plus Hand**](https://www.theplasticsfella.com/intrinsic-plus/#non-surgical-management-of-the-intrinsic-plus-hand) Non-surgical treatment aims to prevent irreversible contractures, employing methods like elevation, splinting, and manual stretching depending on the joints involved. [****Surgical Management of the Intrinsic Plus Hand**](https://www.theplasticsfella.com/intrinsic-plus/#surgical-management-of-the-intrinsic-plus-hand) Surgical options vary based on severity and affected joint, ranging from distal/proximal releases to muscle slides or ulnar neurectomy, targeting the restoration of hand function and correction of deformities. --- ## Definition of Intrinsic Plus ****Key Point** "Intrinsic Plus" is the tightness of interossei & lumbricals causing MCPJ hyperflexion and PIPJ hyperextension, first noted by Finochietto in 1920 and detailed by Bunnell in 1946. "Intrinsic Plus" is the **tightness** of the interossei & lumbricals. This results in an imbalance of forces that presents as **MCPJ** **hyperflexion** and **PIPJ hyperextension.** Chronic tightness can result in contractures and [swan-neck deformities](https://www.theplasticsfella.com/swan-neck-deformity-vs-boutonnieres/). It was described by ([Finochietto](https://p3.usal.edu.ar/index.php/signos/article/view/2712/3334?ref=theplasticsfella.com), 1920) and later expanded upon by ([Bunnell](https://pubmed.ncbi.nlm.nih.gov/18874816/?ref=theplasticsfella.com), 1946). ![Definition of Intrinsic Plus Hand, IPJ Extension, MPCJ Flexion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Intrinsic-Plus-Hand-.png) Definition of Intrinsic Plus Hand 💡 ****Tip:** Intrinsic ****tightness** is passively correctable. Intrinsic ****contracture** is ****not** passively correctable. --- ## Intrinsic Muscle Anatomy ****Key Point** Interossei and lumbricals muscles provide MCPJ flexion and IPJ extension. They also contribute to grip strength and pinch strength. An **intrinsic muscle** is defined as those having an origin and insertion within the hand. This includes the thenar and hypothenar muscles, **interossei**, and **lumbricals**. In general, the fingers are controlled by 6 muscles - **3 intrinsic**: dorsal and palmar interossei, lumbrical - **3 extrinsic:** FDS, FDP and EDC (index & little have an extra extensor) The intrinsic muscles produce **MCPJ flexion** and **IPJ extension** because the muscles travel **volar** to the axis of rotation of the MCPJ but **dorsal** to the axis of rotation of the IPJ. 😎 ****Fun Fact:** Interosseous muscles have shorter fibers but the same physiological cross-sectional area as the FDS muscles ([Brand](https://openlibrary.org/works/OL1825538W/Clinical%5Fmechanics%5Fof%5Fthe%5Fhand?ref=theplasticsfella.com), 1999). ### Interossei The fingers are stabilised by **4 dorsal** & **3 volar** interossei. These muscles' primary functions are: - **MCP flexion**/stabilization and **IPJ** extension. - **Palmar** interossei also **adduct** the finger - **Dorsal** interossei also **abduct** the finger ([Lauer](https://pubmed.ncbi.nlm.nih.gov/10188604/?ref=theplasticsfella.com), 1999) Please note that the little finger has a slight variation in horizontal movements. The little finger is abducted by the extensor digiti quinti and abductor digiti quinti. Below is the visualization of this. ![Anatomy of the Interossei Muscles, ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Intrinsic-Plus-Interroseous-Muscles-1.png) Anatomy of the Interossei Muscles, Intrinsic Muscle Anatomy These muscles originate on the side of the metacarpals. Their insertion points differ. Volar interossei insert onto the index, ring, and small fingers. Whereas the **dorsal interossei** insert onto the index, middle and ring. More specifically: - **1st interosseous** inserts onto the index finger. - **2nd and 3rd interossei** insert onto the middle finger - **4th interosseous** inserts onto the ring finger. The action of these muscles largely hinges on their insertion sites, not their origin. Therefore, they have often been classified based on their insertion site ([Stack](https://boneandjoint.org.uk/Article/10.1302/0301-620X.44B4.899?ref=theplasticsfella.com), 1962 and [Zancolli](https://www.amazon.com/Structural-dynamic-bases-hand-surgery/dp/0397503954?ref=theplasticsfella.com), 1979) 😎 ****Fun Fact:** Interossei insertion can vary. ****1st** insertions to proximal phalanx, extensors and volar plate, essential for pinching. ****2nd-4th also** insert into the lateral band. Volar interossei have no bony attachments. ### Lumbricals There are **4 lumbricals** in the hand innervated by the **median** (radial lumbricals) and **ulnar** (ulnar lumbricals) nerves. - **1st & 2nd** lumbricals originate from the radial side of index & middle FDP, insert onto the dorsal expansion as the radial lateral band. - **3rd & 4th** lumbricals are bipennate & originate from the middle/ring and ring/little finger FDP. Here is the anatomy of the lumbrical muscles. ![Lumbricals of the Hand, Intrinsic Muscle Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Intrinsic-Plus-Lumbrical-Muscles-1.png) Lumbricals of the Hand 😎 ****Fun Fact:** The intrinsic muscles account for approximately 53% of grip strength and 85% of pinch strength ([Kozin](https://pubmed.ncbi.nlm.nih.gov/10048518/?ref=theplasticsfella.com), 1999) --- ## Intrinsic Plus Aetiology ****Key Point** Intrinsic tightness, shortening of interosseous muscles, arises from local issues (e.g., fractures) or systemic conditions (e.g., Rheumatoid Arthritis). ### Overview Intrinsic tightness/contracture is the shortening of the interosseous muscles. It can be the result of ischaemia, adhesions, displacement, or spasticity. These pathophysiological states are associated with localised or systemic conditions: - **Localised**: fractures, infection, burns, compartment syndrome, lumbrical-plus - **Systemic**: Rheumatoid Arthritis, spasticity **Fractures** - **Metacarpal fractures** can result in oedema, immobilization, adhesions and ultimately fibrosis of the tendons and muscle bellies ([Paksima](https://pubmed.ncbi.nlm.nih.gov/22117926/?ref=theplasticsfella.com), 2012) - **Proximal phalanx fractures** can displace the lateral bands and stretch with callous formation. Adhesions may also form within the lateral bands, which would reduce PIP flexion **regardless of MCPJ position** ([Paksima](https://pubmed.ncbi.nlm.nih.gov/22117926/?ref=theplasticsfella.com), 2012). This is why some extra-articular proximal phalanx fractures can still affect the PIPJ movement post-operatively. **Mallet finger** - Redirects intrinsic force solely to the PIP joint - Can progress to swan neck deformity and intensifying intrinsic contracture due to volar plate attrition ([Schweitzer](https://pubmed.ncbi.nlm.nih.gov/15465241/?ref=theplasticsfella.com), 2004). **Lumbrical Plus Finger** - **Cause**: FDP injury distal to the origin of lumbrical, lax tendon graft, distal amputation, high median nerve palsy. - **Effect**: FDP (lumbrical origin) retracts proximally, increases tension on the lumbrical & its insertion (lateral band) ([Parkes](https://pubmed.ncbi.nlm.nih.gov/5578219/?ref=theplasticsfella.com), 1971) - **Result**: "paradoxical extension" of the PIPJ with flexion/difficult PIPJ flexion. 😎 ****Fun Fact:** The lumbrical muscle is unique in that it originates on a flexor tendon and inserts onto the extensor mechanism via the lateral band****.** **Rheumatoid Arthritis** - These intrinsic tightness types result from adhesions, inflammation & potentially hypoxia ([Akhavani](https://pubmed.ncbi.nlm.nih.gov/21463729/?ref=theplasticsfella.com), 2011). - Rheumatoid arthritis can also cause intrinsic contractures due to MCPJ dislocations and ulnar deviation ([Heywood](https://pubmed.ncbi.nlm.nih.gov/488793/?ref=theplasticsfella.com), 1979) **Spasticity** - This can be related to cerebral palsy, stroke, tetraplegia, or traumatic brain injuries. It can be associated with shoulder & elbow contractures. --- ## Intrinsic Plus Clinical Picture ****Key Point** "Intrinsic plus" hand is clinically diagnosed through reduced PIPJ flexion in MPCJ extension (Bunnel's Test). Severe cases can cause non-correctible contractures and swan-neck deformities. An "intrinsic plus" hand is a clinical diagnosis that can be supported by specific investigations to identify the aetiology. It is important to note that **intrinsic tightness** describes a less severe process - PIPJ flexion deficiency is still **passively correctable**. ### Loss of grip strength Patients may complain of difficulty with grasping large cylindrical objects. This is because of a restricted PIPJ when the MCP is extended. More specifically: - **Normal Intrinsics:** when the fingers grasp around a large sphere, the FDP, FDS and intrinsic simultaneously flex the DIPJ, PIPJ and MCPJ, respectively - **Abnormal Intrinsics**: IPJs flex before the MCPJs to produce a hook fist. There is also limited PIPJ flexion when MCPJ is extended. Patients are often still able to flex the IP joints due to the flexor tendons ability to overpower the intrinsic. 💡 ****Tip:** If passive DIPJ flexion affects by PIPJ movement, there is tightness of the oblique retinacular ligament. ### Bunnel's Test The intrinsic tightness test was developed by [Bunnell](https://pubmed.ncbi.nlm.nih.gov/18874816/?ref=theplasticsfella.com) in 1946\. - **Step 1**: passively **extend** MCPJ (stretch intrinsics), measure PIPJ flexion. - **Step 2:** passively **flex** the MCPJ (relaxes intrinsics) and measure PIPJ flexion - **Result**: a PIPJ flexion **increase** suggests isolated intrinsic tightness. Below image visualizes the Bunnell Test. ![Bunnell's Test for Intrinsic Tightness, Intrinsic Contracture, Intrinsic Plus](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Bunnells-Test-for-Intrinsic-Tightness.png) Bunnell's Test for Intrinsic Tightness This test can be also performed in radial or ulnar deviation. For example, placing the MCPJ into radial deviation during the test would further tighten the ulnar-side intrinsic tendons. 💡 ****Tip:** If the force required to flex the IP increases with f****lexion of the MCP**, this indicates contracture of the **extrinsic extensor.** ### Swan neck deformity A [swan neck deformity](https://www.theplasticsfella.com/swan-neck-deformity-vs-boutonnieres/) can occur in severe **chronic** contractures by the following mechanism. - **Cause:** Progressive PIPJ contracture leads to hyperextension. - **Effect:** Terminal tendon slackens while the FDP tendon tightens. - **Result:** DIPJ flexion ensues, leading to a [swan neck deformity](https://www.theplasticsfella.com/swan-neck-deformity-vs-boutonnieres/). Over time this can result in volar plate attenuation or collateral ligament capsular contraction Here's a visual representation of Swan Neck Deformity. ![Swan Neck Deformity in Chronic Intrinsic Tightness, Intrinsic Plus Hand ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Swan-Neck-Intrinsic-Plus.png) Swan Neck Deformity in Chronic Intrinsic Tightness 💡 ****Tip:** Passive and active motion of all joints should be assessed to distinguish joint from muscle contracture. ### Investigations **An intrinsic-plus hand is primarily a clinical diagnosis**. Adjunctive investigations can be considered, such as: - Isolated **strength** & **pinch** measurements. - **X-rays** to assess subluxation in rheumatoid patients. - Rheumatoid **serology** testing. - **Nerve block** in spasticity before the intrinsic tightness test can assist the examiner in discerning increased muscle tone from fixed contractures. - Dynamic electromyography (**EMG**) to evaluate the level of volitional control. --- ## Non-Surgical Management of the Intrinsic Plus Hand ****Key Point** Treatment for finger intrinsic contractures depends on the cause. ****Determine whether it involves just the PIPJ or both PIPJ and MCPJ to guide management**. The **primary** goal of treatment is to prevent a contracture that is no longer passively correctable. Non-surgical treatment should be continued until progress is no longer observed. Options include: - **Elevation** to reduce oedema, serum protein deposition and scar tissue formation. - **Splinting** in the intrinsic plus position (MCPJ flexion 70°, IPJs in extension) to optimise the MCPJ collateral ligaments & keeps intrinsics in a shortened position. - **Manual stretching of the intrinsics** by passive abduction or by MCPJ extension and IPJ flexion ([Seu](https://pubmed.ncbi.nlm.nih.gov/22117927/?ref=theplasticsfella.com), 2012). - **Progressive static splints** hold the MCP joints in extension and allow passive hook exercises (ie: perform the intrinsic tightness test). --- ## Surgical Management of the Intrinsic Plus Hand ****Key Point** Mild intrinsic tightness can be treated with hand therapy or distal release. Severe disease requires correction of swan neck deformity. Nonfunctioning intrinsics may be completely released or denervated. A variety of procedures are available to the intrinsic-plus patient. The choice is dependent on the aetiology, severity and **most importantly the joint involved**. Options include proximal and distal releases, slides, or translocations. Below table shows the surgical treatment options available for Intrinsic Tightness. ![surgical treatment for Intrinsic Tightness, Surgical intervention](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Intrinsic-Plus-Surgical-Managment.png) surgical options for Intrinsic Tightness. 😎 ****Fun Fact:** Muscle tone is often absent under general anesthesia and, therefore, the intrinsic tightness test is not positive under anesthesia. ### PIPJ Treatment **Distal Intrinsic Release for PIPJ** - **Indication**: Consider mild cases to improve PIPJ motion when patients struggle to make a full fist or weakness of grip. - **Purpose**: decrease the intrinsic force on the PIPJ without affecting the intrinsic flexion of the MCPJ. - **Technique**: resection of the ulnar and/or radial lateral bands & oblique fibres in the distal third of the proximal phalanx. This is distal to the transverse fibres that are responsible for MCPJ flexion. If the release is inadequate, then progressively more volar and proximal tissue is released until passive PIPJ flexion is achieved. ([Espiritu](https://pubmed.ncbi.nlm.nih.gov/16182064/?ref=theplasticsfella.com), 2011) 💡 ****Tip:** When MCP flexion contractures are present, a Distal Intrinsic Release is not adequate. ### MCPJ Flexion Treatment MCP flexion contractures secondary to intrinsic tightness are treated based on severity and aetiology. Options include a proximal intrinsic release (PIR), intrinsic muscle slide, botox injections, or ulnar nerve neurectomy. **Proximal Intrinsic Release** - **Indication**: MCPJ flexion contracture when intrinsic muscles have become fibrotic and no intrinsic muscle function is anticipated: - **Technique**: divide radial and ulnar interosseous tendons proximal to the MCPJ. The sagittal hood fibres of the extrinsic extensor are identified and preserved while the transverse and oblique fibres of the intrinsic mechanism are released proximal to the MCP joint. The transverse portion of the intrinsic flexes the MCPJ. 💡 ****Tips:** This results in a loss of the primary flexors of the MCPJ. **Interosseous Muscle Slide/Fractional Lengthening** - **Indication**: residual intrinsic function from ischemic or spasticity. - **Technique**: Elevate periosteal origins of dorsal and volar interossei from metacarpals ± first dorsal interosseous attachment to the thumb metacarpal. Splint MCP joints in full extension to allow the origin to heal distally. - **Tip**: fractional lengthening is an alternative option. Obliquely incise the tendinous part of the myotendinous junction, preserving the muscular portion. 💡 ****Tip:** A trial Botox injection into the interosseous muscles approximate the effect of reducing intrinsic tone. ([Tafti](https://pubmed.ncbi.nlm.nih.gov/18664635/?ref=theplasticsfella.com), 2008) **Ulnar Neurectomy** - **Indication**: spastic patients without volitional control. - **Technique**: Excise the ulnar nerve's motor branch in the Guyon canal. Index/middle lumbricals remain slightly active. - **Note**: In pronounced spasticity, extrinsics can overshadow intrinsic tightness. Post-extrinsic release, if MCP extends passively, neurectomy halts intrinsic contracture. If not, tenotomy near MCP aids extension. 💡 ****Tip:** In cases where there is increased intrinsic tone but good volitional control, a trial of botulinum toxin type A or phenol injection. ### Swan-Neck Deformity Chronic intrinsic tightness results a swan neck deformity with volar plate laxity. **Intrinsic Tenodesis** - **Indication**: swan neck deformity due to chronic PIPJ hyperextension. - **Technique**: Distal release of tighter intrinsic, reroute contralateral intrinsic tendon beneath the Cleland ligament to counteract hyperextension. Secure the tendon to the proximal phalanx after tenotomizing at its proximal third. - **Tip**: a lateral band **translocation** can be performed if concerns regarding Cleland ligament's strength in holding volarly-positioned lateral bands. Divide Cleland, locate the volar plate and flexor sheath, create a dorsal flap, translocate the lateral band volar, and reposition the flap anatomically. **Lateral Band Mobilisation** - **Indication**: Rigid swan neck deformity. - **Technique**: extensor tenolysis, dorsal capsulectomy, and lateral band mobilization via a dorsal incision. Release lateral bands from central slip and triangular ligament. ### Lumbrical-plus Finger **Radial Lateral Band Resection** - **Indication**: lumbrical plus finger resulting from lumbrical tightness. - **Technique:** Transect radial lateral band at the origin (palm) or insertion (dorsal apparatus) to mitigate paradoxical extension. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Intrinsic Plus Hand Definition:** Gained a comprehensive understanding of the Intrinsic Plus condition, its historical background by Finochietto and Bunnell, and its clinical presentation of tight interossei and lumbricals causing characteristic hand deformities. ****2\. Intrinsic Muscle Anatomy and Function:** Learned about the anatomy of interossei and lumbricals, their contribution to hand movement, grip, and pinch strength, and how their dysfunction leads to the Intrinsic Plus hand. **3\. Intrinsic Plus Aetiology:** Recognized the various local and systemic causes of intrinsic tightness, including fractures, Rheumatoid Arthritis, and other conditions affecting the interosseous muscles. ****4\. Diagnostic Approach to Intrinsic Plus Hand:** Gained knowledge on diagnosing the Intrinsic Plus hand, particularly through Bunnell's Test, and understanding the potential progression to non-correctible contractures and swan-neck deformities. ****5\. Non-Surgical and Surgical Management:** Explored non-surgical treatment options aimed at preventing irreversible contractures and looked into the surgical management of the Intrinsic Plus hand, understanding the procedures available depending on the severity and specific joint affected. --- ## Further Reading 1. Akhavani MA, Paleolog EM, Kang N. [Muscle hypoxia in rheumatoid hands: does it play a role in ulnar drift?](https://pubmed.ncbi.nlm.nih.gov/21463729/?ref=theplasticsfella.com) J Hand Surg Am. 2011 Apr;36(4):677-85\. doi: 10.1016/j.jhsa.2011.01.035\. PMID: 21463729. 2. Brand PW. [Clinical mechanics of the hand](https://openlibrary.org/works/OL1825538W/Clinical%5Fmechanics%5Fof%5Fthe%5Fhand?ref=theplasticsfella.com). 1985 3. BUNNELL S, DOHERTY EW, CURTIS RM. [Ischemic contracture, local, in the hand](https://pubmed.ncbi.nlm.nih.gov/18874816/?ref=theplasticsfella.com). Plast Reconstr Surg (1946). 1948 Jul;3(4):424-33\. doi: 10.1097/00006534-194807000-00004\. PMID: 18874816. 4. Zancolli E. [Structural and dynamic bases of hand surgery](https://www.amazon.com/Structural-dynamic-bases-hand-surgery/dp/0397503954?ref=theplasticsfella.com). 1979. 5. Espiritu MT, Kuxhaus L, Kaufmann RA, Li ZM, Goitz RJ. [Quantifying the effect of the distal intrinsic release procedure on proximal interphalangeal joint flexion: a cadaveric study](https://pubmed.ncbi.nlm.nih.gov/16182064/?ref=theplasticsfella.com). J Hand Surg Am. 2005 Sep;30(5):1032-8\. doi: 10.1016/j.jhsa.2005.05.003\. PMID: 16182064. 6. Finochietto R. [Retraccion de volkmann de los musculos intrinsecos de la mano](https://p3.usal.edu.ar/index.php/signos/article/view/2712/3334?ref=theplasticsfella.com). 1920. 7. Kozin SH, Porter S, Clark P, Thoder JJ. [The contribution of the intrinsic muscles to grip and pinch strength](https://pubmed.ncbi.nlm.nih.gov/10048518/?ref=theplasticsfella.com). J Hand Surg Am. 1999 Jan;24(1):64-72\. doi: 10.1053/jhsu.1999.jhsu24a0064\. PMID: 10048518. 8. Lauer RT, Kilgore KL, Peckham PH, Bhadra N, Keith MW. [The function of the finger intrinsic muscles in response to electrical stimulation](https://pubmed.ncbi.nlm.nih.gov/10188604/?ref=theplasticsfella.com). IEEE Trans Rehabil Eng. 1999 Mar;7(1):19-26\. doi: 10.1109/86.750547\. PMID: 10188604. 9. Paksima N, Besh BR. [Intrinsic contractures of the hand](https://pubmed.ncbi.nlm.nih.gov/22117926/?ref=theplasticsfella.com). Hand Clin. 2012 Feb;28(1):81-6\. doi: 10.1016/j.hcl.2011.10.001\. PMID: 22117926. 10. Parkes A. [The "lumbrical plus" finger](https://pubmed.ncbi.nlm.nih.gov/5578219/?ref=theplasticsfella.com). J Bone Joint Surg Br. 1971 May;53(2):236-9\. PMID: 5578219. 11. Schweitzer TP, Rayan GM. [The terminal tendon of the digital extensor mechanism: Part I, anatomic study](https://pubmed.ncbi.nlm.nih.gov/15465241/?ref=theplasticsfella.com). J Hand Surg Am. 2004 Sep;29(5):898-902\. doi: 10.1016/j.jhsa.2004.04.022\. PMID: 15465241. 12. Seu M, Pasqualetto M. [Hand therapy for dysfunction of the intrinsic muscles](https://pubmed.ncbi.nlm.nih.gov/22117927/?ref=theplasticsfella.com). Hand Clin. 2012 Feb;28(1):87-100\. doi: 10.1016/j.hcl.2011.09.001\. PMID: 22117927. 13. Stack, H. G. (1962). [MUSCLE FUNCTION IN THE FINGERS](https://boneandjoint.org.uk/Article/10.1302/0301-620X.44B4.899?ref=theplasticsfella.com). The Journal of Bone & Joint Surgery British Volume, 44-B(4), 899-909\. https://doi.org/10.1302/0301-620X.44B4.899 14. Tafti MA, Cramer SC, Gupta R. [Orthopaedic management of the upper extremity of stroke patients](https://pubmed.ncbi.nlm.nih.gov/18664635/?ref=theplasticsfella.com). J Am Acad Orthop Surg. 2008 Aug;16(8):462-70\. doi: 10.5435/00124635-200808000-00005\. PMID: 18664635. ### Tuberous Breast Deformity: Features, Classification, and Surgery URL: https://www.theplasticsfella.com/tuberous-breast-deformity/ Last updated: 2024-07-26T14:19:07.000Z #### Summary Card [****Definition**](https://www.theplasticsfella.com/tuberous-breast-deformity/#definition-of-tuberous-breasts) A congenital deformity characterized by constricted, elevated, herniated, and hypoplastic features, while maintaining normal function. [****Clinical Features**](https://www.theplasticsfella.com/tuberous-breast-deformity/#clinical-features-of-tuberous-breasts) Features vary widely, commonly including asymmetry, hypoplasia, constricted base, IMF elevation, herniated nipple, ptosis, and skin envelope insufficiency. [****Classification**](https://www.theplasticsfella.com/tuberous-breast-deformity/#classification-of-tuberous-breasts) Von Heimburg's 1996 system is crucial for assessing the condition, emphasizing the identification of specific affected areas to inform surgical strategies. [****Surgery**](https://www.theplasticsfella.com/tuberous-breast-deformity/#surgery-for-tuberous-breasts) Aims to release constrictions, restore volume, reposition the inframammary fold, and achieve symmetry, involving techniques like periareolar incisions, radial scoring, and dual-plane pocket creation, and may require single or two-stage procedures depending on severity. ****Primary Author:** Dr Kurt Lee Chircop, Plastic Surgery Trainee, Malta --- ## Definition of Tuberous Breasts ****Key Point** Tuberous breast is a congenital deformity characterized by a constricted, elevated, herniated, and hypoplastic appearance, with normal function retained. A "tuberous breast" is a congenital breast deformity that results in a constricted, elevated, herniated and hypoplastic breast (Rees, [1976](https://pubmed.ncbi.nlm.nih.gov/1261187/?ref=theplasticsfella.com)). The breast maintains normal function and physiology. ![Tuberous Breasts, Breast Deformity](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/Tuberous-Breast-Definition-1.png) Definition of Tuberous Breasts **True incidence** is unknown in view of significant under-reporting, especially with the minor forms of the spectrum of deformity. Typically found in patients presenting for breast augmentation or mastopexy with incidence of 30-50% (Klinger, [2016](https://pubmed.ncbi.nlm.nih.gov/27271839/?ref=theplasticsfella.com)) 😎 ****Fun Fact:** It's aetiology is most likely of embryologic origin. It occurs due to peri­-areolar ring constriction and thin or hypoplastic areolar fascial support (Pacifico, [2007](https://pubmed.ncbi.nlm.nih.gov/17399653/?ref=theplasticsfella.com)) --- ## Clinical Features of Tuberous Breasts ****Key Point** Tuberous breast deformity features asymmetry, hypoplasia, constriction, and ptosis, making accurate diagnosis crucial for effective aesthetic correction beyond just volume increase. Tuberous breast deformities present on a clinical spectrum. The condition can be unilateral or bilateral and is very commonly **asymmetric** in nature. The key clinical findings include the following: - **Volume**: parenchymal hypoplasia and asymmetry. - **Base constricted:** deficient width (horizontal) and height (vertical) - **IMF**: medial and or lateral elevation; complete absence. - **Nipple**: herniated and widened - **Ptosis:** mild to severe, often defies stan­dard classification. - **Skin envelope**: insufficiency, typically inferior pole. Below image identifies the clinical features of Tuberous Breast Deformity. ![Clinical Features of a Tuberous Breast, Breast Deformity, Surgical Procedures](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Tuberous-Breast-Deformity-CLinical-Features-1.png) Clinical Features of a Tuberous Breast 💡 ****Tip:** The diverse and asymmetrical nature of tuberous breasts complicates aesthetic corrections. Proper diagnosis is key, as solely increasing volume may not yield satisfactory outcomes. (Rees, [1976](https://pubmed.ncbi.nlm.nih.gov/1261187/?ref=theplasticsfella.com)). --- ## Classification of Tuberous Breasts ****Key Point** Von Heimburg's 1996 classification is key for accurately assessing and predicting outcomes of tuberous breast deformity by detailing specific affected areas. Precise nomenclature and classification are crucial for preoperative assessment of tuberous breast deformity, enabling the identification of specific characteristics and their severity to ensure more predictable outcomes. Among the various classification systems **Von Heimburg's** 1996 framework has been popularised. It categorises the deformity based on the affected areas (von Heimburg, [1996](https://pubmed.ncbi.nlm.nih.gov/8881778/?ref=theplasticsfella.com)) ![von Heimburg Classification of Tuberous Breasts, Breast Deformity Treatment](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Tuberous-Breast-Deformity-von-Heimburg-Classification.png) Classification of Tuberous Breasts 😎 ****Fun Fact:** The Northwood index, calculated by dividing the nipple's forward projection from the areola edge by the areola's diameter (both in centimeters), objectively identifies tuberous breasts in a clinical setting; a ratio over 0.4 suggests areolar herniation indicative of the condition --- ## Surgery for Tuberous Breasts ****Key Point** Tuberous breast correction surgery involves periareolar incision for precise adjustments, radial scoring to release constrictions, and dual-plane pocket creation for optimal shape, with procedures varying from single to two-stage based on individual needs for achieving desired breast volume and symmetry. ### **Goals of Surgery** For patients dissatisfied with their breast shape or size due to tuberous deformity, surgical correction aims to: 1. Release **constrictions.** 2. Restore **breast volume.** 3. Reposition the **inframammary fold.** 4. Achieve **symmetry**. Typically, a single-stage procedure suffices, leveraging the distensibility of soft tissues. However, for severe cases or when larger volumes are desired and tissues lack pliability, two-stage procedures with expanders may be necessary. Check out these below video for more insights on the surgical procedure for Tuberous Breasts. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/Screenshot-2024-02-24-at-15.19.14-1.png) [1 hour Video on Surgical Technique](https://www.youtube.com/watch?v=7ZdUbTi4IwI&ref=theplasticsfella.com) ### Overview of Surgical Technique This guide outlines common steps in tuberous breast correction surgery, noting that techniques may vary among surgeons. - **Periareolar Skin Incision**: Allows areolar reduction, access to the subglandular plane, and radial release of constriction rings. - **Dissection**: Proceeds down to the subglandular prefascial plane, extending inferiorly to the new inframammary fold (IMF) position. - **Radial Scoring**: Involves radial incisions into the glandular tissue perpendicular to the subglandular layer, particularly at the lower pole to release constrictions and facilitate expansion. - **IMF Positioning**: Through transglandular dissection to the prepectoral fascial plane, defining the new lower limit of the breast. - **Pocket Creation**: Establishes a dual-plane pocket via a horizontal incision in the lower part of the pectoralis major muscle, combined with retropectoral dissection, resulting in a Dual-Plane Type 3 pocket. - **Volume Replacement**: Selection between implants or expanders, round versus anatomical shapes. Utilizes a sizer with tailor tacking before final insertion. - **NAC (Nipple-Areola Complex) Herniation/Ptosis Correction**: Employs circumareolar and/or vertical mastopexy techniques, either immediate or delayed. This includes concentric de-epithelialization for areolar size reduction and circumareolar mastopexy using round-block suturing. ### **Specific Aspects to Surgery** ### Skin Incision A periareolar incision is crucial for precise breast reshaping, combining flexibility and predictability. Advantages include: - Allowing precise inframammary fold adjustment. - Providing direct access to correct glandular constrictions. - Effective in treating herniation, enlarged NAC, and ptosis. ### Radial Scoring Radial scoring involves transglandular dissection towards the prepectoral fascia, extending to the new lower breast boundary. This method targets the constricting fascial bands, employing perpendicular (vertical/radial) cuts from the subglandular layer, aiming to: - Expand the breast's lower pole. - Visually eliminate the memory of any preexisting inframammary fold. In cases of severe constriction, subdermal scoring may be employed for enhanced results. ### Pocket Creation The dual-plane technique, combining the benefits of both submuscular and subglandular placements, is favored for tuberous breast corrections. It facilitates lower pole expansion and shaping while maintaining minimal fill in the upper pole, allowing the muscle to move up, away from the adjusted inframammary fold (IMF). This approach enhances the natural contour, improves soft-tissue coverage, stabilizes breast position, and reduces the risk of capsular contracture. Conversely, subglandular placement directly shapes and expands the breast but can lead to: - Higher capsular contracture rates. - Visible implant edges and rippling. - Risk of implant malposition. - Unnatural appearance, particularly due to the scoring and thinning required in tuberous breast correction. ### Single-stage vs Two-stage In tuberous breast correction, choosing between single-stage and two-stage procedures depends on individual patient factors and desired outcomes: **Single-stage correction** is suitable for patients with distensible lower pole skin and soft tissues who have conservative size expectations. This approach allows for immediate correction and repositioning of the breast tissue and inframammary fold in a single procedure. **Two-stage correction**, involving initial tissue expander placement followed by implant insertion, is recommended for: - Patients desiring a fuller outcome with moderate to severe breast hypoplasia. - Situations where overcoming the memory of the preexisting inframammary fold is challenging. - Cases with severe constriction and superior malposition of the inframammary fold, allowing for a secondary "fine-tuning" procedure to enhance breast symmetry and achieve optimal aesthetic results. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Nature of Tuberous Breast Deformity:** Acquired knowledge of tuberous breasts, a congenital condition characterized by a variety of physical manifestations including asymmetry, constricted base, and herniated nipple, while maintaining normal breast function. ****2\. Clinical Features and Diagnosis:** Enhanced the ability to recognize the clinical features of tuberous breasts, crucial for accurate diagnosis and effective aesthetic correction, acknowledging the condition's spectrum from asymmetry and hypoplasia to ptosis and skin envelope insufficiency. ****3\. Classification of Tuberous Breast Deformity:** Learned about Von Heimburg's 1996 classification system, an essential tool for assessing tuberous breast deformity, facilitating the identification of specific areas affected to inform tailored surgical strategies. ****4\. Surgical Interventions:** Gained insights into the surgical goals and techniques for correcting tuberous breasts, including the importance of releasing constrictions, restoring volume, repositioning the inframammary fold, and achieving symmetry, with the choice between single or two-stage procedures tailored to the severity of the condition and patient desires. --- ## Further Reading 1. Klinger M, Caviggioli F, Giannasi S, Bandi V, Banzatti B, Veronesi A, Barbera F, Maione L, Catania B, Vinci V, Lisa A, Cornegliani G, Giaccone M, Siliprandi M, Klinger F. T[he Prevalence of Tuberous/Constricted Breast Deformity in Population and in Breast Augmentation and Reduction Mammaplasty Patients](https://pubmed.ncbi.nlm.nih.gov/27271839/?ref=theplasticsfella.com). Aesthetic Plast Surg. 2016 Aug;40(4):492-6\. doi: 10.1007/s00266-016-0650-9\. Epub 2016 Jun 6\. PMID: 27271839. 2. Pacifico MD, Kang NV. [The tuberous breast revisited](https://pubmed.ncbi.nlm.nih.gov/17399653/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2007;60(5):455-64\. doi: 10.1016/j.bjps.2007.01.002\. Epub 2007 Feb 21\. PMID: 17399653. 3. Rees TD, Aston SJ. [The tuberous breast](https://pubmed.ncbi.nlm.nih.gov/1261187/?ref=theplasticsfella.com). Clin Plast Surg. 1976 Apr;3(2):339-47\. PMID: 1261187. 4. von Heimburg D, Exner K, Kruft S, Lemperle G. [The tuberous breast deformity: classification and treatment](https://pubmed.ncbi.nlm.nih.gov/8881778/?ref=theplasticsfella.com). Br J Plast Surg. 1996 Sep;49(6):339-45\. doi: 10.1016/s0007-1226(96)90000-4\. PMID: 8881778. ### Mohs Micrographic Surgery URL: https://www.theplasticsfella.com/mohs-micrographic-surgery/ Last updated: 2024-04-09T15:10:12.000Z #### Summary Card [****Introduction**](https://www.theplasticsfella.com/mohs-micrographic-surgery/#introduction) Dr. Frederic Mohs developed the tissue-sparing MMS in the 1930s for high-risk skin cancers, especially non-melanoma types. [****Indication for Moh's Surgery**](https://www.theplasticsfella.com/mohs-micrographic-surgery/#indication-for-mohs-surgery) MMS treats high-risk skin cancers, considering factors like recurrence, prior treatments, histological signs, and patient immunosuppression. [****Moh's Surgery Technique**](https://www.theplasticsfella.com/mohs-micrographic-surgery/#mohs-surgery-technique) MMS involves precise excision, microscopic examination for clear margins, and consecutive stages till tumour-free margins are achieved. [****Moh's vs. Standard Excision**](https://www.theplasticsfella.com/mohs-micrographic-surgery/#mohs-vs-standard-excision) MMS provides a same-day, comprehensive margin assessment and tumour removal. Standard Excision might necessitate multiple visits. [****Advantages and Disadvantages of Moh's Surgery**](https://www.theplasticsfella.com/mohs-micrographic-surgery/#advantages-and-disadvantages-of-mohs-surgery) While MMS is exceptional for tissue conservation and NMSC outcomes, it demands specialized expertise and might be time-intensive. ****Authors:** Emma Yanko & Brandon Spink**. University of Saskatchewan, College of Medicine* --- ## Introduction Dr. Frederic Mohs, an American general surgeon in the 1930s, developed the Mohs micrographic surgery (Mohs surgery or MMS) technique.1 It is a tissue-sparing surgical technique used to remove skin cancers with a high risk of recurrence and located in areas of functional and aesthetic importance. ![Frederic Moh, Moh's Surgery, Cancer Treatment](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Moh-s-Surgery.png) Frederic Moh - Founder of Moh's Surgery 💡 ****Tip:** Mohs surgery is most commonly used for the removal of non-melanoma skin cancers (NMSC)2 --- ## Indication for Moh's Surgery ****Key Point** MMS targets high-risk skin cancers, especially in areas like the H-zone where tissue preservation is crucial, considering factors such as recurrence, unclear margins, and patient immunosuppression. MMS is predominantly endorsed for managing **high-risk** skin cancers with **high-risk** pathology located in **high-risk** anatomical sites3-8. **Criteria for High-risk Non-melanoma Skin Cancers:** This criteria relates to high-risk [basal cell](https://www.theplasticsfella.com/basal-cell-carcinoma/#low-risk-vs-high-risk-bcc) and [squamous cell carcinoma](https://www.theplasticsfella.com/squamous-cell-carcinoma/#risk-groups-for-squamous-cell-carcinoma). - Recurrence - Incomplete excision post-previous therapeutic interventions - Prior radiotherapy - Indistinct margins - Neoplasms manifesting histological hallmarks indicative of potential local recurrence, inclusive of: - Micronodular - Morphoeic/Infiltrative - Perineural invasion - Perivascular invasion - Neoplasms are diagnosed in patients with immunosuppression An example of differentiating between high and low-risk [basal cell carcinomas](https://www.theplasticsfella.com/basal-cell-carcinoma/) can be visualised below. ![A table differentiating high and low-risk basal cell carcinomas](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Low-risk-vs-high-risk-Basal-Cell-Carcinoma.png) High and Low-Risk [BCC](https://www.theplasticsfella.com/basal-cell-carcinoma/)s **High-risk Areas** - **H-zone:** eyelids, medial canthus, nasal apex and ala, preauricular sulcus, ears, and labia. In these regions, tissue conservation is paramount for maintaining dermal functionality and esthetic integrity. - **Cosmetic** areas where tissue preservation is paramount. ![High Risk H Zones in basal cell carcinomas](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/H-Zones.png) High Risk H Zones 💡 ****Tip:** The American Academy of Dermatology (AAD) formulated the [Mohs Appropriate Use Criteria (AUC)](https://www.aad.org/member/publications/apps/mohs?ref=theplasticsfella.com) for clinicians. --- ## Moh's Surgery Technique ****Key Point** Mohs Micrographic Surgery is a meticulous process where skin cancer is marked, excised with precision, and examined microscopically in successive stages until clear margins are achieved, followed by surgical site closure8. Moh's micrograph surgery is usually performed in the following steps: 1. **Preparation:** Mark cancer and administer local anaesthetic. 2. **Tumour**anaesthetic **Removal:** Debulk the tumour and excise it with a circumferential margin (tissue around and beneath the tumor). 3. **Mapping:** Post-excision, sketch a map of the surgical site and corresponding tissue sections to maintain orientation. 4. **Initial Dressing:** Apply a dressing to the surgical site as the tissue undergoes microscopic evaluation. 5. **Laboratory Processing:** Segment the tissue sample, often bisecting or quartering it, and stain with dyes, typically H&E and toluidine blue. 6. **Microscopic Examination:** Freeze the tissue sample and inspect it under a microscope in the lab. 7. **Precision Removal:** If the microscope reveals a residual tumour, refer to the Mohs map and excise the specific area from the patient. Repeat until margins are tumour-free. 8. **Closure:** Conclude by closing the surgical site, either immediately or during a subsequent appointment. This can be visualised in the [video](https://youtu.be/opJaS8i2xUk?si=Gd3cPWOxHaw177OY&t=87&ref=theplasticsfella.com) below. [![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Screenshot-2023-10-20-at-18.34.50.png)](https://youtu.be/opJaS8i2xUk?si=Gd3cPWOxHaw177OY&t=87&ref=theplasticsfella.com) [JAMA Surgery Video](https://youtu.be/opJaS8i2xUk?si=Gd3cPWOxHaw177OY&t=87&ref=theplasticsfella.com) \- Click to play --- ## Moh's vs Standard Excision ****Key Point** Mohs Micrographic Surgery offers 100% margin assessment, same-day pathology reports, and single-session tumor removal. In contrast, Standard Excision may require multiple visits for re-excision and typically provides pathology reports in 1-2 weeks. Mohs micrographic surgery and standard surgical excision differ in their techniques and outcomes. While standard excision might require multiple visits if margins are positive, Mohs ensures complete tumour removal in a same-day outpatient procedure with 100% margin assessment3–6. A complete comparison between the two surgical techniques can be visualised below. ![Standard Excision vs Moh's Surgery Comparison Table](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Moh-s-Surgery-1.png) Standard Excision vs Moh's Surgery --- ## Advantages and Disadvantages of Moh's Surgery ****Key Point** Mohs surgery excels in conserving tissue and ensuring NMSC outcomes but faces limitations in specialist access and extended procedure time. Mohs Micrographic Surgery offers significant benefits in terms of tissue conservation, comprehensive margin assessment, and superior long-term outcomes for NMSC. However, its applicability is limited by the availability of trained specialists and the procedure's extended duration. This is explained in the table below. ![Advantages and Disadvantages of Moh's Surgery, Surgical Interventions](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Moh-s-Surgery-2.png) Advantages and Disadvantages of Moh's --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Origins and Applications of Mohs Surgery:** Understood the development of Mohs micrographic surgery (MMS) by Dr. Frederic Mohs in the 1930s as a tissue-sparing technique for treating high-risk skin cancers, primarily non-melanoma types. ****2\. Indications for Mohs Surgery:** Learned that MMS is indicated for high-risk skin cancers, with criteria including recurrence, unclear margins, prior treatments, histological signs indicative of aggressive behavior, and patient immunosuppression, especially in cosmetically sensitive or functional areas. ****3\. Mohs Surgery Technique:** Gained insights into the step-by-step process of Mohs surgery, highlighting its precision and the iterative examination of excised tissue until clear margins are achieved, culminating in surgical site closure. ****4\. Comparison of Mohs to Standard Excision:** Understood the advantages of Mohs surgery over standard excision, including comprehensive, same-day margin assessment and tumor removal, in contrast to the potential need for multiple visits with standard excision. ****5\. Advantages and Limitations of Mohs Surgery:** Acknowledged the benefits of Mohs surgery in tissue conservation and efficacy for non-melanoma skin cancer (NMSC) outcomes, while noting challenges such as the necessity for specialized expertise and the potential for extended procedure times. --- ## Further Reading 1. Fe M. [Chemosurgery for the microscopically controlled excision of cutaneous cancer](https://pubmed.ncbi.nlm.nih.gov/755808/?ref=theplasticsfella.com). *Head Neck Surg*. 1978;1(2). doi:10.1002/hed.2890010209 2. Ho C, Argáez C. [*Mohs Surgery for the Treatment of Skin Cancer: A Review of Guidelines*](https://www.ncbi.nlm.nih.gov/books/NBK546997/?ref=theplasticsfella.com). Canadian Agency for Drugs and Technologies in Health; 2019\. Accessed November 27, 2022\. http://www.ncbi.nlm.nih.gov/books/NBK546997/ 3. Connolly SM, Baker DR, Coldiron BM, et al. [AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: A report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery](https://pubmed.ncbi.nlm.nih.gov/22959232/?ref=theplasticsfella.com). *J Am Acad Dermatol*. 2012;67(4):531-550\. doi:10.1016/j.jaad.2012.06.009 4. Narayanan K, Hadid OH, Barnes EA. [Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390281/?ref=theplasticsfella.com). *Cochrane Database Syst Rev*. 2014;2014(12):CD007041\. doi:10.1002/14651858.CD007041.pub4 5. Ferry AM, Sarrami SM, Hollier PC, Gerich CF, Thornton JF. [Treatment of Non-melanoma Skin Cancers in the Absence of Mohs Micrographic Surgery](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787325/?ref=theplasticsfella.com). *Plast Reconstr Surg Glob Open*. 2020;8(12):e3300\. doi:10.1097/GOX.0000000000003300 6. [Surgical Management of Melanoma in Situ on Chronically Sun-Damaged Skin](https://journals.sagepub.com/doi/10.1177/107327480801500304?ref=theplasticsfella.com). doi:10.1177/107327480801500304 7. Woodhouse JG, Vidimos AT. Chapter 16 - [Mohs micrographic surgery](https://books.google.lk/books?hl=en&lr=&id=lD9Gig2IKsMC&oi=fnd&pg=PA199&dq=Woodhouse+JG,+Vidimos+AT.+Chapter+16+-+Mohs+micrographic+surgery.+In:+Vidimos+AT,+Ammirati+CT,+Poblete-Lopez+C,+eds.+Dermatologic+Surgery.+The+Requisites+in+Dermatology.+W.B.+Saunders%3B+2009:199-206.+doi:10.1016/B978-0-7020-3049-9.00016-6&ots=fao0L-4CRk&sig=Fs8NqI11c%5FPQD7Fvr6hDQ1aUQcQ&redir%5Fesc=y&ref=theplasticsfella.com#v=onepage&q&f=false). In: Vidimos AT, Ammirati CT, Poblete-Lopez C, eds. *Dermatologic Surgery*. The Requisites in Dermatology. W.B. Saunders; 2009:199-206\. doi:10.1016/B978-0-7020-3049-9.00016-6 8. Benedetto PX, Poblete-Lopez C. [Mohs Micrographic Surgery Technique](https://www.derm.theclinics.com/article/S0733-8635%2811%2900015-5/abstract?ref=theplasticsfella.com). *Dermatol Clin*. 2011;29(2):141-151\. doi:10.1016/j.det.2011.02.002 ### Anatomy of Hard and Soft Palate: Bones, Muscle, Artery, and Nerves URL: https://www.theplasticsfella.com/anatomy-of-hard-and-soft-palate/ Last updated: 2024-04-09T15:11:19.000Z #### Summary Card [****Hard Palate**](https://www.theplasticsfella.com/anatomy-of-hard-and-soft-palate/#hard-palate) Maxilla and palatine bones are covered by 3 mucosal zones with 3 portals (incisive, greater and lesser palatine). [****Soft Palate**](https://www.theplasticsfella.com/anatomy-of-hard-and-soft-palate/#soft-palate) 5 paired muscles are innervated by the pharyngeal plexus and trigeminal nerve. [****Neurovascular Supply**](https://www.theplasticsfella.com/anatomy-of-hard-and-soft-palate/#neurovascular-supply) Primarily by the ****greater palatine artery and nerve**, and the ****lesser palatine artery and nerve.** [****Embryology of the Palate**](https://www.theplasticsfella.com/anatomy-of-hard-and-soft-palate/#embryology) Palate forms during the second month of gestation as the mandible grows, the tongue descends and shelves turn horizontal. [****Cleft Palate Anatomy**](https://www.theplasticsfella.com/anatomy-of-hard-and-soft-palate/#cleft-palate-anatomy) A spectrum of abnormal muscular and bony anatomy relating to the hard and soft palate. --- ## Hard Palate ****Key Point** The hard palate is formed by the maxilla and palatine bones. It is covered by 3 mucosal zones and has 3 portals (incisive, greater and lesser palatine). ### Bones The primary and secondary hard palate is created by 2 bones: **maxilla** and **palatine.** - **Primary palate** is *anterior* to the incisive foramen and is formed by the lip, nostril sill, alveolus, premaxillary portion of the maxilla. - **Secondary palate** is *posterior* to the incisive foramen and is formed by the palatal processes of maxilla (anterior), palatine bone (posterior) and soft palate. These hard palate bones are visualised in the image below. ![Hard Palate Anatomy, surgical procedure](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Bones-of-the-Hard-Palate-1.png) Hard Palate Anatomy 😎 ****Fun Fact:** Cleft lip involves the ****primary** palate, and cleft palate involves the ****secondary** palate. ### Mucosa A mucoperiosteal layer covers the hard palate in 3 zones. 1. **Central Zone**: thin *palatal* mucosa on the horizontal palate that grows the shelves before they rotate horizontally. 2. **Middle Zone:** thick*maxillary* mucosa on the curved aspect of the palate that assists with maxillary growth. 3. **Outer Zone:** *gingival* mucosa adjacent to the teeth. These mucosal zones of the palate are visualised in the image below. ![Hard Palate Mucosa, hard palate anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Mucosa-of-the-Palate.png) Hard Palate Mucosa ### ### Foramina/Canals There are three main portals into the hard palate: 1. **Incisive foramen:** course of the nasopalatine nerve. 2. **Greater palatine foramen:** located medial to 3rd molar tooth, location of greater palatine nerve and vessels. 3. **Lesser palatine foramen:** located in the pyramidal process of the palatine bone and is the course of the lesser palatine nerve. ### --- ## Soft Palate ****Key Point** The soft palate is composed of 5 paired muscles innervated by the pharyngeal plexus and trigeminal nerve. These muscles are involved in the cleft palate. The soft palate is a **muscular** structure that separates the nasopharynx from the oropharynx.There are 5 paired soft palate muscles. They are all innervated by the pharyngeal plexus (IX, X and cranial part of XI), except for tensor veli palitini (trigeminal) and muscular uvulae (lesser palatine nerve). See the below image to get a better idea of the muscles of the soft palate. ![Muscles of Soft Palate, soft palate anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Muscles-of-Soft-Palate-1.png) Muscles of Soft Palate **Tensor Veli Palitini (TVP)** - **Origin**: membranous wall of the Eustachian tube and sphenoid bone. - **Insertion**: posterior hard palate. - **Function**: form palatal aponeurosis, eustachian tube opening. **Levator Veli Palitini** This is the main functional muscle of the soft palate. - **Origin**: temporal bone and eustachian tube. - **Insertion**: posterior palatine aponeurosis. - **Function**: forms muscle sling for posterior elevation of the soft palate, which closes the space between the nasopharynx and oropharynx. **Muscularis uvulae** This muscle may be absent in patients with a submucous cleft. - **Origin + Insertion:** found within the uvulae (tip, it's in the name!) - **Function**: elevates and shorterns the uvulae. **Palatopharyngeus** - **Origin**: posterior pharynx (superior thyroid cartilage, superior pharyngeal constrictor). - **Insertion**: anterior velum (oral side of levator). - **Function**: depresses the soft palate, elevates and constricts the oropharnyx. **Palatoglossus** - **Origin**: tongue (tip, it's in the name!) - **Insertion**: velum (more specifically, the LVP). - **Function**: depresses the soft palate and pulls anteriorly. Other muscles involved in the pharyngeal movement include: - **Superior Pharyngeal Constrictor:** movement of lateral pharyngeal wall. - **Salpingopharyngeus:** does not contribute to velopharyngeal closure. - **Stylopharyngeus**: does not contribute to velopharyngeal closure. 💡 ****Tip:** In cleft palate, the muscles do not form a sling in the midline. The insert abnormally into the posterior edge of the hard palate. --- ## Neurovascular Supply ****Key Point** The palate receives is supplied primarily by the ****greater palatine artery and nerve**, and the ****lesser palatine artery and nerve.** The palate receives arterial supply primarily from the **greater palatine artery** and the **lesser palatine artery** through the greater and lesser palatine foramen. Collateral supply is received from other arteries, as detailed below. Venous drainage is into the **pterygoid venous plexus**. The below image visualizes this. ![Blood and Nerve Supply to the Palate, anatomy of the palate](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Blood-Supply-to-the-Palate.png) Blood and Nerve Supply to the Palate ### Hard Palate **Greater Palatine Nerve and Artery** - **Origin:** Trigeminal nerve & Maxillary Artery (via descending palatine artery). - **Function**: *hard palate* sensation and vascular supply. - **Location**: travels through the greater palatine foramen. 💡 ****Tip:** the Greater Palatine Artery is the main blood supply to the palate. **Nasopalatine Nerve and Artery** - **Origin**: Trigeminal Nerve and Maxillary artery via the sphenopalatine artery. - **Location**: joins greater palatine artery and nerve at the incisive foramen. - **Function**: sensation and vascular supply to the premaxilla. **Anterior and Posterior Superior Alveolar Arteries** - **Origin**: anterior via maxillary and infraorbital, posterior via maxillary artery. - **Function:** Supplies anterior and posterior alveoli. ### Soft Palate **Lesser Palatine** - **Origin:** maxillary artery via desceding palatine artery and trigeminal nerve. - **Function**: soft palate sensation and vascular supply. - **Location**: travel through the lesser palatine formen. Soft palate also receives a major blood supply from the asecending pharygngeal (from external carotid artery) and ascending palatine arteries (from facial artery). --- ## Embryology of the Palate ****Key Point** Palate forms during the second month of gestation as mandible grows, tongue descends and shelves turn horizontal. The palate begins to grow intrauterine at weeks 7-10 of gestation. 1. **Head and mandible** grows. 2. **Tongue** descends downwards. 3. **Palatal shelves** rotate upwards from a vertical to a horizontal position. 4. **Vomer** and **palatal shelves** fuse at incisive foramen via epithelial apoptosis. 5. **Primary** and **secondary** palate fuse proximally and distally away from incisive foramen, respectively. Males and right-sided palatal shelves become horizontal before females and left-sided palate shelves. This can explain the increased incidence of females and left-sided clefts. The below image shows the development of palatal shelves. ![Palatal Shelves: Embryology of the Palate, anatomy of the palate](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Embryology-of-the-Palate.png) Palatal Shelves: Embryology of the Palate 😎 ****Fun Fact:** Failure of tongue descent results in failure of the upward palate rotation. ****This results in a cleft palate**. It is unilateral when the vomer remains attached to one palatal shelf and bilateral when the vomer is not attached to either palatal shelf. --- ## ## Cleft Palate Anatomy ****Key Point** Cleft palate is a spectrum of abnormal muscular and bony anatomy releating to the hard and soft palate. Cleft palate is a spectrum from mild bifid uvula's to bilateral clefts. Generally speaking, there are abnormal insertions of the tensor and levator veli palitini: - **TVP**: inserts into bony margins of the cleft instead of the posterior border of the hard palate. - **LVP**: inserts into TVP aponeurosis. These muscles run parallel to the cleft margin and do not join in the middle to form a sling. As a result, there is dysfunction of the velopharyngeal and eustachian tubes. See the image below for a visualization of the Bifid Uvula. ![Bifid Uvula, anatomy of the palate](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Bifid-uvula.png) Bifid Uvula --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Palate Anatomy:** Gained an understanding of the hard and soft palate anatomy, including the role of the maxilla and palatine bones, the mucosal zones, and the unique muscular structure of the soft palate. ****2\. Neurovascular Supply:** Acquired knowledge on the primary neurovascular supply to the palate, the importance of the greater and lesser palatine arteries, and nerves in the palatal region's function and health. ****3\. Embryological Development:** Learned about the critical stages of palate formation during gestation, the process leading to the horizontal positioning of the palatal shelves, and the significance of these events in normal palate development. ****4\. Cleft Palate:** Explored the spectrum of cleft palate anatomy, understanding how it presents a range of muscular and bony abnormalities that affect both the hard and soft palate, along with the implications for velopharyngeal and eustachian tube function. ****5\. Surgical Implications:** Highlighted the complexity of cleft palate correction, which involves not just the repair of physical abnormalities but also the restoration of functional integrity to the affected regions. ### Maxillary Reconstruction: Anatomy, Classifications, and Algorithms URL: https://www.theplasticsfella.com/maxillary-reconstruction/ Last updated: 2024-04-08T19:16:29.000Z --- #### Summary Card [****Maxilla Reconstruction Anatomy**](https://www.theplasticsfella.com/maxillary-reconstruction/#maxilla-reconstruction-anatomy) The maxilla has 1 body, 4 processes and 6 walls. It provides midfacial skeletal support and function for speech, swallowing and chewing. [****Maxillectomy Indications**](https://www.theplasticsfella.com/maxillary-reconstruction/#maxillectomy-indications) Benign or malignant tumours of the nose & paranasal sinuses. The commonest malignancy is squamous cell carcinoma & benign tumour is inverted papilloma. [****Maxillary Classifications**](https://www.theplasticsfella.com/maxillary-reconstruction/#maxillectomy-classifications) Cordeiro classification describes 4 defects based on the number of walls, palate and orbital resection. It guides reconstruction options. [****Maxillary Reconstruction Principles**](https://www.theplasticsfella.com/maxillary-reconstruction/#maxillary-reconstruction-principles) The aim is to reconstruct the defect's volume, surface and components. Common options include RAFF, free rectus ± bone graft, and obturator insertion. [****Maxillary Flap Reconstruction**](https://www.theplasticsfella.com/maxillary-reconstruction/#maxillary-flap-reconstruction) Regional flaps, soft tissue, osteocutaneous flaps, and obturators, tailored to defect specifics and aimed at balancing aesthetics with function [****Maxilla Reconstruction Algorithm**](https://www.theplasticsfella.com/maxillary-reconstruction/#maxilla-reconstruction-algorithm) Large volume and surface area, consider rectus abdominis Small surface area, consider radial artery forearm free flap Bone defects consider bone grafts or vascularized bone flaps Palate consider skin paddles or obturator. ****Primary Contributor:** Waruguru Wanjau, Plastic Surgery Trainee, South Africa. --- ## Maxilla Reconstruction Anatomy ****Key Point** The maxilla has 1 body, 4 processes and 6 walls. It provides midfacial skeletal support and function for speech, swallowing and chewing. The maxillaconsists of the a pyramidal **body** and its **four processes**: frontal, zygomatic, palatine, and alveolar. It has several articulating surfaces, which include: - **Superiorly:** frontal bone - **Posteriorly:** sphenoid bone, palatine and lacrimal bones and ethmoid bone - **Medially** with the nasal bone, vomer - **Inferior:** nasal concha - **Laterally:** with the zygomatic bone. The maxilla contributes to the anterior margin and floor of the bony orbit, the nasal cavity and the infratemporal fossa. These cavities that need to be kept separate in the reconstruction of the maxilla. ![anatomy of the maxilla, maxillary reconstruction, maxillary processes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Anatomy-of-the-Maxilla-Ma.png) Anatomy of the Maxilla It can be described as a hexahedrium (geometric structure with six walls) that creates a "maxillary antrum" within the central portion of the maxilla1. - **Roof**: supports the ocular globe. - **Medial wall:** a lateral wall of the nasal cavity and part of the lacrimal system - **Floor**: anterior portion of the hard palate and alveolar ridge - **Buttresses:** 2 horizontal and 3 vertical buttresses provide projection & height - **Other walls:** formation of paranasal sinuses The buttresses are key to the integrity of the maxilla and need to be considered during reconstruction of the maxilla. They are vertical and horziontal: - **Vertical:** Nasomaxillary, Zygomatic, Pterygomaxillary - **Horizontal:** Frontal, Orbital, Maxillary, Alveolar The below image helps you better understand the anatomy of a Maxilla. ![Anatomy of the Maxilla, Maxillary Reconstruction, Surgical Processes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Maxilla-Anatomy.png) Anatomy of the Maxilla 💡 ****Tip:** The role of the two maxillae is to provide support to the midfacial skeletal and function for mastication, speech, and swallowing --- ## Maxillectomy Indications ****Key Point** Maxillary resections are usually for benign or malignant tumours of the nose and paranasal sinuses. The commonest malignancy is squamous cell carcinoma and benign tumour is inverted papilloma. Maxilla resections can be indicated in malignant and benign tumours of the: - Nose - Paranasal sinuses of the nasal cavity - Oral cavity tumour extending into the hard palate - Treatment of fulminant invasive fungal sinusitis Nasopharyngeal tumours are often treated with chemoradiotherapy and surgery has a more prominent role in recurrent disease. 😎 ****Fun Fact:** Tumours of the nasopharynx arise from the mucous epithelium and are linked to the Ebstein-Barr Virus. The most common location of a tumour is the maxillary sinus, followed by the nasal cavity. The most common malignancy is squamous cell carcinoma. Other types of tumours include: - **Epithelial**: adenocarcinoma, neuroblastoma, melanoma, adenoid cystic - **Sarcoma**: osteosarcoma, chondrosarcoma. rhabdomyosarcoma - **"Benign"**: inverted papilloma, juvenile angiofibroma, osteoma, encephalocele (soft, blue, compressible neural tube defect). A juvenile angiofibroma typically presents in males during their 2nd decade of life. This locally invasive benign tumour can cause life-threatening epistaxis. Treatment can be ligation or embolisation of the sphenopalatine artery, but not the anterior or posterior ethmoidal arteries (as these supply the retina!). 😎 ****Fun Fact:** Inverted papilloma is the most common sinonasal pathology with a high risk of local invasion and recurrence. It is histologically similar to a well-differentiated [squamous cell carcinoma](https://www.theplasticsfella.com/squamous-cell-carcinoma/). --- ## Maxillectomy Classifications ****Key Point** Cordeiro classification describes 4 defects based on the number of walls, palate and orbital resection. It guides reconstruction options. A range of maxillary defect classification systems has been described, often within a broader category of complex midfacial defects2-4. ### Cordeiro Classification The **Cordeiro classification** describes a systematic approach for the reconstruction of the complex maxillectomy/midfacial defect1. It assesses the surface area to volume requirement, the need for orbital reconstruction and the need for palatal closure. This classifies four types of resection defects: 1. **Type I Limited maxillectomy:** one or two maxillary walls, excluding palate. 2. **Type II Subtotal maxillectomy:** maxillary arch, palate, anterior & lateral walls (lower five walls), with preservation of the orbital floor. 3. **Type III Total maxillectomy:** all six walls of the maxilla with orbital content preservation (IIIa) or exenteration (IIIb) 4. **Type IV Orbitomaxillectomy:** orbital contents, upper five maxillary walls and preservation of the palate. This classification system is used as a communication tool, for research and for guiding maxillary reconstruction algorithms. ### Brown's Classifications Brown et al. 4 published a modified classification system in 2000 to help guide treatment. It describes maxillary defects well both **vertically** and **horizontally.** **Vertical:** 1. **Type I:** maxillectomy not causing oronasal fistula 2. **Type II:** not involving the orbit 3. **Type III:** involving orbital adnexa with orbital retention 4. **Type IV:** with orbital enucleation or exenteration 5. **Type V:** orbitomaxillary defect 6. **Type VI:** nasomaxillary defect **Horizontal classification:** - a—palatal defect only, not involving the dental alveolus - b—less than or equal to 1/2 unilateral - c—less than or equal to 1/2 bilateral or transverse anterior - d—greater than 1/2 maxillectomy 💡 ****Tip:** The loss of the vertical component causes an aesthetic issue, while the horizontal component loss results in functional deficits. --- ## Maxillary Reconstruction Principles ****Key Point** Maxillary reconstruction aims to reconstruct the defect's volume, surface and components. Common options include RAFF, free rectus ± bone graft, and obturator insertion. The goal of maxillary reconstruction is to provide volume, soft tissue cover, support and preserve oral function (speech, swallowing and mastication)7. Reconstruction can be achieved either by using an obturator prosthesis or by surgical reconstruction. The following key reconstructive principles should be adhered to: 1. **Reconstruct** the type of defect (skin, soft tissue, palate, orbital floor, and bony structural deficits) and its volume and surface area. 2. **Obliterate dead space** in the reconstructed maxillary walls with soft tissue (muscle/fat). 3. **Resurface** intraoral cheek, palatal, nasal lining, or external resurfacing with skin paddles. Not all surfaces are necessarily relined. It is key to anatomically partition the oral and nasal environments 4. **Rebuild** required support structures, such as the maxillary arch and orbital floor, with vascularized bone or bone grafts. 5. **Build walls** between to recreate orbital and oropharyngeal cavities and separate the aerodigestive tract from intracranial space 💡 ****Tip:** Vascularised bone grafts are indicated in the maxillary arch if osseointegration is required and to maintain the anterior projection of the midface. --- ## Maxillary Flap Reconstruction ****Key Point** Maxillary reconstruction utilizes regional flaps, soft tissue, osteocutaneous flaps, and obturators, tailored to defect specifics and aimed at balancing aesthetics with function. Generally speaking, surgical reconstructive options described for maxillectomy defects include: 1. Regional soft tissue 2. Free flaps with soft tissue alone 3. Free flaps with bone 4. Combinations of soft tissue flaps and alloplastic implants ### Regional Soft Tissue Flaps For regional maxilla reconstruction, selecting the appropriate flap type is critical based on defect characteristics. - **FAMM Flap:** Ideal for small and relatively lateral defects. - **Buccal Pad of Fat:** Suitable for small and relatively lateral defects. - **Reverse Submental Flap:** Utilized for inferior maxillary defects. - **Temporalis Myofascial Flaps:** Can lead to dehiscence in larger defects and may result in trismus. It can be transposed into the mouth, usually in older patients with contraindications for free flap surgery, not used for palatal reconstruction. It has a short arc of rotation. ### Soft Tissue Free Flaps Soft tissue free flaps are selected for cases where the orbital floor remains intact. In situations requiring additional bony support, augmentation with a free bone graft, titanium mesh or obturator prosthesis is an option. The benefit of free flaps includes - Facilitate primary healing across extensive and intricate maxillofacial defects. - Enhance support for maxillary buttresses and facial contours. - Provide a robust base for subsequent dental implant placement. Several soft tissue free flaps options do exist: - **Radial Forearm Flap:** Features a long pedicle, simplifying vascular anastomosis in the neck area. Large surface area with small to medium volume defects. These can befasciocutaneous or osteocutaneous. - **Rectus Abdominis:** Benefits from large-caliber vessels and a low risk of atherosclerosis. May require flap revision, especially if excessive bulk persists post-radiation. Large volume with medium to large surface-area defects. It can provide skin to reline the maxillary sinus and repair the palatal defect. Risk of flap ptosis into the oral cavity. - **Anterolateral Thigh Flap:** Offers the versatility of creating multiple skin paddles. - **Latissimus Dorsi:** Similar to the Rectus Abdominis, there's a potential for flap ptosis into the oral cavity. ### Osteocutaneous Flaps Bone reconstruction is advisable for medium to large maxillectomy defects with a favorable oncologic outlook, especially when the restoration of oral function, midface aesthetics, and orbital structure are paramount. The integration of bone in maxillary reconstructions aims to: 1. Reestablish the contour of the midface. 2. Offer support to the orbital floor. 3. Substitute the absent alveolar bone. 4. Serve as an anchor for dental implants. Many osteocutaneous flaps have been described: - **Fibula Osteocutaneous Flap:** can be used to close the palatal defect to prevent nasal regurgitation, can also accept osseointegrated implants due to the good quality of bone stock associated with this flap. Adequate bone density for secure dental implant installation and extensive pedicle length. Limted by the fact it s insufficient soft tissue for maxillary cavity filling and inflexible for orbital floor support shaping. - **Coronoid Process of the Mandible (Temporalis Muscle):** Challenges in mobilization. Limited soft tissue coverage. - **Superficial Temporal Artery (STA) and Vein-Based Calvarial Bone Flaps:** Movement difficulties. Inadequate soft tissue coverage. - **Radial Forearm Osteocutaneous Flap:** Extended pedicle. Broad skin paddle suitable for cheek or palatal coverage. Limited and thin bony portion. - **Deep Circumflex Iliac Artery-Based Iliac Crest Flap:** Effective in restoring facial buttresses when placed vertically. Abundant cortical bone and potential muscle tissue. Short pedicle length. High donor site morbidity and excessive bulk. Limited soft-tissue flexibility relative to the bone. - **Scapula Flap:** Capability to harvest multiple independent skin paddles, muscle, and bone from the lateral aspect of the scapula. **Additional Bone Flap Options:** - Rectus abdominis with ribs. - Tensor fasciae latae (TFL) with iliac crest and internal oblique. - Medial femoral condyle flap. These considerations underscore the importance of flap selection tailored to specific reconstruction goals, balancing the need for bone support, soft tissue coverage, and the overall aesthetic and functional restoration of the maxilla 💡 ****Tip:** Orbital floor reconstruction maintains the ocular globe position and can often be with bone grafts (minimal supportive strength is required)6. ### The Role of the Obturator Prostheses can be used for obturation but are preferred for smaller defects. Prosthetic retention can be difficult or impossible in sizable defects, particularly when there are few teeth to stabilize the prosthesis. When considering the use of an obturator for maxilla reconstruction, it is crucial to evaluate both its benefits and limitations: **Advantages**: - Immediate dentition - Able to monitor for recurrences **Disadvantages:** - Inadequate sealing leading to poor oro-nasal separation - Instability of the prosthesis due to the lack of buttressing areas4 - Poor quality of life - Poor quality speech - Difficult to tolerate if radiation is considered5 --- ## Maxilla Reconstruction Algorithm ****Key Point** The Maxilla Reconstruction Algorithm highlights the importance of defect classification in determining tailored reconstructive strategies for maxillectomy defects. Defect classification plays a pivotal role in guiding the selection of reconstructive strategies for maxillectomy, ranging from limited to extensive defects with varying needs for tissue replacement and structural support. ### Cordeiro Classification This table discusses maxillary reconstruction based on Cordeiro classification. ![Maxillary Reconstruction - Cordeiro Classification, Maxillary classifications, anatomy of the maxilla, Surgical processes](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Cordeiro-Classification-Maxilla-Reconstruction.png) Maxillary Reconstruction - Cordeiro Classification **Type I Limited Maxillectomy:** - Small volume, large surface-area defect. - Consider nonvascularized bone grafts, obturation & radial artery forearm flap. **Type II Subtotal Maxillectomy:** - Medium volume, large surface-area defects. - Consider radial artery forearm flap (can reline palatal mucosal surface and nasal floor when folded over). **Type IIIA Total Maxillectomy with Sparing of Orbital Contents:** - Medium-large volume and medium-large surface-area defects. - Require orbital floor reconstruction (bone grafts) and palatal reconstruction (the cutaneous aspect of a flap or obturator). **Type IIIB Total Maxillectomy with Orbital Exenteration:** - Large volume and large surface-area defects. - Requires reconstruction of nasal lining (medial maxilla wall) & external defect with multiple skin islands. - If the external skin is intact, a rectus-free flap with a skin island is used to close the palate, a second skin island to restore the lateral nasal wall, third skin island can be used to provide closure of the external skin deficit if necessary. **Type IV Defects: Orbitomaxillectomy** - Large volume and surface-area defects with an intact palate. - Consider rectus abdominis flap to obliterate dead space and provide external skin resurfacing if needed. 💡 ****Tip:** midface reconstruction is challenged by the long distance from the midface to the neck that needs to be spanned for reliable donor vessels. ### Brown's Classification In the context of maxillectomy defects and their reconstruction, Brown's classification provides a structured approach to match the type of defect with appropriate reconstructive options8: - **Class I: Maxillectomy Not Causing an Oronasal Fistula** - Reconstruction options include Obturation, Regional flaps, and Radial forearm flap. - **Class II: Defects Not Involving the Orbit** - Options for reconstruction are Obturation, Regional flaps, Radial forearm flap, Fibula flap, Deep Circumflex Iliac Artery (DCIA), and Scapula flap. - **Class III: Involving the Orbital Adnexae with Orbital Retention** - Reconstruction can be achieved with the Fibula flap, DCIA, Scapula flap, and Rectus abdominis flap. - **Class IV: With Orbital Enucleation or Exenteration** - Suitable reconstructive options include Rectus abdominis, Latissimus dorsi, DCIA, and Scapula flap. - **Class V: Orbitomaxillary Defect** - Reconstruction methods involve Temporalis flap, Radial forearm flap, Anterolateral Thigh (ALT) flap, Radial osteocutaneous forearm flap, and Thoracodorsal Artery Angular (TDAA) flap with scapula tip. - **Class VI: Nasomaxillary Defect** - The Radial osteocutaneous forearm flap and TDAA flap with scapula tip are recommended for reconstruction. These classifications and corresponding reconstructive options provide a comprehensive guide for surgeons to tailor their approach based on the specific nature and extent of the maxillectomy defect. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Maxilla Anatomy and Importance:** Understood the maxilla's anatomy, including its body, processes, and walls, emphasizing its role in midfacial skeletal support and functions such as speech, swallowing, and chewing. ****2\. Maxillectomy Indications:** Gained knowledge about the reasons for undergoing maxillectomy, focusing on the treatment of benign and malignant tumors of the nose and paranasal sinuses, with specific mention of squamous cell carcinoma and inverted papilloma as the most common types. ****3\. Defect Classification Systems:** Familiarized with the Cordeiro and Brown classifications for maxillary defects, which are essential for guiding the selection of appropriate reconstructive strategies post-maxillectomy. ****4\. Reconstruction Principles and Techniques:** Gained insights into the principles of maxillary reconstruction for restoring the defect's volume, surface, and components. Learned about the use of different flaps and obturators, each with specific defect characteristics for the best aesthetic and functional outcomes. ****5\. Algorithm for Maxilla Reconstruction:** Understood the structured approach of the reconstruction algorithm, helping in the selection of the most suitable reconstructive option based on the type and extent of the defect. --- ## Further Reading 1. Cordeiro PG, Santamaria E. [A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. ](https://pubmed.ncbi.nlm.nih.gov/10845285/?ref=theplasticsfella.com)Plast Reconstr Surg. 2000 Jun;105(7):2331-46; discussion 2347-8\. doi: 10.1097/00006534-200006000-00004\. PMID: 10845285. 2. Spiro, R. H., Strong, E. W., and Shah, J. P. [Maxillectomy and its classification](https://pubmed.ncbi.nlm.nih.gov/9213109/?ref=theplasticsfella.com). *Head Neck* 19: 309, 1997. 3. Wells, M. D., and Luce, E. A. [Reconstruction of midface defects after surgical resection of malignancies](https://pubmed.ncbi.nlm.nih.gov/7743712/?ref=theplasticsfella.com). *Clin. Plast. Surg.* 22: 79, 1995. 4. Brown JS, Rogers SN, McNally DN, Boyle M. [A modified classification for the maxillectomy defect](https://pubmed.ncbi.nlm.nih.gov/10585601/?ref=theplasticsfella.com). Head Neck. 2000 Jan;22(1):17-26\. doi: 10.1002/(sici)1097-0347(200001)22:1<17::aid-hed4>3.0.co;2-2\. PMID: 10585601. 5. Cordeiro, P. G., and Santamaria, E. [Primary reconstruc- tion of complex midfacial defects with combined lip- switch procedures and free flaps](https://pubmed.ncbi.nlm.nih.gov/10359244/?ref=theplasticsfella.com). *Plast. Reconstr. Surg.* 6. Cordeiro, P. G., Santamaria, E., Kraus, D., et al. [Reconstruction of total maxillectomy defects with preservation of the orbital contents](https://pubmed.ncbi.nlm.nih.gov/9810982/?ref=theplasticsfella.com). *Plast. Reconstr. Surg.* 102: 1874, 1998. 7. Lenox ND, Kim DD. [Maxillary reconstruction](https://pubmed.ncbi.nlm.nih.gov/23642669/?ref=theplasticsfella.com). Oral Maxillofac Surg Clin North Am. 2013 May;25(2):215-22\. doi: 10.1016/j.coms.2013.01.004\. PMID: 23642669. 8. Brown, J.S. and Shaw, R.J., 2010\. [Reconstruction of the maxilla and midface: introducing a new classification](https://pubmed.ncbi.nlm.nih.gov/20932492/?ref=theplasticsfella.com). The lancet oncology, 11(10), pp.1001-1008\. ### Special Edition: Meet the new PlasticsFellows, behind the scenes podcast & future plans. URL: https://www.theplasticsfella.com/april-7th/ Last updated: 2024-04-07T13:55:11.000Z --- #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/april-7th/#a-letter-from-pfella) thePlasticsFellows are here - say hi 👋 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/april-7th/#the-sunday-quiz) New Season - $100 for the Winner! 3. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/april-7th/#upcoming-events) 10 events in 2024\. 4. ****🚀** [****New Features**](https://www.theplasticsfella.com/april-7th/#new-features) P'Fella is building "Surgical Techniques" 5. ****🔥** [****3 Interesting Breast Articles**](https://www.theplasticsfella.com/april-7th/#articles-of-the-week) Flaps, Tips & Tricks, Early Discharges. With 1 sentence summaries! ## A Letter from P'Fella Meet your 4 new team members! 👋 ****Hey Friends!** This month, thanks to your unwavering support, ThePlasticsFella is growing. I'm thrilled to introduce our expanded team, who are as passionate and dedicated as ever to uplift our mission together 👇 I’m excited to share a **heartwarming** update that ushers in a new era for ThePlasticsFella. Your steadfast support has propelled us to a remarkable milestone. This month, I've welcomed **three paid educational fellows** and a **paid Editor** into our fold, each bringing their own passion and expertise. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Meet-the-Team-1.png) ### So how is this possible? To have 4 paid employees. **Well, to put it simple. Thanks to you.** This expansion is a direct result of our **community's support.** Every subscription, every piece of feedback has been reinvested into our mission to provide a unique, **independent educational experience**. It's your trust that has allowed us to maintain our autonomy and focus solely on what matters most—enhancing your learning journey. This past year alone, **we've seen our user base grow by >60%**, and our content library has nearly doubled in size. These milestones are a testament to the power of community support, and they motivate us to push the boundaries of what we can offer. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/Zones-of-the-Hand-Journal-Club.png) Over the next nine months, our new team aims to create over **200 pieces** of new educational content, including: - **Main Articles**: Updated with the latest research and surgical advancements. - **Clinical Cases**: Expanded to cover a wider range of real-world scenarios. - **Surgical Techniques**: Enhanced with foundational & innovative procedures. - **Student Version**: tailored database to meet specific needs of students. - **Flashcard Database**: Updated for effective revision and memorization. ## Behind the scenes access If you want to follow this **journey** with the **team**, soon we'll be launching *Behind the 'Fella* \- a new podcast offering a raw, behind-the-scenes look at our educational platform. Dive into how we shape our team, enhance clinical and non-clinical skills, and engage with top experts to deepen our understanding and spark creativity. ❤️ P'Fella 💡 ****tl;dr** ****· Team Expansion**: Welcomed three educational fellows and an Editor/Content Coordinator. ****· Community Driven**: Your support has directly fueled our growth—40% increase in users, doubled content library. ****· New Content**: 200+ new articles, case studies, and more in the pipeline and a behind the scenes podcast. ## The Sunday Quiz New Season, $100 prize for the Winner Welcome to a ****new season** of The Weekly Quiz in thePlasticsPaper! This section has become a fan favorite, and while we've experimented with various formats previously, this season brings an exciting six-week quiz challenge. Each of the next ****six editions** of thePlasticsPaper will feature one quiz question. Stay sharp and participate each week for your chance to win a ****$100 voucher** at the end of the series. Let's kick off Week 1! 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Basal-Thumb-Osteoarthritis-Definition.png) ## Upcoming Events A Curated List of Webinars, Courses & Conferences ### ## New Features Surgical Techniques will be coming soon! Thanks to our new team, new educational tools are going to be added over the next few months! The goal is to curate a unique collection of surgical "recipes." These **step-by-step guides** will simplify complex procedures into manageable, easy-to-follow instructions. I am also reaching out to you, our community, to hear what specific techniques you're eager to learn about. This collaborative approach ensures that our content is directly tailored to your needs and interests. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/04/Finger-Replanta.png) Example of a Surgical Technque Dive in and tell us which surgical techniques you want us to feature. Your input is crucial in shaping a practical, user-friendly resource that empowers you to excel in your practice. ## Articles of the Week 3 Breast Recon Articles! (with 1 sentence summaries) #### 3 Trending Articles 1. ****Tips and Tricks for Breast Recon** ([PRS](https://journals.lww.com/plasreconsurg/fulltext/2024/04000/oncoplastic%5Ftechniques%5Fand%5Ftricks%5Fto%5Fhave%5Fin%5Fyour.5.aspx?ref=theplasticsfella.com), April 2024) A guide to integrating aesthetic techniques with cancer surgery to improve both the oncologic and cosmetic outcomes after partial mastectomies. 2. ****Same day discharge post breast reconstruction** ([PRS](https://journals.lww.com/plasreconsurg/fulltext/2024/04000/same%5Fday%5Fdischarge%5Ffor%5Fimmediate%5Fbreast.6.aspx?ref=theplasticsfella.com), April 2024) Research on 14,387 patients shows that same-day discharge after breast reconstruction with tissue expanders is as safe as next-day discharge, reducing hospital costs and the risk of infection without increasing complications. 3. ****DIEP vs PAP vs LAP** ([PRS](https://journals.lww.com/plasreconsurg/abstract/9900/%5Fdiep%5Fflap%5Fvs%5Fpap%5Fflap%5Fvs%5Flap%5Fflap%5F%5Fa%5Fpropensity.2278.aspx?ref=theplasticsfella.com), March 2024) The study compared DIEP, PAP, and LAP flaps and found no significant difference in patient satisfaction across the three methods, though LAP flaps were rated higher aesthetically in a direct comparison. ## Thanks for reading this... ### I hope you enjoyed it 😄 --- ### Basal Thumb Osteoarthritis: Anatomy, Pathophysiology, Diagnosis, Treatment URL: https://www.theplasticsfella.com/basal-thumb-osteoarthritis/ Last updated: 2024-04-11T18:59:26.000Z #### Summary Card [****Definition of Basal Thumb Osteoarthritis** ](https://www.theplasticsfella.com/basal-thumb-osteoarthritis/#definition-of-basal-thumb-osteoarthritis) The destruction of hyaline articular cartilage. It refers carpometacarpal joint (CMCJ) and STT joint [****Anatomy of the Thumb**](https://www.theplasticsfella.com/basal-thumb-osteoarthritis/#anatomy-of-the-thumb) Thumb base osteoarthritis management hinges on the unique saddle joint's stability, provided by crucial ligaments like the volar beak and posterior oblique, and its articulation with adjacent bones. [****Pathophysiology of Basal Thumb Arthritis** ](https://www.theplasticsfella.com/basal-thumb-osteoarthritis/#pathophysiology-of-basal-thumb-arthritis) Osteoarthritis results in cartilage loss, bone changes, and ligament instability, causing joint narrowing, deformities, and finger nodules. [****Clinical Picture of Basal Thumb Osteoarthriti**](https://www.theplasticsfella.com/basal-thumb-osteoarthritis/#clinical-picture-of-basal-thumb-osteoarthritis)****s** Diagnosis of basal thumb OA involves pinpointing grip pain and differentiating it from other wrist conditions via history and physical exams. [****Classification of Basal Thumb Osteoarthritis** ](https://www.theplasticsfella.com/basal-thumb-osteoarthritis/#xray-classification-of-basal-thumb-osteoarthritis) The Eaton and Glickel classification for thumb osteoarthritis spans from normal to severe, involving the scaphotrapezial joint, but may not correlate with pain or function. [****Management of Basal Thumb Arthritis** ](https://www.theplasticsfella.com/basal-thumb-osteoarthritis/#management-of-basal-thumb-arthritis) Thumb osteoarthritis treatment ranges from pharmacotherapy and splinting to surgical options like trapeziectomy and arthroplasty for pain relief and functional improvement. Author: Dr Suzanne Thompson --- ## Definition of Basal Thumb Osteoarthritis Basal thumb osteoarthritis is the destruction of hyaline articular cartilage. It refers carpometacarpal joint (CMCJ) and STT joint. This includes the scaphoid, 1st metacarpal, trapezium, trapezoid. It can be subclassified into: - **Primary**: ligament laxity and attenuation over time - **Secondary** from previous trauma/injury. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Basal-Thumb-Osteoarthritis-Definition.png) Definition of Basal Thumb Arthritis 😎 ****Fun Fact:** the first CMCJ has 16 ligament attachments. The most important is the dorsoradial and deep anterior oblique ligaments. --- ## Anatomy of the Thumb ****Key Point** The base of the thumb features a unique saddle joint stabilized by key ligaments, notably the volar beak and posterior oblique, with its articulation with surrounding bones crucial for managing osteoarthritis The base of the thumb features a complex anatomical structure crucial for its function and involvement in osteoarthritis (OA) development: - **Joint**: A biconcave trapezeiometacarpal saddle joint, allowing versatile movement. - **Ligament**: Stabilized by over 16 ligaments, with the volar beak ligament and posterior oblique ligaments being paramount in OA progression. - **Articulations**: The trapezium bone connects with the trapezoid and scaphoid bones. 😎 ****Fun Fact:** Arthritic process at the scaphotrapezial joint aids classification and direct management. --- ## Pathophysiology of Basal Thumb Arthritis ****Key Point** Osteoarthritis leads to joint degeneration, characterized by cartilage degradation, bone changes, and ligament instability, which results in reduced joint space, bone deformities, and characteristic finger nodes. Osteoarthritis manifests through a cascade of joint alterations, including matrix breakdown, cartilage wear, and bone changes, leading to distinctive symptoms and structural deformities. The progression entails: - **Initial Changes:** Matrix destruction, cartilage issues (dehydration, erosion), and bony alterations (cysts, osteoporosis, sclerosis). - **TM Joint Impact:** Eburnation in the TM joint prompts ligament instability, notably in the beak ligament, shrinking joint space evident in radiographs. - **Advanced Symptoms:** Progression is marked by bone density shifts, growth of osteophytes, deformities, and specific nodes (Heberden’s and Bouchard's) at finger joints, occasionally with cysts. - **Ligament Effects:** Compromised posterior oblique and volar beak ligaments cause the metacarpal to shift, leading to notable joint deformities such as subluxation. 😎 ****Fun Fact:** Eburnation is the result of bony friction at the site of cartilage erosion and turns the underlying bone into ivory like surface. This wearing away of the surface also causes volar beak ligament instability --- ## Clinical Picture of Basal Thumb Osteoarthritis ****Key Point** Diagnosis of thumb osteoarthritis hinges on identifying grip pain, assessing joint tenderness. It is important to differentiate it from other radial-sided wrist pain aetiology. In evaluating thumb osteoarthritis, it's crucial to discern its typical symptoms, such as pain during grip movements, from those of other hand conditions through careful examination and consideration of the patient's history. ### Symptoms Basal thumb osteoarthritis patients commonly present with the following **symptoms**. - Dull radial-sided wrist/hand pain **exacerbated by prolonged movement** - Temporary morning stiffness - Reduced range of movement Important questions to ask in the history: - Symptoms: where, when and exacerbating factors - Function: impact on ADLs, ROM - Expectations 😎 ****Fun Fact:** Pain in wrist and thumb suggests pantrapezial osteoarthritis. ### Signs On **examination**, key clinical findings include: **Look:** - CMCJ adducted and subluxed to create a "square appearance" (severe cases) - MCPJ Compensatoryhyperextension - IPJs has Heberden's (DIPJ) or Bouchard (PIPJ) nodes. 💡 ****Tip:** Assessment for pain should extend to the scaphoid, trapezoid, and sesamoid areas. **Feel:** - Tenderness at anatomical snuffbox. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Basal-Thumb-Osteoarthritis-Clinical-Features.png) **Move**: - Crepitus and pain on movement of CMCJ - CMCJ subluxation when force applied - Grind test +: pain on axial load and rotation of the thumb metacarpal. - Weak lateral pinch, pincer grip and key pinch. 💡 ****Tip:** The degree of MCPJ instability can have implications for surgical management of CMC joint when trapeziectomy procedures are indicated. The **Kapandji score (**[**1986**](https://pubmed.ncbi.nlm.nih.gov/3963909/?ref=theplasticsfella.com)**)**, a prevalent tool for thumb opposition, offers an alternative to angular measurements. This method uses the hand as its reference, eliminating the need for angle measurements. The scoring system is visualised below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Kapajandi-Score.png) Kapanji Score 😎 ****Fun Fact:** Pure STT OA gives pain on wrist movement only with more proximal tenderness at the anatomical snuffbox --- ## XRay Classification of Basal Thumb Osteoarthritis ****Key Point** The Eaton and Glickel classification of thumb osteoarthritis ranges from normal to advanced scaphotrapezial joint involvement, not always reflecting pain or functional loss. Standard X-Ray views (**AP**, **lateral**, **oblique**) are often sufficient to diagnose and stage the severity of CMCJ osteoarthritis. The classic findings are loss of joint space, sclerosis, osteophytes and cysts. Some of these osteoarthritic findings at the CMCJ/basal thumb are illustrated below: ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/Signs-of-osteoarthritis.png) Signs of Osteoarthritis Basal Thumb The Eaton classification describes the severity of radiological changes in basal thumb arthritis. Eaton and Littler described it in [1987](https://pubmed.ncbi.nlm.nih.gov/3693416/?ref=theplasticsfella.com): - **Stage I:** The joint appears normal, though there may be slight widening due to synovitis. - **Stage II:** Features joint space narrowing with the presence of debris and osteophytes smaller than 2mm. - **Stage III:** Characterized by further joint space narrowing, debris, and larger osteophytes exceeding 2mm. - **Stage IV:** Involves the scaphotrapezial joint, indicating advanced disease. This can be visualised in the image below ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Eaton-Classification-Osteoarthritis.png) Eaton Classification Osteoarthritis Tips to remember this classification include: 1. If the trapezio-metacarpal joint is widened: **stage is ≥1** 2. If the trapezio-metacarpal joint is narrowed: **stage is ≥2** 3. If osteophytes are >2mm: **stage is ≥ 3** 4. If scapho-trapezial joint is narrowed: **stage is ≥ 4** 💡 ****Tip:** Some literature describes "Stage 5" pantrapezial arthritis. MRI or CT are rare neccessary for operative procedures or surgical decision making. Other views quotes in the literature include: - **Gedda**: superior but require accurate positioning of the thumb, - **Roberts**: beam centered on trapezium and metacarpal with thumb flat and hyperpronated. This is considered a true PA view of the joint - **Stress** views demonstrate joint laxity but cannot differentiate between painless constitutional laxity and painful pathologic laxity. 😎 ****Fun Fact:** Patients will often have normal inflammatory blood marks (CRP, ESR) --- ## Management of Basal Thumb Arthritis ****Key Point** Management of thumb osteoarthritis encompasses non-operative strategies, such as pharmacotherapy and splinting, and surgical interventions like trapeziectomy and arthroplasty, aimed at pain relief and functional restoration in affected patients. The management of basal thumb arthritis integrates a spectrum of strategies aimed at alleviating pain and restoring function for those affected. The approaches include non-operative and surgical treatments as discussed below. Treatment includes: - **Lifestyle modifications and education** - **Therapy**: Splinting and exercises, ideally mobilising the IPJ. - **Analgesia**: Topical and oral remedies, with intermittent pain challenges - **Surveillance**: Monitoring hand function - **Injections**: Steroid injections with potential imaging guidance (X-Ray or USS) - **Reassurance**: Surgery is viable even at late disease stages. 😎 ****Fun Fact:** A [****2004 RCT**](https://pubmed.ncbi.nlm.nih.gov/15361383/?ref=theplasticsfella.com)showed no clinical benefit was gained from intra-articular steroid injection to the CMCJ in moderate to severe osteoarthritis compared with placebo (saline) injection. The following video shows a technique for CMCJ steroid injection. CMCJ Steroid Injection In addressing thumb osteoarthritis surgically, the goal is to mitigate pain, restore function, and halt joint deterioration. The choice of technique is pivotal, tailored to the individual's disease stage and overall health profile. ### **Surgical Techniques** ### Surgical management ranges from minimally invasive procedures to more comprehensive reconstructive techniques, each with specific indications and outcomes. Surgical correction of basal thumb arthritis focuses on two anatomical points - bone & soft tissue. This is listed below: - **Bone**: trapeziectomy, arthroplasty, arthrodesis, osteotomy, implant. - **Soft Tissue:** ligament reconstruction, tendon interposition, nerve denervation 😎 ****Fun Fact:** Numerous publications on surgical management are mostly retrospective and single-center. No technique has consistently outperformed others. **Trapeziectomy:** An excisional arthroplasty has often been considered the 'gold standard' for treating basal thumb arthritis. It is the most commonly performed procedure for osteoarthritis in the upper limb. Since Gervis' intital description in 1948, variations have been published. This procedure, pivotal in the surgical treatment of thumb osteoarthritis, involves the removal of the trapezium bone. It can be performed as: - **En bloc:** Removing the trapezium in one piece. - **Piecemal:** Taking out the trapezium in smaller sections. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Trapzeiectomy-for-Basal-Thumb-Osteoarthritis.png) Trapzeiectomy for Basal Thumb Osteoarthritis Following trapeziectomy, suspension techniques are often employed to prevent the thumb metacarpal from shifting. These include a tendon interposition with: - Abductor pollicis longus (APL) - Flexor carpi radialis (FCR) tendon following methodologies by Burton, Pelligrini, or Tomaino. - The palmaris longus tendon, as described by Brunelli and Iwasaki, serves as an alternative for ligament reconstruction. - Optionally reinforced with k-wires. ### Arthrodesis This is a fusion of the CMCJ (the trapeziometacarpal joint) into a functional plane to provide pain relief, stability and length preservation. This can be a potential option: - young manual labourers - secondary osteoarthritis from trauma - patient prefers strength over mobility - isolated TMC OA This should be considered a less suitable option if scaphotrapezial joint involvement as fusion of the CMCJ will increase the force on the scaphoid. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Arthrodesis-for-Basal-Thumb-Osteoarthritis.png) Arthrodesis for Basal Thumb Osteoarthritis **CMCJ Denervation** Joint denervation offers a surgical option to alleviate pain in thumb osteoarthritis, focusing on the carpometacarpal (CMC) joint. While this procedure can significantly reduce pain, it does not prevent the progression of joint deformity. The CMC joint's complex innervation involves several nerves, necessitating a precise approach for effective denervation. Nerve Supply: - **Dorsally:** the posterior interosseous nerve and terminal branches of the superior radial nerve. - **Volarly:** the lateral antebrachial cutaneous nerve and the palmar branch of the median nerve. Surgical Approaches: - A **single incision volar approach**, such as the Wagner incision, is traditionally used but associated with higher re-operation rates due to persistent pain. - Some surgeons opt for a **two-incision approach** to address this issue more comprehensively. 💡 ****Tip:** An anatomical study has pointed out the potential role of the median motor branch (post-innervation to the opponens muscle) contributing to the trapezium. Failure to divide this branch may result in ongoing pain post-denervation. **Osteotomy** An abduction-extension osteotomy can be used to change the pressure angle of the first metacarpal to the palmar surface of the CMCJ. This can be considered in patients with minimal osteoarthritis at the CMCJ but not considered if hypermobility or fixed subluxation of the CMC joint. 💡 ****Tip:** In assessing thumb osteoarthritis (OA), it's essential to recognize that radiographic findings might not always match the patient's pain level and functional limitations, which are critical in deciding on surgical intervention. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Anatomy of the Thumb Base**: Acquired a thorough understanding of the thumb base's anatomical structure, focusing on its unique saddle joint and essential ligaments like the volar beak and posterior oblique. This knowledge is vital for the effective management of osteoarthritis. ****2\. Pathophysiology of Basal Thumb Arthritis**: Enhanced your insight into the degenerative processes leading to basal thumb arthritis, including cartilage wear, bone changes, and the critical role of ligament instability in disease progression. ****3\. Clinical Diagnosis and Differentiation**: Enhanced your ability to diagnose basal thumb osteoarthritis by distinguishing its symptoms from other radial-sided wrist pain causes, utilizing patient history and specific examination techniques. ****4\. Classification and Staging of Thumb OA**: Learned about the Eaton and Glickel classification system for thumb OA, understanding its stages from normal to advanced disease, and recognizing the discrepancy that may occur between radiographic findings and patient-reported symptoms. ****5\. Management Strategies for Basal Thumb Arthritis**: Gained insights into the comprehensive management approaches for thumb OA, from non-operative treatments aimed at pain relief and functional support to various surgical interventions designed to restore function and halt disease progression, including the detailed considerations for selecting appropriate surgical techniques based on individual patient needs. --- ## Further Reading 1. Myohanen M, Waris E, Nordback PH, Mattila S, Aspinen S. [Substantial Increase in the Incidence of Surgery for Osteoarthritis of the Base of the Thumb Between 1997 and 2019 in Finland.](https://pubmed.ncbi.nlm.nih.gov/35241539/?ref=theplasticsfella.com) In Vivo. 2022 Mar-Apr;36(2):833-838\. doi: 10.21873/invivo.12770\. PMID: 35241539; PMCID: PMC8931894. 2. Eaton RG, Glickel SZ. [Trapeziometacarpal osteoarthritis. Staging as a rationale for treatment.](https://pubmed.ncbi.nlm.nih.gov/3693416/?ref=theplasticsfella.com) Hand Clin. 1987 Nov;3(4):455-71\. PMID: 3693416. 3. Tsujii M, Iida R, Oshima Y, Odake K, Satonaka H, Kokubu N, Sudo A. [Arthroscopic ligamentoplasty for osteoarthritis of the thumb carpometacarpal joints: Clinical and radiological outcomes with a minimum 2-year follow-up.](https://pubmed.ncbi.nlm.nih.gov/30962096/?ref=theplasticsfella.com) J Orthop Sci. 2020 Mar;25(2):241-246\. doi: 10.1016/j.jos.2019.03.012\. Epub 2019 Apr 6\. PMID: 30962096. 4. Kawamura D, Funakoshi T, Iwasaki N. [Trapeziectomy with Ligament Reconstruction and Interposition Arthroplasty Using the Palmaris Longus Tendon: An Average 5-Year Follow-up.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6867923/?ref=theplasticsfella.com) Clin Orthop Surg. 2019 Dec;11(4):453-458\. doi: 10.4055/cios.2019.11.4.453\. Epub 2019 Nov 12\. PMID: 31788169; PMCID: PMC6867923. 5. Burton RI, Pellegrini VD Jr. [Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstruction with tendon interposition arthroplasty.](https://pubmed.ncbi.nlm.nih.gov/3711604/?ref=theplasticsfella.com) J Hand Surg Am. 1986 May;11(3):324-32\. doi: 10.1016/s0363-5023(86)80137-x. PMID: 3711604. 6. Tomaino MM, Pellegrini VD Jr, Burton RI. [Arthroplasty of the basal joint of the thumb. Long-term follow-up after ligament reconstruction with tendon interposition.](https://pubmed.ncbi.nlm.nih.gov/7890782/?ref=theplasticsfella.com) J Bone Joint Surg Am. 1995 Mar;77(3):346-55\. doi: 10.2106/00004623-199503000-00003\. PMID: 7890782. 7. van der Meulen C, van de Stadt LA, Claassen A, Kroon FPB, Ritt MJPF, Rosendaal FR, Terpstra SES, Vochteloo AJH, Kloppenburg M. [Surgical denervation as a treatment strategy for pain in hand osteoarthritis: a systematic literature review. ](https://www.oarsijournal.com/article/S1063-4584%2823%2900493-4/fulltext?ref=theplasticsfella.com)RMD Open. 2023 Aug;9(3):e003134\. doi: 10.1136/rmdopen-2023-003134\. PMID: 37532467; PMCID: PMC10401234. 8. Weber AE, Bolia IK, Trasolini NA. [Biological strategies for osteoarthritis: from early diagnosis to treatment. ](https://pubmed.ncbi.nlm.nih.gov/33078204/?ref=theplasticsfella.com)Int Orthop. 2021 Feb;45(2):335-344\. doi: 10.1007/s00264-020-04838-w. Epub 2020 Oct 19\. PMID: 33078204. --- ### Flexor Tendon Injury: Diagnosis, Treatment, and Repair URL: https://www.theplasticsfella.com/flexor-tendon-injury-repair/ Last updated: 2024-03-25T21:55:36.000Z #### Summary Card [****Describing a Flexor Tendon Injury Repair**](https://www.theplasticsfella.com/flexor-tendon-injury-repair/#describing-a-flexor-tendon-injury-repair) Tendon repairs are described by zone of injury, technique, material. [****Zones of Flexor Tendon Repairs**](https://www.theplasticsfella.com/flexor-tendon-injury-repair/#zones-of-flexor-tendon-repairs) Verdan's zones of repairs divide the volar hand into 5 zones. [****Suture Technique for Flexor Tendons**](https://www.theplasticsfella.com/flexor-tendon-injury-repair/#suture-technique-for-flexor-tendons) Core sutures can range from 2-8 strands. This is a surgical decision. [****The "Ideal" Flexor Tendon Repair**](https://www.theplasticsfella.com/flexor-tendon-injury-repair/#ideal-flexor-tendon-repair) Strickland described the ideal repair focusing on core sutures, knot placement & several other factors. [****Tendon Anatomy**](https://www.theplasticsfella.com/flexor-tendon-injury-repair/#tendon-anatomy) Tendon anatomy involves collagen bundles and varied blood supply sources. [****Tendon Healing**](https://www.theplasticsfella.com/flexor-tendon-injury-repair/#tendon-healing) A tendon can heal through an extrinsic or intrinsic pathway through 3 phases: inflammation, proliferation and remodelling. --- ## Describing a Flexor Tendon Injury Repair Flexor tendon injury repairs are intricate procedures critical for restoring hand functionality after injury. There are 3 common ways to describe flexor tendon injury repairs. 1. **Zone of injury:** Zone 1-5 as described by Kleinert1 & Verdan2. 2. **Suture technique:** eponymous name, core strands, configuration. 3. **Suture material:** size, absorbable and non-absorbable. This article will detail these 3 methods. --- ## Zones of Flexor Tendon Repairs ****Key Point** Zones of the Flexor Tendons were initially described by Kleinert and Verdan. There are 5 commonly described volar zones (zones 1-5). [Zones of Flexor Tendon](https://www.theplasticsfella.com/zones-of-the-hand/) injuries were popularised by Kleinert1 & Verdan2. They have an important role in providing: - A universal language for flexor tendon injuries. - Anatomical guide to pertinent structures. - Predicting Rehabilitation Prognosis Below is the visualization of the Flexor/Volar zones of the hand. ![Zones of Flexor Tendon Injuries and Repairs, Flexor Tendon Zones, Zones, Flexor Tendons](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/Image-of-Flexor-Tendon-Injury-Repairs.png) Zones of Flexor Tendon Repairs Check out the table below for the location of the Flexor/Volar zones of the hand and the clinical significance of each of them. ![Flexor/Volar Zones of the Hand, Flexor Tendon Injury Repair, Flexor Tendon Injury, ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/Zones-of-Flexor-Tendon-Injury-Repairs.png) Flexor/Volar Zones of the Hand in Flexor Tendon Injury Repair, Zones of the hand For more insights, check out this article on [Zones of the Hand](https://www.theplasticsfella.com/zones-of-the-hand/). --- ## Suture Technique for Flexor Tendons ****Key Point** A flexor tendon repair can be described by its eponymous name, the number of core strands, configuration, knot location, and epitendinous suture. There are a large number of variables deciding on your suture technique for flexor tendon injury repairs. It is further complicated by eponymous names (which are often incorrectly labeled). ### 2-Strand Tendon Repairs The table below details the different options for 2 strand tendon repairs. These are centered on the Kessler repair and its modifications. ![Flexor Tendon Injury, Flexor Tendon Repair, 2strand, Kessler, Modified Kessler](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/2-Strand-Flexor-Tendon-Injury-Repairs.png) 2-Strand Flexor Tendon Injury Repairs 💡 ****Tip:** Knots are the weakest aspect of tendon repairs. ### 4-Strand Tendon Repair It is generally accepted that 4-strand tendon repairs are the “minimum” number of core strands necessary for early motion exercises4. The table below summarizes the 4-strand tendon repairs. ![Flexor Tendon Injury, Flexor Tendon Repair, 4-Strand, Adelaide Repair, Modified Becker, Indiana Repair](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/03/4-Strand-Flexor-Tendon-Repairs.png) 4-Strand Flexor Tendon Repair As the technology and understanding of flexor tendon biology have increased, so too has the number of core strands. In literature and current clinical practice, 6-strand, and 8-strand flexor tendon repairs are used. These are listed below: **6-Strand** - Tsuge (Tang Modification) - Savage (with Modifications) - Lim-Tsai **8-Strand** - Knotless Barbed Suture - Winters Gelberman 💡 ****Tip:** Epitendinous sutures increases strength, reduce gapping and gliding friction. --- ### The "Ideal" Flexor Tendon Repair Strickland described the ideal repair as having the following characteristics1: 1. Easy suture placement 2. Secured knots 3. Smooth end-to-end tendon apposition 4. Minimal to no gapping at the repair site 5. Avoiding injury to tendon vasculature 6. Having enough strength for early active postoperative motion It is important to understand that there is "no gold standard" optimal repair algorithm. --- ## Tendon Anatomy ****Key Point** Tendons are bundles of collagen wrapped in layers of adventitia with an array of blood supply sources. Tendons are bundles of collagen arranged in a spiral fashion that contains fibroblasts, synovial cells and tenocytes. It can best be remembered by the "rules of 3": 1\. There are 3 **types of collagen**: - Collagen 1 (predominant) - Collagen III - Collagen IV 2\. There are 3 main **layers to the tendon:** - **Endotendon**: wraps the bundles of tendon - **Epitenon**: the outer layer of synovial tendons - **Paratenon**: a vascularised adventitial layer 3\. There are 3 **blood supply** options: - Vincular (not present in extensor tendons) - Musculotendinous junction - Bony insertions --- ## Tendon Healing ****Key Point** A tendon can heal through an extrinsic or intrinsic pathway through 3 phases: inflammation, proliferation and remodelling. ### Intrinsic and Extrinsic Pathways These are two different mechanisms by which a tendon can heal. - **Extrinsic healing** forms fibrous attachment between sheath & tendon that occurs in immobilised tendons - **Intrinsic healing** is based on the early mobilisation of tendon injuries to allow blood flow and diffusion of nutrients from synovial fluid. ### Phases of Wound Healing There are 3 phases to wound healing: inflammation, proliferation and remodelling. There are the key components to each phase. **Inflammation** - Cells enter the wound - Activation of growth factors - Attraction of fibroblasts **Proliferation** - Fibroblasts secrete Type III collagen and GAGs. - Disorganised arrangement of collagen (makes it weak) **Remodelling** - Begins \~3 weeks of injury repair - Replacement of type III collagen with Type I collagen. - Reorganization of collagen into a more organised structure (like [wound healing](https://www.theplasticsfella.com/wound-healing/)) 💡 ****Tip:** Mobilisation of a tendon repair increases its strength and prevents adherence of tendon to sheath --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Fundamentals of Flexor Tendon Repair:** Gained a comprehensive overview of how flexor tendon injuries are repaired, emphasizing the importance of the injury's zone, suture techniques, and materials used. ****2\. Tendon Anatomy and Healing:** Enhanced your understanding of the complex structure of tendons, their healing mechanisms, and the critical phases of tendon repair, from inflammation to remodeling. ****3\. Exploring Surgical Techniques:** Delved into the specifics of various suture techniques, from 2-strand to 8-strand repairs, and the rationale behind choosing each based on the injury's specifics. ****4\. Importance of Epitendinous Repairs:** Learned about the role of epitendinous repairs in improving the strength of the tendon repair and minimizing friction during the healing process. ****5\. Insights into Rehabilitation:** Acquired knowledge on the rehabilitation process following flexor tendon repair, including the significance of early motion exercises and strategies to prevent adhesion formation, ensuring a successful recovery. --- ## References & Contribution **Thank you to** **Amir Mahmoud Mohamed Labib Ghareib for helping create this article as part of the Authorship Program.** 1. Kleinert H, Kutz J, Ashbell T, et al: [Primary repair of lacerated flexor tendons in “no man's land](https://www.sciencedirect.com/science/article/abs/pii/S0039610916423819?ref=theplasticsfella.com). J Bone Joint Surg Am 1967; 49: pp. 577 2. Verdan CE: [Half a century of flexor-tendon surgery: current status and changing philosophies](https://pubmed.ncbi.nlm.nih.gov/4560071/?ref=theplasticsfella.com). J Bone Joint Surg Am 1972; 54: pp. 472-491 3. Strickland JW. [Development of flexor tendon surgery: twenty-five years of progress](https://pubmed.ncbi.nlm.nih.gov/10722813/?ref=theplasticsfella.com). J Hand Surg Am. 2000;25(2):214e235. 4. Chauhan, A., Palmer, B. A., & Merrell, G. A. (2014). [*Flexor Tendon Repairs: Techniques, Eponyms, and Evidence*](https://pubmed.ncbi.nlm.nih.gov/25154573/?ref=theplasticsfella.com)*. The Journal of Hand Surgery, 39(9), 1846–1853.*doi:10.1016/j.jhsa.2014.06.025 5. Pruitt DL, Aoki M, Manske PR. [Effect of suture knot location on tensile strength after flexor tendon repair](https://pubmed.ncbi.nlm.nih.gov/8969417/?ref=theplasticsfella.com). J Hand Surg Am. 1996;21(6):969e973. 6. Labana N, Messer T, Lautenschlager E, Nagda S, Nagle D.[ A biomechanical analysis of the modified Tsuge suture technique for repair of flexor tendon lacerations](https://pubmed.ncbi.nlm.nih.gov/11469829/?ref=theplasticsfella.com). J Hand Surg Br. 2001;26(4): 297e300. 7. Waitayawinyu T, Martineau PA, Luria S, Hanel DP, Trumble TE. [Comparative biomechanic study of flexor tendon repair using FiberWire](https://pubmed.ncbi.nlm.nih.gov/18590853/?ref=theplasticsfella.com). J Hand Surg Am. 2008;33(5):701e708. 8. Barrie KA, Wolfe SW, Shean C, Shenbagamurthi D, Slade JF, Panjabi MM. [A biomechanical comparison of multistrand flexor tendon repairs using an in situ testing model.](https://pubmed.ncbi.nlm.nih.gov/10811755/?ref=theplasticsfella.com) J Hand Surg Am. 2000;25(3):499e506. 9. Joyce CW, Whately KE, Chan JC, Murphy M, O’Brien FJ, Carroll SM. [Flexor tendon repair: a comparative study between a knotless barbed suture repair and a traditional four-strand mono-filament suture repair](https://pubmed.ncbi.nlm.nih.gov/23695149/?ref=theplasticsfella.com). J Hand Surg Eur Vol. 2014;39(1):40e45. 10. Savage, R., & Tang, J. B. (2016). [*History and Nomenclature of Multistrand Repairs in Digital Flexor Tendons*](https://www.sciencedirect.com/science/article/abs/pii/S0363502315014665?ref=theplasticsfella.com)*. The Journal of Hand Surgery, 41(2), 291–293.