HAND
Congenital hand
Embryology
o Limb bud at 3 weeks, hand at 5 weeks, fingers at 8 weeksu.
o XR: capitate first seen on XR, pisiform senen last
o Genes: limb bud development = FGF, proximal to distal = AER (apical ectodermal ridge), radial to
ulnar = ZPA to SHH, dorsal to ventral = Wnt1 with LMX (LIMX homobox), polydactyly = SHH
Polydactyly
o Thumb
 Type I: bifid distal phalanx  each type goes past joint and then additional bone
 Rx: excise radial digit and preserve ulnar thumb, maintain UCL*** for pinch; reinsert FPB
and APB to stabilize
Syndactyly
o 3rd webspace MC affected
o Operate btwn 6 months and 2 years of age, border digits early side
o Principles
 Dorsally based rectangular flaps = webspace
 FTSG for digital resurfacing
 Always long-arm cast
Thumb hypoplasia
o I
Small thumb
No Rx
o II
Small thumb, hypoplasia thenar m., UCL instability Opponensplasty-Huber, UCL recon
o IIIA
Intact CMCJ, stable joint
Tendon transfers
o IIIB
Absent CMCJ
Pollicization, ablate remain thumb
o IV
Pouce flottant, no MC
Pollicization, ablate remain thumb
o V
Complete absence of thumb
Pollicization
o Pollicization
 Ligate radial br to long finger
 Divide A1 and A2 pulleys
 Extensor tendons mobilized
 Shorten MC by division (shaft removed)
 Index finger rotated 150 deg pronation, 40 deg abduction, 70 degrees into palm
o New index finger roles
 First dorsal interosseous: reattached to radial lateral band  APB = dorsal abduction
 First palmar interosseous: adductor pollicis = palmar adduction
 FDP  FPL, FDS  FPB, EIP  EPL, EDC  APL
Others
o Cleft hand (ectrodactyly): failure of formation – establish 1st webspace
o Trigger thumb: flexed at IPJ; Notta nodule = thickening of FPL; A1 pulley release at 3yo
o Amniotic band syndrome: oligohydramnios
o Camptodactyly: flexion contracture of PIPJ (JOINT issue) – usually little finger – abnormal
insertion of lumbrical on FDS
 Splinting (6-12 months)* = PREFERRED; surgical has high recurrence
 Operate if >30 degree deformity – release accessory collateral ligament, transfer
lumbrical to extensor, stabilize MCPJ to prevent hyperextension
o Clinodactyly: delta phalanx – excessive radial or ulnar angulation of digit (usually small)
o Kirner deformity – distal phalanx BONE issue
 Volar-radial curvature of distal phalanx – tethering due to abnormal FDP insertion
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Macrodactyly: lipomatous hamartoma within digital nerves
 Rx: debulking procedure + epiphysiodesis when fingers at ADULT length
Brachydactyly: shortened fingers
 Rx: lengthen small and ring fingers to facilitate power grip and opposition
 Non-vascularized toe phalanx grafting
Radial longitudinal deficiency
 VATER, Holt-Oram, Fanconi, TAR
 Holt-Oram: cardiac arrhythmias
 Fanconi: auto recessive; lethal pancytopenia
 TAR: thrombocytopenia
 VACTERL: vertebral, anal atresia, cardiac, TE fistula, renal, limb anomalies
 Type IV: complete absence – centralize ulna into carpus
Central longitudinal deficiency (ectrodactyly)
 Absent/deficient central digits
 Rx: first web space deepening
Madelung deformity
 Congenital distal radius abnormality with carpal bones between radius and ulna
 Rx: observe if mild, Darrach if severe
Arthrogryposis: progressive joint contracture present at birth
Amniotic band syndrome: SPONTANEOUS
 Oligohydramnios
 Young mother, multigravida mother
 Low birth weight, prematurity
Fingertip amps
Nailbed injuries
o Sterile matrix injury: primary repair, sterile matrix STSG (toe, same digit)
 Hook-nail deformity occurs because of lack of bony support to the sterile matrix
o Germinal matrix: germinal matrix FTSG if > 2mm loss, from 1 or 2nd toe
o Pincer nail: transverse curvature of nail plate – elevate, dermal grafting
Reconstruction
o Excision and primary repair of nail matrix – can be done delayed
o Secondary intention: <1cm, better recovery than FTSG
o Local flaps
 Kulter VY: transverse defect – sensate
 Atasoy-Kleinert VY: taken from volar skin  dorsal defects – sensate
 Volar VY: volar defect – less than 1.5cm
 Cross-finger: volar defect - FTSG covering donor site
 Reverse cross-finger: dorsal defect – insensate
 Moberg: volar thumb defect – based on b/l volar digital artery
 FDMA: volar thumb defect – FDMA courses within 1st dorsal interosseoi muscle –
terminal branch of radial artery, superficial radial nerve - SENSATE
 Thenar flap: volar index, long and ring finger – avoid in elderly
 Homodigital island flap: raises tissue on same finger based on one NVB and advanced
distally – SENSATE
 Litler: neurovascular island pedicle flap
Dupuytren’s
Biology
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o Autosomal dominant
o Proliferation of myofibroblasts
o Increased type 2 to type 1 collagen
Anatomy
o Natatory: web-space adduction
o Pre-tendinous: MCPJ
o Spiral: MCPJ and PIPJ – displaces NVB midline, superficial, proximal (made of spiral band, lateral
digital sheet, Grayson ligament)
o Lateral cord: PIPJ and DIPJ
o ADM: small finger PIPJ and DIPJ
o Retrovasular: DIPJ
o *Cleland not involved, Grayson’s ligament involved
Indications
o Table top test
o MCPJ > 30 degrees, ANY PIPJ contracture
Rx
o Collagenase
o Limited fasciectomy
o Needle aponeurotomy
o PIPJ release: accessory collateral ligament, chekrein ligament, palmar plate
o *SMALL FINGER PIPJ treatment has highest complications
Vascular
Scleroderma
o CREST: calcinosis, raynaud’s, esophageal, scleroderma, telangiectasias
o Rx:
 Perivascular botox injection in palm
 Ulcer debridement and bone resection
 PIPJ arthrodesis
 Local excision of calcium deposits
Buerger’s disease (thromboangiitis obliterans)
o Sxs: painful and cold hands with large tender blood vessels
o Rx: NO tobacco, surgical sympathectomy, amputate affected limb if infected
High-pressure paint gun injuries – requires EMERGENT incision and drainage
Chronic hand ischemia
o Sympathectomy: no identifiable occlusion
o Interpositional bypass grafting: resectable segment of occlusion
o Venous arterialization: non-resectable segment of occlusion
Amputations
Minimal stump length for prosthesis fitting is 5-10cm distal to elbow with at least 5cm of bony stump
Ring avulsion: most important factor for survival is # of dorsal veins repaired
Hand tumors
Benign soft tissue
o Ganglion cyst
 Dorsal wrist overlying SL ligament (btwn 3rd and 4th extensor compartment)
 Volar wrist overlying radioscaphoid ligament
 Volar retinacular
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Wrist
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 Mucus cyst: DIPJ with osteophyte, causes nail grooving
 *OBSERVE in pediatric patients as it spontaneously regresses
o Giant tumor cell of tendon sheath
 Yellow SQ mass on volar surface from flexor tendon sheath
 Histology: fibrous xanthoma, multinucleate giant cells, foam cells
o Schwannoma: most common benign nerve tumor; mobile transversely but not longitudinally
o Infantile digital fibromatosis: “kissing lesions” – intracytoplasmic eosinophilic inclusion bodies
 Wide excision, skin grafting, local flaps
o Glomus tumor: cold insensitivity, paroxysmal pain, pinpoint localization
Malignant soft tissue
o Epitheliod sarcoma: usually on volar surface
 Rx: preop XRT, WLE, postop chemo
Benign bone
o Enchondroma: P1 > MC > P2
 Rx: curettage and bone grafting (10% risk of recurrence) – majority heal FINE
 If pathologic fracture, bony stabilization and allow to HEAL before resecting
 Malfucci and Ollier disease – multiple enchondromas
o Osteochondroma: cartilage with bony exostosis – 1% risk of malignant transformation
o Osteoid osteoma: <1.5cm area of lucency surrounded by reactive sclerosis
 Worse pain at night, relieved with NSAIDs
o Giant cell tumor of bone: metastasizes to lung, high recurrence – LYTIC lesion with no borders