*doi:10.1016/j.jhsa.2015.11.012 --- ### Posterior Interosseous Nerve Syndrome/Palsy: Aetiology, Diagnosis and Management URL: https://www.theplasticsfella.com/posterior-interosseous-nerve-syndrome/ Last updated: 2024-04-08T11:50:59.000Z #### Summary Card [****Anatomy of Posterior Interosseous Nerve**](https://www.theplasticsfella.com/posterior-interosseous-nerve-syndrome/#anatomy-of-posterior-interosseous-nerve) Motor branch of the radial nerve Origin: the radial tunnel at the Arcade of Froshe Course: between superficial and deep extensors Innervation: All Extensors except brachioradialis, ERCB, ERCL [****Causes of PIN Syndrome**](https://www.theplasticsfella.com/posterior-interosseous-nerve-syndrome/#causes-of-posterior-interosseous-syndrome) Compression or entrapment is the cause of a Posterior Interosseous Nerve palsy. This compression may be due to trauma, inflammation or iatrogenic. [****Clinical Picture of PIN Syndrome**](https://www.theplasticsfella.com/posterior-interosseous-nerve-syndrome/#diagnosis-of-posterior-interosseous-syndrome) Pain and tenderness is less common than in radial tunnel syndrome Loss of finger and thumb extension Wrist extension with radial deviation as ERCL is preserved No sensory disturbance [****Treatment of PIN Syndrome**](https://www.theplasticsfella.com/posterior-interosseous-nerve-syndrome/#treatment-of-posterior-interosseous-syndrome) Non-Surgical: Physiotherapy and Splinting Surgical: Radial Tunnel Decompression +/- removing cause of compression --- ## Anatomy of Posterior Interosseous Nerve ****Key Point** The ****Posterior Interosseous Nerve** is the ****motor** branch of the radial nerve. This nerve originates at the Arcade of Froshe and travels between the superficial and deep extensors. It innervates all the extensor muscles/tendons except for brachioradialis, ERCB, ERCL. ### Origin The **Posterior Interosseous nerve** (C7,8) is the motor branch of the radial nerve, which arises in the radial tunnel. The Radial Tunnel is a 5 cm tunnel from the radiocapitellar joint to the distal edge of the supinator with well-defined anatomical boundaries: - **Lateral**: Brachioradialis, ERCL, ECRB - **Medial**: Biceps tendon, brachial - **Floor**: Capsule of the radiocapitellar joint This anatomical description can be visualised in the image below: ![Radial Tunnel, Anatomy, PIN Nerve, PIN Palsy, PIN Syndrome](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/image.png) Radial Tunnel Anatomy ### Course After the Arcade of Froshe, the posterior interosseous nerve travels in a fascial plane between the superficial and deep extensors. The course of the posterior interosseous nerve is visualised in the image below: ![Anatomy of the Posterior Interosseous Nerve and it's course in the arm in causing Posterior Interosseous Nerve syndrome and palsy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/PIN-Palsy-1.png) Course of the Posterior Interosseous Nerve ### Innervation The **Posterior Interosseous Nerve** innervates all forearm extensors apart from ECRL, ECRB and brachioradialis – these muscles are innervated by the radial nerve above the elbow. This innervation by the Posterior Interosseous nerve is visualise below. ![Muscles Innervated by the Posterior Interosseous Nerve (Palsy, Syndrome)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/PIN-Palsy.png) Muscles Innervated by the Posterior Interosseous Nerve 😎 ****Fun Fact:** The arcade of Frohse was ****named after German anatomist, Fritz Frohse** (1871–1916 --- ## Causes of Posterior Interosseous Syndrome ****Key Point** Posterior Interosseous Nerve syndrome is caused by compression or entrapment. This is commonly due to trauma, inflammation or iatrogenic. ### Common Causes of PIN Syndrome/Palsy The causes of posterior interosseous nerve syndrome/palsy primarily relate to compression. This can be anatomical, pathological or iatrogenic. | Cause | Example | | ------------ | ------------------------------------------------------ | | Trauma | Radial Head fracture or dislocation | | Inflammation | Rheumatoid Synovitis | | Swelling | Ganglion, Lipomas | | Iatrogenic | Injections for tennis elbow, plating a radius fracture | | Anatomical | Common compression site is Arcade of Froshe | ### Radial Tunnel Compression Sites The Posterior Interosseous Nerve is commonly compressed at the Arcade of Froshe. Whilst other compression sites do exist, these occur more proximally and are therefore more relevant to [Radial Tunnel Syndrome](https://www.theplasticsfella.com///////verified/radial-tunnel-syndrome/) The potential compressions are illustrated below: ![Sites of Radial Tunnel Compression and Entrapment in radial tunnel syndrome and Posterior Interosseous nerve palsy/syndrome.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Radial-Tunnel-Syndrome-1.png) Sites of Radial Tunnel Compression --- ## Diagnosis of Posterior Interosseous Syndrome ****Key Point** Posterior Interosseous Syndrome has motor but no sensory issues. Patients with this palsy have loss of finger and thumb extension, radial deviation on wrist extension (ERCL is preserved). Pain and tenderness is less common than in [radial tunnel syndrome](https://www.theplasticsfella.com/radial-tunnel-syndrome/). ### Function Posterior Interosseous Nerve (PIN) Palsy presents a unique set of clinical manifestations primarily affecting the motor function of the forearm and hand, with distinct characteristics as follows: - Difficulty extending the fingers and thumb. - Wrist extension is spared because ECRL has a more proximal innervation from radial nerve proper. - Radial deviation with wrist extension may be noted due to ECRB and ECU weakness. - There is no sensory disturbance - There may be a Tinel’s Positive Sign 😎 ****Fun Fact:** Pain is not a **distinct* feature of posterior interosseous nerve entrapment. Tenderness on the extensor compartment just distal to elbow. ### Investigations ### To diagnose Posterior Interosseous Nerve (PIN) Palsy Syndrome, the following specific investigations are conducted to assess nerve integrity and identify potential contributing factors: **Nerve Conduction Studies** - In contrast to [radial tunnel syndrome](https://www.theplasticsfella.com///////verified/radial-tunnel-syndrome/), nerve conduction studies is useful - Fibrillations and denervation potentials in the extensor musculature, are commonly identified. **Imaging** - A case-by-case basis - Consideration for Ultrasound or MRI if concern for soft tissue mass. ### Differential Diagnosis - [Radial Tunnel Syndrome](https://www.theplasticsfella.com///////verified/radial-tunnel-syndrome/) - Tennis Elbow – Lateral Epicondylitis will have tenderness over lateral epicondyle. - Attritional Rupture – the presence of a normal tenodesis confirms tendon integrity (passive MPJ extension with wrist flexion --- ## Treatment of Posterior Interosseous Syndrome ****Key Point** Posterior Interosseous Syndrome/Palsy can be treated non-surgically (Physiotherapy and Splinting) and surgically (Radial Tunnel Decompression +/- removing cause of compression). ### Non-Surgical - In the absence of a pathological compression, non-operative measures can be considered a period of up to 3 months before denervation and muscle atrophy. - Physiotherapy for strength and modify provocative manoeuvres - Intermittent extension splinting of the MP joints ### Surgical Decompression Generally speaking, surgical decompression is recommended if no recovery after 3 months. A number of different radial tunnel decompression techniques and modifications have been described. The key principles involve: 1. Correct any pathological cause of the palsy 2. Release Medial border of ERCB 3. Release Arcade of Froshe 4. Release Leash of Henry 5. Superficial head of supinator This can be performed through different approaches: 1. Volar approach between brachioradialis and FCR in the antecubital fossa. This allows good access to proximal sites of compression 2. Dorsal approach between ECRL and ECRB or brachioradialis and ECRL. This provides good access to distal sites of compression​8​. 3. Combined approach along the margins of the brachioradialis muscle through a single incision. --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Understanding PIN Syndrome**: Grasping the clinical presentation of PIN Syndrome as a motor deficit without sensory involvement due to nerve compression. 2\. ****Nerve Anatomy**: Becoming familiar with the anatomy and course of the Posterior Interosseous Nerve and its significance in forearm extensor function. 3\. ****Identifying Causes**: Identifying common causes of PIN Syndrome, with an emphasis on compression from various sources. 4\. ****Recognizing Symptoms**: Differentiating the clinical presentation of PIN Syndrome from similar conditions by focusing on unique motor symptoms. 5\. ****Approaching Treatment**: Exploring both non-surgical and surgical treatment options, understanding when each is appropriate based on condition progression. ### RIP original journal submissions, Pie-crusting & Tuberous Breasts. URL: https://www.theplasticsfella.com/march-24th/ Last updated: 2024-03-23T22:26:06.000Z --- #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/march-24th/#a-letter-from-pfella) The end of original journal submissions 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/march-24th/#the-sunday-quiz) How well do you know tuberous breasts? 3. ****🎈** [****Upcoming Events**](https://www.theplasticsfella.com/march-24th/#upcoming-events) 10 events in 2024\. 4. ****🫵** [****Trending this Week**](https://www.theplasticsfella.com/march-24th/#trending-this-week) Pie crusting is making a comeback? 5. ****🚀** [****New Features**](https://www.theplasticsfella.com/march-24th/#new-features) P'Fella is now multi-lingual. 6. ****🔥** [****3 Interesting Hand Articles**](https://www.theplasticsfella.com/march-24th/#articles-of-the-week) Dupuytrens, Trigger Finger, Flaps. With 1 sentence summaries! ## A Letter from P'Fella The end of original scientific publications. 👋 ****Happy Friends!** Just ran into a real head-scratcher that’s rippling through the academic world – a saga where AI is quietly slipping into scientific papers, under everyone's radar. It's a curious mix of innovation and oversight, sparking debates on the very fabric of research integrity. ****👇** **"‘As an AI model, I cannot...’"** – believe it or not, phrases like this are finding their way into scientific papers, completely unnoticed by authors and peer reviewers. It's a startling indication that AI-generated content is sneaking into research, and we're all missing the signs. This whole saga, now known as **#PaperGate**, highlights a complex issue that's got everyone talking. If you're unfamiliar with how chatGPT works. Essentially, a common phrases are "Here is a possible...", "As an AI model, I cannot...", "I don't have access to...". All these phrases are now appearing in published manuscripts. ![Image](https://pbs.twimg.com/media/GIucphRXYAAZBsC?format=jpg&name=900x900) ![Image](https://pbs.twimg.com/media/GInkOEPXsAArIDF?format=jpg&name=medium) Authors & Editors obviously have not proof-read their submissions. **Here's the important bit to understand:** These AI systems digest, analyze, and refine content, blurring the lines of originality in what's supposed to be novel research. The situation gets even trickier when you consider that these AI-enhanced submissions help to further train - these AI models are being refined with potentially unchecked and inaccurate information. This feedback loop poses significant challenges for the integrity of academic publishing. I'm really curious about your take on this. How do we navigate these murky waters, what can we do to ensure the authenticity and reliability of our scientific endeavors? ❤️ P'Fella ## The Sunday Quiz The Tuberous Breast ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/03/Tuberous-Breast-Deformity-CLinical-Features-1.png) #### Summary Card [****Definition**](https://www.theplasticsfella.com/tuberous-breast-deformity/#definition-of-tuberous-breasts) A congenital deformity characterized by constricted, elevated, herniated, and hypoplastic features, while maintaining normal function. [****Clinical Features**](https://www.theplasticsfella.com/tuberous-breast-deformity/#clinical-features-of-tuberous-breasts) Features vary widely, commonly including asymmetry, hypoplasia, constricted base, IMF elevation, herniated nipple, ptosis, and skin envelope insufficiency. [****Classification**](https://www.theplasticsfella.com/tuberous-breast-deformity/#classification-of-tuberous-breasts) Von Heimburg's 1996 system is crucial for assessing the condition, emphasizing the identification of specific affected areas to inform surgical strategies. [****Surgery**](https://www.theplasticsfella.com/tuberous-breast-deformity/#surgery-for-tuberous-breasts) Aims to release constrictions, restore volume, reposition the inframammary fold, and achieve symmetry, involving techniques like periareolar incisions, radial scoring, dual-plane pocket creation, and may require single or two-stage procedures depending on severity. Reveal this week's question In the surgical management of tuberous breast deformity, which of the following statements best describes the rationale behind the use of radial scoring techniques? - To increase the risk of capsular contracture by intentionally creating more fibrous tissue around the implant. - To decrease postoperative breast volume by compressing the breast parenchyma. - To facilitate expansion of the breast's lower pole and improve the contour by releasing constricted fascial bands. - To enhance the projection of the nipple-areola complex (NAC) without affecting the base of the breast. Name: Email: ## Upcoming Events A Curated List of Webinars, Courses & Conferences ## Trending this Week "Pie Crusting" is here (again) 🙄 So there is this surgical technique gaining some traction on Twitter called "Pie Crusting". It seems to be popular with those who arne't trained in soft tissue reconstruction and unfortunately are suffering from a familiarity bias. ****So here's the original post** 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/03/Screenshot-2024-03-23-at-21.08.48.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/03/Screenshot-2024-03-23-at-21.10.10.png) The fundamental purpose is to allow a primary wound closure. ****Yet it also defies the basic principles of wound closure.** Here's why: • ****Tension**: it' still present. Even after pie-crusting, the patients have notable track marks on your patient. Some patients still required staples and heavy sutures. There are also early signs of scar contraction. • ****Blood Supply**: Reduced+++. The common indication for this technique (apparently) is post-fasciotomy. We all know this incision opens up the fascia - so the fascial blood supply is already compromised. This further affects dermal supply. To add to this, it seems to have been published in many journals (not plastic reconstructive journals to the best of my knowledge). As you can see images below from a publication. ![](https://tsaco.bmj.com/content/tsaco/8/1/e001212/F3.large.jpg?width=800&height=600&carousel=1) [Original](https://tsaco.bmj.com/content/8/1/e001212?ref=theplasticsfella.com) [Publication](https://tsaco.bmj.com/content/8/1/e001212?ref=theplasticsfella.com) ****What should you do if you can't fully close a wound?** Every situation is unique, but generally, the best approach is to partially close the wound and apply a thin split-thickness skin graft. After the area has healed and if the patient is not satisfied with the appearance of the graft, there's an option to gradually remove it over time. --- ### ## New Features P'Fella is now Multi-Lingual! Big news from thePlasticsFella - we're all about breaking down barriers and making plastic surgery know-how available for everyone, everywhere. One major hurdle we've tackled? **Language**. With our shiny new AI assistant, **Sidekick**, chatting with thePlasticsFella just got way more inclusive. We're talking loads of languages now supported. **Go ahead, give your preferred language a whirl below!** --- --- Over time, the plan will be to build a team of plastic surgeons to translate this entire platform into several different languages (an idea I got from a twitter DM!). If you're interested, just shoot reply to this newsletter 😄 ## Articles of the Week 3 Interesting Hand Articles! (with 1 sentence summaries) #### 3 Trending Articles 1. ****Risk factors for Dupuytren's?** ([PRS](https://journals.lww.com/plasreconsurg/fulltext/2024/03000/polygenic%5Frisk%5Fassociations%5Fwith%5Fclinical.26.aspx?ref=theplasticsfella.com), March 2024) The genetic risk profile for Dupuytren disease is significantly associated with family history, age at onset, early onset, recurrence, and negatively correlated with BMI. 2. ****Repeat trigger finger injections?** ([J Hand Surg,](https://www.jhandsurg.org/article/S0363-5023%2823%2900648-2/abstract?ref=theplasticsfella.com) 2024) Repeated corticosteroid injections for recurrent trigger finger have diminishing success over 12 months, with high disease grade, BMI ≥ 25 kg/m^2, and a short symptom-free period after prior injection being strong predictors of treatment failure 3. ****Don't forget about the medial arm flap!** [(JPRAS, 2024)](https://pubmed.ncbi.nlm.nih.gov/38518625/?ref=theplasticsfella.com) The medial arm flap (MAF) is a reliable reconstructive option with a low complication rate, primarily used for defects in the head and neck, hand, and elbow, and is notably underutilized despite its benefits, including a well-hidden donor scar. ## Thanks for reading this... ### I hope you enjoyed it 😄 --- ### Fatigue worsens your surgery, "fake" melanoma & ST3 Interview Guide. URL: https://www.theplasticsfella.com/february-18th/ Last updated: 2024-02-18T14:23:41.000Z --- #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/february-18th/#a-letter-from-pfella) Fatigue worsens your surgery. Fact. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-18th/#the-sunday-quiz) Scaphoid & its ligaments 3. ****🫵** [****Picks of the Week** ](https://www.theplasticsfella.com/february-18th/#picks-of-the-week) AI Melanoma (Fake??) & Finger Injury Robots. 4. ****🚀** [****New Features** ](https://www.theplasticsfella.com/february-18th/#new-features) ST3 Interview Guide (updated). 5. ****🔥** [****3 Hot Mico Articles**](https://www.theplasticsfella.com/february-18th/#articles-of-the-week) Kiss Flaps, Lower Limb Recon, Assessment Tools. With 1 sentence summaries! ## A Letter from P'Fella Fatigue worsens your surgery. 👋 ****Happy Sunday!** This week, we're peeling back the surgical drapes to reveal an often-overlooked aspect of our operating theatres: our own energy levels. Yes, I'm talking about fatigue – the silent shadow that trails every dedicated surgeon. ****👇** A groundbreaking systematic review in the *British Journal of Surgery* has cast new light on this familiar foe, analyzing over 1.6 million cases to uncover how fatigue truly affects our work. **The revelation?** Simulated surgeries show performance drops due to fatigue, yet real-life results reveal surgeons' resilience to fatigue. This resilience is commendable, yet it brings forth a crucial consideration. The ability to 'push through' should not obscure the importance of addressing fatigue head-on for the sake of our well-being and our patients'.This discrepancy raises an important dialogue about the nature of our profession and the inherent drive to maintain high standards of care, regardless of the circumstances. This chart shows % of outcome measures negatively affected, positively affected, or unaffected by fatigue per category. Its interesting 👇 ![Percentage of outcome measures negatively affected, positively affected, or unaffected by fatigue per category](https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/bjs/111/1/10.1093_bjs_znad397/1/znad397f2.jpeg?Expires=1711141805&Signature=EnUkNK1ktdNLmp4RS5sF-MAaWXuo1qguJI8BSsw-nN5N9w0eYOv0AwFhTvkOSx1wFowKlCje9JsXlF0hgEbtIgd2bFUzjezzv9Tl~oY~wSCw-aVc0c~aJt~wxdzp3nFf67SQDyR7AOQPrc0kop9YqNgmltYtkLiWPRzSqo4AN9qQ2QT14tnsRNJOojL88QaHi4MxBJUsqKE~jZlfiBS565Tls9Zn22iwlaEwjILLSJ0HQa-dmGLMGt4sirn1MaPPdgu4jABYPIelWosDofSVhT1bBEbnHAgrzbuGq0jMOm9Irez0QIS6WA3e2u0cQh1XZzK4EyYtxTpGhyqFApmHKQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA) [Original Publication](https://academic.oup.com/bjs/article/111/1/znad397/7473433?ref=theplasticsfella.com) This conversation is not about questioning our dedication or ability. It is about recognizing that acknowledging and managing fatigue can enhance our performance, patient outcomes, and personal health. It's about fine-tuning our practice to ensure we are always operating (pun intended) at our best. ❤️ P'Fella. ****tl;dr** \- ****Simulated** surgery studies reveal performance decreases with fatigue. \- ****Real-life** surgical outcomes show surgeons' resilience, maintaining quality care despite fatigue. ## The Sunday Quiz The Scaphoid & its ligaments #### Summary Card [****Bone Anatomy**](https://www.theplasticsfella.com/scaphoid-anatomy/#scaphoid-bone-anatomy) The scaphoid has three regions: proximal pole, waist (corresponding to the anatomical snuffbox), and distal pole. [****Ligament Anatomy** ](https://www.theplasticsfella.com/scaphoid-anatomy/#scaphoid-ligament-anatomy)Key ligaments include Scapholunate Interosseous and Radioscaphocapitate, with volar ligaments being stronger. [****Vascular Anatomy**](https://www.theplasticsfella.com/scaphoid-anatomy/#blood-supply-to-the-scaphoid) Radial artery provides 70-80% of blood supply. Dorsal blood enters via dorsal ridge foraminae; volar supply is 20-30% of internal vascularity, mainly in the distal pole. [****Imaging**](https://www.theplasticsfella.com/scaphoid-anatomy/#imaging-the-scaphoid-anatomy) Multiple angles needed, including PA view in ulnar deviation, 60° pronation, and 60° supination. Lateral view detects DISI or VISI deformities 0:00 /0:00 1× ⚒️ The Sunday Quiz is under construction (updating Leaderboard). Check back next week for the new version 😄 ## Picks of the Week Weekly highlights from the plastic surgery community. Every Sunday, thePlasticsFella will curate all the highlights in the world of plastic surgery. If you have a highlight, just reply to this email! ## [Tweet](https://twitter.com/PlasticsFella?ref=theplasticsfella.com) of the Week Robotics for Hand Injuries > Engineer Ian Davis designed his own Bionic hand, after his insurance company wouldn't pay for one after his accident, stating that 'fingers are not medically necessary'[pic.twitter.com/TsSU8FrhLa](https://t.co/TsSU8FrhLa?ref=theplasticsfella.com) > > — ȡ (@cattychinss) [February 13, 2024](https://twitter.com/cattychinss/status/1757463605966987558?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Image of the Week AI-Generated Melanoma ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/Melanoma-neck.png) The quality is 🔥 (more coming to [Clinical Cases](https://www.theplasticsfella.com/tag/clinical-cases/) soon) ## Question of the Week Generated by the [AI Search Tool](https://www.theplasticsfella.com/#chatbotContainer) currently in beta-testing for thePlasticsPro's. ❔ ****"Why does claw hand occur in cubital tunnel syndrome?"** Claw hand deformity in Cubital Tunnel Syndrome occurs due to the compression of the ulnar nerve at the elbow level. The ulnar nerve provides motor innervation to the majority of the intrinsic muscles of the hand, including the hypothenar muscles, the medial two lumbricals, all interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. When the ulnar nerve is compressed, these muscles can become weak or paralyzed, leading to the characteristic claw hand deformity. Specifically, the loss of function of the lumbricals and interossei results in hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints, creating the appearance of a claw. In addition, the ulnar nerve innervates the skin of the medial one and a half fingers and the associated palm area, so sensory deficits can also be present in these areas. ## Event of the Week P'Fella showcases one upcoming event you might like ![The Aesthetic Meeting 2024](https://meetings.theaestheticsociety.org/the-aesthetic-meeting/images/Banner2024.png) More Info [Here](https://meetings.theaestheticsociety.org/the-aesthetic-meeting/index.php?ref=theplasticsfella.com) ## New Features Updated Guide for ST3 Interviews (UK) Heard your feedback loud and clear: **"Make finding stuff easier!"** Challenge accepted. First fix? Dropdown menus! Small change, big impact. More improvements on the way. Stay tuned. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/Screenshot-2024-02-18-at-12.15.22.png) #### [Read the Guide](https://www.theplasticsfella.com/st3-plastic-surgery-interview/) ## Articles of the Week 3 Trending Microsurgery Articles! (with 1 sentence summaries) #### 3 Trending Articles 1. ****Kiss Flaps for the Hand (**[****PRS, Feb '24**](https://journals.lww.com/plasreconsurg/abstract/2024/02000/mini%5Fshaped%5Fkiss%5Fflap%5Fdesign%5Ffor%5Fpalmar%5Fand.28.aspx?context=featuredarticles&collectionid=2&ref=theplasticsfella.com)****)** The "mini-shaped kiss flap" technique, developed for palmar and digital soft-tissue resurfacing, successfully reconstructs with minimal donor-site morbidity, using flaps based on common palmar digital arteries for excellent aesthetic and functional outcomes 2. ****Microsurgery Assessment Tool (**[****JPRAS, Oct' 21**](https://www.jprasurg.com/article/S1748-6815%2821%2900449-6/abstract?ref=theplasticsfella.com)****)** The study introduced a novel benchmarking tool in a 5-day simulated microsurgery course with 118 participants, revealing that as trainees performed more micro-anastomoses, their Global Rating Scale scores significantly increased from a range of 45.5-62 to 89.5-93, indicating a direct correlation between practice and skill improvement in microsurgery. 3. ****Best Lower Limb Free Flaps (**[****Micro**](https://onlinelibrary.wiley.com/doi/full/10.1002/micr.30020?ref=theplasticsfella.com)****, Jan' 16)** A meta-analysis of 30 studies involving 1,397 free flaps for lower extremity soft tissue reconstruction reported a 6% total flap loss rate, indicating that microsurgical reconstruction in this area is both safe and reliable, although standardization in reporting perioperative parameters and outcomes is needed ## Thanks for reading this... ### I hope you enjoyed it 😄 --- ### The 'perfect' male bum, UMSLE cheats & 4 Flashcard Principles. URL: https://www.theplasticsfella.com/february-11th/ Last updated: 2024-02-11T15:01:07.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/february-11th/#a-letter-from-pfella) 4 Principles to the perfect flashcard. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/february-11th/#the-sunday-quiz) VRAM Flap - is it versatile? 3. ****🫵** [****Picks of the Week** ](https://www.theplasticsfella.com/february-11th/#picks-of-the-week) USMLE Cheats, Incisions & AI Interview Prep. 4. ****🚀** [****New Features** ](https://www.theplasticsfella.com/february-11th/#new-features) Dropdown menus! Simple, but good. 5. ****🔥** [****3 Hot Cosmetic Articles**](https://www.theplasticsfella.com/february-11th/#articles-of-the-week) The Perfect Male Bum, Botox, Ozempic. Now with 1 sentence summaries! (****NEW**) ****PS -** Articles on thePlasticsFella.com have been read +****1,000,000** times since April 2021\. Huge thanks for your support! ❤️ ## A Letter from P'Fella Designing the perfect flashcard. 👋 ****Hey team!** Imagine trying to distill the essence of a complex surgical technique or a nuanced anatomical concept into a flashcard. **The goal?** **To make it whisper the concept into your ear as though it's the simplest truth you've always known.* ****👇** After piecing together almost [11,000 flashcards](https://www.theplasticsfella.com/untitled-5/) over a 3 year period, I took a step back and really thought about what makes a flashcard not just good, but awesome. That thinking time led me to **four principles**: 1. **Single Purpose**: identify the core concept or the 'big idea' of what needs to be communicated. Trim the fat. "What is the one thing a learner must understand from this flashcard?". Not every detail needs a flashcard. Get picky. 2. **Layered Learning**: complex ideas are broken down into a series of simpler, interconnected flashcards. Each card addresses a foundational element that builds towards understanding the more complex whole. 3. **One idea, one flashcard:** Keep it simple. It's tempting to cram as much information as possible onto a single card, but true effectiveness comes from focusing on a single question followed by one clear answer. 4. **Word Precision:** obsessed with word choice. Every term, every phrase is weighed for clarity and immediacy. The right word can turn a lightbulb on; the wrong one can muddy the waters. Check out these **4 principles** in action with the Thumb Reconstruction flashcards. The original card might've made you juggle two concepts at once — that's a no-go now. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/thePlasticsPaper.png) This methodology might mean a greater number of flashcards, but the trade-off is a deeper, more genuine understanding and retention of knowledge. This all came about because of amazing feedback from [one of the community](https://www.instagram.com/dr%5Fstephen%5Fwilson/?ref=theplasticsfella.com). 😎 ****Fun Fact:** Over next few months, the entire [flashcard](https://www.theplasticsfella.com/untitled-5/) and [Anki](https://www.theplasticsfella.com/anki-builder/) database will receive a makeover with these principles: Lots of love, P'Fella ❤️ ****tl;dr** The 4 Principles to a 'perfect' flashcard: ****1\. Single Purpose**: Distill each concept to its essence. ****2\. Layered Learning**: Build progressively with each card. ****3\. One idea, one card**: One concept per card for optimal retention. ****4\. Precision**: Select words for clarity and immediate comprehension. ## The Sunday Quiz The VRAM Flap The VRAM flap is a composite myocutaneous flap consisting of three layers: skin, subcutaneous fat, and muscle. Its versatility allows it to be dissected and raised as the following: - **Muscle**\-only - **Segmen­tal muscle** flap with preservation of part of the muscle - **Myocutaneous** flap with a transverse, oblique, or vertical skin island flap - **Osseomyocutaneous** (when including inferior ribs - not common) The most commonly used myocutaneous composition consists of skin, anterior rectus sheath, rectus muscle, and the perforating vessels which connect them. ![VRAM Flap, VRAM anatomy, RAM Flap, vertical rectus abdominis muscle flap, rectus abdominis muscle, anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/VRAM-Flap-Blood-Supply.png) Reveal this week's question What are the primary advantages of using a VRAM flap in reconstructive surgery? - It requires changing the patient's position during surgery. - It exclusively improves the cosmetic appearance without addressing functional needs. - It offers reliability, versatility, and can improve both cosmesis and functional deficits. - It increases the risk of hernia without providing significant cosmetic or functional benefits. Name: Email: ## Picks of the Week A weekly round up of some highlights in the plastic surgery community. Every Sunday, thePlasticsFella will curate all the highlights in the world of plastic surgery. If you have a highlight, just reply to this email! ## [Tweet](https://twitter.com/PlasticsFella?ref=theplasticsfella.com) of the Week A Deep-Dive on USMLE Cheating > I’ve gotten DMs asking “How could the USMLE prove they cheated? High scores alone don’t prove that!” > > \-and- > > “How do I know my high score won’t be flagged as evidence of cheating just because of where I took the test?” > > Lemme explain how I think these cheaters were caught. > > (🧵) [https://t.co/W1iGCzF1bY](https://t.co/W1iGCzF1bY?ref=theplasticsfella.com) > > — Bryan Carmody (@jbcarmody) [February 1, 2024](https://twitter.com/jbcarmody/status/1752891543143215298?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Image of the Week The Evolution of Carpal Tunnel Releases. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/GFpvdcwWYAAZHaa.jpeg) [Original Post](https://twitter.com/HatanMortada?ref=theplasticsfella.com) by Hatan Mortada ## Question of the Week Generated by the [AI Answer Composer](https://www.theplasticsfella.com/ai-interview-composer/) for Interview Prep. ❔ ****Whats the best way to answer this question:** ****"How do you define an audit?"** An audit, in the context of clinical practice, is a systematic review and evaluation of current practice against defined, evidence-based standards. It's a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. It involves a cycle where practice is examined, compared to a standard, changes are implemented if necessary, and then re-audited to ensure improvement. The stages of an audit cycle include selecting a topic, setting standards, collecting data, comparing results with standards, implementing changes and then re-auditing. It's a crucial part of maintaining high standards in healthcare and driving continuous improvement. ## Event of the Week P'Fella showcases one upcoming event you might like ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/02/Screenshot-2024-02-10-at-18.47.39.png) [More Event Info](https://www.instagram.com/p/C3Az0z2NynI/?utm%5Fsource=ig%5Fweb%5Fcopy%5Flink) ## New Features Dropdown menus in the navigation bar! Heard your feedback loud and clear: **"Make finding stuff easier!"** Challenge accepted. First fix? Dropdown menus! Small change, big impact. More improvements on the way. Stay tuned. 0:00 /0:16 1× ## Articles of the Week 3 Trending Cosmetic Articles! (with the new 1 sentence summary!) #### 3 Trending Articles 1. [****Ozempic is trending up 📈**](https://academic.oup.com/asj/article/44/1/60/7218900?searchresult=1&ref=theplasticsfella.com) **(ASJ, July '23)** The study reveals a substantial increase in Google search interest for Ozempic for cosmetic weight loss, with a relative search volume (RSV) growth rate of 0.957 over five years, highlighting the need for plastic surgeons to stay informed as public demand escalates. 2. [****Botox for the Forehead (PRS, Feb '24)**](https://journals.lww.com/plasreconsurg/abstract/2024/02000/anatomical%5Fproposal%5Ffor%5Fbotulinum%5Fneurotoxin.17.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com) By examining the frontalis muscle's characteristics, the research suggests new injection sites to mitigate common issues like ptosis and 'samurai eyebrows,' aiming for optimal results with minimal BoNT usage. 3. [****The Best Male Bum (PRS, Feb '24)**](https://journals.lww.com/plasreconsurg/fulltext/2023/12000/defining%5Fthe%5Fideal%5Fmale%5Fbuttocks.17.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com) The study identified the ideal male buttocks as having a lateral thigh-to-buttock ratio of 1.18, an oblique projection angle of 60 degrees, and a posterior waist-to-hips ratio of 0.66, based on over 2,000 survey responses ## Thanks for reading this... ### I hope you enjoyed it 😄 --- ### ST3 Plastic Surgery Interview: Structure, Guides & Tools. URL: https://www.theplasticsfella.com/st3-plastic-surgery-interview/ Last updated: 2024-07-25T20:33:39.000Z #### Summary Card [****Tools for ST3 Interview**](https://www.theplasticsfella.com/st3-plastic-surgery-interview/#tools-for-st3-interview) Enhance clinical knowledge, craft compelling answers, and build confidence for the ST3 Plastic Surgery Interview with specific tools and practice strategies. [****Interview Structure**](https://www.theplasticsfella.com/st3-plastic-surgery-interview/#interview-structure) The ST3 Plastic Surgery Interview assesses clinical acumen, communication proficiency, and broader professional competencies through a structured process tailored for UK candidates. [****Section 1: OSCE and Communications**](https://www.theplasticsfella.com/st3-plastic-surgery-interview/#section-1) Evaluate informed consent and communication skills under pressure through role-play and scenario-based exercises. [****Section 2: Clinical Scenario**](https://www.theplasticsfella.com/st3-plastic-surgery-interview/#section-2) Test clinical reasoning, diagnostics, and management planning in plastic surgery with emphasis on evidence-based decision-making and patient safety. [****Section 3: Structured Interview**](https://www.theplasticsfella.com/st3-plastic-surgery-interview/#section-3) Assess achievements, experiences, and skills beyond clinical practice, focusing on research, teaching, and leadership through reflection and structured responses. ## Tools for ST3 Interview To achieve success in the ST3 Plastic Surgery Interview, focus on enhancing clinical knowledge, crafting compelling answers, and building confidence. Here's a concise overview of essential tools to aid your preparation: ### Crafting Impactful Answers - [**Answer Templates:**](https://www.theplasticsfella.com/interviews/#answer-template)Utilize SCALPEL!, IDEA!, SCARRED!, and ACED! templates for structured responses. Practice across a range of questions to adapt these frameworks to your style. - [**AI Interview Composer:** ](https://www.theplasticsfella.com/ai-interview-composer/)Refine and expand your answers with AI-generated content and feedback. Engage with AI to create and practice answering custom questions. 💡 ****Tip:** Regularly engage with each tool, setting aside specific times for practice and review. ### Building Confidence - [**Mock Interviews:**](https://www.theplasticsfella.com/live-mock-interview/)Mimic the interview environment to improve performance under pressure. Review and adjust based on personal feedback from these sessions. - [**Interview Practice:** ](https://www.theplasticsfella.com/interview-tools/)Develop real-time answering skills and adapt based on personal reflection. Approach each session with the seriousness of an actual interview. 💡 ****Tip:** After mock interviews and live practices, take time to review, reflect and focus on areas for improvement. ### Clinical Knowledge - [**thePlasticsLibrary:**](https://www.theplasticsfella.com/library/) Access a wide range of resources for comprehensive topic coverage.Regularly explore content to stay abreast of surgical standards and innovations - [**Evidence-Based Flashcards:**](https://www.theplasticsfella.com/untitled-5/)Strengthen recall of key concepts through regular review. Vocalize answers to enhance active learning. These tools, when used effectively, will ensure a holistic approach to your interview preparation, blending content mastery with the ability to present confidently and persuasively. ## Interview Structure The ST3 Plastic Surgery Interview is meticulously designed to evaluate candidates across three key dimensions: their **clinical acumen**, **communication proficiency**, and **broader professional competencies**. Designed for UK candidates, this guide simplifies the interview process, meeting the expectations of medical councils and training bodies. It offers objectives, expectations, and preparation tips to enhance your performance, ensuring you're well-prepared for the interview's demands. ## Section 1: ### OSCE and Communications ****Objective**: To evaluate your ability to obtain informed consent and communicate effectively in challenging scenarios, reflecting real-life clinical situations. ****Time:** 10 minutes The OSCE and Communications section is divided into two distinct parts, each lasting 5 minutes. - **Part 1 Informed Consent:** Demonstrate your ability to explain surgical procedures, including the benefits, risks, and aftercare, in a clear and patient-centered manner. - **Part 2 Communication Skills** in high-pressure situations, such as discussing emergency or critical patient management scenarios with senior colleagues. **What to Expect:** - **Level of Difficulty:** Moderate to high, depending on your familiarity with the procedures and ability to communicate under pressure. - **Types of Questions:** Consent-related questions will involve explaining surgical procedures, risks, and postoperative care. Communication tasks will simulate emergency or critical patient management discussions with seniors. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/For-Interviews-7.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/For-Interviews-2.png) Examples of [Clinical Cases](https://www.theplasticsfella.com/interviews/#clinical-scenario) **Preparation Tips:** - Review the core procedures in plastic surgery, focusing on the rationale, potential complications, and aftercare. - Engage in [role-play exercises](https://www.theplasticsfella.com/interview-tools/) for consent, focusing on clarity, empathy, and comprehensiveness. - Practice [communication scenarios](https://www.theplasticsfella.com/interviews/#clinical-scenario) with peers, focusing on clear, structured, and decisive dialogue. 🚨 ****Common Pitfalls:** ****Overlooking Patient Concerns:** Failing to adequately address patient anxieties or questions about procedures. ****Lack of Clarity:** Providing explanations that are either too technical for the patient to understand or too vague to be meaningful. ****Poor Time Management:** Spending too much time on one aspect of the consent or communication process and not covering all necessary points. --- ## Section 2: ### Clinical Scenario ****Objective**: To assess clinical reasoning, diagnostic capability, and management planning in the context of plastic surgery. ****Time:** 10 minutes The Clinical Scenario station, a critical part of the ST3 Plastic Surgery Interview, evaluates candidates' clinical reasoning, diagnostics, and management planning in plastic surgery over 10 minutes. This section tests the application of medical knowledge to practical scenarios, highlighting the importance of evidence-based decision-making and patient safety in the surgical field. **What to Expect:** - **Level of Difficulty:** High, as it tests the ability to synthesize information, make judgments, and propose management plans. - **Types of Questions:** Expect to discuss diagnosis and management of common plastic surgery conditions, with emphasis on surgical decision-making and patient safety. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/12/Finger-Replant--Interview--3.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/For-Interviews-9.png) **Preparation Tips:** - Deep dive into the most [frequent and critical conditions](https://www.theplasticsfella.com/free-flap-monitoring/) in plastic surgery, studying current guidelines and treatment pathways. - [Practice](https://www.theplasticsfella.com/interview-tools/) articulating your thought process from presentation through to management plan, emphasizing evidence-based choices. - Utilize [clinical case](https://www.theplasticsfella.com/interviews/) studies to familiarize yourself with a variety of scenarios, refining your ability to quickly identify key issues and propose solutions. 🚨 ****Common Pitfalls:** ****Insufficient Detail:** Not providing enough detail when describing the diagnosis process, management plan, or rationale behind decisions. ****Ignoring Patient Safety:** Failing to highlight considerations of patient safety and risk management in the proposed treatment plan. ****Inflexibility in Thinking:** Sticking rigidly to one diagnosis or treatment plan without considering alternatives. --- ## Section 3: #### Structured Interview ****Objective**: To explore your achievements, experiences, and skills in areas beyond clinical practice, such as research, teaching, and leadership. ****Time:** 10 minutes The Structured Interview segment of the ST3 Plastic Surgery Interview, lasting 10 minutes, is designed to assess candidates' professional development beyond clinical work. This includes achievements in research, teaching, leadership, and ethical decision-making. It's an opportunity to showcase how your unique experiences and skills make you a well-rounded candidate for the specialty. **What to Expect:** - **Level of Difficulty:** Varies, largely dependent on your experiences and how well you can articulate and reflect on them. - **Types of Questions:** Questions will probe into your past experiences with audits, research projects, teaching roles, leadership positions, and ethical dilemmas. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/-ACED--Must-have-Answer-Template---Structure-2.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Your-Thoughts--IDEA-Answer-Structure-for-Facts---Opinons.png) [Answer Templates](https://www.theplasticsfella.com/interviews/#answer-template) for Structured Interview **Preparation Tips:** - Reflect deeply on your CV, identifying experiences that highlight your strengths in the areas to be discussed. Use the [free answer templates](https://www.theplasticsfella.com/interviews/#answer-template) provided by the [interview coach](https://www.theplasticsfella.com/interviews/). These serve as structured guides to formulating responses that are coherent, comprehensive, and directly aligned with what interview panels are looking for. These templates can be particularly beneficial in structuring answers for the Structured Interview section, where candidates discuss their achievements, experiences, and skills. - Practice in a [live mock interview](https://www.theplasticsfella.com/live-mock-interview/), ensuring you can convey their significance and relevance to the panel within a tight timeframe. - Utilise the [AI answer composer ](https://www.theplasticsfella.com/ai-interview-composer/)to optimise your interview answers. 🚨 ****Common Pitfalls:** ****Being Too General:** Providing responses that are vague or overly broad, without giving specific examples. ****Not Reflecting on Experience:** Missing the opportunity to demonstrate what you've learned from your experiences and how they've prepared you for a career in plastic surgery. ****Underestimating Soft Skills:** Overlooking the importance of showcasing communication, teamwork, and leadership skills. --- ## Key Take-away points The ST3 Plastic Surgery Interview is a comprehensive assessment designed to gauge your readiness for advanced training in plastic surgery. By understanding the objectives of each section and preparing methodically, you can navigate the interview with confidence. Remember, success in this interview hinges not just on your clinical knowledge but also on your ability to communicate effectively, demonstrate professional competencies, and reflect on your experiences with insight. 💡 Remember, preparing for the ST3 Plastic Surgery Interview is a marathon, not a sprint. Taking care of your mental and physical health is essential for reaching the finish line in your best condition. By adopting a holistic approach to your preparation, you not only enhance your chances of success but also set the foundation for a healthy, balanced lifestyle that will serve you well throughout your career in plastic surgery. Your well-being is the bedrock upon which your professional achievements are built, so give it the attention it deserves. ****Preparation, self-awareness, and the ability to articulate your experiences and knowledge clearly are key to success in the ST3 Plastic Surgery Interview.** ### Introducing: $10,000 Educational Fellowship Program (& more...) URL: https://www.theplasticsfella.com/january-28th/ Last updated: 2024-01-27T20:50:15.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/january-28th/#a-letter-from-pfella) Get Paid: Your Plastic Surgery Work Matters 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-28th/#the-sunday-quiz) Tissue Expansion - the finer details 3. 🔦 [****Spotlight**](https://www.theplasticsfella.com/january-28th/#spotlight) Sidekick AI is now trained on GPT4\. It can also improve your interview answers. 4. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/january-28th/#tweets-of-the-week) What was hot on Twitter this week. 5. 🤔 [****Ask Sidekick**](https://www.theplasticsfella.com/january-28th//#ask-sidekick) The best question asked by you. 6. ****📝** [****3 Trending Hand Articles**](https://www.theplasticsfella.com/january-28th/#articles-of-the-week) Pain relief, Intramedullary + WALANT in 2024 7. ****📢** [****Special Announcement** ](https://www.theplasticsfella.com/january-28th/#special-announcement) Work with P'Fella, earn $10,000 & more. 8. 💕 [****What do you want to read?**](https://www.theplasticsfella.com/january-28th/#feedback) Suggest ideas & give feedback! ****PS -** so far, 80+ applicants for the [International Educational Fellow ](https://www.theplasticsfella.com/january-28th/#special-announcement)position. ## A Letter from P'Fella Get Paid: Your Plastic Surgery Work Matters 👋 ****Hey team!** This week we're going to start ****flipping the script**. In a world where your expertise in plastic surgery often earns applause, its time for a reality check and also a paycheck. ****👇** It’s time for some hard truths about the value of your work in the world of plastic surgery and academia. The status quo? **It’s a narrative that profits off your brilliance and dedication without offering a dime in return.** I've seen too many passionate professionals pour their hearts and souls into fellowships or editorial gigs that offer immense value but overlook one crucial detail – **the pay-check.** **Here’s what's currently expected of you:** - Work for free because it'll boost your career, they say. But at what cost? - Invest your expertise in reviewing articles without any compensation. It's for the 'greater good,' but whose good, really? - Present your research globally. But remember, every ticket, every stay – it’s on you, while your hard work adds zeros to their profits. ![Scale of Scholarly Publishing – Library 101 Toolkit](https://sites.duke.edu/library101_instructors/files/2018/08/profit-table-with-revenues.jpg) Elsevier Profit Compared to Amazon **Here's what P'Fella has in mind:** Your work, your time, your ideas – they’re invaluable, and it’s high time they were treated as such. Your skills, your time, your innovation – they’re worth more than just a pat on the back. **They deserve a spot on your bank statement.** Let's flip the script with the [International Educational Fellowship](https://create.theplasticsfella.com/?ref=theplasticsfella.com) at thePlasticsFella. This gig is about putting respect – and real dollars – behind your hard work. ****tl;dr** • Academia and plastic surgery typically reward prestige over pay. • Expect unpaid work, article reviews, and self-funded research. • [P'Fella's fellowship](https://create.theplasticsfella.com/?ref=theplasticsfella.com) offers financial compensation for your efforts. • Time to move from unpaid labor to deserved earnings. ## The Sunday Quiz What changes during tissue expansion? Tissue expansion increases soft tissue availability by optimising the skin's viscoelastic properties. Architectural and histological changes occur to the [skin](https://www.theplasticsfella.com/anatomy-of-the-skin/), subcutaneous tissue & blood supply through **mechanical creep**, **biological creep** and **stress relaxation**. Neuman first described it in 1957. ![Tissue expansion results in physical and cellular changes to soft tissue structures.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Changes-Tissue-Expansion.png) Reveal this week's question What is the primary mechanism by which mechanical creep contributes to the effectiveness of tissue expanders in plastic surgery? - Promoting rapid cell death and replacement in the expanded tissue. - Causing an immediate and permanent increase in skin elasticity. - Inducing alignment of collagen fibers parallel to the vector force and disrupting elastic fibers. - Increasing the rate of infection in the expanded tissue to stimulate healing. Name: Email: ## Spotlight SideKick AI is now trained on GPT-4 Sidekick AI on thePlasticsFella just leveled up with GPT-4, making it smarter and more intuitive for your needs. **What's the benefit of this update?** The shift to GPT-4 is a big deal; it means sharper insights and a richer understanding in areas. Check it out below 👇 Your browser does not support iframes The model has been retrained on all thePlasticsFella content and also developed for [**interview prep**](https://www.theplasticsfella.com/theplasticsinterviews/)! Soon I'll be enhancing your learning experience even further with new features for clinical cases, flashcard curation, and quizzes. Sidekick is not just evolving; it's revolutionizing the way you learn and practice ## Tweets of the Week Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > I know we're not in the business of treating x-rays but, what would you be thinking of offering this 39-year-old? No previous imaging. No history of trauma. [pic.twitter.com/sMXlOZxLYd](https://t.co/sMXlOZxLYd?ref=theplasticsfella.com) > > — RJ (@northwoods1980) [January 19, 2024](https://twitter.com/northwoods1980/status/1748416122171363606?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > How your Zoom background affects judgements of trust and competence — wish I had this analysis 2 years ago[https://t.co/co8VCd1wcQ](https://t.co/co8VCd1wcQ?ref=theplasticsfella.com) [@PaddyRoss1](https://twitter.com/PaddyRoss1?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/HXCLyu7Za8](https://t.co/HXCLyu7Za8?ref=theplasticsfella.com) > > — Alvin (@alvie\_barr) [January 25, 2024](https://twitter.com/alvie%5Fbarr/status/1750550756564836789?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > When I was a trainee in the 90s, the way to safely get rid of an underperforming surgeon was by blocking their academic promotion. Today, the safest way is to promote them to full professor and sell them as chief to a large tertiary center affiliated with an academic institution. > > — George Tolis (@georgetolisjr) [January 25, 2024](https://twitter.com/georgetolisjr/status/1750334263994536011?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask SideKick The best question from [Sidekick](https://www.theplasticsfella.com/sidekick/) this week. Every Sunday, [Sidekick AI ](https://www.theplasticsfella.com/sidekick/)answers a top anonymous question, no personal details stored. Just ask, learn, and enjoy - ****totally private**! ❔ What are the variations in raising the lat dorsi flap? There are several variations in raising the latissimus dorsi flap, and the choice of technique depends on the patient's habitus and the preferences of both the patient and surgeon. Here are some of the variations: ****1\. Extended Latissimus Dorsi Flap:** This involves detaching a large ellipse of skin from its surrounding skin on the back but leaving it attached to the underlying fat and muscle. The remaining skin is elevated just deep to the superficial fascial system (Scarpa’s fascia), leaving a layer of fat over the whole latissimus dorsi muscle ****2\. Augmented Musculocutaneous Latissimus Dorsi Flap:** This variation involves the use of an implant to augment the volume of the flap. ****3\. Muscle-Only Flap:** This technique involves using only the latissimus dorsi muscle for coverage, typically of the lower pole of an implant. ****4\. Thoracodorsal Artery Perforator Flap**: In this technique, the muscle is left in situ, and only the skin and fat are mobilized based on the thoracodorsal artery perforator. Remember, the choice of technique should be individualized to each patient, taking into account factors such as the patient's body habitus, the desired aesthetic outcome, and the patient's overall health status ❤️ Sidekick ## Articles of the Week 3 Trending Hand Articles! #### 3 Trending Hand Articles 1. [****Best post-op pain relief in hand surgery** ](https://www.jhsgo.org/article/S2589-5141%2823%2900134-2/fulltext?ref=theplasticsfella.com) Multimodal Pain Management After Outpatient Orthopedic Hand Surgery: A Prospective Randomized Trial, Asif M. Ilyas et al. J hand Surg, Oct 2023\. 2. [****WALANT Updates in 2024** ](https://journals.lww.com/prsgo/fulltext/2024/01000/wide%5Fawake%5Flocal%5Fanesthetic%5Fno%5Ftourniquet%5Fin%5Fhand.30.aspx?ref=theplasticsfella.com) Wide Awake Local Anesthetic No Tourniquet in Hand and Wrist Surgery: Current Concepts, Indications, and Considerations. Sawhney et al. PRS Go, Jan 2024\. 3. [****Intramedullary Fixation in Hand Fractures** ](https://www.jhandsurg.org/article/S0363-5023%2823%2900473-2/fulltext?ref=theplasticsfella.com) Intramedullary Fixation of Hand Fractures and Arthrodeses. Hassan K et al. J Hand Surg Am. 2024 Jan; ## Special Announcement P'Fella is looking for someone to join me! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/01/Untitled--400-x-250-px-.png) #### Deadline is in 7 days! ****International Educational Fellow - Now Open!** I'm on the lookout for someone passionate about plastic surgery education to join me. ****It's important to be paid for your work**, and now the thePlasticsFella can finally do that. The Educational Fellow will create engaging content, develop their own skills/knowledge and network. ****100% remote**, ****flexibility to work around your schedule**. This isn't your typical clinical job – it's a unique chance to experience something new and different in plastic surgery. [Read about the $10,000 Salary](https://create.theplasticsfella.com/?ref=theplasticsfella.com) ## Feedback ### ****What do you want in your newsletter?** Any suggestions, ideas and even negative feedback is appreciated! --- ### Interview Prep with AI, Research Rats & Anki updates. URL: https://www.theplasticsfella.com/january-21st/ Last updated: 2024-11-19T14:10:25.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/january-21st/#a-letter-from-pfella) Your "Fluff" Research is **eroding** your Clinical Skills. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/january-21st/#the-sunday-quiz) Gorlin's syndrome - a common exam question 3. 🔦 [****Spotlight**](https://www.theplasticsfella.com/january-21st/#spotlight) Plastic Surgery Interview Prep in 2024 now with ****AI**. Limited to 30 participants. 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/january-21st#image-of-the-week) AI-generated vascular tumour. 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/january-21st/#tweets-of-the-week) What was hot on Twitter this week. 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/january-21st//#ask-pfella) How to apply for plastics. 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/january-21st/#articles-of-the-week) Dupuytren's, Carpal Tunnel and Fatigue 8. 💕 [****Feedback**](https://www.theplasticsfella.com/january-21st/#feedback) Suggest ideas & give feedback! ****PS -** the Anki Deck Builder is improved - less buggy now! ## A Letter from P'Fella "Fluff" Research ****Erodes** Clinical Skills. 👋 ****Hey team!** What's up? I've got something on my mind that's been gnawing at me lately. Noticed how it seems like everyone's racing to rack up research papers? It's like there's this obsession with publishing, and I can't help but feel we're missing the big picture here.. ****👇** **Every hour lost to mediocre research is an hour not spent in the trenches, learning from real patient interactions or sharpening our clinical expertise.** Ever noticed how **CVs are now jam-packed** with publications and presentations? Yeah, it's like ever since test scores and grades took a backseat, there’s this mad rush to fill up pages with research stuff. But are we actually learning and improving, or just trying to look good on paper? ❗ ****Red Flag:** 54.3 abstracts, presentations, and publications needed to "Match Plastic Surgery" in America. That's a big number. Check it out below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/01/match-publciatn.png) **"Fluff Research"** Here's what's up: a lot of what's passing as research these days is just fluff. It's the kind that boosts CVs more than it boosts our knowledge or makes a real impact. And don't get me started on those 'Open Publications' - feels like they're just cashing in, not really pushing science forward. But let's be real, we can spot fluff a mile away, and it's usually the research rats churning it out. ❗ ****Red Flag:** And then there's the social media show-off game. Have you seen folks boasting about how many papers they've published It's like a competition to see who looks the smartest, not who actually is. **So, what should we do?** Here's what I think: Research shouldn't be a mandatory tick-box, especially in competitive specialties. It's leading to a focus on quantity over quality. We’re talking about skilled clinicians feeling pressured into research they’re not passionate about. We need to recalibrate. Solid, meaningful research should complement, not compromise, our clinical expertise. Because what’s the point of being a doctor if our practical skills aren’t up to par? Don't get me wrong, I'm all for top-notch research - the stuff that genuinely enlightens us. **Can’t wait to hear your thoughts on this. Just reply to this email!** P'Fella ❤️ ****tl;dr** · Obsession with publishing overshadows core surgical skills. · 54 abstracts, presentations, publications "needed" to "Match" · 'Fluff research' is about CV padding than real science. · Social media publication counts now a bragging contest. · Research should complement clinical skills, not be mandatory for all. ## The Sunday Quiz Steps to a Finger Replant Gorlin syndrome (Basal Cell Naevus Syndrome) is an autosomal dominant condition associated with PTCH gene mutations on chromosome 9\. It can also be a sporadic mutation in \~50% of patients. Features of this systemic condition include: - **Skin**: Multiple early BCCs (before the age of 20) - **Limbs**: Palmar and planter pitting - **Brain**: Falx cerebri calcification, low IQ, blind, paediatric medulloblastoma - **Craniofacial**: odontogenic keratocysts, supraorbital ridging, [hypertelorism](https://www.theplasticsfella.com/hypertelorism/). - **Torso**: bifid ribs, ovarian fibromas, hypogonadism ![Finger Replant](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/01/Gorlin-Syndrome--2-.png) Reveal this week's question Which of the following statements is true regarding the management of Basal Cell Carcinoma (BCC)? - Mohs micrographic surgery is recommended for all types of BCC regardless of risk profile. - Topical therapy with imiquimod is not an approved treatment modality for superficial BCC. - Radiotherapy is primarily recommended for patients with Gorlin Syndrome presenting with BCC. - Cryosurgery is an effective treatment for selected low-risk, well-defined BCCs. Name: Email: ## Spotlight thePlasticsInterview - Limited Spots in 2024 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/01/thePlasticsInterview-3.png) #### thePlasticsInterview (now with AI) A specialized platform for comprehensive plastic surgery interview preparation. It focuses on essential areas like interview skills, academic knowledge, and clinical expertise, offering AI-enhanced personalization and expert resources to foster genuine professional growth in the field. ****What to expect?** - 📄 ****Answer Templates:** structured responses specific to Plastics - 📚 ****Academic Skills:** Enhance your knowledge in key areas of Audit, Research, Evidence-based Practice, Clinical Risk Management, and Teaching. - ****🧑‍🏫 Probity/Professionalism:** Focus on Governance, Ethics, Open Disclosure. - ****🧑‍🏫 Commitment:** Specialized content on suitability for surgery, personal development, and training insights. - ✋ ****Clinical Knowledge:** Tackle 20 scenarios in plastic surgery emergencies and clinical cases. - 🧑 ****Personal Skills:** Build confidence in presenting personal strengths and weaknesses, coping under pressure, and problem-solving. - 🧠 ****AI Personalisation:** Use AI to refine your answers, with a model trained on GPT-4. - ****⚽ Live Mock Practice:** Practice with past interview questions using a webcam. Record and improve your technique. [thePlasticsInterview 2024](https://www.theplasticsfella.com/theplasticsinterviews/) ****Limited Enrollment Notice:** thePlasticsInterview maintains a ****strict limit of** ****30 participants per year**. This selective approach guarantees a personalised and authentic interview preparation experience. Our goal is to ensure that your answers remain unique and tailored, reflecting your individual strengths and characteristics. ## ## Image of the Week AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Infantile-Haemangioma-Clinical-Scenario-1.png) ****This AI-generated image has been created for the clinical case scenario on** [****paediatric vascular tumours**](https://www.theplasticsfella.com/vascular-tumour-clinical-case/)****.** ## Tweets of the Week Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Attendings keyboard looking like this [pic.twitter.com/WSQbkJ0NeV](https://t.co/WSQbkJ0NeV?ref=theplasticsfella.com) > > — Gerardo Calderon (@GCalderonMD) [January 19, 2024](https://twitter.com/GCalderonMD/status/1748468728503701834?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > FDA just cleared the first AI device detecting all major skin cancer by DermoSensor. > > Its pivotal trial showed sensitivity of 96% and a 97% chance of accurately identifying a skin lesion as benign. > > Notably, the approval process began back in 2016\. [pic.twitter.com/DgzaURlchD](https://t.co/DgzaURlchD?ref=theplasticsfella.com) > > — Mindaugas Galvosas, MD (@MGalvosas) [January 18, 2024](https://twitter.com/MGalvosas/status/1747971248947068932?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Old habits die hard..even when we have the evidence . Take the surgical management of the Axilla as an example . [https://t.co/qephD9BWDx](https://t.co/qephD9BWDx?ref=theplasticsfella.com) > > — Rick Linforth (@RICKLIN4TH) [January 16, 2024](https://twitter.com/RICKLIN4TH/status/1747178030781378945?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella You ask, P'Fella answers. Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. ❓ ****Mary's Question** Any advice for 3rd year medical students who want to apply to plastics with average clerkship scores and a few publications to their name? How can we make it work? Thanks! Gotcha, here's a friendly and straightforward take: 1. **Good Research Matters**: Focus on a few meaningful projects you're actually into. 2. **Impress in Rotations**: Use your clinical time to show your skills and dedication. 3. **Network Smartly**: Chat with folks in plastics, get insights and make connections. [Have you seen this?](https://community.theplasticsfella.com/?ref=theplasticsfella.com) 4. **Personalize Your Application**: Your personal statement and recommendations should reflect who you are and your passion for plastics. 5. **Be Real in Interviews**: Just be yourself and share your genuine interest in the field. 6. **Have a Backup Plan**: Consider other options or a research year if needed. 7. **Look After Yourself**: Stay balanced and avoid burnout. Hope this helps! Keep your spirits up, and good luck! P'Fella --- Ask P'Fella Now 11 questions submitted in the last 30 days... ## Articles of the Week 3 must-read articles! #### 3 Must-reads 1. [****Amyloid in Carpal Tunnel Syndrome?**](https://journals.sagepub.com/doi/10.1177/17531934231218997?ref=theplasticsfella.com) Brunet J et al. Prevalence of transthyretin amyloidosis in patients undergoing carpal tunnel surgery: a prospective cohort study and risk factor analysis. J Hand Surg Eur Vol. 2023 Dec. 2. [****Send Dupuytren's to the lab?**](https://pubmed.ncbi.nlm.nih.gov/35933252/?ref=theplasticsfella.com) Liu D et al. Utility of Routine Pathologic Examination for Fasciectomy for Dupuytren Contracture. J Hand Surg Am. 2023 Dec;48(12):1273.e1-1273.e5\. 3. [****Don't operate when tired!**](https://pubmed.ncbi.nlm.nih.gov/38097353/?ref=theplasticsfella.com#:~:text=Results%3A%20From%20the%207251%20studies,using%20direct%20measures%20of%20fatigue.) Reijmerink IM et al. Impact of fatigue in surgeons on performance and patient outcome: systematic review. Br J Surg. 2024 Jan ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### P'Fella is looking for an educational fellow! Ready to dive into the world of plastic surgery education? P'Fella is looking for a sharp, eager Educational Fellow to join the team. ****What You'll Do:** - Collaborate with P'Fella - Read articles and create insightful journal club analyses. - Keep your finger on the pulse of the latest in plastic surgery. - Enjoy a role that ****pays** you to explore your passion! 📍 Flexible Location 💼 Part-Time 💸 Competitive Salary 🗂️ Full accreditation for your CV. [Email support@theplasticsfella.com](https://plasticsfella-4.ghost.io/?ref=theplasticsfella.com) ## Feedback ### Any suggestions, ideas and even negative feedback is appreciated! ### SCALPEL! Answer Template URL: https://www.theplasticsfella.com/scalpel/ Last updated: 2024-06-27T20:23:42.000Z ****SCALPEL Mnemonic** 1\. ****S**tructure: Signpost and list. 2\. ****C**oncise answers: Never too long. 3\. ****A**nswer directly: Don't be vague. 4\. ****L**anguage: Power words, active verbs. 5\. ****P**atient-centred: Most important people! 6\. ****E**xamples: Support your statements. 7\. ****L**ook forward! Never reflect on bad answers. --- ## Structure ****Key Point** Effectively structuring your answers is crucial. Here, we focus on using signposting and listing to provide clear and memorable responses. There is a large amount of evidence suggesting humans (in non-stressful environments) can only remember 3-4 points. One can only assume that this number is reduced in the stressful environment of the interview. **Signposts and lists** are an easy way for **you** to remember your answers, and more importantly for the **interviewer** to follow your answer. - **Good Candidate**: "To address this question, I will first discuss A, then B." - **Poor Candiate**: "I will talk about several things related to this question." This approach clearly outlines the structure of the response, making it easier for the interviewer to follow and understand the candidate's thought process. It shows organizational skills and the ability to communicate effectively. 🔗 Check out this ****signposted** response on "[Benefts of an Audit](https://www.theplasticsfella.com/audit/)" Many candidates can signpost, but here are some of the techniques P'Fella recommends. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/SCAPLEL--Signposting-Examples.png) These are recommended by ThePlasticsFella because they **aren't** the mundane "first, secondly, finally" interlinking words, and also they aren't too "essay-like". It's important to be **fluent and conversational** using your own, every day, vocabulary. --- # Concise Answers ****Key Point** Conciseness is key. Avoid monologues that can lead to interviewer disengagement. The number one symptom in an interview is **boredom**. This is usually down to long monotonous answers, which even the most astute interviewer will find it difficult to concentrate and listen to. **Example**: - **Good Candidate**: "I manage clinical risks by adhering to protocols, continuous learning, and teamwork." - **Poor Candidate**: "In my practice, I always follow the established protocols diligently, ensure that I am up to date with the latest developments in plastic surgery, and collaborate effectively with colleagues..." 🔗 Quickly idenfity the ****purpose** of this question when concisely "[Discussing your Strengths](https://www.theplasticsfella.com/strength/)" This concise answer directly addresses the topic, demonstrating the candidate's ability to communicate key information efficiently. It reflects clarity of thought and respect for the interviewer's time P'Fella has a rule of thumb: **you should not be able to hear your own vice for 90 seconds straight**(even that length is a pretty long time!). Let's use this TEDTalk for an example. Whilst it is a great presentation, **ThePlasticsFella** challenges you to watch 90 seconds of the video without your mind wandering. That exercise *should* get the point across - nobody wants to hear your voice for too long!! Keep that in mind during your interview preparation. 💡 ****Tip:** Conciseness can demonstrate a candidate’s ability to prioritize and synthesize information --- ## Answer Directly ****Key Point** Focus on answering what is asked. Avoid veering off-topic or giving generic responses. Your course has been developed with several priorities - the ability to **answer directly** is one of them. - **Good Candidate**: "I enhance patient safety by enforcing strict sterilization protocols, evidenced by a 30% reduction in post-operative complications in my department." - **Poor Candidate**: "Patient safety is vital. I like reading medical history and organized team activities during my internship, which indirectly contributes to safety." This response is focused and relevant, directly linking personal actions to measurable outcomes. It shows the interviewer that the candidate is result-oriented and can apply their skills effectively. 🔗 See how P'Fella directly answers this question on "[Open Disclosure](https://www.theplasticsfella.com/open-disclosure/)" It's essential you listen to the question and you answer the question. This might seem pretty simple advice, but under the pressure of an interview, nothing is simple. Let's use this as an example below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/SCALPEL---Direct-Answer-Example.png) It's quite clear the Plastic Surgery interviewee did not under the purpose of the question. The question is about **you**, not anybody else. **Failure to critically interpret the premise of the question results in failure to answer the question directly.** --- ## Language ****Key Point** Your choice of words can significantly impact your message. Use strong, active verbs to convey a sense of action and commitment. Mastering the use of power words and active verbs can dramatically elevate the impact of your responses, showcasing your actions and achievements with clarity and dynamism. - **Good Candidate**: "I optimized patient recovery protocols by implementing an advanced monitoring system, which revitalized our post-surgical care and reduced recovery times by 20%." - **Poor Candidate**: "We made some changes to how we take care of patients after surgery, which helped them get better a bit faster." The good example effectively uses power words like "optimized" and active verbs like "implementing" and "revitalized" to convey a strong, action-oriented approach. In contrast, the poor example lacks impact and specificity, failing to demonstrate the same level of initiative and effectiveness 🔗 This is a really importnat skill when discussed your [personal development](https://www.theplasticsfella.com/personal-development-and-achievements/) and career Throughout the Plastic Surgery interviews, there are some of P'Fella's favorite phrases which contain "power words and active verbs". ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/SCALPEL---Power-Words--Active-Verbs-2.png) Don't remember these power words and phrases now. You can always come back to this lesson. And, you'll be picking up some more vocabulary on your journey. 💡 ****Tip:** Powerful language can demonstrate confidence and leadership qualities --- # Patient First ****Key Point** Always position the patient's needs and safety at the forefront of your answers. This is a simple lesson to learn - put patients first! There are only a handful of important people in your interview. This is explained in the infographic below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/SCALPEL---PATIENTS-FIRST.png) This companion will teach you when to prioritize the important people in your answer. Clue - it's always the patient! - **Good Candidate**: "In a recent reconstructive surgery, I prioritized the patient's concerns about post-surgical scarring. By choosing a less invasive technique, we not only addressed the functional aspect but also significantly reduced the emotional impact, leading to higher patient satisfaction and a quicker recovery." - **Bad Candidatev**: "In my surgeries, I focus on getting the procedure done efficiently. While patient concerns are considered, the primary goal is to complete the surgery successfully This answer illustrates a compassionate approach, showing that the candidate values patient concerns and well-being. It demonstrates the ability to make patient-centered decisions, a crucial skill in plastic surgery. 🔗 Check out this answer on [patient advocacy](https://www.theplasticsfella.com/professionalism/) in professionalism. By prioritizing patient needs and safety in your answers, you illustrate your commitment to holistic care, which is a key differentiator in a competitive field like plastic surgery. Remember, successful surgeons are those who blend technical skill with patient-centered care, and conveying this balance in your interviews can significantly elevate your candidacy. --- # Examples ****Key Point** Focus on how to effectively align your real-world experiences with the question asked. From an interviewer's perspective, it's easy to distinguish a "good" from an "amazing" Plastic Surgery interview candidate by their uses of **real-world examples** and **quality evidence**. A candidate must support their subjective and objective statements through their CV, their surgical logbook, and evidence-based knowledge, where applicable. **You must qualify what you quantify, otherwise what you say will just disqualify.** Here is an example below. Two candidates, with two different approaches. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/SCALPEL---EVIDENCE.png) It's pretty clear that differences in the two candidates. Surprisingly, most candidates don't follow the lead of candidate 1\. It's either because they have not prepared well or because they have crumbled under the pressure of an interview. 📖 ***Storytime** **In a notable case, a plastic surgeon encountered a young patient requiring facial reconstruction. The patient, an aspiring artist, was particularly concerned about maintaining facial expressions, vital for their art.* **Acknowledging these concerns, the surgeon adapted the usual procedure, choosing a technique that better preserved the patient's facial muscles. This approach required more precision and care but was crucial for the patient's quality of life.* **The results were impressive. Not only was the reconstruction successful, but the patient retained complete expressiveness, enabling them to continue their artistic pursuits without any hindrance.* **This story highlights the impact of a patient-first approach in plastic surgery, where understanding and prioritizing individual patient needs can lead to significantly better outcomes and satisfaction.* 💡 ****Tip: S**pecific examples can illustrate a candidate’s hands-on experience and problem-solving skills could be helpful --- # Look Forward! ****Key Point** Develop techniques to stay composed and focused, even after challenging questions. In the traditional interview setting, it was relatively "easy" to forget a bad interview question as you took a break between interview stations. In the virtual interview environment, this can be much harder. The interviewers are essentially always watching. thePlasticsFella recommends a 3-second breath-hold. During this momentary pause, you will regather your confident thought process. And the best thing is, the interviewers on the other side of the webcam won't notice your stress levels. 💡 ****Tip:** ****Breath-Hold Exercise**: Practice a 3-second breath-hold to reset and regain composure. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/How-to-Execute---Lesson-Notes.png) ### IDEA! Answer Template URL: https://www.theplasticsfella.com/idea/ Last updated: 2024-01-06T17:46:54.000Z IDEA! is a specialized framework designed for answering thought-provoking questions in plastic surgery interviews, particularly those assessing professionalism, probity, clinical governance, and ethics. 💡 ****IDEA Mnemonic** [****"I,I,I"**](https://www.theplasticsfella.com/idea/#I)****:** integrate their personal experiences [****Develop**](https://www.theplasticsfella.com/idea/#develop): expand ideas with well-structured statements [****Examples**](https://www.theplasticsfella.com/idea/#examples)****:** citing specific & impactful examples [****Awareness**](https://www.theplasticsfella.com/idea/#awareness)****:** think critical with different perspective. While **many candidates** are adept at reciting facts, the real challenge in a plastic surgery interview lies in forming and expressing well-rounded opinions on diverse healthcare topics. IDEA! is designed to bridge this gap, enabling you to articulate your viewpoints confidently ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Your-Thoughts---Facts-and-Opinions.png) Unlike **traditional interview** responses, the IDEA! framework excels in blending fact-based information with your personal opinions and sentiments. This approach ensures your answers stand out, showcasing a well-rounded understanding and personal insight. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Your-Thoughts--IDEA-Answer-Structure-for-Facts---Opinons.png) **Pay attention to the cues in interview questions**. It’s essential to grasp what interviewers are seeking – a nuanced blend of factual knowledge and personal perspective. The IDEA! framework helps you strike this balance, ensuring your answers are both informative and reflective of your individual experiences and viewpoints. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Your-Thoughts---Identify-the-Purpose-of-the-Question.png) These leading sentences at the beginning of the question are a big clue for you. They should make you realize what the emphasis of the question is. This is further explained in the infographic below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Your-Thoughts---Examples-of-Fact-and-Opinion.png) Hopefully, now you understand how important is to understand what the interviewer is looking for you. It's never 100% fact or 100% opinion, it's a delicate balance between the two. Here is an example below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Thoughts---Adapt-the-IDEA--Template.png) --- ## **I** ****Key Point** Incorporate your personal experiences or perspectives into your response, ****making it unique to you**. Begin by connecting your personal journey or insights to the question. Choose experiences that highlight key competencies in plastic surgery or ethical considerations that are relevant to the field. - **Good Candidate:** "In my clinical practice, I encountered a situation where a patient's religious beliefs conflicted with the recommended treatment. Navigating this required sensitive communication and respect for the patient's perspective, which taught me the importance of cultural competence in patient care" - **Bad Candidate:** "Dealing with patients of different backgrounds can be challenging." The good example demonstrates a specific, complex scenario where personal experience with cultural sensitivity is highlighted. It shows depth in understanding patient care complexities. The bad example is too vague and misses the opportunity to demonstrate how personal experiences influence professional practice. 💡 ****Tip:** Relate the topic to your own experiences or viewpoints to make your answer stand out. Avoid generic statements that don't reflect your personal journey or insights. --- ## **Develop** ****Key Point** Build upon your initial personal insights with thoughtful, well-articulated statements. When incorporating personal experiences, structure your story to have a clear beginning, middle, and end. Start by setting the scene (beginning), describe the actions you took or the challenge you faced (middle), and conclude with the outcome or what you learned (end). This approach helps in creating an engaging narrative that resonates with the interviewers. Use a storytelling approach to delve into the '**why**' and '**how**' aspects. This helps in developing a compelling narrative that reflects both personal views and a broader understanding of the field **For exmample:** - **Beginning:** "During my rotation in reconstructive surgery, I encountered a patient with a rare condition..." - **Middle:** "I collaborated closely with my team to devise a tailored treatment plan, navigating through various challenges..." - **End:** "This experience not only led to a successful patient outcome but also taught me the importance of teamwork and innovative thinking in plastic surgery." Here are some examples used by former candidates: - **Good Candidate:** "This experience led me to research more about cultural sensitivity in healthcare. I learned that effective communication goes beyond language barriers; it's about understanding and respecting diverse belief systems, which can significantly impact patient outcomes." - **Bad Candidate:** "Cultural issues are just one part of patient care." The good example effectively develops the initial insight into a broader understanding of cultural sensitivity, showing a deep dive into the topic. In contrast, the bad example glosses over the complexity of the issue without offering any insightful development of the idea. 💡 ****Tip:** Utilize storytelling or current medical examples to build a narrative that is both personal and reflective of the field's complexities --- ## **Examples** ****Key Point** Choose and articulate examples that effectively support your points and demonstrate your understanding of the field. Select examples that not only illustrate your point but also demonstrate your grasp of complex issues like ethical decision-making or patient-centered care. - **Good Candidate:** "For example, in a case where a patient refused blood transfusion due to religious reasons, I worked with the team to explore alternative treatment methods, demonstrating respect for patient autonomy while ensuring effective care." - **Bad Candidate:** "You sometimes have to respect patient wishes." The good example provides a specific, relevant instance that demonstrates ethical decision-making and patient-centered care. The bad example fails to provide a concrete scenario, making the response less impactful and insightful. 💡 ****Tip:** Choose examples that are directly relevant and clearly demonstrate your point. Avoid vague or irrelevant examples that don't effectively support your argument. --- ## **Awareness** ## ****Key Point** Acknowledge the complexity of the topic and show awareness of various perspectives. Recognize different viewpoints on the topic, demonstrating your ability to think critically and consider multiple aspects of an issue. - **Good Candidate:** "While I believe in respecting patient autonomy, I also recognize scenarios where this might conflict with medical necessity, such as in emergency situations where the patient is unable to communicate their wishes." - **Bad Candidate:** "Patient autonomy should always be respected." The good example acknowledges the complexity of respecting patient autonomy, especially in critical situations, showing a nuanced understanding of the topic. The bad example presents a one-dimensional view, lacking the depth required for a comprehensive understanding of the issue. 💡 ****Tip:** Show that you understand the topic's complexities and are aware of different perspectives. Avoid presenting your opinion as the only valid viewpoint, disregarding others. --- ### SCARRED! Answer Template URL: https://www.theplasticsfella.com/scarred/ Last updated: 2024-01-06T15:12:02.000Z Plastic surgery interview panels typically utilize a universal approach to gauge candidates' actions and decisions. They focus on themes central to the profession — how you handle pressure, manage clinical situations, and communicate with patients and colleagues. The SCARRED template is specifically designed to align with these themes, ensuring your answers resonate with the critical competencies sought in the field. ****SCARRED Mnemonic** 1\. [****S**ituation](https://www.theplasticsfella.com/scarred/#situation): Setting the scene with precision. 2\. [****C**ontext](https://www.theplasticsfella.com/scarred/#context): Providing a backdrop to frame the situation. 3\. [****A**ction](https://www.theplasticsfella.com/scarred/#action): What, how, why? 4\. [****R**esult](https://www.theplasticsfella.com/scarred/#result): Objective Outcome 5\. [****R**eflection](https://www.theplasticsfella.com/scarred/#reflection): Subjective Assessment 6\. [****ED**ucation](https://www.theplasticsfella.com/scarred/#education): Learning points & how they've shaped you This is the perfect answer template when asked about any example, **situation**, or behavioral-based **scenario** in the Plastic Surgery Interview. This can be visualized in the infographic below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Your-Actions---When-to-used-SCARRED--1-.png) There are specific themes to the "action" questions. But it's important for your brain to be able to recognise them quickly. After all, you really only have a few seconds in the interview to think. Below is the commonest questions asked, and when you hear them, you should flick on the "SCARRED answer structure template" ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Your-Actions---Overview-Common-Questions.png) --- ## Situation ****Key Point** Precisely outline the specific scenario, focusing on its relevance and complexity. When asked a behavioural-based question, begin by concisely setting the stage for the scenario. This involves outlining the specific situation you were in, ensuring clarity and relevance to the question asked. - **Good Example:** "During my rotation in pediatric surgery, I was faced with an emergency where quick decision-making was crucial." - **Bad Example:** "I have faced many difficult situations in my career." This response is too broad and non-specific. It fails to provide a concrete scenario, making it difficult for the interview panel to assess your problem-solving abilities or understand the context of your actions. 💡 ****Tip:** Be precise and succinct in describing the situation, avoiding unnecessary details. --- ## Context ****Key Point** Elaborate on the setting and delineate your role, emphasizing the significance of your position in the scenario. Provide details about the environment and your specific role or responsibilities in that context. - **Good Example:** "As the lead surgeon, I was responsible for assessing the patient's condition and coordinating the team's response." - **Bad Example:** "I was working at the hospital at that time." This statement is vague and does not establish the relevant background or your specific role in the situation. It lacks detail on the setting or the challenges inherent to that particular context, which are crucial for understanding your response to the situation.. 💡 ****Tip:** Highlight your role and responsibilities to give insight into your involvement. 🔗 Visit [this link](https://www.theplasticsfella.com/clinical-risk-management/) to gain insights into clinical risk management, crucial for effectively framing the medical context and challenges of your scenarios --- ## Action ****Key Point** Clearly detail your actions, highlighting the decision-making process and the rationale behind your choices. Detail the specific actions you undertook in response to the situation, showcasing your skills and decision-making. - **Good Example:** "I quickly evaluated the patient and directed the team to prepare for immediate surgery, prioritizing tasks efficiently." - **Bad Example:** " "I did what was necessary at the moment." This answer is overly general and doesn't describe the specific actions taken. It fails to demonstrate your decision-making process, critical thinking, or specific skills applied in the situation, which are key elements the interview panel is looking to evaluate. 💡 ****Tip:** Focus on actions that highlight your competencies and problem-solving skills. 🔗 Explore [this station](https://www.theplasticsfella.com/mistakes/) to refine your decision-making and problem-solving skills, essential for articulating your actions in complex medical situations. --- ## Result ****Key Point** Describe the direct outcomes of your actions, focusing on both patient and team impacts. Describe the results of your actions, focusing on both the immediate and any long-term outcomes. - **Good Example:** "The surgery was successful, and the patient recovered quickly, demonstrating the effectiveness of our team's rapid response." - **Bad Example:** "Everything turned out fine in the end." This reply is unsatisfactory as it doesn't quantify the results or outcomes of your actions. It misses the opportunity to showcase the effectiveness of your decision-making and the positive impact of your actions. 💡 ****Tip:** Quantify results where possible to strengthen your response. --- --- ## Reflection ****Key Point** Provide deep insights into what you learned and how the experience influenced your approach to plastic surgery. Offer insights into what you learned from the situation and how it impacted your professional growth. - **Good Example:** "This experience taught me the value of quick decision-making under pressure and reinforced the importance of teamwork in crisis situations." - **Bad Example:** "It was a learning experience for me." This response is cliché and lacks depth. It doesn't articulate what was learned or how the experience contributed to your professional growth. Reflective answers should provide insight into your thought process and how such experiences have refined your approach or philosophy in plastic surgery. 💡 ****Tip:** Use reflections to demonstrate your capacity for growth and learning. 🔗 To enhance your reflective responses, especially regarding handling pressure, check out [this page](https://www.theplasticsfella.com/coping-with-pressure/) for valuable strategies and insights --- ## EDucation ****Key Point** Connect the experience to your educational growth and professional development in a tangible and specific manner. In the EDucation component, focus on how the particular situation has influenced your educational journey and professional growth in plastic surgery. This is about connecting real-life experiences to your continuous development as a medical professional, highlighting any new skills, knowledge, or perspectives gained. - **Good Example:** "Following the complex case I managed during my residency, I identified a gap in my knowledge regarding advanced reconstructive techniques. This led me to enroll in a specialized course on microvascular reconstruction, significantly enhancing my surgical skills and understanding of patient-specific approaches." - **Bad Example:** "I always try to learn from my experiences." The good example effectively shows how a specific experience directly influenced a decision to pursue further education, leading to tangible professional growth. The bad example is too general and fails to demonstrate a direct link between experience and educational development. The bad example is too generic and doesn't tie the learning back to the specific situation or how it influenced your educational path or professional development. Effective answers should connect the experience to specific learning outcomes or future goals. Clearly articulate how the situation prompted a specific educational pursuit or professional advancement. This could include additional training, certifications, research, or any form of formal or informal education that contributed to your growth as a plastic surgeon. 💡 ****Tip:** Unlike the Reflection section, which is more about personal insights and lessons learned, the EDucation section should focus on tangible steps taken towards professional development and skill enhancement as a direct result of the experiences faced. --- ### ACED! Answer Template URL: https://www.theplasticsfella.com/aced/ Last updated: 2024-01-06T14:31:08.000Z In plastic surgery interviews, personal questions play a pivotal role in assessing a candidate's suitability for the specialty. These questions delve into various aspects of your profile, from your CV highlights to your motivation and long-term plans. The ACED mnemonic is a strategic tool designed to help you effectively showcase your qualifications, commitment, and vision in plastic surgery, ensuring you present a well-rounded and compelling narrative. **It is designed to align with the core competencies of technical expertise, ethical practice, continuous learning, and patient-centered care.** 💡 ****ACED Mnemonic** [****A**chievements](https://www.theplasticsfella.com/aced/#achievements): Highlight your successes [****C**ommitment](https://www.theplasticsfella.com/aced/#commitment): Show your dedication to plastic surgery [****E**nthusiasm](https://www.theplasticsfella.com/aced/#enthusiasm): Express your passion for the field [****D**evelopment](https://www.theplasticsfella.com/aced/#development): Discuss your growth and future goals. Whether you're a seasoned practitioner or an aspiring surgeon, the ACED template empowers you to present a comprehensive and authentic picture of yourself, ensuring that every aspect of 'you' aligns with the high standards and dynamic nature of the plastic surgery field. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/-ACED--Must-have-Answer-Template---Structure-2.png) In the fast-paced environment of plastic surgery interviews, our answer structure is intentionally straightforward. Each heading - Achievements, Commitment, Enthusiasm, Development - acts as a guide, ensuring clarity and focus in your responses. While P'Fella offers foundational advice, you're encouraged to weave in your personal experiences, making each answer uniquely yours. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/ACED---EXPANDED-POINTS.png) The effectiveness of the good examples lies in their specificity, relevance, and alignment with the key qualities sought in plastic surgery candidates: expertise, dedication, passion, and a clear developmental trajectory. Conversely, the bad examples suffer from vagueness, lack of focus, and a failure to convincingly showcase these qualities --- ## Achievements ****Key Point** Highlight your notable accomplishments in your medical career or education. Your achievements are testament to your skill and potential in the field of plastic surgery. Highlighting them is not just about showcasing past successes; it's about demonstrating how these successes make you a prime candidate for further challenges in plastic surgery. A common pitfall is being too general. Better candidates have specific achievements tied to measurable outcomes or recognitions are more impactful. 🔗 Learn how to effectively communicate your [past successes and achievements](https://www.theplasticsfella.com/personal-development-and-achievements/) in your plastic surgery career. - **Good Example**: "In my master's thesis, I explored innovative skin graft techniques, which was later published in a renowned medical journal. This achievement showcases my commitment to advancing plastic surgery practices." - **Bad Example**: "I've completed several assignments during my studies." Stating "I've completed several assignments during my studies" is too vague and general. It doesn't provide any detail on the relevance or impact of these assignments, making it a weak demonstration of achievement. 💡 ****Tip:** Relate achievements to personal experiences or challenges you've overcome, adding depth to your narrative. --- ## Commitment ****Key Point** Show your long-standing and active engagement in plastic surgery. Illustrating your commitment reflects your dedication and long-term interest in plastic surgery, an essential trait for professionals in this evolving field. It’s important because plastic surgery is a demanding field requiring a long-term, sustained commitment. 🔗 Explore this [station](https://www.theplasticsfella.com/why-plastic-surgery/) to express your dedication to plastic surgery and articulate why you're committed to this specialty. - **Good Example**: "For the past two years, I have been involved in a community project providing free reconstructive surgery, demonstrating my commitment to the humanitarian aspect of plastic surgery." - **Bad Example**: "I occasionally volunteer at health camps." The example of being involved in a community project for free reconstructive surgery over two years demonstrates sustained and significant engagement. It not only shows dedication but also aligns with the humanitarian values of plastic surgery, making it a strong indication of commitment. 💡 ****Tip:** Discuss consistent and relevant activities that show your ongoing commitment to the field of plastic surgery. Don't just mention sporadic or one-off activities. Consistency is key. --- ## Enthusiasm ****Key Point** Share your genuine passion and why plastic surgery captivates yo Convey your genuine passion for plastic surgery and what drives it. Genuine enthusiasm for plastic surgery is infectious and indicative of your motivation. This is crucial in a field that's as demanding as it is rewarding. Discuss what specifically in plastic surgery excites you, and how your experiences have fueled this passion. 🔗 Visit this [station](https://www.theplasticsfella.com/training/) to passionately communicate your reasons for training in plastic surgery and express your genuine enthusiasm for the field. - **Good Example**: "My passion for plastic surgery was ignited during my first clinical rotation in reconstructive surgery, where I saw the profound impact on patient’s lives. This experience solidified my commitment to pursuing this challenging yet rewarding field." - **Bad Example**: "I think plastic surgery is interesting and offers good career prospects." Saying "I think plastic surgery is interesting and offers good career prospects" is a superficial statement. It lacks personal connection and fails to convey a genuine, intrinsic interest in the field, coming across as more career-oriented than passion-driven. 💡 ****Tip:** Share personal stories or experiences that sparked your interest in plastic surgery to make your response more authentic and engaging. Avoid generic statements. Your enthusiasm should be specific and well-articulated. --- ## Development ****Key Point** Paint a picture of your growth trajectory and future aspirations in plastic surgery. Illustrate your professional growth and future goals in plastic surgery. Discussing your growth and future goals shows you’re thinking ahead and are eager to contribute to the evolution of plastic surgery. A common pitfall is vague or overly broad future plans can seem unfocused. Be specific about your aspirations. 🔗 [Click here](https://www.theplasticsfella.com/your-future/) to discuss your career plans in plastic surgery, highlighting your professional growth and aspirations for the future - **Good Example**: "Starting as a medical intern, I have progressively taken on more complex cases in plastic surgery. My goal is to specialize in pediatric reconstructive surgery, contributing to both clinical practice and research in this area." - **Bad Example**: "I've been working in surgery for a while now and plan to keep improving." In the good example: the journey from a medical intern to handling complex cases, with a future goal of specializing in pediatric reconstructive surgery, illustrates a clear growth trajectory. This progression shows ambition, a willingness to learn, and a specific direction for future development in the field. 💡 ****Tip:** Map out your journey, showing how past experiences have led to your current expertise and how they align with your future aspirations in the field. --- ### Paid mentorship is a sin, new community platform & Tinel's sign (my fave). URL: https://www.theplasticsfella.com/november-26th/ Last updated: 2024-02-11T20:06:46.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/november-26th/#a-letter-from-pfella) Don't pay for mentorship. Please. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-26th/#the-sunday-quiz) Steps to a Finger replant. 3. 🔦 [****Spotlight**](https://www.theplasticsfella.com/november-26th/#spotlight) 'Community' - a new venture. 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/november-26th/#image-of-the-week) AI-generated thumb replant. 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/november-26th/#tweets-of-the-week) What was hot on Twitter this week. 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/november-26th/#ask-pfella) 3D printing - watch this space. 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/november-26th/#articles-of-the-week) Eponymous publications! Love them. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/november-26th/#feedback) Suggest ideas & give feedback! ****PS -** updated the [landing page](https://www.theplasticsfella.com/landing/) this week too. ## A Letter from P'Fella Please do not pay for a 'mentor'. 👋 ****Hey team!** Hey Fam, I wanted to chat about something that's been bugging me lately: this new trend of ****paid mentorship**. But I think I have a solution. ****👇** **Mentorship is supposed to be about sharing experiences and wisdom, right?** It's a bit off-putting to see it turning into a business transaction. I stumbled upon a Twitter thread that really put things into perspective. It seems I'm not the only one who feels that mentorship is losing its true meaning in the rush to make a buck. I kinda get it, though. Finding a mentor in our field can be like looking for a needle in a haystack. It's tough, and that's probably why some folks think it's okay to charge for mentorship. Here's what people want in an educational community 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/a-the-Plastics-Pro-22.png) [Original Article](https://pubmed.ncbi.nlm.nih.gov/34432703/?ref=theplasticsfella.com) **So, here's what I'm thinking: let's start "**[**Community**](https://community.theplasticsfella.com/?ref=theplasticsfella.com)**" – a totally free mentorship platform**. It's P'Fella's way of saying no to turning mentorship into a marketplace. We're talking about a place for open, honest sharing, where we all can learn and grow together. P'Fella is all about making connections easier and keeping the spirit of helping each other out alive. Remember how our mentors were there for us, asking nothing in return? That's the vibe we're aiming for. It's our turn to pass on the torch and keep the real essence of mentorship going strong in plastic surgery. So, what do you say? Let's team up and make mentorship in our field something truly special and accessible for everyone. The goal is to build a comprehensive platform where we can exchange insights on exams, delve into the latest research, share practical surgical tips, and guide each other through fellowships and more. [Check out Community](https://community.theplasticsfella.com/?ref=theplasticsfella.com) Cheers, P'Fella ❤️ ## The Sunday Quiz Steps to a Finger Replant ****Finger replantation - its time to get comfortable!** The process involves using equipment like a microscope and microsurgical instruments, along with radiography. It's recommended to have two teams, each preparing one of the two segments. The ****bone** is treated with open reduction and internal fixation (ORIF), possibly involving shortening with K-wires. Both ****flexor** and ****extensor** tendons undergo repair, followed by epineural repair of ****nerves**. ****Arterial** anastomosis may include a vein graft if needed. ****Vein** anastomosis is a strong predictor of survival, emphasizing its importance. Additionally, ****skin** plays a role in venous drainage. While there is no "perfect order" for these procedures, there's a general consensus to address bone and tendons first, with some surgeons preferring to do arterial and venous work before nerve repair to minimize ischemia time. ![Finger Replant](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Copy-of-Rotational-Flap-4-1.png) Reveal this week's question What are the "absolute" indications for replantation? - Zone III - Index Finger - Little Finger - Single-digit distal to FDS - Single-digit proximal to FDS Name: Email: ## Spotlight Key events, select webinars, tailored courses & new features! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/community.png) #### Launching Community! Mentorship is losing its essence to commercialization, so P'Fella is launching 'Community,' a free platform for genuine sharing and growth in plastic surgery, covering everything from exams and research to surgical tips and fellowships ****Community Features:** - 🔍 ****Search:** Find topics and resources fast. - 📰 ****Latest Discussions:** Catch up with recent talks. - 🆕 ****New Topics:** Explore fresh content. - 🌟 ****Top Categories:** Dive into popular areas. ****Suggested Topics:** - 🧪 ****Research:** Latest findings and methods. - 🎓 ****Fellowships:** Opportunities and advice. - 🛠️ ****Surgical Tips:** Practical techniques shared. - 📚 ****Exams:** Strategies and resources. - 🗣️ ****Interviews:** Tips for success. - 💬 ****General Chit-Chat:** Casual conversations and stories. [Check out Community](https://community.theplasticsfella.com/?ref=theplasticsfella.com) ## ## Image of the Week AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Thumb-Amptuation.png) Patient awaiting thumb reconstruction ## Tweets of the Week Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Sci Hub is a "pirate" website with 88M research papers freely available. > > Using it is not advisable. We should all try to make billion-dollar acdemic publishers richer. > > Here's a thread on integrating Zotero with Sci Hub to get free articles. > > PLEASE DON'T DO THIS 😉 > > — Mushtaq Bilal, PhD (@MushtaqBilalPhD) [November 25, 2023](https://twitter.com/MushtaqBilalPhD/status/1728433661274468858?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > So universities make research professors pay for their entire salary & research through grant funding, but then the university also takes a cut of your grant funding? Seems like you’d have to always apply for grants, so when do you do research? Is this why you’re all kinda grumpy > > — Dr. Glaucomflecken (@DGlaucomflecken) [November 19, 2023](https://twitter.com/DGlaucomflecken/status/1726284170039886083?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > New paper in [@AcuteMedJournal](https://twitter.com/AcuteMedJournal?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) today by [@zackferguson](https://twitter.com/zackferguson?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) \- they have mapped out the transition doctors undergo when they become the med reg > > Consultants/trainers need to think about how we can support docs navigating this transition. Study tells us we aren’t getting this right yet. [pic.twitter.com/gWjgzwIe4y](https://t.co/gWjgzwIe4y?ref=theplasticsfella.com) > > — Ben Lovell (@DrBenLovell) [November 3, 2023](https://twitter.com/DrBenLovell/status/1720359399351296270?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella You ask, P'Fella answers. Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. ❓ ****Msry's Question** Any advice for 3rd year medical students who want to apply to plastics with average clerkship scores and a few publications to their name? How can we make it work? Thanks! --- Ask P'Fella Now 11 questions submitted in the last 30 days... ## Articles of the Week 3 must-read articles! #### 3 Must-reads 1. [****Eponymous Names In Surgical Approaches**](https://www.jhandsurg.org/article/S0363-5023%2823%2900410-0/fulltext?ref=theplasticsfella.com) Moses MJ, Cheng C, Styron JF. Eponyms of Upper Extremity Surgical Approaches: A Historical Perspective. J Hand Surg Am. 2. [****Eponymous instruments in plastic surgery**](https://journals.lww.com/plasreconsurg/abstract/2011/01000/eponymous%5Finstruments%5Fin%5Fplastic%5Fsurgery.62.aspx?ref=theplasticsfella.com) Harijan A, Halvorson EG. Eponymous instruments in plastic surgery. Plast Reconstr Surg. 2011 Jan;127(1):456-465\. 3. [****Anatomical Eponyms of the Ulnar Nerve**](https://linkinghub.elsevier.com/retrieve/pii/S0363-5023%2822%2900572-X?ref=theplasticsfella.com) Bi AS, Qiu CS, Dellon AL, Rettig ME. A History of Anatomical Eponyms of the Ulnar Nerve. J Hand Surg Am. 2022 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Tinel's Signs - The Original The legendary Tinel's Test. This original 1915 case series explores the efficacy in assessing peripheral nerve damage. The study presents Tinel's Sign as a potentially valuable component in the nerve injury diagnostic process. [Tinel's signs - Original Publication](https://www.theplasticsfella.com/tinels-sign-original-publication/) ## Feedback ### Any suggestions, ideas and even negative feedback is appreciated! ### Tinel's Sign - Original Publication URL: https://www.theplasticsfella.com/tinels-sign-original-publication/ Last updated: 2023-11-25T09:16:12.000Z ## Article Summary ### An independent fresh perspective that can differ from the authors' abstract. #### Article Summary ****Level of Evidence: Case Series** ****Evidence Snapshot** This study falls under "Case Series." It's essentially a collection of patient cases, offering insights without the rigidity of a controlled trial. ****Hypothesis** Tinel's Sign is more than just a clinical test; it's a valuable tool for assessing nerve damage. It helps in discerning the severity and location of nerve injuries and is an early detector of nerve regeneration. ****Aim** The primary objective is to leverage Tinel's Sign for a comprehensive analysis of nerve damage – determining its completeness, pinpointing injury location, and tracking early nerve repair. ****Methods** The study involved a series of six patients, focusing on observations rather than a structured follow-up or outcome measurement protocol. ****Results** The presence or absence of tingling sensations offers significant clues about nerve damage and recovery. Specific tingling patterns correlate with injuries to nerves like the radial and sciatic, and bullet wounds can exacerbate these effects. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/8308447/?ref=theplasticsfella.com) ## Deep Dive ### An anlaysis to identify key findings, limitations, clinical practice improvements, and additional reading. ## Methodology ****Key Point** The study, designed as a retrospective case series, aims to classify peripheral nerve injuries using tingling sensations as a diagnostic and prognostic tool. However, the procedure is vague about the specifics of pressure application and fails to address the standardization of differentiating between pain and tingling, considering the varied pain perceptions among individuals. **Study Design and Participants** - **Design:** Retrospective case series - **Location and Duration:** Uknown - **Eligibility:** Uknown **Objective**: The study aims to differentiate between various types of peripheral nerve injuries (severed, compressed, torn, obstructed, or regenerating) based on the tingling sensations produced by pressure on the nerve. The primary goal is to determine if this tingling can provide valuable diagnostic and prognostic information. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Tinel-s-Sign-Original-Publication.png) **Procedure**: - Pressure is applied to an injured nerve trunk to determine if it produces a tingling sensation. - This tingling sensation, felt by the patient at the periphery of the nerve, is localized to a specific skin area. 💡 ****Critique:** The procedure lacks detailed information on the application and duration of pressure, as well as the measurement methods for the tingling sensation. Additionally, there's no clarity on standardizing the differentiation between pain and tingling, given the subjectivity of pain perception among patients. --- ## Results ****Key Point** The study demonstrates that tingling sensations produced by pressure on a nerve can provide valuable diagnostic and prognostic information regarding peripheral nerve injuries. The results are interspersed with anecdotal evidence, making it difficult to differentiate systematic findings from one-off observations. A more structured approach, like tables or segmented sections, would make the findings clearer. **Patients Recruited** This study looked at a total of 6 patients. Their clinical features are summarised below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Tinel-s-Sign-Original-Publication-1.png) Summary of Patients in this Case Series 💡 ****Critique:** The study's findings are mixed with anecdotal evidence, lacking a clear structure and concise summary. The absence of quantitative data or statistical analyses limits the ability to gauge the significance of the observations. Obviously, the sensitivity and specificity of this clinical examination has subsequently been proven. **Clinical Features** The tingling sensation has the following features - Elicited by direct pressure on a specific point on the nerve's pathway at the point of axonal disruption. - It is in a well-defined cutaneous area of the nerve. - It is only on the path of the nerve and no other place can be found above or below the injury where pressure can cause tingling. 💡 ****Critique:** The author provides specific features of the tingling sensation, but the description remains subjective and lacks quantitative measures. Ambiguities in terms like "direct pressure" and the absence of visual aids or clear methodologies could hinder reproducibility. --- ## Take Home Points ### 1 Learning Point, 1 impact on clinical practice, 1 article for further reading. ### **Learning Point: Pain vs. Tingling** It is extremely important to differentiate tingling from pain. Both can be elicited by direct pressure on a traumatised nerve but there is a key difference: - Pain: **localised hyperaesthesia** to where the nerve is under pressure. - Tingling: **transmitted paraesthesia** ("electricity") to a cutaneous area. Tingling is a sign of axonal regeneration. They rarely co-exist on the same nerve. --- ## **Impact on Practice: Role of Tinel's Sign** The systematic study of tingling caused by pressure on the nerve very often enables us to: 1. Find out if the interruption to the nerve is complete or partial. 2. Determine the exact location and the extent of the injury. 3. Detect regeneration of the axons at an early stage Tingling can only be of use when combined with all the other clinical symptoms. ### ## Further Reading **Tinel's vs Phalen's vs Durkan's - Who Wins?** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Screenshot-2023-11-25-at-09.06.56.png) [Read here](https://www.jhandsurg.org/article/S0363-5023%2899%2983909-4/fulltext?ref=theplasticsfella.com) [Cubital Tunnel SyndromeCubital Tunnel Syndrome is a compression neuropathy of the ulnar nerve at the level of the elbow. This article reviews the current literature in relation to anatomy, clinical diagnosis, and treatment options of Cubital Tunnel Syndrome.![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/size/w256h256/2022/07/Logo-Small-2.png)thePlasticsFellaPlasticsFella![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Cubital-Tunnel-Syndrome-7.png)](https://www.theplasticsfella.com/cubital-tunnel-syndrome/) --- ### Meet your new AI sidekick, Anki Deck Builder launched & interview tips! URL: https://www.theplasticsfella.com/november-19th/ Last updated: 2023-11-19T11:03:46.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/november-19th/#a-letter-from-pfella) Success in Plastic Surgery Interviews 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/november-19th/#the-sunday-quiz) What actually is Moh's? 3. 