o Aneurysmal bone cyst: lytic lesion with thin rim of surrounding bone – curettage or cryosurgery
Malignant bone
o Chondrosarcoma: most common
o Osteosarcoma: MC site of met = lung
o Metastatic prostate CA: most common metastatic tumor
Nail malignancies
o SCC: no nail bed = 1cm margins, yes nail bed = DIPJ amputation
o Melanoma: shave biopsy (no full thickness)
 Subungal MIS: WLE with nailbed graft
 Subungual melanoma: SLNB, DIPJ amputation
Anatomy
o Capitate first seen on XR, pisiform seen last
Injuries
o Bone
 MC fractures: distal radius  scaphoid  triquetrum  trapezium  lunate
 Hook of hamate fracture = ulnar nerve injury
 Scaphoid fracture: fix if intrascaphoid angle > 45 degrees on lateral
o Ligament
 SL injury = lunate DISI deformity – incr SL angle (fix if >60 deg on lateral) and interval
 LT injury = lunate VISI deformity – decr SL angle
Basilar thumb arthritis (CMC joint)
o Anatomy
 Due to attenuation of anterior oblique ligament
 Trapezial-MC joint is biconcave saddle joint
 MCPJ hyperextension o Sxs
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Pain at base of thumb, difficulty pinching and grasping
Painful CMC grind test
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NSAIDs, thumb spica, steroid = first line
Closing wedge dorsal extension osteotomy of 1st MC = early disease
Trapeziectomy + LRTI = MC procedure (FCR used) but trapeziectomy with less
complications
Trapeziometacarpal (CMC) arthrodesis = young male heavy laborers
Rx

Hand fractures and dislocations
Metacarpal dislocations
o Thumb: dorsal dislocation – volar place, sesamoid, FPL, collateral ligaments
o Index finger: radial = lumbrical, ulna = flexor tendon
o Small finger: radial = flexor tendon, ulnar = abductor digiti minimi
PIPJ dislocations
o Volar dislocation: central slip and lateral band form noose around condyle of prox phalanx
o Dorsal dislocation: FDP tendon, volar plate
Jersey finger (FDP avulsion with distal phalanx fx)
o Type 1: tendon retracts into palm – repair within 1-2 wks
o Type 2: FDP retracts to PIPJ maintained by fracture fragment stuck in A3 = within 3 months
o Type 3: FDP retracts to A4 pulley – just proximal to DIPJ = ORIF anytime
Arthrodesis measurements
o MCPJ: thumb = 15, index = 25, middle = 30, ring = 35, small = 40
o PIPJ:
index = 40, middle = 45, ring = 50, small = 55
Supracondylar humerus fracture in children  compartment syndrome  Volkmann’s contracture
o Rx: median and ulnar nerve neurolysis, tendon lengthening (muscle slide)
Tendons/ligaments
Lateral band control
o Triangular ligament: prevents volar subluxation of LB = prevents boutonniere deformity
o Transverse retinacular ligament: prevents dorsal migration = prevents swan neck deformity
Rheumatoid
o Boutonniere deformity is MC  swan-neck
o EPL is MC ruptured tendon (ulnar to radial)  EPQ
o A1 pulley should NEVER be divided in a rheumatoid patient  tenosynovectomy and
debridement of tendons
Lateral epicondylitis: ECRB is main muscle affected
Swan neck in RA
Boutonniere in RA
Treatment of RA wrist diseases
Tendon Transfers
Radial nerve & PIN
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o Elbow extension
o Wrist extension
o Finger extension
o Thumb extension
Low median nerve
o Thumb opposition
High median nerve
o Thumb IP flexion
o Index and middle flexion
Ulnar nerve
o Thumb adduction
o Finger abduction
o Reverse clawing
Donor
deltoid, lat, biceps
PT
FCR, FCU, FDS (4)
PL
Recipient
triceps
ECRB
EDC
EPL
FDS (ring)
EIP, PL, ADM
APB or base of P1 – use FCU as pulley
APB
BR
FDP (ring and small)
FPL
FDP index and middle
FDS or ECRB
APL, ECRL, EIP
FDS, ECRL
Ad pollicis
1st dorsal interosseous
Lateral bands of ulnar digits (active)
A2 pulley (dynamic)
Nerves
Anatomy
o Axillary block sometimes misses musculocutaneous nerve – comes off proximal to block
o Radial nerve: between brachialis and triceps in upper arm and then btwn EDC and ECRB (PIN),