🔦 [****Spotlight**](https://www.theplasticsfella.com/november-19th/#spotlight) SideKick AI and Anki Deck Builder 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/november-19th/#image-of-the-week) AI-generated melanoma 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/november-19th/#tweets-of-the-week) What was hot on Twitter this week. 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/november-19th/#ask-pfella) Eh, prefabrication vs prelamination? 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/november-19th/#articles-of-the-week) 3 well designed publications. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/november-19th/#feedback) Suggest ideas & give feedback! ****PS -** If you love ****Anki**, then [this](https://www.theplasticsfella.com/anki-decks/) is for you. ## A Letter from P'Fella What Makes a Great Plastic Surgery Interview? 👋 ****Hey team!** In some parts of the world, it's that time of year again – interview season is just around the corner! I hope you're all revved up and ready to make a splash. I've been deep-diving into some fascinating studies, here's some key takeway points. ****If you want to prepare well, check out** [****thePlasticsInterview**](https://www.theplasticsfella.com/theplasticsinterviews/)****.** ****👇** ### **Interview Timing – It's Kinda a Big Deal** Guess what? The day you interview could actually sway your ranking. Crazy, right? So, when you're picking dates, mix it up – a little early, a little late. It’s all about balance! This is an article worth reading 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Screenshot-2023-11-19-at-10.09.46-1.png) ### **Play the Field** Here's the deal: more applications, more interviews, more chances to shine. And hey, if you've got killer grades, make sure they know it. Flaunt it if you’ve got it! In some parts of the world, you can interview for many programs in different locations. For those, the more interviews you nab, the better your shot at success. It’s all about showing off what you know and your passion for the field. Keep that interview outfit ready – you're going to need it! ### **Nailing the Virtual Interview Scene** Virtual interviews are the new normal, and they're all about the details. Good lighting, quiet room, snazzy outfit – make sure you look and sound your best. First impressions matter, even on a screen! This is an article worth reading 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Screenshot-2023-11-19-at-10.11.24-1.png) ### **Quick Tips to Keep in Your Back Pocket** - **Network Like a Boss:** The more people you know, the better. - **Research and Publications:** Show off your brainy side with some solid research work. - **Mock Interviews are Your BFFs:** Practice, practice, practice. It's all about being cool, calm, and collected. Use [thePlasticsInterview](https://www.theplasticsfella.com/theplasticsinterviews/) if you like. - **Personalize Those Apps:** Make each program feel like they're your top choice. - **Stay in the Loop:** Keep up with the latest in the world of plastic surgery. Knowledge is power! ### **Awesome Reads to Check Out** - **Interview Day vs. Rank Order (J Surg Educ. 2023)**: How the date of your interview might just tip the scales. - **Secrets to Plastic Surgery Match Success (Ann Plast Surg. 2013)**: Get the inside scoop on what makes a candidate stand out. - **What Makes a Winning Match (Ann Plast Surg. 2010)**: A deep dive into the do’s and don'ts of landing that spot. - **Ace Those Virtual Interviews (Cureus. 2021)**: Your ultimate guide to impressing through a screen. - And of course, [thePlasticsInterview](https://www.theplasticsfella.com/theplasticsinterviews/). Remember, these tips and reads are just guides – your unique vibe and experiences are what will truly make you shine. So go out there, be your awesome self, and nail those interviews! Cheering you on, P'Fella ❤️ ## The Sunday Quiz Ah, Moh's Surgery! Dr. Frederic Mohs, an American general surgeon in the 1930s, developed the [Mohs micrographic surgery](https://www.theplasticsfella.com/mohs-micrographic-surgery/) (Mohs surgery or MMS) technique. It is a tissue-sparing surgical technique used to remove skin cancers with a high risk of recurrence and located in areas of functional and aesthetic importance. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Moh-s-Surgery-1.png) Reveal this week's question What is a key feature of Mohs Micrographic Surgery (MMS)? - MMS is primarily used for the treatment of melanoma skin cancers. - MMS involves the use of general anesthesia for tumor removal. - MMS includes same-day comprehensive margin assessment and tumor removal. - MMS often requires multiple visits for complete tumor excision. Name: Email: ## Spotlight Key events, select webinars, tailored courses & new features! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Sidekick-AI-2.png) #### Launching Sidekick AI! Your innovative AI companion redefining your educational experience & ****trained on thePlasticsFella's knowledge base** 💡 Interactive Q/A: SBA, MCQs, detailed answers. 📖 Custom Text Summaries: Simplified medical insights. 🗣️ Dynamic Discussions: Enhanced journal clubs and case studies. 🏥 Case Simulations: Real-world scenarios with feedback. 📈 Tailored Interview Prep: Focused ThePlasticsInterview guidance. ****Seamlessly integrated into every aspect of thePlasticsFella**. More than just answers, Sidekick actively aids in your learning process. It can craft custom content based on your level of training. It transforms passive reading into an engaging, interactive experience. ****Education is now a personal conversation**. [Learn with Sidekick](https://www.theplasticsfella.com/sidekick/) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Anki-Decks-for-Plastic-Surgeons-4-1.png) #### NEW: Anki Deck Builder Build Anki decks from the ****world's largest collection** of over ****10,000** plastic surgery flashcards. 🔍 ****Advanced Filtering**: Tailor sessions for focus and retention. 🏆 ****Competitive Learning**: Track with evolving 'Difficulty' ratings. 🚀 ****Rapid Build & Export**: Customize and convert decks to CSV. 🔄 ****Continuous Updates**: Access the latest information. ****Build your deck by Topic, Focus and Difficulty. Simple.** [Build an Anki Deck](https://www.theplasticsfella.com/anki-decks/) ## ## Image of the Week AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Melanoma.png) AI-generated melanoma ## Tweets of the Week Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Surgical job expectations: Westminster Hospital 1983\. [pic.twitter.com/RVQFGBqKEj](https://t.co/RVQFGBqKEj?ref=theplasticsfella.com) > > — Simon Noble (@SimonNoble) [November 9, 2023](https://twitter.com/SimonNoble/status/1722562263490437471?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Re-posting my [@BJS](https://twitter.com/BJs?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) Instrumentalist article on needle holders now that it is officially out in the November issue. 😎 > > It is suitable for students and early surgical trainees. > > If you have suggestions for a topic for my next submission, let me know. 🧐[https://t.co/tZC5Qffdiy](https://t.co/tZC5Qffdiy?ref=theplasticsfella.com) > > — Ron Barbosa MD FACS (@rbarbosa91) [November 3, 2023](https://twitter.com/rbarbosa91/status/1720338016844066948?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > The Abilene Paradox - How smart doctors do dumb things [pic.twitter.com/c5WLsy6NMi](https://t.co/c5WLsy6NMi?ref=theplasticsfella.com) > > — Adi Kumar (@adi\_kumar1) [November 8, 2023](https://twitter.com/adi%5Fkumar1/status/1722189785391886429?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella You ask, I'll answer p.s today, this was answered by [Sidekick](https://www.theplasticsfella.com/sidekick/) Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. ❓ A****nkit's Question** Could you please highlight the differences between ****prefabrication and** ****prelamination**? Hey! Yeah this is can get pretty confusing. Think of **prefabrication** as giving a piece of tissue its own personal blood supply by hooking it up with a blood vessel network. It's like rigging it to be self-sufficient before moving it to where it's needed, sort of like preparing a plant with its pot before you transplant it to a garden. **Prelamination** is more like assembling a mini-layer cake of different tissues on top of a blood vessel bed, so it's all ready to be moved as one fancy unit. This is super handy when you need to fix up an area that needs a few different tissue types - like creating a deluxe sandwich with all the fixings before you deliver it to the table. So, you're either gearing up a single piece of tissue to survive on its own, or you're building a complex tissue structure from scratch, complete with its own blood flow. Prefabrication is about inducing blood supply into an existing tissue while prelamination is about creating a new multi-layered tissue structure with its own blood supply. Hope that helps! P'Fella ❤️ --- Ask P'Fella Now 9 questions submitted in the last 5 days... ## Articles of the Week 3 must-read articles! #### 3 Must-reads 1. [****Nerve Conduction Studies in Carpal Tunnel** ](https://pubmed.ncbi.nlm.nih.gov/37812524/?ref=theplasticsfella.com#:~:text=They%20are%20the%20best%20available,the%20evaluation%20of%20treatment%20response.) Bland JDP. Use of nerve conduction studies in carpal tunnel syndrome. J Hand Surg Eur Vol. 2023 Nov;48(10):976-985\. 2. [****When Trigger Finger Releases Fail**](https://pubmed.ncbi.nlm.nih.gov/36988215/?ref=theplasticsfella.com) Jeon N, Yoo SG, Kim SK, Park MJ, Shim JW. Failure rates and analysis of risk factors for percutaneous A1 pulley release of trigger digits. J Hand Surg Eur Vol. 2023 Oct;48(9):857-862 3. [****More scrubbed = more infections?** ](https://pubmed.ncbi.nlm.nih.gov/37032513/?ref=theplasticsfella.com) Miller JE, Raman S, Chishom TA, Mountziaris PM. Stopping Traffic: An Analysis of Number of Scrubbed Personnel and Infection in Implant-Based Breast Reconstruction. Aesthet Surg J. 2023. There is no deep-dive journal club this week. P'Fella was too busy building [Sidekick AI](https://www.theplasticsfella.com/sidekick/) and the [Anki Deck Builder](https://www.theplasticsfella.com/anki-decks/) ## Feedback ### Any suggestions, ideas and even negative feedback is appreciated! ### FRCS Plastic Surgery (Plast) Exam URL: https://www.theplasticsfella.com/frcs-plastic-surgery/ Last updated: 2024-02-01T22:39:21.000Z #### ✅ Summary Card ****What's the FRCS Plast All About?** A rigorous JCIE-governed exam that certifies a surgeon's consultant-level expertise in plastic surgery. ****Are You Eligible?** Entry requirements span a recognized medical degree, years of experience, curriculum adherence, and professional references. ****Structure of the FRCS Plast Exam** The exam unfolds in two stages: a computer-based test followed by a two-day hands-on clinical evaluation. ****Key Dates for the FRCS Plast Exam** The exam takes place multiple times a year; don't miss the application deadlines! ****Tools to Boost Your FRCS Plast Prep** Discover specialized tools like thePlasticsPro, tailor-made to help you succeed. ****Success Rates and the Coveted Gold Medal** CCT trainees tend to shine, and standout performances can earn the prestigious Ian McGregor Medal. ****Unraveling the Cost** The £1904 fee is a comprehensive package, supporting various operational and developmental aspects of the exam. --- ## What is the FRCS Plastic Surgery (Plast) exam? ****Key Point** The FRCS Plastic Surgery (Plast) Exam is a rigorous assessment overseen by the Joint Committee on Intercollegiate Examinations, designed to validate a surgeon's ability to practice safely and effectively as a consultant in plastic surgery. The **FRCS Plastic Surgery (Plast) Exam**, officially recognized as the "Intercollegiate Specialty Examination in Plastic Surgery," is governed by the Joint Committee on Intercollegiate Examinations. This prestigious 'exit exam' stands as a testament to a surgeon's capability, earned after the successful completion of a rigorous two-part assessment. It's designed to ensure that candidates possess the vital knowledge and adeptness to practice autonomously as a consultant in plastic surgery. ![FRCS Governance, FRCS Plastic Surgery, FRCS Plast, FRCS Exam](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/FRCS-Plast-6.png) FRCS Governance While the examination is generally perceived as challenging, it's also seen as fair, with stringent quality assurance measures in place. Beyond testing factual knowledge, the exam emphasizes clinical acumen, ensuring that candidates can safely practice and communicate effectively. The overarching goal is for candidates to demonstrate their readiness to provide care at the consultant level, emphasizing safety and effective communication. 💡 ****Tip:** JCIE oversees the Specialty Fellowship Examinations on behalf of the four surgical Royal Colleges of Great Britain and Ireland, as mandated by the GMC. Additionally, the JCIE serves as the overarching entity for its ten surgical Specialty Boards. --- ## FRCS Plastic Surgery (Plast) Exam Eligibility ****Key Point** Eligibility for the FRCS Plastic Surgery (PLAST) Exam requires a recognized medical qualification, six years post-qualification experience, adherence to the Intercollegiate Surgical Curriculum, and three professional references as set by the JCIE. The FRCS Plastic Surgery (Plast) Exam is a key qualification for those aiming to establish their prowess in the field of plastic surgery. Governed by the Joint Committee on Intercollegiate Examinations (JCIE), this exam sets high standards for candidates, ensuring their readiness for consultant-level practice. ![FRFRCS Plastic Surgery Eligibility, FRCS Plastic Surgery, FRCS Plast, FRCS Exam, FRCS Plast Exam](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/FRCS-Plast-7.png) FRCS Plastic Surgery Eligibility As illustrated above, to be eligible for the the FRCS Plastic Surgery exam, the following criteria must be met. This also applies for overseas doctors. - **Medical Qualification:** Must be recognized by the GMC UK or the Medical Council of Ireland, with a minimum of six years post-qualification. - **Clinical Competence:** Candidates must provide evidence of meeting the standards set by the Intercollegiate Surgical Curriculum. This can be derived from a combination of qualifications, training, or experience. - **References:** Three structured references are mandatory. These should be in the format prescribed by JCIE and ideally from senior colleagues who are familiar with the applicant's current clinical practice. - **Timeframe:** The entire examination journey has to be completed within a span of 7 years. This includes: - **Section 1:** 4 attempts within a two-year window from their initial try. - **Section 2:** Candidates have a maximum of 4 attempts. Prospective candidates should be aware that detailed regulations and guidelines are available through the JCIE's official documentation online. It's pertinent to note that thePlasticsFella is not affiliated with JCIE. [FRCS Plastic Surgery Exam RegulationsthePlasticsFella is not affiliated with JCIE. This PDF is in the public domain. FRCS Plastic Surgery Exam Regulations (Last Revised 2023).pdf278 KBdownload-circle](https://www.theplasticsfella.com/content/files/2023/11/FRCS-Plastic-Surgery-Exam-Regulations--Last-Revised-2023-.pdf "Download") 💡 ****Tip:** It's essential to understand that merely passing the Intercollegiate Specialty Examination doesn't guarantee a placement on the Specialist Register. It's a part of the comprehensive evidence required. --- ## FRCS Plastic Surgery (Plast) Exam Structure ****Key Point** The FRCS Plast exam consists of two sections: Section 1, a computer-based test with Single Best Answer (SBA) papers, and Section 2, a two-day clinical assessment integrating patient interactions and oral examinations. Successful completion of Section 1 is a prerequisite to attempt Section 2. There are 2 sections to the FRCS Plastic Surgery exam. Candidates must meet the required standard in Section 1 in order to gain eligibility to proceed to Section 2 ### Section 1 FRCS Plast Exam Format Section 1 of the FRCS Plast exam consists of two computer-based Single Best Answer (SBA) papers. These papers, tailored to effectively assess the curriculum content, are administered at Pearson VUE Test Centres across the UK and Ireland. - **Paper 1** 120 Single Best Answer for 2 hours 15 mins - **Paper 2** 120 Single Best Answer for 2 hours 15 mins This can be visualised in the image below. ![FRCS Plastic Surgery Exam Format, FRCS Plastic Surgery, FRCS Plast, FRCS Exam, FRCS Plast Exam](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/FRCS-Plast-8.png) FRCS Plastic Surgery Exam Section 1 The design of these test questions is based on the plastic surgery syllabus. This can be downloaded below. [FRCS Plast SyllabusThis is the work of JCIEFRCS Plast Syllabus.pdf478 KBdownload-circle](https://www.theplasticsfella.com/content/files/2022/03/FRCS-Plast-Syllabus.pdf "Download") ### Section 2 FRCS Plast Exam Format The FRCS PLAST Section 2 is the clinical component of the examination, conducted over two days. It integrates patient interactions, clinical scenarios, and structured medical interviews. The examination gauges advanced cognitive skills, such as decision-making, interpretation, and judgement. The quality of responses, depth of questions tackled, clarity, and confidence in answers, along with the degree of guidance required, are key evaluation parameters. For each session, two examiners are present: one administers the exam while the other records the proceedings. They mark separately to ensure objective evaluation. Candidates are expected to appear for this in-person examination in professional business attire. 💡 ****Tip:** "****Volunteers"** are typically past or current patients relevant to the specialty, brought in by the examining host. Examinations take place at selected host centers across the UK and Ireland and the format (effective from August 2022) is as follows: **Day 1: Clinical Examinations** The clinical examination segment is a comprehensive 90-minute assessment that integrates patient interactions with clinical scenario evaluations. Examinees engage with 'volunteers'—actual patients—and are evaluated by two examiners, with a potential addition of an external examiner. This structure ensures a rigorous yet focused evaluation of the candidates' clinical proficiency. A broad overview can be visualised below. ![FRCS Plastic Surgery Exam Format, FRCS Plastic Surgery, FRCS Plast, FRCS Exam, FRCS Plast Exam](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/FRCS-Plast-5.png) FRCS Plastic Surgery Exam Format In more detail, the exam format is structured as follows: - **Long Cases:** Within a 30-minute session, candidates interact with **two** **volunteers**, dedicating approximately 15 minutes to each. - **Medium Cases:** This 30-minute segment involves **three** **volunteers**, allotting roughly 10 minutes per volunteer. - **Short Cases**: The final 30-minute portion covers **five clinical scenarios**, with an average of 6 minutes devoted to each. This is traditionally been referred to as "The Shorts". In the Long and Medium Cases, you'll be evaluated on: Basic knowledge, Higher-order processing, Clinical skills, and Professionalism. For Short Cases, the assessment covers Basic knowledge and Higher-order processing. 💡 ****Tip:** No breaks are given between individual cases within a section, like the long case. However, short breaks are provided between different sections, such as transitioning from the long case to the medium case. **Day 2 Oral Examinations** The Oral Examinations of the FRCS Plast involve a 90-minute oral test, broken down into three 30-minute stations. Each station concentrates on three specific themes, with two scenarios provided for each theme. The objective is to discuss all three themes within the allocated 30 minutes for each segment This section has been traditionally referred to as the '*Vivas*'. ![FRCS Plastic Surgery Exam Format, FRCS Plastic Surgery, FRCS Plast, FRCS Exam, FRCS Plast Exam](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/FRCS-Plast-4.png) FRCS Section 2 Oral Examinations - **Oral Station 1** delves into Trauma, Burns, and the Adult Upper Limb. Within this, candidates will discuss the intricacies of burn management, the spectrum of upper limb traumas, and various facial and lower limb traumatic injuries. - **Oral Station 2** centers on Acute Head and neck Tumours, Congenital anomalies, and Trunk and perineal reconstruction. This involves a deep dive into head and neck surgical procedures, management of congenital deformities like cleft lip and palate, and the nuances of perineal and breast reconstruction. - **Oral Station 3** encompasses a wide range of topics from Generic Plastic Surgery Techniques to Skin Cancer, Sarcoma, and General Professional Capability. This session ensures a comprehensive evaluation of a candidate's skill in wound management, vascular anomalies, ethical considerations, and more." 💡 ****Tip:** Section 2 is conducted in a different hospital each year. Some hospitals may have specific interests, for example, brachial plexus or lower limb trauma. This FRCS Plastic Surgery exam structure can be visualised in the table below. It is important to note, that the Intercollegiate Specialty Board in Plastic Surgery reserves the right to modify the format of the examination. ![FRCS Exam Syllabus, Curriculum, FRCS Plastic Surgery, FRCS Plast, FRCS Exam, FRCS Plast Exam](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/FRCS-Plast-1.png) FRCS Plastic Surgery Exam Structure 💡 ****Tip:** Generally, between each oral station you will have break and return to the 'green room'. This is approximately 15 minutes. The Joint Committee on Intercollegiate Examinations (JCIE) is dedicated to continually refining its exam processes for optimal reliability. Notably: - Examiners work in pairs but mark independently. - The exam consists of 114 marking events. - A score of 6 on a scale of 4 to 8 is deemed as passing, setting the pass threshold at a cumulative score of 684\. This may change based on JCIE decisions. **Performance Metrics:** Candidates are assessed across four pillars: 1. **Basic Knowledge**: Measures your foundational grasp. 2. **Higher Order Processing**: Gauges analytical, decision-making, and prioritization capabilities. 3. **Clinical Skills**: Evaluates expertise in clinical history taking, examination, and diagnosis. 4. **Professionalism**: Assesses interpersonal skills, ethical understanding, respect, and empathy. **Rating Insights**: - **4**: Major deficiencies in knowledge and skills, inappropriate conduct. - **5**: Some gaps in knowledge, challenges with clinical skills and decisions. - **6**: Satisfactory across all areas with decent interpersonal behaviour. - **7**: Strong knowledge and skills; builds rapport effectively. - **8**: Exceptional in all dimensions; showcases exemplary behaviour and understanding. To thrive, candidates should aspire to excel in knowledge, analytical acumen, clinical expertise, and professional demeanour. All candidates achieving the required score or above can pass, with no set group pass rate for clinical sections 💡 ****Tip:** If you feel you didn't perform well in a particular segment, don't lose hope. You have the opportunity to compensate in the following sections. --- ## FRCS Plastic Surgery (Plast) Exam Dates The FRCS Plast Exam is conducted several times a year. **Section 1** *usually* takes place in March and November**. Section 2** *usually* takes place in February and October. The timeline of events is illustrated below with an *example.* ![ FRCS Plastic Surgery, FRCS Plast, FRCS Exam, FRCS Plast Exam, FRCS Plast Exam Dates, FRCS Plastic Surgery Exam Dates](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/FRCS-Plast-9.png) FRCS PLAST Example Timeline It's crucial to be aware of the application deadlines, which are usually set a few months before the actual exam dates. Late applications might not be entertained. For precise exam dates, please click [here](https://www.jcie.org.uk/calendar/calendar.aspx?ref=theplasticsfella.com). --- ## FRCS Plastic Surgery (Plast) Preparation Tools ****Key Point** Leveraging educational tools tailored for the FRCS Plast can significantly boost preparation, enhance understanding, and increase the likelihood of success in the exam. Everyone is different. Here is a collection of resources you might find useful. In the challenging journey of preparing for the FRCS Plast, it's essential to have the right resources by your side. FRCS plastic surgery revision courses have notoriously been quite expensive, unfortunately. [thePlasticsPro](https://www.theplasticsfella.com/landing/) offers a suite of educational tools designed specifically for the FRCS: [**thePlasticsFlash**](https://www.theplasticsfella.com/theplasticsflash/) Dive into a collection of over +1000 Plastic Surgery flashcards. Curated from past exams, these cards come with detailed answers and references, ensuring comprehensive coverage. With Anki compatibility being rolled out, they're perfect for active recall and spaced repetition. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/Screenshot-2023-11-04-at-23.55.43-1.png) Largest Online Flashcard [Database](https://www.theplasticsfella.com/theplasticsflash/) [**AI-generated Clinical Cases**](https://www.theplasticsfella.com/tag/clinical-cases/) This assesses your clinical expertise, decision-making, and management skills through an oral "viva" structure, using real-world scenarios representative of clinical practice and exams ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/aCubital-Tunnel-Syndrome-1.png) An example clinical case [**thePlasticsPaper**](https://www.theplasticsfella.com/theplasticspaper-newsletter/) Stay updated with the latest in plastic surgery. Every week, enjoy curated content from trusted resources. The "Articles of the Week" section offers concise summaries of recent evidence, an excellent resource for your FRCS Plast exam. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/thePlasticsPaper-Logo---Official-4.png) ## thePlasticsPaper 3000+ readers updated on Plastic Surgery, every Sunday. Read Email sent! Check your inbox to complete your signup. No spam. Unsubscribe anytime. [**Journal Club**](https://www.theplasticsfella.com/tag/journals/): Deepen your understanding by exploring clinical cases. This feature offers a practical approach, ensuring you're well-prepared for clinical scenarios in the exam. [**Twitter Community**](https://twitter.com/PlasticsFella?ref=theplasticsfella.com): Engage with a vibrant community of peers, experts, and enthusiasts. Discuss topics, share insights, and stay updated on the latest trends and developments in plastic surgery. **thePlasticsQuiz (Soon!)**: Engage with the largest online question bank dedicated to FRCS plastic surgery revision. Continually updated, this tool offers detailed answers, references, and images. A unique platform to identify and bridge knowledge gaps. By integrating [thePlasticsPro](https://www.theplasticsfella.com/landing/) into your study plan, you're not just preparing for an exam; you're immersing yourself in a holistic learning experience. Remember, while the FRCS Plast is challenging, with the right resources and dedication, success is within reach. 💡 ****Tip:** Consistency is key. Regularly using these tools can enhance retention and understanding, giving you a distinct advantage in the examination. ### --- ## FRCS Plastic Surgery (Plast) Pass Rate & Gold Medal. ****Key Point** Over the span from 2009 to 2023, CCT trainees consistently demonstrated superior performance in the FRCS Plast Section 1 and 2 examinations compared to their Non-CCT and "Out of Training" counterparts. However, all groups witnessed fluctuations in pass rates, with a general upward trend observable, especially in the latter years As we delve into the performance metrics from 2009 to 2023, it becomes evident that while there are variances across different training backgrounds, a commitment to excellence remains a common thread. This [data](https://www.jcie.org.uk/content/content.aspx?ID=9&ref=theplasticsfella.com) is publicly available. **Overall Pass Rate** The FRCS Plast Section 1 examination pass rates from June 2009 to June 2023 predominantly hovered above 80%. A peak performance was observed in June 2012 with a 98% pass rate. A brief decline to 58% in November 2015 is noticeable, followed by a recovery and consistent high pass rates in subsequent years, underscoring the resilience and high standards of the candidates. ![ FRCS Plastic Surgery, FRCS Plast, FRCS Exam, FRCS Plast Exam, FRCS Plast Exam Rates, FRCS Plastic Surgery Exam Pass Rates](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/11/FRCS-Plast-10.png) FRCS Plastic Surgery Exam Pass Rates Analyzing the FRCS Plast examination results from 2009 to 2023 provides a comprehensive understanding of pass rates across different candidate categories in both Section 1 and Section 2: **Section 1**: - **CCT Trainees**: Fluctuating pass rates, peaking at 96% in June 2019 and dipping to 55% in June 2015. - **Non-CCT Trainees**: High variability, with a top rate of 79% in November 2021 and a low of 26% in the same month. - **Out of Training**: Ranged from 100% in June 2021 to 44% in June 2023. - **Overall**: Upward trend, reaching 85% in June 2019 and settling at 70% by June 2023. **Section 2**: - **CCT Trainees**: Varied rates, highest at 90% in 2023 and lowest at 57% in September 2009. - **Non-CCT Trainees**: Fluctuations with a peak of 79% in March 2017 and a trough of 33% in September 2016. - **Out of Training**: High of 100% in May 2021 and low of 30% in February 2022. 💡 ****Tip:** Formalized training, like the CCT program, has consistently been shown to enhance success rates in the FRCS Plast exams. Consider this route for optimal results **"Gold" Medal** The Ian McGregor Medal is a prestigious accolade awarded to the top-performing candidate during their first attempt at Section 2 of the FRCS(Plast) examination. Endowed by the Association to celebrate exceptional achievement. The Intercollegiate Board selects the recipient, and the medal is engraved with the winner's name and credentials. 😎 This honour is not automatically conferred each time but is reserved for truly outstanding performances. --- ## FRCS Plastic Surgery (Plast) Cost ****Key Point** The FRCS Plast exam fee of £1904 covers a wide range of operational, developmental, and logistical costs associated with ensuring a high-quality and rigorous assessment experience. **Examination Fee Breakdown** The comprehensive fee for the FRCS Plast exam stands at £1904\. This is divided into £552 for Section 1 and £1352 for Section 2\. Candidates must pay the full amount during the online application process, which is credited to their individual fee account. If a candidate needs to re-sit any part of the examination, the corresponding fee will be deducted from their fee account. **Allocation of the Fee** The Joint Committee on Intercollegiate Examinations (JCIE) operates as a self-financing entity. The examination fee primarily funds: - Running costs of the JCIE, including salaries and pensions. - Operational costs for the JCIE and its 10 Intercollegiate Specialty Boards (ISBs). - Development of the examination. - All expenses related to Section 2 examination venues, including catering. - Travel and accommodation for patients and examiners. **Compensation for Examiners** Examiners involved in the FRCS Plast examination do not receive any financial compensation for their contribution. They generously volunteer their time and expertise, showcasing their dedication to the continuous improvement and evolution of the examinations. 💡 ****Tip:** Don't forget to include transportation to the examination venues and accommodation costs when budgeting. --- ## Summary of FRCS Plastic Surgery (Plast) Exam ****Key Point** The FRCS Plast exam, divided into written and clinical sections, rigorously assesses surgeons' competence in plastic surgery. Tailored resources aid in focused preparation for success. **Objective and Essence** The FRCS Plast stands as a robust testament to a surgeon's competence, emphasizing not just knowledge, but the ability to safely and effectively serve as an independent consultant in the specialized field of plastic surgery. **Exam Structure** The FRCS Plast exam is meticulously designed with two distinct sections: 1. **Written Examination (Section 1)**: This section assesses a surgeon's foundational knowledge through single-best answer (SBA) papers, ensuring a comprehensive grasp of the plastic surgery curriculum. 2. **Clinical and Oral Examinations (Section 2)**: These are hands-on evaluations that delve deeper, testing a candidate's clinical acumen, decision-making capabilities, and interpersonal skills through real-world patient interactions, scenarios, and viva voce examinations. **Preparation Resources** Embarking on the FRCS Plast journey necessitates rigorous preparation. Fortunately, a plethora of resources, ranging from flashcards to AI-generated clinical cases, are at a candidate's disposal. The key is to discern which tools and techniques resonate best with one's learning style and preferences. **Tips for Aspirants** While the journey is demanding, it's crucial to approach it with a strategic mindset. Consistency, active recall, and engagement with a community of peers and experts can enhance one's chances of success. Remember, the objective isn't just to pass an exam, but to emerge as a well-rounded, proficient consultant in plastic surgery. --- ### 💌 WALANT bros, Interview Prep, Hand Anatomy & more. URL: https://www.theplasticsfella.com/october-8th/ Last updated: 2023-10-08T14:49:07.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/october-8th/#a-letter-from-pfella) Reproducibility > surgical outcomes? 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-8th/#the-sunday-quiz) Intrinsic tightness is confusing +++ 3. 🔦 [****Spotlight**](https://www.theplasticsfella.com/october-8th/#spotlight) Updated Interview Prep for the new season. 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/october-8th/#image-of-the-week) AI-generated eyelid tumour. 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/october-8th/#tweets-of-the-week) WALANT bro memes & more. 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/october-8th/#ask-pfella) Best prep for the interviews? 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/october-8th/#articles-of-the-week) 3 hot reads on interview success! 8. 💕 [****Feedback**](https://www.theplasticsfella.com/october-8th/#feedback) Suggest ideas & give feedback! ****PS -** If you have an upcoming interview, these [answer templates](https://www.theplasticsfella.com/theplasticsinterviews/#answer-templates) will help you. ## A Letter from P'Fella ### Reproducibility > Outcomes 👋 ****Hey team!** Picture this: you're sipping your morning brew, scrolling through the Twitter universe, and suddenly you tumble down a rabbit hole of surgical wisdom and debate. So, grab your mug (maybe make it a double) and let’s dissect this together, shall we? ****👇** The [dialogue](https://x.com/georgetolisjr/status/1708902370443235512?s=20&ref=theplasticsfella.com) started with a striking observation: numerous promising s**urgical techniques don't get the widespread acceptance they deserve because they aren't universally reproducible**. The assumption, for a procedure to gain widespread acceptance, reproducibility is paramount. ![Image](https://media.discordapp.net/attachments/1098313749074554930/1159926709345329233/tpfeducation_surgical_decision_making_and_teaching_juniors_surg_2081249b-e676-4816-96a2-5c101f772784.png?ex=6532cced&is=652057ed&hm=8c321d69bc2194f46060c668fedfb102b56bc0bb8cf8f9c327b1898193c20c24&=&width=1028&height=1028) When diving deep into a topic like reproducibility in surgery, the terrain is multi-faceted and ever-evolving. Here are some key takeaways that emerged: - **Selection Bias:** Are we inadvertently favoring certain surgeries or surgeons, leaving others overlooked? - **The Training Timeline:** The timing of exposure during training can significantly shape a surgeon's journey. Early introductions to innovative procedures can set emerging surgeons on a transformative path. - **Navigating the Politics:** Tightening referral guidelines and stringent credentialing can cause shifts in our medical community. This approach might lead to a scenario where a select few become guardians of their domains, potentially inhibiting broader progress. - **Teachability, Reproducibility, and Equality:** A surgical procedure's success hinges on its teachability and reproducibility. Moreover, it's essential to address any lurking biases or monopolies in the medical world. Ensuring that all voices are equally represented and respected is vital for the collective growth of the medical community. **A Side Note on Publications:** Interestingly, while there's a plethora of publications discussing [reproducibility](https://pubmed.ncbi.nlm.nih.gov/7065877/?ref=theplasticsfella.com) in research, there seems to be a notable gap when it comes to reproducibility in surgery. It's an area demanding more spotlight and scholarly attention. Reproducibility isn't solely about mastering a technique; it encapsulates training, exposure, politics, and beyond. As we march forward in the surgical domain, our compass should always point towards patient well-being. Till our next tête-à-tête, P'Fella ❤️ ## The Sunday Quiz ### [Intrinsic Muscle](https://www.theplasticsfella.com/intrinsic-plus/) Anatomy "[Intrinsic Plus](https://www.theplasticsfella.com/intrinsic-plus/)" is the ****tightness** of the interossei & lumbricals. This results in an imbalance of forces that presents as ****MCPJ** ****hyperflexion** and ****PIPJ hyperextension.** Chronic tightness can result in [intrinsic contractures](https://www.theplasticsfella.com/intrinsic-plus/) and swan-neck deformities. It was described by Finochietto in [1920](https://p3.usal.edu.ar/index.php/signos/article/view/2712/3334?ref=theplasticsfella.com) and later expanded upon by Bunnell in [1946](https://pubmed.ncbi.nlm.nih.gov/18874816/?ref=theplasticsfella.com). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Bunnells-Test-for-Intrinsic-Tightness-1.png) Reveal this week's question Which statement correctly describes the "Intrinsic Plus" condition in the hand? - It is a condition caused by the imbalance between the interossei & lumbricals, leading to MCPJ hyperextension and PIPJ hyperflexion. - It was first identified and completely described by Bunnell in 1946. - "Intrinsic Plus" is marked by tightness in the interossei and lumbricals causing MCPJ hyperflexion and PIPJ hyperextension, first identified by Finochietto in 1920. - Intrinsic tightness in the hand is primarily a result of injuries like high median nerve palsy and doesn't involve issues like fractures or Rheumatoid Arthritis. Name: Email: ## Spotlight ### Updated Interview Prep for 2023-2024 In this section, you'll discover noteworthy events, must-attend webinars, and curated courses tailored just for you. Plus, get exclusive first looks at our latest features. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/2-10.png) #### Interview prep Tailored for 2023-2043 Plastic Surgery interviews, diving into past questions & successful candidate experiences. 🚀 Mock interviews, making prep feel more like the real deal. 🎯 Answer Templates: basically, your interview cheat sheets. 🧠 Academic: Get "fluent" in Plastic Surgery lingo 🤗 Personal Skills: Learn to hype yourself up – in the right way! ✅ Probity & Integrity: guaranteed interview stations. 🔥 Commitment & Development: Show 'em you're in it for the long haul. 🩺 Clinical Knowledge: real scenarios on hot plastic surgery topics. 💼 Real-time practice with feedback as an option. It's pretty popular every year! 🚀 [Check it out! ](https://www.theplasticsfella.com/theplasticsinterviews/) ## ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/cyst-eyelid.png) AI-generated Upper Eyelid Lesion ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > WALANT bros be like… [pic.twitter.com/bPiaPhESqN](https://t.co/bPiaPhESqN?ref=theplasticsfella.com) > > — thePlasticsFella (@PlasticsFella) [September 23, 2023](https://twitter.com/PlasticsFella/status/1705650416485101780?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Insane. [#GPT4](https://twitter.com/hashtag/GPT4?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) Vision can even read doctor's notes! [pic.twitter.com/ZZy4nmvL32](https://t.co/ZZy4nmvL32?ref=theplasticsfella.com) > > — DataChazGPT 🤯 (not a bot) (@DataChaz) [October 2, 2023](https://twitter.com/DataChaz/status/1708859825562546408?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > One view is NO view [pic.twitter.com/OxUS0jQ0dE](https://t.co/OxUS0jQ0dE?ref=theplasticsfella.com) > > — Sameer Raniga (@samrad77) [October 1, 2023](https://twitter.com/samrad77/status/1708447232192638991?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [](https://x.com/OBandarchi/status/1708214418998468789?s=20&ref=theplasticsfella.com) ## Ask P'Fella ### You ask, I'll answer Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. ❓ ****Suzanne's Question** I’ve found P’Fella’s ****interview section** extremely helpful for interview practice. With an interview looming do you have any advice on what to focus on the day before? Thanks and good luck to everyone with interviews coming up! Hey! First off, thanks for the kind words about the [interview section](https://www.theplasticsfella.com/theplasticsinterviews/)! 🙌 Seems to have helped a lot of **successful candidates**. Alright, so here's my two cents for the day before: 1. **Chill Mode On**: Seriously, just take a breather. Whether that's jamming to your favourite tunes, meditating, or taking a stroll – just do you and relax. 2. **Quick Glance**: Dive into those [Answer Templates](https://www.theplasticsfella.com/theplasticsinterviews/#answer-templates) – SCALPEL!, ACED!, SCARRED!, and IDEA!. They're like the **cheat codes** for your interview game. 3. **Daydream a Bit**: Picture yourself nailing that interview. Sounds silly, but trust me, it helps. 4. **Hit the Hay Early**: Nothing beats being fresh. So, get some solid Zzz's. I personally believe in the "less is more" philosophy, especially the day before a big event. A clear, uncluttered mind works wonders. P'Fella ❤️ --- Ask P'Fella Now 4 questions submitted in the last 7 days... ## Articles of the Week ### 3 must-read articles on [interviews](https://www.theplasticsfella.com/theplasticsinterviews/)! 📚 #### 3 Must-reads 1. [****Does the interview affect your ranking?** ](https://pubmed.ncbi.nlm.nih.gov/37301643/?ref=theplasticsfella.com) De May H, Marquez JL, Scott K, Pires G, Crombie C. The Association Between Interview Day and Rank Order in Plastic Surgery Match: Is Recency Effect to Blame? J Surg Educ. 2023 Aug;80(8):1172-1178\. 2. [****How the virtual interview changes things**](https://pubmed.ncbi.nlm.nih.gov/35819981/?ref=theplasticsfella.com) Ferry AM, Asaad M, Elmorsi R, Rajesh A, Williams EM, Wolf SE, Rohrich RJ, Pederson WC, Maricevich RS. Impact of the Virtual Format on Plastic Surgery Residency and Fellowship Interviews: A National Cross-Sectional Study. Plast Reconstr Surg. 2022 Sep 1;150(3):684e-690e. 3. [****Plastic Surgery Interview Optimisation** ](https://pubmed.ncbi.nlm.nih.gov/34699504/?ref=theplasticsfella.com) Rohrich RJ, Rodriguez ED, Unger JG. How to Put Your Best Self Forward in Plastic Surgery Residency Interviews. Plast Reconstr Surg. 2021 Nov 1;148(5S):97S-100S. doi: 10.1097/01.prs.0000794904.88349.7e. PMID: 34699504. ## Feedback ### P'Fella is trying out a new format, spotlighting one major topic each week. Do you prefer this focused approach? ### Suitability for Plastics URL: https://www.theplasticsfella.com/why-plastic-surgery/ Last updated: 2023-10-08T14:38:39.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Finger Replant URL: https://www.theplasticsfella.com/finger-replant-interview/ Last updated: 2023-10-08T14:39:46.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Free Flap Monitoring URL: https://www.theplasticsfella.com/free-flap-monitoring/ Last updated: 2024-02-03T11:26:49.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Personal Development & Achievements URL: https://www.theplasticsfella.com/personal-development-and-achievements/ Last updated: 2023-10-08T14:38:57.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Pigmented Lesion URL: https://www.theplasticsfella.com/pigmented-lesion/ Last updated: 2023-10-08T14:35:09.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Clinical Governance URL: https://www.theplasticsfella.com/clinical-governance/ Last updated: 2024-06-21T05:15:58.000Z Dear Lord, this is such a boring question! It's one of those questions which P'Fella hates to love. Hate that it is so predictable, love that it is so predictable! #### In this Section 1. [Overview of Governance](https://www.theplasticsfella.com/clinical-governance/#overview) 2. [7 Pillars](https://www.theplasticsfella.com/clinical-governance/#7-pillars) 3. [Alternative Questions](https://www.theplasticsfella.com/clinical-governance/#alternative-questions) 4. [Mock Interview and Answers](https://www.theplasticsfella.com/clinical-governance/#mock-interview) --- ## Overview There are 3 types of interview candidates - those who ****recite** definitions, those who ****put** the definition in their own words, and those who make clinical governance ****personal** to their experiences. Be the latter. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Clinical-Governance---What-is-it.png) To be able to answer questions about clinical governance well, you need to understand its origins, purpose, and development since its introduction. This can be explained in the infographic below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Clinical-Governance---Origin.png) --- ## 7 Pillars Realistically, you would not need to recite these 7 pillars in your interview. Your goal is to be fluent in 3 pillars relevant to both you and plastic surgery. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Clinical-Governance---Pillars.png) You would not need to recite these 7 pillars in your interview. Your goal is to be fluent in 3 pillars relevant to both you and plastic surgery. You should be aware of the remaining 4 pillars and be able to briefly discuss them if pushed. 💡 ****Tip**: link your examples with your previous answers. When you think about it, any type of question in the interview has a shade of clinical governance in it. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Clinical-Governance---Examples-of-the-7-Pillars.png) P'Fella recommends being *fluent* in **3 pillars of clinical governance**. The three recommendations are **clinical effectiveness & research**, **audit**, and **education & training.** They are most relevant to Plastic Surgery and also allow you to **overlap** with other commonly asked questions (**research, audit, and courses**). When you think about it, overlapping questions in clinical efficiency, which in turn is a form of governance \*mind blown\*. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Clinical-Governance---Examples-of-Opening-Lines.png) --- ## Alternative Questions Generally speaking, the "clinical governance questions" are not curveballs. They are very straightforward and boring (a little bit like the topic itself). Nonetheless, it's really important to be able to identify other potential questions. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Clinical-Governance---Related-Questions-2.png) Those questions above as past Plastic Surgery interview questions. When you think about it, they are all asking the same thing (to a certain degree). It's a technique and skill to be able to recognise the *purpose* of the question, regardless of the way it is asked. This skill is developed in more detail in the next lesson. --- ## Mock Interview ****Question**: How do you define clinical governance? #### Mock Answer 1 Clinical governance, for me, is a framework that forms the focus of my current practice and training in plastic surgery. Traditionally, there are 7 pillars to clinical governance. There are 3 aspects that are particularly relevant to both me and my team. Firstly, clinical effectiveness through research and audit is center-stage in my training. I am proud to practice evidence-based medicine and translate my research into clinical practice. Secondly, training and education play an active role in my training. From the beginning of the year, I set out a personal development plan which I am happy to say I achieved. This included performing 15 flexor tendons and 20 extensor tendons, for example. This clinical skill was augmented by my frequent attendance at webinars, online courses, and reading ThePlasticsFella weekly newsletter (thePlasticsPaper) Finally, risk management is incredibly important to my team's patient care. For example, I run the monthly M&M meeting and often advocate for my patients. In the future, and if I am successful in my interview today, I feel other pillars, such as staff management will become more relevant to me, my team, and my patients. #### Mock Answer 2 Clinical governance is the structure within which we all work on a daily basis in order to provide the best possible standard of care for our patients, but personally, I feel that the most relevant aspects to my practice are education, risk management, and audit. Through the COVID pandemic, I have tried to make the most of educational opportunities by branching out into less traditional forms of learning such as online webinars in order to keep my knowledge base up to date and have managed to attend a microsurgery and hand fracture course in between lockdowns. With regards to passing on knowledge, I am keen to teach, with a background as an anatomy demonstrator, and am currently a Trainee Lead. Risk management is encountered constantly and subtly, from the WHO checklist to safety netting patients. Finally, I am an active participant in my department's audit process. I have recently closed an audit loop looking at trauma waiting times to theatre and presented it at the local meeting, and am planning to close the loop on a further service evaluation on virtual follow up for skin cancer in order to ensure that the best possible standards are maintained in the department. #### Mock Answer 3 Clinical governance is a framework and structure by which organizations and individuals are accountable for the clinical care that they provide and develops a culture of constant quality improvement aiming for the best possible patient care and outcomes, as well as the best possible experience and outcomes for staff and for the institution itself. It traditionally comprises seven pillars of which I feel three are most relevant to me at this stage of my career. These are clinical effectiveness and research, audit and teaching and training. With regards research - I have been actively involved in research throughout my training, notably I have 14 publications, and have been recently involved in setting up, protocol writing and obtaining ethics committee approval for a randomised control trial. I also try to practice evidence based surgery as much as possible. With regards audit, I am actively involved in audit and quality improvement projects in my department, I have completed 6 audits in the last few years of which 5 I designed and lead and completed the audit cycle. Additionally I have published the results of one audit and presented another at a national conference. I am currently involved in an audit of efficiency in the trauma service and compliance with national standards. With regards teaching and education, I am heavily involved in teaching junior colleagues and medical students. I have a formal teaching role where I prepare the final year students for their examinations and for clinical practice. I am also focussed on my own training and development, I not only strive to attend educationcal courses and webinars related to my clinical work and skills e.g. micro, burns etc but also to other areas of my practice e.g. leadership and teaching. --- ### Ethics - Pillars, Research, Devices. URL: https://www.theplasticsfella.com/ethics/ Last updated: 2023-10-08T14:37:21.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Flexor Tendon Injury URL: https://www.theplasticsfella.com/flexor-tendon-injury-interview/ Last updated: 2023-10-08T14:39:38.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Evidence-Based Plastic Surgery URL: https://www.theplasticsfella.com/evidence-based-plastic-surgery/ Last updated: 2023-10-08T14:39:06.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Necrotizing Fasciitis URL: https://www.theplasticsfella.com/nectrozing-fasciitis/ Last updated: 2024-01-06T22:11:15.000Z The aim of this section is to improve your ability to diagnose and treat necrotizing fasciitis. A good candidate will be able to convey the important details, explain the severity of the emergency to the patient, and be aware of the urgency of the condition. _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### "Safe" Mistakes in Plastic Surgery URL: https://www.theplasticsfella.com/mistakes/ Last updated: 2023-10-08T14:37:35.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Your Future URL: https://www.theplasticsfella.com/your-future/ Last updated: 2023-10-08T14:38:29.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### A "Modest" Strength URL: https://www.theplasticsfella.com/strength/ Last updated: 2023-10-08T14:37:45.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Final Mock Interview URL: https://www.theplasticsfella.com/final-mock-interview/ Last updated: 2023-10-08T14:34:17.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Awareness of your weaknesses URL: https://www.theplasticsfella.com/weakness/ Last updated: 2023-10-08T14:37:59.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### 💌 "Ozempic Face" is now a thing, ulnar nerve insights, & updated clinical cases. URL: https://www.theplasticsfella.com/october-1st/ Last updated: 2024-02-11T20:06:57.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/october-1st/#a-letter-from-pfella) "Ozempic Face" - it's arrived. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/october-1st/#the-sunday-quiz) Do you **really* know the ulnar nerve? 3. 🔦 [****Spotlight**](https://www.theplasticsfella.com/october-1st/#spotlight) Clinical cases is growing. 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/october-1st/#image-of-the-week) AI-generated ulnar nerve signs. 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/october-1st/#tweets-of-the-week) P'Fella's 3 favourite tweets 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/october-1st/#ask-pfella) Should we mix local anaesthetics? 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/october-1st/#articles-of-the-week) 3 hot reads on the ulnar nerve! 8. 💕 [****Feedback**](https://www.theplasticsfella.com/october-1st/#feedback) P'Fella spotlighted the ulnar nerve. Do you like this focused format? ****PS -** Collectively, you've spent ****485,000 minutes** reading thePlasticsFella content over the past 30 days. That's phenomenal! ****Thank you!** ## A Letter from P'Fella ### "Ozempic Face" - it's arrived. 👋 ****Hey team!** I've stumbled upon an intriguing trend that's been gaining traction, and it's something we should all be in the know about. So, pour yourself a cup of joe (or tea) and let's delve into the phenomenon known as the “****Ozempic face**”! ****Dive in with me 👇** With the global spike in obesity, the hunt for effective solutions has been fervent. Making waves in this space are Ozempic, Wegovy, and Rybelsus - all champions of semaglutide. While they're predominantly in the diabetes ring, they're also making **off-label appearances in the weight loss arena**. But here's the curveball: Ozempic’s rapid weight loss magic can morph into the “**Ozempic face**,” marked by **drooping** skin and enhanced **wrinkles** due to the dip in facial fat. Picture shedding those cherubic cheeks only to be greeted by a prematurely aged reflection! ![Weight loss drugs: The science and side effects behind Ozempic and Wegovy | New Scientist](https://images.newscientist.com/wp-content/uploads/2023/07/25160939/SEI_165374972.jpg?width=1200) **What do the trends show? Quick Dive into the Latest Trends:** Cosmetic surgery is not just in vogue, it's exploding! There’s been a 19% surge since 2019\. - **Facelifts** alone have climbed by 8% in the last year. Given the “Ozempic face” trend combined with our selfie-dominant era, this spike doesn’t really shock. - **Eyes** are capturing attention, with eyelid surgery ranking fourth in popularity. - And, let's roll out the red carpet for **lip augmentation**! Clocking in a staggering 1,378,631 procedures in 2022, it seems like the globe is all set to flaunt those plush lips post-lockdown. Kudos to the influencer brigade! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/Screenshot-2023-10-01-at-10.17.38.png) Data from the recent [ASPS](https://www.plasticsurgery.org/plastic-surgery-statistics?ref=theplasticsfella.com) publication **In a Nutshell:** While Ozempic and its kin dangle the allure of a trimmer silhouette, they come packaged with the **unintentional tag of accelerated facial ageing**. As we ride this wave, let's ensure our dialogues remain open, guiding our patients with top-tier advice. Cheers and chat soon, P'Fella ❤️ ## The Sunday Quiz ### Cubital Tunnel Syndrome Cubital Tunnel Syndrome arises from the ****compression** of the ****ulnar** nerve within the cubital tunnel, manifesting as ****motor** and ****sensory** deficits. It ranks as the second most common compressive neuropathy ****Common sites of compression are (FLAME)** 1\. ****F** **CU Fascia:** forms the arcuate ligament with Osborne Ligament. 2\. ****L** **igament of Osborne:** roof of the cubital tunnel. 3\. ****A** **rcade of Struthers:** from intermuscular septum to medial triceps. 4\. ****M** **edial Intermuscle Septum** ****5** **.** ****E** **picondyle** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Cubital-Tunnel-Syndrome-2.png) Reveal this week's question A 50-year-old pianist presents to the clinic with complaints of paresthesia in her little finger and the ulnar side of the ring finger. She also reports reduced grip strength. On examination, the physician notes clawing, little finger abduction, and wasting of the 1st webspace. She demonstrates a positive Tinel’s test at the cubital tunnel and a positive elbow flexion test. To confirm her diagnosis, which investigation would be most indicative? - A) High-frequency ultrasound of 14 Hz measuring the ulnar nerve cross-sectional area of 0.065 squared cm. - B) MRI visualization of the C8-T1 nerve roots. - C) Two-point discrimination test in the little finger. - D) X-ray showing the presence of bone spurs at the elbow. Name: Email: ## Spotlight ### Clinical Cases is growing! In this section, you'll discover noteworthy events, must-attend webinars, and curated courses tailored just for you. Plus, get exclusive first looks at our latest features. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/a-Clinical-Cases-1.png) #### Clinical Scenarios 🌍 Real-world scenarios to mirror clinical practice and exams. 🎤 Structured as an oral "viva" to assess clinical expertise 🔍 Detailed exploration of the current evidence. 📅 Regularly updated cases, ensuring current content. 🚸 Coverage of a wide range of topics 💡 Learn decision-making and management skills. [Check them out! ](https://www.theplasticsfella.com/tag/clinical-cases/) ## ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/aCubital-Tunnel-Syndrome-2.png) AI-generated ulnar nerve palsy [Check out this ulnar nerve palsy patient](https://www.theplasticsfella.com/ulnar-nerve-palsy-clinical-case/) ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Guyon's canal: > An anatomic space along volar ulnar aspect of wrist,contains distal branches of ulnar nerve &artery ;venous & lymphatic vessels. Ulnar n can be compressed at 3 zones at canal: > Zone 1👉results in mixed motor & sensory symptoms > Zone 2👉only motor > Zone 3👉only sensory [pic.twitter.com/nNCUxUGTrr](https://t.co/nNCUxUGTrr?ref=theplasticsfella.com) > > — Dr.OMID BANDARCHI ,M.D. (@OBandarchi) [August 2, 2023](https://twitter.com/OBandarchi/status/1686608120565407744?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > just another of hundred cases with (sub)luxating ulnar nerve[https://t.co/x8goQJJCYS](https://t.co/x8goQJJCYS?ref=theplasticsfella.com) [pic.twitter.com/mYo82p5hED](https://t.co/mYo82p5hED?ref=theplasticsfella.com) > > — Sᴡɪss Uʟᴛʀᴀsᴏᴜɴᴅ Cᴇɴᴛᴇʀ - UZR (@Rheumatology) [September 10, 2023](https://twitter.com/Rheumatology/status/1700879916449861678?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Spotlight: Snapping Ulnar Nerve 🦾[#Diagnosis](https://twitter.com/hashtag/Diagnosis?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) is made from [#physicalexam](https://twitter.com/hashtag/physicalexam?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) where the ulnar nerve is observed to snap over the inside part of the humerus [#bone](https://twitter.com/hashtag/bone?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) called the medial epicondyle. > > MRI & X-Ray are also frequently obtained to assess for other associated [#injuries](https://twitter.com/hashtag/injuries?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/tVdes2EeYE](https://t.co/tVdes2EeYE?ref=theplasticsfella.com) > > — Dr. Chris Ahmad (@drchrisahmad) [August 22, 2023](https://twitter.com/drchrisahmad/status/1693906412668334279?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [ ](https://x.com/OBandarchi/status/1708214418998468789?s=20&ref=theplasticsfella.com) ## Ask P'Fella ### You ask, I'll answer Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. ❓ ****Libby's Question** Hello, I was wondering if you could help with a question about local anaesthetic. If mixing lidocaine and bupivacaine, can you use the maximum dose of each or do you have to taper it (e.g using 50% of the maximum dose of each)? I’ve had registrars and consultants telling me inconsistent things so hoping you could shed some light! Thank you 😊 Hey there! **This is a great question.** Thanks for bringing up this question about mixing lidocaine and bupivacaine. It's a grey area with varying practices. **I personally do not mix local anaesthetics.** Both these local anaesthetics are amides that **block** sodium channels to stop nerve signals. Some folks mix them for a better balance of fast action and long-lasting relief, while others stick to one based on the situation. The main thing to watch out for is keeping the total dose within safe limits to dodge toxicity. Some references like [Budney](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635186/?ref=theplasticsfella.com) (2019) suggest sticking to a combined max dose. **So, if you go half-max on lidocaine, the other half should be the max you go with bupivacaine.** For a quick example, in a 50kg person, 10ml of 1% lidocaine is half the max dose, and 10ml of levobupivacaine at 2.5mg/ml is a quarter of the max. Mixing 20ml of these two stays within the 75% of the max dose, which is on the safe side. But a 40ml mix hits 150% of the max, which could lead to trouble. Throwing adrenaline into the mix can up the max dose allowance for lidocaine, letting you use a larger volume safely ([French](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3954146/?ref=theplasticsfella.com), 2012) ![The class, duration, dose and toxicity of different local anaesthetics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Local-Anaesthetic.png) [Types of LA](https://www.theplasticsfella.com/local-anaesthetic/) Hope that clears things up a bit. Feel free to bounce back any more questions or thoughts P'Fella --- Ask P'Fella Now 4 questions submitted in the last 7 days... ## Articles of the Week ### 3 must-read articles! 📚 #### 3 Must-reads 1. [****What to do if you injure an ulnar nerve?** ](https://pubmed.ncbi.nlm.nih.gov/25442770/?ref=theplasticsfella.com) Woo A, Bakri K, Moran SL. Management of ulnar nerve injuries. J Hand Surg Am. 2015 Jan;40(1):173-81\. doi: 10.1016/j.jhsa.2014.04.038\. Epub 2014 Nov 6\. PMID: 25442770. 2. [****An algorithm for cubital tunnel syndrome** ](https://pubmed.ncbi.nlm.nih.gov/26243318/?ref=theplasticsfella.com) Boone S, Gelberman RH, Calfee RP. The Management of Cubital Tunnel Syndrome. J Hand Surg Am. 2015 Sep;40(9):1897-904; quiz 1904\. doi: 10.1016/j.jhsa.2015.03.011\. Epub 2015 Aug 1\. PMID: 26243318. 3. [****What actually is Guyon's Canal?**](https://pubmed.ncbi.nlm.nih.gov/25446410/?ref=theplasticsfella.com) Maroukis BL, Ogawa T, Rehim SA, Chung KC. Guyon canal: the evolution of clinical anatomy. J Hand Surg Am. 2015 Mar;40(3):560-5\. doi: 10.1016/j.jhsa.2014.09.026\. Epub 2014 Oct 29\. PMID: 25446410; PMCID: PMC4791630. ## Feedback ### P'Fella is trying out a new format, spotlighting one major topic each week. Do you prefer this focused approach? ### Audit - Definition, Examples & Questions URL: https://www.theplasticsfella.com/audit/ Last updated: 2023-10-08T14:39:23.000Z Audits are similar to pressure sores - not really that exciting, but an essential part of the Plastic Surgery curriculum. This section will focus on the commonly asked audit questions to help build your answer. _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Ulnar Nerve Palsy - Clinical Scenario URL: https://www.theplasticsfella.com/ulnar-nerve-palsy-clinical-case/ Last updated: 2024-09-04T19:17:08.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/10/aCubital-Tunnel-Syndrome-1.png) #### ****Objectives** ****1\.** Clinical diagnosis of an ulnar nerve palsy ****2\.** Describe the anatomical course of the ulnar nerve ****3.** Be aware of different aetiological theories ****5.** Provide justified investigations to the patient ****6\.** Joint decision-making process for a treatment option 7.. Have a thorough understanding of [cubital tunnel syndrome](https://www.theplasticsfella.com/cubital-tunnel-syndrome/) #### ## Section 1 ### Clinical Assessment _This post is for subscribers on the thePlastics Pro tier only._ ### Coping with Pressure URL: https://www.theplasticsfella.com/coping-with-pressure/ Last updated: 2023-10-08T14:38:09.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Professionalism URL: https://www.theplasticsfella.com/professionalism/ Last updated: 2023-10-08T14:35:44.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Clinical Risk Management URL: https://www.theplasticsfella.com/clinical-risk-management/ Last updated: 2023-10-08T14:38:21.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Open Disclosure URL: https://www.theplasticsfella.com/open-disclosure/ Last updated: 2023-10-08T14:36:04.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Your Training URL: https://www.theplasticsfella.com/training/ Last updated: 2023-10-08T14:36:35.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### Teaching in Plastic Surgery URL: https://www.theplasticsfella.com/teaching/ Last updated: 2023-10-08T14:36:53.000Z _This post is for subscribers on the the Plastics Lover and thePlastics Pro tiers only._ ### 💌 Females are better surgeons, flashcards 2.0, new paper format, & ganglions URL: https://www.theplasticsfella.com/september-10th/ Last updated: 2024-02-11T20:07:22.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/september-10th/#a-letter-from-pfella) Females are better surgeons. Evidence says so. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/september-10th/#the-sunday-quiz) How do you treat a ganglion? 3. 🔦 [****Spotlight**](https://www.theplasticsfella.com/september-10th/#spotlight) Join the waiting list for an updated flashcard system. 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/september-10th/#image-of-the-week) AI-generated hand swelling. 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/september-10th/#tweets-of-the-week) P'Fella's 3 favourite tweets 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/september-10th/#ask-pfella) Topical timolol for Infantile haemangiomas. 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/september-10th/#articles-of-the-week) 3 hot reads ganglions management. Deep dive: the best technique for ganglion aspiration? 8. 💕 [****Feedback**](https://www.theplasticsfella.com/september-10th/#feedback) P'Fella spotlighted ganglion cysts. Do you like this focused format? ****ps -** P'Fella is trying out a new format, spotlighting one major topic each week. Do you prefer this focused approach? ## A Letter from P'Fella ### Evidence suggests females are rocking the surgical world. 👋 ****Hey there!** Hope you're having a fabulous Sunday. I've got a little nugget of info for you that's been buzzing around recently. Have you heard that patients operated on by female surgeons seem to have slightly better outcomes? It's a headline that caught my eye in the [New York Times](https://www.nytimes.com/2022/02/08/well/live/female-male-surgeon.html?ref=theplasticsfella.com) and [Guardian](https://www.theguardian.com/society/2023/aug/30/female-surgeons-patient-outcomes-better-studies?ref=theplasticsfella.com) newspapers. Now, before you jump to conclusions, let's unwrap this! ****Dive in with me 👇** So, a couple of interesting studies from [Canada](https://jamanetwork.com/journals/jamasurgery/article-abstract/2786671?ref=theplasticsfella.com) and [Sweden](https://jamanetwork.com/journals/jamasurgery/fullarticle/2808895?ref=theplasticsfella.com) took a deep dive into over a million patient records. The scoop? Patients treated by female surgeons had fewer complications and needed less follow-up care than those treated by male surgeons. ![](https://static01.nyt.com/images/2022/02/08/well/08bakalar-surgeon/08bakalar-surgeon-articleLarge.jpg?quality=75&auto=webp&disable=upscale) Illustration by Eleni Kalorkoti **Why the Difference, Though?** It's not about being better or worse; it's about different approaches: - **Technique & Speed:** Female surgeons often take things a tad slower, focusing more on precision. - **Risk-Taking:** They tend to stick to the plan, switching techniques mid-surgery less often. **A Glimpse at the Numbers:** Here's a brief overview of the data presented in published articles from [Canada](https://jamanetwork.com/journals/jamasurgery/article-abstract/2786671?ref=theplasticsfella.com) and [Sweden](https://jamanetwork.com/journals/jamasurgery/fullarticle/2808895?ref=theplasticsfella.com). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/aaaUntitled-design.png) **But Hold Up! Some Caveats:** Studies have limits. While we see correlations, they don't mean direct causation. Some factors to consider: - **Complexity**: Varying case complexities might play a role. - **Data Gaps**: Some missing data and potential misattributions of lead surgeons. - **Scope**: Results are region-specific and might not be universally applicable. - **Assumptions**: A surgeon's time spent doesn't necessarily equate to precision. - **Shifting Views**: The image of the lone surgeon is outdated. **Here's the Real Talk:** This isn’t a competition. It's all about learning from each other. If we can pick up a trick or two from our colleagues, no matter their gender, then why not? At the end of the day, it's about the patient. If they're happy and healthy, then we've done our job. And hey, maybe we can all slow down a bit and see if it makes a difference. What do you think? Got any insights or stories? Hit reply; I'm all ears! Cheers and chat soon, P'Fella ❤️ ## The Sunday Quiz ### Best Management of a Ganglion The three main treatments for [ganglions](https://www.theplasticsfella.com/ganglion-cysts/) are observation, aspiration, and excision. ****\- Observation**: Reassurance with education on change of self-resolution ****\- Excision**: open or arthroscopic ****\- Aspiration ± injection** (commonly corticosteroids) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Recurrence-rates-Ganglion-Cyst-of-the-Hand.png) Reveal this week's question Which of the following statements regarding the treatment of ganglions is accurate? - A) Observation is a treatment method that offers instant symptom resolution and has the highest patient satisfaction. - B) Surgical excision, specifically open excision, has a recurrence rate of 59%. - C) Aspiration has a mean complication rate of 14%. - D) Open surgical excision has a higher rate of post-operative wrist weakness compared to other treatments. Name: Email: ## Spotlight ### thePlasticsFlash 2.0 is nearly here! In this section, you'll discover noteworthy events, must-attend webinars, and curated courses tailored just for you. Plus, get exclusive first looks at our latest features. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Pick-4-1.png) #### thePlasticsFlash 2.0 🌍 World's Largest Database. Period. 🛠️ Customise your deck. 🔍 Filter topics & levels. 🤖 AI spots & tackles weaknesses. 📊 Compare with peers in real-time. 🔢 AI crunches your performance. ⚡ Instant scores & updates. 🔁 Micro-spaced repetitions. 🎯 Focus or Casual? You choose [Get early eaccess](https://www.theplasticsfella.com/plastic-surgery-flashcards/) ## ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/eventsss.png) #### 6 Upcoming Events 1. [****BAPRAS Celtic Meeting**](https://bapras.eventsair.com/bapras-celtic-2023?ref=theplasticsfella.com) \- Dunblane, 14th Sept. 2. [****ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 3. [****BAPRAS Cleft Lip, Palate & EAR**](https://bapras.eventsair.com/bapras-aec---53?ref=theplasticsfella.com) \- Sheffield, 10th Oct 4. [****European Hand Trauma Congress**](https://handprevention2023.org/?ref=theplasticsfella.com) \- Bulgaria, Oct 19\. 5. [****Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 6. [****BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/AI-generated-image-ganglion.png) AI-generated [ganglion](https://www.theplasticsfella.com/ganglion-cysts/) (with only 4 fingers!) ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Given only this X-ray, can you initially determine the disease the patient is suffering from?[#MedTwitter](https://twitter.com/hashtag/MedTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#ortho](https://twitter.com/hashtag/ortho?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/1CkFcETFal](https://t.co/1CkFcETFal?ref=theplasticsfella.com) > > — Jian Wang, MD, PhD, FCMDA (@OrthoJianWANG) [September 8, 2023](https://twitter.com/OrthoJianWANG/status/1699986658224189668?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Interview Tip: > > Before each interview, google the name of the hospital you’re interviewing at and click “News” at the top of Google. > > Stay up to date with the things that are going on in that program / hospital. It makes for good small talk to show you’ve thoroughly investigated… > > — Dr. Austin Price | Action Potential Mentoring, LLC (@action\_ap) [September 8, 2023](https://twitter.com/action%5Fap/status/1699957639784927359?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > In progress….[#trauma](https://twitter.com/hashtag/trauma?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#unfallchirurgie](https://twitter.com/hashtag/unfallchirurgie?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#medicine](https://twitter.com/hashtag/medicine?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#medicalart](https://twitter.com/hashtag/medicalart?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#medicalillustration](https://twitter.com/hashtag/medicalillustration?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#MedTwitter](https://twitter.com/hashtag/MedTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#TraumaTwitter](https://twitter.com/hashtag/TraumaTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#illustration](https://twitter.com/hashtag/illustration?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#procreate](https://twitter.com/hashtag/procreate?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#digitalart](https://twitter.com/hashtag/digitalart?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#anatomy](https://twitter.com/hashtag/anatomy?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#muscles](https://twitter.com/hashtag/muscles?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#bones](https://twitter.com/hashtag/bones?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#pelvis](https://twitter.com/hashtag/pelvis?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/Z0nlPNV9Tr](https://t.co/Z0nlPNV9Tr?ref=theplasticsfella.com) > > — Kimberly Ohm (@ohm\_kimberly) [September 7, 2023](https://twitter.com/ohm%5Fkimberly/status/1699667535279378505?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella ### You ask, I'll answer Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. ❓ ****Suzanne's Question, from Mexico.** "Small, isolated, superficial infantile haemangioma in pre-auricular area. 2x5mm. Otherwise well 2 month old. No associated features/concerns re visual/airway/auditory obstruction - purely cosmetic concern. Would topical timolol be indicated? Unclear risk/benefit from NICE 2015 review. Any other relevant evidence? Thanks Hey there! For the 2-month-old with a small infantile hemangioma (IH) in the pre-auricular area, topical timolol might be worth considering. Since its first report of its use in 2010, let's break down what the evidence says: A recent [consensus guideline](https://pubmed.ncbi.nlm.nih.gov/30584062/?ref=theplasticsfella.com) states: - "May prescribe topical timolol maleate for thin and/or superficial IHs" - Evidence is **moderate** - **62% clearance**... **7%** of infants required subsequent systemic β-blocker A clinical trial ([JAMA](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027942/?ref=theplasticsfella.com), 2021) showed that while topical timolol didn't significantly speed up the resolution of IH, it did improve the color of the lesion. So, even if the hemangioma doesn't disappear faster, it might look better with the treatment. There's some retrospective data suggesting that timolol might be a safe option for treating ulcerated IHs up to about 3 cm in size ([Boos](https://pubmed.ncbi.nlm.nih.gov/26892656/?ref=theplasticsfella.com), 2013). That said, if an IH does ulcerate, oral propranolol is often the go-to. We know a lot about infantile hemangiomas. Most of them just shrink on their own. Once parents get that these little growths usually peak in the first few months and then chill out, it often puts them at ease. Hope that helps! P'Fella --- Ask P'Fella Now 4 questions submitted in the last 7 days... ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. [****What is the best management of ganglions?**](https://pubmed.ncbi.nlm.nih.gov/25708437/?ref=theplasticsfella.com) Head L et al. Wrist ganglion treatment: systematic review and meta-analysis. J Hand Surg Am. 2015 Mar;40(3):546-53.e8\. doi: 10.1016/j.jhsa.2014.12.014. 2. [****How often do ganglions self-resolve?**](https://pubmed.ncbi.nlm.nih.gov/17950209/?ref=theplasticsfella.com) Dias JJ et al. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007 Oct;32(5):502-8. 3. [****Splint after ganglion excision?**](https://pubmed.ncbi.nlm.nih.gov/34096351/?ref=theplasticsfella.com) Wong CR et al. Immobilization of the Wrist After Dorsal Wrist Ganglion Excision: A Systematic Review and Survey of Current Practice. Hand (N Y). 2023 Mar;18(2):254-263.. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### What's the best way to aspirate a ganglion? Ever dealt with pesky wrist ganglia? Dive into our latest Journal Club where we compare old-school surgical remedies to an innovative technique using triamcinolone. Discover which method offers a quicker recovery with fewer side effects. Plus, get access to further reading for an even deeper dive [Read the deep-dive!](https://www.theplasticsfella.com/ganglion-cysts-journal-club/) ## Feedback ### P'Fella is trying out a new format, spotlighting one major topic each week. Do you prefer this focused approach? ### Technique for Aspirating Ganglions URL: https://www.theplasticsfella.com/ganglion-cysts-journal-club/ Last updated: 2023-09-10T11:39:40.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Screenshot-2023-09-10-at-11.54.22.png) #### In this Journal Club ****Summary** Wrist ganglia, those benign cystic nuisances, have two primary treatments: surgery or aspiration. This study throws a curveball: what if we drain the cyst and follow up with triamcinolone? Over 219 patients, the results were promising, especially for the triamcinolone route. ****Deep-Dive Critique** - ****Methodology:** It's a prospective study with a decent sample size, but is it blinded? A longer follow-up might offer more insights. - ****Demographics:** Most ganglia patients? Women in their 20s and 30s. - ****Results:** Triamcinolone? Fewer comebacks and side effects. Surgery? Longer recovery and higher recurrence. ****Take-Home Points** - ****Learning Point:** Ganglia treatments are evolving. Draining the cyst and adding triamcinolone might be the new kid on the block. - ****Clinical Practice:** Think twice about surgery. Triamcinolone shows fewer side effects and lower recurrence. Surgery has its merits, but also its downsides like post-op pain and recovery time. - ****Further Reading:** Interested in a deeper dive into wrist ganglia? Check out this [article](https://www.theplasticsfella.com/ganglion-cysts/) on hand and wrist ganglion cysts or this [systematic review](https://pubmed.ncbi.nlm.nih.gov/25708437/?ref=theplasticsfella.com) on PubMed. ## Article Summary ### An independent fresh perspective that can differ from the authors' abstract summary. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/Screenshot-2023-08-13-at-10.51.51.png) #### ****Level of Evidence: Prospective Study** ****Background:** Ganglia? Those benign wrist lumps. They're a common sight on wrists, and guess what? Surgery and non-surgery methods kinda work the same. ****Aim**: This study? It's all about seeing if draining the cyst and using triamcinolone beats regular surgery. ****Methods:** We had 219 folks with wrist ganglia. Half got the cyst drained and triamcinolone treatment, the other half? Straight-up surgery. We kept an eye on them for two years to see who had a comeback of the ganglion. ****Results:** Surgery had its issues: pain, less wrist movement, and 21.5% saw their ganglia return. But the triamcinolone crew? Just 8.4% had a recurrence. ****Conclusions:** Empty the cyst, add some triamcinolone, and you've got a neat solution. Fewer comebacks and less hassle than surgery. [Read the Article](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890133/?ref=theplasticsfella.com) ## Deep Dive ### An anlaysis to identify key findings, limitations, clinical practice improvements, and additional reading. _This post is for subscribers on the thePlastics Pro tier only._ ### Ganglion Cyst - Clinical Case URL: https://www.theplasticsfella.com/ganglion-cysts-clinical-case/ Last updated: 2024-09-04T19:15:39.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/Clinical-Case-Ganglion-Cyst-1.png) #### ****Objectives** ****1\.** Clinical diagnosis of a ganglion ****2\.** Describe the anatomical origins of ganglions ****3.** Be aware of different aetiological theories ****5.** Provide justified investigations to the patient ****6\.** Joint decision-making process for treatment options ## Section 1 ### Basic Science _This post is for subscribers on the thePlastics Pro tier only._ ### VRAM Flap URL: https://www.theplasticsfella.com/vram-flap/ Last updated: 2025-12-29T19:47:51.000Z #### In this Article 1. [Indications for a VRAM Flap](https://www.theplasticsfella.com/vram-flap/#indications-for-a-vram-flap) 2. [VRAM Flap Anatomy](https://www.theplasticsfella.com/vram-flap/#vram-flap-anatomy) 3. [Surgical Technique (+ Video)](https://www.theplasticsfella.com/vram-flap/#vram-flap-technique) 4. [Advantages and Disadvantages](https://www.theplasticsfella.com/vram-flap/#discussion) 5. [References](https://www.theplasticsfella.com/vram-flap/#references) **5 Key Points** 1\. VRAM is a Type III [Mathes and Nahai](https://www.theplasticsfella.com/mathes-and-nahai-classification/) Flap 2\. The most common indication is for pelvic reconstruction 3\. Dominant supply is from Deep Superior & Inferior Epigastric Arteries 4\. Can be raised as muscle-only, myocutaneous, osseomyocutaneous (rare) 5\. It obliterates dead space but results in a weakened abdominal wall. --- ## Indications for a VRAM Flap VRAM Flaps are primarily used in pelvic reconstruction. Prior to DIEP flaps, rectus abdominis muscle was commonly used in breast reconstruction. The VRAM flap is versatile to be used in breast, head & neck, and pelvic reconstruction3. Pelvic reconstruction is its primary use and indications are listed below: - Post-pelvic exenteration - Abdominoperineal resection - Vaginal wall reconstruction - Radiation-induced necrosis Chest reconstruction uses the superior pedicle whilst pelvic reconstruction uses the inferior pedicle. 💡 **Fun Fact:** The RAM flap was first described by Holmstron in 1979\. It was then popularised by Hartrampf. --- ## VRAM Flap Anatomy Type III [Mathes and Nahai](https://www.theplasticsfella.com/mathes-and-nahai-classification/) Flap based on the dominant Deep Superior and Inferior Epigastric Arteries. ### Rectus Abdominis Muscles The rectus abdominis muscles are paired, thin and flat muscle separated by the avascular line alba. It has a triangular-like shape as the base (6cm) is wider than the insertion (3cm). ![VRAM Flap, VRAM anatomy, RAM Flap, vertical rectus abdominis muscle flap, rectus abdominis muscle](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Rectus-Abdominis-Muscle-Anatomy.png) Anatomy of Rectus Abdominis **Key points are:** - **Origin**: anterior costal cartilages VI-VIII and xiphoid process. - **Insertion**: pubic symphysis and body. - **Innervation**: intercostal nerves (segmental supply reduces its role in functional muscle transfer) - **Function**: tension, restrict abdominal contents, and 30° of a sit-up/crunch. ### Rectus Sheath The **anterior and posterior rectus sheath** can be confusing in relation to the arcuate line. To understand it, it's important to understand the 3 types of structures involved: 1. **1** arcuate line: posterior sheath & transversalis fascia junction at level of ASIS 2. **2** sheaths: anterior and posterior sheath 3. **3** muscles: external (EO) & internal oblique (IO), transversus abdominis (TA) There is also the transversalis fascia (TF), preperitoneal fat and peritoneum deep to the posterior sheath. ![Arcuate Line, Anterior Rectus Sheath, Posterior Rectus Sheath, VRAM Flap, Anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/09/arcaute-line-aantomy.png) The Arcuate Line in the VRAM Flap The simplest way to understand this concept is by looking at each individual sheath above and below the arcuate line: **Anterior Sheath:** - **Above** the AL is formed by the EO + IO - **Below** the AL is formed by EO + TA + IO **Posterior Sheath:** - **Above** the AL is formed by the IO + TA + TF - **Below** the AL is replaced by transversalis fascia (TF) 💡 **Tip:** posterior sheath is replaced by the transversalis fascia below the arcuate line. ### Flap Composition The VRAM flap is a composite myocutaneous flap consisting of three layers: skin, subcutaneous fat, and muscle. Its versatility allows it to be dissected and raised as the following: - **Muscle**\-only - **Segmen­tal muscle** flap with preservation of part of the muscle - **Myocutaneous** flap with a transverse, oblique, or vertical skin island flap - **Osseomyocutaneous** (when including inferior ribs - not common) The most commonly used myocutaneous composition consists of skin, anterior rectus sheath, rectus muscle, and the perforating vessels which connect them. ### Flap Blood Supply The rectus abdominis muscle has two major pedicles (hence [Mathes and Nahai ](https://www.theplasticsfella.com/mathes-and-nahai-classification/)III) - **DIEA (Inferior):** dominant, external iliac artery branch. - **DSEA (Superior):** dominant, internal mammary artery branch It is worth noting it does receive additional supply from the **subcostal and intercostal arteries.** ![VRAM Flap, VRAM anatomy, RAM Flap, vertical rectus abdominis muscle flap, rectus abdominis muscle, anatomy](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/VRAM-Flap-Blood-Supply.png) VRAM Flap Blood Supply The superficial superior epigastric and circumflex arteries also play a minor role. ### Venous drainage of the flap The venous drainage primarily follows the arterial supply. The main veins involved are: - Deep Inferior Epigastric Vein - Deep Superior Epigastric Vein - Superficial Inferior Epigastric Vein VRAM flap has a motor & sensory innervation from the 7th–12th intercostal nerves. 💡 **Tip:** Inferiorly-based pedicles can be raised as a free flap. --- ## VRAM Flap Technique The design and size of the flap depend on surgical technique and characteristics of the donor and recipient areas. ### Design The design should be considered in conjunction with the ablative surgeons in relation to stomas and planned surgical incisions. 1. **Identify** the amount of skin island required overlying the rectus muscle. 2. **Mark** an outline of the rectus muscle 3. **Incise** vertically (along the muscle axis), just lateral to the midline. 4. **Consider** includingparaumbilical myocutaneous perforators into the paddle. 💡 **Prepping the patient:** consider getting a pre-operative CT angiogram or check for suitable perforators with a Doppler. ### Dissection and Elevation Essentially, this operation is the elevation of the rectus muscle, anterior sheath and overlying skin paddle based on the deep inferior epigastric vessels with preservation of the posterior sheath. 1. **Incise** down to the posterior rectus sheath 2. **Release** the rectus from its origin, semilunaris and linea alba. 3. **Ligate** the superior epigastric vessels 4. **Elevate** the rectus with the anterior rectus sheath and overlying skin paddle. 5. **Release** the rectus from its insertion at the pubis Many surgeons prefer to raise the VRAM prior to the laparotomy - to minimise potential contamination. 💡 **Tip:** protect the anterior sheath as it contains the vascular perforators to the overlying skin. ### Inset of Flap 1. **Rotate the flap** 180° on its DIEA pedicle 2. **Tunnel** via an intraperitoneal route into the pelvis (gives more length) or extrapelvic subcutaneous route to the perineum. 3. **Assess** the tension on the pedicle (not too much tension!) ### Closure 1. **Decide** if the anterior abdominal wall needs to be reinforced with an onlay mesh (above the arcuate line of the posterior sheath is often sufficient) 2. **Make** sure the omentum is hanging towards/in the pelvis. 3. **Suture** in 3 layers + drain insertion ### Post-operative Care A series of protocols have been designed and published. This is reflective of the different practices in departments. The following is the "Swansea" Protocol published in 20172. - **Bedrest**: 5 days in a lateral position, then start mobilizing. - **Catheter**: remove Day 10 - **Sutures**: remove Week 3 - **Sit out**: Week 3 - **Drains:** removeif <30mL/day. ### Variations VRAM flap variations do exist and are well described 1. - **Extended VRAM flap:** extra flap bulk & reach (supply by intercostals) - **Fascia-sparing:** lower hernia/bulge rate - **Component separation** donor-site closure: lower hernia & mesh rate - **Mesh fascial closure:** less fascial tension (bridged technique) - Include **greater omental flap**: reduced dead space, increase healthy tissue - **Deepithelialized** skin paddle: greater volume of the flap, can act as a sling. --- ## Discussion ### Advantages - **Ergonomics**: often don't need to change the position of the patient - **Cosmesis**: can improve body contour - **Reliability**: consistent blood supply - **Versatility**: raised in different compositions, inset into different areas ### Disadvantages - Abdominal wall weakening and increase risk of hernia. - Slight functional deficit - Difficult dissection in obese patients with increased risk of fat necrosis --- ## References on VRAM Flap 1. Campbell CA, Butler CE. Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg. 2011 Aug;128(2):447-458\. doi: [10.1097/PRS.0b013e31821e6fd2](https://pubmed.ncbi.nlm.nih.gov/21788836/?ref=theplasticsfella.com). PMID: 21788836. 2. Warbrick-Smith, J., & Drew, P. J. (2018). Post-operative care of VRAM flaps for perineal reconstruction: Results of a UK practice survey and literature review. Journal of Plastic, Reconstructive & Aesthetic Surgery, 71(2), 271–273\. doi:10.1016/j.bjps.2017.10.014 3. [Pelvic Reconstruction with Omental and VRAM Flaps: Anatomy, Surgical Technique, Normal Postoperative Findings, and Complications](https://pubs.rsna.org/doi/abs/10.1148/rg.317115112?ref=theplasticsfella.com)Tara L. Sagebiel, Silvana C. Faria, Aparna Balachandran, Justin M. Sacks, Y. Nancy You, and Priya R. BhosaleRadioGraphics201131:7, 2005-2019 4. Blondeel N, Vanderstraeten GG, Monstrey SJ et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50(5): [322–330](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiC6pC%5FkJb1AhVMa8AKHcQwC00QFnoECAYQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F9245865%2F&usg=AOvVaw2y3pHpGwGrKLa3X5JfTwBw). 5. Blondeel PN, Arnstein M, Verstraete K et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000; 106(6): 1[295–1299](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjYyNTGkJb1AhUKV8AKHaU%5FAVMQFnoECAUQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F11083558%2F&usg=AOvVaw3JqEruETPmD4twz%5F84h3A1). 6. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984; 73(1):[ 1–16](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjBqe3QkJb1AhWUlFwKHaMKAJMQFnoECAQQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F6197716%2F&usg=AOvVaw19kvK78PZ80yW7Jhe5ErIC). 7. Codner MA, Bostwick J 3rd, Nahai F, Bried JT, Eaves FF. TRAM flap vascular delay for high­risk breast reconstruction. Plast Reconstr Surg 1995; 96(7): [1615–1622.](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjG7o3XkJb1AhUQiFwKHXK6CzEQFnoECAYQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F7480281%2F&usg=AOvVaw2vgUPpLj65oswb4sfV9FkX) 8. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42(6): [645–648](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjfhMHdkJb1AhUIXMAKHSPXDykQFnoECAQQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F2605399%2F&usg=AOvVaw2gjGtl7yaMMvsvGNWPWBgE). 9. Mathes SJ, Nahai F. General principles. In: Mathes SJ, Nahai F (eds) Reconstructive surgery: principles, anatomy and technique. Churchill Livingstone, New York, [1997: 3–161](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwj%5Fy6bjkJb1AhXMUMAKHXXbAfcQFnoECAoQAQ&url=https%3A%2F%2Fwww.scirp.org%2F%28S%28vtj3fa45qm1ean45vvffcz55%29%29%2Freference%2FReferencesPapers.aspx%3FReferenceID%3D134181&usg=AOvVaw3WmSOTdEbO1mONJvrTF7At). 10. Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J Plast Surg 1984; 37(3): [330–350](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjR3qXrkJb1AhXClFwKHa3KCBkQFnoECAoQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F6234962%2F&usg=AOvVaw3KxG0J3oZ3%5Fr506DKPP9VA). --- ### Smoking when operating, 9 events, Scaphoids & Landmark Papers URL: https://www.theplasticsfella.com/august-13th/ Last updated: 2024-01-21T09:36:24.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/august-13th/#a-letter-from-pfella) Smoking in the Operating Room 🚬 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/august-13th/#the-sunday-quiz) The scaphoid & its blood supply 3. ****🎭**[ **New & Upcoming**](https://www.theplasticsfella.com/august-13th/#new-and-upcoming) 9 upcoming events to check out. 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/august-13th/#image-of-the-week) AI-generated scar revision. 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/august-13th/#tweets-of-the-week) P'Fella's 3 favourite tweets 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/august-13th/#ask-pfella) Tips to improve your surgical markings. 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/august-13th/#articles-of-the-week) 3 hot reads on sensation, antibiotics and carpal tunnel. Deep dive: should we treat scaphoid fractures? 8. 💕 [****Feedback**](https://www.theplasticsfella.com/august-13th/#feedback) Always looking to improve :) ****BTW: You can ask P'Fella a question** [****here**](https://www.theplasticsfella.com/august-13th/#ask-pfella)****.** ## A Letter from P'Fella ### Smoking in the Operating Room 🚬 👋 ****Happy Sunday,** There's a smoky issue lurking in our operating rooms and it's becoming a surgeon's unintended cigarrete. Surgical smoke may be as bad, if not worse, than cigarettes. Let's dive in! Read more 👇 Today, I'm diving deep into an issue that's been 'floating' around our operating rooms: surgical smoke. Thought your only encounter with smoke was when passing by that local cigar lounge? Think again. A slew of evidence published has shed light on a surprising revelation: the smoke generated during surgical procedures could be as harmful, if not worse, than puffing on those notorious cigarettes. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/image-1.png) **What's in the Smoke?** Surgical smoke arises from operated tissues, releasing more than just visible fumes: - **Cellular Material:** Contains both dead and live cells, risking disease transmission. - **Water Vapor:** While abundant, the real concern lies in what's mixed with it. - **Chemicals:** Houses over 80 harmful substances, including benzene and formaldehyde. - **Viruses & Bacteria:** Certain procedures release viruses and possibly aerosolized bacteria. - **Odorous Compounds:** The distinctive smell hints at various, sometimes carcinogenic, compounds. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/image.png) [Effectiveness of the evacuation systems](https://occup-med.biomedcentral.com/articles/10.1186/s12995-020-00259-y?ref=theplasticsfella.com) **What's the Impact?** Surgical smoke presents silent threats in the operating room. From the review "A systematic review of the harmful effects of surgical smoke inhalation on operating room personnel": - **Particle Size:** Easily inhalable. - **Viral Presence:** Contains viral DNA. - **Chemicals:** Packed with carcinogens, often beyond safe levels. Further, the study "Impact of Surgical Smoke on the Surgical Team and Operating Room Nurses" indicates: | Category | Description | | -------------------- | ------------------------------ | | Carcinogenicity | Elevates cancer risks. | | Mutagenicity | Potential for genetic changes. | | Respiratory Diseases | Linked to various lung issues. | | Pathogenic Spread | Can transmit HPV DNA and HBV. | | Tumor Transmission | Risks moving tumor cells. | Considering this, exhaust ventilation and protective measures are crucial. And ventilation works! Just check out the data above. Your thoughts on this subject? Hit reply and let's chat. Lots of love, P'Fella ❤️ ## The Sunday Quiz ### The Scaphoid's Blood Supply 🩸 The [scaphoid's](https://www.theplasticsfella.com/scaphoid-anatomy/) vascular supply is predominantly retrograde, intricately moving from distal to proximal. It primarily receives its blood supply from the ****radial artery**, which further bifurcates into the ****dorsal carpal branch** and the ****superficial palmar/volar branch**. These vessels enter the scaphoid through ****distal** half of the bone. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/Scaphoid_bone_-left_hand-_-_animation02.gif) Reveal this week's question What percentage of the scaphoid bone's intraosseous blood supply is provided by the radial artery, and how is the remaining supply distributed? - A) 60-70% by the radial artery, 30-40% by the volar branch - B) 70-80% by the radial artery, 20-30% by the superficial palmar/volar branch - C) 50-60% by the radial artery, 40-50% by the dorsal carpal branch - D) 80-90% by the radial artery, 10-20% by the ulnar artery Name: Email: ## New and Upcoming ### Educational Tools, Events & Courses P'Fella spotlights impactful events, crucial webinars, and hand-picked courses we know you'll love. Also, if there's a new feature, you'll be the first to know right here. ## ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/eventsss.png) #### 9 Upcoming Events 1. [****World Reconstructive Microsurgery**](https://www.wsrm.net/?ref=theplasticsfella.com) \- 18th August 2. [****New Zealand Plastics Annual**](http://nzaps2023.w.events4you.currinda.com/?ref=theplasticsfella.com#schedule) \- Queenstown, 18 August 3. [****PLASTA Facial Rehabilitation**](https://us02web.zoom.us/webinar/register/WN%5Fs5GCpttoQ4ecdA3eoPoX5g?ref=theplasticsfella.com#/registration) \- 30th August 4. [****BAPRAS Celtic Meeting**](https://bapras.eventsair.com/bapras-celtic-2023?ref=theplasticsfella.com) \- Dunblane, 14th Sept. 5. [****ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 6. [****BAPRAS Cleft Lip, Palate & EAR**](https://bapras.eventsair.com/bapras-aec---53?ref=theplasticsfella.com) \- Sheffield, 10th Oct 7. [****European Hand Trauma Congress**](https://handprevention2023.org/?ref=theplasticsfella.com) \- Bulgaria, Oct 19\. 8. [****Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 9. [****BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/aaaAI-generated-image.png) Patient requiring oral commissure reconstruction post dog-bite. ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > A 🧵 of peer reviewed published scientific research where the authors left out a key coauthor 😉: > > “As an AI language model…” [@MicrobiomDigest](https://twitter.com/MicrobiomDigest?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/AKvyIGyZq8](https://t.co/AKvyIGyZq8?ref=theplasticsfella.com) > > — Andrew Kean Gao (@itsandrewgao) [August 10, 2023](https://twitter.com/itsandrewgao/status/1689634600086315008?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Crafting a medical illustration or animation? Elevate your work with our detailed 3D model of the appendix. Explore now: [https://t.co/Nn7VX3DcAo](https://t.co/Nn7VX3DcAo?ref=theplasticsfella.com) [#3dmodel](https://twitter.com/hashtag/3dmodel?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#medical](https://twitter.com/hashtag/medical?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#appdevelopment](https://twitter.com/hashtag/appdevelopment?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#medicalanimation](https://twitter.com/hashtag/medicalanimation?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#science](https://twitter.com/hashtag/science?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#meded](https://twitter.com/hashtag/meded?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#medstudents](https://twitter.com/hashtag/medstudents?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#appendix](https://twitter.com/hashtag/appendix?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#vray](https://twitter.com/hashtag/vray?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/h0j3gzUWJQ](https://t.co/h0j3gzUWJQ?ref=theplasticsfella.com) > > — SciePro (@SciePro) [August 11, 2023](https://twitter.com/SciePro/status/1690016063415533568?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Is there a department out there that has used AI to create the perfect rota for a team of doctors so that there is both continuity and within working hours? > > I think the human-designed rota templates are not good enough anymore and have destroyed teams/firms & continuity > > — David Naumann (@davidnnaumann) [July 30, 2023](https://twitter.com/davidnnaumann/status/1685697678125006849?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella ### You ask, I'll answer Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. ❓ ****Pedro's Question, from Mexico.** Hola, desde Mexico , soy residente de primer año y tengo mucho problema con lo de los marcajes preoperatorios , siento que necesito mejorar mi relación con el espacio y la orientación , hay videos de marcajes o algo que ayude..? **Translation: Hello, from Mexico, I am a first-year resident and I have a lot of problems with the preoperative markings, I feel that I need to improve my relationship with space and orientation, are there videos of markings or something that helps...?* First off, kudos for reaching out! We've all been there, and trust me, preoperative markings can be tricky at first. But with time and practice, it'll become second nature. Here are some tips to help you out: 1. **Videos**: Check out YouTube. There are tons of surgeons sharing their marking techniques for different procedures. It's a goldmine! 2. **Workshops**: Keep an eye out for any local workshops or conferences. They often have hands-on sessions where you can learn from the pros. 3. **Find a Mentor**: If there's someone at your place who's a whiz at markings, maybe shadow them for a bit? It's always great to learn from someone with experience. 4. **Simulators**: There are some cool surgical simulators out there. They might help you get the hang of things. 5. **Back to Basics**: A quick anatomy refresher never hurts. There are some cool apps out there that can help with this. 6. **Feedback**: After you're done, ask someone to check your markings. It's the best way to learn. Hang in there, and keep practicing. And remember, every surgeon started where you are now. --- Ask P'Fella Now 3 questions submitted in the last 24 hours... ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. [****Sensation in lower limb flap reconstructio**](https://journals.lww.com/plasreconsurg/Fulltext/2023/08000/The%5FFate%5Fof%5FSensation%5Fin%5FNoninnervated%5FPerforator.40.aspx?ref=theplasticsfella.com)****n** Kim et al. The Fate of Sensation in Noninnervated Perforator Free Flaps in the Lower Extremity. Plastic and Reconstructive Surgery 152(2):p 440-449, August 2023. 2. [****Decrease your use of antibiotics in hand surgery**](https://www.jhandsurg.org/article/S0363-5023%2823%2900208-3/fulltext?ref=theplasticsfella.com) McKay et al. Evidence-Based Antibiotic Prophylaxis in Clean Hand Surgeries: An Educational Intervention to Decrease Use. J Hand Surg Am. 2023 Aug;48(8):770-779. 3. [****Endoscopic carpal tunnel release, not a good idea?**](https://www.jhandsurg.org/article/S0363-5023%2823%2900234-4/fulltext?ref=theplasticsfella.com) Carroll et al. Endoscopic Versus Open Carpal Tunnel Surgery: Risk Factors and Rates of Revision Surgery. J Hand Surg Am. 2023 Aug;48(8):757-763. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### How should we treat Scaphoid Fractures? This study investigates surgical versus non-surgical treatments for [scaphoid](https://www.theplasticsfella.com/scaphoid-anatomy/) fractures, focusing on those with displacements of 2mm or less. The multicenter, randomized trial shows no significant difference in pain and function beyond 12 weeks, but surgical fixation can increase complications. [Read the deep-dive!](https://www.theplasticsfella.com/scaphoid-fractures-journal/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) ### How should we treat scaphoid fractures? URL: https://www.theplasticsfella.com/scaphoid-fractures-journal/ Last updated: 2023-09-10T11:10:56.000Z #### In this Journal Club **[Summary](https://www.theplasticsfella.com/scaphoid-fractures-journal/#summary)** In a trial across 31 NHS hospitals, surgical treatment and cast immobilization for scaphoid waist fractures showed "similar" outcomes at 52 weeks. **[Deep-Dive: Good Design! ](https://www.theplasticsfella.com/scaphoid-fractures-journal/#deep-dive)** The multicentric study has broad applicability but potential open-label biases. More long-term data is needed. Detailed results and recruitment enhance validity. Validated tools and multiple analyses highlight the study's rigor and transparency. **[Take-Home Point: When to Operate! ](https://www.theplasticsfella.com/scaphoid-fractures-journal/#take-home-points)** Surgery and cast methods for scaphoid fractures show similar outcomes. Despite a surgical trend, 73 fractures need surgery over casting to prevent one non-union; larger displacements favor surgery **[Further Reading! ](https://www.theplasticsfella.com/scaphoid-fractures-journal/#further-reading)** Check out this other RCT on scaphoid fractures from 2005\. ## Summary ### An independent fresh perspective that can differ from the authors' abstract summary. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/08/Screenshot-2023-08-13-at-10.51.51.png) #### **Level of Evidence:** Multicentre RCT **Background**: Scaphoid fractures, representing a staggering 90% of carpal fractures, predominantly affect young men. Scaphoid fractures have seen an increasing trend towards surgical management, even though evidence of its superiority over non-surgical treatments remains inconclusive. **Aim** This study aimed to compare the clinical effectiveness of the two treatments, especially for fractures displaced by 2mm or less. **Methods** The study employed a robust design: a multicentre, randomized superiority trial. Adults aged 16 or older with a bicortical fracture of the scaphoid waist were included. Two groups were formed: one received early surgical fixation, and the other received cast immobilisation with immediate fixation for fractures failing to unite. **Results** The study observed no significant difference in pain and function between the surgery and cast immobilisation groups beyond 12 weeks. However, complications such as infection, nerve issues, and CRPS were more likely post-surgical fixation. Notably, screw penetration of joints was higher than anticipated in the surgery group, risking potential irreversible damage. **Conclusions** While surgery might offer short-term benefits in pain and function, the long-term outcomes between the two treatments show little difference. The broader trends in surgical treatments indicate an increasing preference for surgical intervention. The study's results, consistent with prior research, stress the importance of achieving fracture union. [Read the Article](https://pubmed.ncbi.nlm.nih.gov/32771106/?ref=theplasticsfella.com) ## Deep Dive ### An anlaysis to identify key findings, limitations, clinical practice improvements, and additional reading. _This post is for subscribers on the thePlastics Pro tier only._ ### Better surgeons operate more, new journal club & the CMC joint. URL: https://www.theplasticsfella.com/july-16th/ Last updated: 2024-01-21T09:36:42.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/july-16th/#a-letter-from-pfella) Surgery: A Numbers Game to Perfection 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/july-16th/#the-sunday-quiz) CMCJ arthritis classification (tips to remember) 3. ****🎭**[ **New & Upcoming**](https://www.theplasticsfella.com/july-16th/#new-and-upcoming) New Educational tools and upcoming events 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/july-16th/#image-of-the-week) AI-generated nodular melanoma 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/july-16th/#tweets-of-the-week) P'Fella's 3 favourite tweets 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/july-16th/#ask-pfella) Submit & I'll answer! 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/july-16th/#articles-of-the-week) 3 hot reads on UCLs, fractures and orthoplastics. Deep dive: should we treat mallet fingers? 8. 💕 [****Feedback**](https://www.theplasticsfella.com/july-16th/#feedback) Always looking to improve :) ****BTW: Have your heard the** [****deep-dive journal clubs**](https://www.theplasticsfella.com/july-16th/#articles-of-the-week) **are really good?** ## A Letter from P'Fella ### Surgery: A Numbers Game to Perfection 👋 ****Happy Sunday,** Got a fresh spin on "practice makes perfect" for you. A study in The BMJ found that surgeons who perform more surgeries have better patient outcomes - the more we do, the better we get. Read more 👇 Got a fresh (and evidence-based) spin on an old saying for you: practice makes perfect. But it's not just about repetition, it's about the numbers game in surgery. Intrigued? Let's get into it. A study just out in [The BMJ](https://www.bmj.com/content/381/bmj-2023-075355?ref=theplasticsfella.com) has found a fascinating link between the number of surgeries a surgeon performs and the outcomes for patients who undergo elective shoulder replacement surgery. Now, I hear you: "I'm a plastic and reconstructive surgeon, what's this got to do with me?" Stick with me here. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/Screenshot-2023-07-09-at-12.19.44.png) Association of mean annual consultant volume and deviation annual consultant volume on risk of serious adverse events (30 day and 90 day). Shaded areas represent 95% confidence intervals The study found that surgeons who clocked in more than 10.4 shoulder replacements per year had better patient outcomes. We're talking lower rates of revision surgery and reoperation, fewer serious adverse events, and shorter hospital stays. The takeaway? The more surgeries a surgeon performed, the better the outcomes for their patients. So, what's the scoop for us? It's a nudge about the power of experience and the value of sharpening our skills through repetition. Whether we're talking rhinoplasty or breast reconstruction, the principle holds: the more we do, the better we get. But it's not just about us leveling up. It's about our patients leveling up, too. Shorter hospital stays and fewer adverse events mean a smoother recovery process and a better overall experience for our patients. And that's the real win, isn't it? ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/10-000-hours.png) [10,000 hours rule](https://pubmed.ncbi.nlm.nih.gov/24602698/?ref=theplasticsfella.com) I'm curious to hear your thoughts on this. Are you seeing a similar trend in your practice? Is there a 'magic number' of surgeries that we, as plastic and reconstructive surgeons, should be aiming for each year? Hit reply and let P'Fella in on your thoughts. Until next time, keep practicing, keep perfecting, and keep making a difference. Lots of love, P'Fella ❤️ ## The Sunday Quiz ### Classifying Osteoarthritis ****Basal thumb osteoarthritis** is the destruction of hyaline articular cartilage of the scaphoid, 1st metacarpal, trapezium, trapezoid and distal radius surface. It can be subclassified into primary (ligament laxity and attenuation over time) and secondary (trauma). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/Basal-Thumb-Osteoarthritis-Definition-1.png) Reveal this week's question What stage of the Eaton classification is there widening of the trapezio-metacarpal joint? - A. Stage 1 - B. Stage 2 - C. Stage 3 - D. Stage 4 Name: Email: ## New and Upcoming ### Educational Tools, Events & Courses P'Fella spotlights impactful events, crucial webinars, and hand-picked courses we know you'll love. Also, if there's a new feature, you'll be the first to know right here. ## ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/eventsss.png) #### 4 Upcoming Events 1. [****World Reconstructive Microsurgery**](https://www.wsrm.net/?ref=theplasticsfella.com) \- 18th August 2. [****ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 3. [****Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 4. [****BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov ["Connect" with more Events](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/melanoma-AI.png) AI-generated image: nodular melanoma ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Blood gas when coming down from the summit of Everest. 😳 [#TC2023](https://twitter.com/hashtag/TC2023?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@Anaes\_Trainees](https://twitter.com/Anaes%5FTrainees?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/yVbVMUOBMw](https://t.co/yVbVMUOBMw?ref=theplasticsfella.com) > > — Emily (@dr\_doddle) [July 7, 2023](https://twitter.com/dr%5Fdoddle/status/1677277941762338822?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > I hope people’s takeaway message from recent medtwitter stories about mistakes, shortening medical school, and overall expertise is that medicine is quite difficult, actually. And we all should be campaigning for maximising training, not seeking the minimal viable product model. > > — Medlife Crisis (Rohin) (@MedCrisis) [July 8, 2023](https://twitter.com/MedCrisis/status/1677622251535908865?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > 🧵regarding 'the crimp' and other technical pointers having to do with securing surgical drains with suture. > > We'll go over my preferred method, other methods like the Roman sandal, some errors people make, and other factoids. > (1/ ) [pic.twitter.com/2nTB41hOuC](https://t.co/2nTB41hOuC?ref=theplasticsfella.com) > > — Ron Barbosa MD FACS (@rbarbosa91) [July 6, 2023](https://twitter.com/rbarbosa91/status/1676840058631098369?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella ### You ask, I'll answer Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. ❓ ****Mike's Question** How long your observe a keratoacanthoma ? ❗ ****P'Fella's Answer** Keratoacanthomas, they can be a bit of a headache. You gotta make sure the diagnosis is spot on. Mistaking them for something else might lead you to misdiagnose a high-risk skin cancer called SCC. So, these Keratoacanthomas grow pretty fast, like a few weeks fast, mainly on sun-exposed skin. You can spot them by their central crater filled with a "keratin plug". Now, if you've got a patient with a classic Keratoacanthoma, I'd schedule a follow-up in about 6 weeks. If the spot hasn't started to shrink by then, it's time to dig deeper with a biopsy for a clearer diagnosis. You might wonder, "Why not just remove it at first sight?" Well, it's not that simple. Under the microscope, Keratoacanthomas and SCCs look pretty much the same, making them hard to tell apart. So, if you remove a Keratoacanthoma thinking it's an SCC, the patient may end up with unnecessary lifelong check-ups per SCC guidelines. If you want to dive deeper into the nitty-gritty of these things, like the challenges in identifying them under the [microscope](https://pubmed.ncbi.nlm.nih.gov/20043514/?ref=theplasticsfella.com), how they [behave](https://pubmed.ncbi.nlm.nih.gov/25676096/?ref=theplasticsfella.com) over time, and when they [appear](https://www.jprasurg.com/article/S0007-1226%2804%2900157-2/fulltext?ref=theplasticsfella.com), there's plenty of reading material out there. Ask P'Fella Now 3 questions submitted in the last 24 hours... ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. [****When is "metal" risky in finger fractures?**](https://pubmed.ncbi.nlm.nih.gov/35305847/?ref=theplasticsfella.com) Grisdela et al. Factors Associated With Implant Removal Following Plate-and-Screw Fixation of Isolated Metacarpal Fractures. J Hand Surg Am. 2023 2. [****When can I go back to sport? UCL injuries**](https://www.jhsgo.org/article/S2589-5141%2823%2900045-2/fulltext?ref=theplasticsfella.com) Allahabadi et al. Return to Play After Thumb Ulnar Collateral Ligament Injuries Managed Surgically in Athletes-A Systematic Review. J Hand Surg Glob Online. 2023 3. [****Orthoplastic protocols actually work.**](https://www.injuryjournal.com/article/S0020-1383%2823%2900576-4/fulltext?ref=theplasticsfella.com) Ylitalo et al. Implementing an orthoplastic treatment protocol for open tibia fractures reduces complication rates in tertiary trauma unit. Injury. 2023 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### How should we treat Mallet Fingers? Uncover the intriguing journey from Mallet Finger Fractures to osteoarthritis in this riveting study! Despite a surprising twist of high OA incidence and diminished mobility post non-surgical treatment, the patient-reported outcomes surprisingly remain minimally affected - an unexpected plot twist that keeps you on the edge of your seat! [Read the deep-dive!](https://www.theplasticsfella.com/mallet-fractures-journal/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) ### How should we treat mallet fractures? (J Hand Surg 2023) URL: https://www.theplasticsfella.com/mallet-fractures-journal/ Last updated: 2023-07-16T09:57:40.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/Creative-and-Minimal-Portfolio-Presentation-2.png) #### In this Journal Club 1. **[Summary](https://www.theplasticsfella.com/mallet-fractures-journal/#summary)** Independent fresh perspective that differs from the authors. 2. **[Deep-Dive](https://www.theplasticsfella.com/mallet-fractures-journal/#deep-dive)** 3 Key Points 3 Limitations 3 ways to improve your clinical practice 3 recommended readings 3. **[Powerpoint Slides](https://www.theplasticsfella.com/mallet-fractures-journal/)** Coming soon! --- ## Summary ### An independent fresh perspective that can differ from the authors' abstract summary. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/07/Screenshot-2023-07-16-at-08.37.25.png) #### **Level of Evidence:** Retrospective cohort study **Background**: Treat mallet finger fractures (MFF) to minimize extension lag, reduce subluxation, and restore DIP joint congruency. This should prevent secondary osteoarthritis (OA). **Aim** Evaluate OA, functional outcomes, and PROMS after MFF. **Methods** Assessed radiographic osteoarthritis (OA), range of motion, pinch strength, and PROMs. The patient's healthy contralateral DIPJ was used as the control. **Results** A cohort of 52 MFF patients (mean duration: 12.1 years). \~40% had OA, with \~25% showing more severe OA than healthy joint. Slight reduction in outcomes & PROMS, which were moderately correlated with radiographic OA. **Conclusions** MFF-related radiological OA resembles natural joint degeneration in the DIP joint. It leads to reduced DIP joint range of motion but does not clinically impact PROMs. [Read the Article](https://www.jhandsurg.org/article/S0363-5023%2823%2900181-8/fulltext?ref=theplasticsfella.com) --- ## Deep Dive ### An anlaysis to identify key findings, limitations, clinical practice improvements, and additional reading. ## **Key Points** · **Learning**: Treatments, long-term stiffness and osteoarthritis · **Limitations**: Retrospective, bias, small size, and confounders · **Clinical practice:** Education, OA strategies, judicious surgery · **Further reading:** Systematic Reviews, Q-DASH, Natural History. --- ## 3 Learning Points There are 3 important learning points in this article: treatment of mallet fractures, complications of mallet finger injuries, and how to write a proper abstract. ### Treatment & Complications of Mallet Fractures ✅ The article accurately highlights that there's a scarcity of long-term studies on the non-surgical treatment of MFFs. Existing studies show a wide range in outcomes due to study design variation, small sample sizes, and differing osteoarthritis classification. The "Background" and "Discussion" sections of this article provide a solid foundation into the treatment options and complications of mallet finger injuries. - The **non-operative** treatment uses an extension splint on the Distal Interphalangeal (DIP) joint for 24/7 usage over 6-8 weeks. This approach suits acute soft tissue injuries, minimally displaced bony mallet injuries without joint subluxation. - **Operative** treatments like Closed Reduction Percutaneous Pinning (CRPP) and Open Reduction Internal Fixation (ORIF) are necessary for cases like volar subluxation of the distal phalanx or when more than 50% of the articular surface is involved or the articular gap is over 2mm. The treatment goal for mallet finger fractures (MFFs) is to ensure healing in a near anatomical position to reduce extension lag, subluxation, and restore DIP joint congruency. Undertreatment risks chronic issues like secondary osteoarthritis, flexion deformity, and persistent DIP joint stiffness. ### Long Term Outcomes from Non-Operative Management ❓ It is difficult to say if these findings as just "common sense". But it is nice to have a scientific basis to outcomes most hand surgeons would already hypothesise. From this study, the are a few important points and facts that can be drawn from the results 1. Patients will likely develop a stiffer finger than a non-injured finger 2. There will be greater degree of OA on the injured finger. 3. Non-union is unlikely. 4. Radiological findings do not strongly correlate to clinical findings. ### How to write a "proper" abstract ❌ The authors did not provided a clear abstract. There are some basic issues that should be improved upon. The structuring of the abstract could be improved, as the Results section appears to intrude upon the Methods section. The sentence, "At follow-up, there was an increase in OA in 41% to 44% of the MFFs" should be properly placed in the Results section as it describes the outcomes of the study, not the methodologies employed. The **conclusion** drawn in the study would benefit from more explicit phrasing and definitive assertions. The statement, "Radiological OA after an MFF is similar to the natural degenerative process in the DIP joint" needs to be explained more clearly for better understanding of the findings. I**nstead of using vague comparisons**, it would be more beneficial to state the impact of the results and their significance in the field. --- ## 3 Limitations P'Fella identified 3 limitations in the authors study design, outcome assessment and long term follow-up. **1\.** Retrospective design introduces potential inaccuracies and bias. **2\.** Radiographic disparities, small sample size, and low power skews results. **3**. Long-term follow-up and uncontrolled variables adds confounders. **Study Design** - **Retrospective Nature**: As a retrospective cohort study, it relies on past data and patient records, which might contain errors or omissions. The retrospective nature doesn't allow for control of variables or interventions during the course of the study, potentially affecting the validity of the results. As the authors state: "no radiograph of the healthy control digit at time of injury was obtained; thus, we do not know the true progression of degenerative changes in the healthy control DIP joint". - **Selection Bias**: Patients were selected based on diagnosis treatment codes, potentially not representing the full affected population. The exclusion of certain groups (those who can't communicate in Dutch or English, those with contralateral or multiple MFFs) can limit the generalizability of the results. - **Partial Blinding**: Despite some blinding, it might not be entirely possible to blind the patients or the clinicians to the patient's injury status, which could introduce bias. ❌ The authors "control" was the contra-lateral non-injured finger, so some of these findings are just "common sense". It was **not compared** to surgical management. **Outcome Assessment and Analysis** - **Radiographic Interpretation**: Radiographic assessments were conducted by two independent raters, which may have led to differences in interpretation. Even though consensus was reached, disagreements might have impacted the results' validity. - **Sample Size:** The small sample size of 52 patients might limit the study's power to detect significant differences and affect the results' generalizability. The authors states: "Since this is a retrospective cohort study, we aimed for as many inclusions as possible; therefore, we did not perform a sample size analysis". - **Post Hoc Power Analysis**: The post hoc power analysis revealed an inadequate power for the KL and OARSI classifications, indicating a high risk of type II errors (failing to detect a difference where one exists), which impacts the reliability of the study findings. As the authors state: "Post hoc power analyses showed inadequate power, meaning that only a descriptive analysis was possible". ✅ The authors clearly state their own limitations: "56% patients were not willing to participate or were lost to follow-up. This may have resulted in selection bias, leading to underestimation or overestimation of the radiological degree of OA" **Potential Confounders** - **Long Follow-Up Period:** The lengthy follow-up period of 10-15 years might introduce additional variables like changes in a patient's health status, lifestyle, or treatments, which could affect the results. - **Uncontrolled Variables**: The study didn't account for other factors like smoking, diet, other diseases, and physical activities. These could affect the progression of OA, introducing confounding variables. --- ## 3 Ways to Improve Your Clinical Practice P'Fella identified 3 ways to improve your clinical practice based on this publication. **1\.** Improved patient education **2\.** Proactive managment of OA. **3**. Consideration of Surgical Intervention . **Improved Patient Education** We could improve our practice by providing comprehensive patient education about the potential risks and outcomes of Mallet Finger Fractures (MFFs). This includes the likelihood of developing osteoarthritis (OA), the potential for a decrease in range of motion (ROM), and possible aesthetic changes to the hand. By informing patients of these risks prior to treatment, they can have realistic expectations about their recovery and potential long-term outcomes. **Proactive Management of Osteoarthritis** Given the observed increase in OA after MFF, surgeons should consider proactive strategies to manage and potentially delay the onset of OA. This could include exercises to maintain joint flexibility, medications, or lifestyle advice to slow the progression of OA. Additionally, more frequent follow-ups might be needed to monitor OA progression in MFF patients. **Consideration of Surgical Intervention** While all patients in this study were treated non-surgically, the results indicate that some patients (29%) had complaints post-treatment and two required arthrodesis due to persistent deformity. Surgeons might consider surgical interventions in some cases of MFF, especially in patients with severe fractures or those who prioritize hand aesthetics. Careful patient selection for surgical intervention, possibly taking into account factors like patient's activity level, profession, or personal preferences, might lead to better overall outcomes. --- ## 3 Further Recommended Readings [Complications and prognosis of treatment of mallet finger - PubMedThis study reviews complications of treatment in 123 mallet fingers treated operatively and nonoperatively. In the 84 digits splinted there was a 45% rate of complications, mostly skin related; however, these complications were almost always transient. For the 45 surgically treated digits the compli…![](https://cdn.ncbi.nlm.nih.gov/coreutils/nwds/img/favicons/favicon-192.png)PubMedP J Stern![](https://cdn.ncbi.nlm.nih.gov/pubmed/persistent/pubmed-meta-image.png)](https://pubmed.ncbi.nlm.nih.gov/3379263/?ref=theplasticsfella.com) [Surgical and Nonsurgical Management of Mallet Finger: A Systematic Review - PubMedTherapeutic IV.![](https://cdn.ncbi.nlm.nih.gov/coreutils/nwds/img/favicons/favicon-192.png)PubMedJames S Lin![](https://cdn.ncbi.nlm.nih.gov/pubmed/persistent/pubmed-meta-image.png)](https://pubmed.ncbi.nlm.nih.gov/29174096/?ref=theplasticsfella.com) [Development of the QuickDASH: comparison of three item-reduction approaches - PubMedThe concept-retention version is named the QuickDASH. It contains eleven items and is similar with regard to scores and properties to the full DASH. A comparison of item-reduction approaches suggested that the retention of clinically sensible and important content produced a comparable, if not sligh…![](https://cdn.ncbi.nlm.nih.gov/coreutils/nwds/img/favicons/favicon-192.png)PubMedDorcas E Beaton![](https://cdn.ncbi.nlm.nih.gov/pubmed/persistent/pubmed-meta-image.png)](https://pubmed.ncbi.nlm.nih.gov/15866967/?ref=theplasticsfella.com) --- ## ### 💌 Copy-Paste Medical Crisis, BCC Insights & AI Advances URL: https://www.theplasticsfella.com/june-25th/ Last updated: 2024-11-19T14:01:39.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-25th/#a-letter-from-pfella) +50% of medical records are now copy-paste. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-25th/#the-sunday-quiz) What actually is a high-risk BCC? 3. ****🎭**[ **New & Upcoming**](https://www.theplasticsfella.com/june-25th/#new-and-upcoming) Educational tools and new events 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/june-25th/#image-of-the-week) AI-generated keratotic horn 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/june-25th/#tweets-of-the-week) P'Fella's 3 favourite tweets 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/june-25th/#ask-pfella) Submit & I'll answer! 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/june-25th/#articles-of-the-week) 3 hot reads on fingers, face and infections. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/june-25th/#feedback) Always looking to improve :) ****BTW: Did you know you can** [****Ask P'Fella?**](https://www.theplasticsfella.com/june-25th/#ask-pfella) ## A Letter from P'Fella ### +50% of medical records are copy-paste. **Imagine if half of what you wrote was just copied from your past work, and not only that, but the amount you copied kept increasing each year!** Sounds crazy, right? Well, that's exactly what's happening in the world of electronic medical records (EMRs). A study by [JAMA](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796664?ref=theplasticsfella.com) found that about **50% of all text in EMRs was duplicated from previous entries**, and that the fraction of duplicated content increased from 33% in 2015 to over **54% in 2020!** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/06/Screenshot-2023-06-25-at-15.21.27.png) More notes, more duplication. This not only wastes our precious time but also casts doubt on the veracity of the information in the medical record. Try finding and verifying information when you're wading through a sea of repetition! It's not just about our frustration, though. At the end of the day, it's about providing the best care for our patients, and this, folks, is a hurdle in that path. So what do we do about it? Well, we have a couple of hazards to tackle, namely **information overload** and information **scatter**. **Overload** is when there's so much information (in this case, thanks to duplication) that it's like trying to find a needle in a haystack. **Scatter**, on the other hand, is when the info is fragmented across many locations, making it tough to retrieve and synthesize. Both of these problems are, frankly, a royal pain. These issues stem from the way our EMRs are organized, the old note paradigm, where every encounter with a patient needs a separate document and different authors have separate documents. This system may have worked wonders in the era of paper-based charts, but in the digital age, it's like using a horse-drawn carriage on a superhighway. It's clear we need to rethink this system and consider more modern software advances like document editing, collaborative documentation, or version history tracking. **Lots of love,** **P'Fella** ❤️ ****TL;DR:**Duplication in electronic medical records is a growing issue, compromising efficiency and record accuracy. Rooted in an antiquated system, a shift towards modern, collaborative documentation methods is necessary to improve patient care ## The Sunday Quiz ### High risk vs Low Risk BCC It can be hard to remember what actually is a high risk BCC. The followsection came from thePlasticsFella's [clinical cases](https://www.theplasticsfella.com/periocular-bcc-clinical-case/) . ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/06/high-risk-bcc.png) High Risk BCC The NICE and RCPath Guidelines provide clinical and pathological risk assessments, respectively. This equates to the NCCN guidelines. **Clinical Factors: (DRIP)** - **D**imensions: Any size "mask areas of face", genitals, distal limbs (hands, nails, feet), >10mm in non-"mask areas", neck and pretibial, >20mm trunk and proximal limbs - **R**ecurrence or Radiotherapy - **I**mmunosuppression - **P**oorly defined borders **Pathological Factors: (SHIELD)** - **S**tage**: ≥**pT2 (pT2 = tumour 20mm-40mm) - **H**istological Type: infiltrating, morphoeic, micronodular, basosquamous - **I**nvasion Perineural: Named nerve, *or* ≥0.1mm, *or* beyond the dermis - **E**xcisional Margins: positive or narrow (< 1 mm) - **L**evel of Invasion: beyond subcutaneous fat - **D**epth: > 6 mm (granular layer of the nearest adjacent normal epidermis to the deepest point of the tumour) - **D**ifferentiation: present Reveal this week's question Which of the following is not a clinical or pathological factor in the NICE and RCPath Guidelines for risk assessments? - A. Dimensions: Any size "mask areas of face", genitals, distal limbs (hands, nails, feet), >10mm in non-"mask areas", neck and pretibial, >20mm trunk and proximal limbs - B. Recurrence or Radiotherapy - C. Invasion Perineural: Named nerve, or ≥0.1mm, or beyond the dermis - D. Patient's age and gender Name: Email: ## New and Upcoming ### Educational Tools, Events & Courses P'Fella spotlights impactful events, crucial webinars, and hand-picked courses we know you'll love. Also, if there's a new feature, you'll be the first to know right here. ## Upcoming Events #### 4 Recommendations 1. [****BAAPS**](https://baaps.org.uk/about/events/1663/baaps%5Fsupport%5Fnonsurgical%5Fwebinar?ref=theplasticsfella.com)****:** Non-surgical webinar 28th June 2. [****ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 3. [****Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 4. [****BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov ["Connect" with more Events](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) ## New Features P'Fella has been coding hard these past few months. Here's a sneakpeak of what is coming in version 3 of thePlasticsFella.com (hint: AI space repetition flashcards that learn your study style). 0:00 /0:32 1× ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/06/cyst-eyelid.png) AI-generated image: keratotic horn on the upper eyelid ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Data on [#swearing](https://twitter.com/hashtag/swearing?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) in clinical setting[https://t.co/iXAy0fDx7Z](https://t.co/iXAy0fDx7Z?ref=theplasticsfella.com) [pic.twitter.com/tWJeYwIHCw](https://t.co/tWJeYwIHCw?ref=theplasticsfella.com) > > — Jack Iwashyna🫁 (@iwashyna) [June 24, 2023](https://twitter.com/iwashyna/status/1672613275161477120?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > The top photo holds great historical significance as it captures a pivotal moment in medical history. Dr. Zbigniew Religa, a renowned heart surgeon, is seen resting in the photo after completing the first successful heart transplant in Poland in 1987\. This groundbreaking surgery… [pic.twitter.com/5xJ3LpZa3N](https://t.co/5xJ3LpZa3N?ref=theplasticsfella.com) > > — Historic Vids (@historyinmemes) [June 21, 2023](https://twitter.com/historyinmemes/status/1671629475996467201?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Is this classified as a ‘herd’? [pic.twitter.com/LkwRQZIwbX](https://t.co/LkwRQZIwbX?ref=theplasticsfella.com) > > — Silas 🫀 (@GenerallyUnwell) [June 15, 2023](https://twitter.com/GenerallyUnwell/status/1669315342928158721?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella ### You ask, I'll answer Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. Ask P'Fella ****Inno's Question:**What study tips can you share in order to identify the key areas tested in plastic surgery examinations and to maximize retention of knowledge in the background of the ever rapidly growing body of knowledge. It’s no longer one or two textbooks in plastics we have numerous and there are multiple journals with enormous amount of publications monthly. How does one remember it all? Please help. #### P'Fella's Answer Hey, that's a really solid question! We all know the world of plastic surgery is huge, and it feels like it's only getting bigger, right? That's actually why thePlasticsFella was created, to help navigate this ocean of knowledge without having to juggle a library of textbooks or chase a thousand different sources. But let's dive into some handy tips to help tackle this beast: 1. ****Do the Basics:** Start with the core principles and common procedures. Foundation first, the fancy stuff later. 2. ****Check Old Exams:** Sneak a peek at old exams. They're a goldmine for figuring out what gets tested often. 3. ****Be Active:** Don't just read. Get active. Make flashcards, teach others, quiz yourself. 4. ****Keep Tidy:** Organized notes = organized mind. It's science (probably). 5. ****Review Often:** Remember that friend who only shows up once in a while but you never forget their face? Be that friend to your notes. Use spaced repetition. 6. ****Find a Squad:** Get a study group together. Different perspectives, more fun, and less chance of missing something important. 7. ****Self-care:** Don't forget to eat your veggies, catch those Z's, and break a sweat. A healthy brain is a learning machine. 8. ****Keep Going:** This is a marathon, not a sprint. Keep at it, step by step. And remember, it's okay to take a breather. ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. [****What's the best reconstruction for nasal defects?**](https://journals.lww.com/plasreconsurg/Abstract/2023/06000/Outcomes,%5FConcepts,%5FTechnical%5FRefinements,%5Fand.33.aspx?ref=theplasticsfella.com) Menick et al. Outcomes, Concepts, Technical Refinements, and Challenges in the Microvascular Repair of Full-Thickness Nasal Defects. PRS. June 2023\. 2. [****How to reconstruct a fingertip.**](https://journals.lww.com/prsgo/Fulltext/2023/05000/P3%5FFlap%5F%5FTechnique%5Ffor%5FFingertip%5FReconstruction.32.aspx?ref=theplasticsfella.com) Petrella et al. Technique for Fingertip Reconstruction. Plastic & Reconstructive Surgery-Global Open 11(5):p e5002, May 2023 3. [****Hand surgery performed in the "procedure room"**](https://www.jhandsurg.org/article/S0363-5023%2823%2900117-X/fulltext?ref=theplasticsfella.com) Zhuang T et al. Is Hand Surgery in the Procedure Room Setting Associated With Increased Surgical Site Infection? J Hand Surg Am. 2023 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### New update coming soon! In this upcoming new update, the focus will be more on infographics and generating discussion - so people can share their own experiences and critiques. [Check back next week](https://www.theplasticsfella.com/june-25th/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be!Let me know your thoughts below :) ### 💌 "Open Access" fees are now removed, new podcast format, & P'Fella answers your questions. URL: https://www.theplasticsfella.com/june-11th/ Last updated: 2024-11-19T13:58:03.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/june-11th/#a-letter-from-pfella) "Open Access" fees are now removed. 2. ****🤓** [****The Sunday Quiz**](https://www.theplasticsfella.com/june-11th/#the-sunday-quiz) Calculate local anaesthetic (properly) 3. ****🎭**[ **New & Upcoming**](https://www.theplasticsfella.com/june-11th/#new-and-upcoming) New events and educational tools. 4. 📸 [****Image of the Week**](https://www.theplasticsfella.com/june-11th/#image-of-the-week) AI-generated Keloid Scar 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/june-11th/#tweets-of-the-week) P'Fella's 3 favourite tweets 6. 🤔 [****Ask P'Fella**](https://www.theplasticsfella.com/june-11th/#ask-pfella) Submit & I'll answer! 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/june-11th/#articles-of-the-week) 3 hot reads on nerves, bones and anatomy. 8. 💕 [****Feedback**](https://www.theplasticsfella.com/june-11th/#feedback) Always looking to improve :) ****BTW:** There'll be a new episode of "Prep with P'Fella" on [Spotify](https://podcasters.spotify.com/pod/show/theplasticsfella?ref=theplasticsfella.com) and [Apple](https://podcasts.apple.com/podcast/prep-with-pfella/id1686751426?ref=theplasticsfella.com) on Monday. ## A Letter from P'Fella ### "Open Access" fees are now removed (at least they should be). Hey there, Today, I bring **exciting** news on the open access publishing front. The EU just rolled out a ruling that could be a game-changer. Here's the scoop: "Immediate and unrestricted open access should be the norm in publishing research involving public funds." **In plain English?** If you're a researcher funded by public sources, you should be able to publish your work in open access journals without shelling out a single dime. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/06/Screenshot-2023-06-11-at-10.45.47.png) Official EU Document **This is a massive victory for open access publishing**. It's a nod from the EU acknowledging that open access is the key to making scholarly knowledge accessible to all. **Publishers will feel the heat to offer open access options**, and it'll be a smoother ride for researchers to get their work published in open access journals. So, **why am I stoked about this ruling?** It's more than just a positive step for open access publishing. It's a testament to the importance of democratizing scholarly knowledge. I encourage you to hop on board this movement. **But, I am still skeptical.** At the end of the day, we all know that open journals were created to make more revenue for the publishing companies. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/06/Screenshot-2023-06-11-at-10.59.37.png) Revenue from Journals [(Source)](https://www.theguardian.com/science/2017/jun/27/profitable-business-scientific-publishing-bad-for-science?ref=theplasticsfella.com) Do you expect some seismic shifts in the scholarly publishing landscape from this ruling? Reply to this email to let P'Fella know your thoughts. **Lots of love,** **P'Fella** ❤️ ****TL;DR:** The EU now requires publicly funded research to be published in open access journals for free. This is a step towards democratizing knowledge, but skepticism exists due to the profit-driven origins of open access journals ## The Sunday Quiz ### How to calculate LA doses (properly) Local anaesthetic blocks ****voltage-gated sodium channels** to prevent the conduction and propagation of nerve impulses. There are ****two types** of local anaesthetics/anaesthesia. 1\. ****Esters**: para-aminobenzoic acid (PABA)–based anaesthesia 2\. ****Amide**: non-para-aminobenzoic acid (nPABA)–based anaesthesia An important difference is the manner in which they are metabolised 1\. ****Esters:** metabolised in plasma by pseudocholinesterase to PABA 2\. ****Amide:** metabolised in the liver, less allergy risk. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/06/Copy-of-Untitled-2--1-.png) ps can you spot the original thePlasticsFella Logo? Reveal this week's question Which of the following statements about local anaesthetics is incorrect? - A. Local anaesthetics work by blocking voltage-gated sodium channels, preventing nerve impulse generation and conduction - B. Amides and esters are the two main types of local anaesthetics, with amides presenting a higher risk of allergies due to their metabolism in the liver. - C. The calculation of local anaesthetic volumes requires knowledge of the patient's body weight, maximum dose, and maximum concentration. - D. Local anaesthetic toxicity, while rare, is a potentially lethal complication that requires immediate resuscitation and a lipid rescue protocol. Name: Email: ## New and Upcoming ### Features, Courses, Conferences, Webinars P'Fella spotlights impactful events, crucial webinars, and hand-picked courses we know you'll love. Also, if there's a new feature, you'll be the first to know right here. #### 4 Recommendations 1. [****BAAPS**](https://baaps.org.uk/about/events/1663/baaps%5Fsupport%5Fnonsurgical%5Fwebinar?ref=theplasticsfella.com)****:** Non-surgical webinar 28th June 2. [****ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 3. [****Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 4. [****BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov ["Connect" with more Events](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) 0:00 /1:28 1× New Episode coming ****Monday** on [Spotify](https://podcasters.spotify.com/pod/show/theplasticsfella?ref=theplasticsfella.com) and [Apple](https://podcasts.apple.com/podcast/prep-with-pfella/id1686751426?ref=theplasticsfella.com)! ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/06/Keloid.png) AI-generated image: residual keloid scar after multiple steroid injection ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > This is a 363-page academic writing guide book for writing at the highest level. > > The author is a [@Harvard](https://twitter.com/Harvard?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) teacher-scholar. > > This book will perfect your writing and help you graduate🎓 > > Access it here: [https://t.co/Cio8kUViEL](https://t.co/Cio8kUViEL?ref=theplasticsfella.com) [pic.twitter.com/CaB4dd2lOn](https://t.co/CaB4dd2lOn?ref=theplasticsfella.com) > > — Amina Yonis, PhD (@DrAminaYonis) [June 8, 2023](https://twitter.com/DrAminaYonis/status/1666731108887609344?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > The hematologist Oswald H. Robertson pioneered the idea of "blood banks" in WWI by packing glass jars of citrated blood from universal donors in an ice-filled chest that he had constructed from ammunition cases. Learn more in my book [#TheFacemaker](https://twitter.com/hashtag/TheFacemaker?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com): [https://t.co/ecUMB1X10A](https://t.co/ecUMB1X10A?ref=theplasticsfella.com) [pic.twitter.com/KA09bJGPJF](https://t.co/KA09bJGPJF?ref=theplasticsfella.com) > > — Dr Lindsey Fitzharris (@DrLindseyFitz) [June 10, 2023](https://twitter.com/DrLindseyFitz/status/1667633899365625859?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Dr. Paige Fox, an associate professor of surgery [@StanfordPlastic](https://twitter.com/StanfordPlastic?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com), led an initiative to reduce waste in minor hand surgeries. Read the full story: [https://t.co/V4ZjQHkhEs](https://t.co/V4ZjQHkhEs?ref=theplasticsfella.com) > > — Stanford Plastic Surgery (@StanfordPlastic) [June 7, 2023](https://twitter.com/StanfordPlastic/status/1666485761531854848?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella ### You ask, I'll answer [Ask P'Fella](https://www.theplasticsfella.com/june-11th/#ask) Every Sunday, you can ask P'Fella anything related to plastic surgery. You'll be answered the following week. Let's check out what questions came in. 🤔 ****JD, 4th Resident:** **Still not sure exactly what I want me career to look like, other than that I want to have a broad, diverse practice. Thinking about non-traditional opportunities, such locums tenens, for my first few years out of residency while I figure it out. Would be interested to hear your thoughts.* #### P'Fella's Answer In the ever-changing medical field, desiring a broad, diverse practice is understandable. Locum tenens roles can be a powerful way to explore your options post-residency. They offer exposure to various practices and patient populations, fostering a wide-ranging perspective. These roles enable diverse experiences without long-term commitment. You'll learn new methodologies and understand different healthcare systems. But, consider the trade-offs: continuity of care is less attainable, and frequent adaptation to new environments is required. Ultimately, the value of locum tenens depends on your personal goals, lifestyle, and professional interests. It's a time for exploration and self-discovery, and remember, it's as important to learn what you don't want as what you do. Every step contributes to your unique career path. 🤔 ****Suzanne's Question: :** Where do you predict AI will have the biggest impact in the plastic & reconstructive surgery field? Is P’Fella as accurate as a magic 8 ball? #### P'Fella's answer In the face of the AI revolution, plastic and reconstructive surgery is poised for transformation. AI's role in enhancing surgical planning, execution, and post-surgery monitoring is emerging. I But here's the real game-changer: Artificial General Intelligence, or AGI for short. Now, I know AGI isn't here yet, but when it arrives, it's going to be like nothing we've ever seen. We're talking about the potential to automate some of the simpler surgical tasks and maybe even whole procedures. Imagine surgical robotics with AGI on board. Human error? That could be a thing of the past. But, no matter how flashy AGI gets, it's not going to replace us. We're surgeons, and our human judgement, critical thinking, and hands-on skills? Absolutely irreplaceable. So, as we keep our eyes on this AI-to-AGI journey, let's make sure our training keeps up with the tech, and that patient safety is always at the front of our minds. Bottom line? Let's stay excited about the tech evolution, but remember: our humanity is our superpower, and nothing, not even AGI, can change that. --- ## Ask ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. [****Where actually is the facial nerve?**](https://journals.lww.com/plasreconsurg/Abstract/2020/01000/Facial%5FNerve%5FDanger%5FZones.21.aspx?ref=theplasticsfella.com) Stuzin, James M. M.D. et al. Facial Nerve Danger Zones. Plastic and Reconstructive Surgery 145(1):p 99-102\. 2. [****Metacapral fractures in Footballers**](https://www.jhandsurg.org/article/S0363-5023%2822%2900051-X/fulltext?ref=theplasticsfella.com) Sharareh et al. Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play. J Hand Surg Am. 2023 3. [****Nerve Transfers after Cancer Resection**](https://www.sciencedirect.com/science/article/pii/S1748681523002036?dgcid=coauthor&ref=theplasticsfella.com) Jawad AM et al. Resect, rewire, and restore: Nerve transfer salvage of neurological deficits associated with soft tissue tumors in a retrospective cohort series at a tertiary reconstructive center. J Plast Reconstr Aesthet Surg. 2023\. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### New update coming soon! In this upcoming new update, the focus will be more on infographics and generating discussion - so people can share their own experiences and critiques. [Check back next week](https://www.theplasticsfella.com/june-18th/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be!Let me know your thoughts below :) ### 🗞️ We're not ready for AI in plastic surgery, "Ask P'Fella", & intra-op errors coping mechanisms. URL: https://www.theplasticsfella.com/may-21st/ Last updated: 2023-05-21T17:42:49.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/may-21st/#a-letter-from-pfella)** Are you ready for the AI hype train? 2. **🤓 [The Sunday Quiz](https://www.theplasticsfella.com/may-21st/#the-sunday-quiz)** Gorlin Syndrome and BCCs 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/may-21st/#upcoming-events)** Top 6 events in 2023. 4. **🔥[New Features ](https://www.theplasticsfella.com/may-21st/#new-features)** "Ask P'Fella" - you ask, P'Fella answers. 5. 📸 **[Image of the Week ](https://www.theplasticsfella.com/may-21st/#image-of-the-week)** AI-generated Congenital Naevus 6. **🐣 [Tweets of the Week](https://www.theplasticsfella.com/may-21st/#tweets-of-the-week)** P'Fella's 3 favourite tweets 7. 🤔 **[Ask P'Fella](https://www.theplasticsfella.com/may-21st/#ask-pfella)** Submit & I'll answer! 8. **📝 [Articles of the Week](https://www.theplasticsfella.com/may-21st/#articles-of-the-week)** How to cope with intra-op mistakes & 3 hot reads. 9. 💕 **[Feedback](https://www.theplasticsfella.com/may-21st/#feedback)** Always looking to improve :) **BTW:** There'll be a new episode of "Prep with P'Fella" on [Spotify](https://podcasters.spotify.com/pod/show/theplasticsfella?ref=theplasticsfella.com) and [Apple](https://podcasts.apple.com/podcast/prep-with-pfella/id1686751426?ref=theplasticsfella.com) this week. ## A Letter from P'Fella ### We are not ready for the "AI in Plastic Surgery" hype train. AI is no longer just a buzzword in plastic surgery, it's becoming a reality. The number of AI-related publications in our field has skyrocketed from just a **handful in 2010 to over a thousand by 2020**. This surge in interest is not just a passing trend, it's a sign of the transformative role AI is starting to play in our field. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/-22AI-22----22PlasticSurgery-22.png) The AI Hype Train As we look to the future, it's clear that AI is a powerful tool that can assist us in diagnosis, therapeutic decisions, preoperative planning, and outcome prediction and evaluation. **But let's be clear, it's not about to replace us**. Until we reach the point of Artificial General Intelligence (AGI), the final decision will always rest with us, the surgeons. We bring to the table years of experience and a nuanced understanding of our patients' unique needs and desires. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/-22AI-22----22PlasticSurgery-22-1.png) AI won't replace surgeons until "AGI" One aspect of this AI revolution that I want to highlight is the role of journals. **We need more than just any doctor reviewing AI research**. We need reviewers who are well-versed in both plastic surgery and AI. This will ensure that the research we base our practice on is sound, and the AI tools we use are reliable and effective. And let's face it, **journals are likely to be more than willing to publish AI topics**. It's a hot field, and more publications on AI means more citations, which in turn means a higher impact factor. It's a win-win situation. But here's something we need to be mindful of. **AI has the potential to outsmart any human verification system**. This means we need to be vigilant when it comes to the validity of results. As we move forward, we need to ensure that the AI-generated data and results we're using are accurate and reliable. So, are we prepared to welcome AI into our operating rooms and consultation suites? By keeping ourselves updated with the latest research, championing for stringent review standards, and staying vigilant of potential pitfalls, we can leverage AI to not just enhance our practice, but also to redefine the standards of patient care. This isn't just about keeping up with the times - it's about being pioneers in a new era of plastic surgery. Let's lead the charge together, and see where this exciting journey takes us. **Lots of love,** **P'Fella** ❤️ **TL;DR:** 1\. AI is reshaping plastic surgery but won't replace surgeons until AGI is achieved. 2\. Journals need AI-savvy reviewers to ensure the validity of AI research and tools. 3\. Embracing AI requires vigilance and rigorous review standards to enhance patient care. ## The Sunday Quiz ### Gorlin Syndrome and BCCs Gorlin syndrome (Basal Cell Naevus Syndrome) is an autosomal dominant condition associated with PTCH gene mutations on chromosome 9\. Some of the clinical features of Gorlin syndrome are illustrated below ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/Gorlin-Syndrome--1-.png) Reveal this week's question Which of the following is true regarding Gorlin Syndrome? - A. These patients tend to get BCCs after age of 60\. - B. \~50% are sporadic mutations - C. Are more likely to get melanoma than BCC. - D. Have narrow eyes Name: Email: ## Upcoming Events ### Events, Courses, Conferences, Webinars P'Fella will bring you a weekly roundup of major events, informative webinars, and fantastic courses. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/-22AI-22----22PlasticSurgery-22-2.png) Top 6 Events ["Connect" with more Events](https://connect.theplasticsfella.com/events?ref=theplasticsfella.com) ## New Features ### "Ask P'Fella" every week. **Introducing "[Ask P'Fella](https://www.theplasticsfella.com/may-21st/#ask-pfella)" - Your new hotline.** I'm excited to get to know all of you better because you're all amazing. That's why I'm introducing a new section in our newsletter called "Ask P'Fella," where you can ask me anything you'd like. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/ask-p-fella.png) [Ask now!](https://www.theplasticsfella.com/may-21st/#ask-pfella) Whether you're seeking advice on **plastic surgery, career choices, study tips, or curious about the future of thePlasticsFella platform, this is your chance to get the answers you need**. There are no boundaries to the topics you can explore! **How does it work?** It's as easy as pie! Just send me your questions, and I'll personally respond with expert insights and guidance in the next edition. You have the power to shape the conversation, so don't hesitate to ask away! [Ask P'Fella Now!](https://www.theplasticsfella.com/may-21st/#ask-pfella) ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/AI-generated-image.png) AI-generated congenital melanocytic naevus ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > how would you reconstruct this? > > a congenital melanocytic naevus extends into the philtrum and across the vermilion border onto mucosa. > > 😅 [pic.twitter.com/Axf3qbfkOX](https://t.co/Axf3qbfkOX?ref=theplasticsfella.com) > > — thePlasticsFella (@PlasticsFella) [April 27, 2023](https://twitter.com/PlasticsFella/status/1651646390370443275?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Hand of an X-ray Technician at the Royal London Hospital in the 1900s. > > Physicist Wilhelm Conrad Röntgen unveiled one of the most significant breakthroughs in medical history with the discovery of X-rays. While experimenting with cathode light's ability to penetrate glass,… [pic.twitter.com/k6hWY2xhtS](https://t.co/k6hWY2xhtS?ref=theplasticsfella.com) > > — Historic Vids (@historyinmemes) [May 20, 2023](https://twitter.com/historyinmemes/status/1659968803256631296?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > The problem is not people being uneducated. > The problem is that people are educated just enough to believe what they have been taught, and not educated enough to question anything from what they have been taught. 🧠 > > — Prof. Feynman (@ProfFeynman) [May 19, 2023](https://twitter.com/ProfFeynman/status/1659583573010046978?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Ask P'Fella ### NEW: You ask, I'll answer ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. **[Clinical Examination not needed? ](https://pubmed.ncbi.nlm.nih.gov/36729071/?ref=theplasticsfella.com)** Emanuelli et al. Preoperative Examination Is Not Associated with Postoperative Function following Radial Forearm Free Flap Harvest. Plastic and Reconstructive Surgery 151(5):p 828e-837e, May 2023 2. **[Unraveling the Mysteries of the Superficial Fascia System](https://journals.lww.com/plasreconsurg/Fulltext/2023/05000/The%5FSuperficial%5FFascia%5FSystem%5F%5FAnatomical.13.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) \-** Plastic and Reconstructive Surgery, May 2023\. Rohrich, Rod J. M.D.; Surek, Christopher C. D.O.; Cho, Min-Jeong M.D., Ph.D. 3. **[Changes in Aesthetic Surgery Interest in Men](https://link.springer.com/article/10.1007/s00266-023-03344-9?ref=theplasticsfella.com)** Published in Aesthetic Plastic Surgery, May 2023\. Authors: Melinda Lem, Jason T. Pham, Joshua KyungHo Kim & Cathy J. Tang ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### How to cope with intra-operative errors! Study highlights need for interventions/training to improve coping skills/support for surgeons & staff after intraoperative errors. Effective strategies: error disclosure, calmness, communication. Poor coping behaviors: anger, blame. [Read this Journal Club](https://www.theplasticsfella.com/how-to-cope-with-intra-operative-errors-journal-club/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) ### How to cope with intra-operative errors (Journal Club) URL: https://www.theplasticsfella.com/how-to-cope-with-intra-operative-errors-journal-club/ Last updated: 2023-05-21T17:22:15.000Z #### Summary Card **Level of Evidence:** Therapeutic **Background**: Surgeons' coping with intraoperative errors can significantly impact patient outcomes. **Methods:** A survey of operating room staff at four academic hospitals was conducted to examine surgeon coping behaviors following intraoperative errors. **Results**: Among 294 respondents, effective coping strategies included error disclosure, calmness, and communication, while poor coping behaviors included anger and blame **Conclusion**: These findings highlight the need for interventions and training programs to improve coping skills and support for surgeons and operating room staff. ⚡ The complete journal club analysis is for **thePlasticsPro users**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - May 7th URL: https://www.theplasticsfella.com/may-7th/ Last updated: 2023-05-07T08:43:43.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/may-7th/#a-letter-from-pfella)** 5 Steps to Optimize Your Audio Study, Backed by Research 2. **🤓 [The Sunday Quiz](https://www.theplasticsfella.com/may-7th/#the-sunday-quiz)** Are you the smartest plastic surgeon in the world? 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/may-7th/#upcoming-events)** Top 5 webinars, courses and conferences. 4. **🔥[New Features ](https://www.theplasticsfella.com/may-7th/#new-features)** "Prep with P'Fella" (first episode now live!) 5. 📸 **[Image of the Week ](https://www.theplasticsfella.com/may-7th/#image-of-the-week)** AI-generated Melanoma 6. **🐣 [Tweets of the Week](https://www.theplasticsfella.com/may-7th/#tweets-of-the-week)** P'Fella's 3 favourite tweets 7. **📝 [Articles of the Week](https://www.theplasticsfella.com/may-7th/#articles-of-the-week)** Infantile haemangiomas, research importance, nerve gaps. 8. 💕 **[Feedback](https://www.theplasticsfella.com/may-7th/#feedback)** Always looking to improve :) **Fun Fact:** P'Fella is now on [Spotify](https://podcasters.spotify.com/pod/show/theplasticsfella?ref=theplasticsfella.com) and [Apple](https://podcasts.apple.com/podcast/prep-with-pfella/id1686751426?ref=theplasticsfella.com)! ## A Letter from P'Fella ### 5 Steps to Optimize Your Audio Study, Backed by Research Audio-based learning is a powerful tool that can complement traditional learning methods, making it easier to understand complex topics and engage with the material. With the wealth of podcasts, audiobooks, and other audio resources available, there's no better time to incorporate audio into your study routine. Here are five key steps to optimize audio in your study, supported by peer-reviewed research, but let's keep it casual and informal! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/Prep-with-P-Fella-logo.png) [**First episode is now live!**](https://www.theplasticsfella.com/may-7th/#new-features) **Choose High-Quality Content** The first step is to select high-quality content. Research by Alley and Neeley (2005) shows that well-prepared audio lectures can engage students and improve learning outcomes. So, make sure you pick reputable sources, engaging speakers, and well-produced audio resources to make the most of your audio-based learning. So what's a good podcast? Here's my thoughts 1. **Prep with P'Fella** (on [Apple](https://podcasts.apple.com/podcast/prep-with-pfella/id1686751426?ref=theplasticsfella.com) and [Spotify](https://podcasters.spotify.com/pod/show/theplasticsfella?ref=theplasticsfella.com)) 2. **PRS Global Open**: Damien Marucci is a great host! 3. **The Upper Hand Podcast**: an easy listen! Can be more ortho orientated. 4. **PRS Journal Club**: ehh pretty dodgy audio at times. 5. If there are any other great podcasts, reply to this email! **Combine Audio with Other Learning Methods** Mayer and Moreno (2003) found that using audio narration alongside visuals reduces cognitive load and leads to better learning outcomes. So, it's a good idea to combine audio with other learning methods, like taking notes, creating mind maps, or using visuals to reinforce the material. **Use Audio to Reinforce Your Learning** Rogowsky, Calhoun, and Tallal (2015) discovered that students who preferred auditory learning saw improved comprehension when using audio-based instruction. Recording your own summaries or explanations of complex topics and listening to them later can help solidify your understanding and reinforce your learning. **Leverage Downtime for Audio-Based Learning** One of the advantages of audio-based learning is its flexibility. You can listen to audio resources during downtime, such as commuting, exercising, or doing chores. Although there isn't specific research on this, it's a common-sense approach to maximize your learning time while enjoying the benefits of audio resources. **Experiment with Different Audio Formats and Content Types** Finally, experiment with different audio formats and content types to find what works best for you. While there might not be a specific study on this, it's always a good idea to explore various learning resources and adapt them to your personal preferences and needs. **TL;DR:** 1\. Choose high-quality content for optimal learning outcomes. 2\. Combine audio with other learning methods for better retention. 3\. Use audio to reinforce your learning and solidify your understanding. 4\. Leverage downtime for audio-based learning to maximize your study time 5\. Experiment with different audio formats to find what works best for you. **Lots of love,** **P'Fella.** ## The Sunday Quiz ### Are you the smartest plastic surgeon in the world? Great news, the leaderboard is now built! This will allow you to compare your progress over the next 6 questions. Vascular anomalies can be classified as malformations or tumours. The ISSVA system, developed by Mulliken and Glowacki, categorizes vascular abnormalities into two main types: high-flow and low-flow. Vascular tumors are characterized by abnormal growth of blood vessels and can be benign, borderline, or malignant. These tumors do not grow in proportion to the patient's growth. Vascular malformations are structural abnormalities that occur during fetal development and grow in proportion to the patient. They can be simple, combined, or associated with other conditions. Unlike vascular tumors, they do not involve abnormal growth of blood vessels. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/Vascular-Anomaly-Classification-ISSVA-.png) [How smart are you?](https://www.theplasticsfella.com/the-sunday-quiz/) ## Upcoming Events ### Events, Courses, Conferences, Webinars P'Fella will bring you a weekly roundup of major events, informative webinars, and fantastic courses. #### Top 5 Events 1. [**ICOPLAST** ](https://registrations.dxblive.com/CommunityPortal/Registration/ICOPLAST20.aspx?registrantID=861d5933-db8a-4021-b129-2e47889b18e3&ref=theplasticsfella.com)2nd World Congress, Dubai - 7th May 2. [**FESSH**](https://fessh2023.com/?ref=theplasticsfella.com) Annual Meeting - Rimini, 10th May 3. [**ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 4. [**Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 5. [**BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov ["Connect" with more events](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) ## New Features ### "Prep with P'Fella" is now live! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/aaPrep-with-P-Fella.png) **Elevate your plastic surgery knowledge with "Prep with P Fella"** A podcast that combines high-quality, evidence-based insights with an engaging and entertaining approach. Designed for quick coffee breaks or last-minute cramming, you'll look forward to every episode. Learn from the best in the field and e**ven hear from some famous voices who have joined the fun!** Don't miss out on this unique learning experience. ## 🎧 Listen now! 🎧 ### [Apple](https://podcasts.apple.com/podcast/prep-with-pfella/id1686751426?ref=theplasticsfella.com) and [Spotify](https://podcasters.spotify.com/pod/show/theplasticsfella?ref=theplasticsfella.com) ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/05/melanoma.png) AI-generated nodular melanoma ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > I love that my hospital’s newest interim CEO doesn’t bother PRETENDING to care. No wasting my time with “how can I help you meetings” that will lead to no change. > > He sits in his office and does nothing. I do ortho stuff. We coexist peacefully. > > — Very General Orthopaedist (@generalorthomd) [May 5, 2023](https://twitter.com/generalorthomd/status/1654297013054210048?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > In our new cadaveric feasibility study, we used augmented reality to guide head and neck cancer re-resection with a mean relocation error of 4 mm. Check it out‼️ [https://t.co/7tBUOQpRM4](https://t.co/7tBUOQpRM4?ref=theplasticsfella.com) [@TopfHNS](https://twitter.com/TopfHNS?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@EbenRosenthal](https://twitter.com/EbenRosenthal?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@Alexis\_B\_Miller](https://twitter.com/Alexis%5FB%5FMiller?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@VanderbiltENT](https://twitter.com/VanderbiltENT?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#HeadandNeckCancer](https://twitter.com/hashtag/HeadandNeckCancer?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#AugmentedReality](https://twitter.com/hashtag/AugmentedReality?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/yvyOtSBARK](https://t.co/yvyOtSBARK?ref=theplasticsfella.com) > > — Kavita Prasad (@\_KavitaPrasad) [May 4, 2023](https://twitter.com/%5FKavitaPrasad/status/1654223643805888512?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Given how much we obsess about trainees interpretation of research...maybe we should listen to our own wisdom a little more... [pic.twitter.com/z3zC3YGP3n](https://t.co/z3zC3YGP3n?ref=theplasticsfella.com) > > — James Tomlinson (@jamestoml1) [May 3, 2023](https://twitter.com/jamestoml1/status/1653866365890056198?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. [**Stretching Promotes Wound Contraction??**](https://journals.lww.com/prsgo/Fulltext/2023/04000/Stretching%5FPromotes%5FWound%5FContraction%5FThrough.50.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Kawai et al. Stretching Promotes Wound Contraction Through Enhanced Expression of Endothelin Receptor B and TRPC3 in Fibroblasts. Plastic & Reconstructive Surgery-Global Open 11(4):p e4954, April 2023. 2. **[Is research actually important during training?](https://journals.lww.com/academicmedicine/Abstract/9900/Residency%5FProgram%5FDirectors%5F%5FViews%5Fon%5FResearch.430.aspx?ref=theplasticsfella.com)** Wolfson et al. Residency Program Directors’ Views on Research Conducted During Medical School: A National Survey. Academic Medicine April 21, 2023\. 3. **[What's the best way to bridge a nerve gap?](https://journals.lww.com/plasreconsurg/Fulltext/2023/05000/A%5FSystematic%5FReview%5Fand%5FMeta%5FAnalysis%5Fof%5FNerve%5FGap.24.aspx?ref=theplasticsfella.com)** Lans, et al. A Systematic Review and Meta-Analysis of Nerve Gap Repair: Comparative Effectiveness of Allografts, Autografts, and Conduits. Plastic and Reconstructive Surgery 151(5):p 814e-827e, May 2023. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Oral Propranolol for Infantile Hemangiomas (NEJM Journal Club) Oral propranolol effectively treats infantile hemangiomas in 60% of participants compared to 4% with placebo in a randomized controlled trial. Further research is needed to determine optimal treatment duration and assess long-term effects [Read this Journal Club](https://www.theplasticsfella.com/oral-propranolol-for-infantile-hemangiomas/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) ### Oral Propranolol for Infantile Hemangiomas (NEJM Journal Club) URL: https://www.theplasticsfella.com/oral-propranolol-for-infantile-hemangiomas/ Last updated: 2023-05-06T21:04:33.000Z #### Summary Card **Level of Evidence:** Randomized Controlled Trial **Background**: Infantile hemangiomas are benign vascular tumors affecting 5-10% of infants. Oral propranolol is a potential treatment option. **Methods:** A double-blind, randomized trial compared oral propranolol (3 mg/kg/day) to placebo in 460 infants with hemangioma. **Results**: Propranolol achieved successful treatment in 60% of participants, compared to 4% in the placebo group. **Conclusion**: Oral propranolol is an effective and well-tolerated treatment for infantile hemangiomas, but further research is needed for optimal treatment duration and long-term effects. ⚡ The complete journal club analysis is for **thePlasticsPro users**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - April 30th URL: https://www.theplasticsfella.com/april-30th/ Last updated: 2023-04-30T21:40:19.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/april-30th/#a-letter-from-pfella)** The future is open-sourced not "open publication" 2. **🤓 [The Sunday Quiz](https://www.theplasticsfella.com/april-30th/#the-sunday-quiz)** Local Anaesthetic - how to calculate. 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/april-30th/#upcoming-events)** Top 5 webinars, courses and conferences. 4. **🔥[New Features ](https://www.theplasticsfella.com/april-30th/#new-features)** "Prep with P'Fella" (for those last minute crams) 5. 📸 **[Image of the Week ](https://www.theplasticsfella.com/april-30th/#image-of-the-week)** AI-generated BCC on the ear 6. **🐣 [Tweets of the Week](https://www.theplasticsfella.com/april-30th/#tweets-of-the-week)** P'Fella's 3 favourite tweets 7. **📝 [Articles of the Week](https://www.theplasticsfella.com/april-30th/#articles-of-the-week)** The best way to treat gynaecomastia 8. 💕 **[Feedback](https://www.theplasticsfella.com/april-30th/#feedback)** Always looking to improve :) **Fun Fact: 97% of you told me to build [this](https://www.theplasticsfella.com/april-30th/#new-features).** ## A Letter from P'Fella ### **The future is open-sourced not "open publication"** **I've got an idea brewing in my mind that I want to share with you**. While it's just an idea for now, I believe it has the potential to change the way we approach plastic surgery in the future. **Picture this:** a true open-source plastic surgery journal, inspired by platforms like GitHub, where all data, research, and findings can be submitted to a public repository, accessible to anyone and everyone. So what's the difference between open publications and open source? This table explains it. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/Open-Source.png) However, there are some **limitations** to open-source repositories that will need to be addressed: 1. **Quality Control**: Ensuring rigorous peer review and maintaining high standards for submissions will be crucial. 2. **Sustainability**: A sustainable financial model to cover operational costs without relying on author fees or subscriptions. 3. **Data** **Security**: Protecting sensitive information and respecting patient privacy while maintaining an open platform. Despite these challenges, I believe we can join forces to make this truly open-source journal a reality. It's going to take passion, dedication, and collaboration from all of us, but I know we're up for the challenge! **What do you think?** Let's keep this conversation going and see where it takes us. Lots of love, P'Fella. ## The Sunday Quiz ### Week 4: Local Anaesthetic Local anaesthetic provides a temporary block of voltage-gated sodium channels. This prevents nerve impulse generation and conduction Amides and esters are the two categories of local anaesthetics. They have different durations of action and side-effect profiles. Calculation of local anaesthetic volumes requires knowledge of the patient's body weight, max dose, and max concentration. Toxicity is a rare but potentially lethal complication that should be treated with a lipid rescue protocol. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/Local-Anaesthetic.png) 💡 Ok, so turns out, building a leaderboard is actually quite hard. Thanks everyone for always engaging in this section, the quiz will be live soon! ## Upcoming Events ### Events, Courses, Conferences, Webinars P'Fella will bring you a weekly roundup of major events, informative webinars, and fantastic courses. #### Top 5 Events 1. [**ICOPLAST** ](https://registrations.dxblive.com/CommunityPortal/Registration/ICOPLAST20.aspx?registrantID=861d5933-db8a-4021-b129-2e47889b18e3&ref=theplasticsfella.com)2nd World Congress, Dubai - 5th May 2. [**FESSH**](https://fessh2023.com/?ref=theplasticsfella.com) Annual Meeting - Rimini, 10th May 3. [**ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 4. [**Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 5. [**BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov ["Connect" with more events](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) ## New Features ### P'Fella is always building and improving. Great news - [**97%**](https://twitter.com/PlasticsFella/status/1651288132900331525?s=20&ref=theplasticsfella.com) **of you are super excited** about our new short and sweet snippets! We're stoked to hear that you're as pumped about this as we are. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/aaPrep-with-P-Fella.png) **Here's a teaser below, have a listen!** ![audio-thumbnail](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/media/2023/04/df567828-0adf-4cf2-aaa8-9648993c8034_thumb.png?v=1682860500080) Prep with P'Fella (First Episode Teaser) 0:00 /4:19 1× But before we get too carried away, **I want to make sure we're hitting the mark with our content.** We're all about helping you out, so if you have any suggestions or topics you'd like us to cover in future episodes, let us know by replying to this email. Your input is super important to us, and we want to create content that you find helpful and engaging. Please hit us up with any thoughts or ideas you have. ## Image of the Week ### AI-generated clinical images ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/Ear.png) AI-generated infilatrative BCC ([read this twitter chat](https://twitter.com/PlasticsFella/status/1650561525122228242?s=20&ref=theplasticsfella.com)) ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > On my OR days, I actually scrub my hands at the scrub sink, using the brush, and rinsing them with water: > > — Ron Barbosa MD FACS (@rbarbosa91) [April 29, 2023](https://twitter.com/rbarbosa91/status/1652394942764060672?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > At least one thing made me laugh tonight [pic.twitter.com/lhJtIEVx1m](https://t.co/lhJtIEVx1m?ref=theplasticsfella.com) > > — Kristin Gee, MD (@kmgee9) [April 29, 2023](https://twitter.com/kmgee9/status/1652133262616133632?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > If you want to excel under pressure, remember this critical principle: > > The Yerkes-Dodson Law 🧵 [pic.twitter.com/zs2rphOMq3](https://t.co/zs2rphOMq3?ref=theplasticsfella.com) > > — PJ Milani | Visual Teacher💡 (@milanicreative) [April 29, 2023](https://twitter.com/milanicreative/status/1652296701456310273?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. **[Make plastic surgery greener! ](https://pubmed.ncbi.nlm.nih.gov/37079880/?ref=theplasticsfella.com)** Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries. Br J Surg. 2023 Apr 20 2. **[Whats the best zone II flexor tendon outcome? ](https://www.jhandsurg.org/article/S0363-5023%2822%2900722-5/fulltext?ref=theplasticsfella.com)** Xu H et al. Outcome of Surgical Repair and Rehabilitation of Flexor Tendon Injuries in Zone II of the Hand: Systematic Review and Meta-Analysis. J Hand Surg Am. 2023 3. **[Trigger Finger and Capral Tunnel are married? ](https://pubmed.ncbi.nlm.nih.gov/35131113/?ref=theplasticsfella.com)** Wessel et al. Incidence of Trigger Finger in Surgically and Nonsurgically Managed Carpal Tunnel Syndrome. J Hand Surg Glob Online. 2022 Nov 24;5(2):164-168 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### The best way to surgically correct gynaecomastia. This systematic review found gynecomastia revealed high patient satisfaction and improved physical and psychological symptoms with various surgical techniques. Tailoring surgical technique to patient needs, providing education, and ensuring long-term follow-up are crucial for optimal outcomes. [Read this PRS Open Article](https://www.theplasticsfella.com/surgical-management-of-gynecomastia-journal-club/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) ### Surgical Management of Gynaecomastia (Journal Club) URL: https://www.theplasticsfella.com/surgical-management-of-gynecomastia-journal-club/ Last updated: 2023-04-30T21:42:00.000Z #### Summary Card **Level of Evidence**: Systematic Review **Background**: Gynecomastia is a common condition affecting men, characterized by an enlargement of the male breast tissue. Surgical treatment options include liposuction, gland excision, and skin reduction, each with their own advantages and limitations. **Methods**: A comprehensive review of the literature examining outcomes and complications of various surgical techniques for gynecomastia, focusing on patient satisfaction, recurrence rates, and complication rates associated with different surgical approaches. **Results**: Overall patient satisfaction was high across all surgical techniques, with significant improvements in both physical and psychological symptoms. The complication rate was low across all techniques but varied depending on the specific approach. Recurrence rates were also low but slightly higher in cases where liposuction alone was used. **Conclusion**: This systematic review demonstrates the effectiveness of various surgical techniques in managing gynecomastia and improving patient satisfaction. The choice of surgical technique should be tailored to the patient's specific needs and the severity of their condition, and patient education and long-term follow-up are essential for optimal outcomes. ⚡ The complete journal club analysis is for **thePlasticsPro users**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - April 16th URL: https://www.theplasticsfella.com/april-16th/ Last updated: 2023-04-16T19:46:01.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/april-16th/#a-letter-from-pfella)** Flashcards: the good, the bad, the ugly. 2. **🤓 [The Sunday Quiz](https://www.theplasticsfella.com/april-16th/#the-sunday-quiz)** Tissue Expansion - an essential. 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/april-16th/#upcoming-events)** +10 webinars, courses and conferences. 4. **🔥[New Features ](https://www.theplasticsfella.com/april-16th/#new-features)** Book reviews (for nerds, like me) 5. 📸 **[Image of the Week ](https://www.theplasticsfella.com/april-16th/#image-of-the-week)** AI-generated Menick's subunits 6. **🐣 [Tweets of the Week](https://www.theplasticsfella.com/april-16th/#tweets-of-the-week)** P'Fella's 3 favourite tweets 7. **📝 [Articles of the Week](https://www.theplasticsfella.com/april-16th/#articles-of-the-week)** 1% risk of regret with gender reassignment. 8. 💕 [**Feedback**](https://www.theplasticsfella.com/april-16th/#feedback) Always looking to improve :) **FYI:** Have you "[**Connected**](https://connect.theplasticsfella.com/?ref=theplasticsfella.com)" with your peers? ## A Letter from P'Fella ### Flashcards: the good, the bad, and **the** **ugly**. For **decades**, flashcards have remained a **popular** study tool for students of all ages and academic levels. These small cards, often made of paper or index cards, have been shown to be an effective way to learn and retain information. However, like any tool, they have their limitations. **Let's deep-dive into the good, the bad and the ugly.** ### The Good One benefit of flashcards is that they allow for **active recall**, a powerful learning technique that involves recalling information from memory. This process strengthens neural pathways in the brain and improves long-term retention (Kornell & Bjork, 2008). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/Topic.png) **Launching in 2 weeks!** Additionally, flashcards can be used in conjunction with spaced repetition software, enabling students to optimize their study time and retention (Roediger & Karpicke, 2006). **Personalization** is another advantage of flashcards, as students can create their own cards with information they need to learn or use pre-made ones that align with their course materials or standardized exams (Dunlosky et al., 2013). Lastly, flashcards are **portable** and can be used anywhere, allowing students to review them during their commute, at a coffee shop, or while waiting in line (Kornell & Bjork, 2008). ### The Bad However, **flashcards also have their limitations**. They present information out of context, hindering understanding and retention, and may not be as effective for learning complex concepts or higher-order thinking skills (Karpicke & Roediger, 2007; Dunlosky et al., 2013). Moreover, flashcards can give students a **false sense of confidence** in their knowledge and abilities, leading to overconfidence on flashcard-based assessments and struggles on exams that require more application and critical thinking (Kornell & Bjork, 2008). Finally, creating and reviewing flashcards can be **time-consuming**, potentially leading to students neglecting other study techniques or not having enough time to review all of their material (Roediger & Karpicke, 2006). ### The Ugly When it comes to the "**ugly**" side of flashcards, one software that often comes to mind is Anki. While **Anki** has gained popularity among students and language learners, it also has a **steep learning curve** and can be very difficult to use. The interface can be **overwhelming** for beginners, with many options and settings that can be confusing to navigate (Hersh, 2016). Here are the 15 steps to get started on Anki: yikes! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/the-ugly.png) Anki's steep learning curve. A common support email I get is, **"Umm so how do I downloa the Anki?"**. It can be time-consuming to set up, especially for students who are not tech-savvy. Anki's spaced repetition algorithm is a powerful tool for improving retention, it can also be challenging to adjust the settings to suit individual learning needs. Students may struggle to find the optimal interval for each card or to adjust the difficulty level of their decks, leading to frustration and discouragement (Hersh, 2016). **TL;DR** Flashcards are a popular and effective study tool due to their active recall and portability. They can be personalized and used with spaced repetition software to optimize learning. However, they present information out of context and may not be effective for complex concepts. Anki, a popular flashcard software, has a steep learning curve and can be time-consuming to set up and adjust to individual need ## The Sunday Quiz ### Week 3: Tissue Expansion Tissue expansion optimises the viscoelastic properties of skin and increases tissue availability through a process of creep and stress relaxation. Creep can be mechanical (acute) and biological (chronic). During the tissue expansion, histological changes occur. The epidermis is the only anatomical layer that increases in thickness. Tissue expanders are designed in different shapes, sizes, textures and expansion directions to fit their specific indication. Four zones or layers form a capsule around the expander. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/Tissue-Expansion-Description.png) *Original 1957 publication by Neuman* 💡 Check back next week for the Sunday quiz! Unfortunately, the initial leaderboard was only able to accommodate 150 names, causing it to reset. Update coming! Sorry :( ## Upcoming Events ### Events, Courses, Conferences, Webinars P'Fella will bring you a weekly roundup of major events, informative webinars, and fantastic courses. #### 1. [**Rhinoplasty Society**](https://rhinoplastysociety.org/meetings?ref=theplasticsfella.com) Annual Meeting - Florida, 19th April 2. **[BSSH](https://www.bssh.ac.uk/about/events/4541/bssh%5Fspring%5Fscientific%5Fmeeting%5F2023?ref=theplasticsfella.com)** Spring Meeting - Swansea, 19th April. 3. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-2-hand-surgery-advances?ref=theplasticsfella.com): Advances in Hand Surgery - 27th April. 4. [**AAPS**](https://meeting.aaps1921.org/?ref=theplasticsfella.com) 10th Annual Meeting - Chicago, 29th April. 5. **[Kings College](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/facial-aesthetic-dissection-course?ref=theplasticsfella.com)** \- Facial Aesthetic Dissection- 4th May. 6. [**ICOPLAST** ](https://registrations.dxblive.com/CommunityPortal/Registration/ICOPLAST20.aspx?registrantID=861d5933-db8a-4021-b129-2e47889b18e3&ref=theplasticsfella.com)2nd World Congress, Dubai - 5th May 7. [**FESSH**](https://fessh2023.com/?ref=theplasticsfella.com) Annual Meeting - Rimini, 10th May 8. [**ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 9. [**Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 10. [**BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov ["Connect" with more events](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) ## New Features ### P'Fella is always building and improving. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/Screenshot-2023-04-16-at-20.05.30.png) #### Book Reviews I have some exciting news to share with you - there is now new feature on our website called Book Reviews! P'Fella will be reviewing both current and historical textbooks that are still relevant and useful today, and providing recommendations for those who are just starting out on their learning journeys. Not only that, but we'll also be delving into more niche textbooks, perfect for those who want to explore specific subject areas in greater depth. So, head over to our website and discover your next must-read textbook! We hope that you'll find this new feature helpful, and we welcome your feedback on what you'd like to see more of in the future. [Read the first book review](https://www.theplasticsfella.com/key-notes-on-plastic-surgery-book-review/) ## Image of the Week ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/FnqXMiNXEAkH_U1.jpeg) AI-generated subunits of the nose ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Fish skin can be grafted onto burn victims. The material uses the body's own cells and is converted eventually into living tissue. Read more: [https://t.co/1RCSGM1ReA](https://t.co/1RCSGM1ReA?ref=theplasticsfella.com) [pic.twitter.com/1bTZwCwaRn](https://t.co/1bTZwCwaRn?ref=theplasticsfella.com) > > — Fascinating (@fasc1nate) [April 12, 2023](https://twitter.com/fasc1nate/status/1646181793425391619?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Always check neurovascular status after distal radius fracture. Here we can see an open fracture and ulnar affection. It is important to check before and after reduction, neurovascular problems. An ulnar nerve injury grade II-III axonotmesis. Always fix and check [pic.twitter.com/qqdoC6DfwE](https://t.co/qqdoC6DfwE?ref=theplasticsfella.com) > > — HOMID FAHANDEZH (@HOMIDFAHANDEZH) [April 12, 2023](https://twitter.com/HOMIDFAHANDEZH/status/1646190894884716544?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > So THIS is why medical student car insurance is higher than generic university student insurance [https://t.co/JgS5wtgOTb](https://t.co/JgS5wtgOTb?ref=theplasticsfella.com) [pic.twitter.com/5GhNSVnyEh](https://t.co/5GhNSVnyEh?ref=theplasticsfella.com) > > — Trishika #LiveableNHSBursary (@TrishikaSuji) [April 10, 2023](https://twitter.com/TrishikaSuji/status/1645346765854441472?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. **[So, what imaging is needed for head and neck cancers?](https://www.clinicaloncologyonline.net/article/S0936-6555%2823%2900119-X/fulltext?ref=theplasticsfella.com)** Bhattacharya et al. Imaging of Neck Nodes in Head and Neck Cancers – a Comprehensive Update, March 2023\. Clinical Oncology 2. **[4 Principles of Abdominal Wall Recon ](https://journals.lww.com/prsgo/Fulltext/2019/12000/The%5F4%5FPrinciples%5Fof%5FComplex%5FAbdominal%5FWall.19.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)** Khansa et al. 4 Principles of Complex Abdominal Wall Reconstruction. Plastic and Reconstructive Surgery - Global Open 7(12):p e2549, December 2019\. 3. **[How to Ultrasound a Flexor Tendon. ](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3478697/?ref=theplasticsfella.com)** Bianchi et al. Ultrasound of the digital flexor system: Normal and pathological findings(). J Ultrasound. 2007 Jun;10(2):85-92\. doi: 10.1016/j.jus.2007.03.002. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Gender Reassigment: 1% regret. This systematic review found that regret after gender affirmation surgery is rare, with a prevalence of 1.0%. However, the review had limitations such as a focus on Western countries, reliance on self-reported data, and a lack of examination of long-term outcomes [Read this PRS Article](https://www.theplasticsfella.com/regret-gender-reassignment/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) ### Regret after Gender Reassignment (PRS Journal) URL: https://www.theplasticsfella.com/regret-gender-reassignment/ Last updated: 2023-04-30T17:03:07.000Z #### Summary Card Level of Evidence: Systematic Review and Meta-Analysis **Findings:** • Regret after gender affirmation surgery was 1.0%. • Higher in vaginoplasty (1.3%) compared phalloplasty (0.5%) • Younger age, poor social support, and mental health problems were predictors of regret after surgery. **Implications**: • Healthcare professionals should prioritize preoperative counseling and support to minimize the risk of regret after gender affirmation surgery. • Identifying and addressing risk factors for regret during preoperative counseling can help to reduce the likelihood of regret after surgery. **Citation**: van de Grift, T.C., Elfering, L., and Kreukels, B.P.C. (2021). Regret after Gender Affirmation Surgery: A Systematic Review and Meta-Analysis. Plastic and Reconstructive Surgery - Global Open. 9(3):e3426\. doi: 10.1097/GOX.0000000000003426. --- ## Article Summary This systematic review found that regret after gender affirmation surgery is rare, with a prevalence of 1.0%. However, the review had limitations such as a focus on Western countries, reliance on self-reported data, and a lack of examination of long-term outcomes ### Background **Key Point** Gender affirmation surgery is a crucial aspect of transgender healthcare that can significantly improve quality of life, but there is a potential risk of regret that needs to be considered and addressed by healthcare professionals. Gender affirmation surgery is a significant step for transgender individuals seeking to transition physically to align their body with their gender identity. Although the majority of transgender individuals report improved quality of life and satisfaction with gender affirmation surgery, some may experience regret after surgery. The authors conducted this study to investigate the prevalence and predictors of regret after gender affirmation surgery. ### Methods **Key Point** The study utilized a systematic review of existing literature to investigate the prevalence and predictors of regret after gender affirmation surgery. The authors conducted a systematic review of 29 studies published between 2004 and 2019, including a total of 15,784 transgender individuals who underwent gender affirmation surgery. The review aimed to examine the prevalence and predictors of regret after surgery, including factors such as age, social support, mental health problems, and surgical procedure. ### Results **Key Point** The overall prevalence of regret after gender affirmation surgery was found to be low, at 1.0%. The meta-analysis found that the overall prevalence of regret after gender affirmation surgery was 1.0%. The prevalence of regret was higher among individuals who underwent vaginoplasty (1.3%) compared to those who underwent phalloplasty (0.5%). The review also found that younger age, poor social support, and mental health problems were predictors of regret after surgery. ### Discussion The study's findings indicate that regret after gender affirmation surgery is rare, with an overall prevalence of 1.0%. The authors highlight the importance of preoperative counseling and support to minimize the risk of regret. The study's findings suggest that younger age, poor social support, and mental health problems may increase the risk of regret after surgery. The authors recommend that healthcare professionals work to identify and address these risk factors during preoperative counseling to minimize the risk of regret after gender affirmation surgery. --- ## Article Discussion **Key Point** Healthcare professionals can improve clinical practice by prioritizing preoperative counseling and support, identifying and addressing risk factors for regret, and staying up-to-date on the latest research and guidelines related to gender affirmation surgery. Limitations of the study include the Western-centric focus, reliance on self-reported data, and lack of examination of long-term outcomes ### Three Learning Points: 1. Regret after gender affirmation surgery is rare, with an overall prevalence of 1.0%. 2. Vaginoplasty is associated with a slightly higher prevalence of regret (1.3%) compared to phalloplasty (0.5%). 3. Younger age, poor social support, and mental health problems are predictors of regret after surgery. ### Three Limitations: 1. The study's focus on Western countries may limit its generalizability to other regions. 2. Self-reported data used in the review may be subject to social desirability bias. 3. The review did not examine long-term outcomes, differentiate between regret related to surgical outcomes versus other factors, account for variations in definitions and criteria, consider non-English language studies, assess the impact of surgeon experience and skill, or evaluate the role of postoperative care and support. ### Three Further Reading Recommendations: 1. American Society of Plastic Surgeons. Gender Affirming Surgery. Accessed April 15, 2023\. [https://www.plasticsurgery.org/reconstructive-procedures/gender-affirming-surgery](https://www.plasticsurgery.org/reconstructive-procedures/gender-affirming-surgery?ref=theplasticsfella.com). 2. James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality; 2016. 3. WPATH. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Seventh Version. WPATH; 2011. **Three Ways to Improve Clinical Practice:** 1. Healthcare professionals should prioritize preoperative counseling and support to minimize the risk of regret after gender affirmation surgery. 2. Identify and address risk factors for regret, such as younger age, poor social support, and mental health problems, during preoperative counseling. 3. Stay up-to-date on the latest research and guidelines related to gender affirmation surgery to ensure the best possible care for transgender patients. --- ### thePlasticsPaper - April 9th URL: https://www.theplasticsfella.com/april-9th/ Last updated: 2023-04-09T17:20:25.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/april-9th/#a-letter-from-pfella)** Troubling Trend in Plastic Surgery Research 2. **🤓 [The Sunday Quiz](https://www.theplasticsfella.com/april-9th/#the-sunday-quiz)** Vascular Malformations (improved format) 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/april-9th/#upcoming-events)** +10 webinars, courses and conferences. 4. **🔥[New Features ](https://www.theplasticsfella.com/april-9th/#new-features)** "thePlasticsFlash 2.0" - check this out 5. 📸 **[Image of the Week ](https://www.theplasticsfella.com/april-9th/#image-of-the-week)** "Fake" post-op Rhinoplasty pictures 6. **🐣 [Tweets of the Week](https://www.theplasticsfella.com/april-9th/#tweets-of-the-week)** P'Fella's 3 favourite tweets 7. **📝 [Articles of the Week](https://www.theplasticsfella.com/april-9th/#articles-of-the-week)** Adrenaline, Nailbeds, and Flap Necrosis **Fun Fact: P'Fella is looking for a [team member.](https://connect.theplasticsfella.com/opportunities?ref=theplasticsfella.com)** ## A Letter from P'Fella ### The Troubling Trend in Plastic Surgery Research While the importance of research in plastic surgery cannot be overstated, there is a growing concern that the field has become too focused on quantity over quality. The pressure to publish as many articles as possible have led to a culture of "**publish or perish**," where researchers are more concerned with the [number of publications on their CVs](https://twitter.com/PlasticsFella/status/1642116555264671744?s=20&ref=theplasticsfella.com) than the actual impact of their work. This has resulted in an abundance of mediocre studies being published in **predatory journals**, which ultimately do more harm than good to the field. One of the biggest drivers of this trend is the **flawed incentive structure** in academic medicine. Researchers are often evaluated based on metrics such as the number of publications, the impact factor of the journals they publish in, and the grant funding they receive. While these metrics are intended to measure productivity and impact, they are often used as a proxy for success and are frequently misinterpreted by institutions and individuals. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/if.png) [Source](https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjac186/6631231?ref=theplasticsfella.com) Another issue is the **proliferation of predatory journals**, which prey on researchers' desire to publish and lack of understanding of the publishing process. These journals often have lax peer-review processes and, in some cases, will publish anything for a fee. This has led to a proliferation of low-quality studies that do not contribute to advancing the field but instead serve to inflate researchers' publication records. Not only does this undermine the integrity of the field, but it can also have serious consequences for patients if low-quality research is used to guide clinical practice. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/predator.png) Illustration from [Nature](https://www.nature.com/articles/d41586-019-03759-y?ref=theplasticsfella.com) To address these concerns, some publications have implemented **innovative peer review models**. For example, the Journal of Plastic, Reconstructive & Aesthetic Surgery has introduced a “registered reports” format, in which authors submit a detailed research proposal before conducting their study. Another way to promote quality research is to **increase transparency** and data sharing. The [RSTN](https://reconstructivesurgerytrials.net/?ref=theplasticsfella.com) is doing good work on this. Having a large database can help address the issue of selective reporting, where researchers only report positive results and fail to report negative or inconclusive findings, which can bias the literature. The future of plastic surgery research must prioritize quality over quantity to ensure that the field continues to advance and improve patient care. While the current incentive structure and the proliferation of predatory journals present significant challenges, addressing these issues is critical to the integrity and credibility of the field. But at the end of the day, this poll speaks for itself. > What’s your main motivation for publishing in journals? > > — thePlasticsFella (@PlasticsFella) [April 1, 2023](https://twitter.com/PlasticsFella/status/1642116555264671744?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) **TL;DR** Plastic surgery research prioritizes quantity over quality due to flawed incentives and predatory journals, leading to a proliferation of low-quality studies and a "publish or perish" culture that must be addressed by prioritizing impact and responsible publishing practices. ## The Sunday Quiz ### Week 2: Vascular Malformations ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/Infantile-Haemangioma-Clinical-Scenario-1.png) What is the natural history of this lesion? A. No change to size B. Self-resolution by 3 months C. Proliferates for 1 year, then involuted D. This will be excised. ## Upcoming Events ### Events, Courses, Conferences, Webinars P'Fella will bring you a weekly roundup of major events, informative webinars, and fantastic courses. #### 1. [**Rhinoplasty Society**](https://rhinoplastysociety.org/meetings?ref=theplasticsfella.com) Annual Meeting - Florida, 19th April 2. **[BSSH](https://www.bssh.ac.uk/about/events/4541/bssh%5Fspring%5Fscientific%5Fmeeting%5F2023?ref=theplasticsfella.com)** Spring Meeting - Swansea, 19th April. 3. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-2-hand-surgery-advances?ref=theplasticsfella.com): Advances in Hand Surgery - 27th April. 4. [**AAPS**](https://meeting.aaps1921.org/?ref=theplasticsfella.com) 10th Annual Meeting - Chicago, 29th April. 5. **[Kings College](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/facial-aesthetic-dissection-course?ref=theplasticsfella.com)** \- Facial Aesthetic Dissection- 4th May. 6. [**ICOPLAST** ](https://registrations.dxblive.com/CommunityPortal/Registration/ICOPLAST20.aspx?registrantID=861d5933-db8a-4021-b129-2e47889b18e3&ref=theplasticsfella.com)2nd World Congress, Dubai - 5th May 7. [**FESSH**](https://fessh2023.com/?ref=theplasticsfella.com) Annual Meeting - Rimini, 10th May 8. [**ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 9. [**Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 10. [**BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov [See more events](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) ## New Features ### P'Fella is always building and improving. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/flashsss.png) 👋 **Exciting news! ThePlasticsFlash 2.0 is on the way.** P'Fella has been hard at work building a new and improved flashcard tool that is designed to help you learn more effectively. With features like the ability to mark flashcards as **correct** or **incorrect** and find your **live score**, you'll be able to **track** your progress and stay motivated. And that's just the beginning. Soon, you'll also be able to compare your performance to the **average** **score** per flashcard, **add flashcards** back into the deck, and track your progress over time. As development continues, we plan to add even more features like **AI-powered recommendations** and the ability to create your own flashcards. With all of these tools at your fingertips, you'll have everything you need to master any subject. Check out our working prototype below, and stay tuned for more updates as we continue to refine and improve thePlasticsFlash 2.0. 0:00 / 1× [Check out the current version](https://www.theplasticsfella.com/theplasticsflash/) ## Image of the Week ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/04/FsPr2U0WwA02J2g.jpeg) AI-generated pre- and post-op rhinoplasty patient ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > ⛔️ STOP scheduling back to back meetings! ✋ > Science now proves that it is bad for our stress levels and contributes to burnout. > > Put breaks in between meetings. Your health and productivity will be boosted. > > Ban back to back meetings in your organisation. ❌ [pic.twitter.com/6WJrjyJNx4](https://t.co/6WJrjyJNx4?ref=theplasticsfella.com) > > — Emma Clayton (@Brilliant\_Teams) [April 1, 2023](https://twitter.com/Brilliant%5FTeams/status/1642059505612599303?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > I asked AI to imagine doctors throughout history posing for selfies. > > Here's what it came up with, starting with Ancient Egypt: [pic.twitter.com/jwRJArF7VJ](https://t.co/jwRJArF7VJ?ref=theplasticsfella.com) > > — David Hindin, M.D.  (@DavidHindin) [March 27, 2023](https://twitter.com/DavidHindin/status/1640457931530579968?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > How to boost your H-index? Just publish a two-page paper with 72 self-citations out of 73 total references. Elsevier journals will publish it, and it will be indexed under Scopus indexes. [pic.twitter.com/BdLakqxaI6](https://t.co/BdLakqxaI6?ref=theplasticsfella.com) > > — Nicola Tomassetti (@N\_Tomassetti) [March 24, 2023](https://twitter.com/N%5FTomassetti/status/1639333549642752000?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. [**Max dose of Adrenaline??**](https://www.theplasticsfella.com/indocyanine-green-angiography-overpredicts-necrosis/) Shih, Sabrina et alMaximum Dose of Plain Epinephrine in Plastic Surgery: Room to Explore. Plastic & Reconstructive Surgery-Global Open 11(4):p e4912, April 2023\. 2. [**Tips for Partial Ear Reconstruction** ](https://parjournal.net/article/view/4587?ref=theplasticsfella.com) Rosi-Schumacher et al Partial auricular reconstruction surgery for facial skin cancer. *Plast Aesthet Res* 2022;9:11\. 3. [**NINJA! Should we replace the nail in fingerbeds?** ](https://academic.oup.com/bjs/article/110/4/432/7083485?login=false&ref=theplasticsfella.com) NINJA Collaborative, Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial, **British Journal of Surgery*, Volume 110, Issue 4, April 2023 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Is Indocyanine green overrated for detecting necrosis? A study compared ICG angiography and MSRI for assessing tissue viability in breast reconstruction surgery. MSRI was more accurate than ICG angiography in predicting postoperative necrosis. MSRI may be a better option for plastic surgeons. [Read this PRS Article](https://www.theplasticsfella.com/indocyanine-green-angiography-overpredicts-necrosis/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) ### Indocyanine Green Angiography Overpredicts Necrosis? (PRS) URL: https://www.theplasticsfella.com/indocyanine-green-angiography-overpredicts-necrosis/ Last updated: 2023-04-09T13:52:06.000Z #### Summary Card **Level of Evidence:** Case Series This study compares indocyanine green (ICG) angiography and multispectral reflectance imaging (MSRI) to determine tissue viability in breast reconstruction surgery patients. The study found that ICG angiography overpredicted postoperative necrosis in comparison to MSRI. MSRI accurately predicted viability in almost all patients, while ICG angiography incorrectly predicted necrosis in many cases. The study suggests that MSRI may be a better option for plastic surgeons in determining the likelihood of postoperative necrosis. **Citation** George RE, Elwood ET, Jones GE. Indocyanine Green Angiography Overpredicts Postoperative Necrosis Compared to Multispectral Reflectance Imaging. Plast Reconstr Surg. 2023 Mar 1;151(3):412e-419e. doi: 10.1097/PRS.0000000000009917\. Epub 2022 Nov 22\. PMID: 36730439. **Disclaimer:** MSRI device used is Kent Snapshot. The senior author is the medical director of plastic surgery for Kent Imaging. **Article** **Reviewer** Mr Chad Chang FRCS (Plast) --- ## Background **Key Point** The article compares MSRI and ICG angiography for tissue perfusion assessment in breast reconstruction surgery. The authors suggest that angiography may overpredict tissue necrosis, while MSRI is a non-invasive method that can analyze tissue oxygenation without any tracer or dye. _This post is for subscribers on the thePlastics Pro tier only._ ### Key Notes on Plastic Surgery - Book Review URL: https://www.theplasticsfella.com/key-notes-on-plastic-surgery-book-review/ Last updated: 2024-02-01T22:38:29.000Z #### Summary Card ****Key Points** The book uses a highly illustrated, bullet-point format to explain key concepts, making it easy to understand and retain information. ****Structure** The book's layout is well-organized, with each chapter covering a specific topic and concluding with a summary of key points, making it easy to navigate and find information quickly. ****Illustrations** The book's illustrations are a nice feature, of high quality and clearly labeled, making it easy to understand the surgical techniques being described. The authors could have provided more illustrations on important concepts. The illustrations aren't real patients. ****Other reviews** The book is highly practical and useful, with many reviewers on online bookstores praising its concise and clear explanations of surgical techniques. ****Overall** While the book may have some limitations in terms of depth of coverage, it is an excellent resource that is definitely worth checking out for anyone interested in plastic surgery. [Get the Book](https://www.amazon.co.uk/Notes-Plastic-Surgery-Adrian-Richards-dp-1444334344/dp/1444334344/ref=dp%5Fob%5Ftitle%5Fbk??ref=theplasticsfella.com) "Key Notes on Plastic Surgery" is a comprehensive guide to the field of plastic surgery, authored by two renowned plastic surgeons, Adrian Richards and Hywel Dafydd. The book covers a wide range of plastic surgery topics, including facial surgery, breast surgery, body contouring, and non-surgical procedures. Aimed at medical students, plastic surgery trainees, and practicing plastic surgeons, this textbook is an essential resource for anyone seeking to deepen their knowledge and understanding of plastic surgery. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/4-1.png) One of the strengths of this book is its clear and concise presentation of complex topics. The authors use a highly illustrated, bullet-point format to explain key concepts, making it easy for readers to understand and retain information. The book's layout is well-organized, with each chapter covering a specific topic and concluding with a summary of key points. This makes it easy to navigate and find information quickly. The book's illustrations are a standout feature. They are of high quality and clearly labeled, making it easy to understand the surgical techniques being described. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/2-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/3-1.png) Many reviewers on Amazon and other online bookstores have praised the book for its practicality and usefulness. One reviewer writes, "This textbook is an absolute gem. It is concise, well-structured, and provides clear explanations of surgical techniques. The illustrations are top-notch and the clinical photographs are a valuable addition." Another reviewer notes, "As a plastic surgery trainee, I have found this book to be an invaluable resource. It covers all the essential topics in a clear and concise manner and has helped me to improve my surgical skills." However, there are some limitations to the book that should be noted. Some readers may find that the book is too basic and lacks detail in certain areas. For example, the authors briefly mention the use of non-surgical treatments, such as injectables and fillers, but do not provide in-depth explanations of these procedures. Additionally, while the textbook provides detailed descriptions of surgical techniques, it does not cover the management of complications or potential adverse events that may occur during or after surgery. Despite these limitations, "Key Notes on Plastic Surgery" is an excellent resource for anyone looking to deepen their knowledge of plastic surgery. Its clear and concise presentation of complex topics, along with high-quality illustrations and clinical photographs, make it a valuable reference for medical students, plastic surgery trainees, and practicing plastic surgeons alike. Whether you are looking to improve your surgical skills or simply want to gain a better understanding of plastic surgery, this book is definitely worth checking out. In conclusion, "Key Notes on Plastic Surgery" by Adrian Richards and Hywel Dafydd is a highly recommended resource for anyone interested in plastic surgery. Its clear and concise presentation, high-quality illustrations, and clinical photographs make it an invaluable reference for both beginners and experienced practitioners. While it may have some limitations in terms of depth of coverage, its practicality and usefulness cannot be denied. If you are looking for a comprehensive guide to plastic surgery, this book is definitely worth your time and investment. Overall, "Key Notes on Plastic Surgery" is a highly recommended resource for anyone interested in the field of plastic surgery. Its clear and concise presentation of complex topics, high-quality illustrations, and practical focus make it an invaluable reference for medical students, plastic surgery trainees, and practicing plastic surgeons alike. Despite some limitations, it is an excellent resource that is definitely worth checking out. ### thePlasticsPaper - March 26th URL: https://www.theplasticsfella.com/march-26th/ Last updated: 2023-03-26T18:43:13.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/march-26th/#a-letter-from-pfella)** I used AI for 1 month. Here are my thoughts. 2. **🤓 [Study on Sunday](https://www.theplasticsfella.com/march-26th/#study-on-sunday)** Ectropions are tricky. 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/march-26th/#upcoming-events)** 10 webinars, courses and conferences. 4. **🔥**[**New Features** ](https://www.theplasticsfella.com/march-26th/#new-features) "Connect" will change how you network. 5. 📸 **[Image of the Week ](https://www.theplasticsfella.com/march-26th/#image-of-the-week)** AI-generated skin lesion. 6. **🐣 [Tweets of the Week](https://www.theplasticsfella.com/march-26th/#tweets-of-the-week)** P'Fella's 3 favourite tweets 7. **📝 [Articles of the Week](https://www.theplasticsfella.com/march-26th/#articles-of-the-week)** Replants, Breast Reductions, and Caffeine **Fun Fact:** the average rating for thePlasticsPaper is 9.7/10\. What's your take on it? Share your [feedback](https://www.theplasticsfella.com/march-26th/#feedback) ## A Letter from P'Fella ### I used AI for 1 month. Here are my thoughts. Hey everyone! I've been using different AI software for the past month and discovered how AI is transforming the research landscape. I have been using and I have to say, I'm pretty impressed. Here's a screenshot of the interface below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/eleictor.png) Elicit.org is my #1 AI tool at the moment. I've been playing around with different AI tools and have found some cool things about how AI is changing research. Here are three things I think are pretty great, and three things we need to keep in mind **Positives:** 1. **Efficiency**: AI is incredibly fast and efficient in processing data, allowing researchers to analyze more data in a shorter amount of time. This means we can uncover insights and trends faster and get answers to our research questions quicker. 2. **Accuracy**: Unlike humans, AI algorithms can analyze data with incredible accuracy, reducing errors and increasing the reliability of research results. 3. **Innovation**: AI can help researchers identify patterns and relationships in data that may not be immediately apparent to humans, leading to new and innovative research questions and discoveries. **Negatives**: 1. **Bias**: AI is only as unbiased as the data it's trained on. If the data is biased, so will be the AI's analysis, leading to flawed research results. It's important to be aware of this potential bias and work to minimize it. 2. **Ethical concerns**: There are ethical concerns related to the use of AI in research, particularly when it comes to data privacy and informed consent. We need to be mindful of these issues and ensure that our research is conducted in an ethical manner. 3. **Accessibility**: Not all researchers have access to AI tools, which can create a divide between those who can and cannot use AI in their research. It's important to work towards making AI tools and technology more accessible to everyone. As a fellow research enthusiast, I encourage you to keep exploring the role of AI in research and stay engaged with the latest developments in this field. Together, we can work towards creating a more accessible, equitable, and responsible research landscape that leverages the full potential of AI. **TL;DR** I've discovered some amazing ways that AI is changing the research landscape. AI is fast, accurate, and can lead to innovative discoveries. We need to be mindful of potential bias, ethical concerns, and accessibility issues. Let's continue exploring the role of AI in research and work towards creating a responsible and equitable research landscape. ## Study on Sunday ### Ectropion (+ new quiz!) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/Eyelid-Ectropian-1-2.png) [Sunday Quiz](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) 😄 This is a brand-new quiz format. You'll get live results and a live leaderboard. The winner is announced after Week 6! ## Upcoming Events ### Events, Courses, Conferences, Webinars P'Fella will bring you a weekly roundup of major events, informative webinars, and fantastic courses. #### 1. [**Rhinoplasty Society**](https://rhinoplastysociety.org/meetings?ref=theplasticsfella.com) Annual Meeting - Florida, 19th April 2. **[BSSH](https://www.bssh.ac.uk/about/events/4541/bssh%5Fspring%5Fscientific%5Fmeeting%5F2023?ref=theplasticsfella.com)** Spring Meeting - Swansea, 19th April. 3. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-2-hand-surgery-advances?ref=theplasticsfella.com): Advances in Hand Surgery - 27th April. 4. [**AAPS**](https://meeting.aaps1921.org/?ref=theplasticsfella.com) 10th Annual Meeting - Chicago, 29th April. 5. **[Kings College](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/facial-aesthetic-dissection-course?ref=theplasticsfella.com)** \- Facial Aesthetic Dissection- 4th May. 6. [**ICOPLAST** ](https://registrations.dxblive.com/CommunityPortal/Registration/ICOPLAST20.aspx?registrantID=861d5933-db8a-4021-b129-2e47889b18e3&ref=theplasticsfella.com)2nd World Congress, Dubai - 5th May 7. [**FESSH**](https://fessh2023.com/?ref=theplasticsfella.com) Annual Meeting - Rimini, 10th May 8. [**ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 9. [**Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 10. [**BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov [See more events](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) ## New Features ### P'Fella is always building and improving. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/Connect.png) 👋 **It's time to meet "Connect".** P'Fella has been building a new hub for plastic trainees and surgeons to post jobs, fellowships, research proposals, and upcoming events. It will make networking easier. With \~40,000 monthly visitors, I hope thePlasticsFella can now be an effective tool for anyone to promote information within the community. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/Events.png) Here are some planned features: 1. **Create, Engage, Share:** Create a profile to showcase your work and expertise. Engage with like-minded professionals in the plastic surgery field 2. **Register for Events:** Attend the most anticipated plastic surgery events worldwide. Learn from and join conversations with other professionals in the field. 3. **Find Opportunities:** Browse for job opportunities, fellowships, research positions, and more. Connect with recruiters and employers in the plastic surgery industry. 4. **Discuss Clinical Cases (soon!):** teach and learn from interesting clinical cases. Gain insights and expertise from other professionals in the field 5. **Forum (soon!)** Share your experiences and insights with others in the plastic surgery field. Ask for advice and connect with other professionals. [Check out the beta-version](https://connect.theplasticsfella.com/?ref=theplasticsfella.com) ## Image of the Week ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/AI-Image.png) AI-generated skin lesion ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > Handy reminders of Type I and Type II Errors: 2/2 (an old one but my favourite) [pic.twitter.com/7xurXzEHv1](https://t.co/7xurXzEHv1?ref=theplasticsfella.com) > > — NIHR Applied Research Collaboration (ARC) West (@ARC\_West) [February 6, 2023](https://twitter.com/ARC%5FWest/status/1622544110958559233?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > ChatGPT for Research > > No more sifting through endless research papers to find the answer you need. > > Just ask any question and Consensus AI will deliver a GPT-4-powered summary of the top 5-10 papers. [pic.twitter.com/SgNhvqs8uW](https://t.co/SgNhvqs8uW?ref=theplasticsfella.com) > > — Shubham Saboo (@Saboo\_Shubham\_) [March 24, 2023](https://twitter.com/Saboo%5FShubham%5F/status/1639284731136057350?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > What’s the most boring thing about performing surgeries? The writing and documentation afterwards. But why not use [#AI](https://twitter.com/hashtag/AI?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) to write the reports? What do you think? Good enough? Or more details needed? [#spinetwitter](https://twitter.com/hashtag/spinetwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#neurosurgery](https://twitter.com/hashtag/neurosurgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#spinesurgery](https://twitter.com/hashtag/spinesurgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/caCJ3w1LqD](https://t.co/caCJ3w1LqD?ref=theplasticsfella.com) > > — Clemens Weber (@clemensweber) [March 13, 2023](https://twitter.com/clemensweber/status/1635335424322473986?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. **[Don't give heparin post-finger replant.](https://www.jhandsurg.org/article/S0363-5023%2822%2900471-3/fulltext?ref=theplasticsfella.com)** Zhu LM et al.The Role of Intravenous Heparin Following Digital Replantation: A Retrospective Cohort Study on 1,155 Digits. J Hand Surg Am. 2023 Mar;48(3):263-272. 2. **[So coffee doesn't affect the heart? ](https://www.nejm.org/doi/10.1056/NEJMoa2204737?url%5Fver=Z39.88-2003&rfr%5Fid=ori:rid:crossref.org&rfr%5Fdat=cr%5Fpub%20%200pubmed&ref=theplasticsfella.com)** Marcus GM et al. Acute Effects of Coffee Consumption on Health among Ambulatory Adults. N Engl J Med. 2023 Mar 23;388(12):1092-1100. 3. **[Blood thinners don't affect STSG](https://journals.lww.com/prsgo/Fulltext/2022/12000/Neither%5FAntiplatelet%5Fnor%5FAnticoagulant%5FTherapy.21.aspx?ref=theplasticsfella.com).** Walters et al. Neither Antiplatelet nor Anticoagulant Therapy Increases Graft Failure after Split-thickness Skin Grafting. Plastic and Reconstructive Surgery - Global Open 10(12):p e4221, December 2022. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### How to do a Breast Reduction. This article [introduces](https://www.theplasticsfella.com/cosmetic-breast-reduction/#introduction) a stepwise approach for cosmetic breast reduction using a mosque dome skin marking and a superomedial pedicle, best for patients with small to moderate breast hypertrophy. This strategy may be helpful for trainees or plastic surgeons early in their practice. [Read this PRS Article](https://www.theplasticsfella.com/cosmetic-breast-reduction/) ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) ### A Step-by-Step Approach to a Successful Cosmetic Breast Reduction (PRS) URL: https://www.theplasticsfella.com/cosmetic-breast-reduction/ Last updated: 2023-04-09T12:56:18.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/journal-today.png) #### Summary Card **Level of Evidence:** Case Series This article [introduces](https://www.theplasticsfella.com/cosmetic-breast-reduction/#introduction) a stepwise approach for cosmetic breast reduction using a mosque dome skin marking and a superomedial pedicle, best for patients with small to moderate breast hypertrophy. The described [steps](https://www.theplasticsfella.com/cosmetic-breast-reduction/#step-by-step-approach) can also be used with an inferior pedicle and a Wise pattern marking. The approach includes treating the pillars, using stay sutures, shaping the lateral breast, and skin tailoring. This strategy may be helpful for trainees or plastic surgeons early in their practice. This is [discussed](https://www.theplasticsfella.com/cosmetic-breast-reduction/#article-discussion) in detail. This article has been reviewed by Mr Chad Chang FRCS (Plast) --- ## ## Introduction **Key Point** Breast reduction removes excess tissue, relocates the nipple, minimizes scarring, and maintains sensation using various techniques and careful pre-operative planning. Breast reduction aims to remove excess tissue, relocate the nipple, and create a pleasing shape while minimizing scarring & maintain sensation. The most common technique used is the inverted-T, inferior pedicle design with Wise pattern skin markings, but other techniques have emerged. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/03/Wise.png) Initial Wise-Pattern publication by Robert Wise 1956 Adequate pre-operative markings and intraoperative strategies can simplify the procedure and achieve satisfactory results with a step-by-step approach described in this article. --- ## Step-by-Step Approach **Key Point** Key steps are pre-operative markings, early design of pillars, key untied stay sutures, restoring lateral breast contour, pedicle suspension, NAC fixation before pillars closure, pillars closure with hanging breast, intersection suture, and horizontal skin excision. 