courses ulnar and deep to the EPL
o Median nerve: MAT in arm (median nerve, brachial Artery, biceps Tendon)  anterior to
brachialis  btwn deep and superficial heads of pronator
Injury
o Ulnar nerve injury above wrist benefits from “babysitter” procedure for maximal recovery of
intrinsic muscles – nerve transfer at time of immediate repair (branch of AIN)
o Wartenberg syndrome: radial nerve dorsal sensory branch – entrapped btwn BCR and ECRL
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Flaps
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Brachial plexus injuries – best 5 procedures
o Oberlin procedure: ulnar nerve  musculocutaneous n. (biceps)
o Leechavengvongs: radial nerve (triceps br)  axillary nerve
o Free FMT (gracilis) to FDS and FPL
o Radial nerve tendon transfer
o C5-C6 nerve with sural nerve graft to posterior divisions
Elbow flexion
Shoulder abduction
Elbow and finger flexion
Wrist and digit extension
Osteocutaneous radial forearm
o Bony window made btwn pronator teres and BCR
o Perforators are in septum btwn BCR and FCR
Osseous ulnar forearm
o Harvest cuff of EPL muscle to maintain blood supply
Lateral arm flap
o Based on posterior radial collateral artery
o Sensate with posterior brachial cutaneous nerve
o Osteocutaneous if include 1/3 of humerus
o Reverse flap based on radial recurrent artery – anastomoses w/ PCRA above lateral epicondyle
Medial arm flap
o Based on superior ulnar collateral
Lateral gastroc flap
o Careful of common peroneal nerve injury
AESTHETICS
Lasers
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Common chromophores: water, melanin, Hb
o Q-switched lasers  based on SELECTIVE photothermolysis – minimizes scarring
By color
o Nd:YAG – black and dark blue, hair reduction
o Q-switched alexandrite – blue and green tattoo
o Q-switched ruby – violet/purple/orange tattoo
o Q-switched Nd:YAG – red
By type
o Pulsed-dye laser: capillary malformation, telangiectasias
o KTP: hemangiomas (superficial red vessels)
o Er-Yag: lymphatic malformation, high affinity for skin resurfacing
 Absorbs more water  penetrates less deeply, less hypopigmentation
o CO2: benign lesions, nevi
Scars
o Pulsed dye laser
o Fractional CO2
Vascular anomalies
Infantile hemangioma (GLUT-1)
o Rapidly growing
o Watch for first 1-2 years unless in sensitive spot
o Can give local steroid injection or systemic steroids
o Propanolol if very large
o Only resect if does not disappear after 3-4 years
o MicroRNA-126 can be urine marker used to assess response to therapy
Congenital hemangioma
Capillary malformation: laser (Pulsed-dye)
o Sturge-Weber syndrome
Venous malformation: sclerotherapy – exacerbated by limb dependency
o Malfucci syndrome
Lymphatic malformation: sclerotherapy (if macrocystic) or resection if microcystic
AVM: embolization +/- resection
o Parker-Weber syndrome: high output cardiac failure with AV fistulae
Klippel-Trenaunay: combined malformations – limb discrepancy, unilateral limb hypertrophy, increased
risk of DVT/PE
Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia = HHT)
o AV shunting in mucosa – at risk for bleeding and anemia
o Genes: ENG, SMAD4
CLOVES (congenital lipomatous overgrowth, vascular malformation, epidermal nevi, spinal/scoliosis)
o Mutation in PIK3CA
o Need spinal MRI to screen for CNS AVM
o Have other slow-flow vascular malformations
Migraines
Temporal headache: zygmaticofrontal br of trigeminal nerve (ZTBTN)
o Through temporalis muscle
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o Avoid injury to temporal br of facial nerve
Occipital headache: greater occipital nerve
o Intertwined with greater occipital artery
o Points of compression: semispinalis, tranpezius fascia / muscle
Rhinogenic headache: nasociliary, sphenopalatine ganglion
o Due to concha bullosa, enlarged turbinates, septal deviation
o Rx: septoplasty, turbinate reduction or outfracture