📹 This open journal provides a video tutorial. You can watch it [here](· http://links.lww.com/PRSGO/A988). ### Step 1: Symmetrical Preoperative Markings - Mark the midline and inframammary fold. - Medial markings must be symmetrical between both breasts. For highly asymmetric breasts, lateral markings may differ. - Estimate the centre of the new nipple position by tracing a horizontal line 1cm over the inframammary fold and marking the breast mound at the level of the breast meridian. - The superior border of the areola should be marked approximately 2cm above this marking, and the standard diameter for the areola is 4cm. ### Step 2: Early Design of Pillars - Before parenchymal excision, define the medial and lateral pillars by tracing 7cm vertical lines on each side from the lower limit of the new areolar opening. - Keep the medial pillar full thickness for improved fullness and projection, and thin the lateral pillar to around 2cm. - Excise tissue at the inferior and lateral areas along the mastectomy cleavage plane, leaving a 4-5mm adipocutaneous flap. ### Step 3: Key Untied Stay Sutures - Placed two untied nylon 3-0 stay sutures between the new areolar opening and the areola (12 o’clock, and 6 o’clock) after parenchymal excision and secured with 2 Kelly forceps. - The stay sutures provide a 3-dimensional perspective of the new breast by pulling towards the zenith, aiding in size estimation between both breasts, and helping during pillars closure. ### Step 4: Restoring Lateral Breast Contour - A curvilinear piece of glandular tissue is excised from the caudal part of lateral pillar, leaving a thin dermal flap. This is to restore the natural lateral breast contour. - The location and extent of excision is determine by outlining the ideal lateral breast curvature on the skin. - Consider adding liposuction to the lateral breast in large reductions to avoid extended horizontal scars and improve shape at the end of the procedure. ### Step 5: Pedicle Suspension - Rotate or displace the pedicle superiorly without tension. - Fix the pedicle to the pectoralis fascia using 2-3 nonabsorbable sutures in the superior limit of the upper pole dissection. - Keep the cephalic dissection limit around the most superior extent of the breast footprint. ### Step 6: NAC Fixation before Pillars Closure - Suture the NAC to the new areolar opening before closing the pillars. - This reduces tension during closure and prevents undesired downward traction of the nipple. - It also helps to avoid abnormal protrusion of the areola after breast assembly. ### Step 7: Pillars Closure with Hanging Breast - Keep traction of the breast mound toward the zenith with an assistant. - Close pillars using 2 layers of nonabsorbable sutures. - Hanging the breast during closure exposes the correct alignment of the pillars and often results in increased projection and better shape. ### Step 8: Intersection Suture - Place a stay suture at the intersection between the meridian and both medial and lateral flaps. - The suture assists with tailoring of skin excess - Keep the suture in place until breast closure is completed. ### Step 9: Horizontal Skin Excision - Horizontal skin excess is removed at the end of the procedure, reducing final scar length. - Redundant skin is incised at the superior border, forming two inferiorly based skin flaps. - With assistant pushing the breast caudally, use the the natural crease of the IMF as a guide for determining the amount of skin excision needed. --- ## Article Discussion **Key Point** This article presents the importance of symmetrical pre-operative markings, stay sutures for size estimation, and lateral breast contouring in breast reduction surgery. Positives include a stepwise approach and an excellent marking video. Limited by its applicability to small to moderate-sized reductions, and potential changes to a practice involving precise marking, pedicle suspension, and lateral breast contouring. ### 3 Learning Points - Importance of keeping medial marking symmetrical. - Use of stay sutures around NAC to improve size estimation. - Lateral breast contouring ### 3 Discussion Points: Positives, Limitations - Nice stepwise approach for cosmetic breast reduction using a mosque dome skin marking and a superomedial pedicle. - This is limited to small to moderate sized reduction – might be less applicable in the UK. - Excellent video on marking the breast. ### 3 Ways to change your practice. - Precise marking is essential. - Pedicle suspension - Lateral breast contouring ### 3 Recommended Reads 1. Hall-Findlay EJ, Shestak KC. [Breast reduction](https://pubmed.ncbi.nlm.nih.gov/26397273/?ref=theplasticsfella.com). *Plast Reconstr Surg*. 2015;136:531e–544e. 2. Andrades P, Prado A. [Understanding modern breast reduction techniques with a simplified approach](https://pubmed.ncbi.nlm.nih.gov/18502712/?ref=theplasticsfella.com). *J Plast Reconstr Aesthet Surg*. 2008;61:1284–1293. 3. Davison SP, Mesbahi AN, Ducic I, et al. [The versatility of the superomedial pedicle with various skin reduction patterns](https://pubmed.ncbi.nlm.nih.gov/18040175/?ref=theplasticsfella.com). *Plast Reconstr Surg*. 2007;120:1466–1476. --- ### Periocular BCC - Clinical Case URL: https://www.theplasticsfella.com/periocular-bcc-clinical-case/ Last updated: 2024-09-04T19:14:54.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Lower-Eyelid-Reconstruction-Scenario.png) #### ****Objectives** ****1\.** Clinical diagnosis of a basal cell carcinoma ****2\.** Classify and stage high and low risk lesions ****3.** Provide a treatment plan and algorithm ****5.** Management of deep-margins ****6\.** Describe reconstruction techniques ****7.** Provide evidence for Moh's, surgery and radiotherapy --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - January 15th URL: https://www.theplasticsfella.com/january-15th/ Last updated: 2023-01-15T15:35:10.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/january-15th/#a-letter-from-pfella)** What 422 members said about P'Fella. 2. **🤓 [Study on Sunday](https://www.theplasticsfella.com/january-15th/#study-on-sunday)** Describing a vascular anomaly 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/january-15th/#upcoming-events)** 17 webinars, courses and conferences. 4. 📸 **[Image of the Week ](https://www.theplasticsfella.com/january-15th/#image-of-the-week)** AI-generated melanoma. 5. **🐣 [Tweets of the Week](https://www.theplasticsfella.com/january-15th/#tweets-of-the-week)** P'Fella's 3 favourite tweets 6. **📝 [Articles of the Week](https://www.theplasticsfella.com/january-15th/#articles-of-the-week)** Cancer sounds, scrub colours, breast reduction **Fun Fact:** the average rating for thePlasticsPaper is 9.6/10\. What's your take on it? Share your [feedback](https://www.theplasticsfella.com/january-8th/#feedback) --- ## A Letter from P'Fella ### What 422 members have to say about P'Fella. 422 people answered one question, "When you hear 'thePlasticsFella', what do you think of?" I am thrilled to share the feedback we've received from our community. The responses we've received, including comments such as "**One of the best sites I ever found**" and "**An interesting and interactive way to digest difficult concepts of Plastic Surgery**", are a testament to the effort put in to make our platform useful and accessible to all plastic surgery enthusiasts. This feedback has been instrumental in guiding the efforts to continue pushing the boundaries in plastic surgery education. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/graph.png) 422 Respondents The **top 10 words** that came out of the feedback were: **Great**, **Plastic**, **Education**, **Good**, **Learning**, **Cool**, **Resource**, **Fellowship**, **Help** and **Interesting**. However, I want to remind you that these are just a tiny representation of the feedback, and our platform is not just about these words. As this platform's founder, **I believe continuous learning is important for growth.** That's why I am proud to be a part of a community that shares that value. I will continue working hard to bring you the latest and most helpful information about plastic surgery. I am always striving to improve and provide you with the best resources possible to help guide professionals to success in plastic surgery. From information on hand incision to the quick literature search and exam revision, **I want this platform to be the go-to resource**. I couldn't have done this without the support of our community. I am grateful for being a part of this community, and I want to thank you for being a part of it. Thank you for supporting us in our mission to provide the best plastic surgery education and resources. P'Fella ❤️ --- ## Study on Sunday ### & compare your answers with the community. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/IH-tpp.png) ## Upcoming Events ### Courses, Conferences and Webinars in 2023 P'Fella will bring you a roundup of major events, informative webinars, and fantastic courses each week. #### 1. [**Pulvertaft**](https://us02web.zoom.us/webinar/register/WN%5F8VTat5f9SUu3YODgYXmxUw?ref=theplasticsfella.com): Why Hand Surgery is a Failure - 16th Jan. 2. **[PRS Journal Club](https://twitter.com/prsjournal/status/1611475175626756102?ref=theplasticsfella.com) \-** Breast Implants Jan 15th. 3. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/my-plastic-surgery-course---essential-skills-in-plastic-surgery-for-junior-doctors-2023?ref=theplasticsfella.com)**:** Essential Skills for Juniors - 19th Jan. 4. [**Stoke Mandeville**](https://us06web.zoom.us/webinar/register/WN%5FDi7%5FWWzXQaOK1HyjZqFMTg?ref=theplasticsfella.com): 30 years as a surgeon - 31st Jan 5. [**ASRM**](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) Microsurgery Annual Meeting - Florida, 24th Jan. 6. [**ASPS**](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) Virtual Spring Meeting - 3rd March. 7. [**Dallas**](https://dallasrhinoplastyandcosmeticmeeting.com/?ref=theplasticsfella.com) Rhinoplasty Meeting - 9th March 8. [**Pulvertaft**](https://pulvertafthandcentre.org.uk/courses/hand-fracture-fixation-course-2023/?ref=theplasticsfella.com) Hand Fracture Fixation - Derby, 22nd March. 9. [**Rhinoplasty Society**](https://rhinoplastysociety.org/meetings?ref=theplasticsfella.com) Annual Meeting - Florida, 19th April 10. **[BSSH](https://www.bssh.ac.uk/about/events/4541/bssh%5Fspring%5Fscientific%5Fmeeting%5F2023?ref=theplasticsfella.com)** Spring Meeting - Swansea, 19th April. 11. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-2-hand-surgery-advances?ref=theplasticsfella.com): Advances in Hand Surgery - 27th April. 12. [**AAPS**](https://meeting.aaps1921.org/?ref=theplasticsfella.com) 10th Annual Meeting - Chicago, 29th April. 13. **[Kings College](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/facial-aesthetic-dissection-course?ref=theplasticsfella.com)** \- Facial Aesthetic Dissection- 4th May. 14. [**ICOPLAST** ](https://registrations.dxblive.com/CommunityPortal/Registration/ICOPLAST20.aspx?registrantID=861d5933-db8a-4021-b129-2e47889b18e3&ref=theplasticsfella.com)2nd World Congress, Dubai - 5th May 15. [**FESSH**](https://fessh2023.com/?ref=theplasticsfella.com) Annual Meeting - Rimini, 10th May 16. [**ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 17. [**Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 18. [**BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ## Image of the Week ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Nose-Clincial-Images.png) AI-Generated Melanoma ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > On the history of 'palming' the needle holder: > > In 1973 Oschner noted that palming was widespread due to the influence of the trainees of Frederick Coller, surgery chief at U Michigan. > > Oschner's father then told him the real reason why Coller 'palmed' was that he had arthritis: [pic.twitter.com/raO7nCDAE2](https://t.co/raO7nCDAE2?ref=theplasticsfella.com) > > — Ron Barbosa MD FACS (@rbarbosa91) [January 11, 2023](https://twitter.com/rbarbosa91/status/1613095115832324103?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > I don’t know what’s funnier: the fact that they forced chatGPT take USMLE exams or that they made the AI bot an author ahead of real people [pic.twitter.com/6SdL1dW5MS](https://t.co/6SdL1dW5MS?ref=theplasticsfella.com) > > — Naina 🦴 (@Narniarawr) [January 12, 2023](https://twitter.com/Narniarawr/status/1613519885123960834?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Here is one of my latest medical illustrations showing the classification of phalangeal neck fractures on the basis of displacement and bony contact. [pic.twitter.com/gOYrje1no2](https://t.co/gOYrje1no2?ref=theplasticsfella.com) > > — Hatan Mortada | هتان مرتضى (@HatanMortada) [January 10, 2023](https://twitter.com/HatanMortada/status/1612864375328575503?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ### ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. **[Steps to a Cosmetic Breast Reduction](https://journals.lww.com/prsgo/Fulltext/2019/04000/A%5FStep%5Fby%5FStep%5FApproach%5Fto%5Fa%5FSuccessful%5FCosmetic.25.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)** Guridi et al. A Step-by-Step Approach to a Successful Cosmetic Breast Reduction. PRS Global Open 7(4) 2019. 2. **[The sound of cancer? ](https://pubmed.ncbi.nlm.nih.gov/36585869/?ref=theplasticsfella.com)** Catalino et al. Tumor sound, auditory cues, and tissue pathology in glioma surgery: a proof-of-concept study. J Neurosurg. 2022 Dec 30:1-9 3. [**Don't wear black scrubs?**](https://pubmed.ncbi.nlm.nih.gov/36630142/?ref=theplasticsfella.com) Hribar CA et al Association Between Patient Perception of Surgeons and Color of Scrub Attire. JAMA Surg. 2023 Jan 11. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Kanavel Signs - The Original This 1912 publication by Allen B Kanavel provided a standardised method to diagnose flexor tenosynovitis. This journal club critiques the methods, results and conclusions of this landmark paper [Kanavel signs - Original Publication](https://www.theplasticsfella.com/kanavel-publication/) --- ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) --- ### Original Publication - Kanavel Signs URL: https://www.theplasticsfella.com/kanavel-publication/ Last updated: 2023-01-15T15:02:03.000Z **Original Publication:** *Infections of the hand: a guide to the surgical treatment of acute and chronic suppurative processes in the fingers, hand, and forearm.* Kanavel, Allen B. 1912 In the early 1900s, Allen B Kanavel (1874-1938) wrote a masterpiece on infections of the hand. A 6-volume collection just on infections. Pretty impressive. The cardinal signs of flexor tenosynovitis were first described in this work. They have stood the test of time. This journal club will look at the key points of the publication and the current literature over 100 years since its first publication. Journal club is for thePlasticsPro users. If you want to keep reading, try a free trial or you can just stick to thePlasticsLibrary for your free education. _This post is for subscribers on the thePlastics Pro tier only._ ### Cleft Hand - Clinical Case URL: https://www.theplasticsfella.com/cleft-hand-clinical-case/ Last updated: 2024-09-04T19:12:51.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Hand---Clinical-Case-1.png) #### ****Objectives** ****1\.** Clinical diagnosis of a central longitudinal deficiency ****2\.** Classify and stage the congenital malformation ****3.** Describe the aetiology of this condition ****5.** Order and report on relevant investigations ****6\.** Develop a treatment timeline ****7.** Describe soft tissue and bony reconstruction options --- --- ## Section 1 ### Clinical Assessment #### Describe what you see in this clinical photograph. This patient has clinical features consistent with a left cleft hand. Examining this hand from radial to ulnar - Thumb is present; it does not appear hypoplastic - 1st webspace is mildly narrowed - Central cleft result in divergence of the index and ring finger - The little finger is unremarkable on inspection - There is no secondary malformation, such as syndactyly. To conclude the exam - Compared to the right hand - Examine the wrist, elbows, shoulders - Assess for secondary associations (e.g. EEC - ectrodactyly, ectodermal dysplasia, facial clefts). - Formal hand assessment to assess movement, prehension and grip. - Take a detailed history. So, in summary, this 3-month-old baby has a left-side cleft hand. I would support these clinical findings by following up with relevant investigations. #### How do you classify the degree of first webspace narrowing? This patient has a mildly narrow first webspace. Therefore, it is an IIA as per the Manske and Haliki classification. The grades of this classification are as follows: - ****Type I:** normal first webspace - ****Type II:** narrowed (A: mildly, B: severely) - ****Type III**: thumb-index syndactyly - ****Type IV:** Index ray suppressed, first web space merged with cleft - ****Type V:** thumb suppressed, absent first webspace. #### What is the classfication of cleft hand? This patient has a central longitudinal deficiency. The Swanson classification describes this as a failure of formation, and OMT classifies this condition as a malformation. #### Explain the core concepts of upper limb embryology The upper limb develops during weeks 4-8 from 3 axes with specific signalling centres and proteins. More specifically: - ****AP axis** "ulnarises" the limb via zone of polarising activity, and sonic hedgehog protein - ****PA axes** "distalises" the limb via apical ectodermal ridge, and FGFR proteins - ****DV axes** "dorsalises" the limb via dorsal ectoderm and WNT7A. You can read more about [embryology](https://www.theplasticsfella.com/upper-limb-embryology/). ## Section 2 ### Investigations ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Hand---Clinical-Case-xray-1.png) #### Report the X-Ray above. This is a PA x-ray of the 3-month-old baby's left hand. It supports the clinical diagnosis of a cleft hand. Important features to note include: - The thumb is well formed and not syndactylised to the index - Transverse bone in the central cleft area. This will only increase the width of the cleft over time. - The ring and little finger are radiologically normal. ## Section 4 ### Management of Cleft Hand #### What are your treatment principles for achieving a cleft hand? The goals are guided by the patient's clinical and radiological findings. These can include: 1. [Syndactyly release](https://www.theplasticsfella.com/syndactyly/#management-of-syndactyly) 2. Removal of transverse bones 3. First web space [reconstruction](https://www.theplasticsfella.com/syndactyly/#management-of-syndactyly) 4. [Pollicisation](https://www.theplasticsfella.com/thumb-hypoplasia/#index-pollicisation-for-thumb-hypoplasia) if an absent thumb or free toe transfer 5. Correct feet deformity 6. Closure of the cleft using the Snow-Littler technique #### Would you operate on all patients? It's important to individualise patient care. During my initial assessment, there are some specific markers I look out for. These include: - Prehension - Dexterity - Impact of QOL/ADLs - Delayed presentation If the patient is coping well and has minimal psychosocial issues or impact on quality of life, I would be unlikely to operate. #### What is your technique for cleft closure? I use the Snow-Littler technique for soft tissue and a 2nd-3rd metacarpal transfer for bone reconstruction. In terms of the ****Snow-Littler Technique** - Palmar-based flap transposed to the first webspace - Random-pattern flap that can be axial if volar vessel identified - The donor site closed primarily with a Barksy flap for the commissure In terms of ****bony** reconstruction: - Transfer 2nd metacarpal to the 3rd metacarpal base - Secured with K-wire. --- ### Radial Longitudinal Deficiency - Clinical Case URL: https://www.theplasticsfella.com/radial-longitudinal-deficiency-clinical-case/ Last updated: 2024-09-04T19:11:18.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Radial-Longitudinal-Deficiency.png) #### ****Objectives** ****1\.** Clinical diagnosis of a radial longitudinal deficiency ****2\.** Knowledge of associated conditions ****3.** Describe X-Ray findings of a "club hand." ****4.** Provide a long-term management plan for these patients. ****5.** Screening investigations for associated conditions ****6\.** Surgical options for centralisations --- _This post is for subscribers on the thePlastics Pro tier only._ ### Polydactyly - Clinical Case URL: https://www.theplasticsfella.com/polydactyly-clinical-case/ Last updated: 2024-09-04T19:10:38.000Z #### ****Objectives** ****1\.** Clinical diagnosis of a polydactyly ****2\.** Hand examination of a polydactyly patient ****3.** Classification systems for this condition ****4.** Identify the correct digits to excise ****5.** Order relevant investigations ****6\.** Surgical options specific to the patient ****7.** Relevant anatomy to reconstruction _This post is for subscribers on the thePlastics Pro tier only._ ### Vascular Tumour - Clinical Case URL: https://www.theplasticsfella.com/vascular-tumour-clinical-case/ Last updated: 2024-09-04T19:09:23.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Infantile-Haemangioma-Clinical-Scenario-1.png) #### ****Objectives** ****1\.** Clinical diagnosis of a vascular malformation ****2\.** Create and justify a differential diagnosis ****3.** Describe the natural history and aetiology of this condition ****4.** Identify and treat complications and associated conditions ****5.** Order relevant investigations ****6\.** Treat this condition in the short and long term ****7.** Be aware of novel techniques and indications for surgery --- ## Section 1 ### Clinical Diagnosis _This post is for subscribers on the thePlastics Pro tier only._ ### Cleft Lip - Clinical Case URL: https://www.theplasticsfella.com/cleft-lip-clinical-case/ Last updated: 2024-09-04T19:08:24.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Lip-Clinical-Scenario.png) #### ****Objectives** ****The following 20 oral questions will assess:** ****1\.** Clinical assessment of a cleft lip ****2.** Identify specific features of a cleft lip ****3.** Describe the aetiology and genetics of this condition ****4.** Differ microform, incomplete and Simonart bands ****5.** Describe the components of a cleft team ****6**. Pre-operative workup for a cleft patient ****7**. Surgical techniques and markings of cleft repairs ****8.** Correction of nasal deformities and alveolar gaps [Start Assessment](https://www.theplasticsfella.com/cleft-lip-clinical-case/#section-1) ## Section 1 ### Clinical Assessment of a Cleft Lip #### Describe what you see, please. This is a clinical photograph of a complete right-sided cleft lip, alveolus and associated nasal deformity. Concerning the lip: - Skin: discontinuity, vertical and transverse deficiency - Muscle: abnormal insertions into the alar base and nasal spine - Alveolus: gapping with a hard palate defect. Concerning the nose: - Columella, nasal spine and caudal septum deviate away and posterior from the cleft, resulting in dislocation from the vomer groove. - Nasal tip is broad due to the separation of alar domes and sagging/kinking of the lateral crus on the cleft side. - Classically on the cleft side, upper and lower lateral cartilages separate and nasal bones flatten. I would like to conclude my examination by assessing - ****Palate**: confirm the defect anterior to incisive foramen and no involvement of the soft palate. - ****Maxilla**: rotated and prominent premaxilla, a retropositioned and hypoplastic lateral maxilla. - ****Secondary feature**s: such as lower lip pitting in van der Woude. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/4-1.png) #### What are some key questions to ask in history? - ****Obstetric History**: antenatal diagnosis, type of delivery, neonatal care - ****Risk Factors:** Smoking, phenytoin, diabetes, retinoic acid, alcohol - ****Family History**: cleft lip/palate, syndromes (e.g. van der Woude). - ****Social History**: home support, employment and domestic issues - ****Postnatal**: feeding, thriving, airway and psychological concerns - ****Knowledge**: assessing parental knowledge and timeline of treatments. #### What is a cleft lip? A cleft lip is a congenital malformation of the ****primary** ****palate** (lip, alveolus and hard palate anterior to the incisive foramen). It may be complete or incomplete, bilateral or unilateral, syndromic and non-syndromic. #### Why does a cleft lip occur? The main theory relating to the embryological changes that produce a cleft lip is "failure of fusion" of the ****medial nasal** ****and maxillary processes.** These arise from the central frontonasal prominence and the first [pharyngeal arch](https://www.theplasticsfella.com/pharyngeal-arches/#pharyngeal-arches). A unilateral cleft lip occurs when the vomer remains attached to one palatal shelf. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/3.png) #### What is the familial risk or incidence of cleft lip? If there is no family history, the relative risk is 0.1%. This risk increases as the number of family members with cleft increases. - ****1 sibling**: 4% - ****1 parent**: 7% - ****2 siblings**: 9% - ****1 parent and 1 sibling:** 17%. #### Describe a cleft lip classification system My personal preference is to "describe what I see": - Unilateral or bilateral - Complete or incomplete - Associated with a cleft palate or submucous cleft - Syndromic or non-syndrome I know other classification systems such as the Veau, Kernahan or LAHSHAL. - ****Veau** describes cleft lip and palate as 4 groups (soft palate, hard and soft palate, palate through to alveolus, and complete bilateral clefts) - ****LAHSHAL** represents ****L**ip, ****A**lveolus, ****H**ard Palate and ****S**oft Palate from right to left. - Kernahan Striped-Y is a graphical classification numbered 1-9\. This is drawn below ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Kernahan-striped-Y.png) #### What is an "incomplete" cleft lip? A cleft lip with an intact nostril sill, so the full height of the lip is not involved. A mild form of the incomplete cleft is called "forme fruste" or microform, which has features of: - A vermillion notch - A nasal ala kink on the cleft side - A vertical fibrous band from the red line to the nostril floor. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Forme-Fruste-Cleft-Lip.png) #### What is a Simonart Band? A soft tissue bridge that traverses a complete cleft lip. It does not contain any muscle and does not convert a complete into an incomplete cleft lip. Pictured below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Simonart-Bands.png) #### Explain the cleft diagnosis to the parents - Congratulate new parents - Explain cleft lip as a birth defect - Emphasize multifactorial causes, no specific fault - Discuss the risks of further siblings if appropriate - Mention treatable with surgery - Explain the expected treatment timeline. - Remind of ongoing support from a specialist MDT. ## Section 2 ### Management of a Cleft Lip #### Who is part of a "cleft team"? - ****Core Group:** Cleft coordinator, patient and their family. - ****Surgeons**: Plastics, Maxillofacial, ENT, Orthodontist, Dentist, - ****Medical**: Paediatrician, Neonatologists, Geneticist - ****Additional**: SLT, psychologist, audiologist, photographer All team members play important roles in caring for patients with cleft conditions and work together to provide best possible treatment and support #### How would you repair this cleft lip? I will repair the lip and hard anterior palate at 6 months. My department's anaesthetic colleagues prefer a 6-month timeline to reduce anaesthetic risk. I prefer a Fisher repair and a vomer flap.. I do not routinely use pre-surgical orthodontics or lip adhesion. If there is any remaining cleft in the secondary palate, I will repair this at 12 months. #### Do you use pre-surgical orthodontics? I do not use this technique in my department because of the low level of high-quality evidence to support its use and the significant burden of care. I am aware of its key points, and these include: - Application of passive or dynamic appliances to narrow the cleft deformity, align the alveolar process and mould the nasal deformity. - The idea is to make surgical repair easier and improve outcomes - Evidence does suggest it may have an inhibitory effect on growth. #### Would you perform a lip adhesion? In this patient, I would not perform lip adhesion. I generally reserve this operating for: - Wide clefts can be converted into less difficult incomplete clefts. - Bilateral clefts with a protruding maxillary segment - In patients that can wait 3 months more for definitive lip repair. I know the technique involving the skin and mucosal flaps designed within future discarded tissue. #### Consent the parents for a cleft lip repair There are intra-operative and post-operative risks that can relate to surgery and the anaesthetic. Specific to a cleft lip repair - ****Wound**: dehiscence, infection, bleeding, fistula - ****Scar**: multiple scars that may widen or contract - ****Anaesthetic**: airway, allergies and barotrauma. - ****Multiple surgeries**: bleeding or revisions further down the line As a side note, I often try to highlight the change in facial features early. This often can be an initial shock or surprise to the parents. #### Describe the landmarks in Fisher's unilateral cleft lip repair 25 points can be marked using callipers on the medial lip, nasal floor and lateral lip, as outlined in the initial [PRS publication in 2005](https://pubmed.ncbi.nlm.nih.gov/15988248/?ref=theplasticsfella.com). - ****Point 1:** the midline of the philtrum at the columellar base. - ****Point 2:** height of the **non-cleft* side philtrum column (mirrors point 3). - ****Point 3:** height of the **cleft-*side philtrum column (mirrors point - ****Points 4:** upper lip midline (the trough of cupids bow) - ****Points 5, 6:** peaks of Cupid's bow at the vermilion-cutaneous junction. - ****Points 7, 8:** white-roll cutaneous junctions at each cupid bow peak. - ****Point 9**: midline of the philtrum (inferior) - ****Points 10:** at the midline and wet-dry mucosa. - ****Points** ****11, 12**: below the peaks of Cupid's bow to form a "red-line" - ****Points 13, 14:** right and left alar base (inferior point of alar-lip junction) - ****Point 15**: convexity of sill at lip-columellar crease (symmetric with 16) - ****Point 16:** height of the lip at the proposed closure in the nostril sill. - ****Point 17:** cutaneous roll and red line converge medially at the vermilion-cutaneous junction, also known as Noordhoff's point - ****Point 18:** above the cutaneous roll, perpendicular to the vermilion-cutaneous junction. - ****Point 19:** the closure point in the nostril sill and is the same distance from point 14 as points 13 to 15 (non-cleft nasal floor width). - ****Points 20:** between points 18 and 19 (using calipers). - ****Point 21:** between 19- 20 so lines 19-21 equals 3-16, 20-21 equals 3-8. - ****Point 22:** forms an isosceles triangle with points 18 and 20\. The base of the triangle is equal the required vermilion augmentation (lines 5-11 minus 6-12) and should fit the back cut. - ****Point 23:** the wet-dry border on the cleft side - ****Point 24:** along a line connecting points 17 and 23 equal to line 6-12 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/6.png) #### How do you prep and drape the patient in the theatre? - ****General Anaesthetic** with endotracheal tube secured to chin midline. - ****Position:** supine and slight neck extension using a shoulder roll and table at a slight reverse Trendelenburg position. - ****Sterile**: Prep and drape the face with sterile tapes over the closed eyelids - ****Document** presurgical photographs - ****Markings** tattooed with gentian violet dye and a 25-gauge needle. - ****Local Anaesthetic:** Bilateral infraorbital nerve blocks with infiltration of the cleft-side alar base, piriform rim, and inferior turbinate with 1% lidocaine with epinephrine 1:200,000 (maximum dose, 0.5 ml/kg). No infiltration of the lip is performed. - ****Mouth** ****pack** inserted. #### Describe the steps of medial lip dissection in Fisher's technique 1. Incise above the cutaneous roll but not through muscle. 2. Discard cleft marginal tissue 3. Dissect muscle from overlying skin, vermilion and mucosa. 4. Preserve philtral dimple by limiting skin-muscle dissection to 1mm from cut edge. 5. Free orbicularis from its columellar base and alveolar cleft margin insertions. 6. Position lip and columellar base to predict the final position, and an appropriate downward rotation of the cleft side peak of Cupid’s bow is verified. 7. Lateral lip markings can then be altered if necessary. #### What other techniques exist for cleft lip repair? Cleft lip repair techniques can be classified by their movements. ****The Millard Rotation Advancement** - ****Technique**: Triangular flap from upper lip advanced into the rotated area of the medial segment. - ****Benefits**: recreates philtrum, allowing for adjustments to be made during the surgery, and making future revisions easier. - ****Limitations**: changes to the nose (such as a scar at the base of the nose or constriction of the nostrils) and the lip (such as a short lip or vertical deficiency) ****Tennison-Randall Technique** - ****Technique**: 10 markings involving a lower z-plasty - ****Benefits**: good tension at the alveolar ridge (normal pouting) - ****Limitations**: challenging to adjust intra-operatively, does not restore philtral column, creates a long lip or vertical excess. Other techniques to consider include the Skoog, Trauner, Le Mesurier, Delaire, and Rose-Thompson straight-line repair. #### How would you correct this patient's nasal deformity? My preference is for a delayed secondary rhinoplasty. This is because releasing the orbicularis muscles and repairing the cleft will correct some nasal deformities. It also allows delayed correction after nasal and midfacial growth is complete in the patient's teenage years. I only consider primary nasal surgery in patients with a wide cleft using a limited McComb technique. This involves shortening the nose on the cleft side by repositioning the caudally rotated lower lateral cartilage through percutaneous sutures. More specifically: - Dorsal supra-cartilaginous dissection - Separation of cleft alar cartilage from the piriform aperture - Percutaneous sutures from the nasal lining to alar cartilage and bolsters to lift the cartilage into the correct position. Other techniques include Anderl and Tajima techniques. #### Would you do bone grafting at the time of lip repair? In my department, I would not do this as the bone may resorb, and it may affect facial growth. I prefer to perform this at a time of "mixed dentition", about 10 years of age. This is when the permanent canine is about to erupt and can be predicted by monitoring the contralateral canine or x-ray examination. This is performed under a general anaesthetic and involves 1. ****Preparing the recipient site**: raise gingivoperiosteal flaps at the defect and close the nasal mucosa to separate it from the oral cavity. 2. ****Harvest graft**: cancellous bone from the iliac crest 3. ****Inset graft**: pack it into the defect and close the oral mucosa. ### thePlasticsPaper - January 8th URL: https://www.theplasticsfella.com/january-8th/ Last updated: 2025-03-28T18:50:53.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/january-8th/#a-letter-from-pfella)** Are we not operating enough? Solutions. 2. **🤓 [Study on Sunday](https://www.theplasticsfella.com/january-8th/#study-on-sunday)** Describing a cleft lip (+new quiz!) 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/january-8th/#upcoming-events)** 17 webinars, courses and conferences. 4. 📸 NEW: **[Image of the Week ](https://www.theplasticsfella.com/january-8th/#image-of-the-week)** An original AI-generated cleft lip. 5. **🐣 [Tweets of the Week](https://www.theplasticsfella.com/january-8th/#tweets-of-the-week)** P'Fella's 3 favourite tweets 6. **🚀[ New Features](https://www.theplasticsfella.com/january-8th/#new-features)** Clinical cases! Do the first one! 7. **📝 [Articles of the Week](https://www.theplasticsfella.com/january-8th/#articles-of-the-week)** Flaps, carpal tunnel, clefts and more! **Fun Fact:** the average rating for thePlasticsPaper is 9.6/10\. What's your take on it? Share your [feedback](https://www.theplasticsfella.com/january-8th/#feedback) --- ## A Letter from P'Fella ### Are we operating enough? Have you guys seen the results of that **Twitter poll** about the **operating** frequency? It was super interesting to see the wide range of responses, with 28% of respondents saying they operate 1-2 days per week, 28% operating 2-3 days per week, 22% operating 3-4 days per week, and 22% operating more than 4 days per week. And it's not just a small sample size either - the poll received nearly 80 replies and was international, with a lot of departmental variation. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/twitter-poll.png) **But what do these results mean for us as plastic surgery trainees and residents?** That's what I want to talk to you about today. Well, first of all, it's clear that there's a wide range of operating frequencies out there. And that makes sense - **everyone's situation is different**, and there are a lot of factors that can impact how often you're able to get into the operating room. But while it's important to manage your workload and take care of yourself, it's also worth considering the benefits of operating more frequently. I mean, think about it - the more time you spend in the OR, the more experience you're going to get, and the better you're going to become at your craft. And let's face it; **there's no substitute for the real thing when it comes to plastic surgery.** 💡 **Research Idea:** I reviewed PubMed and Google Scholar to see if there is any current literature on the frequency of surgery - to the best of my knowledge, there isn't much out there! **So, what can you do if you want to increase your operating frequency?** One option is to seek out opportunities to assist on cases or to take on additional cases whenever possible. Collaborating with your colleagues and working as a team can also be a big help in increasing the number of cases you can complete in a week. And finding ways to make the operating room more efficient, like using technology or streamlining processes, can help you get more done in less time. But it's not all about working harder and taking on more cases. It's also important to find a **good balance** and make time for yourself outside of work. It's easy to get caught up in the hustle and bustle of surgery, but it's crucial to take breaks and find ways to decompress. Trust me, your colleagues and your patients will thank you for it. So there you have it - a rundown of the poll results and some thoughts on what they might mean for us as plastic surgery trainees and residents. I hope you found this helpful and that it gives you some food for thought. ❤️ P'Fella --- ## Study on Sunday ### & compare your answers with the community. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Lip-Clinical-Findings-1.png) ## Upcoming Events ### Courses, Conferences and Webinars in 2023 Each week, P'Fella will bring you a roundup of major events, informative webinars, and fantastic courses. #### 1. **[Pulvertaft](https://us02web.zoom.us/webinar/register/WN%5Fk-b6kPZBT0OA80zMZayM0A?ref=theplasticsfella.com)** \- "Mallets, Baseballs & DIPJ" - Jan 9th. 2. **[PRS Journal Club](https://twitter.com/prsjournal/status/1611475175626756102?ref=theplasticsfella.com) \-** Breast Implants Jan 15th. 3. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/my-plastic-surgery-course---essential-skills-in-plastic-surgery-for-junior-doctors-2023?ref=theplasticsfella.com)**:** Essential Skills for Juniors - 19th Jan. 4. [**Stoke Mandeville**](https://us06web.zoom.us/webinar/register/WN%5FDi7%5FWWzXQaOK1HyjZqFMTg?ref=theplasticsfella.com): 30 years as a surgeon - 31st Jan 5. [**ASRM**](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) Microsurgery Annual Meeting - Florida, 24th Jan. 6. [**ASPS**](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) Virtual Spring Meeting - 3rd March. 7. [**Dallas**](https://dallasrhinoplastyandcosmeticmeeting.com/?ref=theplasticsfella.com) Rhinoplasty Meeting - 9th March 8. [**Pulvertaft**](https://pulvertafthandcentre.org.uk/courses/hand-fracture-fixation-course-2023/?ref=theplasticsfella.com) Hand Fracture Fixation - Derby, 22nd March. 9. [**Rhinoplasty Society**](https://rhinoplastysociety.org/meetings?ref=theplasticsfella.com) Annual Meeting - Florida, 19th April 10. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-2-hand-surgery-advances?ref=theplasticsfella.com): Advances in Hand Surgery - 27th April. 11. [**AAPS**](https://meeting.aaps1921.org/?ref=theplasticsfella.com) 10th Annual Meeting - Chicago, 29th April. 12. **[Kings College](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/facial-aesthetic-dissection-course?ref=theplasticsfella.com)** \- Facial Aesthetic Dissection- 4th May. 13. [**ICOPLAST** ](https://registrations.dxblive.com/CommunityPortal/Registration/ICOPLAST20.aspx?registrantID=861d5933-db8a-4021-b129-2e47889b18e3&ref=theplasticsfella.com)2nd World Congress, Dubai - 5th May 14. [**FESSH**](https://fessh2023.com/?ref=theplasticsfella.com) Annual Meeting - Rimini, 10th May 15. [**ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 16. [**Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 17. [**BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ## Image of the Week ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/image-of-the-week.png) ## Tweets of the Week ### Don't forget to follow [P'Fella](http://twitter.com/plasticsfella?ref=theplasticsfella.com)! > In a 13-question survey distributed to 145 residency programs, YouTube was ranked as the primary reference in preparing for surgical procedures [pic.twitter.com/QdfU4FjYt1](https://t.co/QdfU4FjYt1?ref=theplasticsfella.com) > > — Christopher Bayne (@baynece) [December 24, 2022](https://twitter.com/baynece/status/1606680677659082752?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > It must be a daunting task for an immensely successful and widely respected surgeon who is inevitably facing retirement in a few years to have to deal with the consequences of not having taken care of their family life for the last three or four decades. > > — George Tolis (@georgetolisjr) [January 6, 2023](https://twitter.com/georgetolisjr/status/1611363231573970951?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Hospital design committee sometime in the past > > “Let’s get boxes of clinical gloves that open on top, and mount them with that surface vertically. This way, when a clinician pulls out a glove, an additional three will fall on the floor” > > “Great idea - motion passed! What’s next?” > > — Cliff Reid (@cliffreid) [January 4, 2023](https://twitter.com/cliffreid/status/1610525989037297664?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## New Features ### Clinical cases are now here. ### **Check out our new "Clinical Cases" section!** This resource features real-life clinical vignettes to help you think on the spot and delve deeper into diagnosing, managing, and treating complications. As a growing database, it will become an invaluable tool for trainees and residents accomplishing exams. Please note: this is just a beta-version and many more updates to come! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Lip-Clinical-Scenario-1.png) [Test yourself! (beta-version)](https://www.theplasticsfella.com/cleft-lip-clinical-case/) --- ## Articles of the Week ### 3 must-read articles, 1 deep-dive! 📚 #### 3 Must-reads 1. [**Useful Flaps for Plastic Surgeons to Know**](https://pubmed.ncbi.nlm.nih.gov/36576829/?ref=theplasticsfella.com). Neligan PC. Plast Reconstr Surg. 2023 Jan 1;151(1):148e-157e. 2. [**Carpal tunnel decompression in patients with normal NCS**](https://journals.sagepub.com/doi/full/10.1177/1753193419866646?journalCode=jhsc&ref=theplasticsfella.com) Mackenzie et al. Journal of Hand Surgery (European Volume). 2020;45(3):260-264\. 3. [**Management of self-harm injuries**](https://journals.sagepub.com/doi/full/10.1177/17531934221138433?ref=theplasticsfella.com): a review of the evidence Oakley B et al. Journal of Hand Surgery (European Volume). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Lower Lip Reconstruction The Karapandzic flap was described in 1974 after a 5-year case series of lip defect reconstruction. This journal club critiques the methods, results and conclusions of this landmark paper [Karapandzic Flaps - Original Publication](https://www.theplasticsfella.com/karapandzic-flaps-original-publication/) --- ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) --- ### thePlasticsPaper - New Year's Day (Special Edition) URL: https://www.theplasticsfella.com/special-edition-2022/ Last updated: 2023-01-01T19:50:22.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/special-edition-2022/#a-letter)** How P'Fella will teach you in 2023 using AI. 2. **🤓 [Study on Sunday](https://www.theplasticsfella.com/special-edition-2022/#study-on-sunday)** Your study patterns over the last 12 months. 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/special-edition-2022/#upcoming-events)** What are the big events in 2023? 4. **🐣 [Tweets of the *Year* ](https://www.theplasticsfella.com/special-edition-2022/#tweets)** The top 8 tweets shortlisted 5. **🚀[ New Features](https://www.theplasticsfella.com/special-edition-2022/#new-features)** The most popular new educational tools. 6. **📝 [Articles of the Year](https://www.theplasticsfella.com/special-edition-2022/#articles-of-the-year)** P'Fella's article of the year and a top 10 shortlist! **Fun Fact:** thePlasticsFella community collectively studied for 206,000 minutes in 2022\. --- ## A Letter ### from P'Fella: How thePlasticsFella will use AI to teach you in 2023. The advent of artificial intelligence has resulted in a shift towards more efficient and effective ways of learning and practising medicine. One major change that has already begun to take hold is the end of traditional teaching methods, which often rely on memorization and repetition of vast amounts of information. One AI project that garnered significant attention in the healthcare industry is Google DeepMind, which uses machine learning algorithms to analyze and interpret medical images, predict patient outcomes, and even assist with diagnosis and treatment planning. Here are some examples of images created by myself with some AI prompts. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/12/DALL-E-2022-12-28-14.48.44---a-lower-eyelid-ectropion-causing-an-inflammation-of-the-conjunctiva-1.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/12/DALL-E-2022-12-28-14.50.45-4.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/12/DALL-E-2022-12-28-14.51.06.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/12/DALL-E-2022-12-28-14.49.34---a-young-female-patient-with-a-large-dorsal-hump-on-her-nose-and-a-bulbous-nasal-tip--1.png) However, it's important to note that the **current examination systems**, such as the FRCS and boards, may be slow to react to this technological shift. While we must embrace this new teaching and learning phase, it is also important to remember that traditional teaching and knowledge consumption will still be a necessary part of our education for the foreseeable future. However, the quicker we embrace this new teaching phase, the quicker our exams will truly reflect current clinical practice. Here is an example of a Google Deepmind project **answering USMLE questions**. You can read the full article [here](https://arxiv.org/pdf/2212.13138.pdf?ref=theplasticsfella.com) on this new project. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/12/Pink-Peach-Retro-Abstract-Background-Motivational-Quote-Instagram-Post-1.png) Of course, it's important to remember that **AI does not replace human expertise** and experience. It is simply a tool that can enhance and supplement our learning and practice. As plastic surgery trainees and residents, we must embrace this technology and use it to our advantage as we continue to grow and develop as professionals. So, while the end of traditional teaching may seem daunting at first, it is ultimately an exciting opportunity for us to adapt and evolve as practitioners in a rapidly changing field. Let's **embrace the power of AI** and use it to our advantage as we continue on our journey as plastic surgery trainees and residents. **P'Fella x** *p.s I'll be testing out AI to tailor study plans and create clinical cases in the near future.* --- ## Study on Sunday ### P'Fella studied your behaviour! It's been an exciting year for thePlasticsFella! We've seen tremendous growth over the last 12 months, and we have all of you to thank for your support of our mission. It's been amazing to see which parts of the world have shown the most growth and to discover which articles have been the most popular. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/2022-review.png) To give you a better idea of the data, we've compiled a comprehensive overview of our members' locations, their preferred devices for accessing the platform, and the growth in unique visitors over time. Thanks again for your support and for helping to make thePlasticsFella such a success. Here's to even more growth in the future! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/2022-data-.png) --- ## Upcoming Events ### in 2023 This list will be updated weekly to showcase some of the major events happening this year. Please note that there are many more events than listed here; these are just some major events. In future updates, we will also include information about webinars and weekly events. #### 1. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/my-plastic-surgery-course---essential-skills-in-plastic-surgery-for-junior-doctors-2023?ref=theplasticsfella.com)**:** Essential Skills for Juniors - 19th Jan. 2. [**ASRM**](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) Microsurgery Annual Meeting - Florida, 24th Jan. 3. [**ASPS**](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) Virtual Spring Meeting - 3rd March. 4. [**Dallas**](https://dallasrhinoplastyandcosmeticmeeting.com/?ref=theplasticsfella.com) Rhinoplasty Meeting - 9th March 5. [**Pulvertaft**](https://pulvertafthandcentre.org.uk/courses/hand-fracture-fixation-course-2023/?ref=theplasticsfella.com) Hand Fracture Fixation - Derby, 22nd March. 6. [**Rhinoplasty Society**](https://rhinoplastysociety.org/meetings?ref=theplasticsfella.com) Annual Meeting - Florida, 19th April 7. [**BAPRAS**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-2-hand-surgery-advances?ref=theplasticsfella.com): Advances in Hand Surgery - 27th April. 8. [**AAPS**](https://meeting.aaps1921.org/?ref=theplasticsfella.com) 10th Annual Meeting - Chicago, 29th April. 9. **[Kings College](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/facial-aesthetic-dissection-course?ref=theplasticsfella.com)** \- Facial Aesthetic Dissection- 4th May. 10. [**ICOPLAST** ](https://registrations.dxblive.com/CommunityPortal/Registration/ICOPLAST20.aspx?registrantID=861d5933-db8a-4021-b129-2e47889b18e3&ref=theplasticsfella.com)2nd World Congress, Dubai - 5th May 11. [**FESSH**](https://fessh2023.com/?ref=theplasticsfella.com) Annual Meeting - Rimini, 10th May 12. [**ASSH**](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) Annual Meeting - Toronto, 5th October 13. [**Plastic Surgery**](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- The Meeting: Texas, 26th Oct 14. [**BAPRAS Congress**](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-congress-2023?ref=theplasticsfella.com) \- 29th Nov [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ## Tweets ### of the year! A shortlist! > Reddish skin discoloration in the median nerve distribution after carpal tunnel glucocorticoid injection (vasomotor disturbance) [#medtwitter](https://twitter.com/hashtag/medtwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/jUeE3CyvUp](https://t.co/jUeE3CyvUp?ref=theplasticsfella.com) > > — Avraham Z. Cooper, MD (@AvrahamCooperMD) [July 22, 2022](https://twitter.com/AvrahamCooperMD/status/1550286780292792322?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Clinical pearl; A One minute Neuro hand exam, I call > 'Check your Six'. Ask your patient to give you a boy scout salute (three finger salute- median/ulnar), an Ok (ant interroseus), then play 'Rock (median), Paper (radial), Scissors (Ulnar) and sign off with a Thumbs up (radial) [pic.twitter.com/oFbnyCTs7o](https://t.co/oFbnyCTs7o?ref=theplasticsfella.com) > > — Neurophilia (@bobvarkey) [July 31, 2022](https://twitter.com/bobvarkey/status/1553885663812268032?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > How to Read Research Articles of Various Types 📚 & Assess Methodological Quality? (to UNDERSTAND, write better REVIEW & find RESEARCH GAP) > 10 points Thread > Links to resource at the end[#AcademicTwitter](https://twitter.com/hashtag/AcademicTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@PhDVoice](https://twitter.com/PhDVoice?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@PhD\_Genie](https://twitter.com/PhD%5FGenie?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@ThePhDPlace](https://twitter.com/ThePhDPlace?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@AcademicChatter](https://twitter.com/AcademicChatter?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > > 1\. How to Read a Paper? [pic.twitter.com/reAZXE7dYO](https://t.co/reAZXE7dYO?ref=theplasticsfella.com) > > — Saleem Bokhari (@SaleemBokhari1) [November 3, 2022](https://twitter.com/SaleemBokhari1/status/1588181183929597952?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Look at this awesome view of the brachial plexus and surrounding anatomy. [pic.twitter.com/jAVKK0IYWo](https://t.co/jAVKK0IYWo?ref=theplasticsfella.com) > > — Oren Gottfried, MD (@OGdukeneurosurg) [July 8, 2022](https://twitter.com/OGdukeneurosurg/status/1545531196985278470?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > The literature [pic.twitter.com/GvY88kFjtU](https://t.co/GvY88kFjtU?ref=theplasticsfella.com) > > — Oded Rechavi 🦉 (@OdedRechavi) [July 3, 2022](https://twitter.com/OdedRechavi/status/1543627986339069962?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Rare pic of an Orthopaedic surgeon with his ego![#MedTwitter](https://twitter.com/hashtag/MedTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#orthotwitter](https://twitter.com/hashtag/orthotwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/cyoavGwU0R](https://t.co/cyoavGwU0R?ref=theplasticsfella.com) > > — anconeus (@pratikorho) [June 2, 2022](https://twitter.com/pratikorho/status/1532386581662687234?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Facial prosthesis, c.1917\. THREAD👇 > > From the moment the first machine gun rang out over the Western Front, one thing was clear: Europe’s military technology had wildly surpassed its medical capabilities. Bodies were battered, gouged, hacked, and gassed. [pic.twitter.com/NeKpcZSXLP](https://t.co/NeKpcZSXLP?ref=theplasticsfella.com) > > — Dr Lindsey Fitzharris (@DrLindseyFitz) [May 1, 2022](https://twitter.com/DrLindseyFitz/status/1520847480858058752?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > How to determine a PIP joint fracture dislocation (involving 30-50% surface) INSTABILITY? > > Instability = SURGERY. > > (Ans: Dorsal “V sign” on X-ray). [pic.twitter.com/VY7vXUn8vj](https://t.co/VY7vXUn8vj?ref=theplasticsfella.com) > > — Dr Karan Choudhry (@KaranChoudhry6) [April 29, 2022](https://twitter.com/KaranChoudhry6/status/1520120513036660736?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## New Features ### Most popular tools launched in 2022! 🔥 ### Wow, P'Fella has had an amazing year at ThePlasticsFella! A ton of new features to the platform, focusing on providing a comprehensive educational suite of tools for plastic surgery trainees. Hopefully, you have enjoyed these new features as much as P'Fella has had to create them. Keep an eye on us because we're one to watch in the coming years (thanks to your support!) #### Most popular new features 1. [+200](https://www.theplasticsfella.com/tags/) new evidence-based topics. 2. +2000 new verified plastic surgery [flashcards](https://www.theplasticsfella.com/theplasticsflash/) 3. [Journal club with Powerpoint slides](https://www.theplasticsfella.com/tag/journals/) 4. [Summary cards](https://www.theplasticsfella.com/microtia/) at the beginning of each article 5. A [library](https://www.theplasticsfella.com/tags/) that allows you to browse by "chapters." 6. [Live video](https://www.theplasticsfella.com/interview/) for interview practice 7. [Progress bars](https://www.theplasticsfella.com/melanoma/) as you scroll down an article 8. [Bookmarks](https://www.theplasticsfella.com/bookmarks/) to save your favourite articles 9. "Student Support" for discounts to thePlasticsPro 10. [Carbon Removal](https://climate.stripe.com/DT1pUL?ref=theplasticsfella.com) contribution for every member. 11. "Ask the Expert" every Sunday Oh, and by the way, this updated interface for the flashcard database will be rolling out soon. This will allow auto-grading and the Feynman technique to improve your active recall. Check it out below. 0:00 / 1× [Get Early Access](https://www.theplasticsfella.com/theplasticsflash-wait) --- ## Articles of the Year ### P'Fella's shortlist! 📚 P'Fella keeps track of the articles he reads. In 2022, that totalled over 200\. A mixture of new publications, seminal papers and historical landmark papers changed plastic surgery. Here's the best article (in P'Fella's opinion) and the top 10 shortlist. #### Article of the Year This is P'Fella's personal opinion. I recently discovered this interesting article by JPRAS about zone 1 flexor tendon techniques. It was published in 2013, but I only stumbled upon it this year. It's become one of my favourites and has impacted my clinical practice. [Read the Artice](https://pubmed.ncbi.nlm.nih.gov/23672773/?ref=theplasticsfella.com) ### #### Top 10 Shortlist 1. [**Bi-ALCL Guidelines**](https://www.jprasurg.com/article/S1748-6815%2820%2930562-3/fulltext?ref=theplasticsfella.com) UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Turton et al. Volume 74, Issue 1, P13-29, January 2021 2. [**The First GLOBAL Plastic Trainee Survey** ](https://journals.lww.com/prsgo/Fulltext/2022/10000/Plastic%5FSurgery%5FTraining%5Facross%5FSeven%5FContinents%5F.6.aspx?ref=theplasticsfella.com) Lindqvist et al. Plastic and Reconstructive Surgery - Global Open: October 2022 - Volume 10 - Issue 10 - p e4520 3. [**The non-operative treatment of mallet finger**](https://www.jhandsurg.org/article/S0363-5023%2817%2930045-X/fulltext?ref=theplasticsfella.com) Lin JS et al. Nonsurgical Management of Mallet Finger: A Systematic Review. J Hand Surg Am. 2018 Feb;43(2):146-163.e2\. doi: 10.1016/j.jhsa.2017.10.004\. 4. [**Finger Replants don't need a vein** ](https://journals.lww.com/plasreconsurg/Abstract/2022/07000/Management%5Fof%5FArtery%5FOnly%5FDigit%5FReplantation%5F%5FA.24.aspx?ref=theplasticsfella.com) Crowe et al Management of Artery-Only Digit Replantation: A Systematic Review of the Literature, Plastic and Reconstructive Surgery: July 2022 - Volume 150 - Issue 1 - p 105-116 5. [**Creating International Microsurgery Club Series** ](https://journals.lww.com/plasreconsurg/Fulltext/2022/08000/Knowledge%5FRevolution%5Fduring%5FCOVID%5F19%5FPandemic%5F.66.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Sung et al. Knowledge Revolution during COVID-19 Pandemic: International Microsurgery Club Webinar Series. Plastic and Reconstructive Surgery: August 2022 - Volume 150. 6. **[Sustainability in Theatre](https://jamanetwork.com/journals/jamasurgery/article-abstract/2795362?ref=theplasticsfella.com)** Belliveau S, Gold MS. The Surgical Suite—A Field Laboratory for Sustainability. **JAMA Surg.* Published online August 17, 2022\. doi:10.1001/jamasurg.2022.2346 7. [**How to ACTUALLY use the p-value**](https://journals.sagepub.com/eprint/KV5PARIGVWF5JQB7JU9G/full?ref=theplasticsfella.com#.YvUE-oKymj8.twitter) Stunt et al. Statistics in publishing: the (mis)use of the p-value (Part 2). **Journal of Hand Surgery (European Volume)*. August 2022. 8. **[A review of the plastic surgery interview ](https://journals.lww.com/plasreconsurg/Fulltext/2022/08000/Difficult%5FConversations.1.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)** Phillips et al The Plastic Surgery Residency Interview Revisited: Virtual Interviews and Beyond. Plastic and Reconstructive Surgery: November 2020 9. **How to Run a Meeting,** Colwell et al. [Plastic and Reconstructive Surgery](https://journals.lww.com/plasreconsurg/Fulltext/2022/06000/How%5Fto%5FRun%5Fa%5FMeeting.1.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter): June 2022 - Volume 149 - Issue 6 - p 1283-1285 10. **Outcome measurement in adult flexor tendon injury: A systematic review.** Shaw et al. JPRAS, Sept 2021\. [doi.org/10.1016/j.bjps.2021.08.033](https://doi.org/10.1016/j.bjps.2021.08.033?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### The Most Popular in 2022 Menick's original publication was the most-viewed journal club in 2022! It's not a surprise, really, as it's a commonly examined topic that genuinely impacts clinical practice and decision-making. [Nasal Subunits Journal Club](https://www.theplasticsfella.com/nasal-subunits/) --- ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) --- ### Cleft Palate - Clinical Case URL: https://www.theplasticsfella.com/cleft-palate-clinical-case/ Last updated: 2024-09-04T19:07:38.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Cleft-Palate--case-1.png) #### ****Objectives** ****1\.** Clinical diagnosis of a cleft palate ****2\.** Describe the natural history and aetiology of this condition ****4.** Detail a management plan specific to clinical findings. ****5.** Explain the role of the MDT and key members ****6\.** Knowledge of the cleft anatomy (muscles, bone, foramen) ****7.** Draw the different reconstructions for hard and soft palate ****8**. Recognise complications and treat them accordingly. ## Section 1 ### Essential Knowledge in Cleft Palate --- _This post is for subscribers on the thePlastics Pro tier only._ ### Velopharyngeal Insufficiency - Clinical Case URL: https://www.theplasticsfella.com/vpi-clinical-case/ Last updated: 2024-09-04T19:04:36.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/VPI-Cleft-1.png) #### ****Objectives** ****1\.** Describe the clinical findings of a submucous cleft ****2\.** Converse with parents regarding cleft pathology ****3.** Order investigations and justify specific reasons. ****4.** Interpret the investigations to conclude a diagnosis ****5.** Detail a treatment plan and discuss surgical options ****6\.** Describe specific indications for VPI surgery ## Section 1 ### Clinical Assessment --- _This post is for subscribers on the thePlastics Pro tier only._ ### 13th November URL: https://www.theplasticsfella.com/13th-november/ Last updated: 2022-11-13T21:00:12.000Z #### In this week's edition 1. **✍️ [Letter from P'Fella ](https://www.theplasticsfella.com/13th-november/#a-letter)** The Feynman technique will improve your knowledge. 2. **🤓** [**Study on Sunday + Quiz** ](https://www.theplasticsfella.com/13th-november/#study) Can you design a Z-plasty? 3. **🎭[ Upcoming Events ](https://www.theplasticsfella.com/13th-november/#upcoming)** 7 new upcoming events for you. 4. **🐣 [Tweets of the Week ](https://www.theplasticsfella.com/13th-november/#tweets)** Memes, virals & threads. 5. **🚀[ New Features ](https://www.theplasticsfella.com/13th-november/#new)** +2100 flashcards (with auto-grading) 6. **📝 [Articles of the Week](https://www.theplasticsfella.com/13th-november/#articles)** 3 quick-reads to stay up to date 1 deep-dive (Bruner incisions!) **Fun Fact:** thePlasticsFella now has +2000 community members. Thanks for all the support :) --- ## A Letter ### from P'Fella ✍️ ### **What is the best way to learn?** This is an age-old question. And one, perhaps, nobody knows the answer to. At the end of the day, it's a personal choice. The best way for you may not be the best way for others. I am well aware of this and also the different methods that have shown to be consistent. So I embarked on a journey to create an [educational tool](https://www.theplasticsfella.com/theplasticsflash-wait/) that enables a combination of **space repetition**, **active recall** and the **Feynman Technique** (my favourite!). Below is a description of this latter technique. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/11/Leitner-System-Flashcards.png) **So what does the evidence say?** We know that highlighting, rereading and summarising is a waste of time ([Dulonksy et al](https://pubmed.ncbi.nlm.nih.gov/26173288/?ref=theplasticsfella.com)). The evidence suggests a "distributive and repetitive" pattern of study can "tame the complexity of the design space and to identify schedules to enhance knowledge acquisition and retention" ([Walsh et al](https://pubmed.ncbi.nlm.nih.gov/36190659/?ref=theplasticsfella.com)). **Based on all this, P'Fella built this new [educational tool](https://www.theplasticsfella.com/theplasticsflash-wait/), and you should [check](https://www.theplasticsfella.com/theplasticsflash-wait/) it out.** --- ## Study ### on Sunday 👩‍🎓 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/11/3-14-2.png) #### Z-plasty is a procedure involving the [transposition](https://www.theplasticsfella.com/classification-of-flaps/#flap-movement-classification) of two interdigitating triangular flaps. It is a common and widely practised plastic and reconstructive technique used for revisional scar surgery resulting in a functionally better and/or cosmetically appealing scar. The goal of the z-plasty procedure is to: 1. **Lengthen** a contracted scar 2. **Change the direction** of a scar and align it with relaxed skin tension lines. 3. **Improve** cosmesis [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## Upcoming ### Events, Webinars, Courses. ### #### 1. **[Pulvertaft](https://us02web.zoom.us/webinar/register/WN%5Fs8EMTgs0SD28-uKNXX%5FN1A?ref=theplasticsfella.com)** Nerve Biology - Nov 14th. 2. [**EURAPS**](https://www.euraps.org/meetings/webinar/?ref=theplasticsfella.com) Eyelid Surgery - November 15th. 3. [**PLASTA**](https://us02web.zoom.us/webinar/register/WN%5FKW4NL80CQkq6fhMr3KJ0Eg?ref=theplasticsfella.com) ST3 Interviews - Nov 16th 4. [**PLASTA** ](https://us02web.zoom.us/webinar/register/WN%5FbbsCKgmgTke2KNV7r9YGRg?ref=theplasticsfella.com)Plastic Surgery Elective - Nov 18th. 5. [**BAPRAS Congress** ](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/bapras-2022?ref=theplasticsfella.com) November 30th 2022 6. [**iBreastBook** ](https://us02web.zoom.us/webinar/register/WN%5FSMIoHah0Q2Kb37yAgliDZQ?ref=theplasticsfella.com)\- Research Paper Analysis Dec 3rd 7. [**EURAPS Facial Paralysis**](https://us06web.zoom.us/webinar/register/WN%5FIdakP6IkTlyC4l8TNbyBzg?ref=theplasticsfella.com) \- December 15th [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ## Tweets ### of the week! > A little study of the muscles of facial expression [pic.twitter.com/MDeB1fh2Qb](https://t.co/MDeB1fh2Qb?ref=theplasticsfella.com) > > — Terouz Pasha (@TerouzP) [November 10, 2022](https://twitter.com/TerouzP/status/1590706965365547008?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > 🥳🥳🥳 [pic.twitter.com/FFamQCdqbf](https://t.co/FFamQCdqbf?ref=theplasticsfella.com) > > — Lyndsey Forbes (@coollyndz) [November 8, 2022](https://twitter.com/coollyndz/status/1590033325024251905?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > How to Read Research Articles of Various Types 📚 & Assess Methodological Quality? (to UNDERSTAND, write better REVIEW & find RESEARCH GAP) > 10 points Thread > Links to resource at the end[#AcademicTwitter](https://twitter.com/hashtag/AcademicTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@PhDVoice](https://twitter.com/PhDVoice?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@PhD\_Genie](https://twitter.com/PhD%5FGenie?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@ThePhDPlace](https://twitter.com/ThePhDPlace?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@AcademicChatter](https://twitter.com/AcademicChatter?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > > 1\. How to Read a Paper? [pic.twitter.com/reAZXE7dYO](https://t.co/reAZXE7dYO?ref=theplasticsfella.com) > > — Saleem Bokhari (@SaleemBokhari1) [November 3, 2022](https://twitter.com/SaleemBokhari1/status/1588181183929597952?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## New ### features this week! 🔥 ### **[+2100 Flashcards.](https://www.theplasticsfella.com/theplasticsflash-wait)** Yep! That's right! **This is the largest online plastic surgery flashcard [deck](https://www.theplasticsfella.com/theplasticsflash-wait).** P'Fella has been working hard to create a high-quality, verified and up-to-date database of flashcards which covers over 80 different topics. Check out a demo below... 0:00 / 1× [Get Early Access](https://www.theplasticsfella.com/theplasticsflash-wait) --- ## Articles ### of the week! 📚 ### #### 3 must-read articles 1. **[Bi-ALCL Guidelines](https://www.jprasurg.com/article/S1748-6815%2820%2930562-3/fulltext?ref=theplasticsfella.com)** UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Turton et al. Volume 74, Issue 1, P13-29, January2021 2. [**How to reconstruct sarcoma defects** ](https://journals.lww.com/plasreconsurg/Abstract/2022/11000/Practical%5FStrategies%5Fin%5FReconstruction%5Fof.42.aspx?context=FeaturedArticles&collectionId=2&ref=theplasticsfella.com) Aten et al. Practical Strategies in Reconstruction of Soft-Tissue Sarcoma. Plastic and Reconstructive Surgery: November 2022 - Volume 150 - Issue 5. 3. [**The non-operative treatment of mallet finger**](https://www.jhandsurg.org/article/S0363-5023%2817%2930045-X/fulltext?ref=theplasticsfella.com) Lin JS et al. Nonsurgical Management of Mallet Finger: A Systematic Review. J Hand Surg Am. 2018 Feb;43(2):146-163.e2\. doi: 10.1016/j.jhsa.2017.10.004\. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### 1 Deep Dive! Do you know the origin of the Bruner Incision? A surgical technique that is widely adopted in the literature and clinical practice. [Original Publication](https://www.theplasticsfella.com/bruner-incision/) --- ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be! Let me know your thoughts below :) --- ### Bruner Incision - Original 1967 Publication URL: https://www.theplasticsfella.com/bruner-incision/ Last updated: 2022-11-13T20:32:42.000Z ‌ #### Summary Card **Introduction and Hypothesis** "Good exposure and clear vision of the structures". Bruner hypothesised this basic principle had been ignored in hand surgery prior to 1967\. **Why the Midlateral Incision should be replaced** The Midlateral incision was the status quo. Bruner felt it has 3 key limitations: indirect approach, damage to secondary structures, and difficulty to work between fingers. **Origins of the "Zig Zag Incision"** In 1965, Bruner started experimenting with an incision that is direct access, good exposure, and does not disturb the neurovascular bundles **Conclusion** "I believe that such a frontal attack shall replace attacks from the flank" **Powerpoint Slides** You can download these slides for your journal club. _This post is for subscribers on the thePlastics Pro tier only._ ### Vascular Malformation - Clinical Case URL: https://www.theplasticsfella.com/vascular-malformation-clinical-case/ Last updated: 2024-09-04T19:03:53.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2023/01/Capillary-Malformations-Case.png) #### ****Objectives** ****1\.** Clinical diagnosis of a vascular malformation ****2\.** Create and justify a differential diagnosis ****3.** Describe the natural history and aetiology of this condition ****4.** Identify and treat complications and associated conditions ****5.** Order relevant investigations ****6\.** Treat this condition in the short and long term ## Section 1 ### Clinical Assessment and Diagnosis --- --- #### Comment on this patient's face. This patient has a pink-red, well-defined, flat macular lesion on her right forehead. These features are clinically consistent with a capillary malformation. Most likely, a cutaneous capillary malformation. It appears to be in the territory of the ophthalmic division of the trigeminal nerve. My concern would be for Sturge Weber Syndrome. I complete my examination by looking for mucosal capillary malformations and midline and cephalic cutaneous malformations. #### What questions would you like to ask the parents? Firstly, in terms of the ****lesion**: - Present at birth (congenital hemangioma or vascular malformation) - Growing in proportion with the body (tumour) or no change to size (malformation) - Preceded by a herald patch (infantile hemangioma) - Has it started to shrink? (involution infantile hemangioma or a rapid-involvuting congential hemangioma) Secondly, in terms of the ****patient**: - Any antenatal/pregnancy-related issues - Neonatal or infantile issues such as seizure or visual disturbances. Finally, in terms of the ****parents:** - Obstetric History - Family History - Pyschosocial supports ## Section 2 ### Treatment and Investigations #### Explain the diagnosis of a capillary malformation to the parents. A capillary malformation, also known as a "port wine stain," is a type of birthmark caused by dilated blood vessels in the skin. It appears as a flat, pink, red, or purple mark on the skin, usually on the face, neck, or arms. It is a benign condition and does not require treatment. However, it is important to note that in rare cases, capillary malformations can be associated with other medical conditions such as Sturge-Weber syndrome, which can affect the nervous system and cause seizures. Therefore, if a capillary malformation is present on the face, it is important to monitor the child's development and consult a neurologist if there are any concerns. As your child ages, the skin around the malformation may become thicker, and the colour may become darker. In some cases, the malformation may also become more noticeable due to changes in skin tone or the development of wrinkles. If the parents or patient wishes, it can be treated with laser therapy, but it's important to note that the treatment may not completely remove the malformation and multiple sessions are often required. #### Would you consider any specific investigations for this patient? Yes, I would order an MRI brain as I am concerned about Sturge-Weber Syndrome. This may identify ipsilateral leptomeningeal anomalies. If the capillary malformation is midline spinal, I would also MRI this area to identify any possible encephalocele or spinal dysraphism. I would also arrange a neurology opinion and ask for an ophthalmology consult, as this condition can be associated with glaucoma. #### The mother informs you that she had a red patch between her eyes. What is she most likely referring to? The mother most likely had a naevus simplex, also referred to as a angel kiss. They classically occur in the glabellar or nape of neck. Over time these flat pale pink lesions fade and do not require treatment. ### thePlasticsPaper - October 9th URL: https://www.theplasticsfella.com/october-9th/ Last updated: 2024-11-19T14:16:45.000Z #### In this week's edition 1. ****✍️** [****Letter from P'Fella**](https://www.theplasticsfella.com/october-9th/#survivorship-bias) "Survivorship bias" in Plastic Surgery 2. 🧨[****Ask the Expert**](https://www.theplasticsfella.com/october-9th/#how-to-get-published) How to get your paper published 3. ****🤓**[ **Study on Sunday + Quiz**](https://www.theplasticsfella.com/october-9th/#basal-cell-carcinoma) do you **really* know basal cell carcinoma? 4. ****🎭**[ **Upcoming Events**](https://www.theplasticsfella.com/october-9th/#10-courses-conferences-and-webinars) 10 upcoming events for you. 5. ****🐣** [****Tweets of the Week**](https://www.theplasticsfella.com/october-9th/#3-top-picks) Memes, virals & threads. 6. ****🚀**[ **New Features**](https://www.theplasticsfella.com/october-9th/#journal-club-with-powerpoint-slides) Journal club with Powerpoint slides! 7. ****📝** [****Articles of the Week**](https://www.theplasticsfella.com/october-9th/#3-new-articles) 3 quick-reads to stay up to date 1 deep-dive (under renovation this week!) ****Fun Fact:** Last week's journal club on[ Pitanguy's line](https://www.theplasticsfella.com/pitanguys-line/) was the most popular so far! The powerpoint slides were used in 19 different countries. --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Letter-from-PFella-3.png) ### Survivorship Bias ****What can we learn from WWI Bomber planes?**During WWI, all ****returning** airplane bombers were assessed to determine the locations on the aircraft in which they underwent the most fire. Most people would have reinforced these areas! To ensure planes keep returning home! Instead, these locations were actually spots in which aircraft could sustain many bullet holes and still return, while the planes that sustained enemy fire in other locations were the ones that went down. Reinforcements were applied to locations less represented in the data of returned planes—as a result, they made more effective predictions and saved many lives.Check out the image below. Red circles are the bullet holes. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/10/Survivorship-bias.svg.png) ****So how does a cognitive fallacy apply to Plastic Surgery?**We are reinforcing the wrong aspects of Plastic Surgery training. There is a culture of looking a "successful" Plastic Surgeons and seeing how to replicate their path to success. Instead, we should be looking at the trainees who are struggling to make it through their journey. Examine their **armour* (so to speak) and see which parts weren't reinforced early enough.As it was wisely written in this [BMJ](https://blogs.bmj.com/bmj/2020/11/30/all-of-us-have-a-survivorship-bias-in-regard-to-how-we-were-trained-in-medicine/?ref=theplasticsfella.com) blog post, "what we don’t take into account with this bias, is the people who leave training posts. There is no standard practice of exit interviews from training programmes, or debriefing for those are struggling and nearly quit". --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/10/ask-the-expert.png) ### How to get Published! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/10/Untitled-design-1.png) #### ****Expert: Hatan Mortada, Plastic & Reconstructive Surgery Resident, Saudi Arabia.** When I started my plastic surgery residency, I was worried about maintaining my passion for academic writing and publishing scientific papers with the busy hours during duty. To maintain my passion for research during my first year of residency, I have mentioned a few tips that helped me. 1\. Schedule your writing time when you are most productive. For me, I dedicate a full day of my week to research writing and starting new projects. 2\. Make an outline. An outline of what you want to write is essential. Once I knew "what" I wanted to write, it was a lot easier to sit down and write. 3\. During your dedicated research hours, turn off your emails, phone, and anything else that might distract you. 4\. Don't listen to your inner perfectionist. When you're writing, don't worry about grammar or spelling. That's what editing is for. 5\. Keep up with newly published research ideas in your field. You will be able to write and find new ideas to conduct, sparking creativity and new insights. I use an app called researcher, it's an amazing application to keep up with the latest articles in your field of interest. 6\. Consistency and persistence are key. For my work, I use the pomodoro technique, which I set me 50 minutes of focused work and 10 minutes for rest, then repeat. [Follow Hatan on Twitter](https://twitter.com/HatanMortada?s=20&t=QFGY-MWdIQuf3ahvrEXq6A&ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Study-on-SUnday.png) \- ### Basal Cell Carcinoma ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/10/Definition-of-Basal-Cell-Carcinoma.png) #### Basal cell carcinomas are caused by several compounding factors. - ****Genetic**: xeroderma pigmentosum, Bazex, Rombo, albinism. - ****Environmental**: Exposure to ultraviolet radiation (UVR), prior radiotherapy - ****Immunosuppressed**: transplant, HIV, hematologic malignancy, Gorlins - ****Pre-existing lesions:** naevus sebaceous. The development of BCC is associated with loss of inhibition of the Hedgehog signalling pathway, which regulates cell growth and differentiation. This is the result of: - Inactivating mutations in tumour-suppressor protein patched homologue 1 ****(PTCH1)** gene - Activating mutations in smoothened (****SMO**) transmembrane protein gene - Suppressor of fused (****SUFU**) gene in Gorlin syndrome [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) ## --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Upcoming-Events.png) ### 10 Courses, Conferences and Webinars #### 1. [EURAPS](https://www.euraps.org/meetings/webinar/?ref=theplasticsfella.com) Brachial Plexus - October 13th 2. RSTN Becoming a plastic surgeon - Oct 18th 3. Plastic Surgery, The Meeting - Oct 2022. 4. PLASTA Breast TIG Fellowship - Oct 17th 5. BAPRAS Lower Limb Reconstruction - Oct 26th 6. Aec 5.1 Limb Reconstruction - Oct 26th. 7. EURAPS Eyelid Surgery - November 15th 8. BAPRS Congress - November 30th 2022 9. BAPRAS 2022 Congress - November 2022. 10. EURAPS Facial Paralysis - December 15th [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tweet-sof-the-Werek.png) ### 3 top-picks! > Is the paper you need stuck behind a paywall? > > Five websites every researcher should know to access any research paper for free[@AcademicChatter](https://twitter.com/AcademicChatter?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com)[@OpenAcademics](https://twitter.com/OpenAcademics?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > > — Dr Lisa Nivison-Smith (@LNivisonSmith) [October 5, 2022](https://twitter.com/LNivisonSmith/status/1577772262689624064?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > ppl chat a lot of shit about USA medical training, and I’m not saying it’s perfect, but imagine this: > > 1)the hospital employs you for all of ur residency. they \*need\* to train you: no training as a PGY1 means that you won’t be able to meet the demands of being the senior resident > > — Ronan (@ronansetron) [October 2, 2022](https://twitter.com/ronansetron/status/1576568458221072386?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > “No, the consent form is signed but they can’t leave the ward until you mark the limb with the huge bandage on it.” I’m on my way…[pic.twitter.com/HKNycywZ23](https://t.co/HKNycywZ23?ref=theplasticsfella.com) > > — Sandra McAllister (@Sandra\_McA) [October 5, 2022](https://twitter.com/Sandra%5FMcA/status/1577771149488017408?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/New-Features.png) \- ### Journal club with Powerpoint slides! P'Fella has created an easier way for you to do your journal club.Every week, a journal is reviewed and published on this platform. It's a pretty easy way to stay up with relevant and important topics. The articles are hand picked by P'Fella and usually are classic or seminal papers that helped improve Plastic Surgery (not the ususal publish-for-the-CV quality)!Oh, yeh you can download the powerpoint slides and use them yourself. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/10/Deep.png) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Articles-of-the-Week.png) ### 3 new articles #### 1. [****The First GLOBAL Plastic Trainee Survery**](https://journals.lww.com/prsgo/Fulltext/2022/10000/Plastic%5FSurgery%5FTraining%5Facross%5FSeven%5FContinents%5F.6.aspx?ref=theplasticsfella.com) Lindqvist et al. Plastic and Reconstructive Surgery - Global Open: October 2022 - Volume 10 - Issue 10 - p e4520 2. [****Does BOTOX improve Scars?**](https://journals.lww.com/plasreconsurg/Fulltext/2018/03000/Effects%5Fof%5FBotulinum%5FToxin%5Fon%5FImproving%5FFacial.14.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Hu et al. Effects of Botulinum Toxin on Improving Facial Surgical Scars: A Prospective, Split-Scar, Double-Blind, Randomized Controlled Trial. Plastic and Reconstructive Surgery: March 2018 3. [****Cancer Recurrence after nipple-sparing mastectomy**](https://journals.lww.com/plasreconsurg/Fulltext/2022/10001/Long%5FTerm%5FCancer%5FRecurrence%5FRates%5Ffollowing.3.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Boyd et al. Long-Term Cancer Recurrence Rates following Nipple-Sparing Mastectomy: A 10-Year Follow-Up Study. Plastic and Reconstructive Surgery: October 2022 ### 1 Deep Dive ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Under Renovation! This section is being upgraded to make the journal club experience bettter for you. Check back next week! [Check out the Database](https://www.theplasticsfella.com/) --- ## Feedback ### P'Fella is always looking to make this weekly newsletter as good as can be!Let me know your thoughts below :) --- ### Cleft Hand: Features, Classification, & Treatment. URL: https://www.theplasticsfella.com/cleft-hand/ Last updated: 2024-04-24T17:49:51.000Z Cleft hand is a central longitudinal congenital deficiency. This article details the aetiology, features, classification and treatment. _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - October 2nd URL: https://www.theplasticsfella.com/october-2nd/ Last updated: 2022-10-02T10:13:50.000Z #### In this week's edition 1. **✍️ Letter from P'Fella** "Open journals" do more harm than good? 2. **🤓 Study on Sunday + Quiz** A big black lesion! Melanoma? 3. **🎭 Upcoming Events** 12 upcoming events for you. 4. **🐣 Tweets of the Week** Memes, virals & threads. 5. **🚀 New Features** Summary cards are here! 6. **📝 Articles of the Week** 3 must-reads, 1 deep-dive on Pitanguy's line! **Fun Fact:** On average, it takes 12 minutes to read [Burns Fluid Resuscitation](https://www.theplasticsfella.com/burns-fluid-resuscitation/). --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Letter-from-PFella-3.png) ## **The "open journals". Are they doing more harm than good?** I recently listened to the PRS Global Open Podcast titled: "The Future of Open Access Journals". Generally speaking, it's a great podcast series with a great host talking to well-respected guests. It is an interesting listen. It's worth listening to the entire podcast, but to summarise it in one sentence - **the future is "pay to publish" instead of "pay to read"**. So what difference does that make to the current state of academic plastic surgery? In my opinion, **none**. And here's why. This financial pivot from the reader to the researcher is the same business model at its core. That is **research = money**. The money is just coming from a different pocket. My hypothesis, publishers became acutely aware that plastic surgery trainees are reluctant to pay to research (because it is now free thanks to Sci-hub) but are willing to pay for a few more lines on their CVs. The researchers are independent of this process. They are at the becking of the major publishers. What are your thoughts on this? Reply to this email. I would love to hear them! *P'Fella xx* --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Study-on-SUnday.png) \- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/10/Complications-Congenital-Melanocytic-Naevus-2.png) #### Congenital Melanocytic Naevus A congenital melanocytic naevus presents as a brown or black lesion at birth. It is most commonly found on the trunk and changes appearance over time with multiple satellite lesions. Malignant transformation in patients with giant congenital melanocytic nevi can result in **cutaneous** or **noncutaneous** melanoma. The reported risk of melanoma in patients with giant congenital melanocytic nevi ranges from 3-9%, with a lifetime risk of approximately 6% (\~ 17-fold increased risk of melanoma compared with the general population). In relation to the rate of malignant transformation. - 50% by age 3 - 60% by childhood - 70% by puberty For this reason, surgical excision of high-risk cutaneous lesions is best performed in early childhood rather than delaying treatment until a later age. [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) ## --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Upcoming-Events.png) #### 1. [PULPe](https://pulpe.eu/pulpe-webinar-on-examining-childrens-hands?ref=theplasticsfella.com) Examining children’s hands - September 26th. 2. [AO Hand Trauma Blended Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/ao-trauma-blended-course---management-of-fractures-of-the-hand?ref=theplasticsfella.com) \- September 26th 3. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 4. [Head And Neck Siag Day ](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/head-and-neck-siag-day?ref=theplasticsfella.com)\- Hull, September 30th 5. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September. 6. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- September. 7. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 8. [BAAPS 2022](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/baaps-2022-the-art-of-aesthetic-plastic-surgery?ref=theplasticsfella.com): London, Step 27th 9. [Skills For Junior Plastic](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/surgical-skills-for-aspiring-junior-plastic-surgeons?ref=theplasticsfella.com)s - Alexandra Hospital, 8th Oct 10. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 11. [Aec 5.1 Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- October 26th, 2022. 12. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 13. [BAPRAS 2022 Congress](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com) \- November 2022. [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tweet-sof-the-Werek.png) > La lesión de Stener se caracteriza por un deslizamiento del extremo lesionado del LCC superficial a la aponeurosis del aductor del pulgar > > Provocando la interposición de la aponeurosis del músculo aductor > > Esto evita la curación del LCC y es indicación de reparación quirúrgica [pic.twitter.com/ceJfc9Rlkd](https://t.co/ceJfc9Rlkd?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [August 14, 2022](https://twitter.com/DrBarreraochoa/status/1558866891317420041?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Hand X-Ray anatomy [pic.twitter.com/VKBThKSjOq](https://t.co/VKBThKSjOq?ref=theplasticsfella.com) > > — theRadiologist (@radiologistpage) [August 9, 2022](https://twitter.com/radiologistpage/status/1557032921327976448?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > MRI of a person speaking [pic.twitter.com/EU1W4KUqz5](https://t.co/EU1W4KUqz5?ref=theplasticsfella.com) > > — Historic Vids (@historyinmemes) [August 7, 2022](https://twitter.com/historyinmemes/status/1556237326954762240?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/New-Features.png) \- **Summary Cards!** P'Fella has created an easier way to find your information. At the **top of each article,** there is a summary card that provides a single-sentence summary for each of the main sections on that topic. There is also a link which means you can skip straight to the part you want to read! Check it out below. You can see it in action in [this article here](https://www.theplasticsfella.com/microtia/). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/09/SUmmary-Cards.png) [Check out Summary Cards](https://www.theplasticsfella.com/microtia/) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Articles-of-the-Week.png) #### 3 Top Picks 1. **[First Successful Face AND Bilateral Hand Transplant](https://journals.lww.com/plasreconsurg/Abstract/2022/08000/The%5FFirst%5FSuccessful%5FCombined%5FFull%5FFace%5Fand.37.aspx?ref=theplasticsfella.com)** Ramly et al. The First Successful Combined Full Face and Bilateral Hand Transplant. Plastic and Reconstructive Surgery: August 2022 - Volume 150 - Issue 2 - p 414-428 2. [**Creating International Microsurgery Club Series** ](https://journals.lww.com/plasreconsurg/Fulltext/2022/08000/Knowledge%5FRevolution%5Fduring%5FCOVID%5F19%5FPandemic%5F.66.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Sung et al. Knowledge Revolution during COVID-19 Pandemic: International Microsurgery Club Webinar Series. Plastic and Reconstructive Surgery: August 2022 - Volume 150\. 3. [**Finger Joint Contractures After Dupuytren Disease**](https://www.jhandsurg.org/article/S0363-5023%2822%2900286-6/fulltext?ref=theplasticsfella.com) Eckerdal et al. Finger Joint Contractures 5 Years After Treatment for Dupuytren Disease: A Comparative Cohort Study of Collagenase Injection Versus Surgical Fasciectomy. J Hand Surg Am. 2022 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Pitanguy's Line - Original Publication and Journal Club Pitanguy's line is one of the most recognisable and famous surgical landmarks. This journal club analyses the original publication in the 1960s! [Journal Club (+ slides!)](https://www.theplasticsfella.com/pitanguys-line/) --- ### Pitanguy's Line - Journal Club of Original Publication (with Slides) URL: https://www.theplasticsfella.com/pitanguys-line/ Last updated: 2022-10-01T20:50:22.000Z #### Summary Card **Level of Evidence:** Case Series **Background** Pitanguy believed the "parotid plexus" suffered "constant variations, hampering from the surgical viewpoint, the precise location of the facial branches". **Methods** An analysis of "20 heads" to identify variations in the location of the frontal branch of the facial nerve. **Results** A "great variation in number and disposition" of the temporofrontal branches but in a **constant direction**: 0.5cm inferior to the tragus to 1.5cm above the lateral eyebrow. It can also be used as a surrogate marker for the frontal branch of the temporal artery. **Conclusion** This case series shows a constant direction but a significant number of variations in the frontal branch of the facial nerve. **Powerpoint Slides** thePlasticsPro can use these slides for the next journal club! ⚡ The complete journal club & PowerPoint slides are for **thePlasticsPros**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - 21st August URL: https://www.theplasticsfella.com/21st-august/ Last updated: 2022-08-21T16:59:44.000Z #### In this week's edition 1. **✍️ Letter from P'Fella** Your work-life balance doesn't exist. 2. **🤓 Study on Sunday + Quiz** Extra digits, extra thumbs. 3. **🎭 Upcoming Events** 13 upcoming events for you. 4. **🐣 Tweets of the Week** Memes, virals & threads. 5. **🚀 New Features** Clinical cases are soon (reply to this email)! 6. **📝 Articles of the Week** 3 must-reads, 1 deep-dive for thePlasticsPro **Fun Fact:** [Zones of the hand](https://www.theplasticsfella.com/zones-of-the-hand/) was studied for 174 hours in the last 30 days. --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Letter-from-PFella-3.png) ## **Your work-life balance doesn't exist. Here's why.** In the last several years, there has been a pretty big cultural shift. Those days of *"working all hours"* have slowly dwindled. Now there is an increase in the *"you should try and get out of here"* vibe. That's great, right? **I guess it depends on what you do at home.** Your physical hours at work might be reduced, but your "work for home" hours are probably on the increase. This doesn't change your work-life balance, it only changes the location of your work. As was [tweeted](https://twitter.com/davidnnaumann/status/1559540501799489538?s=20&t=%5FS-FRvmkvrAtaotOUCKuWQ&ref=theplasticsfella.com) during the week, this is why working hours are going down, but burnout is rising. **But what's the solution?** It's hard to say. It seems this shift in culture isn't reducing the incidence of burnout. You could even argue that it has created an impossible jigsaw of training, patient care and teamwork. I think over time, we will become all aware that reduced hours does not result in increased job satisfaction. This thought can be validated by the following infographic. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/FaRsAPxX0AAUX0j-1.jpeg) [Source](https://twitter.com/9Nylon/status/1559593330467651590?s=20&t=Bd59LiooDiwdL2KfRiRgWQ&ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Study-on-SUnday.png) \- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Polydactyly-Definition-1.png) #### Polydactyly Polydactyly is a congenital duplication of a finger. It can be pre-axial (radial), central and post-axial (ulnar) and is caused by disruption at the ZPE and AER [embryological](https://www.theplasticsfella.com/upper-limb-embryology/) signalling zones. It is classified using by Wassell into 7 groups based on the degree of bony duplication. - **I:** Bifid Distal Phalanx - **II:** Duplicate Distal Phalanx - **III:** Bifid Proximal Phalanx + Duplicate Distal Phalanx - **IV:** Duplicate Distal Phalanx + Duplicate Distal Phalanx - **V:** Bifid 1st metacarpal + Duplicate Distal/Proximal Phalanx - **VI:** Duplicate 1st metacarpal + Distal/Proximal Phalanx - **VII:** Triphalangeal thumb + normal thumb [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) ## --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Upcoming-Events.png) #### 1. [Pulvertaft - Phalangeal Fractures](https://us02web.zoom.us/webinar/register/WN%5FHVY5zwuNSSqObzAHcM5xOg?ref=theplasticsfella.com), August 22nd 2. [AO Hand Trauma Blended Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/ao-trauma-blended-course---management-of-fractures-of-the-hand?ref=theplasticsfella.com) \- September 26th 3. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 4. [Head And Neck Siag Day ](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/head-and-neck-siag-day?ref=theplasticsfella.com)\- Hull, September 30th 5. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September. 6. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- September. 7. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 8. [BAAPS 2022](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/baaps-2022-the-art-of-aesthetic-plastic-surgery?ref=theplasticsfella.com): London, Step 27th 9. [Skills For Junior Plastic](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/surgical-skills-for-aspiring-junior-plastic-surgeons?ref=theplasticsfella.com)s - Alexandra Hospital, 8th Oct 10. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 11. [Aec 5.1 Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- October 26th, 2022. 12. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 13. [BAPRAS 2022 Congress](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com) \- November 2022. [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tweet-sof-the-Werek.png) > En defectos en punta de dedos, mi método de reconstrucción favorito es el colgajo de hemipulpejo del hallux > ▪️Piel similar, aporta estabilidad a la pinza digital > ▪️Piel sensible, al suturar un nervio plantar al nervio digital > ▪️Mínimas secuelas zona donante y receptora [pic.twitter.com/p19wLuNMAb](https://t.co/p19wLuNMAb?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [August 18, 2022](https://twitter.com/DrBarreraochoa/status/1560342575940345860?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Leather wrists support, carpel tunnel 1960s-80s [@ManMedMuseum](https://twitter.com/ManMedMuseum?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@LucyBurscough](https://twitter.com/LucyBurscough?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@McrMuseum](https://twitter.com/McrMuseum?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/DHGq9kWdG7](https://t.co/DHGq9kWdG7?ref=theplasticsfella.com) > > — Stephanie (@StephSeville) [August 11, 2022](https://twitter.com/StephSeville/status/1557670338456084483?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Completed our 75th specimen scan today! Great stuff happening [@VanderbiltENT](https://twitter.com/VanderbiltENT?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#3Dscanning](https://twitter.com/hashtag/3Dscanning?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#3Dprinting](https://twitter.com/hashtag/3Dprinting?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#HeadandNeckCancer](https://twitter.com/hashtag/HeadandNeckCancer?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#CADmargin](https://twitter.com/hashtag/CADmargin?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/bY4YC4jbOg](https://t.co/bY4YC4jbOg?ref=theplasticsfella.com) > > — Michael Topf MD (@TopfHNS) [August 16, 2022](https://twitter.com/TopfHNS/status/1559634388060516352?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/New-Features.png) **Clinical Cases are coming!** Over the past few months, P'Fella has received a large number of requests to create clinical cases. This could be for everyday learners, trainees with upcoming exams or for interview prep. The idea is to have an expert publish a case in their area of expertise. thePlasticsFella platform will then be able to comment and engage in discussions with the expert. If you want to create or test a case, then just reply to this email! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/clinical-cases.png) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Articles-of-the-Week.png) #### 3 Top Picks 1. **[Sustainability in Theatre](https://jamanetwork.com/journals/jamasurgery/article-abstract/2795362?ref=theplasticsfella.com)** Belliveau S, Gold MS. The Surgical Suite—A Field Laboratory for Sustainability. *JAMA Surg.* Published online August 17, 2022\. doi:10.1001/jamasurg.2022.2346 2. **[How to save an ischemic finger caused by adrenaline](https://pubmed.ncbi.nlm.nih.gov/35971318/?ref=theplasticsfella.com).** Ibrahim I, Winterton R, Bedford JD. Iloprost rescue in digital ischaemia following injection of local anaesthetic with adrenaline. J Hand Surg Eur Vol. 2022 Aug 3. **[How to create an online club](https://journals.lww.com/plasreconsurg/Fulltext/2022/08000/Knowledge%5FRevolution%5Fduring%5FCOVID%5F19%5FPandemic%5F.66.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)** Sung, et al. Knowledge Revolution during COVID-19 Pandemic: International Microsurgery Club Webinar Series. Plastic and Reconstructive Surgery: August 2022 - Volume 150 - Issue 2 - p 491e-492e doi: 10.1097/PRS.0000000000009319 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Allen's Test - Original Publication and Journal Club Allen's test is one of the most recognisable and famous clinical signs. This journal club analyses the original publication in the 1920s. [Journal Club](https://www.theplasticsfella.com/allen-test-original-publication/) --- ### Allen Test - Original Publication URL: https://www.theplasticsfella.com/allen-test-original-publication/ Last updated: 2022-08-21T16:52:57.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Allen-Test---Journal-Club.png) #### Summary Card **Level of Evidence:** Case Series **Background** Allen wanted to replace "time-consuming mechanical contrivances with the critical examination by vision and palpation". **Methods** A prospective case series of 3 patients utilising the same technique that is still used today (over 90 years later) **Results** Allen Test is a reproducible clinical sign for diagnosing patients with upper limb arterial disease. **Conclusion** The Allen Test has much wider clinical use. Even now, in Plastic Surgery, for example, when testing the patency of the palmar arch prior to a radial forearm flap. **Powerpoint Slides** Use these slides for your next journal club! ⚡ The complete journal club analysis is for **thePlasticsPro users**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - 14th August URL: https://www.theplasticsfella.com/14th-august/ Last updated: 2022-08-18T19:30:41.000Z #### In this week's edition 1. **✍️ Letter from P'Fella** Your work-life balance doesn't exist. 2. **🤓 Study on Sunday + Quiz** Congenital Hand Deformities 3. **🎭 Upcoming Events** 14 upcoming events for you. 4. **🐣 Tweets of the Week** Memes, virals & threads. 5. **🚀 New Features** A pretty big content drop! New and updated 6. **📝 Articles of the Week** 3 must-reads, 1 deep-dive for thePlasticsPro **Fun Fact:** thePlasticsFella gets 17,000 unique visitors/month. --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Letter-from-PFella-3.png) ## **Your work-life balance doesn't exist. Here's why.** In the last several years, there has been a pretty big cultural shift. Those days of *"working all hours"* have slowly dwindled. Now there is an increase in the *"you should try and get out of here"* vibe. That's great, right? **I guess it depends on what you do at home.** Your physical hours at work might be reducing, but your "work for home" hours are probably on the increase. This doesn't change your work-life balance, it only changes the location of your work. As was [tweeted](https://twitter.com/davidnnaumann/status/1559540501799489538?s=20&t=%5FS-FRvmkvrAtaotOUCKuWQ&ref=theplasticsfella.com) during the week, this is why working hours are going down, but burnout is rising. This thought was [tweeted](https://twitter.com/JazSeehra/status/1557639708007714819?s=20&t=uXBHaLw4gjzlzllMYzo82A&ref=theplasticsfella.com) the week. And yes, it is pretty true! Unfortunately. The current status of surgical training is slowly shifting to a tick-box exercise. At first, it was research and publication, then it was feedback and mentorship, and now it has become the surgical logbook. As one Twitter user pointed out, this can be explained via the [McNamara fallacy](https://en.wikipedia.org/wiki/McNamara%5Ffallacy?ref=theplasticsfella.com). This viewpoint is supported in the peer-reviewed literature. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Screenshot-2022-08-13-at-17.30.37.png) **But what's the alternative?** What's the better alternative to numbers and tickboxes? Is there a way to quantity surgical skills? These are difficult questions to answer but important ones. One simple solution is better feedback. A more vested interest by seniors rather than the "do more" feedback. At the same time, the surgical resident or trainee must accept responsibility for their own training and have insight into the weaknesses. A surgical trainee should have the maturity to know when their logbook doesn't truly reflect their skillset. Let P'Fella know your thoughts on this! --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Study-on-SUnday.png) \- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Squamous-Cell-Carcionoma-appearance.png) #### Squamous Cell Carcinoma Primary cutaneous squamous cell carcinoma (SCC) is a malignant tumour that arises from the keratinocytes of the epidermis or its hair follicles. Aggressive histologic subtypes include adenoid (acantholytic), adenosquamous, desmoplastic or metaplastic. Follow-up of patients with squamous cell carcinoma is based on the risk group and extent of the disease. 30%-50% of these patients will develop another SCC within 5 years and 70% of SCC recurrences occur within 2 years [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) ## --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Upcoming-Events.png) #### 1. [Long-term management of the military amputee](https://www.boa.ac.uk/learning-and-events/webinars/support-for-ukraine-surgical-webinar-series.html?ref=theplasticsfella.com), 16th August 2. [Diagnosing Infection in the Burn Patient, ](https://us06web.zoom.us/webinar/register/WN%5F3fVwqkkASTiOWoP0TB%5F25A?ref=theplasticsfella.com)August 19th 3. [AO Hand Trauma Blended Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/ao-trauma-blended-course---management-of-fractures-of-the-hand?ref=theplasticsfella.com) \- September 26th 4. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 5. [Head And Neck Siag Day ](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/head-and-neck-siag-day?ref=theplasticsfella.com)\- Hull, September 30th 6. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September. 7. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- September. 8. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 9. [BAAPS 2022](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/baaps-2022-the-art-of-aesthetic-plastic-surgery?ref=theplasticsfella.com): London, Step 27th 10. [Skills For Junior Plastic](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/surgical-skills-for-aspiring-junior-plastic-surgeons?ref=theplasticsfella.com)s - Alexandra Hospital, 8th Oct 11. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 12. [Aec 5.1 Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- October 26th, 2022. 13. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 14. [B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress - November 2022. [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tweet-sof-the-Werek.png) > Happy Friday! The fibula is named after the Latin term for buckle, clasp, or pin. A fibula is also an ancient type of brooch used for fastening (similar to a safety pin). There's definitely a resemblance! [#CAT2022](https://twitter.com/hashtag/CAT2022?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#etymology](https://twitter.com/hashtag/etymology?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/NNhmkkJmGl](https://t.co/NNhmkkJmGl?ref=theplasticsfella.com) > > — Clinical Anatomical Terminology (@AACAnatomy\_CAT) [August 12, 2022](https://twitter.com/AACAnatomy%5FCAT/status/1558094666909847553?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Leather wrists support, carpel tunnel 1960s-80s [@ManMedMuseum](https://twitter.com/ManMedMuseum?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@LucyBurscough](https://twitter.com/LucyBurscough?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@McrMuseum](https://twitter.com/McrMuseum?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/DHGq9kWdG7](https://t.co/DHGq9kWdG7?ref=theplasticsfella.com) > > — Stephanie (@StephSeville) [August 11, 2022](https://twitter.com/StephSeville/status/1557670338456084483?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > An easy to follow MAP of every ARTERY in the HUMAN body. [pic.twitter.com/bgmHdGIPZ7](https://t.co/bgmHdGIPZ7?ref=theplasticsfella.com) > > — Oren Gottfried, MD (@OGdukeneurosurg) [August 6, 2022](https://twitter.com/OGdukeneurosurg/status/1555900404512301057?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/New-Features.png) **New and updated content!** thePlasticsFella has been busy improving the user experience and updating the evidence-based articles on the platform. In the last few weeks, new articles have been released with accompanying flashcard decks. Here are some new and updated articles you might have missed: \- [Melanoma](https://www.theplasticsfella.com/melanoma/) \- [Congenital Melanocytic Naevus](https://www.theplasticsfella.com/cogenital-melanocytic-naevus/) \- [Lip Reconstruction](https://www.theplasticsfella.com/lip-reconstruction/) \- [Ectropion](https://www.theplasticsfella.com/ectropion/) \- [Maxillary Reconstruction](https://www.theplasticsfella.com/maxillary-reconstruction/) \- [Neck Dissection](https://www.theplasticsfella.com/neck-dissection/) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Articles-of-the-Week.png) #### 3 Top Picks 1. **[How to train residents in cosmetic surgery](https://journals.lww.com/plasreconsurg/Abstract/2022/08000/Preparing%5Ffor%5Fa%5FCrowded%5FCosmetic%5FMarket%5F%5FA.18.aspx?ref=theplasticsfella.com)** Marks et al Preparing for a Crowded Cosmetic Market: A Resident Training Model for Minimally Invasive Cosmetic Treatments. Plastic and Reconstructive Surgery: August 2022 2. **[A review of the plastic surgery interview ](https://journals.lww.com/plasreconsurg/Fulltext/2022/08000/Difficult%5FConversations.1.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)** Phillips et al The Plastic Surgery Residency Interview Revisited: Virtual Interviews and Beyond. Plastic and Reconstructive Surgery: November 2020 3. [**How to ACTUALLY use the p-value**](https://journals.sagepub.com/eprint/KV5PARIGVWF5JQB7JU9G/full?ref=theplasticsfella.com#.YvUE-oKymj8.twitter) Stunt et al. Statistics in publishing: the (mis)use of the p-value (Part 2). *Journal of Hand Surgery (European Volume)*. August 2022. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Mustarde Technique for Otoplasty - Original Publication and Journal Club This was a landmark paper in the management of prominent ears. The author changed surgical management by designing this new technique nearly 60 years ago! [Journal Club](https://www.theplasticsfella.com/mustarde-technique/) --- ### Mustarde Technique for Otoplasty - Original Publication URL: https://www.theplasticsfella.com/mustarde-technique/ Last updated: 2022-08-14T17:29:12.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Screenshot-2022-08-13-at-18.36.22.png) #### Summary Card **Level of Evidence:** Anecdotal **Background** Prior to this publication, the correction of prominent ears resulted in suboptimal outcomes. **Methods** Prospective case series of a 5-year period utilising a new technique of mattress sutures to recreate the antihelical fold. **Results** No formal results. **Conclusion** This is a successful technique for the correction of prominent ears by simple mattress sutures. **Powerpoint Slides** Download these slides for your next journal club. ⚡ The complete journal club analysis is for **thePlasticsPro users**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - August 7th URL: https://www.theplasticsfella.com/august-7th/ Last updated: 2022-08-07T10:53:44.000Z #### In this week's edition 1. **✍️ Letter from P'Fella** Sci-hub is so important to your career. 2. **🤓 Study on Sunday + Quiz** Hypertelorism and the wide-eyed patient 3. **🎭 Upcoming Events** 14 upcoming events for you. 4. **🐣 Tweets of the Week** Memes, virals & threads. 5. **🚀 New Features** Find your favourite articles quicker - Bookmarks! 6. **📝 Articles of the Week** 3 must-reads, 1 deep-dive for thePlasticsPro **Fun Fact:** thePlasticsFella now has 200 verified Plastic Surgery articles and topics. --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Letter-from-PFella-3.png) ## **Sci-Hub is pretty amazing.** Alexandra Elbakya (the founder of Sci-Hub) recently published a pretty interesting infographic. It showed that 20 countries account for more than 90% of all Sci-Hub downloads worldwide made in the last month. It's a nice random fact. Check it out below... ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/FZQ1iS1XoAM86g4-2.jpeg) **But what does all this mean?** To put it simply, Sci-hub is probably one of the most important innovations in academia. The free dissemination of knowledge allows access to evidence-based publications. There have been some peer-reviewed publications assessing the impact of Sci-hub. We now know that articles downloaded from Sci-Hub were cited [1.72 times](https://link.springer.com/article/10.1007/s11192-020-03806-w?ref=theplasticsfella.com) more than papers not downloaded from Sci-Hub. Eventually, there will be continued erosion in institutional libraries willing (or able) to pay substantial funds to scientific publishers (e.g. >[$1million ](https://www.zmescience.com/other/feature-post/sci-hub-effects-academic-publishing/?ref=theplasticsfella.com)for Elsevier subscriptions) for access to their repositories of scientific literature. There is potentially a downside to all this free information. To compensate for the loss of subscription revenues, publications are charging authors a publication fee. Now it's a pay-to-publish model. **Does P'Fella use Sci-hub?** Yes, sir! It's the main way the evidence-based articles are created and, of course, the popular [**journal club**](https://www.theplasticsfella.com/tag/journal-club/) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Study-on-SUnday.png) \- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Microtia-3-3.png) #### Microtia Microtia is a congenital hypoplastic deformity that can occur in isolation or in a syndrome. It presents a clinical spectrum of minor deficiencies to the complete absence of the auricle Major research and surgical development was performed by Tanzer in the second half of the 20th century. It is graded in accordance with the number of vestigial ear structures present. - **Anotia**: complete absence of the external ear. - **Lobule-type:** remnant ear & lobule without concha, acoustic meatus & tragus. - **Concha-type:** lobule, concha, acoustic meatus, tragus & incisura tragica are present to variable degrees. - **Small concha-type**: remnant lobule, small indentation representing concha. - **Atypical microtia:** patients who cannot be classified above. [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) ## --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Upcoming-Events.png) #### 1. [Nerve Reconstruction for Spinal Cord](https://olympiahospital.webex.com/mw3300/mywebex/default.do?nomenu=true&siteurl=olympiahospital&service=6&rnd=0.39724850686148283&main%5Furl=https%3A%2F%2Folympiahospital.webex.com%2Fec3300%2Feventcenter%2Fevent%2FeventAction.do%3FtheAction%3Ddetail%26%26%26EMK%3D4832534b00000005cfc21557f2045f053f0192610e8f232d74368db6bf28a07a35e17981ee5233d2%26siteurl%3Dolympiahospital%26confViewID%3D234624007745311430%26encryptTicket%3DSDJTSwAAAAVytnfc45kNyMklBrbVMyY2gP3fap9z4hYaiveAf66D0w2%26&ref=theplasticsfella.com), August 13th 2. PULM: Pediatric Upper Limb & Microsurgery, August 2022 3. [Yorkshire FRCS(Plast) Course-](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/the-yorkshire-frcs%28plast%29-course?ref=theplasticsfella.com) August 12th 4. [AO Hand Trauma Blended Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/ao-trauma-blended-course---management-of-fractures-of-the-hand?ref=theplasticsfella.com) \- September 26th 5. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 6. [Head And Neck Siag Day ](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/head-and-neck-siag-day?ref=theplasticsfella.com)\- Hull, September 30th 7. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September. 8. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- September. 9. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 10. [BAAPS 2022](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/baaps-2022-the-art-of-aesthetic-plastic-surgery?ref=theplasticsfella.com): London, Step 27th 11. [Skills For Junior Plastic](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/surgical-skills-for-aspiring-junior-plastic-surgeons?ref=theplasticsfella.com)s - Alexandra Hospital, 8th Oct 12. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 13. [Aec 5.1 Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- October 26th, 2022. 14. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 15. [B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress - November 2022. [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tweet-sof-the-Werek.png) > Medicine note Surgery note > | | > | | > V V[pic.twitter.com/TbP4OjOmA5](https://t.co/TbP4OjOmA5?ref=theplasticsfella.com) > > — Adi (@IDdocAdi) [August 5, 2022](https://twitter.com/IDdocAdi/status/1555376842294657025?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Clinical pearl; A One minute Neuro hand exam, I call > 'Check your Six'. Ask your patient to give you a boy scout salute (three finger salute- median/ulnar), an Ok (ant interroseus), then play 'Rock (median), Paper (radial), Scissors (Ulnar) and sign off with a Thumbs up (radial) [pic.twitter.com/oFbnyCTs7o](https://t.co/oFbnyCTs7o?ref=theplasticsfella.com) > > — Neurophilia (@bobvarkey) [July 31, 2022](https://twitter.com/bobvarkey/status/1553885663812268032?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > The Feynman Technique (how to learn anything): > > — Sahil Bloom (@SahilBloom) [July 31, 2022](https://twitter.com/SahilBloom/status/1553717736932532224?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/New-Features.png) **Bookmarks!** Now you can find your favourite articles much quicker! When you sign in to thePlasticsFella platform, your article will be accessible using the left-hand tabbed menu. It's a small improvement, but a much-requested one! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/BOOKMARKS.png) ### --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Articles-of-the-Week.png) #### 3 Top Picks 1. **[How is the ACTUALLY innervated? ](https://journals.lww.com/plasreconsurg/Abstract/2022/08000/Innervation%5Fof%5Fthe%5FFemale%5FBreast%5Fand%5FNipple%5F%5FA.2.aspx?ref=theplasticsfella.com)** Smeele et al. Innervation of the Female Breast and Nipple: A Systematic Review and Meta-Analysis of Anatomical Dissection Studies. Plastic and Reconstructive Surgery: August 2022 2. [**A template for those difficult conversations**](https://journals.lww.com/plasreconsurg/Fulltext/2022/08000/Difficult%5FConversations.1.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Lin, I-Chun F. B.A.; Kane, Robert L. M.D.; Chung, Kevin C. M.D., M.S.. Difficult Conversations. Plastic and Reconstructive Surgery: August 2022 3. **[Botox for Depression?? ](https://journals.lww.com/plasreconsurg/Abstract/2022/07000/Glabellar%5FBotulinum%5FToxin%5FInjection%5FImproves.46.aspx?ref=theplasticsfella.com)** Crowley et al. Glabellar Botulinum Toxin Injection Improves Depression Scores: A Systematic Review and Meta-Analysis. Plastic and Reconstructive Surgery: July 2022 - Volume 150 - Issue 1 - p 211e-220e ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### MSLT II Trial - Summary and Journal Club This was a landmark paper in the management of melanoma. The authors answered a very important question - what is the **actual** efficacy of lymph node clearance in melanoma patients with positive sentinel lymph nodes? [Journal Club](https://www.theplasticsfella.com/mslt-ii-trial-journal-club/) --- ### MSLT II Trial - Summary and Journal Club URL: https://www.theplasticsfella.com/mslt-ii-trial-journal-club/ Last updated: 2022-08-06T19:39:49.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Screenshot-2022-08-06-at-20.31.26-1.png) #### Summary Card **Level of Evidence:** 1 **Background** What is the actual effect of lymph node clearance in melanoma patients with a positive sentinel node? **Methods** Randomised control trial over a 10-year period in which patients were observed (clinical examination and USS) or lymph node clearance. **Results** Lymph node clearance did not increase melanoma-specific survival and increased surgical complications. **Conclusion** Clinical observation with frequent physical exams and ultrasonography is reasonable for certain patients with a positive SLNB ⚡ The complete journal club analysis is for **thePlasticsPro users**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - July 24th URL: https://www.theplasticsfella.com/july-24th/ Last updated: 2022-07-24T14:22:54.000Z #### In this week's edition 1. **✍️ Letter from P'Fella** Plastic Surgery is now the most competitive speciality. 2. **🤓 Study on Sunday + Quiz** Hypertelorism and the wide-eyed patient 3. **🤯 Ask the Expert** Don't miss these important signs on Wrist X-Rays 4. **🎭 Upcoming Events** 18 upcoming events for you. 5. **🐣 Tweets of the Week** Memes, virals & threads. 6. **🚀 New Features** Improved navigation, live updates, new search. 7. **📝 Articles of the Week** 3 must-reads, 1 deep-dive for thePlasticsPro **Fun Fact:** thePlasticsFella community spent 71 hours reading content on this platform last week. Good effort ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Letter-from-PFella-3.png) ## **Plastic Surgery is officially the most competitive speciality.** The has always been that question, "is plastic surgery actually competitive?". Now, thanks for the work of [this guy on Twitter](https://twitter.com/jbcarmody/status/1549052276685283328?s=20&t=%5F7ZU7LeEvN13kXdTxVbcyg&ref=theplasticsfella.com); we finally have the answer. And the answer is yes. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/FX9W1b3X0AEbQ8h.jpeg) Credit: @jbcarmody This is a pretty interesting graph. Essentially it shows that plastic surgery has the highest number of applicants per position in the 2022 match. Man, that's tough. But is this a new concept? Not really. There was a pretty interesting [publication](https://www.sciencedirect.com/science/article/abs/pii/S0022480422002050?ref=theplasticsfella.com) back in 2020 which provided some more details on the application process. "For matched 2020 applicants, integrated plastic surgery had the highest USMLE Step 1 score (249), highest USMLE Step 2 score (tied at 256), and second highest number of abstracts/presentations/publications (19.1)" **So what can you do about it?** Find a mentor, work hard and, of course, do some [interview prep](https://www.theplasticsfella.com/interview/) (sorry, shameless plug). --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Study-on-SUnday.png) \- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Definition-of-Hyperterlorism-1.png) #### Hypertelorism Hypertelorism is a measurement from the dacryon. This is the junction between the maxillary, frontal and lacrimal bones. It is a **radiological**, not a clinical measurement. The average adult interorbital distance can range from 20-30mm. Tessier provides a classification for this. It can be syndromic or non-syndromic: - **Syndromic**: Apert's, Craniofrontonasal dysplasia, Crouzens, Edwards - **Non-syndromic**: Sincipital encephaloceles, facial clefts, midline tumours [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) ## --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Upcoming-Events.png) #### 1. [RSTN](https://t.co/oEUzbfsFCl?ref=theplasticsfella.com) \- Life of an academic plastic surgeon, July 26th 2. Pulvertaft Webinar - DRUJ & ulnar head replacement, July 26th. 3. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 4. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 5. PULM: Pediatric Upper Limb & Microsurgery, August 2022 6. [Yorkshire FRCS(Plast) Course-](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/the-yorkshire-frcs%28plast%29-course?ref=theplasticsfella.com) August 12th 7. [AO Hand Trauma Blended Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/ao-trauma-blended-course---management-of-fractures-of-the-hand?ref=theplasticsfella.com) \- September 26th 8. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 9. [Head And Neck Siag Day ](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/head-and-neck-siag-day?ref=theplasticsfella.com)\- Hull, September 30th 10. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September. 11. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- September. 12. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 13. [BAAPS 2022](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/baaps-2022-the-art-of-aesthetic-plastic-surgery?ref=theplasticsfella.com): London, Step 27th 14. [Skills For Junior Plastic](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/surgical-skills-for-aspiring-junior-plastic-surgeons?ref=theplasticsfella.com)s - Alexandra Hospital, 8th Oct 15. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 16. [Aec 5.1 Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- October 26th, 2022. 17. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 18. [B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress - November 2022. [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tweet-sof-the-Werek.png) > If you never seen what a capsular contracture looks like 👇🏽👇🏽 [pic.twitter.com/rXuQVwrFK8](https://t.co/rXuQVwrFK8?ref=theplasticsfella.com) > > — Abdullah Al Qurashi (@QurashiAbdula) [July 22, 2022](https://twitter.com/QurashiAbdula/status/1550532041875275779?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Love is all we need😂😂😂 [pic.twitter.com/FoDNYdRYRI](https://t.co/FoDNYdRYRI?ref=theplasticsfella.com) > > — Tansu YEĞEN (@TansuYegen) [July 22, 2022](https://twitter.com/TansuYegen/status/1550344162339323905?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Reddish skin discoloration in the median nerve distribution after carpal tunnel glucocorticoid injection (vasomotor disturbance) [#medtwitter](https://twitter.com/hashtag/medtwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/jUeE3CyvUp](https://t.co/jUeE3CyvUp?ref=theplasticsfella.com) > > — Avraham Z. Cooper, MD (@AvrahamCooperMD) [July 22, 2022](https://twitter.com/AvrahamCooperMD/status/1550286780292792322?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/ask-the-expert.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Untitled-design-1.png) #### Radiological signs on Wrist X-Ray **Expert: Karan Choudhry, Orthopaedic Hand Trauma Specialist.** There are 3 important radiological signs to look for when assessing wrist-Xrays. **1\. Gilula’s lines:** proximal and distal carpal rows form 3 arcs. A carpal fracture will disrupt the greater arc and a carpal dislocation with a lesser arc injury. **2\. Signet ring:** A ring-like appearance over the distal portion of the scaphoid because of flexion. The distal pole of the scaphoid overlaps on the waist. It is indicative of scapholunate and lunotriquetral ligament injury. **3\. Terry Thomas sign:** Indicative of a Scapholunate ligament injury on PA view. It may or may not be a result of the initial propagation of the radial styloid fracture. It resembles the teeth gap of the British comedian Terry Thomas. [Follow the Expert on Twitter](https://twitter.com/KaranChoudhry6?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/New-Features.png) **Improved user experience** P'Fella wanted to make it easier for you to find your educational tools and also stay up-to-date with the new topics. Now, you can quickly find your library, flashcards and interview stations in the top bar. You will also see real-time updates every time a topic is created. p.s you will probably also like the new search function :) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/IMPROVED-NAVIGATION.png) ### --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Articles-of-the-Week.png) #### 3 Top Picks 1. **[Tips for Treating Dupuytrens ](https://journals.lww.com/prsgo/Fulltext/2022/01000/Treatment%5FOptions%5Ffor%5FDupuytren%5Fs%5FDisease%5F%5FTips.59.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)** Denkler et al.Treatment Options for Dupuytren’s Disease: Tips and Tricks, Plastic and Reconstructive Surgery - Global Open: January 2022 2. [**CDB for Arthritis**](https://pubmed.ncbi.nlm.nih.gov/35637038/?ref=theplasticsfella.com) Heineman et al. A Randomized Controlled Trial of Topical Cannabidiol for the Treatment of Thumb Basal Joint Arthritis. J Hand Surg Am. 2022 Jul;47(7):611-620 3. [**Carpal Tunnel in CRPS patients**](https://journals.lww.com/plasreconsurg/Fulltext/2022/07000/Outcomes%5Fof%5FCarpal%5FTunnel%5FRelease%5Fin%5FComplex.21.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) del Piñal et al. Outcomes of Carpal Tunnel Release in Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy/Sudeck Disease Patients, Plastic and Reconstructive Surgery: July 2022 - Volume 150 - Issue 1 - p 93-101 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Karapandazic Flap - Original The Karapandzic flap was described in 1974 after a 5-year case series of lip defect reconstruction. This journal club critiques the methods, results and conclusions of this landmark paper. [Journal Club](https://www.theplasticsfella.com/karapandzic-flaps-original-publication/) --- ### Karapandzic Flaps - Original Publication URL: https://www.theplasticsfella.com/karapandzic-flaps-original-publication/ Last updated: 2022-07-23T20:05:28.000Z #### Summary Card **Level of Evidence:** 4 (Case Series) **Background** Karapandzic believed that current flap reconstructions of the lip were not suitable in irradiated tissues due to weak labial artery. **Methods** Over a 5-year period, patients with lower lip defects from 3.5-7cm were reconstructed with this flap. **Results** 58 patients. No formal post-operative assessment. Some patients suffered from microstomia. **Conclusion** A reliable flap for large lower lip defects **Slides** There are no PowerPoint slides for this journal club due to the poor image quality of the [original publication](https://linkinghub.elsevier.com/retrieve/pii/0007-1226%2874%2990068-X?ref=theplasticsfella.com). ⚡ The complete journal club analysis, original images and PowerPoint slides are for **thePlasticsPro users**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - July 17th URL: https://www.theplasticsfella.com/july-17th/ Last updated: 2022-07-17T15:23:20.000Z #### In this week's edition 1. **✍️ Letter from P'Fella** Research **quality**, not **quantity** 2. **🤓 Study on Sunday + Quiz** Do you know salivary gland tumours? 3. **🤯 Ask the Expert (NEW!)** Scan the scaphoid fracture? 4. **🎭 Upcoming Events** 16 upcoming events for you. 5. **🐣 Tweets of the Week** Memes, virals & threads. 6. **🚀 New Features** What is "Ask the Expert"? 7. **📝 Articles of the Week** 3 must-reads, 1 deep-dive for thePlasticsPro (UPDATED!) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Letter-from-PFella-3.png) ## **Let's reward research quality, not research quantity.** Research has become a "tick-box" exercise. Get published, get a line on the CV, and get career progression. But it's probably time for a change to the way we look at this. For too long, plastic surgery journals and their submissions have been of comparatively low quality compared to other medical specialities. There has always been this idea that it's "hard to design good trials in plastics". But frankly, that is no longer true - look at the great work being done by [RSTN](https://reconstructivesurgerytrials.net/?ref=theplasticsfella.com). **So how can we look at research quality, not quantity? There are a couple of simple solutions.** \- **Impact factor:** not a perfect reflection quality. No offence, PRS journal \*cough cough\*). \- **Number of times** that publication has been referenced. This is a pretty good surrogate marker for quality. The limitation is that the quality of the publication can take several years to be appreciated (as citations are time-dependent) \- ****h-index** is an author metric that attempts to measure both the productivity and citation impact of the publications of an author. A researcher with an index of h has published h papers, each of which has been cited in other papers at least h times. What are your thoughts on this? Reply to this email, would be interested to hear them. --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Study-on-SUnday.png) \- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Types-of-Salivary-Gland-Tumours--1.png) #### Salivary Gland Tumours The major and minor salivary glands are associated with a remarkable diversity of neoplasms. WHO histologic classification for salivary gland tumours has over 40 different types of tumours as they can arise from epithelial, mesenchymal and lymphoid tissues. There were recent updates in their [8th edition](https://publications.iarc.fr/?ref=theplasticsfella.com) publication on Salivary Gland Tumours. These are just some examples of the 40+ different types of salivary gland tumours. - **Benign:** pleomorphic adenoma, adenolymphoma, oncocytoma, sebaceous neoplasms, intraductal papilloma. - **Benign Soft Tissue:** Haemangioma (paediatrics), Lipoma, sialolipoma, nodular fasciitis. - **Malignant**: mucoepidermoid, adenoid cystic, acinic cell, mixed, adenocarcinoma, primary SCC, sebaceous, lymphoma. - **Non-neoplastic epithelial:** sclerosing polycystic adenosis, nodular oncocytic hyperplasia, lymphoepithelial sialadenitis, intercalated duct hyperplasia. - **Hematolymphoid:** mucosa-associated lymphoid tissue (MALT lymphoma). [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) ## --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Upcoming-Events.png) 💡 **Special Announcement:** FRCS VIVA exam course at the Royal Free Hospital on 30 July 22 for UK Plastic Surgeons. [Reserve your place](https://www.theplasticsfella.com/june-19th/muholan.kanapathy@nhs.net). 2 spots left 👇 [ FRCS Course RFH 2022 FRCS-Course-RFH-2022.jpeg 145 KB download-circle ](https://www.theplasticsfella.com/content/files/2022/07/FRCS-Course-RFH-2022.jpeg "Download") #### 1. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 2. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 3. PULM: Pediatric Upper Limb & Microsurgery, August 2022 4. [Yorkshire FRCS(Plast) Course-](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/the-yorkshire-frcs%28plast%29-course?ref=theplasticsfella.com) August 12th 5. [AO Hand Trauma Blended Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/ao-trauma-blended-course---management-of-fractures-of-the-hand?ref=theplasticsfella.com) \- September 26th 6. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 7. [Head And Neck Siag Day ](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/head-and-neck-siag-day?ref=theplasticsfella.com)\- Hull, September 30th 8. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September. 9. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- September. 10. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 11. [BAAPS 2022](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/baaps-2022-the-art-of-aesthetic-plastic-surgery?ref=theplasticsfella.com): London, Step 27th 12. [Skills For Junior Plastic](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/surgical-skills-for-aspiring-junior-plastic-surgeons?ref=theplasticsfella.com)s - Alexandra Hospital, 8th Oct 13. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 14. [Aec 5.1 Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- October 26th, 2022\. 15. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 16. [B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress - November 2022. [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tweet-sof-the-Werek.png) > I like this BRACHIAL PLEXUS illustration as it demonstrates the nerves in relation to all surrounding bony, vascular, and muscular anatomy. CREDIT: Picturing Medicine [pic.twitter.com/mv2RnR0Wls](https://t.co/mv2RnR0Wls?ref=theplasticsfella.com) > > — Oren Gottfried, MD (@OGdukeneurosurg) [July 13, 2022](https://twitter.com/OGdukeneurosurg/status/1547303148888506369?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Research can be hard, but there are ways to make it simpler. > > Here are some tips for working in the lab > > 🧵⬇️ > > — Tomás Gomes 🇪🇺 (@tomsgoms) [July 12, 2022](https://twitter.com/tomsgoms/status/1546892959634931712?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Peroné Vascularizado en defecto óseo de clavícula distal (6 cm) > ▪️Microsutura vascular termino-terminal a los vasos toraco-acromiales > ▪️Síntesis mediante placa gancho y plastia coraco-clavicular (en colaboración con el Dr. Mir, la Dra. Marlet y el [@dralabau](https://twitter.com/dralabau?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ) [pic.twitter.com/4pluxTySi5](https://t.co/4pluxTySi5?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [July 10, 2022](https://twitter.com/DrBarreraochoa/status/1546184386957250560?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/ask-the-expert.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Deep-1.png) #### How should I scan the scaphoid? **Expert: Karan Choudhry, Orthopaedic Hand Trauma Specialist.** After confirmation of a scaphoid fracture on X-Ray, you should consider CT or MRI. **CT scan (1mm cuts in the plane of the scaphoid)** \- Check the fracture pattern \- Is it multiplanar? \- Serial monitor the healing **MRI Scan:** \- Pick up occult fractures \- Avascularity in a nonunion situation. [Follow the Expert on Twitter](https://twitter.com/KaranChoudhry6?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/New-Features.png) **"Ask the Expert"** P'Fella wants to introduce new voices into this weekly newsletter. So every Sunday, you'll get an expert answering 1 specific question or hot top. It's designed to be concise but highly relevant to the clinical needs of plastic surgeons and trainees. You can check out the very first "Ask the Expert" - just scroll up the page! ### --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Articles-of-the-Week.png) #### 3 Top Picks 1. [**Social Media and Plastic Surgery**](https://journals.lww.com/plasreconsurg/Fulltext/2022/07000/The%5FScope%5Fof%5FPlastic%5FSurgery%5FIs%5FDistorted%5Fthrough.69.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Cerceo et al. The Scope of Plastic Surgery Is Distorted through the Lens of Social Media, Plastic and Reconstructive Surgery: July 2022 - Volume 150 - Issue 1 - p 245e-246e 2. [**How to inject fat into the breast**](https://academic.oup.com/asj/article/29/5/360/199587?searchresult=1&ref=theplasticsfella.com) Delay et al. Fat Injection to the Breast: Technique, Results, and Indications Based on 880 Procedures Over 10 Years, **Aesthetic Surgery Journal*, Volume 29, Issue 5, September 2009. 3. [**5-step Augmentation Mastopexy** ](https://journals.lww.com/prsgo/Fulltext/2022/06000/Augmentation%5FMastopexy%5F%5FA%5FFive%5Fstep%5FStandardized.29.aspx?context=FeaturedArticles&collectionId=2&ref=theplasticsfella.com) Abdelkader et al. Augmentation Mastopexy: A Five-step Standardized Strategy Approach, Plastic and Reconstructive Surgery - Global Open: June 2022 - Volume 10 - Issue 6 - p e4349 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### Nasal Subunits - Original Burget and Menick published one of the most influential papers in day-case plastic surgery. The nasal subunits have guided reconstructive options (despite its poor research methodology!). This journal club critiques this article and its impact on current practice. [Learn the Nasal Subunits](https://www.theplasticsfella.com/nasal-subunits/) --- ### Nasal Subunits - Original Publication URL: https://www.theplasticsfella.com/nasal-subunits/ Last updated: 2022-07-14T16:20:05.000Z --- #### Summary Card **Background** The authors hypothesise that reconstructing the **entire** subunit results in a greater aesthetic outcome. **Methods** Patients with >50% defect of their subunit have complete resection of their subunit and reconstructed with an FTSG or flap. **Results** 20 patients. No formal scar assessment, just the "surgeon's eye" **Conclusion** No formal conclusion in this study **Slides** Download these Powerpoint slides for your Journal Club ⚡ The complete journal club analysis, original images and PowerPoint slides are for **thePlasticsPro users**. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - July 10th URL: https://www.theplasticsfella.com/july-10th/ Last updated: 2022-07-10T17:56:39.000Z #### In this week's edition P'Fella explores the future of open-source education in Plastic Surgeon, quizzes you on your lip anatomy, provides a content pipeline for the next 6 months and launches the recently renovated "Deep Dive" journal club section. 1. **✍️ Letter from P'Fella** Open-source education is the future of Plastic Surgery. Here's why you should get involved. 2. **🤓 Study on Sunday + Weekly Quiz** How well do you know the anatomy of the lip? 3. **🎭 Upcoming Events** 12 upcoming events for you. 4. **🐣 Tweets of the Week** Memes, viral tweets & educational threads. 5. **🚀 New Features** A huge content drop (and much more to come!) 6. **📝 Articles of the Week** 3 must-read, 1 deep-dive for thePlasticsPro (NEW!) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Letter-from-PFella-3.png) ## Open Source Education **Open-source" should be normal vocabulary in the education world.** It is a term that originally referred to open-source software. Open-source software is code that is designed to be publicly accessible—anyone can see, modify, and distribute the code as they see fit. It is developed in a decentralized and collaborative way, relying on community production. Open-source software is often cheaper, more flexible, and has more longevity than its proprietary peers because it is developed by communities rather than a single author or company. **This is the future of Plastic Surgery.** Open source has become a movement and a way of working that reaches beyond the "for-profit" educational companies. The open-source movement uses the values and decentralized production model to find new ways to solve problems in their communities and industries. **thePlasticsFella is not the central component, it is just one of many components working towards a common goal - independent, evidence-based education.** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Study-on-SUnday.png) ## Anatomy of the Lip The lip is a structure composed of skin, fat, muscle, and mucosa. The lip plays a vital role in oral competence, sensation, speech and cosmesis. The neurovascular anatomy of the lip is detailed below - **Motor**: buccal and mandibular branches of the facial nerve. - **Sensory**: infraorbital (upper) & mental (lower) branches of trigeminal nerve. - **Blood supply:** superior and inferior labial branches of the facial artery - **Lymph**: ipsilateral [submandibular nodes](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-1-cervical-lymph-nodes); the middle can drain to [submental](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/#level-1-cervical-lymph-nodes). [Answer this week's question!](http://quiz.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/1-1.png) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Upcoming-Events.png) #### 1. Pulvertaft Hand: DRUJ and ulnar head replacement, July 12th 2. [iBreastBook](https://us02web.zoom.us/webinar/register/WN%5F1Y-c6QUrSiyRhDcbClMgGg?ref=theplasticsfella.com) \- Localisation Techniques, July 16th 3. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 4. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 5. PULM: Pediatric Upper Limb & Microsurgery, August 2022 6. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 7. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 8. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- September 2022. 9. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 2022 10. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 11. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 12. [B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress - November 2022. [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Tweet-sof-the-Werek.png) > Proyecciones en superficie cara anterior del muslo: > 📌 AdL: m. aductor largo > 📌 TF: triángulo femoral > 📌 Ro: rótula > 📌 LR: ligamento rotuliano > 📌 TC: tendón del m. cuádriceps femoral > 📌 Rf: m. recto femoral > 📌 Sar: m. sartorio > 📌 VL: m. vasto lateral > 📌 VMed: m. vasto medial [pic.twitter.com/lIHDYo4882](https://t.co/lIHDYo4882?ref=theplasticsfella.com) > > — Pasión por la Anatomía (@PasionAnatomia) [July 10, 2022](https://twitter.com/PasionAnatomia/status/1546040798336192512?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Look at this awesome view of the brachial plexus and surrounding anatomy. [pic.twitter.com/jAVKK0IYWo](https://t.co/jAVKK0IYWo?ref=theplasticsfella.com) > > — Oren Gottfried, MD (@OGdukeneurosurg) [July 8, 2022](https://twitter.com/OGdukeneurosurg/status/1545531196985278470?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > The literature [pic.twitter.com/GvY88kFjtU](https://t.co/GvY88kFjtU?ref=theplasticsfella.com) > > — Oded Rechavi 🦉 (@OdedRechavi) [July 3, 2022](https://twitter.com/OdedRechavi/status/1543627986339069962?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/New-Features.png) **More content!** Who doesn't like to study more free, evidence-based content? Over the next 6 months, P'Fella will be published 1 new topic every day (there will also be a flashcard deck for each topic :)). The goal is to complete the international plastic surgery curriculum so this platform can become your benchmark for information. Here's how you can monitor the progress 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/new-feature.png) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/Articles-of-the-Week.png) #### 3 Top Picks 1. [**How to create a hand trauma curriculum**](https://journals.lww.com/prsgo/Fulltext/2021/12000/A%5FHand%5FCall%5FCurriculum%5Ffor%5FPlastic%5FSurgery.10.aspx?ref=theplasticsfella.com) Bjorklund et al. A Hand Call Curriculum for Plastic Surgery Residents, Plastic and Reconstructive Surgery - Global Open: December 2021 - Volume 9 - Issue 12 - p e3984 2. [**Finger Replants don't need a vein** ](https://journals.lww.com/plasreconsurg/Abstract/2022/07000/Management%5Fof%5FArtery%5FOnly%5FDigit%5FReplantation%5F%5FA.24.aspx?ref=theplasticsfella.com) Crowe et al Management of Artery-Only Digit Replantation: A Systematic Review of the Literature, Plastic and Reconstructive Surgery: July 2022 - Volume 150 - Issue 1 - p 105-116 3. [**Online reputation is key for breast reduction surgeons.** ](https://journals.lww.com/plasreconsurg/Fulltext/2022/07000/Which%5FFactors%5FAre%5FImportant%5Fto%5FWomen%5FWhen%5FChoosing.9.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Sergesketter et al. Which Factors Are Important to Women When Choosing a Breast Reconstruction Surgeon?, Plastic and Reconstructive Surgery: July 2022 - Volume 150 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### This Week's Journal Club Bruner **did not** like the midlateral incision. That is why he designed a "zig-zag incision" in 1967 that changed clinical practice. In this journal club, learn about the origins of the Bruner incision and its limitations. **There are Powerpoint slides for you to download for your journal club!** [Why did Bruner invent the "zig-zag" incision?](https://www.theplasticsfella.com/bruner-incision/) --- ### June 26th URL: https://www.theplasticsfella.com/june-26th/ Last updated: 2022-07-08T18:39:41.000Z ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/the-Plastics-Paper-Logo-6.png) #### In this week's edition P'Fella explores an increasing trend of scientific fraud, explains burn fluid resuscitation, shows off a new search function, and deep-dives an important publication in Plastic Surgery. 1. **✍️ Letter from P'Fella** Scientific Fraud on Facebook. 2. **🤓 Study on Sunday + Weekly Quiz** How to calculate burns fluid resuscitation**.** 3. **🎭 Upcoming Events** 12 upcoming events for you. 4. **🐣 Tweets of the Week** Memes, viral tweets & educational threads. 5. **🚀 New Features** New search function & progress bars 6. **📝 Articles of the Week** 3 must-read, 1 deep-dive for thePlasticsPro ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/07/A-weekly-Insight-into-P-Fella-s-thoughts-and-actions.png) There was some buzz in the #plasticsurgery world this week when a screenshot went viral. **Viral for pretty much all the wrong reasons.** You can check it out for yourself [here](https://twitter.com/DrMigueQC/status/1539620285120278528?s=20&t=weQh683tYSAgn7jb5BSlAw&ref=theplasticsfella.com). To summarise it for you, a guy was happy to put people as authors on upcoming publications if they paid him. Preying on the anxiety of publications leading up to career applications. Essentially, taking advantage of people at their most vulnerable. In P'Fella's opinion, **this is pretty shocking**. On so many levels. It brings us back to a big problem in currently in research - scientific fraud. [Chop et al ](https://pubmed.ncbi.nlm.nih.gov/2061524/?ref=theplasticsfella.com)describe scientific fraud as "an act of deception or misrepresentation of one's own work, violates these ethical standards. It can take the form of plagiarism, falsification of data, and irresponsible authorship". So how **prevalent** is scientific fraud? Here are some stats on the number of [retractions from PubMed](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479492/?ref=theplasticsfella.com). 67.4% of retractions were due to misconduct and 21.3% were due to a genuine mistake. This misconduct ranged from: \- fraud or suspected fraud (43.4%) \- duplicate publication (14.2%) \- plagiarism (9.8%) The authors of this [article](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479492/?ref=theplasticsfella.com) state this is a 10x increase in fraud since the 1970s. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/2-1.png) **Fluid Resuscitation** There are a number of different formulas used to calculate fluid requirements in burn resuscitation. These include the commonly used Parkland formula and modified-Brooke formula. Check out the diagram below that gives you a breakdown ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Burn-Fluid-Resuscitation-Formulas-1.png) #### Weekly Quiz Each week, P'Fella asks you one question to test your knowledge. You can now see how others have answered too! [Answer this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/3-2.png) #### 1. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 2. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022 3. [PLASTA x RSM Summer Congress 2022](https://www.rsm.ac.uk/events/plastic-surgery/2021-22/psq04/?ref=theplasticsfella.com) \- July 9th 4. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 5. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 6. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 7. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 8. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- September 2022. 9. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 2022 10. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 11. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 12. [B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress - November 2022. [Submit your Event](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/5-1.png) > Proyecciones en superficie los músculos en la cara medial del muslo > 📌 AdL: m. aductor largo > 📌 AdM: m. aductor mayor > 📌 Gr: m. grácil > 📌 Rf: m. recto femoral > 📌 Sar: m. sartorio > 📌 Sem: m. semimembranoso > 📌 Set: m. semitendinoso > 📌 VMed: m. vasto medial [pic.twitter.com/PCuJyJJ734](https://t.co/PCuJyJJ734?ref=theplasticsfella.com) > > — Pasión por la Anatomía (@PasionAnatomia) [June 22, 2022](https://twitter.com/PasionAnatomia/status/1539475657981587456?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Becareful with anatomical variations in hand surgery > Look this distal median and ulnar nerve conection in a patient operated of a thenar motor nerve entrapment [pic.twitter.com/AfLeVlC51v](https://t.co/AfLeVlC51v?ref=theplasticsfella.com) > > — HOMID FAHANDEZH (@HOMIDFAHANDEZH) [June 21, 2022](https://twitter.com/HOMIDFAHANDEZH/status/1539337375813345280?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > I like this brachial plexus drawing because it is anatomically correct, demonstrates the relevant adjacent anatomy like the clavicle, and you can color it in as you’d like. [pic.twitter.com/e42gsJvw1D](https://t.co/e42gsJvw1D?ref=theplasticsfella.com) > > — Oren Gottfried, MD (@OGdukeneurosurg) [June 20, 2022](https://twitter.com/OGdukeneurosurg/status/1538901816296996864?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/4-2.png) **Improved Search & a Progress Bar** **P'Fella has improved the way you can SEARCH.** You can now search the topic titles AND the content in that article. Let's say you're trying to find something quite specific. It could be a sentence, paragraph or subheading. Now you can do that. Check out the video as an example of finding a niche topic: **lightning strikes.** 0:00 / 1× As you scroll, you might night a progress bar appears across the top of your page. This gives your direct feedback on how far you are in your reading. A small thing, but it's kinda cool. --- ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/6-1.png) ## #### 3 Top Picks 1. [Skoff et al.](https://journals.lww.com/prsgo/Fulltext/2022/06000/The%5FPsychological%5Fand%5FSomatic%5FConsequences%5Fof.38.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) The Psychological and Somatic Consequences of Digital Amputation, Plastic and Reconstructive Surgery - Global Open: June 2022 - Volume 10 - Issue 6 - p e4387 2. [Jerome et al. ](https://journals.lww.com/prsgo/Fulltext/2022/06000/Fingertip%5FInjuries%5FOutcome%5FScore.35.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Fingertip Injuries Outcome Score, Plastic and Reconstructive Surgery - Global Open: June 2022 - Volume 10 - Issue 6 - p e4386 3. [Broekstra et al.](https://journals.lww.com/plasreconsurg/Fulltext/2022/06000/Disease%5FCourse%5Fof%5FPrimary%5FDupuytren%5FDisease%5F.21.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Disease Course of Primary Dupuytren Disease: 5-Year Results of a Prospective Cohort Study, Plastic and Reconstructive Surgery: June 2022 - Volume 149 - Issue 6 - p 1371-1378 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep-3.png) #### This Week's Deep Dive. **This is currently under renovation.** As you can prob tell by now, P'Fella is always building and improving. And this section can be better. It is going to be more focused on a "journal club style", maybe even slides for you to present at your own journal club! Check back next week to see the changes! [Suggest your idea! ](https://beta.theplasticsfella.com/?ref=theplasticsfella.com) _This post is for subscribers on the thePlastics Pro tier only._ ### Inhalation Injury URL: https://www.theplasticsfella.com/inhalation-injury/ Last updated: 2025-12-15T19:21:26.000Z #### 👇 On this page **[Pathophysiology](https://www.theplasticsfella.com/inhalation-injury/#pathophysiology-of-inhalation-injuries)** Inhalation injuries are **defined** as an airway's thermal or chemical exposure to a burn, the systemic effects and its complications. **[Diagnosis](https://www.theplasticsfella.com/inhalation-injury/#inhalation-injuries-diagnosis)** It should be suspected in burns in an enclosed environment, **diagnosed** on examination, and supported by investigations. **[Classification](https://www.theplasticsfella.com/inhalation-injury/#classification-of-inhalation-injuries)** They can be **classified** as supraglottic (usually direct thermal burn) or subglottic (usually a chemical exposure) **[Management](https://www.theplasticsfella.com/inhalation-injury/#management-of-inhalation-injuries)** **Treatment** focuses on optimising the airway, fluid resuscitation, medical stabilisation, and burn management. **[Carbon Monoxide Poisoning](https://www.theplasticsfella.com/inhalation-injury/#carbon-monoxide-poisoning)** Carbon Monoxide poisoning is a by-product of incomplete combustion and is treated with high-flow oxygen. **[Flashcards](https://www.theplasticsfella.com/inhalation-injury/#flashcards)** Evidence-based, verified flashcards to improve your active recall. --- ## Pathophysiology of Inhalation Injuries **Key Point** Inhalation injury refers to an airway's thermal or chemical exposure to a burn, the systemic effects and related complications. Inhalation injury refers to the injury to an airway from a thermal burn or chemical exposure, the systemic effects and complications. More specifically: - Direct local **thermal** and **chemical** exposures - Systemic effects of inhaled toxins and burns - Inflammatory and immune responses - Secondary complications and clinical sequelae The local pulmonary effects of the inflammatory responses include **bronchospasm** and **vasospasm**, **bronchorrhea** and **alveolar flooding**, **bronchial exudate** and **cast formation**, and **ventilation-perfusion mismatching**. 💡 Patients with an inhalation injury often required an increased fluid resuscitation volume compared to non-inhalational cutaneous burns ([Sheridan](https://www.google.com/search?client=safari&rls=en&q=Robert+L.+Sheridan%2C+M.D.+nejm&ie=UTF-8&oe=UTF-8&ref=theplasticsfella.com), 2016) --- ## Inhalation Injury Diagnosis **Key Point** Inhalation injury should be considered in all patients with a history of fire in an enclosed space or unconscious. It is a clinical diagnosis supported by baseline investigations. ### Clinical Picture Assessing the clinical presentation is the most reliable method of diagnosis and approximate grading of severity ([Ryan et al](https://pubmed.ncbi.nlm.nih.gov/22425833/?ref=theplasticsfella.com), 2012). Inhalation injury should be considered in all patients with a history of fire in an enclosed space or unconscious. Patients with inhalation injuries may have the following **symptoms**: - **Speaking**: hoarse or weak - **Coughing**: heavy and brassy - **Breathing**: Difficult, shortness of breath ![A patient is burnt with signs of inhalational injury. For example, burns ot face, swollen neck, black soot and singed hair](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Signs-of-an-Inhalational-Injury-in-Burns.png) SIgns of an Inhalational Injury On examination, the following **clinical findings** may be present: - **F**acial skin: burns - **L**ips/Mouth: soot - **A**irway: stridor, swelling. - **S**putum: carbonaceous/black - **H**air: singed 💡 Mnemonic: FLASH are the clinical findings of an inhalational burn - **F**acial Skin, **L**ips, **A**irway, **S**putum, **H**air! ### Investigations Baseline and specialized investigations can help confirm an inhalational injury. - **Vital Signs:** increase respiratory rate and decreased oxygen saturation. - **Chest X-Ray:** initially normal, later shows complications ([Putman et al](https://pubmed.ncbi.nlm.nih.gov/410252/?ref=theplasticsfella.com), 1977) - **Arterial Blood Gas:** metabolic acidosis, hypoxia, respiratory failure - **Carboxyhaemoglobin:** raised levels in CO poisoning - **Bronchoscopy** is the most accurate method for diagnosing an inhalational injury. It can also be used as a lavage treatment option. --- ## Classification of Inhalation Injuries **Key Point** An inhalation injury can be supraglottic or subglottic. This anatomical classification reflects different aetiology and expected clinical courses. The glottis is the opening between the vocal cords in the larynx. It is a "valve" between the throat and the lungs. This anatomical structure is used as a marker for inhalational injuries. This is illustrated below. ![Airflow through the glottis in the larynx](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Glottis-Anatomy.png) Anatomy of the Glottis ### Supraglottic Direct thermal damage is generally confined to the supraglottic airway. - Heat is usually the primary cause - Oedema develops that takes several days to develop - The airway should be secured - Exception: steam inhalation is a thermal burn that can travel subglottic. ### Subglottic Most injuries that occur below the glottis are caused by aerosolized chemicals and incomplete products of combustion. The various particles result in varying degrees of unpredictability. - Causes irritation, bronchospasm, mucosal slough and inflammation, surfactant depletion, and increased bronchial blood flow. - Treated with oxygen, nebulisers, physiotherapy, non-invasive ventilation - May require intubation for bronchial lavage with sodium bicarbonate. This is illustrated in the diagram below. ![Causes irritation, bronchospasm, mucosal slough and inflammation, surfactant depletion, and increased bronchial blood flo](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Inhalation-Injury-Effect-on-Lungs-in-Burns.png) Inhalational Injury effect on the lungs 💡 **Fun Fact:** Histopathology of inhalation parenchymal injury is diffuse alveolar damage (DAD). This can lead to permanent interstitial fibrosis. --- ## Management of Inhalation Injuries **Key Point** The management of inhalation injuries should focus on airway assessment and patency, medical stabilisation, identifying complications, and respiratory optimisation in a multi-disciplinary team. Inhalational injuries should be managed as part of a multi-disciplinary team involving plastic surgeons, anaesthetics/critical care, chest physiotherapists, and respiratory doctors. ### Goals The treatment of inhalational injuries is centred on 4 main aspects of care 1. **Airway** support and prevention of therapy-induced lung and airway injury 2. **Burn** Management 3. **Identifying** and treating complications or clinical sequelae. 4. **Medical** optimisation of the patient ### Acute Treatment Burns are trauma and should be treated as per ATLS guidelines. Here are some guidelines specific to the burn only (remember the patient may have other injuries). - A focused history - Examine the airway, determine patency or threat to patency - Examine cutaneous burns and assess for any other injuries - Perform baseline investigations - If raised carboxyhemoglobin, 100% high-flow oxygen - Fluid resuscitation as per Parkland formula if indicated. 💡 **Please note:** the presence of inhalation injury does not mean mandatory intubation. It is on a case-by-case basis. If initial intubation is not required, the patient should be watched particularly closely to determine whether subsequent intubation is needed. ## Intermediate Treatment The treatment pathway is time-dependent and should be adjusted to the patient's needs and any complications that may arise. The intermediate treatment often focuses on pulmonary optimisation and clearance. This can be achieved through - Standard pressure-controlled, lung-protective ventilation strategies. - Chest physiotherapy - Bronchoscopy lavage - Suctioning (if intubated) - Nebulized heparin and *N*\-acetylcysteine - Monitoring for infections or respiratory failure 💡 **Tip:** Steroids (inhaled or intravenous) or antibiotics are not routinely recommended. ### Intubation Not all inhalation injuries require intubation. It is a case-by-case basis after discussion with critical care/anaesthetic doctors. Relative indications for intubation include: - Overt signs of upper-airway obstruction - Evolving upper-airway obstruction - Worsening gas of gas exchange - Obtunded neurologic status Immediate tracheostomy is rarely necessary. Pulmonary clearance is enhanced by tracheostomy, but this is not a primary indication 💡 **Tip:** Endotracheal tube security is essential because upper-airway oedema makes reintubation difficult. --- ## Carbon Monoxide Poisoning Carbon monoxide, which is released during combustion, is a colourless and odourless gas that is rapidly absorbed after inhalation. Compared to oxygen, it has \~250x affinity to haemoglobin. This results in oxygen displacement from the haemoglobin. 😎 **Fun Fact:** the half-life of carbon monoxide is \~250 minutes, which can be reduced to 40 minutes with the administration of 100% oxygen. ### Pathophysiology Carbon monoxide binds to heme-containing structures (haemoglobin & mitochondrial cytochrome system). The binding results in: - Reduced oxygen delivery through the formation of carboxyhemoglobin. - Reduced oxygen utilization through impaired cytochrome cascade (takes longer to clear) - The binding of one CO molecule to hemoglobin increases the affinity of the other binding spots for oxygen, leading to **a left shift in the dissociation curve** ### Symptoms Carbon monoxide can be asymptomatic at low levels. General guidelines for symptoms are listed below - <20% results in headaches, nausea, confusion - <30% muscle weakness and impaired cognition - <40% results in hallucinations and ataxia - <50% cardiac ischaemia and unconsciousness. - \>60% can be fatal. ![A graph show the effect of carbon monoxide poising on the patient signs and symptoms during an inhalation injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Carbon-Monoxide-Poison.png) Carbon Monoxide Poisoning in an Inhalation Injury 💡 **Tip:** Patients with carbon monoxide poisoning can have cheery red mucous membranes and skin. ### Investigations - Elevated carboxyhaemoglobin (>10% is CO poisoning) - Metabolic acidosis - Chest-Xray (usually normal in the acute stages) - Pulse oximetry cannot differentiate between oxy- and carboxyhaemoglobin because they both absorb light at the same wavelength. ### ### Treatment - The standard treatment is 100% oxygen for 6 hours ([Buckley et al, 2011](https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002041.pub3/full?ref=theplasticsfella.com)) - Monitor metabolic acidosis 💡 **Tip:** hydrogen cyanide is also released during combustion, which affects oxygen at the cytochrome level. It causes persistent acidosis despite resuscitation. Treatment is fluid resuscitation; hydroxocobalamin, sodium thiosulfate or IV sodium nitrite. --- ## Flashcards ⚡ Evidence-based flashcards are designed for active recall and spaced repetition of the verified information you are currently studying. They are continually updated and are for thePlasticsPro users. --- _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - June 19th URL: https://www.theplasticsfella.com/june-19th/ Last updated: 2022-06-19T09:58:51.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/june-19th/#a-letter-from-pfella) \- Justin Bieber's Facial Nerve Palsy 2\. 🤓 [Study on Sunday + Quiz](https://www.theplasticsfella.com/theplasticspaper/june-19th/#study-on-sunday) \- Delay phenomenon 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/june-19th/#upcoming-events) \- New webinars and conferences 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/june-19th/#tweets-of-the-week) \- #plasticsurgery memes, videos and more! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/june-19th/#new-feature) \- Find your information quicker 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/june-19th/#articles-of-the-week) \- 3 rapid reviews, 1 deep-dive. --- ## A Letter from P'Fella ### Justin Bieber's Facial Nerve Palsy ✍️ Every Sunday, you get insights into P'Fella's thoughts and actions. Twitter was chirping this week after Justin Bieber's unfortunate diagnosis of **Ramsay-Hunt Syndrome.** It resulted in a pretty significant right-sided **facial palsy**. Bieber released a video online to explain the diagnosis and the clinical findings provide an excellent opportunity for teaching. > Justin Bieber's unfortunate diagnosis of Ramsay-Hunt does provide a good teaching opportunity for facial nerve paralysis. > > some screenshots (vvideo below)👇 [pic.twitter.com/9Fbz2mVIUO](https://t.co/9Fbz2mVIUO?ref=theplasticsfella.com) > > — thePlasticsFella (@PlasticsFella) [June 11, 2022](https://twitter.com/PlasticsFella/status/1535603452520321025?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) Other examples in the past include **Angelina Jolie's BRCA diagnosis**. In this nature publication, the authors state "Angelina Jolie effect includes a 250% increase in referrals of women with a family history of breast cancer in the UK, increases in rates of BRRM, and health insurance reimbursement for *BRCA* testing". [The Angelina Jolie effect: Contralateral risk-reducing mastectomy trends in patients at increased risk of breast cancer - Scientific ReportsScientific Reports - The Angelina Jolie effect: Contralateral risk-reducing mastectomy trends in patients at increased risk of breast cancer![](https://www.nature.com/static/images/favicons/nature/apple-touch-icon.png)NatureNarendra Nath Basu![](https://media.springernature.com/m685/springer-static/image/art%3A10.1038%2Fs41598-021-82654-x/MediaObjects/41598_2021_82654_Fig1_HTML.png)](https://www.nature.com/articles/s41598-021-82654-x?ref=theplasticsfella.com) **It just goes to show that celebrities do have the power to educate.** --- ## Study on Sunday ### Delay Phenomenon (+Weekly Quiz) 🤓 Your weekly bite-sized topic to keep your knowledge fresh. A series of theories have been proposed to describe the delay phenomenon. Each of these has been encompassed in a "unifying theory" by [Pearl in 1981](https://pubmed.ncbi.nlm.nih.gov/6457549/?ref=theplasticsfella.com). 1. **Increase** axial blood flow by removing blood flow from the periphery. 2. **Increase** tolerance to ischaemia by "training for hypoxia" 3. **Increased** adrenergic state in the initial delay operation reduces minimises the effect of raised vasoconstrictor concentration during the second operation. 4. **Reducing** sympathetic fibres by dividing skin flap borders increases vasodilation and intra-flap shunting of non-nutritive blood. 5. **Converts** [choke vessels](https://www.theplasticsfella.com/angiosomes/#choke-vessels) to "true anastomosis" permanently within 3 days. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Screenshot-2022-06-12-at-12.12.22.png) [Can you answer this week's question?](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) Study on Sunday is now combined with the very popular "weekly Quiz". You can now get **live results,** so you can compare your answers! --- ## Upcoming Events ### 14 Webinars, Conferences, and Courses 🕢 This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, reply to this email! **Special Announcement:** FRCS VIVA exam course at the Royal Free Hospital on 30 July 22 for UK Plastic Surgeons. [Reserve your place](muholan.kanapathy@nhs.net). Flyer in the link below 👇 [ FRCS Course RFH 2022 FRCS Course RFH 2022.jpeg 145 KB download-circle ](https://www.theplasticsfella.com/content/files/2022/06/FRCS-Course-RFH-2022.jpeg "Download") 1. [iBreastBook Webinar](https://us02web.zoom.us/webinar/register/WN%5FMnoG36fwReSH7uF0HKsDwg?ref=theplasticsfella.com) \- Implants vs Flaps, Virtual, June 25 2. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 3. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 4. [PLASTA x RSM Summer Congress 2022](https://www.rsm.ac.uk/events/plastic-surgery/2021-22/psq04/?ref=theplasticsfella.com) \- July 9th 5. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 6. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 7. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 8. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 9. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 10. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 2022 11. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 12. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 13. [](https://t.co/Pepk4mx4G1?ref=theplasticsfella.com)[B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress \- November 2022. --- ## Tweets of the Week 🐣 If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > One of the most emailed [#PRSGlobalOpen](https://twitter.com/hashtag/PRSGlobalOpen?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) papers from 2022 is "An Elegant, Simple Solution to a Newly Described Phenomenon: Traumatic Nasomalar “Ball-valve” Fistula" > > Read this case report to find out what has sparked so much interest from your colleagues: [https://t.co/spxn4vxZVA](https://t.co/spxn4vxZVA?ref=theplasticsfella.com) [pic.twitter.com/VA557bPR6a](https://t.co/VA557bPR6a?ref=theplasticsfella.com) > > — PRS Global Open (@PRSGlobalOpen) [June 16, 2022](https://twitter.com/PRSGlobalOpen/status/1537419732529184770?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > how would you describe the smell of Fournier’s gangrene? > > — Amy Pearlman, MD (@AmyPearlman1) [June 14, 2022](https://twitter.com/AmyPearlman1/status/1536840299774889988?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > my best writing advice for students [pic.twitter.com/EePdZcjmTp](https://t.co/EePdZcjmTp?ref=theplasticsfella.com) > > — W. Andrew Barr - PAPER Lab (@wabarree) [June 14, 2022](https://twitter.com/wabarree/status/1536784001301618689?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### Key Points and Summary Cards Every week, P'Fella builds or updates this platform's features to help create an amazing educational resource. **P'Fella has improved the way you can navigate through an article.** Up until now, the articles were designed for those who enjoyed reading the content at a leisurely pace. Most likely at home. Now, you can read the content when you are in a rush. Maybe in-between cases or patients when you *really* need to find information quickly. Check it out below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/FEATURSS.png) 💡 This new feature will be in all new articles and existing articles will be updated over the next few months. Check it out [here](https://www.theplasticsfella.com/tissue-expansion/) --- ## Articles of the Week 📑 Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Top-Picks 1. [Shigeyoshi et al.](https://journals.lww.com/prsgo/Fulltext/2022/06000/Hemodynamics%5Fand%5FVascular%5FHistology%5Fof%5FKeloid.15.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Hemodynamics and Vascular Histology of Keloid Tissues and Anatomy of Nearby Blood Vessels, Plastic and Reconstructive Surgery - Global Open: June 2022 - Volume 10 - Issue 6 - p e4374 2. [Rasha et al](https://journals.lww.com/prsgo/Fulltext/2022/06000/Augmentation%5FMastopexy%5F%5FA%5FFive%5Fstep%5FStandardized.29.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter). Augmentation Mastopexy: A Five-step Standardized Strategy Approach, Plastic and Reconstructive Surgery - Global Open: June 2022 - Volume 10 - Issue 6 - p e4349 3. [Kehrer et al.](https://www.jprasurg.com/action/showPdf?pii=S1748-6815%2819%2930536-4&ref=theplasticsfella.com) Step-by-step guide to ultrasound-based design of alt flaps by the microsurgeon – Basic and advanced applications and device settings. JPRAS. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep.png) 🚀 **This week's journal:** How to improve your Wide Awake Local Anaesthetic (WALANT) technique (by the godfather of WALANT, Lalonde) *How to Minimize the Pain of Local Anesthetic Injection for Wide Awake Surgery,* Joukhadar & Lalonde, PRS Go. **Fun Fact:** there are 13 steps to a painless local anaesthetic injection. _This post is for subscribers on the thePlastics Pro tier only._ ### Tissue Expansion URL: https://www.theplasticsfella.com/tissue-expansion/ Last updated: 2024-10-11T12:59:00.000Z #### In this Article 1. [Definition of Tissue Expansion](https://www.theplasticsfella.com/tissue-expansion/#definition-of-tissue-expansion) 2. [Mechanism of Tissue Expansion](https://www.theplasticsfella.com/tissue-expansion/#mechanism-of-tissue-expansion) 3. [Changes in Tissue Expansion](https://www.theplasticsfella.com/tissue-expansion/#changes-in-tissue-expansion) 4. [Capsule Formation](https://www.theplasticsfella.com/tissue-expansion/#capsule-formation) 5. [Types of Tissue Expanders](https://www.theplasticsfella.com/tissue-expansion/#types-of-tissue-expanders) 6. [Clinical Indications](https://www.theplasticsfella.com/tissue-expansion/#clinical-application-of-tissue-expanders) 7. [Flashcards](https://www.theplasticsfella.com/tissue-expansion/#flashcards) #### Summary Card Tissue expansion optimises the viscoelastic properties of skin and increases tissue availability through a process of creep and stress relaxation. Creep can be mechanical (acute) and biological (chronic). During the tissue expansion, histological changes occur. The epidermis is the only anatomical layer that increases in thickness. Tissue expanders are designed in different shapes, sizes, textures and expansion directions to fit their specific indication. Four zones or layers form a capsule around the expander. Tissue expanders are not used in a radiated wound bed, under a [skin graft](https://www.theplasticsfella.com/skin-grafts/) or in a wound with an active infection. --- ## Definition of Tissue Expansion Tissue expansion increases soft tissue availability by optimising the skin's viscoelastic properties. Architectural and histological changes occur to the [skin](https://www.theplasticsfella.com/anatomy-of-the-skin/), subcutaneous tissue & blood supply through **mechanical creep**, **biological creep** and **stress relaxation**. Neuman first described it in 1957\. ![Original 1957 publication by Neuman on Tissue Expansion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Tissue-Expansion-Description.png) Original 1957 publication by Neuman --- ## Mechanism of Tissue Expansion **Key Point** Tissue expansion optimises the viscoelastic properties of soft tissue through 3 processes: mechanical creep, biological creep and stress relaxation. Tissue expansion is a **time-dependent** process of **stretch** (mechanical creep), **growth** (biological creep) and **strain** (stress relaxation). Each process has an essential role in **acute** and **chronic** optimisation of the viscoelastic properties of soft tissue. ![Tissue expansion is the process of mechanical creep, biological creep and stress relaxation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Tissue-Expansion-Surgery.png) The mechanism of tissue expansion ### Mechanical Creep Mechanical creep occurs in the **acute** phases of mechanical stress, often seen in intra-operative tissue expansion. It results in the **majority** of soft tissue gain via: - **Collagen restructuring**: fibres align parallel to each other & the vector force - **Elastic fibres disruption**: microfragmenting - **Fluid displacement**: water displaced from the ground substance - **Tissue Migration:** recruitment of nearby tissue into the expanded field. ### Biological Creep Biological creep occurs in the **chronic** phase of mechanical stress and results in **growth**. Cellular growth and tissue regeneration occur via: - Angiogenesis - Fibroblast mitosis - Epidermal proliferation - Growth factor activation ### Stress Relaxation The longer soft tissue undergoes mechanical and biological creep, the less force is required to achieve these changes. As the name suggests, *stress relaxes*. 💡 **Fun Fact:** most tissue creep and growth occur in the first few days. --- ## Changes in Tissue Expansion **Key Point** Tissue expansion results in histological and architectural changes to soft tissue over time. Tissue expansion results in physical and cellular changes to soft tissue structures. These changes are detailed below. - **Epidermis**: increased mitotic rate of the basal layer, increased thickness. - **Dermis**: decreased thickness, increased collagen fibres & realignment. - **Fat**: decreases thickness with some fat necrosis - **Muscle**: decreased thickness, function not affected. - **Blood supply:** increased angiogenesis (like [delay phenomenon](https://www.theplasticsfella.com/delay-phenomenon/)) ![Tissue expansion results in physical and cellular changes to soft tissue structures.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Changes-Tissue-Expansion.png) Changes in Tissue Expansion 💡 **Fun Fact:** epidermis is the only layer that increases in thickness in tissue expansion. --- ## Capsule Formation **Key Point** After insertion, a capsule forms around the tissue expander. This has been shown to develop in 4 layers of different cellular structures. A capsule forms around a tissue expander after being inserted in a short period. This capsule is a collection of collagen, myofibroblasts and fibroblasts structured into 4 layers, as described by Pasyk. - **Inner Layer**: a synovial fibrin lining that contains macrophages. - **Central Layer**: elongated fibroblasts & myofibroblasts - **Transitional Layer**: collagen fibres - **Outer layer:** a vascular layer with collagen fibres. These layers can be visualised in the image below. ![A tissue expander has a capsule form around it after insertion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Tissue-Expander-Capsule.png) Microscopic Features of the Tissue Expander Capsule 💡 **Tip:** the capsule can be excised (capsulectomy) or scored perpendicular to the direction of advancement to increase flap mobility (which can compromise the vascularity). --- ## Types of Tissue Expanders **Key Point** Tissue expanders vary in size, shape, direction of expansion, port location and function. These variations reflect the specific use of indication of that tissue expander. A tissue expander is an inflatable silicone reservoir. There are different types of tissue expanders based on their specific purposes. The main variables relate to the tissue expander **port**, **texture**, **base**, **shape** and **function**. ### Port Location There are two commonly used ports: integrated and remote ports. Their main differences are in their location and their risk profile. **Integrated** - This is part of the tissue expander and is incorporated into the shell. - It is often located by a magnetic finder. - Benefit: no subcutaneous tunnelling or separate port site required. - Risks: could potentially puncture the tissue expander with a needle. **Remote** - They are not directly incorporated into the shell but rather via a tube - The port is often palpable in the subcutaneous tissue (or externally) - Benefit: unlikely to puncture the expander with the needle on expansion - Risks: the tunnel connecting the port and expander can become kinked, or the port can flip over in the subcutaneous tissue. ### Shape, Size & Base Tissue expanders are designed in various shapes and sizes, for example, oval, rectangular, round or square (or even custom). The expected tissue expansion gain is the essential point relating to shape and size differences. - **Round** expanders increase surface area by \~25% (often used in the breast) - **Crescentic** increases surface area \~ 33% (often used on the scalp) - **Rectangular** expanders increase surface area by \~ 40%. The base always has an important role. It should be 2.5 x the diameter of the defect needed to be reconstructed or covered. - **Solid base:** unidirectional expansion - **Soft base:** omnidirectional expansion Volume is a less defining feature because the expanders can often be overinflated. ### Thickness Variations A tissue expander can have variations in thickness and compliance. This is specifically designed to allow differential expansion based on the desired preferences. For example, breast tissue expansion to maintain a ptotic appearance. Differential expansion can be described in two ways - **Isotropic**: expand in any direction - **Anisotropic**: expand in controlled directions ### Surface A tissue expander can have a smooth or textured surface (just like a breast implant). A textured implant has reduced rates of contracture and migration. 💡 **Tip:** Tissue Expanders can be inserted into the subcutaneous, subfascial, submuscular or subgaleal pockets. A couple of weeks are usually needed prior to expansion. --- ## Clinical Application of Tissue Expanders **Key Point** Tissue expansion can be used for a diverse group of reasons. It is commonly used in delayed breast reconstruction. It should not be used in wounds with a high risk of wound breakdown. ### Indications Tissue expansion has a diverse range of indications in most body parts. Their insertion, location and design technique can be adjusted for specific purposes. Examples are detailed below. **Scalp Expansion** - It can be used for male pattern baldness and tissue defects requiring reconstruction. - An expander is inserted into a subgaleal position. - If performing an advancement flap reconstruction, the amount of tissue available for advancementequals the circumference minus the base width of the expander. **Face Expansion** - It can be inserted post-auricular for ear reconstructions or on the forehead for flaps. - Based on the facial subunit principle. **Breast Expansion** - A widespread application for delayed or immediate-delayed breast reconstruction - Subpectoral insertion with integrated port or remote port. 💡 **Tip:** lower limb tissue expansion is associated with a high rate of complications. ### Contraindications There are some instances where tissue expansion should not be used. This is a case-by-case basis and is often related to the wound bed and healing ability. Examples are listed below. - Radiated wound bed - Inserted under a [skin graft](https://www.theplasticsfella.com/skin-grafts/) - Active infection - Poorly healed scar --- ## Flashcards ⚡ Evidence-based flashcards are designed for active recall and spaced repetition of the verified information you are currently studying. They are continually updated and are for thePlasticsPro users. ### Local Anaesthetic URL: https://www.theplasticsfella.com/local-anaesthetic/ Last updated: 2025-12-15T19:44:33.000Z #### In this article 1. [Overview of Local Anaesthetic](https://www.theplasticsfella.com/local-anaesthetic/#overview-of-local-anaesthetic) 2. [Mechanism of Action](https://www.theplasticsfella.com/local-anaesthetic/#mechanism-of-action) 3. [Types of Local Anaesthetic](https://www.theplasticsfella.com/local-anaesthetic/#types-of-local-anaesthesia) 4. [Local Anaesthetic Calculations](https://www.theplasticsfella.com/local-anaesthetic/#local-anaesthestic-calculations) 5. [Local Anaesthetic Toxicity](https://www.theplasticsfella.com/local-anaesthetic/#local-anaesthetic-toxicity) 6. [References ](https://www.theplasticsfella.com/local-anaesthetic/#references) #### Summary Card Local Anaesthetic provides a temporary block to voltage-gated sodium channels. This prevents nerve impulse generation and conduction Amides and esters are the two categories of local anaesthetics. They have a different duration of action and side-effect profiles. Calculation of local anaesthetic volumes requires knowledge of the patient's body weight, max dose, and max concentration. Toxicity is rare but a potentially lethal complication that should be treated with a lipid rescue protocol. --- ## Overview of Local Anaesthetic Local anaesthetics are used in surgery to produce a **reversible loss of sensation** to the desired area by **blocking the voltage-gated sodium channels** required for nerve impulse generation and conduction. --- ## Mechanism of Action **Key Point** Local anaesthetic blocks **voltage-gated sodium channels** to prevent the conduction and propagation of nerve impulses. This occurs quicker when the pKa is similar to the of human tissue and less effective in the presence of an infection. Local anaesthetic blocks **voltage-gated sodium channels** to prevent the conduction and propagation of nerve impulses. Some important pharmacokinetic points are related to pH, lipid solubility, and ionisation. For example: - Local anaesthetics work when in an ionised state - Act faster if acid dissociation constant (pKa) is similar to human tissue (pH 7.4) - Act faster if high diffusion rather than through non-neural tissue - Less effective in infections due to local hypoxia causing a raised tissue pH - More effective when administered in an alkaline state (combined with sodium bicarbonate) - Longer duration of action if more lipid-soluble (high affinity for axons) 💡 **Fun Fact:** most local anaesthetics are vasodilators. --- ## Types of Local Anaesthesia **Key Point** The are two types of local anaesthetics - amides and esters. They have different mechanisms of action and metabolism pathways. ### Amides and Esters There are **two types** of local anaesthetics/anaesthesia. They are classified as: 1. **Esters**: a type of para-aminobenzoic acid (PABA)–based anaesthesia 2. **Amide**: a type of non-para-aminobenzoic acid (nPABA)–based anaesthesia An important difference between these two groups is the manner in which they are metabolised 1. **Esters:** metabolised in plasma by pseudocholinesterase to PABA (anaphylaxis) 2. **Amide:** metabolised in the liver, less allergy risk. Examples of these two types of local anaesthetics include: 1. **Esters**: Benzocaine 2. **Amides**: Bupivacaine Both ester and amide local anaesthetics can be administered in different formulations (ointments, patches, and injections). 💡 **Memory Hook**: local anaesthetic is an amide if the ‘i’ is before the C. ![The class, duration, dose and toxicity of different local anaesthetics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Local-Anaesthetic.png) Local Anesthetic --- ## Local Anaesthestic Calculations **Key Point** There are 4 values in local anaesthetic calculations: maximum **dose**, maximum **volume** and **concentration** and patient's **weight.** ### Principles of Calculations There are 3 important numbers when it comes to a successful local anaesthetic calculation. It is important to note the different units of measurement - these need to be converted! 1. Maximum dose (milligram/kilogram) 2. Concentration (%) 3. Patient's weight (kg) These 3 variables are used to calculate the **maximum recommended volume** of local anaesthetic. ### ### Step 1: Calculate Concentrations There are two concentrations to be calculated - local anaesthetic and adrenaline (if used). They require a unit conversion. **Local Anaesthetic Concentration:** Concentration is expressed as a percentage (%) & max safe dose is mg/kg. - Must convert % to mg/kg by multiplying the % by 10\. - For example, 1% lignocaine is 10mg/ml and bupivacaine 0.25% is 2.5mg/ml **Adrenaline Concentration:** Epinephrine concentrations are expressed as ratios & need to convert to mg/ml. This can be converted in 2 steps - Convert the ratio as a %: 1 in 100 is 1% and 1 in 1000 in 0.1%. - Multiply the % x 10 to get mg/ml. - For example**,** 1:1000 epinephrine is 1mg/ml. ### Step 2: Calculate Body Weight The Devine formulation is the most commonly accepted calculation (most applicable for people at least 60 inches, or 5 feet, tall): - IBW for men (kg) = 50 + 2.3 \* (Height (in)-60) - IBW for women (kg) = 45.5 + 2.3 \* (Height (in)-60 ### Step 3: Determine Maximum Dose This can be done by consulting your local hospital pharmacy guidelines. The table used at the beginning of this article is a guide only and does not replace your official documentation. ### Step 4: Put Steps 1-3 in a formula ![Maximum Volume of Local Anaesthetic (calculation)](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2021/03/Copy-of-Untitled-2.png) --- ## Local Anaesthetic Toxicity **Key Point** Local anaesthetic toxicity is a very rare side effect but it is potentially lethal. It is a progressive deterioration of the central nervous system and cardiovascular system. It is treated with an immediate resuscitation and lipid rescue protocol. ### Signs and Symptoms Local anaesthetic toxicity primarily affects the cardiovascular and central nervous systems. - **Head and Neck:** Dizziness, Disorientation, Tinnitus, Perioral paresthesia - **Heart:** Sinus bradycardia leading to sinus arrest, v. fib with bupivacaine. - **CNS**: Seizures, Coma 💡 Fun Fact: low levels of toxicity cause vasoconstriction and high levels cause vasodilation. ### Treatment Local anaesthetic toxicity should be treated with immediate first aid, consultation with senior colleagues and anaesthetics, and a lipid rescue protocol. An example of this protocol is: - Intralipid 20% bolus 1.5mL/kg - Infusion at 0.25mL/kg/min. Please consult your local guidelines for a hospital protocol. --- ## References 1. 1\. Mustoe TA, Buck DW II, Lalonde DH. The Safe Management of Anesthesia, Sedation, and Pain in Plastic Surgery. **Plastic and Reconstructive Surgery*. October 2010:165e-176e. doi:[10.1097/prs.0b013e3181ebe5e9](https://doi.org/10.1097/prs.0b013e3181ebe5e9?ref=theplasticsfella.com) 2. 2\. Williams D, Walker J. A nomogram for calculating the maximum dose of local anaesthetic. **Anaesthesia*. 2014;69(8):847-853\. [https://www.ncbi.nlm.nih.gov/pubmed/24820093](https://www.ncbi.nlm.nih.gov/pubmed/24820093?ref=theplasticsfella.com). ### Nerve Injury URL: https://www.theplasticsfella.com/nerve-injury/ Last updated: 2022-06-11T20:20:55.000Z 👇 **In this Article** [5 Key Points](https://www.theplasticsfella.com/nerve-injury/#nerve-injury) [Anatomy of a Nerve Injury ](https://www.theplasticsfella.com/nerve-injury/#anatomy-of-a-nerve-injury) [Nerve Injury Pathophysiology](https://www.theplasticsfella.com/nerve-injury/#pathophysiology-of-a-nerve-injury) [Assessment of a Nerve Injury ](https://www.theplasticsfella.com/nerve-injury/#assessment-of-a-nerve-injury) [Classification of a Nerve Injury ](https://www.theplasticsfella.com/nerve-injury/#classification-of-a-nerve-injury) [Flashcards](https://www.theplasticsfella.com/nerve-injury/#flashcards) --- ## Nerve Injury 🖐️ **5 Key Points** **1.** Peripheral nerves are groups of fascicles wrapped in an epineurium **2\.** Nerve injury results in **chromatolysis** & Wallerian degeneration **3.** The degree of nerve injury is classified by the MRC Grading System **4\.** Type of injury is classified by Seddon or Sunderland Classifications **5\.** The epineurium is sutured in epineural nerve repairs. --- ## Anatomy of a Nerve Injury **Key Point** A peripheral nerve is a group of fascicles surrounded by an epineurium. A fascicle is created from anatomical layers of functional and structural components. Nerve anatomy consists of functional and structural components. The functional aspect is the nerve fibre and axons. The structural component is the supportive soft tissue anatomy - for example, the epineurium. ### Neuron/Nerve Fibre Anatomy The neuron is the nerve cell. It is the foundation of the peripheral nerve. There are many elements to its structure, the most important being the axon and its surrounding myelin and Schwann cells. ![The neuron or nerve cell anatomy is composed of a cell body, dendrites, axons, myelin sheath, Schwann cells, Nodes of Ranvier and axon terminals. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Anatomy-of-a-neuron-or-nerve-cell.png) Anatomy of the Nerve Cell (Neuron) Functional components of the neuron include: - **Axons:** nerve fibres that carry the impulses within the endoneurium. - **Schwann Cell:** produce myelin sheath around myelinated nerves. - **Node of Ranvier:** gaps between Schwann cells on myelinated nerves - **Saltatory conduction:** nerve impulse jumping between nodes of Ranvier. 💡 Remember: Schwann cells surround **individual** **myelinated** axons or **several unmyelinated** axons. There are 3 different types of nerve fibres based on their myelin, diameter and velocity. - **Type A:** large diameter, high velocity, myelinated - **Type B (pre-ganglionic):** small diameter, low velocity, myelinated - **Type C (post-ganglionic):** small diameter, small velocity, unmyelinated ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Nerve-Fibre-Neuron-Anatomy.png) Types of Nerve Fibres 💡 **Fun Fact:** type A nerve fibres can be subclassified into **α,** β, γ, δ based on their motor, proprioception and pressure functions. ### Peripheral Nerve Anatomy A peripheral nerve is a group of fascicles surrounded by an epineurium. Neurons (described above) help form the smallest unit of the peripheral nerve that can be surgically treated - fascicles. This is the foundation of a macroscopically visible peripheral nerve. ![A peripheral nerve can be damaged or injured at an axon, fascile or group of fascicles surrounded by the epineurium](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Nerve-Anatomy-Injury.png) Anatomy of a Peripheral Nerve Injury **Structural components** of the peripheral nerve include: - **Endoneurium:** a collagen matrix surrounding an axon. - **Fascicle**: a bundle of nerve fibres/axons wrapped in the perineurium. - **Perineurium**: connective tissue of each fascicle creates a blood-nerve barrier. - **Inner Epineurium:** surrounds the perineurium and contains blood vessels - **Outer Epineurium:** surrounds groups of fascicles to form a peripheral nerve. - **Mesoneurium**: adventitial layer assists in nerve gliding & epineural repairs. 💡 **Tip:** **inner** epineurium is sutured in **fascicular** repairs. **Outer** epineurium is sutured in an **epineural** repair. **Blood supply** to the nerve can come in various ways. Most commonly: - **Arteriae nervosum:** can help orientate your epineural nerve repair - **External vessels:** supply the epineurium - **Capillary plexus:** supplies the endoneurium. --- ## Pathophysiology of a Nerve Injury **Key Point** Nerve injury results in chromatolysis in the proximal the injury, Wallerian degeneration distal to the injury and release of neurotrophic factors. ### Wallerian Degeneration Wallerian degeneration is the active degeneration of myelin and axons **distal** to the site of nerve injury. It was first described by [Waller in 1850](https://royalsocietypublishing.org/doi/abs/10.1098/rstl.1850.0021?ref=theplasticsfella.com) and begins after a brief latent period. Key steps in wallerian degeneration include: - Increase in cytoplasmic calcium - Proliferation of macrophages & Schwann cells (produce neutrophic factors). - Degeneration and phagocytosis of axons and myelin. - Formation of bands of bunger (endoneurial tubes to guide regenerating axons). ![Wallerian degeneration occurs distal to the site of nerve injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Wallerian-Degeneration-Nerve-Innjury.png) Wallerian Degeneration in Nerve Injuries ### Chromatolysis Chromatolysis is the process of **proximal** neuronal cell degeneration to the nearest node of Ranvier that can occur within several hours of injury. Key steps in chromatolysis include: - Degeneration to the nearest node of Ranvier. - Axonal sprouts form a growth cone - Growth cone provides contact guidance to find the correct **distal** stump. ### NeuroTROPISM and NeuroTROPHISM The direction of nerve regeneration is guided by **neurotropism**, **neurotrophism** and **neurotropic factors**. - **Neurotropism:** selective, directional growth of fibres - **Neutrophism:** non-selective, non-directional growth of fibres. - **Neurotrophic factors:** release fromdistal target, produced by Schwann cells. Examples of neurotrophic factors include nerve growth factor, insulin-like growth factor, epidermal growth factor (just to name a few!). 💡 **Fun Fact:** nerve fibre making incorrect connections with another nerve fibre will be denied the maturation factors and will atrophy --- ## Assessment of a Nerve Injury **Key Point** The universal "language" for the grade of a nerve injury is published by the Medical Research council. It categories the motor or sensory injury based on clinical examination. The assessment of a nerve injury should be based on a detail history and thorough clinical examination. The purpose of this section is to focus on key aspects specific to nerves. ### MRC Grade of Nerve Injury This is the official method for stratifying the degree of nerve injury based on clinical examination. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/MRC-Grade-of-Nerve-Injury.png) ### Additional Tests There are a series of adjuncts to clinical examination that can help support your diagnosis. Some examples are list below. - **2-point-discrimination:** innervation density, 6mm static & 3mm dynamic. - **Monofilament**: pressure thresholds (better for compression neuropathies) - **Electrophysiology Studies:** Nerve conducton studies and EMGs. --- ## Classification of a Nerve Injury **Key Point** The Seddon and Sunderland classification systems are commonly used to describe the degree of nerve injury. The classification of a nerve injury is by the Seddon or Sunderland classification. These classification systems are base on the type of injury to the nerve. They can guide management decisions and patient outcomes. ![The Seddon and Sunderland classification of nerve injuries based on the degree of injury to the nerve](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Classification-of-Nerve-Injuries.png) Classification of Nerve Injuries --- ## Flashcards ⚡ Evidence-based flashcards are designed for active recall and spaced repetition of the verified information you are currently studying. They are continually updated and are for thePlasticsPro users. ### Cartilage Grafts URL: https://www.theplasticsfella.com/cartilage-grafts/ Last updated: 2025-12-15T19:36:35.000Z 👇 **In this Article** [5 Key Points](https://www.theplasticsfella.com/cartilage-grafts/#cartilage-grafts) [Cartilage Graft Anatomy](https://www.theplasticsfella.com/cartilage-grafts/#cartilage-graft-anatomy) [Cartilage Graft Types ](https://www.theplasticsfella.com/cartilage-grafts/#cartilage-graft-types) [Cartilage Warping](https://www.theplasticsfella.com/cartilage-grafts/#cartilage-warping) [Flashcards](https://www.theplasticsfella.com/cartilage-grafts/#flashcards) --- ## Cartilage Grafts 🖐️ **5 Key Points** 1\. Cartilage is an avascular structure of type II collagen, elastin & ground substance. 2\. Cartilage grafts are classified as autografts, allografts and xenografts. 3\. Autografts are the gold standard, whilst allografts and xenografts are rarely used due to immunogenicity and resorption. 4\. Cartilage warping is the main complication and relates to Gibson's principle. 5\. Cartilage has no intrinsic blood supply so healing is by fibrosis. --- ## Cartilage Graft Anatomy ### **Key Point:** Cartilage originates from the mesenchyme and forms as chondroblasts transform into chondrocytes. There are different types of cartilage and an innate lack of blood supply. ### Types of Cartilage Cartilage is composed of type II collagen, elastin and ground substance in a dense extracellular matrix. The proportionally large volume of water provides the cartilage structure. These components constitute the different types of cartilage: - Hyaline Cartilage - Fibrocartilage - Elastic cartilage ### ### Vascularity Cartilage is avascular and has a relatively low metabolic rate. This means it is resistant to some aspects of surgery (such as ischaemia) but less forgiving in other parts (slow healing). - There is no cartilaginous intrinsic blood supply - It receives nutrition via the diffusion of nutrients and oxygen. - A lack of blood supply impairs healing and is usually fibrous in nature. --- ## Cartilage Graft Types **Key Point:** In a similar fashion to [bone grafts](https://www.theplasticsfella.com/bone-grafts/), cartilage grafts can be classified as **autografts**, **allografts** or **xenografts**. Generally speaking, the latter two options have **limited** success. ### Cartilage Autografts Cartilage autografts (from the patient) are considered the "gold standard" for reconstruction. Common donor sites include: - Costal cartilage - Conchal Bowl - Cartilaginous nasal septum ![Cartilage grafts can be from the costal cartilage, conchal bowl or cartilaginous septum](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Cartilage-Grafts-DOnor-Sites.png) Cartilage graft donor sites ### Cartilage Non-Autografts Cartilage allografts and xenografts are less commonly used. Here's why: - Allografts undergo rejection and resorption over a long period of time - Xenografts are immunogenic even after processing. --- ## Cartilage Warping **Key Point:** A significant limitation of cartilage is **warping.** This is the tendency of cartilage to change shape over a period of time. It relates to the Gibson principle. Cartilage warping is the unwanted informational change that occurs after cartilage grafting due to a change in mechanical forces. ![When cartilage is scored it will curve away from the scored side. This is important for cartilage warping and cartilage grafts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Gibson-Principle-Scoring-Cartilage.png) Gibson Principle for Cartilage Scoring There have been methods described to reduce the risk of warping 1. Gibson Principle: scoring of the cartilage will result in warping in the other direction (it curves towards the intact side) ([Gibson et al, 1957](https://linkinghub.elsevier.com/retrieve/pii/S0007122657800423?ref=theplasticsfella.com)) 2. Delayed inset after cartilage harvest 3. Perichondrial preservation to reduce tension is less commonly practised now. Unlike [bone grafts](https://www.theplasticsfella.com/bone-grafts/), there is less resorption and more easily shaped. 💡 **Tip:** Cartilage warps **away** from the **injured** surface. The extent of the warping is dependent on the extent of scoring. --- ## Flashcards ⚡ Evidence-based flashcards are designed for active recall and spaced repetition of the verified information you are currently studying. They are continually updated and are for thePlasticsPro users. ### Bone Grafts URL: https://www.theplasticsfella.com/bone-grafts/ Last updated: 2025-05-05T11:11:44.000Z 👇 **In this Article** [5 Key Points](https://www.theplasticsfella.com/bone-grafts/#bone-grafts) [Indications for Bone Grafts](https://www.theplasticsfella.com/bone-grafts/#indications-for-bone-grafts) [Bone Graft Properties](https://www.theplasticsfella.com/bone-grafts/#bone-graft-properties) [Classification of Bone Grafts](https://www.theplasticsfella.com/bone-grafts/#classification-of-bone-grafts) [Autologous Bone Autografts](https://www.theplasticsfella.com/bone-grafts/#autologous-bone-autografts) [Alloplastic Bone Substitutes](https://www.theplasticsfella.com/bone-grafts/#alloplastic-bone-substitutes) [Bone Graft Healing & Incorporation](https://www.theplasticsfella.com/bone-grafts/#bone-graft-healing-and-incorporation) [Bone Graft Survival](https://www.theplasticsfella.com/bone-grafts/#bone-graft-survival) [Flashcards](https://www.theplasticsfella.com/bone-grafts/#flashcards) --- ## Bone Grafts 💛 **5 Key Points** 1\. Bone grafts are **autologous** (humans) or **alloplastic** (engineered) 2\. **Autologous** grafts are autografts (patient) or allografts (cadaver) 3\. They are incorporated through osteoinduction, -conduction, -genesis 4\. Cortical grafts support, and cancellous allow bone regrowth. 5\. Graft survival depends on type of graft, fixation and patient factors. --- ## Indications for bone grafts Bone grafts provide support, encourage bone regeneration and assist fracture healing. There is a diverse array of bone grafting indications. Generally speaking, bone grafts and their substitutes are used for: - Structural support by filling bone gaps secondary to trauma or resection - Improve healing of fractures with delayed or non-unions. - Assist in arthrodeses and spinal fusions --- ## Bone Graft Properties Bone grafts have one or more of the following properties: **osteoconductive**, **osteoinductive**, and **osteogenic**. The biological property of bone focuses on 3 areas - osteoconduction, osteoinduction and osteogenesis. This can be visualised in the image below ![Bone grafts have different amounts of osteoconduction, osteinduction and osteogenesis. There are the biologiical properties of bone and bone grafts](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Bone-Graft-Characteristics.png) Bone Graft Characteristics **Osteoconductive** - Osteoconductive material is a structural framework for bone growth. - For example, demineralized bone matrices (DBMs) - More apparent in cancellous bone grafts. **Osteoinductive** - Osteoinductive material stimulates osteogenesis and induces stem cells - For example, bone morphogenetic protein (BMP) arises from the TGF-B family. **Osteogenic** - Osteogenic material provides bone-producing cells (mesenchymal stem cells, osteoblasts, and osteocytes) to produce more bone. - For example, an autologous bone graft is the only bone graft that contains live mesenchymal precursor cells 💡 **Fun Fact:** cancellous bone has a greater ability than cortical bone to form new bone due to its larger surface area --- ## Classification of Bone Grafts There are several different ways to classify the different types of bone grafts. This image below provides a comprehensive review. ![Bone grafts can be autologous, alloplastic, cortical and cancellous](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Classification-of-Bone-Grafts.png) Classification of Bone Grafts 💡 **Tip:** Autografts can be further subclassified into vascularised and non-vascularised. --- ## Autologous Bone Autografts ### Autologous bone autografts are cortical, cancellous or corticocancellous bone from the patient that can be vascularised and non-vascularised. They retain all biological properties of bone. ### Indications Bone Autografts are **indicated** in bone defects <6cm and: - Well-vascularized bed - Adequate soft tissue cover - Absence of infection ### Biological Properties Bone Autografts are considered the "gold standard" because of their **biological properties**: - Osteogenic **and** osteoinductive **and** osteoconductive properties. - Less immunogenic than other options. ### Types of Autografts Autografts can be cortical, cancellous or a combination. Each option has its own limitations and advantages. Generally speaking, cortical is used when large defects require structural support. **Cortical Bone Grafts** - Less biologically active than cancellous - More structural support than cancellous. - Slower incorporation due to remodelling of Haversian canals (up to 2 months) - Heals primarily by osteoconduction. **Cancellous Bone Grafts** - An osteoconductive 3D scaffold with minimal structural support - A high number of osteoblasts and growth factors. - Rapid incorporation via creeping substitution (within 2 weeks) - Heals primarily by osteogenesis. ### Donor Sites **Donor** site options for autografts include: - Iliac Crest - commonly used and can give cancellous and cortical bone - Fibula - for a vascular autograft (example - fibula graft with peroneal artery) - Ribs - for vascular autografts. - Distal radius - Bone marrow aspirate 💡 **Tip**: Autografts are considered the "gold standard". They can be cortical, cancellous or a combination. **Bone Allografts** Allografts are bone grafts from a (cadaver) donor that can be fresh, freshly frozen or freeze-dried bone derived from a donor. Bone allografts are osteoconductive **only** due to a lack of viable cells. It is limited by its immunogenicity. 💡 **Tip**: Autografts are considered the "gold standard" of bone grafting. --- ## Alloplastic Bone Substitutes There is an array of "synthetic" and "engineered biological" bone substitutes that provide structural support. Alloplastic bone substitutes have a primary role in support. They are primarily osteoconductive with little osteogenic or osteoconductive properties Here are a few examples: - **Demineralised bone matrix** has an osteoinductive and osteoinductive capacity without structural support. It contains collagen, bone morphogenetic proteins, transforming growth factor-beta, residual calcium but does not contain mesenchymal precursor cells. - **Calcium Hydroxyapatite:** brittle but limited resorption. - **Methylmethacrylate (MMA)**: non-resorbable, high density, "bone cement", structural support with osteoconductive properties only. - **Bone morphogenetic proteins (BMP):** osteoinductive only 💡 **Tip**: Alloplasts vary in their osteoconduction, inductive properties, and resorption rates. --- ## Bone Graft Healing and Incorporation Autologous bone grafting incorporates through 3 main mechanisms: **osteoconduction**, **osteoinduction**, and **osteogenesis.** After haematoma formation and an initial inflammatory period, in which necrotic debris stimulates chemotaxis, bone grafts become incorporated into their new bony surroundings. In a similar way, skin grafting becomes [adherent](https://www.theplasticsfella.com/skin-grafts/#stages-of-skin-graft-healing) to a wound bed. This is visualised in the image below. It is different from the [standard bone healing process](https://www.theplasticsfella.com/bone-healing/). ![a bone graft healings and incorporates into the recipient bed through osteoconduction, osteoinduction and osteogenesis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/bone-graft-incorporation-and-healing.png) Bone Graft Incorporation - Osteoconduction, Induction and Genesis ### Osteoconduction - The **bone graft** acts as a scaffold for bone growth via creeping substitution - It provides a matrix for bone growth that enables a blood supply and osteoprogenitor cells to survive. - Occurs in cortical bone, calcium hydroxyapatite, and less so in cancellous bone. ### Osteoinduction - Bone graftgrowth factors stimulate osteogenesis in the **host tissue**. - Osteocytes are formed from the differentiation of the recipient site's mesenchymal cells - Strongly influenced by BMPs. - This process is seen in cancellous bone grafts and demineralised bone matrix ### Osteogenesis - Osteoblasts that survive in the bone graft directly produce new bone. - A faster process in vascularized bone grafts as they do not undergo creeping substitution. - Occurs primarily in vascularized bone grafts and cancellous bone. 💡 **Definition:** Creeping substitution is the osteoclastic resorption of dead bone from the allograft and its replacement by new living bone made by osteoblasts from the host. --- ## Bone Graft Survival Bone grafts are similar to [skin grafts](https://www.theplasticsfella.com/skin-grafts/#skin-graft-failure) in that they are influenced by patient factors, graft factors and the recipient site. ### Patient Factors A medically optimised patient will always have a better outcome for their bone grafts. For example, diabetes control, smoking cessation and adjusting immunosuppression drugs. ### Graft Factors When it comes to the graft, there are so many variables that can have a positive and negative influence on its healing. Here are some key points: 1. **Type of Bone Graft** - **Periosteum** on bone grafts reduces the amount of resorption. - **Cancellous bone grafts are** more readily revascularized than cortical. **2\. Inset of Bone Graft** - **Orthotopic**: if the graft is placed in a normal bone location then there will be less bone resorption. - **Fixation**: bone graft fixation improves survival. - **Quality of recipient:** infection and radiotherapy reduce graft survival. 💡 **Fun Fact:** A bone graft is considered to be incorporated when there is no abrupt histological change between the host bone and the graft --- ## Flashcards ⚡ Evidence-based flashcards are designed for active recall and spaced repetition of the verified information you are currently studying. They are continually updated and are for thePlasticsPro users. --- ### Bone Healing URL: https://www.theplasticsfella.com/bone-healing/ Last updated: 2024-06-27T20:34:59.000Z ‌ ‌ 👇 ****In this Article** [5 Key Points](https://www.theplasticsfella.com/bone-healing/#bone-healing) [Bone Anatomy](https://www.theplasticsfella.com/bone-healing/#bone-healing-anatomy) [Types of Bone Healing](https://www.theplasticsfella.com/bone-healing/#types-of-bone-healing) [Stages of Bone Healing](https://www.theplasticsfella.com/bone-healing/#stages-of-bone-healing) [Complications of Bone Healing](https://www.theplasticsfella.com/bone-healing/#complications-of-bone-healing) [Flashcards](https://www.theplasticsfella.com/bone-healing/#flashcards) --- ## Bone Healing 💛 ****5 Key Points** ****1.** Bone has an inner cancellous layer and an outer cortical layer. ****2\.** Has periosteal, endosteal, epiphyseal and apophyseal blood supply. ****3.** Healing can be primary (no callus) or secondary (callus formation) ****4.** Stages are hematoma, inflammation, proliferation, callus, remodel. ****5.** Complications include non-union, malunion, & delayed union. --- ## Bone Healing Anatomy Bone is derived from ****mesenchyme** through ****intramembranous** and ****endochondral** ossification to give an outer ****cortical** layer and an inner ****cancellous** layer. ### ### Bone Structure Bones have an outer cortical layer and an inner cancellous layer. Each structure has a specific purpose, as detailed below: - **Cortical**: columnar structure and concentric layers connected by longitudinal Haversian canals (central blood vessel) and transverse Volkmann canals (nutrient vessels). - **Cancellous**: loosely woven trabeculae of organic and inorganic bone. These structures are both used in [bone grafting.](https://www.theplasticsfella.com/bone-grafts/#autologous-bone-autografts) 🤓 ****Fun Fact:** cartilage is the precursor for bone formation endochondral ossification. ### Bone Blood Supply Bone receives more than one type of blood supply depending on its location and origin/insertions. The important vascular vessels are: - Periosteal - Apophyseal - Endosteal (nutrient supply to the medullary cavity) - Epiphyseal (growth plates) 🤓 ****Memory hook for Bone Blood Supply:** ****PEACE**· ****P**eriosteal· ****E**piphyseal & ****E**ndosteal (nutrient supply to the medullary cavity)· ****A**pophyseal· ****C**anal of Volkmann (nutrient supply)· ****H**aversian Canals (central supply) --- ## Types of Bone Healing The type of bone healing is dependent on the removal of a fracture haematoma and the type of bone fixation performed. Absolute stability results in primary bone healing. ### Primary Bone Healing This occurs when **absolute stability** is provided to a fracture fixation resulting in **no callus formation**. Normal bone architecture is restored when osteoclasts provide a guide for blood vessels to cross the fracture site. A clinical example is a compression plate. Key aspects to this type of bone healing are: - No callus formation - No inflammatory or proliferative phases of healing - Haversian remodelling/osteonal bone remodelling ### Secondary Bone Healing This occurs when absolute stability is **not** provided to a fracture fixation resulting in **callus formation**. Clinical examples include K-wires, external fixators, and casting/splinting. Key aspects to this type of bone healing are: - Callus formation - Fracture haematoma occurs - Bone healing via endochondral ossification This is different to [bone graft incorporation ](https://www.theplasticsfella.com/bone-grafts/#bone-graft-healing-and-incorporation)seen in bone grafts. 🤓 ****Fun Fact:** a callus is soft, immature woven bone and hyaline cartilage created by osteoblasts and chondroblasts, respectively. It becomes a hard callus (mature woven bone) when the osteoid is mineralised with hydroxyapatite. --- ## Stages of Bone Healing There are 5 phases to bone healing: haematoma, inflammation, proliferation, callus formation, and remodelling. Bone healing is reliant upon osteoblasts and osteocytes. They help form new bone and maintain calcium homeostasis. The 5 phases of bone healing are as follows: 1. **Haematoma:** a "haematoma" is formed at the fracture site. 2. **Inflammation**: haematoma granulates & osteoclasts remove necrotic bone. 3. **Proliferation** of periosteal and endosteal cells at the cortex. 4. **Callus** formation & transformation from a soft callus (osteoid) to a hard callus. 5. **Remodelling** of woven bone to lamellar bone There are some similarities to bone and [wound healing](https://www.theplasticsfella.com/wound-healing/) \- but don't get confused! 🤓 ****Memory Hook for "Bone Cells":**· Osteo****B**lasts ****B**uild bone by producing osteoid.· Osteo****C**ytes maintain ****C**alcium hemostasis in the bone matrix.· Osteo****CL**asts ****CL**ean up the bone (bone resorption) --- ## Complications of Bone Healing Successful bone healing requires several factors to work together. Sometimes this doesn't occur for a variety of reasons. This can lead to some of the following complications 1. Malunion 2. Non-union 3. Delayed union These complications can be treated by [bone grafting](https://www.theplasticsfella.com/bone-grafts/#indications-for-bone-grafts). --- ## Flashcards ⚡ Evidence-based flashcards are designed for active recall and spaced repetition of the verified information you are currently studying.They are continually updated and are for thePlasticsPro users. ### thePlasticsPaper - June 5th URL: https://www.theplasticsfella.com/june-5th/ Last updated: 2022-06-05T17:04:15.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/june-5th/#a-letter-from-pfella) \- 3 study techniques (you might not have heard of) 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/june-5th/#study-on-sunday) \- Mathes and Nahai Classification 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/june-5th/#weekly-quiz-competition) \- Under development! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/june-5th/#upcoming-events) \- New webinars and conferences 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/june-5th/#tweets-of-the-week) \- #plasticsurgery memes, videos and more! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/june-5th/#new-feature) \- Flashcard update (Anki and Leitner System) 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/june-5th/#articles-of-the-week) \- 3 rapid reviews, 1 deep-dive. --- ## A Letter from P'Fella ### 3 Study Techniques (you might not have heard of) ✍️ Every Sunday, you get insights into P'Fella's thoughts and actions. By now, the majority of people would have heard of the **buzz** phrases "**spaced repetition**" and "**active recall**". They are incredibly effective and common ways to learn the material. But there are so many other techniques available to you. Here are **3 you might not have heard** of (and also **work well**!) **1\. Leitner System (P'Fella's favourite)** - The[ **new** method](https://www.theplasticsfella.com/theplasticspaper/june-5th/#new-feature) for [P'Fella's **flashcards**](https://www.theplasticsfella.com/theplasticsflash/) in the next update (**coming soon!**). - Flaschardscards in different "boxes" are used to track when to study each set. - Every card starts in Box 1\. If you get a card right, you move it to the next box. If you get a card wrong, you either move it down a box or keep it in Box 1. - This technique creates a schedule: study box 1 every day, box 3 every 4 days and box 5 every 15 days. **2\. Feynman Technique** is an efficient method of learning a concept quickly - Explain it in plain and simple terms. - By attempting to explain a concept in our own words, we are likely to understand it a lot faster.‌‌ **3\. SQ3R Method** is a reading comprehension technique that stands for the five steps of the reading comprehension process: - ****S**urvey and skim the chapter quickly - ****Q**uestion the purpose of the chapter or topic - ****R**ead the entire article, topic or chapter - ****R**ecite and summarise in your own words (as much as you can) - ****R**eview and clarify any bits you don't understand! --- ## Study on Sunday ### Mathes and Nahai Classification 🤓 Your weekly bite-sized topic to keep your knowledge fresh. The Mathes and Nahai Classification system was first described in 1981 as a way of describing the blood supply to muscle and musculocutaneous flaps. It was first described by Mathes and Nahai in a 1981 [PRS publication](https://www.ncbi.nlm.nih.gov/pubmed/7465666?ref=theplasticsfella.com). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Screenshot-2022-06-05-at-09.22.38-1.png) Key points on the Mathes and Nahai classification system are: - **Type 1:** 1 major pedicle (gastrocnemius) - **Type 2:** 1 major and 1 minor pedicle ([Gracilis Flap](https://www.theplasticsfella.com/gracilis-flap/)) - **Type 3:** 2 major pedicles ([rectus abdominis](https://www.theplasticsfella.com/vram-flap/)) - **Type 4:** Minor segmental pedicles (sartorius) - **Type 5:** 1 major and minor segmental pedicles (latissimus dorsi flap) [Read more on Mathes and Nahai](https://www.theplasticsfella.com/mathes-and-nahai-classification/) --- ## Weekly Quiz Competition ### Always building and improving. 🤠 Currently under development! Improvements coming to allow real-time results and more prizes! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/thePlastics-Quiz-Weekly.png) [New Season launching 12th June!](https://www.theplasticsfella.com/theplasticspaper/may-29th/) --- ## Upcoming Events ### 14 Webinars, Conferences, and Courses 🕢 This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, reply to this email! 1. [PLASTA 'Cut it Out'](https://us02web.zoom.us/webinar/register/WN%5Frk8p4ApJTriRFnDl2nakHQ?ref=theplasticsfella.com) \- June 13th 2. iBreastBook Oncoplastic Atlas - [June 11t](https://us02web.zoom.us/webinar/register/WN%5FMnoG36fwReSH7uF0HKsDwg?ref=theplasticsfella.com)h, 2022. 3. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 4. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 5. [PLASTA x RSM Summer Congress 2022](https://www.rsm.ac.uk/events/plastic-surgery/2021-22/psq04/?ref=theplasticsfella.com) \- July 9th 6. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 7. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 8. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 9. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 10. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 11. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 2022 12. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 13. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 14. [](https://t.co/Pepk4mx4G1?ref=theplasticsfella.com)[B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress \- November 2022. --- ## Tweets of the Week 🐣 If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > Consultants keyboard be like [pic.twitter.com/qwxypew1BX](https://t.co/qwxypew1BX?ref=theplasticsfella.com) > > — Faisal (@Faisalramih) [June 3, 2022](https://twitter.com/Faisalramih/status/1532668297170374656?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Rare pic of an Orthopaedic surgeon with his ego![#MedTwitter](https://twitter.com/hashtag/MedTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#orthotwitter](https://twitter.com/hashtag/orthotwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/cyoavGwU0R](https://t.co/cyoavGwU0R?ref=theplasticsfella.com) > > — anconeus (@pratikorho) [June 2, 2022](https://twitter.com/pratikorho/status/1532386581662687234?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Reconstrucción de Poleas Flexoras > ▪️Lesión Poleas A1 y A2 > ▪️Reconstrucción mediante injerto tendinoso de Palmaris Longus > ▪️Sutura de alta resistencia [#fiberwire](https://twitter.com/hashtag/fiberwire?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@ArthrexMedEd](https://twitter.com/ArthrexMedEd?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/vAvZ3fXDf9](https://t.co/vAvZ3fXDf9?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [May 29, 2022](https://twitter.com/DrBarreraochoa/status/1530954101500035076?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### Leitner System x Flashcards Every week, P'Fella creates or updates the educational platform. All decisions are designed with one ethos: build great educational tools. **P'Fella wants to start introducing evidence-based study techniques into the evidence-based library of information. It's a perfect match.** There are nearly 1000 verified flashcards in thePlasticsFlash deck. Over the next couple of months, there will be a pretty big upgrade to the way you can study these flashcards (that will definitely improve your knowledge!). - **Spaced Repetition:** thePlasticsPro users already have the ability to download their flashcards to Anki. This is a very popular option. You can check the Anki decks out [here](https://www.theplasticsfella.com/anki-decks/). - **Leitner System:** P'Fella is excited about this. You might have read in "Letter from P'Fella" about this study technique. And now, it's going to be introduced into the flashcard database. Check it out below 👇 0:00 / 1× Leitner System for effective flashcard revision (more coming soon!) 💡 This new feature will be rolling out over the next few months. thePlasticsPro users have access to it when studying Angiosomes, [Mathes and Nahai](https://www.theplasticsfella.com/mathes-and-nahai-classification/#flashcards), [Delay Phenomenon ](https://www.theplasticsfella.com/delay-phenomenon/#flashcards)and many more! --- ## Articles of the Week 📑 Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Top-Picks 1. **The Efficacy of Intra-Articular Versus Extra-Articular Corticosteroid Injections in the Thumb Carpometacarpal Joint**. Katt el al. [Journal Hand Surgery](https://doi.org/10.1016/j.jhsg.2022.01.002?ref=theplasticsfella.com), Feb 2022\. 2. **“Nonfungible Tokens in Plastic Surgery”** with Scott Hollenbeck MD and William Tian BSE - a [podcast](https://prsgokeynotes.libsyn.com/nonfungible-tokens-in-plastic-surgery-with-scott-hollenbeck-md-and-william-tian-bse?ref=theplasticsfella.com)! 3. **How to Run a Meeting,** Colwell et al. [Plastic and Reconstructive Surgery](https://journals.lww.com/plasreconsurg/Fulltext/2022/06000/How%5Fto%5FRun%5Fa%5FMeeting.1.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter): June 2022 - Volume 149 - Issue 6 - p 1283-1285 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Deep.png) 🚀 **This week's journal:** Does operating the night before affect our operating skills the next day? *Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before,* Sun et al. JAMA. May 2022 **Fun Fact:** 2.6% of daytime operations are performed by a surgeon who was operating between 11pm-7am the night before. _This post is for subscribers on the thePlastics Pro tier only._ ### Skin Grafts URL: https://www.theplasticsfella.com/skin-grafts/ Last updated: 2024-06-27T20:33:20.000Z 👇 ****In this Article** [Types of Skin Grafts](https://www.theplasticsfella.com/skin-grafts/#types-of-skin-grafts) [Skin Graft Donor Sites](https://www.theplasticsfella.com/skin-grafts/#skin-graft-donor-sites) [Stages of Skin Graft Healing](https://www.theplasticsfella.com/skin-grafts/#stages-of-skin-graft-healing) [Skin Graft Failure](https://www.theplasticsfella.com/skin-grafts/#skin-graft-failure) [Flashcards](https://www.theplasticsfella.com/skin-grafts/#flashcards) --- ## Types of Skin Grafts A skin graft can be a "full-thickness skin graft" or a "split-thickness skin graft". - **Full-thickness** skin grafts contain [epidermis](https://www.theplasticsfella.com/anatomy-of-the-skin/#epidermis) and dermis - **Split thickness** skin grafts contain [epidermis](https://www.theplasticsfella.com/anatomy-of-the-skin/#epidermis) and variable amounts of [dermis](https://www.theplasticsfella.com/anatomy-of-the-skin/#dermis). ![Full thickness skin grafts takes epidermis and variable amounts of dermis whilst split thicikness skin grafts takes epidermis only](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/type-of-skin-graft.png) Types of Skin Grafts --- ## Skin Graft Donor Sites There are many skin graft ****donor** site options. These are influenced by surgical preference and patient factors. **Full-thickness** are taken from areas that can close primarily and have a good colour match to the defect. For example, a pre-auricular or a supraclavicular donor site for defect reconstruction to the nose. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Full-thickness-skin-graft-donor-site.png) Full-thickness skin graft donor sites heal by primary closure **Split thickness** skin grafts are often taken from the lateral thigh or buttock. They heal by [re-epithelialisation](https://www.theplasticsfella.com/wound-healing/#re-epithelialisation-in-wound-healing). This is because there are adnexal remnants left at the donor site. ![a split thickness skin graft donor site heals re-epithelialisation](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/split-thickness-skin-graft-donor-site.png) Split-thickness skin graft donor sites heal by re-epithelialisation 💡 Skin grafts require a ****well-vascularised** wound bed. They do not work well on exposed bone or tendon (an exception to this bone of diploë or medullary bone) --- ## Stages of Skin Graft Healing A skin graft ****healing process** occurs in are ****4** phases. Skin grafts also undergo primary and secondary ****contraction**. ### Stages of Skin Graft Healing A skin graft healing process is often described as "skin graft take". This healing process requires skin graft adherence, imbibition, revascularisation and remodelling. This is detailed below in the image. ![a skin graft heals by a process of adherence, imbibition, revascularisation and remodelling](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/stages-of-skin-graft-healing.png) Stages of Skin Graft Healing/Take **1\. Skin graft adherence** - This occurs **instantly** if a suitable bed has been selected for the skin graft - Fibrin bonds form and the proliferation of fibroblasts replace the fibrin with collagen. **2\. Serum Imbibition** - The graft absorbs fluids **within** **72 hours** resulting in increased graft size - The fluid contains nutrition to keep the graft viable. **3\. Revascularisation** - A small vascular network starts to form in the fibrin layer connected to the graft and the wound bed **after \~72 hours**. - This occurs through inosculation and neovascularization which allow the **outgrowth of capillary buds**. - This brings "pinkness" to the graft. **4\. Remodelling** - Graft architecture returns to "normal skin" 💡 ****Inosculation** is the process of ****direct** anastomosis between the graft and wound bed. It is a key component of revascularisation. ### Skin Graft Contraction Skin grafts undergo primary and secondary contraction. It is influenced by the degree of the dermis (and its elastin) and the thickness of the skin graft. - **Primary** contraction is the immediate recoil of the skin graft that occurs more markedly in **full-thickness skin grafts**. - **Secondary** contraction occurs after the skin graft healing process and is more common in **split-thickness skin grafts**. ![Full thickness and split thickness skin grafts undergo primary and secondary contraction](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Skin-graft-contraction.png) Skin Graft Contraction 💡 ****Full-thickness skin grafts** have ****moreprimary** and ****less secondary** skin graft contraction than split-thickness skin grafts. --- ## Skin Graft Failure Skin graft ****failure** is ****uncommon** but when it does occur it is usually due to a ****collection** preventing adherence, ****infection**, poor ****wound bed** or not being ****secured** to the wound bed. Skin graft failure is a relatively uncommon event. Here are some reasons for failure 1. **Infection:** group A B-haem Strep (Strep Pyogenase) secretes proteases which prevent adherence. 