Frontal headache: supraorbital or supratrochlear
o Decompression by endoscopic or transpalpebral
o Points of compression: corrugator supercili, depressor supercili, procerus
Rhinoplasty
Anatomy
o Arterial
 3 branches of ECA
 Facial artery
o Angular  lateral nasal
o Superior labial artery  columellar artery
 2 branches of ICA  ophthalmic
 Anterior ethmoidal artery  dorsal nasal
o Lateral nasal a. supplies nasal tip after division of columellar br. (avoid dissection above alar
groove)
o Tip sensation: anterior ethmoidal nerve
o Middle meatus is primary pathway of inspiratory current
o Levator labii superioris: dilates nares and keeps external nasal valves patent
o Internal nasal valve: resistance increases when angle less than 10 degrees
Incision types
o Infracartilaginous: below LLC
o Intracartilagionus: within LLC
o Intercartilaginous: btwn LLC and ULC
o Transfixion (hemi): incision to get to septum at caudal edge
o Killian: incision to access septum more cephalad
Deformities
o Open roof deformity: spreader graft
o External nasal collapse / pinched tip: alar batten graft (lateral crural strut)
o Pollybeak deformity: nasal tip graft
o Boxy tip: interdomal sutures
o Inverted V deformity: spreader graft
o Hanging columella: resection of caudal septum
o Saddle deformity: onlay grafting of cartilage or bone
Graft length
o L-strut: preserve 10mm dorsal and caudal septum
o LLC cephalic trim: preserve 5-6mm to prevent lateral wall collapse
Other maneuvers
o Weir excision: wedge of alar base resection for wide/flaring nostrils
Body contouring
Most common complication
o Brachioplasty: hypertrophic scarring
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Thighplasty: prolonged edema (with full vertical)
Abdominoplasty: seroma
Abdominoplasty + liposuction: wound dehiscence (central umbilical region)
Body lift procedures: dehiscence
Liposuction: contour irregularities
Cryolipolysis: hypoesthesia
Liposuction
Max dose of lidocaine: 35mg/kg
1cc of 1% lidocaine has 10mg per cc
Approx 10-30% of lidocaine is in aspirate
Combo of infiltrate + IVF = 2 times aspirate removed
Dry = no infiltrate, wet = 200-300cc / site, super-wet = 1:1 ratio, tumescent = 3:1 ratio
Ultrasound assisted: increased risk of seromas & neuropraxia, less surgeon fatigue
Laser-assisted: similar to suction-assisted, less surgeon fatigue, less postoperative pain
Suction-assisted: MCC death = VTE; avoid zones of adherence
Peels
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Types
o TCA: hyperpigmentation MC
o Phenol: cardiac toxicities; soap increases efficacy (decr penetration, incr absorption)
o Jessner’s solution: contains RESL (resorcinol, ethanol, salicylic acid, lactic acid)
Other products
o Alpha-hydroxy acids (glycolic): increase uniform absorption of peel
o Retinoic acid (vit A derivative): increase epidermal and dermal thickness, type III collagen; thins
stratum corneum
o Isoretinoin: AVOID for 2 years before skin resurfacing
Gynecomastia
Best nipple position: oval 3cm at 4-5th intercostal space
Most common mechanism
o Excessive aromatization of androgens to estrogens (estradiol)
o Biopsy: ductal epithelial hyperplasia with proliferation of stroma and fibroblasts
Leuprolide: synthetic GnRH and acts as agonist in pituitary
o Lowers estradiol and testosterone through downregulation of LH and FSH
o Gynecomastia and breast tenderness (mastodynia) are known side effects
Face rejuvenation
Facelift
o Only 3 muscles innervated from superficial surface (mentalis, levator anguli oris, buccinator)
o Frontal (temporal) br. Is ONLY one that is superficial to deep fascia at any given point
o MC complications
 Hematoma: 5 days post-op  release sutures to evacuate, 7-10 days  aspirate
 Skin slough: local wound care, healing by secondary intention
 Nerve injury: great auricular nerve, marg mandibular (asymmetric smile – treat with