2. **Haematoma** prevents adherence (reduce risk by meshing the skin graft!) 3. **Shearing Forces** (a fancy way of saying lateral forces) disrupt adherence. 4. **Wound Bed:** skin grafts require a blood supply (not good on bone or tendon) ![reasons for skin graft failure](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Skin-Grafts-failure.png) Haematoma is a cause of skin graft failure In certain cases, a skin graft can survive by a phenomenon called "bridging". This can occur if a graft is separated from its wound bed or overlying a non-vascular structure. The graft can link up with an existing vascular network. --- ## Flashcards ⚡ Evidence-based flashcards are designed for active recall and spaced repetition of the verified information you are currently studying.They are continually updated and are for thePlasticsPro users. ### Delay Phenomenon URL: https://www.theplasticsfella.com/delay-phenomenon/ Last updated: 2022-06-01T15:27:59.000Z --- 💡 **In this Article** [Definition of Delay Phenomenon ](https://www.theplasticsfella.com/delay-phenomenon/#definition-of-delay-phenomenon) [Uses](https://www.theplasticsfella.com/delay-phenomenon/#uses-for-the-delay-phenomenon) [Theories](https://www.theplasticsfella.com/delay-phenomenon/#delay-phenomenon-theories) [Flashcards](https://www.theplasticsfella.com/delay-phenomenon/#flashcards) ## Definition of Delay Phenomenon The delay phenomenon renders a piece of tissue partially ischemic in order to undergo neovascularization and enhance its vascularity. It is used in flap reconstruction to increase flap survival. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Delay-Phenomenon-Original-Publication.png) Original Publication of *De Curtorum Chirurgia per insition (1597)* --- ## Uses for the Delay Phenomenon The purpose of the delay phenomenon is to increase flap survival. It is centred on the ability to restrict the flap to the blood vessels on which it will have to rely at the time of the transfer. Essentially, it is "training the flap". It can be used in the following situations: - In **random-pattern** flaps to increase their length: width ratio - In **axial** flaps in order to extend the flap beyond its accepted safe length. - In **pedicled** flaps that require a **staged division** (it becomes downgraded from an axial to a random pattern flap) By isolating the skin flap on its axial blood supply, it will increase axial blood flow, and dilate and reorientate [choke vessels](https://www.theplasticsfella.com/angiosomes/#choke-vessels). . This can be visualised below. ![The delay phenomenon in flap surgery increases the blood flow by isolating the skin flap on it's planned blood supply. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Delay-Phenomenon-Process.png) Delay Phenomenon in Flap Surgery 💡 **Fun Fact:** Renaissance surgeon Gaspar Tagliacozzi is commonly accredited with the discovery as he popularized vascular delay in upper arm flaps in his 1597 work *De Curtorum Chirurgia per insitione.* --- ## Delay Phenomenon Theories A series of theories have been proposed to describe the delay phenomenon. Each of these has been encompassed in a "unifying theory" by [Pearl in 1981](https://pubmed.ncbi.nlm.nih.gov/6457549/?ref=theplasticsfella.com). 1. **Increase** axial blood flow by removing blood flow from the periphery. 2. **Increase** tolerance to ischaemia by "training for hypoxia" 3. **Increased** adrenergic state in the initial delay operation reduces minimises the effect of raised vasoconstrictor concentration during the second operation. 4. **Reducing** sympathetic fibres by dividing skin flap borders increases vasodilation and intra-flap shunting of non-nutritive blood. 5. **Converts** [choke vessels](https://www.theplasticsfella.com/angiosomes/#choke-vessels) to "true anastomosis" permanently within 3 days. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Delay-Phenomenon-Unifying-Theory.png) The Unifying Theory of the Delay Phenomenon 💡 **Fun Fact:** tissue expansion is a form of delay that has similar histological features similar to incisional delay. --- ## Flashcards ### Angiosomes URL: https://www.theplasticsfella.com/angiosomes/ Last updated: 2025-05-26T10:26:45.000Z 💡 ****In this Article** [Definition of Angiosomes](https://www.theplasticsfella.com/angiosomes/#definition-of-angiosomes) [Clinical Significance of Angiosomes](https://www.theplasticsfella.com/angiosomes/#clinical-significance-of-angiosomes) [Choke Vessels](https://www.theplasticsfella.com/angiosomes/#choke-vessels) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Angiosomes-Summary.png) Summary on Angiosomes --- ## Definition of Angiosomes An angiosome is a "vascular territory". It is a three-dimensional block of tissue supplied by a source vessel with its boundary outlined either by an anastomotic perimeter of reduced-calibre [****choke vessels**](https://www.theplasticsfella.com/angiosomes/#choke-vessels) or by true anastomoses with no reduction of vessel calibre. The clinical significance of an angiosome is that it defines the tissues available for composite transfer. It helps our understanding of "[zones of perfusion](https://www.theplasticsfella.com/hartrampfs-zones-of-perfusion/)" and also the [delay phenomenon.](https://www.theplasticsfella.com/delay-phenomenon/) 💡 ****Tip**: a dense network of vessels (for example, scalp, face, axillae, breasts, paraumbilical region, perineum, palms of the hand) correspond to the areas that sweat most profusely A functional angiosome extends beyond the boundaries of an anatomical angiosome if it is connected by a true anastomosis instead of choke vessels. A choke vessel can be converted to a true anastomosis through the [delay phenomenon](https://www.theplasticsfella.com/delay-phenomenon/). ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Angiosomes.png) Original Taylor [Publication](https://pubmed.ncbi.nlm.nih.gov/3567445/?ref=theplasticsfella.com) in British Journal of Surgery 💡 ****Fun Fact:** the first anatomical description of skin perfusion was by Carl Manchot in 1889\. In 1936, Salmon used radiography to provide more detail. This was followed by the work of Taylor in 1987. --- ## Principles of Angiosomes The landmark 1987 publication by Palmar and Taylor has to lead to the development of specific angiosome principles. 1. Angiosomes define the territory of the flap 2. Source vessels follow the connective tissue framework of the body 3. "Law of Equilibrium" - if one vessel is small, its adjacent or contralateral vessel will be larger. For example, a small ALT perforator is small will result in a larger perforator to TFL. 4. Vessels travel from a fixed to a mobile area (long flaps can be raised from mobile areas) 5. There is a neurovascular relationship (can raise with a nerve and vein). 6. Vessels form a continuous unbroken network. 7. A vessel's origin may change but its destination is constant. 💡 ****Tip:** There is a close correlation between the angiosomes and the neurological dermatomes on the torso and in the head. Here is a video from one of Taylor's colleagues. 💡 ****Tip**: a single vessel can supply multiple angiosomes. ### Example: DIEP/TRAM Flap Hartrampfs Zone's of Perfusion provides a nice example of the angiosome theory. The abdomen is divided at the midline to form 2 hemi-abdomens. There are 4 zones and each zone has different levels of perfusion. ![The angiosome principle allows the abdomen to be divided into 4 zones of perfusion](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Angiosomes-Zones.png) Zones of Perfusion showing clinical use of angiosomes 1. Zone I **always** correlates to the zone of the selected perforator (most perfused) 2. Zone II is adjacent to zone I on the contralateral hemi-abdomen. 3. Zone III is lateral to zone I 4. Zone IV is lateral to zone II (least perfused) 💡 ****Tip**: The ****functional** angiosome is the volume of tissue that clinically can be isolated on a source vessel. The area extends beyond its anatomical territory to capture an adjacent territory if connections are by choke anastomoses, or ****more** if they are by true anastomoses. --- ## Choke Vessels ****Choke vessels** can be defined as vessels that travel between two anatomical "vascular territories" or angiosomes. Choke vessels are both arteries and veins. They connect two specific vascular territories. They are reorientated and dilated in the [delay phenomenon](https://www.theplasticsfella.com/delay-phenomenon/). Their understanding plays an important role in plastic surgery. Unlike choke vessels, a "true" anastomosis connecting two angiosomes will not decrease in size and are continuous. Choke vessels can be converted to "true" anastomosis via the [delay phenomenon](https://www.theplasticsfella.com/delay-phenomenon/). This is a permanent change that takes at minimum 3 days to occur. ![Choke Vessels connect two angiosomes or anatomical territories](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Choke-Vessel.png) Choke Vessels Choke Vessels have specific characteristics: - Arterial size and orientation are a product of growth - Arteries have a fixed destination but a varied origin. - Oscillating avalvular veins accompany choke arteries to allow free flow between valve channels and adjacent venous territories. 💡 ****Tip:** superficial veins follow nerves, perforating veins follow perforating arteries. --- . ### thePlasticsPaper - May 29th URL: https://www.theplasticsfella.com/may-29th/ Last updated: 2024-01-27T20:38:08.000Z ****In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/may-29th/#a-letter-from-pfella) \- Johnny Depp's Finger Injury 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/may-29th/#study-on-sunday) \- Anatomy of the Epidermis 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/may-29th/#weekly-quiz-competition) \- Under development! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/may-29th/#upcoming-events) \- New webinars and conferences 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/may-29th/#tweets-of-the-week) \- #plasticsurgery is 🔥 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/may-29th/#new-feature) \- supporting students! 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/may-29th/#articles-of-the-week) \- 3 rapid reviews, 1 deep-dive. --- ## A Letter from P'Fella ### Johnny Depp's Finger Injury. ✍️ Every Sunday, you get insights into P'Fella's thoughts and actions. Over the past month, millions have been watching the **Johnny Depp & Amber Heard trial**. From a plastic surgery perspective, it was interesting to watch the medicolegal **hand surgeon** "experts" testify about his injury. **The question each expert had to answer was** \- how did Johnny Depp *actually* injure his finger? Was it a self-induced crush injury from a door or was it from a vodka bottle thrown by Amber Heard? [![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/skynews-johnny-depp-finger-sliced_5745424.jpg)](https://www.tmz.com/2016/08/15/johnny-depp-cuts-off-finger-amber-heard-photos/?ref=theplasticsfella.com) [![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Screenshot-2022-05-29-at-10.22.45.png)](https://mobile.twitter.com/ThatUmbrella/status/1529813401970647044/photo/1?ref=theplasticsfella.com) Images from [Sky News](https://news.sky.com/story/johnny-depp-tells-court-amber-heard-showed-pure-hatred-for-him-and-would-escalate-into-violence-12594507?ref=theplasticsfella.com) Three hand surgeons testified to the jury (**except** the **original** surgeon that saw him when the injury occured in Australia). They were asked to confirm if the history correlated with clinical findings. Let's put yourself in the shoes of these expert hand surgeons. Remember, none of them were the actual original surgeon that treated him. Regardless, they were expected to answer this question - how do you think he injured his finger? **Live results are updated automatically every 5 minutes.** --- ## Study on Sunday ### Epidermis Anatomy 🤓 Your weekly bite-sized topic to keep your knowledge fresh. Within the epidermis, there are 5 layers: 1. Stratum **Germinativum**: the deepest layer, contains melanocytes 2. Stratum **Spinosum:** containskeratinocytes**.** 3. Stratum **Granulosum:** contains mature keratinocytes. 4. Stratum **Lucidum:** only present in glabrous skin. 5. Stratum **Corneum:** contains non-viable keratinised cells. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Dermis-and-Epidermis-Skin-Layer-Anatomy-2.png) The predominant cell type of the epidermis is keratinocytes. Other cells found in the epidermis include Melanocytes, Langerhans cells (APCs for the immune system) and Merkel Cells (neural crest mechanoreceptors). 💡 Mnemonic for epidermis layers: ****G**ood ****S**kin ****G**ets ****L**ovely ****C**ompliments. --- ## Weekly Quiz Competition ### Always building and improving. 🤠 Currently under development! Improvements coming to allow real-time results and more prizes! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/thePlastics-Quiz-Weekly.png) [Check back next week!](https://www.theplasticsfella.com/theplasticspaper/may-29th/) --- ## Upcoming Events ### 13 Webinars, Conferences, and Courses 🕢 This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, reply to this email! 1. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022. 2. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 3. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 4. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 5. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 6. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 7. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 8. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 9. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 10. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 2022 11. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 12. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 13. [B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress - November 2022. --- ## Tweets of the Week 🐣 If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > To all the haters who said I shouldn't build an x-ray machine in my garage [pic.twitter.com/sZ3eHiJfQr](https://t.co/sZ3eHiJfQr?ref=theplasticsfella.com) > > — WilliamOsman (@WilliamOsman) [May 26, 2022](https://twitter.com/WilliamOsman/status/1529746232515493888?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Literally so cool!!! Now I need to find a way to extract such data for a model hmm [pic.twitter.com/GBKXfn0dVn](https://t.co/GBKXfn0dVn?ref=theplasticsfella.com) > > — sana (@sfkhanvisuals) [May 24, 2022](https://twitter.com/sfkhanvisuals/status/1529131206310350848?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > RESCATE de Artroplastia TMC Burton-Pellegrini dolorosa > ▪️Resecamos el osteofito entre el 1er y 2o MTC e implantamos el cótilo en el tubérculo del escafoides > ▪️Otra posibilidad de rescate en Artroplastias dolorosas, artrosis TMC grado IV o en casos con trapecios planos o pequeños [pic.twitter.com/1uROU0t85o](https://t.co/1uROU0t85o?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [May 22, 2022](https://twitter.com/DrBarreraochoa/status/1528417887257608192?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### Supporting Students! Every week, P'Fella creates or updates the educational platform. All decisions are designed with one ethos: build great educational tools. **P'Fella loves students** ❤️ As you all know by now, thePlasticsFella is **not interested in making money**. It's all about a sustainable business model that uses your support to cover the essential backend and hosting costs. So if you are a student, just **email** P'Fella at **support@theplasticsfella.com** and you'll get sorted! --- ## Articles of the Week 📑 Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Top-Picks 1. **Dress to Impress: Public Perception of Plastic Surgeon Attire.** Fara Dayani, MD, MAS et al. *Aesthetic Surgery Journal*, Volume 42, Issue 6, June 2022, Pages 697–706, [https://doi.org/10.1093/asj/sjab408](https://doi.org/10.1093/asj/sjab408?ref=theplasticsfella.com) 2. **Complications and Quality of Life following Gynecomastia Correction in Adolescents and Young Men.** McNamara, Catherine T et al. Plastic and Reconstructive Surgery: [June 2022 - Volume 149 - Issue 6 - p 1062e-1070e](https://journals.lww.com/plasreconsurg/pages/currenttoc.aspx?ref=theplasticsfella.com) 3. **Gender Disparity Trends in Authorship of Hand Surgery Research** Raylin F. Xu, BA et al, February 25 [https://doi.org/10.1016/j.jhsa.2022.01.002](https://doi.org/10.1016/j.jhsa.2022.01.002?ref=theplasticsfella.com) ### Deep Dive Every Sunday, P'Fella analyses a landmark plastic surgery publication. It is designed for those keen colleagues or those doing a journal club! 🚀 ****This week:** How many finger pulleys can you divide when performing a flexor tendon repair? (Journal Hand Surgery) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Deep-Dive-SLNBx.png) 😵 ****Did you know?** Bowstringing is a complication if you release too many finger pulleys! _This post is for subscribers on the thePlastics Pro tier only._ ### Anatomy of the Skin URL: https://www.theplasticsfella.com/anatomy-of-the-skin/ Last updated: 2026-01-03T19:30:43.000Z #### 5 Key Points 1. There are 3 main layers to the skin: epidermis, dermis and fat. 2. Epidermis consists of the stratum germinativum, spinosum, granulosum, lucidum, corneum. 3. The dermis is made up of a papillary and reticular dermis 4. Skin appendages include hair, hair follicles and glands. 5. Important glands of the skin include eccrine, apocrine and sebaceous. ![The Skin has multiple anatomical layers. The anatomy includes an epidermis, dermis and subcutaenous fat. ](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Skin-Anatomy.png) Anatomy of the Skin --- ## Anatomical Layers of the Skin The skin is comprised of epidermis, dermis and subcutaneous fat. ### Epidermis The skin's epidermis is **stratified squamous epithelium** and is derived from the **ectoderm**. The layers of the skin can be visualised in the image below. ![The layers of the skin is composed of several layers and includes the epidermis, dermis and subctaenous fat. It also contains the stratum layers.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Dermis-and-Epidermis-Skin-Layer-Anatomy.png) Layers of the Skin Within the epidermis, there are 5 layers: 1. Stratum **Germinativum**: the deepest layer, contains melanocytes 2. Stratum **Spinosum:** containskeratinocytes**.** 3. Stratum **Granulosum:** contains mature keratinocytes. 4. Stratum **Lucidum:** only present in glabrous skin. 5. Stratum **Corneum:** contains non-viable keratinised cells. The predominant cell type of the epidermis is keratinocytes. Other cells found in the epidermis include Melanocytes, Langerhans cells (APCs for the immune system) and Merkel Cells (neural crest mechanoreceptors). 💡 Mnemonic for epidermis layers: **G**ood **S**kin **G**ets **L**ovely **C**ompliments. ### Dermis The dermis makes up most of the skin thickness and is derived from the **mesoderm**. There are **two** layers in the dermis. 1. **Papillary** dermis: **superficial**, **fine** collagen fibres, type III collagen. 2. **Reticular** dermis: **deeper**, **coarser** collagen fibres, type I collagen. The layers of the dermis can be seen in the image below. ![Layers of the dermis skin is described as papillary dermis and reticular dermis](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Layers-of-the-Dermis.png) The papillary and reticular anatomical levels of the dermis The structures within the dermis are most commonly produced and secreted by **fibroblasts**. These include: - **Collagen**: standard ratio of type 1: type 3 is 5:1 (some literature quotes 4:1). There are 5 different types of collagen. There is increased collagen III in ageing skin. - **Elastin**: as the name suggests, it provides skin elasticity. - **"Ground Substance"/Glycosaminoglycans**: hyaluronic acid, dermatan sulphate, chondroitin sulphate. - Other cells include fibroblasts and mast cells. 💡 **Fun Fact:** teeth and hair arise from the epidermis and dermis, whilst nails arise from the epidermis only. --- ## Skin Appendages There are several skin appendages in the skin. Their name originates from the fact that they develop as ingrowths of the epidermis into the dermis. The following is a list of important skin appendages. ### Hair Follicles - Arises from the epidermis and dermis of the skin. - Drainage from sebaceous glands via the contraction of arrector pili muscles. - It contains an **inner root** (from epidermis) and an **outer root** (from dermis). ### Hair - Hair is composed of **medulla**, **cortex** and **outer cuticle.** - 2 types of hair: fine vellus and coarse terminal hairs. - They undergo a growth (anagen - most common), regressing (catagen - least common) and resting (telogen) phase. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Hair-Follicle.png) Hair Follicles ### Glands There are three main glands in the skin: eccrine, apocrine and sebaceous - **Eccrine:** *odourless* sweat glands in most locations in the body - **Apocrine:** *odour* sweat glands, mainly found in the axilla and groin. - **Sebaceous**: sebum-producing holocrine glands that drain in pilosebaceous units in hair-bearing skin and directly onto the skin in labia minor and penis. Here is a video illustrating the role of these glands. 0:00 / 1× Other appendages include Meissner's corpuscle (light touch), Pacinian corpuscle (vibration, deep pressure), Bulb of Krause (cold temperature), Ruffini ending (hot temperature). 💡 **Clinical Tip:** hidradenitis supportiva is a disease of **apocrine** glands and sebaceous glands are **not** the only cause of sebaceous cysts (epidermal in origin). --- ## Ageing Skin Anatomy ![The ageing skin undergoes histological changes of the epidermis and dermis.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Skin-Anatomy-changes-with-age.png) Anatomical Changes of Ageing Skin 💡 **Tip**: structures in the skin **reduce** with age, **except** fibroblasts, ground substance and type III collagen in the dermis. --- ## Blood Supply to the Skin The skin is supplied by a series of vascular **plexuses**. These arise from named-**deep** vessels and their **musculocutaneous** & **fasciocutaneous** vessels. It is relatively straightforward to understand the anatomical blood supply to the skin. There are 3 aspects to it: deep vessels, perforating vessels and plexuses. This is explained in the image below. ![The anatomical blood supply to the skin arises from the deep vessels, travels through interconnecting vessels to reach the skin.](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Blood-supply-to-the-skin.png) Blood Supply to the Skin - **Deep** Vessels: arteries such as the aorta or common carotids etc - **Fasciocutaneous** vessels: travel across the fascia **directly** to the skin - **Musculocutaneous** vessels: travel in the muscle and **indirectly** provided perforators to the skin. - **Plexuses**: there are a series of **fascial**, **subcutaneous** and **dermal** plexuses. --- ## Active Recall Test #### 1\. What is the most superficial layer of the skin? The stratum corneum in the epidermis is the most superficial layer. #### 2\. What is the deepest layer of the epidermis? The stratum germinativum (also called basale). It is the origin of various skin cancers and contains melanocytes. #### 3\. Name the most common collagen in the skin? Type I collagen is the most common. It has a ratio of type 1:type III = 5:1\. Type III collagen is increased in ageing and keloid scarring. #### 4\. What is the embryological origin of the skin? The epidermis arises from the ectoderm. The dermis arises from the mesoderm. #### 5\. Where do hair follicles arise from? They arise from the epidermis and dermis of the skin. They receive drainage from the sebaceous glands via the contraction of the erector pili muscles. ### thePlasticsPaper - May 15th URL: https://www.theplasticsfella.com/may-15th/ Last updated: 2022-05-15T14:12:35.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/may-15th/#a-letter-from-pfella) \- Burnout. It's more than just a buzzword. 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/may-15th/#study-on-sunday) \- Xanthelasma (surgery or laser??) 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/may-15th/#weekly-quiz-competition) \- Winners Announced! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/may-15th/#upcoming-events) \- Updated webinars and conferences 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/may-15th/#tweets-of-the-week) \- teaching materials, inspiration. 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/may-15th/#new-feature) \- a new section to thePlasticsPaper (you decide!) 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/may-15th/#articles-of-the-week) \- 3 rapid reviews, 1 deep-dive. --- ## A Letter from P'Fella ### Burnout. It's more than just a "buzzword". ✍️ Every Sunday, you get insights into P'Fella's thoughts and actions. Doctors face mental health challenges just like everyone else. And the stress of being a plastic surgeon can lead to burnout and feelings of isolation. In honour of **Mental Health Awareness Month**, here are a few essential facts on its **definition** and **prevention**. - It's a medical disorder resulting from **excessive** and **prolonged** stress. - It was first coined in the **1970s** by psychologist Herbert Freudenberger. Shortly after, professor Christina Maslach became one of the [foremost researchers on the phenomenon](https://www.researchgate.net/publication/263847499%5FBurned-Out?ref=theplasticsfella.com), helping shed light on its full impact and implications. - The **symptoms** are relatively **non-specific** so it takes great personal insight to recognise them: exhaustion, irritability, inefficiency... There have been many studies looking at the prevention of burnout. They all seem to point to simple tasks that appear somewhat common-sense (but in reality, they aren't). 1. Delegate tasks 🤝 2. Stick to a set schedule ⏰ 3. Give yourself time to unplug completely 🔌 4. Switch up your routine 🌳 5. Prioritise yourself and your support network 💪 ⚡ Any thoughts on this? Reply to this email. P'Fella reads all responses :) --- ## Study on Sunday ### Xanthelasma 🤓 Your weekly bite-sized topic to keep your knowledge fresh. **Xanthelasma palpebrarum** is a benign periorbital xanthoma. Treatment modalities should be considered based on efficacy and the cosmetic outcome. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Xanthelasma-Recon.png) Different treatment modalities, such as simple surgical excision, cryotherapy, chemical peeling with trichloroacetic acid, radiofrequency, and laser, are used to treat xanthelasma palpebrarum. --- ## Weekly Quiz Competition ### The Winners Announced! 🤠 That's the end of this season! 10 rounds! When I first started this 10 round competition, I never thought it would result in a draw! Thank you to everyone who participates in this quiz (+150 people). **Congratulations to the 4 winners!** - **Yassin**, Plastic Surgery Resident/Trainee - Spain - **Chi**, Plastic Surgery Resident/Trainee - UK - **George**, Plastic Surgery Consultant - UK - **Johnny**, Plastic Surgery Resident/Trainee - UK You'll receive an email with your prize in the coming days! The following season will be launching in a couple of weeks! :) --- ## Upcoming Events ### 14 Webinars, Conferences, and Courses 🕢 This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, reply to this email! 1. [Thames Valley Hand Surgery Conference](https://www.google.com/search?client=safari&rls=en&q=eventbrite+thames+valley+hand+surgery+conference&ie=UTF-8&oe=UTF-8&ref=theplasticsfella.com) \- 25th May 2. [Pulvertaft & Donald Summat](https://us02web.zoom.us/webinar/register/WN%5FbiHTiF9%5FQ-iCyHfjma2D1Q?ref=theplasticsfella.com) \- Language of the Hand - May 16th. 3. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022. 4. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 5. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 6. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 7. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 8. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 9. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 10. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 11. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 12. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 2022 13. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 14. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 15. [](https://t.co/Pepk4mx4G1?ref=theplasticsfella.com)[B](https://twitter.com/hashtag/BAPRAS2022?src=hashtag%5Fclick&ref=theplasticsfella.com)APRAS 2022 Congress \- November 2022. --- ## Tweets of the Week 🐣 If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > Interesting case. Piece of wood went under the flexor tendon, into the joint and out dorsally and spared the extensor tendon. Digital artery and nerve ok. A1 pulley torn. [#orthotwitter](https://twitter.com/hashtag/orthotwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/Cce8X5MTBU](https://t.co/Cce8X5MTBU?ref=theplasticsfella.com) > > — Sudeep Taksali, MD (@DrTaksali) [May 14, 2022](https://twitter.com/DrTaksali/status/1525529110348386305?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Be the consultant you wish you had. > > — Abdullah Al Qurashi (@QurashiAbdula) [May 8, 2022](https://twitter.com/QurashiAbdula/status/1523194076430016512?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Facial prosthesis, c.1917\. THREAD👇 > > From the moment the first machine gun rang out over the Western Front, one thing was clear: Europe’s military technology had wildly surpassed its medical capabilities. Bodies were battered, gouged, hacked, and gassed. [pic.twitter.com/NeKpcZSXLP](https://t.co/NeKpcZSXLP?ref=theplasticsfella.com) > > — Lindsey Fitzharris (@DrLindseyFitz) [May 1, 2022](https://twitter.com/DrLindseyFitz/status/1520847480858058752?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### A new addition to thePlasticsPaper Every week, P'Fella creates or updates the educational platform. All decisions are designed with one ethos: build great educational tools. **thePlasticsPaper is growing!** If you have an idea that you think will be an excellent fit for thePlasticsPaper, then submit it below! Always looking for more ideas to help grow this community. P'Fella will be in touch, and you can even help build it if you want! :) --- ## Articles of the Week 📑 Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Top-Picks 1. [**Eyelid Defect Reconstruction,**](https://oaepublishstorage.blob.core.windows.net/414e5fd7-22fc-4752-b3d1-6f7ac41f7fbd/4590.pdf?ref=theplasticsfella.com) Somenek. *Plast Aesthet Res* 2022;9:16 DOI**:** 10.20517/2347-9264.2021.84\. 2. [**The evolution of lower extremity reconstruction.**](https://parjournal.net/article/view/4841?ref=theplasticsfella.com) Evans BGA, Colen DL. *Plast Aesthet Res* 2022;9:34\. http://dx.doi.org/10.20517/2347-9264.2021.134 3. [**Gender Disparity Trends in Authorship of Hand Surgery Research**](https://www.jhandsurg.org/article/S0363-5023%2822%2900023-5/fulltext?ref=theplasticsfella.com), Raylin F. Xu, BA. Feb 2022, Journal Hand Surgery ### Deep Dive 🚀 Every Sunday, P'Fella analyses a landmark plastic surgery publication. It is designed for those keen colleagues or those doing a journal club! **This week: The best way to perform a Sentinel Node Biopsy for Skin Cancer? (CME Review)** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Deep-Dive-SLNBx.png) 😵 **Did you know?** Sentinel lymph node biopsy was first introduced in the management of melanoma patients in 1992 by Morton et al. _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - May 8th URL: https://www.theplasticsfella.com/may-8th/ Last updated: 2022-05-08T10:41:09.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/may-8th/#a-letter-from-pfella) \- Don't make plastic surgery notes. Waste of time. 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/may-8th/#study-on-sunday) \- Levels of the Neck 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/may-8th/#weekly-quiz-competition) \- Round 10! (the final question) 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/may-8th/#upcoming-events) \- 15 webinars, events and conferences 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/may-8th/#tweets-of-the-week) \- History, Intra-op images! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/may-8th/#new-feature) \- thePlasticsFella+ (a new platform) 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/may-8th/#articles-of-the-week) \- 3 rapid reviews, 1 deep-dive. --- ## A Letter from P'Fella ### Don't make plastic surgery study notes. It's a waste of time. ✍️ Every Sunday, you can get insights into P'Fella's thoughts and actions. ### **I spent my entire medical school and plastic surgery training creating notes. This was a mistake.** My study habits were designed on a grand picture of what study notes should look like. Most students and trainees put their hearts and soul into creating the best notes. Late nights are spent making sure all content is covered, they look nice, and they are structured correctly. But guess what? The examiners don't care. Look, the exam doesn't care about your study notes. You've got to be wise in your revision. You need to be efficient. You need to be focused on what is essential. Don't waste your time creating notes that have already been made by 1000s of other plastic surgery students and trainees. Stop creating and start learning! Here are some actionable tips to improve your efficiency (and hopefully your grades and patient care!) 1. Ask your friends or colleagues for notes they used for their exams. 2. If you borrow notes from someone, ask them how they did in their exam. This could be helpful feedback for gaps in their notes, which you can improve. 3. Look at previous exams before making notes. 4. Study notes should be one aspect of revision: your flashcards and past questions in a mixture of active recall and spaced repetition. 5. Use thePlasticsFella.com lol \* shameless plug \* ⚡ If you have any thoughts on this, reply to this email. I'll read it directly :) --- ## Study on Sunday ### Levels of the Neck Lymph Nodes 🤓 Your weekly bite-sized topic to keep your knowledge fresh. Listen to Levels of the Neck 0:00 /2:17 1× Cervical Lymph Nodes of the neck can provide diagnostics clues to the origin of the pathology. There are a total of 7 levels. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Cervical-Lymph-Nodes-of-the-Neck-14-2.png) #### ****Level 1: Submental, -mandibular** - **Superior**: mandible - **Inferior**: anterior and posterior digastric muscle bellies. - **Sublevels**: submental (1A) and submandibular (1B) - **Key Contents**: submental nodes, submandibular nodes & gland. #### ****Level 2: Upper Jugular** - **Roof**: jugular fossa - **Inferior**: hyoid bone - **Walls**: sternohyoid to sternocleidomastoid - **Sublevels**: anterior (2A) and posterior (2B) - divided by SAN. - **Key Contents**: spinal accessory nerve. [Read about the 5 other levels](https://www.theplasticsfella.com/lymph-nodes-of-the-neck/) --- ## Weekly Quiz Competition ### Round 10 (final question for this season!) 🤠 Round 10! It could end up in a tie 😣 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 10 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## Upcoming Events ### 14 Webinars, Conferences, and Courses 🕢 This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, reply to this email! **Featured Event (Free):** [Thames Valley & Wessex Hand Surgery ConferenceWelcome to the Thames Valley & Wessex Hand Surgery Conference 2022! Join us face to face (finally) for an enjoyable and educational event!![](https://cdn.evbstatic.com/s3-build/465159-rc2022-05-04_16.04-23bc555/django/images/favicons/favicon-194x194.png)Eventbrite![](https://img.evbuc.com/https%3A%2F%2Fcdn.evbuc.com%2Fimages%2F253388019%2F870794347113%2F1%2Foriginal.20220323-214853?w=1000&auto=format%2Ccompress&q=75&sharp=10&rect=102%2C0%2C908%2C454&s=523b2c357b2c461c3eb7be51b750afc0)](https://www.eventbrite.com/e/thames-valley-wessex-hand-surgery-conference-tickets-304331532807?ref=theplasticsfella.com) 1. [Stoke Mandeville:](https://twitter.com/DrJamesKKChan/status/1519052078018187267?s=20&t=KLB%5FaXSAFUENN4N4BcpBYg&ref=theplasticsfella.com) Limb Reconstruction - May 10th. 2. [Pulvertaft & Donald Summat](https://us02web.zoom.us/webinar/register/WN%5FbiHTiF9%5FQ-iCyHfjma2D1Q?ref=theplasticsfella.com) \- Language of the Hand - May 16th. 3. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022. 4. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 5. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 6. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 7. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 8. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 9. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 10. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 11. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 12. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 2022 13. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 14. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## Tweets of the Week 🐣 If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > FFMT with skin paddle for elbow flexion and finger flexion using 3rd to 6th Intercostal nerves in chronic BPI patient. > > Questions regarding technique is posted in my IG Account[https://t.co/Y3iQNbbro4](https://t.co/Y3iQNbbro4?ref=theplasticsfella.com) [pic.twitter.com/VgXn8Gy0ff](https://t.co/VgXn8Gy0ff?ref=theplasticsfella.com) > > — Johnny CY Lu, MD, MS (@cylu122) [May 4, 2022](https://twitter.com/cylu122/status/1521898166312128514?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Franz Weitlaner (1872-1944), was an Italian-born Austrian surgeon who invented an ‘automatischer wundspreizer’ (automatic wound spreader) that can be opened with one hand. He created this as he was the only physician in Ottenthal, Austria, and lacked surgical assistance! [pic.twitter.com/BAQuhRUhfz](https://t.co/BAQuhRUhfz?ref=theplasticsfella.com) > > — Legends Of Surgery (@SurgeryLegends) [May 4, 2022](https://twitter.com/SurgeryLegends/status/1521993094857637888?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Tratamiento de la Pseudoartrosis o defectos pequeños óseos > > En no uniones o falta de hueso (< 6 cm), el colgajo óseo vascularizado de cóndilo femoral es una excelente opción > > El diseño en 🍄 es mi favorito, ya que ⬆️ la superficie de contacto y ⬇️ la necesidad de osteosintesís [pic.twitter.com/GCRyMFp3IF](https://t.co/GCRyMFp3IF?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [May 2, 2022](https://twitter.com/DrBarreraochoa/status/1521155364225433600?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### thePlasticsFella+ Every week, P'Fella creates or updates the educational platform. All decisions are designed with one ethos: build great educational tools. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Twitter-Posts-2.gif) **This is currently being built. It's pretty incredible.** The *current* goal of thePlasticsFella is to become a unique educational platform. A single location for your to **study**, **track**, **monitor** and **record** your progress through **flashcards**, **quizzes** and **mini-course**s - all designed on a plastic surgery syllabus that caters to all the leading international curriculums. This will take a few months to build, but P'Fella thought it would be nice to give you a glimpse into the platform's future. **When it's launched, it will initially only be available to users who have joined thePlasticsPro community by July**. This way, the platform can be improved with specific feedback before launch to the general plastic surgery community. 📢 If you have any ideas of suggestions on what you would like to see on this improved platform, just reply to this email! --- ## Articles of the Week 📑 Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Top-Picks 1. **Comparison of long-term outcomes of breast conservation and reconstruction after mastectomy using BREAST-Q.** Joanna Wolska et al, JPRAS. May 06, 2022\. DOI: [https://doi.org/10.1016/j.bjps.2022.04.067](https://doi.org/10.1016/j.bjps.2022.04.067?ref=theplasticsfella.com) 2. **Outcome measurement in adult flexor tendon injury: A systematic review.** Shaw et al. JPRAS, Sept 2021\. [doi.org/10.1016/j.bjps.2021.08.033](https://doi.org/10.1016/j.bjps.2021.08.033?ref=theplasticsfella.com) 3. **Tips and Tricks for Facial Toxin Injections with Illustrated Anatomy**, Plastic and Reconstructive Surgery: February 2022 - Volume 149 - Issue 2 - p 303e-312e. doi: [10.1097/PRS.0000000000008708](https://journals.lww.com/plasreconsurg/Abstract/2022/02000/Tips%5Fand%5FTricks%5Ffor%5FFacial%5FToxin%5FInjections%5Fwith.38.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com) ### Deep Dive 🚀 Every Sunday, P'Fella analyses a landmark plastic surgery publication. Designed for those keen colleagues or those doing a journal club! **This week: What is the best surgical technique for carpal tunnel release? (Cochrane Review)** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Twitter-Posts-20.png) 😵 **Did you know?** Endoscopic carpal tunnel release results in an earlier return to work or activities of daily living. *But this Cochrane review recommends the open release.* Read below to find out why... _This post is for subscribers on the thePlastics Pro tier only._ ### Classification of Vascular Anomalies, Malformations & Tumours URL: https://www.theplasticsfella.com/vascular-malformations-and-tumours/ Last updated: 2025-03-14T09:58:23.000Z --- #### Summary Card ****Classifications** ISSVA system based on the work by Mulliken and Glowacki. High-flow vs Low-flow ****Vascular Tumours** Vasoproliferate disorders that do not grow in proportion to the patient. They can be benign, borderless or malignant. ****Vascular Malformations** Structural abnormalities that grow in proportion to the patient. They can be simple, combined or associated with other conditions. --- ## Classification of Vascular Anomalies ****Key Point** The International Society for the Study of Vascular Anomalies (ISSVA) developed a classification system based on the seminal work by Mulliken and Glowacki. The ISSVA revised its classification system in 2018\. It is now the standard system for classification, communication, and documentation. It is seen in the table below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Vascular-Anomaly-Classification-ISSVA-.png) Classification of Vascular Tumours and Malformations [Original ISSVA Publication](https://www.issva.org/UserFiles/file/ISSVA-Classification-2018.pdf?ref=theplasticsfella.com) Other classification systems have been published. For example 1. **Fishman1**: patterns of flow (fast vs slow) 2. **Mulliken and Glowacki**2: endothelial properties (hemangiomas have proliferative endothelium, vascular malformations have stable endothelium) 3. **Jackson3**: clinical, histologic, and vascular flow ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/High-and-Low-Flow-Vascular-Malformations.png) High and Low Flow Vascular Malformations 🤭 ****Tip:** any malformation with arterial involvement is "high-flow". --- ## Vascular Tumours ****Key Point** Vascular tumours are vasoproliferative disorders with increased endothelial cell tumours. ****They do not grow in proportion with the patient**. Infantile haemangioma is the commonest type. Vascular tumours are vasoproliferative disorders with increased endothelial cell tumours. **They do not grow in proportion with the patient**. These can be benign, locally aggressive or malignant. The most common type is an [infantile hemangioma](https://www.theplasticsfella.com/infantile-haemagioma/). Other types of vascular tumours are illustrated in the table below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Types-of-Vascular-Tumours.png) Types of Vascular Tumours Kaposiform haemangioendothelioma and tufted angioma are both associated with the Kasabach-Merrit phenomenon: - A consumptive coagulopathy with thrombocytopenia and hypofibrogenaemia that results in platelet trapping. 😎 ****Fun Fact:** An [infantile haemangioma](https://www.theplasticsfella.com/infantile-haemagioma/) is the commonest tumour in infancy. --- ## Vascular Malformations ****Key Point** Vascular malformations are "structural abnormalities". ****They grow in proportion to the patient.** They can be related to other systemic anomalies. Vascular malformations are "structural abnormalities". **The grow in proportion to the patient.** These can be simple, combined, or named in relation to a vessel. The types of simple and combined vascular malformations are illustrated in the table below. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/08/Types-of-Vascular-Malformations.png) Vascular abnormalities can be linked to other abnormalities in the body. These include: - **Sturge-Weber Syndrome**: capillary malformation of the trigeminal nerve - **Parkes-Weber Syndrome** - **Klippel-Trenaunay Syndrome** --- ## References 1. Fishman, S.J., and Mulliken, J.B.Vascular anomalies: A primer for pediatricians. *Pediatr. Clin. North Am.* 45: 1455, 1998. 2. Mulliken, J. B., and Glowacki, J. Hemangiomas and vascular malformations in infants and children: A classification based on endothelial characteristics. *Plast. Reconstr. Surg.* 69: 412, 1982. 3. Jackson, I. T., Carreno, R., Potparic, Z., et al. Hemangiomas, vascular malformations, and lymphovenous malformations: Classification and ### thePlasticsPaper - May 1st URL: https://www.theplasticsfella.com/may-1st/ Last updated: 2022-05-01T12:28:04.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/may-1st/#a-letter-from-pfella) \- Twitter is better than a textbook. Here's why... 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/may-1st/#study-on-sunday) \- Kanavel's signs 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/may-1st/#weekly-quiz-competition) \- Round 9! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/may-1st/#upcoming-events) \- 15 webinars, events and conferences 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/may-1st/#tweets-of-the-week) \- Educational threads and videos! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/may-1st/#new-feature) \- flashcard update! 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/may-1st/#articles-of-the-week) \- what happens if you don't operate on BCCs? --- ## A Letter from P'Fella ### Twitter is better than a textbook. ✍️ Every Sunday, you can get insights into P'Fella's thoughts and actions. ### **🐣 Twitter is the best medical education platform.** The Plastic Surgery Twitter community is strong 💪 Every day, people tweet plastic surgery cases, questions and educational threads. And the best thing is you can see other people's thoughts, tips & tricks in the comments section. If you're not on Twitter yet, you should sign up and follow these tremendous educational accounts: [PLASTAUK](https://twitter.com/PLASTAUK?ref=theplasticsfella.com), [Canniesburn](https://twitter.com/Canniesburn?ref=theplasticsfella.com), [Pulvertafthands](https://twitter.com/Pulvertafthands?ref=theplasticsfella.com), [JPRASOpen](https://twitter.com/JPRASOpen?ref=theplasticsfella.com), [prsjournal](https://twitter.com/prsjournal?ref=theplasticsfella.com), [plasticstrainee](https://twitter.com/plasticstrainee?ref=theplasticsfella.com), [DrRodRohrich](https://twitter.com/DrRodRohrich?ref=theplasticsfella.com). Here is an example of what to expect... > How to determine a PIP joint fracture dislocation (involving 30-50% surface) INSTABILITY? > > Instability = SURGERY. > > (Ans: Dorsal “V sign” on X-ray). [pic.twitter.com/VY7vXUn8vj](https://t.co/VY7vXUn8vj?ref=theplasticsfella.com) > > — Dr Karan Choudhry (@KaranChoudhry6) [April 29, 2022](https://twitter.com/KaranChoudhry6/status/1520120513036660736?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ⚡ Check out thePlasticsFella on Twitter [here](https://twitter.com/PlasticsFella?ref=theplasticsfella.com). --- ## Study on Sunday ### Kanavel's Signs in Flexor Tenosynovitis 🤓 Your weekly bite-sized topic to keep your knowledge fresh. In the early 1900s, Allen B Kanavel (1874-1938) wrote a masterpiece on hand infections. A 6-volume collection just on infections. Pretty impressive. The cardinal signs of flexor tenosynovitis were first described in this publication. They have stood the test of time. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Kanavel-Signs-2.png) In this 1912 publication, Kanavel described 3 **main* signs: 1. Tenderness over the sheath 2. Flexion of the finger 3. Pain on extension You might ask, where did the commonly used 4th sign arise from? It's further down the page. It isn't listed as the main sign but rather another feature that may be present. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Kanavel-Signs-4.png) --- ## Weekly Quiz Competition ### Round 9 🤠 Round 9! Second last round before the $100 prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 9 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## Upcoming Events ### 15 Webinars, Conferences, and Courses 🕢 This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, just reply to this email! 1. [Stoke Mandeville:](https://twitter.com/DrJamesKKChan/status/1519052078018187267?s=20&t=KLB%5FaXSAFUENN4N4BcpBYg&ref=theplasticsfella.com) Limb Reconstruction - May 10th. 2. [Pulvertaft & Donald Summat](https://us02web.zoom.us/webinar/register/WN%5FbiHTiF9%5FQ-iCyHfjma2D1Q?ref=theplasticsfella.com) \- Language of the Hand - May 16th. 3. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022. 4. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 5. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022. 6. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 7. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 8. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 9. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 10. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 11. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 12. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 13. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland, September 2022 14. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 15. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## Tweets of the Week 🐣 If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > Rare photos of Alexis Carrel's black-walled experimental operating theatre (c1920s). Too much light impeded thinking, he thought, so it had black fixtures, drapes and even black gowns for 'absolutely ignorant assistants' (his words!) Transplant history was made here [#SpareParts](https://twitter.com/hashtag/SpareParts?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/FPwQ7H2YtJ](https://t.co/FPwQ7H2YtJ?ref=theplasticsfella.com) > > — Paul Craddock (@pwcraddock1984) [April 30, 2022](https://twitter.com/pwcraddock1984/status/1520517249727148033?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Technique to reduce a PROXIMAL PHALANX FRACTURE is similar to metacarpal (JAHSS manoeuver). > > The way it works is different: [pic.twitter.com/rBo4yyfBs4](https://t.co/rBo4yyfBs4?ref=theplasticsfella.com) > > — Dr Karan Choudhry (@KaranChoudhry6) [April 28, 2022](https://twitter.com/KaranChoudhry6/status/1519750788012072960?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > [#MedTwitter](https://twitter.com/hashtag/MedTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) favorite: a severe case of gout. [#orthotwitter](https://twitter.com/hashtag/orthotwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#gout](https://twitter.com/hashtag/gout?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/Vf3bRYGmrP](https://t.co/Vf3bRYGmrP?ref=theplasticsfella.com) > > — Clayton Nuelle, MD, FAAOS (@NuelleSportsMD) [April 14, 2022](https://twitter.com/NuelleSportsMD/status/1514588605368438792?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### More Flashcards! Every week, P'Fella creates or updates the educational platform. All decisions are direct by one simple mantra: build great educational tools. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/What-is-the-Leddy-packer-classification-6-2.png) With this update, there are now even more evidence-based flashcards! Also in the pipeline to create more Anki-compatible cards \* *work in progress\** [Get your flashcards](https://www.theplasticsfella.com/theplasticsflash/) --- ## Articles of the Week 📑 Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Top-Picks 1. **[What to expect in lower limb nerve injuries?](https://parjournal.net/article/view/4711?ref=theplasticsfella.com)** Qiu CS, Hanwright PJ, Khavanin N, Tuffaha SH. Functional reconstruction of lower extremity nerve injuries. *Plast Aesthet Res* 2022;9:19\. http://dx.doi.org/10.20517/2347-**9264.2021.126** 2. **[The Business of Plastic Surgery](https://journals.lww.com/plasreconsurg/Abstract/2022/04000/The%5FBusiness%5Fof%5FEmployed%5FPlastic%5FSurgery%5F%5FCreating.44.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com)** Ellsworth, Warren A. IV, M.D.; Gratzon, Andrew C. M.D.; Friedman, Jeffrey D. M.D. The Business of Employed Plastic Surgery: Creating Your Seat at the Table, Plastic and Reconstructive Surgery: April 2022 - Volume 149 - Issue 4 - p 989-998 3. **[How to prevent seromas?](https://academic.oup.com/asj/article/42/5/497/6430785?ref=theplasticsfella.com)** David M Turer, MD, MS, Al Aly, MD, Seromas: How to Prevent and Treat Them—a 20-Year Experience, **Aesthetic Surgery Journal*, Volume 42, Issue 5, May 2022, Pages 497–504, ### Deep Dive 🚀 P'Fella's **personal** analysis of the chosen article of the week. **Key points**, journal club **critiques**, and impact on your **clinical practice**. This is for thePlasticsPro subscribers. Thank you for your support. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/05/Deep-3.png) 📢 **This week: What happens if you don't operate on a BCC?** A systematic review of observational management of cutaneous basal cell carcinoma. Goodall et al, [JPRAS](https://www.jprasurg.com/article/S1748-6815%2822%2900253-4/fulltext?ref=theplasticsfella.com), April 2022. _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - April 24th URL: https://www.theplasticsfella.com/april-24th/ Last updated: 2022-04-22T20:20:15.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/april-24th/#a-letter-from-pfella) \- P'Fella thinks you can join the team. 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/april-24th/#study-on-sunday) \- Craniosynostosis (boring? not this section). 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/april-24th/#weekly-quiz-competition) \- Round 8! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/april-24th/#upcoming-events) \- 18 webinars, events and conferences 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/april-24th/#tweets-of-the-week) \- Educational Threads, nasty intra-op pics! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/april-24th/#new-feature) \- Merch is here! 7\. ❤️ [Feedback](https://www.theplasticsfella.com/theplasticspaper/april-24th/#feedback) \- you help shape this educational platform 8\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/april-24th/#articles-of-the-week) \- 3 essential reads, 1 deep-dive for thePlasticsPro! --- ## A Letter from P'Fella ### Growing the team! ✍️ Every Sunday, you can get insights into the thoughts and actions of P'Fella. ### **👋 P'Fella is looking for a few friends.** It's nearly my 3rd birthday. I'm getting old. This platform all started as a simple website for myself so I could access some quick notes when at work. It's grown much bigger than ever could have imagined. That's all thanks to you and your support :) Up until now, it's been pretty much a **solo effort**. Writing, editing, illustrating, Twittering... the list goes on. There has been an odd bit of help here and there. But nothing consistent. Nothing long term. In the next 6 months, thePlasticsFella platform is going to **expand quite a lot.** There will be an updated platform, more educational tools and a stronger presence on Instagram, youtube and TikTok. If you have any particular **interest** in plastic surgery education or website development/coding then it'll be great to have you on board. **Any skill set** is welcome to help thePlasticsFella achieve its mission. ⚡ If you feel you have any set of skills that will help thePlasticsFella grow, then **reply to this email** with a few sentences about yourself (nothing too fancy!) : p.s - you can also just quickly leave some [feedback](https://www.theplasticsfella.com/theplasticspaper/april-24th/#feedback) at the bottom :) --- ## Study on Sunday ### Craniosynostosis 🤓 Your weekly bite-sized topic to keep your knowledge fresh. Craniosynostosis is the premature fusion of one or more cranial sutures. It can be an isolated abnormality or part of a syndrome. Here is the timeline of normal suture fusion: - **Posterior Fontanelle:** 3-6 months - **Metopic**: 6-8 months - **Anterior Fontanelle:** 9-12 months. - **Sagittal:** 22 years (most commonly involved) - **Coronal:** 24 years - **Lambdoidal:** 26 years - **Squamosal**: approximately 60 years ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/Cranial-Suture-Anatomy-1-3.png) [Read more](https://www.theplasticsfella.com/craniosynostosis/) --- ## Weekly Quiz Competition ### Round 8 🤠 Round 8! Only 2 more rounds to go before the $100 prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 8 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## Upcoming Events ### 18 Webinars, Conferences, and Courses 🕢 This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, just reply to this email! 1. [PLASTA](https://us02web.zoom.us/webinar/register/WN%5FLmsjCXW3TVSbcS3W%5FqBSBQ?ref=theplasticsfella.com) \- FRCS Lower Limb Trauma - Virtual, April 27th 2. [](https://us02web.zoom.us/webinar/register/WN%5FKvYFduZOT9eZrs6PkNRrjA?ref=theplasticsfella.com)[B](https://bapras.eventsair.com/ntp/registration/Site/Register?ref=theplasticsfella.com)SSH Median and Ulnar Nerve - Virtual, April 30th. 3. [IFSSH Combined Conference](https://ifssh2022.com/?ref=theplasticsfella.com#registration) \- London, April 2022. 4. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 5. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022. 6. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022. 7. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 8. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022. 9. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 10. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 11. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 12. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 13. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 14. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 15. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 16. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland September 2022 17. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 18. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## Tweets of the Week 🐣 If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > Pyrocarbon (PC) metacarpophalangeal joint (MCPJ) arthroplasties won't help much with range of motion but will help with pinch grip and pain relief. A thread🧵 [pic.twitter.com/2aPepQHcpU](https://t.co/2aPepQHcpU?ref=theplasticsfella.com) > > — John Dunn MD (@JohnDunnMD) [April 19, 2022](https://twitter.com/JohnDunnMD/status/1516258484907556866?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Some surgeon somewhere sent me this X-rays asking me about my opinion whether they should leave these wires for 8 or 12 weeks??? 🤦🏻‍♂️ thoughts? [pic.twitter.com/pVeiAmVv3A](https://t.co/pVeiAmVv3A?ref=theplasticsfella.com) > > — Mo Imam (@MoAImam) [April 18, 2022](https://twitter.com/MoAImam/status/1515989400521519104?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > تشريح اليد بين الحقيقة والرسم [pic.twitter.com/unW2kgCrFj](https://t.co/unW2kgCrFj?ref=theplasticsfella.com) > > — ahmed (@ahmedalkhalifha) [April 17, 2022](https://twitter.com/ahmedalkhalifha/status/1515779998203981832?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### Merch! Every week, P'Fella creates or updates the educational platform. All decisions are direct by one simple mantra: build great educational tools. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/your-new-favourite-2-1.png) Okay, some of you saw this early and bought a lot. There are still a few left. [Get your mug! ](https://www.theplasticsfella.com/swag/) --- ## ❤️ ## Feedback --- ## Articles of the Week 📑 Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Important Reads 1. **[An Alternative to Scalp Flaps?](https://journals.lww.com/plasreconsurg/Abstract/2022/02000/Utility%5Fof%5FDermal%5FWound%5FMatrices%5FCompared%5Fwith.30.asp?ref=theplasticsfella.com)** Utility of Dermal Wound Matrices Compared with Local-Tissue Rearrangement and Free Flap Reconstruction for Oncologic Scalp Wounds: A Multidisciplinary Dual Matched-Pair Analysis, Othman et al. Plastic and Reconstructive Surgery: February 2022 2. **[Tips for Dupuytren's Disease:](https://journals.lww.com/prsgo/Fulltext/2022/01000/Treatment%5FOptions%5Ffor%5FDupuytren%5Fs%5FDisease%5F%5FTips.59.aspx?ref=theplasticsfella.com)** Treatment Options for Dupuytren’s Disease: Tips and Tricks, Denkler et al. Plastic and Reconstructive Surgery - Global Open: January 2022 3. **[An algorithm for lower limb reconstruction:](https://parjournal.net/article/view/4767?ref=theplasticsfella.com)** Soft tissue reconstruction of the lower extremity in the pediatric population. Gimenez et al. *Plast Aesthet Res* 2022;9:28. ### Deep Dive 🚀 P'Fella's **personal** analysis of the chosen article of the week. **Key points**, journal club **critiques**, and impact on your **clinical practice**. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/Deep-2.png) **This is for thePlasticsPro subscribers. Thank you for supporting P'Fella's mission :)** _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - April 17th URL: https://www.theplasticsfella.com/april-17th/ Last updated: 2022-04-17T12:24:45.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/april-17th/#a-letter-from-pfella) \- Study Habits of +11,000 Plastic Surgeons. 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/april-17th/#study-on-sunday) \- Lower Eyelid Anatomy (mnemonic + drawing) 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/april-17th/#weekly-quiz-competition) \- Round 7! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/april-17th/#upcoming-events) \- 18 webinars, events and conferences 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/april-17th/#tweets-of-the-week) \- #reduction, Glaucomflecken, X-rays! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/april-17th/#new-feature) \- thePlasticsDiary (become a tester) 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/april-17th/#articles-of-the-week) \- 3 essential reads, 1 deep-dive on keloids! --- ## ✍️ ## A Letter from P'Fella Every Sunday, you can get insight into the thoughts and actions of P'Fella. ### A prospective analysis of your study behaviour Interested in how you learn online? P'Fella analysed +11,000 people using the educational platform over 30 days. This is raw data from March 2022\. It may only interest a few, but it helps understand our behaviour. **Here are four key points:** 1. **A diverse group of people!** These are the top 5 countries. Many assume a connection between P'Fella and the UK, but this data says otherwise. Interesting to note that India increased 100% compared to March 2021; Canadians spend the most time studying. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/FQUwf0zVQAIVhs2.jpeg) 2\. **Mobile is the boss!** There is no surprise that mobile is the most standard method to review topics during this month. Some other facts: laptops study 63 secs more than mobile, mobile increased 300% in 12 months. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/FQUwgO_VEAA4eJC.jpeg) 3\. **How do you get to the platform?** P'Fella's SEO is pretty strong. That's why Google is the number 1 source of traffic during this month. If learners come directly to the website, they spend 2.5x longer studying. That's the benefit of a goal-directed study session rather than browsing. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/FQUwgpcUcAQ69oy.jpeg) 4\. **You have a long attention span!** The average time on a typical website is \~50 seconds. The average time studying the top 10 articles ranges from \~5-50 minutes during March 2022\. You are geeks! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/FQUwhEiVsAYwq1w.jpeg) I hope you've found this data insightful. It's the raw data collected over one month thanks to the privacy-first & non-tracking [@PlausibleHQ](https://twitter.com/PlausibleHQ?ref=theplasticsfella.com). 🧑🏽‍🎓 If you would like access to this data to analyse, publish or present then please reply, "Yes Research" to this email. --- ## 🤓 ## Study on Sunday Your weekly bite-sized topic to keep your knowledge fresh. Quick. ### Eyelid Anatomy The eyelid is a bilamellar structure. Its anatomy is the “Rule of 2’s” - **2 Eyelids** Upper and Lower - **2 Lamellae:** Anterior and Posterior - **2 structures in anterior lamellae:** Skin + Muscle - **2 structures in posterior lamellae:** Tarsus + Conjunctiva. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/FQPlrSDVEAIFnMw.jpeg) [Read more](https://www.theplasticsfella.com/upper-eyelid-anatomy/) --- ## 🧐 ## Weekly Quiz Competition Round 7! Wow, it's competitive for this $100 prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 7 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 18 Webinars, Conferences, and Courses This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, just reply to this email! 1. [iBreastBook ](https://us02web.zoom.us/webinar/register/WN%5F3khabL1eRLiFqynkSw7-EQ?ref=theplasticsfella.com)\- What's new in mastectomy? - Virtual, April 23rd. 2. [](https://us02web.zoom.us/webinar/register/WN%5FKvYFduZOT9eZrs6PkNRrjA?ref=theplasticsfella.com)[B](https://bapras.eventsair.com/ntp/registration/Site/Register?ref=theplasticsfella.com)SSH Median and Ulnar Nerve - Virtual, April 30th. 3. [IFSSH Combined Conference](https://ifssh2022.com/?ref=theplasticsfella.com#registration) \- London, April 2022. 4. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 5. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022. 6. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022. 7. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 8. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022. 9. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 10. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 11. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 12. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 13. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 14. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 15. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 16. [BAPRAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland September 2022 17. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 18. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > A little something for the academic crowd [https://t.co/Vy5RCHMLuk](https://t.co/Vy5RCHMLuk?ref=theplasticsfella.com) > > — Dr. Glaucomflecken (@DGlaucomflecken) [April 16, 2022](https://twitter.com/DGlaucomflecken/status/1515447948108189700?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Jahss manoeuvre is a REDUCTION technique for METACARPAL NECK fracture. [pic.twitter.com/DmpqFiuKHJ](https://t.co/DmpqFiuKHJ?ref=theplasticsfella.com) > > — Dr Karan Choudhry (@KaranChoudhry6) [April 16, 2022](https://twitter.com/KaranChoudhry6/status/1515390337396531200?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Next in the series of [#radiology](https://twitter.com/hashtag/radiology?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) in motion/atypical imaging methods cases: > > Which ligament is not doing its job? May the best gif win![#MSKRad](https://twitter.com/hashtag/MSKRad?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#FOAMed](https://twitter.com/hashtag/FOAMed?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#FOAMrad](https://twitter.com/hashtag/FOAMrad?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#radres](https://twitter.com/hashtag/radres?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#orthotwitter](https://twitter.com/hashtag/orthotwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#orthopedics](https://twitter.com/hashtag/orthopedics?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > > Case courtesy of the great [@dianepaynemd](https://twitter.com/dianepaynemd?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/Bo64YNX0gz](https://t.co/Bo64YNX0gz?ref=theplasticsfella.com) > > — Adam Singer, MD (@AdamSingerMD) [April 15, 2022](https://twitter.com/AdamSingerMD/status/1514768421442908163?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### thePlasticsDiary Every week, P'Fella creates or updates the educational platform. All decisions are direct by one simple mantra: build great educational tools. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/FO343mSX0AIdBa1.jpeg) **I'm really excited about this.** A weekly organiser, surgical diary & study planner designed for plastics. the idea is to organise your week, create study schedules, and write surgical op notes on certain cases. 6 sections (so far) on common duties in plastic surgery: Monthly Calendar · Weekly Planner · Surgical Log · On-Call Records · Revision Coach · Personal Goals ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/FPmodA_XIAgbunV.jpeg) 📧 If you would like to **test** it: reply "YES DIARY" to this email. If you have any **suggestions**, just write away! If P'Fella uses them you have the diary for free :) ### --- ## 📝 ## Articles of the Week This is probably the most popular section of thePlasticsPaper. Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Important Reads 1. [A 15-Year Review of Clinical Practice Patterns in Carpal Tunnel Syndrome Based on Continuous Certification by the American Board of Plastic Surgery, Plastic and Reconstructive Surgery](https://journals.lww.com/plasreconsurg/Abstract/9900/A%5F15%5FYear%5FReview%5Fof%5FClinical%5FPractice%5FPatterns%5Fin.751.aspx?ref=theplasticsfella.com), Sasson et al. PRS Journal April 11, 2022 2. [The “Home Effect”: The Impact of Virtual Interviews on the 2021 Integrated Plastic Surgery Residency Match,](https://journals.lww.com/plasreconsurg/Fulltext/9900/The%5F%5FHome%5FEffect%5F%5F%5FThe%5FImpact%5Fof%5FVirtual.725.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter) Reategui et al. PRS Journal March 22, 2022 3. [Skin Preservation in the Debridement of Necrotizing Fasciitis: A Demonstrative Case Report](https://journals.lww.com/prsgo/Fulltext/2022/04000/Skin%5FPreservation%5Fin%5Fthe%5FDebridement%5Fof.4.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter), AlMarshad et al. PRS Global Open: April 2022 ### Deep Dive 🚀 This section is designed for you to use in your journal clubs or personal learning. It consists of a **comprehensive** summary of key points, evidence-based **critique**, P'Fella's perspective on the article, and its potential **implications** for clinical practice. **This week: What is the best practice for radiotherapy for keloid scars?** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/Journal.png) **Citation**: Wen, P., Wang, T., Zhou, Y. *et al.* A retrospective study of hypofractionated radiotherapy for keloids in 100 cases. *Sci Rep* **11,** 3598 (2021). https://doi.org/10.1038/s41598-021-83255-4 The deep-dive is for thePlasticsPro users who support educational P'Fella's mission. _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - April 10th URL: https://www.theplasticsfella.com/april-10th/ Last updated: 2022-04-10T11:11:59.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/april-10th/#a-letter-from-pfella) \- 5 tremors in surgery (& how to reduce them) 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/april-10th/#study-on-sunday) \- How to classify a flap 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/april-10th/#weekly-quiz-competition) \- Round 6! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/april-10th/#upcoming-events) \- 17 upcoming events for you. 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/april-10th/#tweets-of-the-week) \- Intra-op videos, viral tweets, and more! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/april-10th/#new-feature) \- thePlasticsChat (request your access) 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/april-10th/#articles-of-the-week) \- 3 important reads, 1 deep-dive. --- ## ✍️ ## A Letter from P'Fella ### 5 tremors in surgery (and how to reduce them) Every Sunday, you can get insight into the thoughts and actions of P'Fella. **Everyone has a tremor. Some are just better at hiding it.** But what causes it? A tremor has both **emotional** and **physical** components[3](https://pubmed.ncbi.nlm.nih.gov/6669016/?ref=theplasticsfella.com). Here are 5 common types of tremors you might notice when operating 1. Adrenaline-anxiety tremor (emotional) 2. Exercise-induced tremor (physical) 3. Caffeine-overload tremor (physical) 4. Uncomfortable-position tremor (physical) 5. Lack-of-sleep tremor (physical) From an **emotional** perspective, it's mainly to do with **stress** and **inexperience**. The best way to overcome this is to prepare for the case. Be familiar with the patient, the technique, and the instruments. Watch videos before the operation and visualize the steps needed. Seeing the procedure several times can significantly relieve anxiety. The excitement of performing the case can lead to a natural adrenaline rush. From a **physical** perspective, it's all about you. You should be optimized before going under the microscope. So how can you do that? - Relax the body - Make sure you have eaten (avoid the hypoglycemic shake!) - Reduce the caffeine intake on the day of surgery - Put your hands in a comfortable position (often resting on the patient!)[1](https://pubmed.ncbi.nlm.nih.gov/20853330/?ref=theplasticsfella.com) - Sleep! Lack of sleep will increase your tremor![2](https://pubmed.ncbi.nlm.nih.gov/26585718/?ref=theplasticsfella.com) - Don't hold the instruments too tightly! As you become more experienced, the tremor reduces. But when you hit a certain age that tremor can return (the downside of aging!) --- ## 🤓 ## Study on Sunday ### Flap Classification Your weekly topic to keep your knowledge fresh. A flap can be classified or described by its tissue composition, vascularity, type of movement, and location in relation to the defect ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/Classification-of-Flaps--6.png) thePlasticsFella has created the **"FLAPS MOVE" mnemonic** to describe and classify a type of flap: **f**orm/composition, **l**ocation, **a**ttachments, **p**erfusion, **s**pecial features, and **move**ment of the flap. This memory hook is illustrated below in the diagram. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/Classification-of-Flaps--2--2.png) [Read more](https://www.theplasticsfella.com/classification-of-flaps/) --- ## 🧐 ## Weekly Quiz Competition Round 6! Currently over 100+ competing for a $100 prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 6 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 17 Webinars, Conferences, and Courses This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, just reply to this email! 1. [BAPRAS](https://bapras.eventsair.com/ntp/registration/Site/Register?ref=theplasticsfella.com) Sarcoma Teaching - Virtual, April 11th. 2. [IFSSH Combined Conference](https://ifssh2022.com/?ref=theplasticsfella.com#registration) \- London, April 2022. 3. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 4. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022. 5. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022. 6. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 7. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022. 8. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 9. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 10. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 11. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 12. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 13. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 14. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 15. [BARPAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland September 2022 16. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 17. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > During one of my residency interviews I was asked what surgical instrument I’d be and I said the SUCTION because it’s loud & kind of annoying and is sometimes helpful but mostly just in the way. > > — Rebecca Matthews (@rpm709) [April 7, 2022](https://twitter.com/rpm709/status/1512164699584016386?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Muchas preguntas sobre Sd compartimental de esfuerzo (crónico) de antebrazo > ▪️Aquí tenéis el antes y el después > ▪️Antes: fascia rígida, no distensible que es el origen de la patología > ▪️Después: exeresis fascial con correcto movimiento y coloración muscular [pic.twitter.com/BZQB9fpL8C](https://t.co/BZQB9fpL8C?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [April 8, 2022](https://twitter.com/DrBarreraochoa/status/1512412639732846593?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > هذه مجموعة كبيرة عملتها لأغلب المجلات الطبية بتخصص جراحة التجميل و الترميم مع تفاصيلها 📝: > > \- التخصص الدقيق (جراحة يد، حروق، الخ.. ) > \- المدة المستغرقة حتى الرد الأولي. > \- معدل القبول. > \- صعوبة قبول البحث. > \- رسوم النشر. > \- عامل التأثير. > > اللهم إجعله علمًا نافع ينتفع به 🤍 [pic.twitter.com/inGSkm6dxJ](https://t.co/inGSkm6dxJ?ref=theplasticsfella.com) > > — Hatan Mortada (@HatanMortada) [April 6, 2022](https://twitter.com/HatanMortada/status/1511806618404626437?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### thePlasticsChat Every week, P'Fella creates or updates the educational platform. All decisions are direct by one simple mantra: build great educational tools. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/FKnepi7VUAEjag3.jpeg) thePlasticsChat is now out of alpha-testing. You can request to join the beta program. **What is it?** Essentially, it's a way a new way to learn and network in the plastic surgery community. Chat amongst your peers, share your opinions, and give advice. 📧 **If you want to join the waiting list, reply YES to this email.** ### --- ## 📝 ## Articles of the Week This is probably the most popular section of thePlasticsPaper. Every week, P'Fella links 3 articles you should read. There is also 1 deep-dive review for thePlasticsPro community. ### Important Reads 1. [Revisited Arterial Supply of the Anterior Ear](https://journals.lww.com/annalsplasticsurgery/Abstract/2022/04000/Revisited%5FArterial%5FSupply%5Fof%5Fthe%5FAnterior%5FEar.20.aspx?ref=theplasticsfella.com): Young Soo et al. Annals of Plastic Surgery: April 2022 - Volume 88 - Issue 4 - p 446-450 2. [A randomized placebo-controlled clinical trial on the efficacy of local lidocaine injections and oral citalopram for the treatment of complex regional pain syndrome: ](https://www.jprasurg.com/article/S1748-6815%2821%2900561-1/fulltext?ref=theplasticsfella.com)Fallico et al, JPRAS, November 13, 2021 3. [Facial Palsy and Reconstruction:](https://journals.lww.com/plasreconsurg/Abstract/2012/02000/Facial%5FPalsy%5Fand%5FReconstruction.42.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com) Adel et al, Plastic and Reconstructive Surgery: February 2012 - Volume 129 - Issue 2 - p 340e-352e (CME) ### Deep Dive (thePlasticsPro) **Chest Wall Reconstruction: 500 consecutive patients.** Arnold et al, Mayo Clinic, Minnesota, USA, October 1996\. [PRS Journal ](https://journals.lww.com/plasreconsurg/Abstract/1996/10000/Chest%5FWall%5FReconstruction%5F%5FAn%5FAccount%5Fof%5F500.8.aspx?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/Screenshot-2022-04-10-at-11.59.42.png) _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - April 3rd URL: https://www.theplasticsfella.com/april-3rd/ Last updated: 2022-04-03T18:50:41.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/april-3rd/#a-letter-from-pfella) \- Burnout is output without purpose. 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/april-3rd/#study-on-sunday) \- the Horse and the Chariot! 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/april-3rd/#weekly-quiz-competition) \- Halfway through! It's close! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/april-3rd/#upcoming-events) \- 17 upcoming events for you. 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/april-3rd/#tweets-of-the-week) \- Free Flaps, Drawings, Memes! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/april-3rd/#new-feature) \- Study on the toilet! (April Fools) 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/april-3rd/#articles-of-the-week) \- currently under renovation!! --- ## ✍️ ## A Letter from P'Fella ### Burnout = output without purpose Every Sunday, you can get insight into the thoughts and actions of P'Fella. **Burnout in plastic surgery is an issue.** There are million different ways to define burnout. And it can be hard to get that definition perfect. It is generally accepted that burnout is a constellation of symptoms: emotional exhaustion, depersonalization, or a diminished sense of personal accomplishment related to one’s professional life. In P'Fella's mind, it is output without purpose. It is doing without thinking. When we set unrealistic expectations of ourselves, underestimate how much time is needed to complete a task, neglect our priorities, and fail to set proper boundaries (don't mix business and pleasure!) — it starts a downward spiral. Here are 3 recent publications on burnout in Plastic Surgery 1. [Burnout among Plastic Surgery Residents in India: An Observational Study](https://pubmed.ncbi.nlm.nih.gov/33402769/?ref=theplasticsfella.com) 2. [Professional Burnout in United States Plastic Surgery Residents: Is It a Legitimate Concern?](https://pubmed.ncbi.nlm.nih.gov/31621825/?ref=theplasticsfella.com) 3. [The Perspective of Plastic Surgery Program Directors in Managing Resident Burnout and Mental Health: Are We Doing Enough?](https://pubmed.ncbi.nlm.nih.gov/33885443/?ref=theplasticsfella.com) --- ## 🤓 ## Study on Sunday ### Quadriga phenomenon Your weekly topic to keep your knowledge fresh. Quadriga phenomenon or syndrome is reduced flexion in non-injured fingers caused by a shortened, stiff, or adherent FDP in an adjacent injured finger. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/1-3-4.png) It results in an **active flexion lag* and "weak grip" that can be diagnosed clinically. It was first described by Bunnell3 and later by Verdan2 after a series of terminalisations and [flexor tendon repairs](https://www.theplasticsfella.com/flexor-tendon-injury-repair/). [Read more](https://www.theplasticsfella.com/quadriga-phenomenon/) --- ## 🧐 ## Weekly Quiz Competition Round 5! Currently over 100+ competing for a $100 prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 5 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 17 Webinars, Conferences, and Courses This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, just reply to this email! 1. [BAPRAS](https://bapras.eventsair.com/ntp/registration/Site/Register?ref=theplasticsfella.com) Sarcoma Teaching - Virtual, April 11th. 2. [IFSSH Combined Conference](https://ifssh2022.com/?ref=theplasticsfella.com#registration) \- London, April 2022. 3. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 4. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022. 5. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022. 6. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 7. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022. 8. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 9. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 10. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 11. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 12. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 13. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022. 14. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022. 15. [BARPAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland September 2022 16. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 17. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week If you're not on [Twitter](https://twitter.com/PlasticsFella?ref=theplasticsfella.com), you're not learning. Fact. > Colgajo Vascularizado de Peroné > ▪️Ideal en defectos óseos moderados-grandes… > ▪️Longitud de más de 20 cm > ▪️Pedículo basado en los vasos peroneos > ▪️Se puede levantar junto a una isla cutánea > ▪️Es uno de los colgajos que explicamos en el curso básico y avanzado de colgajos [pic.twitter.com/BZN1Ijck6q](https://t.co/BZN1Ijck6q?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [April 3, 2022](https://twitter.com/DrBarreraochoa/status/1510653024477270017?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Diagnosing myasthenia gravis with an ice pack (ptosis improves after application) [#medtwitter](https://twitter.com/hashtag/medtwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/NuPynrlAlx](https://t.co/NuPynrlAlx?ref=theplasticsfella.com) > > — Avraham Z. Cooper, MD (@AvrahamCooperMD) [April 1, 2022](https://twitter.com/AvrahamCooperMD/status/1510039562059501582?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > One for the hand surgeons[https://t.co/V607bExCnZ](https://t.co/V607bExCnZ?ref=theplasticsfella.com) [#medicalart](https://twitter.com/hashtag/medicalart?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/fWrEaTp2FN](https://t.co/fWrEaTp2FN?ref=theplasticsfella.com) > > — Conor Jones (@ConorJones921) [April 2, 2022](https://twitter.com/ConorJones921/status/1510305526202220557?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### Study on the Toilet Every week, P'Fella creates or updates the educational platform. All decisions are direct by one simple mantra: build great educational tools. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/Twitter-Posts-12.png) **This was an April Fools joke! Please don't buy!!** During the week, April 1st was upon us. P'Fella couldn't miss the opportunity to create another amazing educational tool ;) It was launched on twitter. Some people spotted the joke, whilst others actually thought it was a good idea. 📧 **If you think this is a good idea and want it, reply YES!** ### --- ## 📝 ## Articles of the Week This is probably the most popular section of thePlasticsPaper. Everyone can read the rapid review article, the deep-dive article is for [thePlasticsPro](https://www.theplasticsfella.com/landing/) users. **This section is currently undergoing improvements!** This section is a very popular part to thePlasticsPaper - but things can always be improved! Check back next week. If you have any suggestions just reply to this email. ### ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/04/Check-back-next-week-.png) [Check out previous articles](https://www.theplasticsfella.com/theplasticspaper/march-27th/#articles-of-the-week) --- ### Wound Healing URL: https://www.theplasticsfella.com/wound-healing/ Last updated: 2025-12-15T19:41:29.000Z 👇 **In this Article** [5 Key Points on Wound Healing](https://www.theplasticsfella.com/wound-healing/#5-key-points-on-wound-healing) [Types of Wound Healing](https://www.theplasticsfella.com/wound-healing/#types-of-wound-healing) [Phases of Wound Healing](https://www.theplasticsfella.com/wound-healing/#phases-of-wound-healing) [Re-epithelialisation ](https://www.theplasticsfella.com/wound-healing/#re-epithelialisation-in-wound-healing) [Contraction ](https://www.theplasticsfella.com/wound-healing/#contraction-in-wound-healing) [Factors affecting wound healing](https://www.theplasticsfella.com/wound-healing/#wound-healing-factors) [Flashcards](https://www.theplasticsfella.com/wound-healing/#flashcards) --- ## 5 Key Points on Wound Healing #### 1\. Types of Wound Healing Wound Healing can be via primary, secondary or tertiary intention #### 2\. Phases of Wound Healing Phases of wound healing are hemostasis, inflammation, proliferation and remodelling. #### 3\. Important cells in wound healing Macrophages, neutrophils and fibroblasts play integral roles in activating pathways, reducing bacterial burden, and promoting collagen formation, respectively. #### 4\. Re-epithelialisation vs Contraction Re-epithelialisation occurs in wounds with an intact epidermal basement membrane via mobilisation, migration, mitosis and differentiation. Contraction occurs in wounds after 3 days and is caused by myofibroblasts. #### 5\. Factors affecting healing There are genetic conditions, acquired systemic issues and local factors that all influence wound healing. ### --- ## Types of Wound Healing There are 3 ways a wound can heal: 1. **Primary closure:** most common 2. **Secondary intention:** open wound that granulates, contracts, epithelialises 3. **Tertiary Intention:** delayed primary (a wound that is closed at a later date) Here is an in-depth video tutorial. --- ## Phases of Wound Healing There are 4 phases to wound healing: **haemostasis**, **inflammation**, **proliferation** and **remodelling**. These stages are the same for both primary and secondary intention healing. ![A healing wound has 4 phases: haemostasis, inflammation, proliferation and remodelling](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/06/Phases-of-Wound-Healing.png) Phases of Wound Healing ### 1\. Haemostasis This occurs acutely and is initiated once a wound has been created. The key aspects of this include: - **Vasoconstriction** from thromboxane & prostaglandins release. - **Activating** platelet-activating factor, von Willebrand, & thromboxane A2\. - **Platelet plug** formation secondary to platelet activation - **Thrombus** formation is secondary to fibrinogen converted to fibrin. This can **weakly** hold the wound together. 💡 At a **cellular** level, **macrophages** release inflammatory **cytokines** and engage in **phagocytosis**, and **neutrophils** infiltrate the wound. ### 2\. Inflammation This occurs within the first 72 hours of the initial activation of the wound healing pathway. The key aspects of this include: - **Cell proliferation** is secondary to the release of platelet-derived growth factors and pro-inflammatory factors (serotonin, bradykinin, histamine). - **Vasodilation** as endothelial cells swells and polymorphonuclear neutrophils travel into the tissue. - **Cellular immunity and antibody production** from T-lymphocytes entering the wound (influence by interleukin-1) and secreting cytokines. 💡 At a **cellular** level, **macrophages** become the dominant cell within 48 hours of the injury until **fibroblast** proliferation. The final cell line is **lymphocytes**. ### 3\. Proliferation This occurs after \~72 hours and is usually complete within 2-4 weeks. The key aspects of this include: - **Matrix formation** fromfibroblasts& glycosaminoglycan production. - **Collagen & elastin production** is secondary to fibroblasts (mainly type III). This can hold the wound together quite strongly. - **Wound contraction** as fibroblasts differentiates into myofibroblasts. - **Angiogenesis** secondary to endothelial stem cell migration. This is assisted by macrophages stimulating nearby vascular endothelium of adjacent capillaries. 💡 **Glycosaminoglycans** production includes hyaluronic acid, chondroitin-4 sulfate, dermatan sulfate and heparin sulfate. ### 4\. Remodelling This occurs after 2-4 weeks from injury and can last >1 year. This phase of wound healing is responsible for the tensile strength of a wound. The **key** aspects of this include: - **Collagen Haemostasis:** no increase in collagen production - **Collagen replacement**: type III collagen is replaced by type I (stronger). - **Collagen re-organisation:** becomes organised with stronger cross-links. - **Apoptosis** removes the capillary network and creates a pale-looking scar. 💡 **Tensile strength** increases at \~day 5 & is 80% pre-injury at \~60 days. The type of cell involved in wound healing changes over time. The first cells are predominantly neutrophils. After 48 hours, macrophages become dominant during the inflammatory phase. Fibroblasts and myofibroblasts play an important role in proliferation and remodelling. --- ## Re-epithelialisation in Wound Healing This is the process of re-establishing epithelial continuity through 4 phases: **mobilisation**, **migration**, **mitosis**, and **differentiation**. Re-epithelialisation occurs after the basement membrane of the [epidermis](https://www.theplasticsfella.com/anatomy-of-the-skin/) has been breached. It occurs from the edges of the wound and [epidermal appendages](https://www.theplasticsfella.com/anatomy-of-the-skin/). The 4 phases of re-epithelialisation are as follows: 1. **Mobilisation:** epithelial cells lose contact with neighbours (contact inhibition) to become flat and long and form pseudopodia. 2. **Migration:** epithelial cells attempt to overcome contact inhibition by moving centrally. 3. **Mitosis**: epithelial cells proliferate once, desmosomes and hemidesmosomes attach to the basement membrane and form a [stratum germinativum](https://www.theplasticsfella.com/anatomy-of-the-skin/). 4. **Differentiation**: cells differentiate to recreate normal stratified squamous epithelium. 💡 If the **basement membrane** is intact then the epithelial cells are replaced by upward migration of keratinocytes. --- ## Contraction in Wound Healing Contraction occurs in the granulating wound when myofibroblasts contract the wound bed. Contraction is a normal phenomenon in a granulating wound bed due to myofibroblasts. Here are some key points on myofibroblasts - First appear \~72 hours after injury and peak at 2-3 weeks. - Contain contractile microfilaments and distinct cellular adhesions (desmosomes and maculae adherens) - Disappear when contraction is complete 💡 Tip: There is **less** contraction when there is **more** dermis. --- ## Wound Healing Factors Wound healing is influenced by medical conditions, systemic factors and local factors. ### Medical conditions The following medical conditions negatively influence the ability of a wound to heal: 1. **Pseudoxanthoma elasticum:** increased collagen degradation giving a pebble-skin appearance. 2. **Epidermolysis Bullosa:** skin is very delicate 3. **Ehler's Danlos Syndrome:** abnormal collage structure 4. **Cutis Laxa:** mutated elastic fibres presenting in newborns as excessive laxity. 5. **Werner Syndrome:** mutated WRN gene presenting similarly to scleroderma. 6. **Progeria:** mutated LMNA gene creating an appearance of "premature ageing". 💡 Clinical Gem: blistering after minor trauma in patients with epidermolysis bullosa is called Nikolsky Sign. ### Systemic Factors The following systemic factors play an important role in wound healing. 1. **Age**: as you age so too does your ability for cell re-growth and tensile strength. 2. **Smoking:** nicotine induces vasoconstriction, carbon monoxide decreases oxygen-carry capacity, and hydrogen cyanide impairs oxygen transport 3. **Comorbidities:** for example diabetes. 4. **Nutrition:** vitamin A (retinol) and C are required for collagen cross-linking and synthesis, respectively. Vitamin E stabilises the membrane. Low albumin is a predictor of poor wound healing. 5. **Medication:** steroids inhibit epithelialisation & decrease collagen production. ### Local Wound Factors Local wound issues are usually the most common reason for delayed wound healing. It can relate to: 1. **Infection**: reduces oxygen tension, pH, epithelialisation and angiogenesis, whilst increasing collagenase activity and inflammation 2. **Radiation**: occludes small vessels, and damages fibroblasts and nuclei. 3. **Temperature**: warm and moist increase epithelialisation and tensile strength. 4. **Oxygen delivery**: microvascular disease results in reduced tissue perfusion. 💡 In a **chronic wound**, the wound is slow to heal due to excessive **metalloproteases** which promote matrix turnover. --- ## Flashcards ⚡ Evidence-based flashcards are designed for active recall and spaced repetition of the verified information you are currently studying. They are continually updated and are for thePlasticsPro users. ### thePlasticsPaper - March 27th URL: https://www.theplasticsfella.com/march-27th/ Last updated: 2024-11-19T15:34:06.000Z ****In this Week's Edition**1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/march-27th/#a-letter-from-pfella) \- Build a career, not a logbook.2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/march-27th/#study-on-sunday) \- Brachial Plexus (oh no!)2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/march-27th/#weekly-quiz-competition) \- A 5-way tie at the top!4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/march-27th/#upcoming-events) \- check out these 19 events5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/march-27th/#tweets-of-the-week) \- it was a quiet week on twittter!6\. 🚀 [New features](https://www.theplasticsfella.com/march-27th/#new-feature) \- updated flashcards (more and improved)7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/march-27th/#articles-of-the-week) \- How to present like Steve Jobs --- ## ✍️ ## A Letter from P'Fella ### Build a career, not a logbook Every Sunday, you can get insight into the thoughts and actions of P'Fella. **Don't let the system distract you from the real goal.** Your main priority always should be to do learn and improve every time you operate. You shouldn't just operate to increase your logbook numbers. When plastic surgery trainee wants to show off their skills, they often quote their logbook numbers. But at the end of the day, they are missing a key point. **The plastic surgery journey is not linear. It be can be quantified and qualified.** Regardless of your training location, there are 4 main ways to operate: observing, assisting, being supervised by someone more senior, or performing independently. But, for most plastic surgery trainees, these phases overlap, coincide, and blend together - they become a number. They are quantified but not qualified. It's *good* to reflect on your skills, to test and **qualify** your ability to operate; to evolve your strategy as you discover areas of weakness. Building a logbook shouldn't be a distraction from building a career. They should work together to serve the same goal. *How* you do that, and in what order, is up to you. --- ## 🤓 ## Study on Sunday ### Brachial Plexus 🥴 Don't study all the time... you'll burn out! Just 1 quick topic on a Sunday. 1\. **Origin**: the plexus arises from the anterior rami of C5-T1 spinal nerves. 2\. **Segments** of the plexus are roots, trunks, divisions, cords, branches. 3\. **Course**: intervertebral foramina to posterior triangle to the axilla. 4\. **Main branches:** median, ulnar, radial, axillary, musculocutaneous. 5\. **Embryology:** develops in the 5th week of gestation. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/9-1-1.png) [Read more on brachial plexus](https://www.theplasticsfella.com/brachial-plexus-anatomy/) --- ## 🧐 ## Weekly Quiz Competition Round 4! Currently 5 people all tied for first place. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 4 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 19 Webinars, Conferences, and Courses This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, just reply to this email! 1. BSSH Hand and Wrist Imaging - March 28th 2. EURAPS Burn Surgery - March 31st 3. [BAPRAS](https://bapras.eventsair.com/ntp/registration/Site/Register?ref=theplasticsfella.com) Sarcoma Teaching - Virtual, April 11th. 4. IFSSH Combined Conference - London, April 2022\. 5. AAPS Centennial Meeting - San Diego, April 2022. 6. BAPRAS AEC Trunk Reconstruction - April 2022\. 7. BAAPS Masterclass in Aesthetic Practice - London, May 2022\. 8. RACS 90th Annual Scientific Conference - Brisbane, May 2022. 9. British Burns Association Annual Meeting - Bristol, May 2022\. 10. Australian ASPS Congress - Goldcoast, June 2022 11. Aesthetics In-Service Exam - Virtual, June 2022. 12. ISAPS World Congress - Istanbul, July 2022 13. ICCPCA Cleft Congress - Edinburgh, July 2022 14. ASSH Annual Meeting - Boston, September 2022. 15. BAAPS Annual Conference 2022 - London, September 2022\. 16. European Society of Craniofacial Surgery - Oxford, September 2022\. 17. BARPAS Celtic Meeting - Dunblane, Scotland September 2022 18. Plastic Surgery, The Meeting - Boston, October 2022. 19. AEC Limb Reconstruction - Virtual, October 2022 --- ## 🐣 ## Tweets of the Week If you're not on Twitter, you're not living. Fact. > [#orthotwitter](https://twitter.com/hashtag/orthotwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@itius](https://twitter.com/itius?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@pratikorho](https://twitter.com/pratikorho?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > > Diagnosis ? [pic.twitter.com/kzrm18qlfy](https://t.co/kzrm18qlfy?ref=theplasticsfella.com) > > — Dr. Anil Bhat (@anilbhatortho) [March 25, 2022](https://twitter.com/anilbhatortho/status/1507411380785221635?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > 10 Life Changing Ideas Visualized out of Lego 🧵 [pic.twitter.com/1tFk21mTAO](https://t.co/1tFk21mTAO?ref=theplasticsfella.com) > > — Kristin Portsmouth (@design\_by\_kp) [March 24, 2022](https://twitter.com/design%5Fby%5Fkp/status/1507120156954267657?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > [#TipTuesday](https://twitter.com/hashtag/TipTuesday?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > > Z-Plasty > > Can't figure out the new scar direction? > Draw a line between A and B. > That's the new direction. [pic.twitter.com/1Cy9JS6Feg](https://t.co/1Cy9JS6Feg?ref=theplasticsfella.com) > > — thePlasticsFella (@PlasticsFella) [March 22, 2022](https://twitter.com/PlasticsFella/status/1506352526559703040?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### More Flashcards!! Every week, P'Fella creates or updates the educational platform. All decisions are direct by one simple mantra: build great educational tools. [Get Flashcards](https://www.theplasticsfella.com/theplasticsflash/) This week, there has been a huge update to thePlasticsFlash. There are nearly 1000 flaschards designed specifically for plastic surgery exams and general revision. Oh, there is also Anki-compatible decks in case you didn't know! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/What-is-the-Leddy-packer-classification-6-1.png) [Get Flashcards](https://www.theplasticsfella.com/theplasticsflash/) --- ## 📝 ## Articles of the Week This is the probably the most popular section of thePlasticsPaper. Every can reed the rapid review article, the deep-dive article is for [thePlasticsPro](https://www.theplasticsfella.com/landing/) users. ### Rapid Review **The Art of a Scientific Presentation: Tips from Steve Jobs** Horiuchi, Sakura B.S.; Nasser, Jacob S. B.S.; Chung, Kevin C. M.D., M.S.Plastic and Reconstructive Surgery: [March 2022 - Volume 149 - Issue 3 - p 533-540](https://journals.lww.com/plasreconsurg/pages/currenttoc.aspx?ref=theplasticsfella.com) - **Aim**: establish a comprehensive list to aid in creating a methodical approach for presenters to evaluate their own presentations to ensure a standard of quality and effectiveness. - **Methods**: a combination of literature review and anecdotal experiences - **Results**: see table below! - **Conclusions:** Preparing, constructing, refining, and personality. These are the key features to a good presentation. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Screenshot-2022-03-27-at-17.14.34.png) ✍️ ****P'Fella's Opinion:**This is an interesting read. The authors clearly did their research in medicine, but more importantly outside of medicine. One of the downfalls of healthcare professionals is our lack of imagination and our reluctance to learn from other areas of life. --- ### Deep Dive: ### Kanavel Signs - a 1912 publication that changed our practice. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Kanavel-Signs-1.png) 🚀 Deep-dive articles are available to those big supporters of P'Fella's mission. You can try it out [here](https://www.theplasticsfella.com/theplasticspaper/march-6th/#/portal/signup). [Read the Deep Dive](https://www.theplasticsfella.com/kanavel-publication/) --- ### thePlasticsPaper - March 20th URL: https://www.theplasticsfella.com/theplasticspaper-march-20th/ Last updated: 2022-03-20T16:50:59.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/march-20th/#a-letter-from-pfella) \- the Plastic Surgery Match! 🎉 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/march-20th/#study-on-sunday) \- 5 features to determine burn depth. 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/march-20th/#weekly-quiz-competition) \- Round 3 (tie leaders!!) 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/march-20th/#upcoming-events) \- New webinars and courses 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/march-20th/#tweets-of-the-week) \- Memes, clinical teaching! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/march-20th/#new-feature) \- P'Fella now helps the climate! 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/march-20th/#articles-of-the-week) \- Rapid review and deep dive! [Start Reading](https://www.theplasticsfella.com/theplasticspaper/march-20th/) --- --- ### thePlasticsPaper - March 20th URL: https://www.theplasticsfella.com/march-20th/ Last updated: 2022-03-20T16:37:58.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/march-20th/#a-letter-from-pfella) \- the Plastic Surgery Match! 🎉 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/march-20th/#study-on-sunday) \- 5 features to determine burn depth. 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/march-20th/#weekly-quiz-competition) \- Round 3 (tie leaders!!) 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/march-20th/#upcoming-events) \- New webinars and courses 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/march-20th/#tweets-of-the-week) \- Memes, clinical teaching! 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/march-20th/#new-feature) \- P'Fella now helps the climate! 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/march-20th/#articles-of-the-week) \- Rapid review and deep dive! --- ## ✍️ ## A Letter from P'Fella ### The Match Every Sunday, you can get insight into the thoughts and actions of P'Fella. **Congratulations to all the new plastic surgery residents!** It was match week this week! Every year, social media get flood with images of people smiling and crying after their successful application. Balloons, champagne and lots of family hugging. Here's a data from the recent 2022 [NRMP](https://www.nrmp.org/wp-content/uploads/2022/03/Advance-Data-Tables-2022-FINAL.pdf?ref=theplasticsfella.com) publication. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlasticsPaper-32.png) So what makes people successful in their application? Here is a breakdown of the 2020 applicants. A few things might have change (for example, pass/fail in USMLE) but it does provide a nice overview. It looks like research experience, PhD and other degrees are less important. ![plastic surgery match, plastic surgery residency](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlasticsPaper-33.png) Plastic Surgery Match Statistics [Read more about Residency](https://www.theplasticsfella.com/plastic-surgery-residency-interview/) --- ## 🤓 ## Study on Sunday Don't study all the time... you'll burnout! Just 1 topic/week. This is your topic this week. A burn can be classified as superficial, partial thickness, or full-thickness. Here is a brekaodwn of the key differences. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Burn-Depth-4-1.png) Differences in Burn Depth [Read more here](https://www.theplasticsfella.com/burn-depth/) --- ## 🧐 ## Weekly Quiz Competition Round 3! Currently over 100+ competing for a $100 prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 3 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 18 Webinars, Conferences, and Courses This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, just reply to this email! 1. [Pulvertaft](https://us02web.zoom.us/webinar/register/WN%5FymQWKCvMQ2qKwRzAH2wMEQ?ref=theplasticsfella.com) \- “Children’s fractures of the hand and wrist“ -Virtual, March 21st. 2. [ASSH](https://www.assh.org/s/course-detail?id=aBP5b00000096y0GAA&ref=theplasticsfella.com) \- Upper Limb Micro Recon - Virtual, March 26th. 3. [IFSSH Combined Conference](https://ifssh2022.com/?ref=theplasticsfella.com#registration) \- London, April 2022\. 4. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 5. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022\. 6. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022\. 7. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 8. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022\. 9. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 10. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 11. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 12. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 13. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 14. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022\. 15. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022\. 16. [BARPAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland September 2022 17. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 18. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week If you're not on Twitter, you're not living. Fact. > Artroplastia TMC en el tratamiento de la Rizartrosis 👍🏻 > ▪️Artroplastia TMC Maïa doble movilidad [@medcomtech\_sa](https://twitter.com/medcomtech%5Fsa?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [@GroupeLepine](https://twitter.com/GroupeLepine?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/lZdxfH4y2C](https://t.co/lZdxfH4y2C?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [March 15, 2022](https://twitter.com/DrBarreraochoa/status/1503727052389855251?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Leaking Silicone Implant > > [#breastimplant](https://twitter.com/hashtag/breastimplant?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#burbankplasticsurgery](https://twitter.com/hashtag/burbankplasticsurgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#drorloff](https://twitter.com/hashtag/drorloff?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#plasticsurgery](https://twitter.com/hashtag/plasticsurgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#plasticsurgeon](https://twitter.com/hashtag/plasticsurgeon?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#beforeandafter](https://twitter.com/hashtag/beforeandafter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/ONuZi5TpXi](https://t.co/ONuZi5TpXi?ref=theplasticsfella.com) > > — Burbank Plastic Surgery (@BurbankPlasSurg) [March 14, 2022](https://twitter.com/BurbankPlasSurg/status/1503245909500514305?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Más colgajos desarrollados durante el curso… > 1️⃣ Colgajo en hélice (propeller) de perforante tibial > ▪️Ideal en cobertura de tibia distal o maleolos > 2️⃣ Colgajo plantar medial > ▪️El mejor colgajo para cobertura del calcáneo [pic.twitter.com/JpIJFUJNDI](https://t.co/JpIJFUJNDI?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [March 14, 2022](https://twitter.com/DrBarreraochoa/status/1503377191635144709?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### Plastic Surgery 🤝 Climate Every week, P'Fella creates or updates the educational platform. All decisions are direct by one simple mantra: build great educational tools. P'Fella contributes **1% of all revenue to carbon removal.** thePlasticsFella has partnered with Stripe. Removing CO₂ from the atmosphere is critical to counteract climate change, but it’s behind. Every purchase from The Plastics Fella helps new carbon removal technologies scale. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlasticsPaper-34.png) Every time you signed up to [thePlasticsStarter](https://www.theplasticsfella.com/landing/), [thePlasticsLover](https://www.theplasticsfella.com/landing/) or [thePlasticsPro](https://www.theplasticsfella.com/landing/), it goes directly towards the climate. [Read more here](https://climate.stripe.com/DT1pUL?ref=theplasticsfella.com) --- ## 📝 ## Articles of the Week This is the probably the most popular section of thePlasticsPaper. Every can reed the rapid review article, the deep-dive article is for [thePlasticsPro](https://www.theplasticsfella.com/landing/) users. ### Rapid Review ### Do we need CT angios before DIEPs? CT angiography prior to DIEP flap breast reconstruction: a randomized controlled trial*, [JPRAS](https://www.jprasurg.com/article/S1748-6815%2821%2900309-0/fulltext?ref=theplasticsfella.com)* - **Aim**: To perform a high quality study to see if its actually needed or not. - **Methods**: Prospective randomisation of CT angio vs no CT angio. - **Results**: 37 patients, shorter operative time for CT angio group but no difference in complication rates. - **Conclusions:** CT angio decreases operative time but doesn't affect postoperative outcomes. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/FOJIigNWQBc6Cmg.jpeg) All credit to JPRAS for this Visual Abstract. ✍️ **P'Fella's Opinion:** I like this study. It's well-designed and it answers a question that is being asked more and more often. When the CT angio came into play for DIEP reconstructions, the traditional surgeons kept to their ways but the new surgeons all adopted this investigation. It's good to see it doesn't affect outcomes. It does make the operation a bit quicker (which is always a benefit in a long operation!!) --- ### Deep Dive: **The Original Publication - Anatomical ariations of the Median Nerve In Carpal Tunnel (Lanz)** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Turquoise-Chalkboard-Animated-Father-s-Day-Card-4-1-2.png) 🚀 Deep-dive articles are available to those big supporters of P'Fella's mission. You can try it out [here](https://www.theplasticsfella.com/theplasticspaper/march-6th/#/portal/signup). [Read the deep dive](https://www.theplasticsfella.com/lanz-median-nerve/) --- ### Anatomical Variations of the Median Nerve In Carpal Tunnel (Lanz) URL: https://www.theplasticsfella.com/lanz-median-nerve/ Last updated: 2022-03-20T16:28:21.000Z Lanz analysed the branching pattern of the median nerve within the carpal tunnel in 246 hands. This paper details these results and compares them with other peer-reviewed literature. _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - March 13th URL: https://www.theplasticsfella.com/march-13th/ Last updated: 2022-03-13T13:27:56.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/march-13th/#a-letter-from-pfella) \- you're overcomplicating your training. 2\. 🤓 [Study on Sunday](https://www.theplasticsfella.com/theplasticspaper/march-13th/#study-on-sunday) \- Design a Z-plasty in 60 seconds. 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/march-13th/#weekly-quiz-competition) \- Round 3, $100 prize 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/march-13th/#upcoming-events) \- too many events to keep up! 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/march-13th/#tweets-of-the-week) \- memes, illustrations, cases 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/march-13th/#new-feature) \- thePlasticsPro & Feedback! 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/march-13th/#articles-of-the-week) \- a rapid review and deep dive! --- ## ✍️ ## A Letter from P'Fella ### You're overcomplicating your Plastic Surgery training Every Sunday, you can get insight into the thoughts and actions of P'Fella. One of the **biggest** challenges facing plastic surgeons is the number of sources available to improve their knowledge and skills. It can be **overwhelming**. It can lead to your training becoming **overcomplicated**. Here are the tips P'Fella has received from the Plastic Surgery community.. 1. **Don't reinvent the "study wheel":** if I hand you a piece of paper and say “make notes” you will just be duplicating work from someone else. If I tell you “make flashcards” you will be able to find information and put them into a format that suits your study preference. 2. **Pick one structure and stick to it:** If you use the same study format every time, you don’t have to decide how to structure your notes every time you sit down at a desk. If you decide you don’t take on a study method (for example, highlighting), just don't do it! 3. **Study for a reason:** when you aim to study for the sake of it, it's a waste of time. Find a particular purpose to study. For example, "I need to revise anatomy for this surgery tomorrow", "I need to read over some things before presenting this journal". Create a purpose and you'll be more efficient. 4. **When you start a new topic, don't forget the other one:** when you study you put on the blinkers. You see a topic, you study it, then move it. Make time to return to your study topics. It's called spaced repetition. It works. 5. **Don’t get bogged down in fine details:** as a trainee, your life is easier if you have broad general knowledge rather than specific in-depth knowledge with large gaps in other areas. Over time, you’ll develop specific knowledge. --- ## 🤓 ## Study on Sunday ### Design a Z-Plasty in 60 seconds 1 new topic every Sunday. Simple. A z-plasty is a a double transposition aiming to increase and change the direction of a scar. The design is based on **3** limbs, **2** angles, and **1** scar. The more you think about a z-plasty, the harder it gets. All you need to know is the **current scar direction** and where you want the **new scar direction** to be. Then just join the dots! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Z-Plasty-2-2.png) [Read more on Z-Plasty](https://www.theplasticsfella.com/z-plasty/) --- ## 🧐 ## Weekly Quiz Competition Round 3! Currently over 100+ competing for a $100 prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 3 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 17 Webinars, Conferences, and Courses This is an incredibly comprehensive list of upcoming events in Plastic Surgery. If you want your event advertised, just reply to this email! 1. [ASPS Spring Meeting](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) \- Virtual, March 2022. 2. [PLASTA ST3 Interview Prep](https://us02web.zoom.us/webinar/register/WN%5FTI0ixEawRyiZlUQLWz%5FVkQ?ref=theplasticsfella.com) \- Virtual, March 17th 2022\. 3. [ASSH](https://www.assh.org/s/course-detail?id=aBP5b00000096y0GAA&ref=theplasticsfella.com) \- Upper Limb Micro Recon - Virtual, March 26th. 4. [IFSSH Combined Conference](https://ifssh2022.com/?ref=theplasticsfella.com#registration) \- London, April 2022\. 5. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 6. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022\. 7. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022\. 8. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 9. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022\. 10. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 11. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 12. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 13. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 14. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 15. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022\. 16. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022\. 17. [BARPAS Celtic Meeting](https://t.co/NfAnON0U4t?ref=theplasticsfella.com) \- Dunblane, Scotland September 2022 18. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 19. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week If you're not on Twitter, you're not living. Fact. > Anesthesia when the surgery resident lets the med student close [pic.twitter.com/vDB973tWJR](https://t.co/vDB973tWJR?ref=theplasticsfella.com) > > — Joseph Azar (@JosephHalimAzar) [March 11, 2022](https://twitter.com/JosephHalimAzar/status/1502177964519264256?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Fractura oblicua larga de 4to MTC Seguimiento a 1 sem post operatorio > ▪️Se realiza mini open dorsal para reducir la fractura y se mantiene reducción temporal con pinza > ▪️Fijación percutanea con tornillo BRM 4 mm de [@medcomtech\_sa](https://twitter.com/medcomtech%5Fsa?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) 🔩 [pic.twitter.com/RzwNbF6a7q](https://t.co/RzwNbF6a7q?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [March 10, 2022](https://twitter.com/DrBarreraochoa/status/1501991481208446979?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > What medical word would be a cute baby name if it didn’t mean what it does? > > I’ll go first: Vicryl > > — Kylie K (@KK\_medicine) [March 7, 2022](https://twitter.com/KK%5Fmedicine/status/1500903662578806793?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature Every week, P'Fella creates or updates the educational platform. All decisions are directed by one simple mantra: build great educational tools. ### thePlasticsPro This is a popular hit! Thanks to everyone for getting early access and testing it out on their 7-day free trial. The feedback has been really positive. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/the-Plastics-Pro-30-3.png) [Check it out](http://theplasticsfella.com/landing/?ref=theplasticsfella.com) ### Improving your educational tools Every time there is a new member to the community they will now get asked a series of **rapid-fire questions** that takes about **30 seconds**. The idea is to get better insight into what you want to see on the platform. After all, this is an educational platform created by **you**. I wish I started this earlier! Because I missed out on getting insights into nearly 1500 of you! If you want to do me a favor, you might fill it out quickly?? pretty please :) --- ## 📝 ## Articles of the Week This is probably the most popular section of thePlasticsPaper. Every can reed the rapid review article, the deep-dive article is for [thePlasticsPro](https://www.theplasticsfella.com/landing/) users. ### Rapid Review Robots for DIEPS?? *Robotic Harvest of the Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: A Case Series, Bishop et al, [PRS](https://journals.lww.com/plasreconsurg/Abstract/9900/Robotic%5FHarvest%5Fof%5Fthe%5FDeep%5FInferior%5FEpigastric.684.aspx?ref=theplasticsfella.com)* - **Aim**: does robotic surgery decrease donor site morbidity in DIEPS? - **Methods**: case series (level of evidence IV) - **Results**: 21 patients over a 12-month period that had a reduced fascial incision and none needed to be converted to "open" - **Conclusions:** a safe and reliable technique that decreases the length of fascial incision and short-term complications associated with the open approach. ✍️ **P'Fella's Opinion:** This is a non-inferiority study. It is also a study that can really only impact a select few plastic surgeons that are actually training in robotic surgery. The study is based on the premise that donor site morbidity is a huge problem DIEPS. Well, it isn't. It is a recognized issue but can be overcome with different abdominal wall closure techniques. It will be great to see more studies that focus on the impact on microsurgery outcomes. It's one to watch! --- ### Deep Dive: ### A Landmark Paper that changes our practice. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Twitter-Posts-1.png) "A New Method for Fingertip Amputation" was one of the first descriptions of the "Kutler Flap". Published in [JAMA](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492195/?ref=theplasticsfella.com) in the 1940s. Nearly 80 years ago and it still stands the test of time. Its fame arises from how often it appears on an exam and less so how often it is used in clinical practice. Level of Evidence: IV (Case Series) 🚀 Deep-dive articles are available to those big supporters of P'Fella's mission. _This post is for subscribers on the thePlastics Pro tier only._ ### Z-Plasty: Flap Design, Indications, Variations URL: https://www.theplasticsfella.com/z-plasty/ Last updated: 2025-02-26T14:14:58.000Z #### In this Article 1. [5 Key Points](https://www.theplasticsfella.com/z-plasty/#5-key-points-on-z-plasty) 2. [Definition of Z-plasty](https://www.theplasticsfella.com/z-plasty/#definition-of-z-plasty) 3. [Indications for Z-Plasty](https://www.theplasticsfella.com/z-plasty/#indications-for-z-plasty) 4. [Z-Plasty Design](https://www.theplasticsfella.com/z-plasty/#z-plasty-flap-design) 5. [Variations in Z-Plasty](https://www.theplasticsfella.com/z-plasty/#z-plasty-variations) 6. [Complications of Z-Plasty](https://www.theplasticsfella.com/z-plasty/#z-plasty-complications) 7. [References and Contributions](https://www.theplasticsfella.com/z-plasty/#z-plasty-references-and-contributions) --- ## 5 Key Points on Z-Plasty 1\. A double [transposition](https://www.theplasticsfella.com/classification-of-flaps/) to increase and change the direction of a scar. 2\. Design is based on ****3** limbs, ****2** angles, and ****1** scar. 3\. The angle of each limb determines the length of the new scar 4\. Variations include multiple z-plasties, different angles and limb lengths 5\. The main complication is flap tip necrosis and delayed healing. --- ## Definition of Z-Plasty 🔑 ****Key Point:** Z-plasty is a double-[transposition flap ](https://www.theplasticsfella.com/classification-of-flaps/)that is designed to increase the length of the scar. Z-plasty is a procedure involving the [transposition](https://www.theplasticsfella.com/classification-of-flaps/#flap-movement-classification) of two interdigitating triangular flaps1. It is a common and widely practiced plastic and reconstructive surgery technique used for revisional scar surgery resulting in a functionally better and/or cosmetically appealing scar. The goal of the z-plasty procedure is to: 1. **Lengthen** a contracted scar 2. **Change the direction** of a scar and align it with relaxed skin tension lines. 3. **Improve** cosmesis ![Z-plasty, Z-plasty flap, z-plasty design, z-plasty technique, z-plasty complications](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/2-9.png) Z-plasty is a double transposition flap --- ## Indications for Z-Plasty 🔑 ****Key Point:** The main indication for a Z-plasty is to lengthen and change the direction of the scar. 1. Treatment of contracted scars by increasing scar length 2. Improving cosmesis by changing scar direction along skin tension lines. 3. Prevention of scar contracture, particularly in hand surgery. 4. Facial surgery, such as McGregor flap for eyelid reconstruction 5. Neck contractures from burns or webbing in Turner's Syndrome. 💡 ****Tip:** Z-plasty is most effective when the contracture is of a "bowstring" type not diffuse (which can often be seen in burns). --- ## Z-Plasty Flap Design ### 3 limbs, 2 angles, 1 scar that has increased in length and changed direction. ![Z-plasty, Z-plasty flap, z-plasty design, z-plasty technique, z-plasty complications](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/3-14.png) Z-Plasty Design 1. **3 limbs:** central limb along contracture line that branches to 2 diagonal limbs. 2. **2 angles:** the central and diagonal limbs usually meet at 60° angle. 3. **1 scar:** changes direction, increases longitudinally & shortens transversely. ![Z-plasty, Z-plasty flap, z-plasty design, z-plasty technique, z-plasty complications](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Z-Plasty-2.png) What is the direction of the new scar? Whilst there is lengthening, there is transverse shortening. This means there must be transverse skin laxity for it to work. Sometimes a scar can limit the ability to have equal angles and lengths. If this is the case then the amount of lengthening is the average expects from each angle alone. ![Z-plasty, Z-plasty flap, z-plasty design, z-plasty technique, z-plasty complications](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/4-6.png) Z-plasty outcomes 💡 ****Tip:** If designed properly, the two triangular flaps naturally fall into their new correct position. --- ## Z-Plasty Variations 🔑 ****Key Point:** Z-plasty can vary in limb length, angle and number of limbs Over time, a series of Z-plasty variations have developed to treat specific areas and scar types. The two main variations are in relation to the angle, length, and the number of limbs designed. ### Different Angles A change in angle results in a change in length gained. An increase in angle does increase the length but it also increases the amount of transverse shortening. This can be seen in the image below. ![Z-plasty, Z-plasty flap, z-plasty design, z-plasty technique, z-plasty complications](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Z-Plasty-5.png) Z-Plasty Variations ### Limb length The amount of tissue available on either side of the scar/central limb determines the amount of length. The larger the length, the larger the Z. ### Multiple Limbs The benefit of multiple-limb z-plasty is that it **reduces**: - amount of transverse shortening without significantly affecting the amount of lengthening. - tension on 1 central limb and distributes it evenly over multiple limbs. Here is an example: - **Single Z-plasty:** 2cm in longitudinal length & 2cm transverse shortening - **4-Flap Z-Plasty** (4 x 0.5cm flaps): same length, 1/4 transverse shortening. ![Z-plasty, Z-plasty flap, z-plasty design, z-plasty technique, z-plasty complications](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/6-2.png) Multiple Z-plasty design Commonly used variations include: - **Double opposing z-plasty:** limited skin availability. For example, medial canthal web or scar contracture. - **Unequal z-plasty or half-z:** varied skin elasticity. For example, scar edges. - **Four flap z-plasty/limber flap**: 2 extra limbs allow a considerable gain in length and are useful in severe scar contractures limiting movement example anterior or lateral neck. - **Compound z-plasty: l**inking several Z-plasties in series, used in the exceptionally large scar. - **Planimetric z-plasty** – allows skin lengthening within the plane of skin with limb incisions twice as long as the central incision. Useful in scar interruption or skin lengthening on planar surfaces It can be designed in "parallel" or as "skewed". Parallel design allows the flap to [transposition](https://www.theplasticsfella.com/classification-of-flaps/) uniformly and avoids a broad-tipped flap with a narrow base (seen in "skewed" designs). 💡 ****Tip:** in reality, there is always less longitudinal lengthening of the scar with multiple z-plasty. There tends to be some loss from one Z to the next Z. --- ## Z-Plasty Complications Z-Plasty combinations arise from a poor design or a poor patient selection. The main issues with this flap is: 1. Flap necrosis 2. Hematoma 3. Wound infection 4. Sloughing of Flap 5. Trapdoor Effect1 💡 ****Tip:** keep the flap base wide and the closure without tension. This will reduce the risk of flap necrosis. --- ## Z-Plasty References & Contributions ****✍️** Thank you for the contributions by Manal Nasir, Karachi, Pakistan. Final year MBBS [1\. Salam GA, Amin JP. The basic Z-plasty. Am Fam Physician. 2003;67(11):2329-32.](https://emedicine.medscape.com/article/879878-overview%23a7?ref=theplasticsfella.com) [2\. Aasi SZ. Z-plasty made simple. Dermatol Res Pract. 2010;2010:982623.](https://emedicine.medscape.com/article/879878-overview%23a7?ref=theplasticsfella.com) [3\. 1\. Z-Plasty: Practice Essentials, Indications, Relevant Anatomy \[Internet\]. Emedicine.medscape.com. 2021 \[cited 5 February 2021\]. Available from: https://emedicine.medscape.com/article/879878-overview#a7](https://emedicine.medscape.com/article/879878-overview%23a7?ref=theplasticsfella.com). 4\. Ahmed M, Loh CYY. Double Z plasty advancement flaps for closure of large defects on the forearm. Int Wound J. 2018;15(6):1052. 5\. Zito PM, Jawad BA, Mazzoni T. Z Plasty. \[Updated 2020 Nov 11\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK507775/](https://www.ncbi.nlm.nih.gov/books/NBK507775/?ref=theplasticsfella.com). 6\. Hove CR, Williams EF, 3rd, Rodgers BJ. Z-plasty: a concise review. Facial Plast Surg. 2001;17(4):289-94. ### Brachial Plexus Anatomy URL: https://www.theplasticsfella.com/brachial-plexus-anatomy/ Last updated: 2022-03-11T23:50:18.000Z #### In this Article 1. [5 Key Points](https://www.theplasticsfella.com/brachial-plexus-anatomy/#5-key-points-on-brachial-plexus-anatomy) 2. [Brachial Plexus **Embryology**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#brachial-plexus-embryology) 3. [Brachial Plexus **Overview**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#brachial-plexus-anatomy-overview) 4. [Brachial Plexus **Roots**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#brachial-plexus-anatomy-roots) 5. [Brachial Plexus **Trunks**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#brachial-plexus-anatomy-trunks) 6. [Brachial Plexus **Divisions**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#brachial-plexus-anatomy-divisions) 7. [Brachial Plexus **Cords**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#brachial-plexus-anatomy-cords) 8. [Brachial Plexus **Branches**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#brachial-plexus-anatomy-branches) 9. [Brachial Plexus **Surface Markings**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#brachial-plexus-anatomy-landmarks) 10. Other ways to **learn** the brachial plexus 11. [**References** and **Contributions**](https://www.theplasticsfella.com/brachial-plexus-anatomy/#references-on-brachial-plexus-anatomy) --- ## 5 Key Points on Brachial Plexus Anatomy 1\. **Origin**: the plexus arises from the anterior rami of C5-T1 spinal nerves. 2\. **Segments** of the plexus are: roots, trunks, divisions, cords, branches. 3\. **Course**: intervertebral foramina to posterior triangle to the axilla. 4\. **Main branches:** median, ulnar, radial, axillary, musculocutaneous. 5\. **Embryology:** develops in the 5th week of gestation. ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/9-1.png) Brachial Plexus Anatomy - Overview --- ## Brachial Plexus Anatomy & Embryology The brachial plexus begins to form at the 5th week of embryonic life. The spinal cord forms motor and sensory nerve ventral and dorsal nerve roots. **Motor nerve fibers:** - originate from cells within the basal plate of developing spinal cord. - emerge to the *ventral* nerve root. **Sensory nerve fibers:** - originate from neural crest cells - are found in the *dorsal* nerve root. ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Brachial-Plexus.png) Spinal Nerve Roots - the origin of the brachial plexus --- ## Brachial Plexus Anatomy Overview ### Origins The brachial plexus is formed by the **anterior primary rami** of spinal nerves **C5, C6, C7, C8, T1**. ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/9-2.png) Brachial Plexus Anatomy - Overview ### Course The plexus travels through the posterior triangle of the neck into the axilla, arm, forearm and hand. ### Structure In general, the course followed by the intricate network is: Roots Trunks Divisions Cord Branches. The *mnemonic is *R*ead *T*hat *D*amn *C*adaver *B*ook.* ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Brachial-Plexus-2.png) Segments of the Brachial Plexus --- ## Brachial Plexus Anatomy Roots Roots start the brachial plexus and arise from the anterior rami C5-T1\. Brachial Plexus ‘roots’ refer to the anterior/ventral rami of spinal nerves C5 - T1\. The dorsal rami innervate the skin and musculature of the intrinsic back muscles Here are key points on the anatomy: - Paired spinal nerves arise leave the spinal cord via the **intervertebral foramina** of the vertebral column and divide into an anterior and posterior ramus. - The anterior rami form the roots of the brachial plexus whlst the posterior rami supply innervation to posterior skin and back muscles - The roots travel between the anterior and medial scale towards the base of the neck. ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/4-5.png) Roots in Brachial Plexus Anatomy 💡 Tip: **only** the **anterior rami** of **C5-T1** form the brachial plexus **roots**. --- ## Brachial Plexus Anatomy Trunks **Roots** combine together to form **3 trunks**: **superior**, **middle**, **inferior**. The C5-T1 brachial plexus roots form three **trunks** as they travel across the posterior triangle of the neck. 1. **Superior trunk** – C5 and C6 roots. 2. **Middle trunk** – C7 root. 3. **Inferior trunk** – C8 and T1 roots. ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/5-5.png) Trunks in Brachial Plexus Anatomy --- ## Brachial Plexus Anatomy Divisions **Divisions** are formed by the anterior and posterior division of trunks. As the brachial plexus **trunks** exist the posterior triangle into the axilla, they divides into **anterior** (*towards the front of the body*) and **posterior** (*towards the back of the body)* **divisions**. This results in the formation of 6 **divisions**: - 3 **anterior** divisions - 3 **posterior** divisions ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/6-1.png) Divisions in Brachial Plexus Anatomy --- ## Brachial Plexus Anatomy Cords **Divisions** form **3 cords**: **lateral**, **medial**, **posterior**. Cords are formed from divisions and are named based on their relationship to the axillary artery. - **Lateral cord (C5-C7):** Anterior divisions of Superior and Middle trunks - **Medial Cord (C8, T1):** Anterior division of the Lower trunk. - **Posterior cord (C5-T1)**: Posterior divisons of the three trunks. ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/7-2.png) Cords in Brachial Plexus Anatomy --- ## Brachial Plexus Anatomy Branches The brachial plexus gives rise to 5 main **branches**: radial, median, ulnar, axillary, musculocutaneous. The brachial plexus is the origin of a large number of nerve branches. Theres can be classified as "main branches" and "minor branches". ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/1-10.png) Branches in Brachial Plexus Anatomy ### Main Branches of Brachial Plexus The 5 main branches that originate from the brachial plexus are: 1. **Axillary Nerve:** C5 and C6. 2. **Musculocutaneous nerve:** C5, C6, C7. 3. **Radial Nerve:** C5, C6, C7, C8, T1 4. **Median Nerve:** C6, C7, C8, T1 5. **Ulnar Nerve:** C8 and T1. These main anatomical branches are seen in the image below. ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/8.png) Main Branches in Brachail Plexus Anatomy ### Minor Branches of Brachial Plexus Minor branches arise from multiple locations on the brachial plexus - from the root to the terminal divisions. These minor branches can be classified as supraclavicular and infraclavicular. A simpler way is to catergorised them from their **origin:** 1. **Roots**: Dorsal scapular (C5), Long thoracic (C5-7) 2. **Upper** **Trunk**: Suprascapular (C5-C6), subclavius (C5-C6) 3. **Lateral Cord**: Lateral pectoral (C5-7) 4. **Medial Cord**: Medial pectoral, medial cutaneous of arm & forearm (C8,T1) 5. **Posterior Cord**: Upper & lower subscapular (C5,6), thoracodorsal (C6-8) Here is a table showing innervation and function of the minor branches. ![brachial plexus, anatomy, brachial plexus anatomy, roots, trunks, divisions, cords, branches](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Brachial-Plexus-3.png) Minor Branches in Brachial Plexus Anatomy --- ## Brachial Plexus Anatomy Landmarks The brachial plexus originates in the posterior triangle of the neck. - It extends from the lateral border of the scalene anterior muscle to the caudal (inferior) border of the pectoralis minor where each of the three cords divides into two terminal branches in the axillary fossa. - The posterior triangle is covered superficially by the skin and superficial fascia, then by the platysma muscle and deep fascia. It is pierced by supraclavicular branches of the cervical plexus (C3 and C4). - At the base of the neck, the plexus is behind the clavicle and subclavius muscle. - Transverse cervical and suprascapular arteries cross over parts of the plexus There are 2 methods to identify the brachial plexus: clinically and surgically. ### On Palpation The brachial plexus can be felt by running the fingers along the superior border of the clavicle, at the base of the neck. At about halfway, the cable can be felt running diagonally. ### Surgically While dissecting the upper limb, identify **the characteristic ‘M’ pattern formation** (Musculocutaneous, Median and Ulnar Nerves), usually superficial to the axillary artery. One can work backwards to identify the cords, divisions and branches. --- ## Different ways to learn Brachial Plexus Anatomy There are so many different ways to learn the anatomy of the brachial plexus. Here are 3 different ways you might find useful. > Let me introduce you to this amazing structure. It scares many people who learned it as medical or paramedical student, but to me it’s wonderful clever & beautiful. A triumph of developmental neurology and essential in all we do- let me introduce the brachial plexus via a thread [pic.twitter.com/2WhIAAblEF](https://t.co/2WhIAAblEF?ref=theplasticsfella.com) > > — Tom Quick (@TJQPNI) [May 3, 2020](https://twitter.com/TJQPNI/status/1256937336987926530?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > this. > > by [@alexludai](https://twitter.com/alexludai?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) 🚂 [pic.twitter.com/NeMqQWNRuV](https://t.co/NeMqQWNRuV?ref=theplasticsfella.com) > > — thePlasticsFella (@PlasticsFella) [February 10, 2022](https://twitter.com/PlasticsFella/status/1491845816927068162?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## References on Brachial Plexus Anatomy ✍️ Thank you to the amazing work and contributions of Dr Harsh Shah 1. Bayot ML, Nassereddin A, Varacallo M. Anatomy, Shoulder and Upper Limb, Brachial Plexus. \[Updated 2020 Jul 27\]. In: [StatPearls](https://www.ncbi.nlm.nih.gov/books/NBK500016/?ref=theplasticsfella.com) \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2021 Jan- 2. Warade AC,Jha AK,Pattankar S,Desai K, Radiation-induced brachial plexus neuropathy: A review. [Neurology India](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwj4hqCD4Ln2AhUCgFwKHU-MB5oQFnoECAkQAQ&url=https%3A%2F%2Fwww.neurologyindia.com%2Farticle.asp%3Fissn%3D0028-3886%3Byear%3D2019%3Bvolume%3D67%3Bissue%3D7%3Bspage%3D47%3Bepage%3D52%3Baulast%3DWarade&usg=AOvVaw08GutsWLYrdsliSQRd8Bww). 2019 Jan-Feb; 3. Abdullah S, Bowden RE. The blood supply of the brachial plexus. [Proc R Soc Med](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwj%5Fz-uM4Ln2AhWDYMAKHcfDDp0QFnoECAIQAQ&url=https%3A%2F%2Fjournals.sagepub.com%2Fdoi%2Fabs%2F10.1177%2F003591576005300311&usg=AOvVaw0L2PAAwYvmoUvFIZvus6wW). 1960 Mar;53:203-5. 4. Desai SS,Varacallo M, Anatomy, Shoulder and Upper Limb, Musculocutaneous Nerve [2018 Jan.](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwim67eV4Ln2AhV1QEEAHVJuCD8QFnoECAkQAQ&url=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fbooks%2FNBK534199%2F&usg=AOvVaw02WO75yOWnNmlKrord3rC-) 5. Elzanie A,Varacallo M, Anatomy, Shoulder and Upper Limb, Deltoid Muscle [2018 Jan.](https://www.ncbi.nlm.nih.gov/books/NBK537056/?ref=theplasticsfella.com) 6. Pester JM,Varacallo M, [Median Nerve Block Techniques ](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjsioKk4Ln2AhWoQUEAHdgCCScQFnoECA0QAQ&url=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fbooks%2FNBK459141%2F&usg=AOvVaw37UCqAp7sIg9Ce3ErjaQTM)2018 Jan 7. Gragossian A,Varacallo M, [Radial Nerve Injury](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwj9hPGq4Ln2AhXVEcAKHb1rCQcQFnoECA4QAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F30725989%2F&usg=AOvVaw2byEXnxgk7BJnU1t1HK-Ma) 2018 Jan. 8. Pester JM,Varacallo M,[ Ulnar Nerve Block Techniques ](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjt6tGy4Ln2AhVIVsAKHetJDP0QFnoECAwQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F29083721%2F&usg=AOvVaw38ZKe4rBQM90kOecGSNYq9)2018 Jan. 9. Thatte MR, Mehta R. Obstetric brachial plexus injury. Indian J Plast Surg. 2011;44(3):380-389.[ doi:10.4103/0970-0358.90805](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwihxOy84Ln2AhUTWsAKHXyjB64QFnoECAkQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F22279269%2F&usg=AOvVaw3yLfQAs8I8MT6FHpahWspr) 10. Kuhn JE, Lebus V GF, Bible JE. Thoracic outlet syndrome. J Am Acad Orthop Surg. 2015 Apr;23(4)[:222-32.](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiIvrPD4Ln2AhUEQEEAHcBIAi8QFnoECAkQAQ&url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F25808686%2F&usg=AOvVaw3vEc88wlYxgJ7pr68%5F8qpX) 11. Johnson D. Pectoral girdle and upper limb: overview and surface anatomy. Standring S,et al, ed-in-chief. In:Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th ed. Churchill Livingstone Elsevier;[ 2008:777-790: chap 45, sec 6: Pectoral Girdle and Upper Limb.](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwizrY3J4Ln2AhXYMMAKHaduD38QFnoECAcQAQ&url=https%3A%2F%2Fadams.marmot.org%2FRecord%2F.b28306880&usg=AOvVaw2AMw7sdbiqoWnziSKlw77g) 12. Shah HR, Takwale AB, Thatte MR. A Brachial Plexus with an Aberrant Middle Trunk: A Rare Anomaly. Indian J Plast Surg. 2019;52(3):364-365\. doi:[10.1055/s-0039-3401523](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiZs9PT4Ln2AhXQa8AKHV3lAR4QFnoECAsQAQ&url=https%3A%2F%2Fwww.thieme-connect.com%2Fproducts%2Fejournals%2Fhtml%2F10.1055%2Fs-0039-3401523&usg=AOvVaw0H6s6PdunAWbzLoH%5FGwWE7) --- ### Burn Depth - Classification, Assessment, Characteristics. URL: https://www.theplasticsfella.com/burn-depth/ Last updated: 2025-12-15T19:21:04.000Z --- #### In this Article 1. [Burn Depth Classification](https://www.theplasticsfella.com/burn-depth/#burn-depth-classification) (Chart + Download) 2. [Superficial Burns](https://www.theplasticsfella.com/burn-depth/#superficial-burn-depth-1st-degree-burns) 3. [Partial Thickness Burns](https://www.theplasticsfella.com/burn-depth/#partial-thickness-burn-depth-2nd-degree-burns): Superficial, Mid, and Deep Dermal 4. [Full Thickness Burns](https://www.theplasticsfella.com/burn-depth/#full-thickness-burn-depth-3rd-degree-burns) 5. [Flashcards on Burns](https://www.theplasticsfella.com/burn-depth/#flashcards-on-burn-depth) 6. [References & Contributions](https://www.theplasticsfella.com/burn-depth/#references-on-burn-depth) --- ## 5 Key Points on Burn Depth Assessment 1\. Burn depth is classified into **superficial**, **partial**, and **full-thickness.** 2\. Assessment focuses on **colour**, **pain**, **blanching**, **blisters**, **sensation.** 3\. **Superficial** burns are like sunburn - hot, red, painful, no blisters. 4\. **Partial-thickness** burns have blisters as the dermis is now involved. 5\. **Full-thickness burns** can be charred, leathery, and insensate. ![Burn Depth Classification Chart, Burn Classification, Depth, Burn, Chart, Superifical, 1st Degree, Superificial Partial, Mid Partial, Deep Partial, Full Thickness, 2nd Degree, 3rd Degree, Burn Depth](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Burn-Depth-2.png) Burn Depth ## --- ## Burn Depth Classification The following chart and table outline the assessment and characteristics for each burn depth. Burn depth and [total body surface area of a burn](https://www.theplasticsfella.com/total-body-surface-area-in-burns/) are two key aspects of a burn assessment. The assessment of burn depth, and as such, the estimation of whether a burn wound is expected to heal on its own within 21 days, is one of the most important roles of the burn surgeon4. Currently, the determination of burn depth based on clinical examination is only 70% accurate1. It can be difficult to effectively stratify burn wounds. A burn is a dynamic process for the first few days and a burn that appears shallow on day 1 may appear deep by day 32. A deeper burn may require more [fluid resuscitation](https://www.theplasticsfella.com/burns-fluid-resuscitation/). ![Burn Depth Classification Chart, Burn Classification, Depth, Burn, Chart, Superifical, 1st Degree, Superificial Partial, Mid Partial, Deep Partial, Full Thickness, 2nd Degree, 3rd Degree, Burn Depth](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Burn-Depth-4.png) Burn Depth Classification Chart Despite the plethora of technological advances, the most common technique for diagnosing burn depth remains the clinical assessment of an experienced burn surgeon. A clue is often in the history - type of burn and immediate first aid. You can download this burn depth chart with the link below. [ Burn Depth Classification Burn Depth Classification.png 232 KB download-circle ](https://www.theplasticsfella.com/content/files/2022/03/Burn-Depth-Classification.png "Download") 💡 **Tip:** it's very rare for a burn to be one specific depth. The majority of burns are "mixed thickness" with one depth more present than the others. --- ## Superficial Burn Depth (1st Degree Burns) A superficial burn is similar to a "sunburn" - red, painful, and generally resolves over a few days. A superficial burn (1st degree) has the following characteristics: - Involve the epidermis - Warm, painful, red/erythematous, soft, and blanching. - No blistering. - A typical example is a sunburn. - Healing by rapid re-epithelialization3 ![Burn Classification, Depth, Burn, Chart, Superifical, 1st Degree, Superificial Partial, Sunburn, Burn Depth](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Superificial-1st-Degree-Burn.png) Superficial Burn 💡 **Tip:** Areas of redness or erythema are not included in the calculation of the [total body surface area of a burn](https://www.theplasticsfella.com/total-body-surface-area-in-burns/). Therefore, it does not influence the volume of [fluid resuscitation](https://www.theplasticsfella.com/burns-fluid-resuscitation/). --- ## Partial Thickness Burn Depth (2nd Degree Burns) A partial-thickness burn has 3 subclassifications: superficial-dermal, mid-dermal, and deep-dermal ### Superficial dermal partial thickness A superficial partial-thickness burn (2nd degree) has the following characteristics: - Involves epidermis and into the papillary dermis - Painful, red, blistered, moist, soft, and blanching when touched. - When blistered are deroofed, the skin is moist, red, and hypersensitive. ![Burn Classification, Depth, Burn, Chart, Superfical-Partial, Blisters, 2nd Degree, Superficial Partial, Burn Depth, Assessment, Characteristics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Superficial-partial-Burn-2nd-degree.png) Superficial-Partial Thickness Burn 💡 **Tip:** Blisters are a collection of fluid between the interface of the epidermis and dermis. If there are blisters, it means the burn cannot be superficial. ### Mid dermal partial thickness ![Burn Classification, Depth, Burn, Chart, Mid-Partial, Blisters, 2nd Degree, Mid Partial, Burn Depth, Assessment, Characteristics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Mid-partial-Burn-2nd-degree..png) Mid-Partial Burn 💡 **Tip:** Burns that heal within 3 weeks generally do so without hypertrophic scarring or functional impairment, although long term pigmentary changes are common ### Deep dermal partial thickness A deep partial-thickness burn (2nd degree) has the following characteristics: - Involves epidermis and into the reticular dermis - It can also blister but is less likely than a superficial dermal burn. - The wound surface is usually a mottled pink immediately following the injury and overtime may progress to a whiter and drier wound. - Blanching is minimal or non-existent (due to capillary damage) - Reduced sensation and less pain. ![Burn Classification, Depth, Burn, Chart, Mid-Partial, Blisters, 2nd Degree, Mid Partial, Burn Depth, Assessment, Characteristics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Deep-partial-Burn-2nd-degree.png) Deep-Partial Burn --- ## Full Thickness Burn Depth (3rd Degree Burns) A full-thickness burn is an insensate, non-blanching, painless burn that can have an overlying black eschar or feel like leather. A full-thickness burn (3rd degree) has the following characteristics: - Involve epidermis, dermis, and into the subcutaneous fat or deeper. - Minimal or no pain - Colour can be white, brown, or charred - Feel firm and leathery with no blanching. ![Burn Classification, Depth, Burn, Chart, Full Thickness, Eschar, 3rd Degree, Burn Depth, Assessment, Characteristics](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Full-Thickness-Burn-3rd-degree-1.png) Full Thickness Burn 💡 **Tip:** Superficial Burns and Full Thickness burns don't have blisters! --- ## Flashcards on Burn Depth Test your knowledge with the largest online flashcard database! ![burn flashcards, plastic surgery flashcards, questions, burns, plastic surgery](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Burn-Depth-3.png) [Get Access to Flashcards](https://www.theplasticsfella.com/theplasticsflash/) --- ## References on Burn Depth ✍️ Thank you to Abdulrahman Abdulaziz Alghamdi for his contribution to this article. 1. Bezuhly, Michael F.R.C.S.C.; Fish, Joel S. F.R.C.S.C. Acute Burn Care, Plastic and Reconstructive Surgery: August 2012 - Volume 130 - Issue 2 - p 349e-358e doi: [10.1097/PRS.0b013e318258d530](https://journals.lww.com/plasreconsurg/Abstract/2012/08000/Acute%5FBurn%5FCare.36.aspx?ref=theplasticsfella.com) 2. Heimbach D, Engrav L, Grube B, Marvin J. Burn depth: a review. World J Surg. 1992 Jan-Feb;16(1):10-5\. doi: 10.1007/BF02067108\. PMID: 1290249. 3. Monstrey S, Hoeksema H, Verbelen J, Pirayesh A, Blondeel P. Assessment of burn depth and burn wound healing potential. Burns. 2008 Sep;34(6):761-9\. doi: [10.1016/j.burns.2008.01.009](https://pubmed.ncbi.nlm.nih.gov/18511202/?ref=theplasticsfella.com). Epub 2008 Jun 3\. PMID: 18511202. 4. Amín D. Jaskille, MD, Jeffrey W. Shupp, MD, Marion H. Jordan, MD, James C. Jeng, MD, Critical Review of Burn Depth Assessment Techniques: Part I. Historical Review, **Journal of Burn Care & Research*, Volume 30, Issue 6, November-December 2009, Pages 937–947, [https://doi.org/10.1097/BCR.0b013e3181c07f21](https://doi.org/10.1097/BCR.0b013e3181c07f21?ref=theplasticsfella.com) --- ### 4 Best Resources for Plastic Surgery Residency Interviews. URL: https://www.theplasticsfella.com/plastic-surgery-residency-interview/ Last updated: 2024-02-01T22:38:57.000Z ## In this Article ### Plastic Surgery Residency Interviews 1\. [Questions Banks and Courses](https://www.theplasticsfella.com/plastic-surgery-residency-interview/#plastic-surgery-residency-interview-question-banks-and-courses) 2\. [Residency Interview Websites](https://www.theplasticsfella.com/plastic-surgery-residency-interview/#plastic-surgery-residency-websites) 3\. [Publications](https://www.theplasticsfella.com/plastic-surgery-residency-interview/#publications-on-the-plastic-surgery-residency-interview) 4\. [Mindset](https://www.theplasticsfella.com/plastic-surgery-residency-interview/#mindset-of-the-plastic-surgery-residency-interview) --- ## Plastic Surgery Residency Interview Question Banks and Courses When it comes to the Plastic Surgery Residency interview 2 things are gauranteed. Firstly, you'll be tempted to pay for an overpiced course! Secondly, you will pay for that overpiced course! Purely out of fear and anxiety. FOMO. This section will help you avoid those courses. ### [the PlasticsInterview ](https://www.theplasticsfella.com/interview/) [thePlasticsInterview](https://www.theplasticsfella.com/interview/) is a 360° companion to the plastic surgery residency interview. It is designed specifically for plastic surgery residency & ST3 interviews. The goal is to help you rank number 1 in your interview. This interview course and companion is used by an international cohort of future plastic surgery trainees. It is popular in the UK, USA, Europe, and Australia residency programs. Every year it is updated to reflect the ever-changing plastic surgery interview landscape. ![plastic surgery residency interviews, residency interviews, plastic surgery interviews, plastic surgery interview questions, interview bank](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Plastic-Surgery-Interview---Landing-Page-2.png) Plastic Surgery Interview Residency [Check out thePlasticsInterview](https://www.theplasticsfella.com/interview/) ### American College of Surgeons Interview Questions This is a nice broad overview of the type of questions to expects in the residency interview process. Unlike [thePlasticsInterview](https://www.theplasticsfella.com/interview/), it isn't plastic surgery specific and there are not any answers or answer templates. [Residency Interview QuestionsWhat questions should you ask during your residency position interview?![](https://www.facs.org/~/media/images/favicon.ashx)American College of Surgeons![](http://www.facs.org/-/media/images/home/social/facebook/2017_fb_three_line_acs_logo_1200x627.ashx)](https://www.facs.org/education/resources/medical-students/faq/questions?ref=theplasticsfella.com) Those above residency interview questions are fromthe Case Western Reserve University (CWRU) Department of Otolaryngology-Head and Neck Surgery Web site. Again, they are not plastic surgery specific, but still insightful. --- ## Plastic Surgery Residency Websites Plastic Surgery residency interviews are a key aspect to the match process. Now, it's time to show-off, be yourself, be confidency and be competent. You'll be observed and you should observe specific parts of the program you are applying to. At the end of the day, you could consider this to be the most important job interview you will ever do. ### Plastics Match Insider This is a website for the Plastic Surgery match. As they say on their homepage, "we are a group of residents and fellows at some of the top integrated and independent plastic surgery programs in the U.S. We recognized that there is no central source for unbiased advice on how to navigate the application, interview, and matching process in plastic surgery". They offer a product called "Integrated & Independent Plastic Surgery Interview Guide". It costs $24.95 (at the time this is written). P'Fella bought it. It's pretty good, but not amazing. In my opinion, it probably should be free but I'm sure they will get a few sales for people taking part in plastic surgery residency interviews ### Inside the Match Interviews This [website](https://www.insidethematch.com/?ref=theplasticsfella.com) is "Everything you wanted to know about the residency match process—but were afraid to ask". Now, it isn't plastic surgery-specific, but it does provide a good number of resources for you. For example, they have a podcast that interviews a broad group of people about their interview experiences and matching for their programs. It is mainly directed at the USA market but no doubt the information could be applied to other areas. [Get Tips](https://www.insidethematch.com/match-tips/tips-for-plastic-surgery-interviews?ref=theplasticsfella.com) ### Residency Institutions or Plastic Surgery Interview Societies As expected, there are a number of governing bodies out there that will provide you with formal guidance for your upcoming plastic surgery interview. It's best to find out about your regional or national training body as they will have all the relevant dates and information. Here are a few important groups (depending on what location you are applying to). 1. [American Society of Plastic Surgery](https://www.plasticsurgery.org/for-medical-professionals/community/career-resources/interviewing-tips?ref=theplasticsfella.com) 2. [American Council of Academic Plastic Surgeons ](https://acaplasticsurgeons.org/interview-dates/?ref=theplasticsfella.com) 3. Individual Regions, for example, [Indiana](https://medicine.iu.edu/surgery/education/residency/plastic-surgery/application/faq-residency-interviews?ref=theplasticsfella.com), [Harvard](https://www.plasticsurgeryresidency.hms.harvard.edu/prospective-applicants?ref=theplasticsfella.com), [Stanford](https://plasticsurgery.stanford.edu/education/residency/programfaq.html?ref=theplasticsfella.com). --- ## Publications on the Plastic Surgery Residency Interview The best way to prepare for your plastic surgery residency interviews is by an evidence-based approach. There is a large number of publications out there to give you insight into the residency process and the best ways to prepare for your plastic surgery interview. Here are a few that will help you in your residency interview preparation 1. [The Plastic Surgery Residency Interview Revisited: Virtual Interviews and Beyond](https://journals.lww.com/plasreconsurg/Fulltext/2020/11000/The%5FPlastic%5FSurgery%5FResidency%5FInterview%5FRevisited%5F.55.aspx?ref=theplasticsfella.com) 2. [The Cost of Applying to Integrated Plastic Surgery Residency](https://pubmed.ncbi.nlm.nih.gov/33564569/?ref=theplasticsfella.com) 3. [Virtual Interviews for the Integrated Plastic Surgery Residency Match: The Program Director Perspective](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8376389/?ref=theplasticsfella.com) 4. [Virtual Interviews for the Independent Plastic Surgery Match: A Modern Convenience or a Modern Misrepresentation?](https://pubmed.ncbi.nlm.nih.gov/32958417/?ref=theplasticsfella.com) 5. [Looking back: the plastic surgery application and interview process](https://pubmed.ncbi.nlm.nih.gov/24076692/?ref=theplasticsfella.com) 6. [The Plastic Surgery Match: A Quantitative Analysis of Applicant Impressions From the Interview Visit](https://pubmed.ncbi.nlm.nih.gov/27740953/?ref=theplasticsfella.com) Hopefully, those interview resources aren't behind a pay wall. They should be free to read. --- ## Mindest of the Plastic Surgery Residency Interview Don't get too distracted by all these amazing plastic surgery interview residency resources. Whilst a lot of them can be helpful as a [companion](https://www.theplasticsfella.com/interview/), it is very important that you believe in yourself as a plastic surgeon. One example is this article called **ASPS Interview Tips** ****Disclaimer**: [ASPS Interview Tips](https://www.plasticsurgery.org/for-medical-professionals/community/career-resources/interviewing-tips?ref=theplasticsfella.com) is not specific to plastic surgery residency interviews. With that in mind, it does provide a bit of context to the interview experience. IF you read through the article, you can find some nice gems in there. It's more for experience rather than the actual content. It's worth a read, even thought it's not specific to the plastic surgery residency interview. [Interviewing TipsYour impressive CV and intelligent cover letter has secured you an interview. Learn how to prepare and what questions do you ask.![](https://www.plasticsurgery.org/resources/icon/android-icon-192x192.png)American Society of Plastic SurgeonsAmerican Society of Plastic Surgeons![](https://www.plasticsurgery.org/images/Logos/asps-social-thumbnail.jpg)](https://www.plasticsurgery.org/for-medical-professionals/community/career-resources/interviewing-tips?ref=theplasticsfella.com) You must have confidence in your preparation. Hope these plastic surgery interview resources can guide you in the right direction --- [![plastic surgery residency interviews, residency interviews, plastic surgery interviews, plastic surgery interview questions, interview bank](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Plastic-Surgery-Interview---Landing-Page-2.png)](https://www.theplasticsfella.com/interview/) Plastic Surgery Interview Residency ### thePlasticsPaper - March 6th URL: https://www.theplasticsfella.com/march-6th/ Last updated: 2022-03-06T10:59:26.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/march-6th/#a-letter-from-pfella) \- what is "indie, open-sourced, not-for-profit"? 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/march-6th/#weekly-quiz-competition) \- Round 2 (updated leaderboard!) 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/march-6th/#upcoming-events) \- 17 events coming soon! 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/march-6th/#tweets-of-the-week) \- memes, images, ideas. 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/march-6th/#new-feature) \- Email Course, Authorships, Anki! 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/march-6th/#articles-of-the-week) \- Rapid Review & Deep Dive [What's the email course?](https://www.theplasticsfella.com/theplasticspaper/march-6th/#new-feature) --- ## ✍️ ## A Letter from P'Fella Have you ever wondered WTF is thePlasticsFella? *"independent, not-for-profit, open-sourced platform creating evidence-based educational tools"* well, what does that all mean? **Independence** To put it simply, P'Fella is not associated with any organization, advertising, pharmaceutical company, society, training body, country, college, or university. Why? There is something romantic, unique & trustworthy about it. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/2-6.png) **Not for Profit. Really?? Yes, really.** The monetization of education is a slippery slope. It's a complete misalignment of incentives. P'Fella has developed a "sustainable business model". Here's how 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/4-2.png) **Open-Sourced.** Do you mean an open journal? No. It's a term coined by software gurus to identify an approach to creating programs. It now represents a much bigger picture & values of open exchange, collaboration, participation, transparency What does that mean for you 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/3-6.png) [Read the Mission](https://www.theplasticsfella.com/about/) --- ## 🤓 ## Weekly Quiz Competition ### Round 2! New Question ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/thePlastics-Quiz-Weekly.png) [Round 2 & Leaderboard!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 17 Webinars, Conferences, and Courses 1. [ASPS Spring Meeting](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) \- Virtual, March 2022. 2. [ASSH](https://www.assh.org/s/course-detail?id=aBP5b00000096y0GAA&ref=theplasticsfella.com) \- Upper Limb Micro Recon - Virtual, March 26th. 3. [IFSSH Combined Conference](https://ifssh2022.com/?ref=theplasticsfella.com#registration) \- London, April 2022\. 4. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 5. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022\. 6. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022\. 7. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 8. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022\. 9. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 10. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 11. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 12. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 13. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 14. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022\. 15. [European Society of Craniofacial Surgery](https://escfs2022.com/?ref=theplasticsfella.com) \- Oxford, September 2022\. 16. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 17. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week ### Here are 3 tweets you might have missed! > [#surgeonsforUkraine](https://twitter.com/hashtag/surgeonsforUkraine?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) 🇺🇦 [pic.twitter.com/OmOgeVyj8J](https://t.co/OmOgeVyj8J?ref=theplasticsfella.com) > > — Jeff Friedrich (@JeffFriedrichMD) [February 28, 2022](https://twitter.com/JeffFriedrichMD/status/1498435326607384585?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Pending editorial decision [pic.twitter.com/MlAFmyzzK7](https://t.co/MlAFmyzzK7?ref=theplasticsfella.com) > > — Oded Rechavi 🦉 (@OdedRechavi) [March 3, 2022](https://twitter.com/OdedRechavi/status/1499335041670959104?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > AIN End to side transfer to ulnar motor branch is a tool to try to obtain a recovery of intrinsic muscle atrophy in patients with severe próximal ulnar nerve compression. Yesterday I developed this patient with my partner Jorge Ruiz MD. [pic.twitter.com/Kw43octwXa](https://t.co/Kw43octwXa?ref=theplasticsfella.com) > > — HOMID FAHANDEZH (@HOMIDFAHANDEZH) [March 5, 2022](https://twitter.com/HOMIDFAHANDEZH/status/1500152372219285514?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### P'Fella has been busy this week **A Free 5-day email course for Plastic Surgery Interviews** It starts tomorrow! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/5-day-email-course-1-1.png) [Register your interest](https://www.theplasticsfella.com/free-email-course/) **Updated the homepage!** Now it's easier to access your flashcards, interview prep, and quizzes! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Untitled-design-36.png) ### Anki-compatible Flaschards This was hotly requested! thePlasticsPro users can now download anki decks directly into their own accounts. The decks are always being updated. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/the-plastics-flash.png) [Get Anki Flashcards!](https://www.theplasticsfella.com/theplasticsflash/) **Updated thePlasticsCreator!** This is a key aspect of a sustainable education model. You can now create content to get access to the premium educational tools (flashcards, pro version of thePlasticsPaper, interview prep, and quizzes) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/brunch-12.png) [Boost your CV!](https://www.theplasticsfella.com/theplasticscreator/) --- ## 📝 ## Articles of the Week ### Rapid-Review & Deep-Dive ### Rapid Review: A new way to diagnose flexor tenosynovitis? *A1 Pulley Tenderness as a Modification to Tenderness along the Flexor Sheath in Diagnosing Pyogenic Flexor Tenosynovitis.* Siska *et al, [PRS](https://journals.lww.com/prsgo/Fulltext/2022/03000/A1%5FPulley%5FTenderness%5Fas%5Fa%5FModification%5Fto.3.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)* - **Aim**: To increase specificity for diagnosing flexor tenosynovitis by including tenderness over the A1 pulley (in addition to the usual sign of tenderness over the flexor sheath). - **Methods**: A retrospective chart review over 8 months - **Results**: 33 patients showed A1 pulley tenderness had the greatest odds ratio, positive predictive value, specificity, and accuracy when compared with all Kanavel signs. When used in conjunction with each Kanavel sign, there was an increase in specificity in all four signs. - **Conclusions:** Tenderness at the A1 pulley can be a useful add-on to the usual of “tenderness over the course of the flexor sheath”. ✍️ **P'Fella's Opinion:** This is a relatively low-yield study that won't change my clinical practice. The level of evidence is low (retrospective chart-review case series). The clinical sign they are describing is already included in a standard clinical examination for flexor tenosynovitis. To put it simply, the A1 pulley is along the flexor sheath - they aren't describing something new. When someone presents with flexor tenosynovitis, they are going to theatre regardless of how tender they are over the A1 pulley. ### Deep Dive: A Landmark Paper that changes our practice forever. *Report of the Committee on Tendon Injuries (International Federation of Societies for Surgery of the Hand)* H E Kleinert, C Verdan. [J Hand Surg 1983](https://pubmed.ncbi.nlm.nih.gov/6630960/?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/1-5.png) 🚀 Deep-dive articles are available to those big supporters of P'Fella's mission. You can try it out [here](https://www.theplasticsfella.com/theplasticspaper/march-6th/#/portal/signup). _This post is for subscribers on the thePlastics Pro tier only._ ### Clinical Case URL: https://www.theplasticsfella.com/upper-eyelid-bcc/ Last updated: 2022-03-05T18:33:59.000Z 44 year-old-female with a biopsy-proven nodular BCC on her right eyebrow. What reconstruction options would you consider? **Comment your answer below!** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Twitter-Posts-8.png) **What is your preference?** Primary closure, local flap, graft. The more specific the better! ### Zones of the Hand (Original Publication) URL: https://www.theplasticsfella.com/zones-of-the-hand-original-publication/ Last updated: 2022-03-05T14:30:20.000Z A "round-table discussion" that decided the way we talk about and treat flexor tendon repairs. The majority of this 1983 publication still stands the test of time. This journal club looks at the classification, nutrition and healing, post-operative rehabilitation of flexor tendon injuries. --- ## Classification To this day, the same classification exists. And it doesn't look like it will be replaced any time soon! You can read more about [flexor tendon zones](https://www.theplasticsfella.com/zones-of-the-hand/). ![zones of the hand, flexor tendon injury, extensor tendon injury](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/2-4.png) Zones of the Hand --- ## Tendon nutrition and healing. This group of people was smart. They were spot on with their understanding. Here are a few important points 1. Flexors are supplied by the vincular system. 2. Sheath is a "synovial fluid propulsion system" 3. Intrinsic blood supply through the synovial fluid. 4. It's not surprising when you see the faculty attendance It's not surprising when you look at all the famous names ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/3-4.png) --- ## Post-operative rehab This is the section that prob hasn't stood the test of time. The publications suggest that early passive range of movement and that both flexor tendons should be repaired. The former is no longer correct, the latter is still debated. --- ## Evaluation of the Injury This is great. And it's prob better than any app or website trying to do the same. It's just simple and to the point. A great table for anyone starting out in plastic surgery ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/4.png) [Read the Article](https://pubmed.ncbi.nlm.nih.gov/6630960/?ref=theplasticsfella.com) ### Quadriga Phenomenon URL: https://www.theplasticsfella.com/quadriga-phenomenon/ Last updated: 2022-03-04T09:50:03.000Z **In this Article** 1\. [Definition of Quadriga ](https://www.theplasticsfella.com/quadriga-phenomenon/#definition-of-quadriga) 2\. [Pathophysiology and History ](https://www.theplasticsfella.com/quadriga-phenomenon/#pathophysiology-of-quadriga) 3\. [Causes of quadriga ](https://www.theplasticsfella.com/quadriga-phenomenon/#causes-of-quadriga) 4\. [Treatment of quadriga](https://www.theplasticsfella.com/quadriga-phenomenon/#treatment-of-quadriga) 5\. [Flashcards](https://www.theplasticsfella.com/quadriga-phenomenon/#flashcards) 5\. [References](https://www.theplasticsfella.com/quadriga-phenomenon/#references) --- ## Definition of Quadriga Quadriga phenomenon or syndrome is reduced flexion in non-injured fingers caused by a shortened, stiff, or adherent FDP in an adjacent injured finger. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/1-3.png) Clinical Diagnosis of Quadriga Syndrome It results in an *active flexion lag* and "weak grip" that can be diagnosed clinically. It was first described by Bunnell3 and later by Verdan2 after a series of terminalisations and [flexor tendon repairs](https://www.theplasticsfella.com/flexor-tendon-injury-repair/). --- ## Pathophysiology of Quadriga *Quadriga* refers to the 4-horse Roman chariots controlled by 1 driver through 1 common rein. If that rein becomes shortened to one horse then the other horses will experience a tethering effect. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/2-2.png) Pathophysiology of Quadriga Syndrome *Quadriga Phenomenon* is based on the principle that excursion of the combined tendons is equal to the shortest tendon. It occurs because: 1. The **injured** FDP tendon becomes shortened, stiff, or adherent. 2. **Non-injured** adjacent FDP tendons are tethered (they share a common origin) and have a reduced excursion. 3. **Non-injured** FDP tendons cannot fully flex their respective digits. 4. The **injured** finger develops a flexion deformity. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/03/Quadriga-Phenomenon-3.png) Anatomy of Quadriga Syndrome The quadriga phenomenon is frequently attributed to the common muscle belly of the FDP. However other factors, such as the interconnections between the FDP tendons, maybe even more important1. --- ## Causes of Quadriga It is important to be aware that there is most than 1 cause. However, by far the most common cause is related to FDP pathology. Causes of Quadriga Syndrome or Phenomenon are: 1. FDP tendon is advanced too far distally in a [repair](https://www.theplasticsfella.com/flexor-tendon-injury-repair/) procedure in [zone 1](https://www.theplasticsfella.com/flexor-tendon-injury-repair/). 2. Tendon graft that is too short 3. A distal finger amputation in which the flexor is sutured over the tip to the extensor tendon. 4. Amputation in which the FDP tendon adheres or has been [repaired](https://www.theplasticsfella.com/flexor-tendon-injury-repair/) to to the proximal phalanx. 💡 **Clinical Tip:** Quadriga and Lumbrical Plus Finger are similar but quite different. In quadriga, the FDP is **overtightened** or scarred resulting in a **weak grip**. Whilst lumbrical plus finger occurs from a **lax** FDP tendon and increase tension in the lumbricals causing a finger **stick out** when attempting to hold an object. --- ## Treatment of Quadriga Treatment is observation if patient is minimally symptomatic. Surgical options do exist. Surgical Options for Quadriga include: - release of FDP tendon of injured digit - tendon lengthening - tenolysis post-[flexor tendon repair](https://www.theplasticsfella.com/flexor-tendon-injury-repair/) - severing of the offending tendon to allow the other normal adjacent fingers to flex fully x --- ## Flashcards [Get more Flashcards](https://www.theplasticsfella.com/flashcards/) --- ## References 1. Schreuders, T. A. R. (2011). *The quadriga phenomenon: a review and clinical relevance. Journal of Hand Surgery (European Volume), 37(6), 513–522.*doi:10.1177/1753193411430810 2. Verdan C: Syndrome of the quadriga. Surg Clin North Am 1960; 40: pp. 425-426 3. Bunnell S: Reconstructive surgery of the hand. Surg Gynecol Obstet 1924; 34: pp. 259-274 ### Kutler Flap - Original Publication URL: https://www.theplasticsfella.com/kutler-flap-publication/ Last updated: 2022-03-13T13:05:43.000Z A classic in plastic surgery peer-reviewed literature. Here's a deep-dive on an important article in plastic surgery history. _This post is for subscribers on the thePlastics Pro tier only._ ### thePlasticsPaper - February 27th URL: https://www.theplasticsfella.com/february-27th/ Last updated: 2022-02-27T11:58:45.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/february-27th/#a-letter-from-pfella) \- Yes, 600+ verified flashcards 2\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/february-27th/#weekly-quiz-competition) \- Round 1 (new season!) 3\. 🔠 [Wordle for Plastics Surgeons](https://www.theplasticsfella.com/theplasticspaper/february-27th/#wordle-for-plastic-surgeons) \- ok, this is hard. 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/february-27th/#upcoming-events) \- 21 webinars & courses. 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/february-27th/#tweets-of-the-week) \- memes, images, ideas. 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/february-27th/#new-feature) \- thePlasticsFlash is here! Popular 🤩 7\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/february-27th/#articles-of-the-week) \- Rapid Review & Deep Dive --- ## ✍️ ## A Letter from P'Fella ### Welcome the newest member of the family - thePlasticsFlash. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/What-is-the-Leddy-packer-classification-3.png) [Get Flashcards](https://www.theplasticsfella.com/flashcards/) **This is great.** It is. Trust me. thePlasticsFella community was asked 1 question - what is your preferred way to study Plastic Surgery? **The answer, flashcards.** So P'Fella created them. 600+ evidence-based flashcards with detailed answers and references. The average flashcard collection costs \~$90 and is never updated. thePlasticsFlash is the lowest possible cost to support the sustainable, not-for-profit, education model. You can now see the family tree below 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/the-Plastics-Fella-family.png) Family Tree --- ## 🤓 ## Weekly Quiz Competition ### Round 1! Don't miss out. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-35.png) Last season, 200+ people took part in the weekly quiz. Now season 2 is here! **The new rules...** 1. There will be a fresh **new leaderboard**! 2. There will be a **$100 voucher prize**. 3. There will be **10 questions** in the season. 4. **1 winner** will be crowned the "smartest plastic surgeon in the world". [Round 1!](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🔠 ## Wordle for Plastic Surgeons ### Created specifically for Plastics! p.s - share your results on Twitter and [@plasticsfella.](http://twitter.com/plasticsfella?ref=theplasticsfella.com) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-28-1-1.png) [Click to Play](https://mywordle.strivemath.com/?word=cfrie&ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 18 Webinars, Conferences, and Courses 1. [Pulvertaft ](https://us02web.zoom.us/webinar/register/WN%5F9FjBNL5KT6OXVfNn7uwlfQ?ref=theplasticsfella.com)\- Polishing your Presentation - Feb 28th 2. [PLASTA](https://us02web.zoom.us/webinar/register/WN%5F51N8fe5sSMSVgrozQUsV%5FQ?ref=theplasticsfella.com) \- ST3 Interview Prep - March 1st 3. [ASPS In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/in-service-exam-for-surgeons?ref=theplasticsfella.com) \- Virtual, March 2022. 4. [ASPS Spring Meeting](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) \- Virtual, March 2022. 5. [ASSH](https://www.assh.org/s/course-detail?id=aBP5b00000096y0GAA&ref=theplasticsfella.com) \- Upper Limb Micro Recon - Virtual, March 26th. 6. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 7. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022\. 8. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022\. 9. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 10. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022\. 11. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 12. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 13. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 14. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 15. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 16. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022\. 17. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 18. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week ### Here are 3 tweets you might have missed! > The [#BrachialPlexus](https://twitter.com/hashtag/BrachialPlexus?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) is a complex web of nerves which control the upper limb. All the information on controlling tone, complex movements, touch, pain and temperature regulation run back and forth through these nerves. All of these functions can be disrupted by injury. [pic.twitter.com/mDth7mE7zW](https://t.co/mDth7mE7zW?ref=theplasticsfella.com) > > — Tom Quick (@TJQPNI) [February 22, 2022](https://twitter.com/TJQPNI/status/1496171896152412167?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Anyone seen this type of deformity before? Five phalanges is too(two?) many! [#bones](https://twitter.com/hashtag/bones?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#joints](https://twitter.com/hashtag/joints?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#hands](https://twitter.com/hashtag/hands?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#fingers](https://twitter.com/hashtag/fingers?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#Xray](https://twitter.com/hashtag/Xray?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#radiology](https://twitter.com/hashtag/radiology?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#surgery](https://twitter.com/hashtag/surgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#orthotwitter](https://twitter.com/hashtag/orthotwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#orthopedics](https://twitter.com/hashtag/orthopedics?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#MedTwitter](https://twitter.com/hashtag/MedTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#medicine](https://twitter.com/hashtag/medicine?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#cool](https://twitter.com/hashtag/cool?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#interesting](https://twitter.com/hashtag/interesting?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#science](https://twitter.com/hashtag/science?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#learning](https://twitter.com/hashtag/learning?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/4o3gU5i4dF](https://t.co/4o3gU5i4dF?ref=theplasticsfella.com) > > — Daniel Brimm, MD (@DanielBrimmMD) [February 20, 2022](https://twitter.com/DanielBrimmMD/status/1495329830413672448?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > My 8 yo with the worksheet mic drop. [#thekidsarealright](https://twitter.com/hashtag/thekidsarealright?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/uivfxn89eK](https://t.co/uivfxn89eK?ref=theplasticsfella.com) > > — Stephanie parks taylor (@StephptaylorCLT) [February 18, 2022](https://twitter.com/StephptaylorCLT/status/1494764017805676546?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### thePlasticsFlash (Launched) 🗂️ **It's built!** And people are using it already. [Get Flashcards](https://www.theplasticsfella.com/flashcards/) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-29-1.png) --- ## 📝 ## Articles of the Week ### New Important Articles **Rapid Review: Is Tranexamic Acid good for blood loss?** Kjersti *et al, [PRS](https://journals.lww.com/plasreconsurg/Fulltext/2022/03000/Safety%5Fand%5FEfficacy%5Fof%5FLocal%5FTranexamic%5FAcid%5Ffor.49.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)* **Aim**: To review the local use of tranexamic acid in soft-tissue surgery, **Methods**: A literature review of publications relating to pharmacological effects and possible adverse reactions, and presents recommendations for use in plastic surgery. **Results**: 14 RCTs were included (a total of nearly 2000 patients) **Conclusions**: *may* reduce blood loss comparably to intravenous prophylactic use with negligible risk of systemic adverse effects. There are concerns for high concentrations, direct contact with nerves, and not knowing what the correct dose should be! **P'Fella's Opinion:** Need more evidence! Still lacking ### Deep Dive Article **Buried vs Exposed Kirschner Wires - What's best?** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-14.png) 📢 From next week, the Deep-Dive article is available for those who support thePlasticsFella's mission by having [thePlasticsPro](https://www.theplasticsfella.com/theplasticspaper/february-27th/#/portal/signup) account. This [PRS Global Open Publication](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977964/pdf/gox-6-e1747.pdf?ref=theplasticsfella.com) in 2018 by the WIRE Research Collaborative provides insight into the attitudes and decision-making behind the question - should we bury K-wires? It's worth reading the entire article [here](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977964/?ref=theplasticsfella.com). **Here are some stats 👇** - \~800 surveyed (423 surgeons, 187 therapists, 187 patients) - 53% of Plastic surgeons prefer to leave K-wires exposed - 34% of Plastic surgeons have no preference - 10% of Plastic surgeons bury their K-Wires. **The decision-making process 👇** - Infection concern → more likely to bury K-wire - Want it easily removed → less likely to bury K-wire - Aesthetics, service provision, economic impact don't influence decisions. **Patient's perspective 👇** - Exposed K-wires → more concerned about infection. **Conclusion👇** - Decisions to bury or expose K-wire are based on dogma rather than evidence. - WIRE Research Collaborative published a [protocol](https://pubmed.ncbi.nlm.nih.gov/34140031/?ref=theplasticsfella.com) for further research. ### What does the community think. A really interesting discussion happened on [Twitter](https://twitter.com/PlasticsFella/status/1463224271266885636?s=20&ref=theplasticsfella.com) this week. P'Fella [tweet](https://twitter.com/PlasticsFella/status/1463224271266885636?s=20&ref=theplasticsfella.com) a poll that received +100 votes. **Should we bury K-wires?** The results of the [Twitter pol](https://twitter.com/PlasticsFella/status/1463224271266885636?s=20&ref=theplasticsfella.com)l are very one-sided 👇 During the thread discussion, this article was pointed out. > I like not burying k-wires because they are easy to take out. > But patients don't like metal sticking out of their fingers. > > What are your thoughts? > > — thePlasticsFella (@PlasticsFella) [November 23, 2021](https://twitter.com/PlasticsFella/status/1463224271266885636?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ### thePlasticsPaper - February 20th URL: https://www.theplasticsfella.com/february-20th/ Last updated: 2022-02-27T09:26:03.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/february-20th/#a-letter-from-pfella) \- 3 reasons why Twitter is the best textbook 2\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/february-20th/#articles-of-the-week) \- 3 Case Reports and Images 3\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/february-20th/#weekly-quiz-competition) \- new season & winners announced!! 4\. 🔠 [Wordle for Plastics Surgeons](https://www.theplasticsfella.com/theplasticspaper/february-20th/#wordle-for-plastic-surgeons) \- round 3! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/february-20th/#upcoming-events) \- 21 webinars & courses. 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/february-20th/#tweets-of-the-week) \- memes, images, ideas. 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/february-20th/#new-feature) \- Flashcards in 7 days!! --- ## ✍️ ## A Letter from P'Fella ### Twitter is the best Plastic Surgery textbook. Here's why... 1. **All the big players are on Twitter.** Twitter allows you access to the best journals (PRS, JPRAS, JHS) or most the influential figures in plastic surgery (Rod Rohrich, Jeff Janis, and of course P'Fella lol). **2\. It's always up-to-date** Twitter is built on the premise that you will also find the most up-to-date information. So if you are active enough, you'll get the journals, the events. and the clinical discussions. **3\. The information finds you** It's easy to give out about the "algorithm". But, it does get you the information you're interested in. When P'Fella logs in, the only thing on the feed is evidence-based discussions. No trolls! (thank god). **Here's a guide on how to use Twitter properly** > Twitter is an amazing free medical journal. > If you use it right, it's quite a powerful platform. > > Here are 3 features P'Fella uses to keep up-to-date. [#meded](https://twitter.com/hashtag/meded?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#medtwitter](https://twitter.com/hashtag/medtwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#PlasticSurgery](https://twitter.com/hashtag/PlasticSurgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > > 👇 > > — thePlasticsFella (@PlasticsFella) [October 28, 2021](https://twitter.com/PlasticsFella/status/1453780096293216260?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 📝 ## Articles of the Week ### Let's focus on some interesting case reports & images... **Acquired glanular hypospadius from a penis piercing.** *MacLeod et al,* [*JPRAS*](https://www.jprasurg.com/article/S0007-1226%2803%2900597-6/fulltext?ref=theplasticsfella.com) **Presentation**: fistula 12 months post piercing to the penis. **Diagnosis**: Acquired glanular hypospadius **Treatment**: Education! and urology! See the images and full article [here](https://www.jprasurg.com/article/S0007-1226%2803%2900597-6/fulltext?ref=theplasticsfella.com). **Persistent Trigger Finger Due to Tendon Subluxation** *Akiki et al, [Journal of Hand Surgery](https://www.jhandsurg.org/article/S0363-5023%2820%2930469-X/fulltext?ref=theplasticsfella.com)* **Presentation:** persistence of triggering after A1 pulley division **Diagnosis:** flexor digitorum superficialis tendon subluxation **Treatment**: longitudinal flexor digitorum superficialis tendon separation. **Image of the Week: Gingival Melanoma** [NEJM](https://www.nejm.org/doi/full/10.1056/NEJMicm2107766?ref=theplasticsfella.com) A 61-year-old woman presented with a rapidly growing pigmented gingival lesion. Incisional biopsy revealed melanoma. Image below 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/f2497134-d751-4db1-83ef-6d1aa1804932.jpeg) Originally published in [NEJM](https://www.nejm.org/doi/full/10.1056/NEJMicm2107766?ref=theplasticsfella.com) --- ## 🤓 ## Weekly Quiz Competition ### A new season is launching! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-35.png) P'Fella was blown away by the enthusiasm for this weekly quiz competition. Over 200+ people took part every week for the past 6 weeks. It's time to bring this to the next level! **Starting next Sunday...** 1. There will be a fresh **new leaderboard**! 2. There will be a **$100 voucher prize**. 3. There will be **10 questions** in the season. 4. **1 winner** will be crowned the "smartest plastic surgeon in the world". 🏅 **Congratulations** to **Ricky** (Consultant/Attending) and **Clemens** (Resident/Trainee) - joint winners of season 1 with 9 questions answered correctly. --- ## 🔠 ## Wordle for Plastic Surgeons ### Created specifically for Plastics! p.s - share your results on Twitter and [@plasticsfella.](http://twitter.com/plasticsfella?ref=theplasticsfella.com) Each week, 1 winner gets some pretty cool merch 🔥 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-28-1-1.png) [Click to Play](https://mywordle.strivemath.com/?word=cfrie&ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 21 Webinars, Conferences, and Courses 1. [BSSH](https://us02web.zoom.us/webinar/register/WN%5FQWPsAkffSIaAM3G5WIhuMA?ref=theplasticsfella.com) Benign and Malignant Tumours of the Hand - Feb 26th 2. [Edinburgh Hand Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/the-edinburgh-hand-course?ref=theplasticsfella.com) \- Edinburgh, Feb 2022 3. [BSSH Arthritis Workshop](https://mailchi.mp/bssh/bssh-spring-2021-abstract-submissions-open-10172149?ref=theplasticsfella.com) \- Manchester, Feb 2022. 4. [AWR Conference](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/awr-europe-february-2022?ref=theplasticsfella.com) \- London, Feb 2022\. 5. [MWSPS Annual Meeting](https://www.mwsps.org/events/mwsps-annual-meeting?ref=theplasticsfella.com) \- UT, USA Feb 2022 6. [ASPS In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/in-service-exam-for-surgeons?ref=theplasticsfella.com) \- Virtual, March 2022. 7. [ASPS Spring Meeting](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) \- Virtual, March 2022. 8. [ASSH](https://www.assh.org/s/course-detail?id=aBP5b00000096y0GAA&ref=theplasticsfella.com) \- Upper Limb Micro Recon - Virtual, March 26th. 9. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 10. [BAPRAS AEC Trunk Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-4-8?ref=theplasticsfella.com) \- April 2022\. 11. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022\. 12. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 13. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022\. 14. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 15. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 16. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 17. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 18. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 19. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022\. 20. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 21. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week ### Here are 3 tweets you might have missed! > Submitting my work to nature… [#academictwitter](https://twitter.com/hashtag/academictwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#phdchat](https://twitter.com/hashtag/phdchat?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#lornegenome](https://twitter.com/hashtag/lornegenome?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) ⁦[@GenomeConf](https://twitter.com/GenomeConf?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com)⁩ [pic.twitter.com/hcO8FTXG0w](https://t.co/hcO8FTXG0w?ref=theplasticsfella.com) > > — AJ Sethi (@\_AJSethi) [February 17, 2022](https://twitter.com/%5FAJSethi/status/1494258633907240961?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Heating up fish at work deserves a prison sentence btw > > — Ab (@abbiexslater) [February 15, 2022](https://twitter.com/abbiexslater/status/1493569968604160005?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > really excited for this... > it's a simple feature, but that makes it great. > > hopefully will help a lot of trainees in different countries. > > ↓ request early access[https://t.co/vPSwSzrc1c](https://t.co/vPSwSzrc1c?ref=theplasticsfella.com)[#plasticsurgery](https://twitter.com/hashtag/plasticsurgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#MedEd](https://twitter.com/hashtag/MedEd?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#Medtwitter](https://twitter.com/hashtag/Medtwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > > — thePlasticsFella (@PlasticsFella) [February 15, 2022](https://twitter.com/PlasticsFella/status/1493671893919956992?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### thePlasticsFlash (Update) 🗂️ It's nearly built! It's gonna be 🚀 P'Fella was testing the waters this week on Twitter. It was amazing to see the demand for flaschards. >98% of people said, "YES, WE WANT FLASHCARDS". SO here it is 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-29-1.png) **Launching Sunday 27th February!** [Notify Me Please!](https://flash.theplasticsfella.com/?ref=theplasticsfella.com) --- --- ### thePlasticsPaper - February 13th URL: https://www.theplasticsfella.com/february-13th/ Last updated: 2022-02-13T16:54:28.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/february-13th/#a-letter-from-pfella) \- Sci-Hub is so important. 2\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/february-13th/#articles-of-the-week) \- 3 new Breast articles 3\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/february-13th/#weekly-quiz-competition) \- leaderboard 4\. 🔠 [Wordle for Plastics Surgeons](https://www.theplasticsfella.com/theplasticspaper/february-13th/#wordle-for-plastic-surgeons) \- harder! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/february-13th/#upcoming-events) \- +20 webinars & courses. 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/february-13th/#tweets-of-the-week) \- memes, images, ideas. 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/february-13th/#new-feature) \- Flashcards!! --- ## ✍️ ## A Letter from P'Fella ### Sci-Hub is key. Here's why... **This is interesting.** Plastic Surgeons dislike "paying to publish" much more than "paying to read". You can see the raw data in the twitter poll below. It's interesting because it shows the general disdain for the predatory "open" journals that are "free to read". Yes, they are free but they are certainly not free. As the saying goes, there is no such thing as a free lunch. > When it comes to journals, which do you dislike more? > > — thePlasticsFella (@PlasticsFella) [February 9, 2022](https://twitter.com/PlasticsFella/status/1491504914060750852?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) It must be hard for people at PRS Global Open (yes, I know they read this), to see stats like this. It's directly against their business model. But there is a big confounder in this twitter poll - that is, the impact Sci-Hub has had on journal access. The issue of paying or signing up or going through a university portal is gone. You can get any article in the world now in just a few clicks. You can see the impact of Sci-Hub by the stats published by it's founder below. She outlines that millions and millions of articles she has made accessible! Its pretty amazing. > I updated Sci-Hub, now you can watch download statistics in real-time, monthly stats and other. Will add more in the future. > > new version is running at [https://t.co/VzYYNrOcna](https://t.co/VzYYNrOcna?ref=theplasticsfella.com) and [https://t.co/HEgPDPvqEh](https://t.co/HEgPDPvqEh?ref=theplasticsfella.com) > on the picture: number of research papers downloaded in last 30 days [pic.twitter.com/eQcXLcef6C](https://t.co/eQcXLcef6C?ref=theplasticsfella.com) > > — Alexandra Elbakyan (@ringo\_ring) [February 12, 2022](https://twitter.com/ringo%5Fring/status/1492419986291408898?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 📝 ## Articles of the Week ### Let's focus on Breast this week **Exercise after Breast Augmentation: A RCT** *Basile et al, [PRS Journal Jan 2022.](https://journals.lww.com/plasreconsurg/Fulltext/2022/01000/Exercise%5Fafter%5FBreast%5FAugmentation%5F%5FA%5FRandomized.13.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com)* **Aim**: is early exercise after breast augmentation is safe? **Methods**: prospective RCT to measure complications, scar, and PROMs comparing excerise at 7 days and 12 weeks. **Results**: 225 participants showed no difference in outcomes. **Conclusions**: Early excercise does not increase complication or reoperation rates or cause a reduction in scar quality after 1 year. PROM's increased in the exercise groups. **Anatomy of the Breast Fascial System: A Systematic Review** *Duncan et al, [PRS Journal Jan 2022](https://journals.lww.com/plasreconsurg/Abstract/2022/01000/Anatomy%5Fof%5Fthe%5FBreast%5FFascial%5FSystem%5F%5FA%5FSystematic.4.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com)* **Aim:** better understanding of fascial & ligamentous breast structures **Methods:** review of anatomical, clinical, histologic, and radiologic studies **Results**: 6 distinct breast fascial structures in the literature. **Conclusions:** \- Cooper ligaments divide the breast parenchyma. \- Superficial and deep layers of superficial fascia created a breest “pocket,” \- Horizontal septum is a reliable neurovascular landmark. \- Vertical septum is a newly discovered fascial structure **Leaving the perfusion zones in DIEPS??** *Ludolph et al, [JPRAS](https://www.jprasurg.com/article/S1748-6815%2821%2900377-6/fulltext?ref=theplasticsfella.com)* **Aim:** look at perfusion patterns to determine ideal zoning in abdominal-based autologous breast reconstruction. **Methods**: Indocyanine green angiography for analysis on 100 flaps. **Results**: No major differences in size of the perfusion area and for lateral or medial located perforators to cross the midline. **Conclusions**: Abdominal zonings play a minor role --- ## 🤓 ## Weekly Quiz Competition ### 194 plastics geeks now do this weekly. The leaderboard is hotting up. Every so often, the leader will be getting a pretty sweet prize. **just a heads up... it's an upper limb question this week!!** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlastics-Quiz-Weekly-1.png) [Answer this week's question ](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🔠 ## Wordle for Plastic Surgeons ### Created specifically for Plastics! p.s - share your results on Twitter and [@plasticsfella.](http://twitter.com/plasticsfella?ref=theplasticsfella.com) The winner gets some pretty cool merch 🔥 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-28-1-1.png) [Click to Play](https://mywordle.strivemath.com/?word=cipry&ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 20 Webinars, Conferences, and Courses 1. [Pulvertaft Webinar](https://us02web.zoom.us/webinar/register/WN%5FBXVQCpYpRyWdmR3xKGshqg?ref=theplasticsfella.com): Salvage Hand Trauma - Feb 14th. 2. [BSSH](https://us02web.zoom.us/webinar/register/WN%5FQWPsAkffSIaAM3G5WIhuMA?ref=theplasticsfella.com) Benign and Malignant Tumours of the Hand - Feb 26th 3. [Edinburgh Hand Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/the-edinburgh-hand-course?ref=theplasticsfella.com) \- Edinburgh, Feb 2022 4. [BSSH Arthritis Workshop](https://mailchi.mp/bssh/bssh-spring-2021-abstract-submissions-open-10172149?ref=theplasticsfella.com) \- Manchester, Feb 2022. 5. [AWR Conference](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/awr-europe-february-2022?ref=theplasticsfella.com) \- London, Feb 2022\. 6. [MWSPS Annual Meeting](https://www.mwsps.org/events/mwsps-annual-meeting?ref=theplasticsfella.com) \- UT, USA Feb 2022 7. [ASPS In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/in-service-exam-for-surgeons?ref=theplasticsfella.com) \- Virtual, March 2022. 8. [ASPS Spring Meeting](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) \- Virtual, March 2022. 9. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 10. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022\. 11. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 12. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022\. 13. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 14. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 15. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 16. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 17. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 18. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022\. 19. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 20. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week ### Here are 4 tweets you might have missed! > Self Portrait on a Late Shift > Oil on board > 2022[#Art](https://twitter.com/hashtag/Art?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#MedTwitter](https://twitter.com/hashtag/MedTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/NwpMJyfZpf](https://t.co/NwpMJyfZpf?ref=theplasticsfella.com) > > — Lena Ibrahim (@DrLenaIbrahim) [February 11, 2022](https://twitter.com/DrLenaIbrahim/status/1492203698201796611?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Nothing on this planet is stronger than the bond between orthopedic surgeons and their Stryker reps. [pic.twitter.com/UDTDJPUiAQ](https://t.co/UDTDJPUiAQ?ref=theplasticsfella.com) > > — ScratchpadMD (@scratchpadMD) [February 10, 2022](https://twitter.com/scratchpadMD/status/1491877215876882435?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > First author on a Nature Genetics paper [pic.twitter.com/e9avBhGKZw](https://t.co/e9avBhGKZw?ref=theplasticsfella.com) > > — Oded Rechavi 🦉 (@OdedRechavi) [February 10, 2022](https://twitter.com/OdedRechavi/status/1491849255174160385?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > this. > > by [@alexludai](https://twitter.com/alexludai?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) 🚂 [pic.twitter.com/NeMqQWNRuV](https://t.co/NeMqQWNRuV?ref=theplasticsfella.com) > > — thePlasticsFella (@PlasticsFella) [February 10, 2022](https://twitter.com/PlasticsFella/status/1491845816927068162?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### thePlasticsFlash 🗂️ Evidence-based flashcards for rapid revision of common exam topics. P'Fella was testing the waters this week on Twitter. It was amazing to see the demand for flaschards. >98% of people said, "YES, WE WANT FLASHCARDS". SO here it is 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-29-1.png) **Launching in 7 days!** [Yes, notify me!!](https://flash.theplasticsfella.com/?ref=theplasticsfella.com) --- --- ### thePlasticsPaper - February 6th URL: https://www.theplasticsfella.com/february-6th/ Last updated: 2022-02-06T11:07:20.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/february-6th/#a-letter-from-pfella) \- saying no to sponsors? 2\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/february-6th/#articles-of-the-week) \- it's a hand theme this week. 3\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/february-6th/#weekly-quiz-competition) \- updated leaderboard 4\. 🔠 [Wordle for Plastics Surgeons](https://www.theplasticsfella.com/theplasticspaper/february-6th/#wordle-for-plastic-surgeons) \- win merch! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/february-6th/#upcoming-events) \- 19 courses and webinars 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/february-6th/#tweets-of-the-week) \- memes, images, ideas. 6\. 🚀 [New features ](https://www.theplasticsfella.com/theplasticspaper/february-6th/#new-feature)\- thePlasticsClub (invite only) 7\. 🛍 [Merch](https://www.theplasticsfella.com/theplasticspaper/february-6th/#new-merch) \- support the mission! Limited supply. ## ✍️ ## A Letter from P'Fella ### Saying no to sponsors? During the week, I put out a [tweet](https://twitter.com/PlasticsFella/status/1489657729635524613?s=20&t=bp0Ju8n5Zg8LPNbGGyv-SA&ref=theplasticsfella.com). **The question was simple,** should P'Fella allow companies to sponsor/advertise in this weekly newsletter? **The result was surprising.** · 71 people voted. · 54% felt taking money to grow the platform is a good idea. · 46% wanted thePlasticsFella to stay independent. Tbh, I was pretty surprised by this! I felt the significant majority (>90%) would want thePlasticsFella to stay totally independent. **There is something romantic about being an "indie".** Perhaps some voters could see the potential of extra money coming into the platform to help it grow. After all, it is a not-for-profit educational platform so all money is reinvested into it. After a lot of thought, **thePlasticsFella will stay independent**. This is the right direction. If you think this is a good or bad idea, just reply to this email - would love to hear your thoughts!! --- ## 📝 ## Articles of the Week ### Let's focus on hand this week **Digit Replantation under Wide-Awake Local Anesthesia** Huang, Hui-Fu M.D.; Matschke, Jan [PRS Journal,](https://journals.lww.com/plasreconsurg/Fulltext/2022/01000/Digit%5FReplantation%5Funder%5FWide%5FAwake%5FLocal.22.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com) Jan 2022. **Aim**: To show the WALANT is a suitable option for replants. **Methods**: Finger replants underwent LA or GA. Outcomes were success, waiting and operative times **Results**: 51 patients (16 WALANT, 35 GA) with an average success rate of 76% and operation time of 207 minutes. **Conclusions**: it is a feasible option for single-digits in a select group of patients with sharp amputations. **5th Metacarpal neck fractures RCT - should I buddy strap?** Martínez-Catalán et al. [Journal of Hand Surgery](https://www.jhandsurg.org/article/S0363-5023%2820%2930280-X/fulltext?ref=theplasticsfella.com), July 2020\. **Aim**: Compare functional outcomes of buddy taping versus reduction and cast immobilization for 5th metacarpal neck fractures. **Methods**: fractures with <70º volar angulation and no rotational deformity were randomized and assessed using DASH. **Results**: 72 patients were assessed for range of motion, pain, grip strength, return to work, radiographic angulation, and complication rate. **Conclusion**: No benefit of fixation over taping --- ## 🤓 ## Weekly Quiz Competition ### ‌Fellow plastics geeks, here is this week's question. The leaderboard is hotting up. **175+ of your peers on it**. Every so often, the leader will be getting a pretty sweet prize. **just a heads up... it's a little bit hard this week!!** ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlastics-Quiz-Weekly.png) [See this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🔠 ## Wordle for Plastic Surgeons ### Created specifically for Plastics! p.s - share your results on Twitter and [@plasticsfella.](http://twitter.com/plasticsfella?ref=theplasticsfella.com) The winner gets some pretty cool merch 🔥 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/thePlasticsPaper-Logo-28-1.png) [Click here to play](https://mywordle.me/?word=gkzup&ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 19 Webinars, Conferences, and Courses 1. [BSSH Hand Infection ](https://us02web.zoom.us/webinar/register/WN%5FI7mmAnNPR3G3WkpTNkDsxw?ref=theplasticsfella.com)\- Zoom, Feb 2022\. 2. [Edinburgh Hand Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/the-edinburgh-hand-course?ref=theplasticsfella.com) \- Edinburgh, Feb 2022 3. [BSSH Arthritis Workshop](https://mailchi.mp/bssh/bssh-spring-2021-abstract-submissions-open-10172149?ref=theplasticsfella.com) \- Manchester, Feb 2022. 4. [AWR Conference](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/awr-europe-february-2022?ref=theplasticsfella.com) \- London, Feb 2022\. 5. [MWSPS Annual Meeting](https://www.mwsps.org/events/mwsps-annual-meeting?ref=theplasticsfella.com) \- UT, USA Feb 2022 6. [ASPS In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/in-service-exam-for-surgeons?ref=theplasticsfella.com) \- Virtual, March 2022. 7. [ASPS Spring Meeting](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) \- Virtual, March 2022. 8. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 9. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022\. 10. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 11. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022\. 12. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 13. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 14. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 15. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 16. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 17. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022\. 18. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 19. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- ## 🐣 ## Tweets of the Week ### Here are 4 tweets you might have missed! > [pic.twitter.com/LfEdSr6aL1](https://t.co/LfEdSr6aL1?ref=theplasticsfella.com) > > — Stefan Tigges (@StefanTigges) [February 4, 2022](https://twitter.com/StefanTigges/status/1489655098468974600?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Remember, kids [pic.twitter.com/TvADrJu3J3](https://t.co/TvADrJu3J3?ref=theplasticsfella.com) > > — Dr. Longissimus (@DrLongissimus) [February 4, 2022](https://twitter.com/DrLongissimus/status/1489650024191561732?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > I’ve reached this point of paper writing [pic.twitter.com/ID2wolfL7K](https://t.co/ID2wolfL7K?ref=theplasticsfella.com) > > — Kaley Brauer 💫 (@kaleybrauer) [February 2, 2022](https://twitter.com/kaleybrauer/status/1488920789420281860?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > pick a fracture and tell us how you wound treat it... [pic.twitter.com/gRTNJkOWGZ](https://t.co/gRTNJkOWGZ?ref=theplasticsfella.com) > > — thePlasticsFella (@PlasticsFella) [February 5, 2022](https://twitter.com/PlasticsFella/status/1489963284165890052?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### thePlasticsClub - an invite-only community. 🤭 If you want to get access, just reply "YES" to this email. It's a **new** feature, still young but eager to grow! For the next couple of months, the focus will be on **[interview](https://www.theplasticsfella.com/interview/)** preparation. Over time, this will expand to other areas of plastic surgery training. Forums and communities are a great place to **learn** and **engage** with your peers. So don't be shy! Here is what it looks like. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Untitled-design-31.png) Reply "YES" to this email if you want access :) --- ## 🛍 ## New Merch This is P'Fella's second "[merch drop](https://www.theplasticsfella.com/swag/)". 🛍️ Reply "MERCH" to this email if you want some merch! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/surgical-checklist-3-2.png) ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/02/Screenshot-2022-02-06-at-10.11.40.png) --- --- ### thePlasticsPaper - January 30th URL: https://www.theplasticsfella.com/january-30th/ Last updated: 2022-01-30T12:56:05.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/january-30th/#a-letter-from-pfella) \- make knowledge cheaper 2\. 📝 [Articles of the Week](https://www.theplasticsfella.com/theplasticspaper/january-30th/#articles-of-the-week) \- don't stitch nerves?? 3\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/january-30th/#weekly-quiz-competition) \- leaderboard 4\. 🔠 [Wordle for Plastics Surgeons](https://www.theplasticsfella.com/theplasticspaper/january-30th/#wordle-for-plastic-surgeons) \- new! 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/january-30th/#upcoming-events) \- +15 soon events 5\. 🐣 [Tweets of the Week](https://www.theplasticsfella.com/theplasticspaper/january-30th/#tweets-of-the-week) \- memes, images, ideas. 6\. 🚀 [New features](https://www.theplasticsfella.com/theplasticspaper/january-30th/#new-feature) \- thePlasticsClub (invite only) 7\. 🏋🏽‍♂️ [Work with P'Fella](https://www.theplasticsfella.com/theplasticspaper/january-30th/#work-with-pfella) \- social media --- ## ✍️ ## A Letter from P'Fella ### Make education more accessible 📖 Guess what is **not** okay? The cost of "interview prep". There is enough emotional stress during this period. The last thing a future plastic surgeon need is financial stress. So that's why P'Fella thought he'll get involved - to create a not-for-profit definitive companion to the plastic surgery interview, called [thePlasticsInterview.](https://www.theplasticsfella.com/interview/) [![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Your-digital-companion.png)](https://www.theplasticsfella.com/interview/) [Check it out](https://www.theplasticsfella.com/interview/) ### Here's why [thePlasticsInterview](https://www.theplasticsfella.com/interview/) was created: #### 1\. We need a level playing field Everyone should have equal access to resources to help them succeed. £800 courses can only be afforded by a select few. Surely a contributing factor to the lack of diversity in plastic surgery? #### 2\. What does a face-to-face course ACTUALLY achieve? Fine, some courses are good. in the short term. experience & insights are usually forgotten within the first week Courses are like reading the blurb of a novel. you have context, but you wouldn't go to a book club 24/7 access is key ✅ #### 3\. Courses prey on your FOMO Interview decides your career, right?! you've paid £££ to resolve your FOMO. All plastic surgery courses are similar (trust me, I've looked at them all) a FOMO increase = a price increase. --- ## 📝 ## Articles of the Week ### 2 articles you should know **📔 What makes an excellent plastic surgery trainee??** *P Hackenberger et al* [*PRS Global Open*](https://journals.lww.com/prsgo/Fulltext/2022/01000/Demonstrating%5FExcellence%5Fin%5FPlastic%5FSurgery.36.aspx?utm%5Fsource=dlvr.it&utm%5Fmedium=twitter)*: January 2022* **Aim:** Identify the important features in excellent trainees **Methods**: a survey of 90 plastic surgeons and trainees. **Results**: "Excellent" trainees have prepared for operations, good bedside manner & personality, leadership, technical expertise. **Conclusion**: "excellence" is reflective of life and work experience. **📔 Glue or suture peripheral nerves in hand surgery??** *Sallam et al, [Journal of Hand Surgery](https://www.jhandsurg.org/article/S0363-5023%2821%2900198-2/fulltext?ref=theplasticsfella.com#%20), May 2021\.* **Aim**: is glue non-inferior to traditional suturing? **Methods**: RCT assessing motor and sensory recovery, operative time. **Results**: 85 patients with similar outcomes but glue had shorter operation. **Conclusion**: glue is great! **P'Fella's Comment:** it's rare for there to be an isolated nerve injury. These patients were splinted for 3 weeks post-operatively. Tendon or muscle belly damage is a confounder in this study that should be accounted for. --- ## 🤓 ## Weekly Quiz Competition ### ‌Fellow plastics geeks, here is this week's question. The leaderboard is hotting up. **150+ of your peers on it**. Every so often, the leader will be getting a pretty sweet prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/thePlasticsPaper-Logo-31-1-1-1.png) [See this week's question](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🔠 ## Wordle for Plastic Surgeons ### Created specifically for Plastics! p.s - share your results on Twitter and [@plasticsfella.](http://twitter.com/plasticsfella?ref=theplasticsfella.com) The winner gets some pretty cool merch. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Weekly-quiz.png) [Click here to play](https://mywordle.me/?word=jsiyp&ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 18 Webinars, Conferences, and Courses 1. [Edinburgh Hand Course](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/the-edinburgh-hand-course?ref=theplasticsfella.com) \- Edinburgh, Feb 2022 2. [BSSH Arthritis Workshop](https://mailchi.mp/bssh/bssh-spring-2021-abstract-submissions-open-10172149?ref=theplasticsfella.com) \- Manchester, Feb 2022. 3. [AWR Conference](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/awr-europe-february-2022?ref=theplasticsfella.com) \- London, Feb 2022\. 4. [MWSPS Annual Meeting](https://www.mwsps.org/events/mwsps-annual-meeting?ref=theplasticsfella.com) \- UT, USA Feb 2022 5. [ASPS In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/in-service-exam-for-surgeons?ref=theplasticsfella.com) \- Virtual, March 2022. 6. [ASPS Spring Meeting](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) \- Virtual, March 2022. 7. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 8. [BAAPS Masterclass in Aesthetic Practice ](https://baaps.org.uk/about/events/1475/masterclass%5Fin%5Faesthetic%5Fpractice%5Fmanagement%5Fby%5Fbaaps%5Fsupport?ref=theplasticsfella.com)\- London, May 2022\. 9. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 10. [British Burns Association Annual Meeting](http://www.bapras.org.uk/professionals/training-and-education/courses-meetings-and-events/british-burn-association---annual-meeting-2022?ref=theplasticsfella.com) \- Bristol, May 2022\. 11. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 12. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 13. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 14. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 15. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 16. [BAAPS Annual Conference 2022](https://baaps.org.uk/about/events/1477/baaps%5Fannual%5Fconference%5F2022?ref=theplasticsfella.com) \- London, September 2022\. 17. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. 18. [AEC Limb Reconstruction](http://www.bapras.org.uk/professionals/training-and-education/bapras-events/aec-5-1-limb-reconstruction?ref=theplasticsfella.com) \- Virtual, October 2022 --- 🐣 ## Tweets of the Week ### Here are 4 tweets you might have missed! **zoom issues...** > Type I Zoom error: you think people can hear you, but you’re actually on mute. > Type II Zoom error: you think your muted, but actually people can hear you. > > — Cynthia Peacock (@CynPeacock) [January 28, 2022](https://twitter.com/CynPeacock/status/1487204599538888713?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) **an amazing illustration** > Distal brachial artery perforator flap used to rebuild a finger post traumatic ring avulsion. ie some bone, skin, and fat w/blood supply & drainage, taken from the elbow to rebuild a finger, that was lost when a ring snagged & pulled it off. Surgeons are amazing. [#plasticsurgery](https://twitter.com/hashtag/plasticsurgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/Vrue7kRXgt](https://t.co/Vrue7kRXgt?ref=theplasticsfella.com) > > — Ciléin Kearns (@artibiotics) [January 27, 2022](https://twitter.com/artibiotics/status/1486801050275225605?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) **some intra-op pics** > ⚠️Sd. Túnel Carpiano Severo⚠️ > ▪️La forma (morfología) en reloj de arena ⏳ de un nervio ➡️ Indica una compresión severa mantenida (crónica) del mismo [pic.twitter.com/ur3uRGuPg0](https://t.co/ur3uRGuPg0?ref=theplasticsfella.com) > > — Dr. Sergi Barrera Ochoa (@DrBarreraochoa) [January 25, 2022](https://twitter.com/DrBarreraochoa/status/1485997916833648646?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) **a solid meme** > [#MedTwitter](https://twitter.com/hashtag/MedTwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#surgery](https://twitter.com/hashtag/surgery?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [#surgtwitter](https://twitter.com/hashtag/surgtwitter?src=hash&ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) [pic.twitter.com/pikmp4CMxz](https://t.co/pikmp4CMxz?ref=theplasticsfella.com) > > — Eli EK MD (@thesurgerylife) [January 23, 2022](https://twitter.com/thesurgerylife/status/1485072363532296195?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## New Feature ### thePlasticsClub - an invite-only community. 🤭 If you want to get access, just reply "YES" to this email. It's a **new** feature, still young but eager to grow! For the next couple of months, the focus will be on **[interview](https://www.theplasticsfella.com/interview/)** preparation. Over time, this will expand to other areas of plastic surgery training. Forums and communities are a great place to **learn** and **engage** with your peers. So don't be shy! Here is what it looks like. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Untitled-design-31.png) Reply "YES" to this email if you want access :) --- ## 🏋🏽‍♂️ ## Work with P'Fella ### P'Fella needs you! ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/Untitled-design-33-3.png) thePlasticsFella is growing faster than P'Fella can do a horizontal mattress suture. Let's create something great together. Over the coming weeks, 1 job opportunity will become available each week to help support the [mission](https://www.theplasticsfella.com/about/). [This Week's Job](https://www.theplasticsfella.com/jobs/) --- ### thePlasticsPaper - January 23rd URL: https://www.theplasticsfella.com/theplasticspaper-january-23rd/ Last updated: 2022-01-23T11:52:28.000Z **In this Week's Edition** 1\. ✍️ [Letter from P'Fella](https://www.theplasticsfella.com/theplasticspaper/theplasticspaper-january-23rd/#a-letter-from-pfella) \- the cost of interviews. 2\. 📝 [Article of the Week ](https://www.theplasticsfella.com/theplasticspaper/theplasticspaper-january-23rd/#articles-of-the-week)\- 2 new publications. 3\. 🧐 [Weekly Quiz Competition](https://www.theplasticsfella.com/theplasticspaper/theplasticspaper-january-23rd/#weekly-quiz-competition) \- 100+ leaderboard 4\. 🎭 [Upcoming Events](https://www.theplasticsfella.com/theplasticspaper/theplasticspaper-january-23rd/#upcoming-events) \- 13 webinars, conferences 5\. 🐣 [Tweet of the Week](https://www.theplasticsfella.com/theplasticspaper/theplasticspaper-january-23rd/#tweets-of-the-week) \- memes, images, journals. 6\. 🚀 [New Features](https://www.theplasticsfella.com/theplasticspaper/theplasticspaper-january-23rd/#testing-new-features) \- interview answer templates ## ✍️ ## A Letter from P'Fella ### The cost of Plastic Surgery Interviews 🤢 Perhaps, one of the most daunting periods in a plastic surgeon's training program is **the interview.** The interview with the potential to essentially decide the rest of your career. These emotions are compounded by the **cost of the interview season**. Everyone is well aware of the submission costs, travel costs, outfit costs. But what really annoys P'Fella is the cost of **"interview prep courses"**. They can range from $200 to $800+. In return, you get a 2-day course centered on past questions and techniques. Whilst some may be useful in the short-term (you forget everything you learned after a few days), the majority are unfortunately preying on the trainees' fear and anxiety. To help **reduce these costs, P'Fella has developed a not-for-profit interview companion.** It's a complete package of past questions, model answers, answer templates, and of course, live practice with mock interviews. If you have an **upcoming interview,** you should check it out below. [Show me thePlasticsInterview ](https://www.theplasticsfella.com/interview/) --- ## 📝 ## Articles of the Week **💉 Collagenase vs Needle Fasciotomy** *Five-Year Results of a Randomized, Controlled Trial of Collagenase Treatment Compared With Needle Fasciotomy for Dupuytren Contracture* Martin Byström MD et al, [Journal of Hand Surgery](https://www.sciencedirect.com/science/article/abs/pii/S0363502321007619?ref=theplasticsfella.com), Jan 2022\. • **Design**: Prospective, randomized, controlled trial • **Patients**: >20° contracture in 1 MCPJ. • **Outcome**: contracture, recurrence, presence of cords, and PROMs • **Results**: 156 patients followed up over 5 years • **Conclusion**: no differences in ROM, contracture, or PROM **🪡 A better way to tie your suture knot** To Tie or Not to Knot: Half Instrument Tie Outdoes Traditional Knot Akiki, Ronald K. M.D et al, [PRS Journal](https://journals.lww.com/plasreconsurg/Fulltext/2022/01000/To%5FTie%5For%5FNot%5Fto%5FKnot%5F%5FHow%5Fthe%5FHalf%5FInstrument%5FTie.75.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com), Jan 2022\. The half instrument tie has many advantages to the surgeon’s knot. 1\. Biomechanical advantage: by avoiding an additional same-direction throw and thus consequently a decrease in knot advancement. 2\. Efficiency: it is relatively simple and fast, and exploits the tension created using a pinching maneuver. 3\. Tension: means by which to hold the tension between the first and second throws, and thus solves the problem of potential unraveling when performing single-throw square knots. Here is a [video](https://journals.lww.com/plasreconsurg/Fulltext/2022/01000/To%5FTie%5For%5FNot%5Fto%5FKnot%5F%5FHow%5Fthe%5FHalf%5FInstrument%5FTie.75.aspx?WT.mc%5Fid=HPxADx20100319xMP&ref=theplasticsfella.com) on the technique --- ## 🤓 ## Weekly Quiz Competition ### ‌Fellow plastics geeks, here is this week's question. The leaderboard is hotting up. **125+ of your peers on it**. Every so often, the leader will be getting a pretty sweet prize. ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/thePlasticsPaper-Logo-31-1-1.png) [Take this week's quiz](https://quiz.theplasticsfella.com/?ref=theplasticsfella.com) --- ## 🎭 ## Upcoming Events ### 13 Webinars, Conferences, and Courses 1. [Journal Hand Surgery Journal Club](https://us02web.zoom.us/webinar/register/WN%5F4is1E68xTF2T%5Fp94JmoSDg?ref=theplasticsfella.com) \- Virtual, Jan 26th 2022. 2. [ICCPCA Webinar ](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com)\- Orthognathic Surgery - January 29th 3. [BSSH Arthritis Workshop](https://mailchi.mp/bssh/bssh-spring-2021-abstract-submissions-open-10172149?ref=theplasticsfella.com) \- Manchester, Feb 2022. 4. [ASPS In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/in-service-exam-for-surgeons?ref=theplasticsfella.com) \- Virtual, March 2022. 5. [ASPS Spring Meeting](https://www.plasticsurgery.org/for-medical-professionals/education/events/spring-meeting?ref=theplasticsfella.com) \- Virtual, March 2022. 6. [AAPS Centennial Meeting](https://meeting.aaps1921.org/?ref=theplasticsfella.com) \- San Diego, April 2022. 7. [RACS 90th Annual Scientific Conference](https://plasticsurgery.org.au/event/racs-90th-annual-scientific-congress-2022/?ref=theplasticsfella.com) \- Brisbane, May 2022. 8. [Australian ASPS Congress - Goldcoast, June 2022](https://plasticsurgery.org.au/event/plastic-surgery-congress/?ref=theplasticsfella.com) 9. [Aesthetics In-Service Exam](https://www.plasticsurgery.org/for-medical-professionals/education/events/life-long-learning-exercise?ref=theplasticsfella.com) \- Virtual, June 2022. 10. [ISAPS World Congress](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiHkYPAlpP1AhUBiFwKHTR8B1gQFnoECAIQAQ&url=https%3A%2F%2Fwww.isapsistanbul2022.com%2F&usg=AOvVaw1KHPezm4hISqyTxqmknhFY) \- Istanbul, July 2022 11. [ICCPCA Cleft Congress](https://cleft2022.com/iccpca-webinar/?ref=theplasticsfella.com) \- Edinburgh, July 2022 12. [ASSH Annual Meeting](https://www.assh.org/annualmeeting/s/?ref=theplasticsfella.com) \- Boston, September 2022. 13. [Plastic Surgery, The Meeting](https://www.plasticsurgerythemeeting.com/?ref=theplasticsfella.com) \- Boston, October 2022. --- ## 🐣 ### Tweets of the Week > Nature does open access [pic.twitter.com/j6kL1G3ZRX](https://t.co/j6kL1G3ZRX?ref=theplasticsfella.com) > > — Dr. Glaucomflecken (@DGlaucomflecken) [January 22, 2022](https://twitter.com/DGlaucomflecken/status/1484679759829209090?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Put👏 Glitter👏 In👏 Dermabond👏 > > — Resus Cric 🥣Souperstar🍲🫕 (@RozehnalMd) [January 21, 2022](https://twitter.com/RozehnalMd/status/1484648757169999878?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) > Reviewer 2 [pic.twitter.com/npQwO2Vluy](https://t.co/npQwO2Vluy?ref=theplasticsfella.com) > > — Adi (@IDdocAdi) [January 20, 2022](https://twitter.com/IDdocAdi/status/1483995487061618689?ref%5Fsrc=twsrc%5Etfw&ref=theplasticsfella.com) --- ## 🚀 ## Testing New Features ### Must-have interview answer templates There is no bigger fear than going "blank" in an interview. No matter how much you prepare, there may be 1 or 2 questions that might catch you by surprise. To avoid this, P'Fella has created answer templates specific to the Plastic Surgery Interview. Here is an example of one 👇 ![](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2022/01/-ACED--Must-have-Answer-Template---Structure-2-2.png) [More templates here! ](https://www.theplasticsfella.com/interview/) ### thePlasticsInterview URL: https://www.theplasticsfella.com/theplasticsinterview/ Last updated: 2024-01-14T19:13:19.000Z Hi there, Have you checked out these **answer templates** and **mock interviews**? If not, here they are: 1. [Clinical Governance](https://www.theplasticsfella.com/theplasticsinterview/clinical-governance/): Deep-Dive, Alternative Questions, Mock Interview (with a live recording for your records!) and 3 answers from past candidates. 2. [Answer Templates](https://www.theplasticsfella.com/theplasticsinterviews/#answer-templates) designed specifically for Plastic Surgery Interviews **Thanks** to everyone that signed up for this first cohort in 2022\. P'Fella will be closing registrations soon. If you're interested in joining a small community to brainstorm scenarios and get those answers polished, then just reply "yes". Happy prepping! P'Fella _Truncated after 5 MiB. Use `/sitemap.xml` for the complete archive of public content._