botox on contralateral side)
 Infection: S. aureus is MC pathogen
 Hairline distortion: MCC of SECONDARY facelift
o
 Pixie ear deformity: tension on earlobe due to excessive trimming of skin flap
Male facelift
 Thick skin – obscures result
 Incision – bald patients require different, retrotragal leads to posterior beard
displacement but if sideburn, then beard can grow as new side burn
Browlift
Anatomy
o Ideal forehead length: 6-10cm
o Ideal eyebrow position: medial eyebrow = level of alar base, eyebrow peak = btwn lateral limbus
and lateral canthus
Techniques
o Lateral brow elevation: release orbital retaining ligament btwn superficial temporal fascia and
lateral orbital rim
o Medial brow elevation: resect corrugator supercilia muscle (also treats vertical glabellar
wrinkling) - avoid injury to supratrochlear nerve
Blepharoplasty
Anatomy
o Tear fluid layers
 Mucin-secreting goblet cells – promotes dispersion of overlying layer
 Lacrimal gland: aqueous layer – osmotic regulation, controls infectious agents
 Meibomian: outer lipid layer – prevents tear evaporation = DRY EYES if dysfunction
o Hering law
 Equal innervation to eyelids with EQUAL signal to BOTH levators despite potential need
for each to work independently
o Eyelid opening and closure
 Closure: lacrimal punctum closes  tear milks lateral to medial  canaliculi shorten 
ampulla closes  lacrimal sac OPENS
 Opening: lacrimal diaphragm relaxes  pressure to propel tears into nasolacrimal duct
 canaliculi reopen to collect more tears
Lower eyelid blepharoplasty
o Transconj: incision ~5mm below tarsus through conjunctiva & capsulopalpebral fascia; dissect
between orbicularis oculi and orbital septum
o Subciliary: remove excess skin and muscle but increased risk of lid retraction
o Fat repositioning: address tear trough deformity – release arcus marginalis (orbitomalar
ligament) and incision of septum
Complications
o Malposition: MC* - negative vector on Hertel’s, lower eyelid laxity, midface descent
o EOM injury: superior oblique is most commonly injured
o Ectropion: highest risk with subciliary incision, less with transconj
o Chemosis: swelling of conjunctiva – separates lower lid from sclera
 Rx: dexamethasone ointment, patch eye, temporary tarsorraphy
o Dry eyes
Asian blepharoplasty
o Asian eyelids: absent or suptarasal fold, short tarsus, descending pre-aponeurotic fat and
minimal connection between levator and upper lid dermis, prominent epicanthal fold
o Main goal to create supratarsal fold
o MCC = asymmetry
CRANIOFACIAL
Anatomy
Skull base exists
o SRO: V1, V2, V3
o Superior orbital fissure: CN 3, 4, V1, 6
 Superior ophthalmic vein drains via SOF to cavernous sinus
o Foramen lacerum: internal carotid, nerve of pterygoid canal, cranial sympathetics
o Jugular foramen: CN 9-11, jugular vein, occipital & ascending pharyngeal arteries
o Stylomastoid foramen: facial nerve
o Foramen spinosum: middle meningeal a/v/n
Ear embryology
o Arch 1 (anterior): tragus, helical crus, helix
o Arch 2 (posterior): antihelix, antitragus, lobule
Nerve pearls
o Hypoglossal nerve: between ICA and IJ vein  deep to stylohyoid  divides into mylohyoid
 At risk of injury during excision of branchial cleft cyst/fistula
o V3 (mandibular) remains WITH distal segment in sagittal split
o Mental nerve: exists mental foramen below 2nd premolar
o Arnold nerve (CN X auricular br): sensory to concha and oropharynx
o Supratrochlear: pierces corrugator supercili
Sinus development
o Ethmoid: FIRST to develop; complete by age 14
 Middle meatus = anterior ethmoid, superior meatus = posterior ethmoid
o Maxillary: expands until age 10
 Hypoplasia of maxillary sinus MC than aplastic frontal sinus
o Sphenoid: not present under age 3  complete by age 12
o Frontal: rudimentary at birth  see on XR at 6yo  large at 12 yo  complete by age 20 (last)
 Enter into middle meatus
Arch Artery
Nerve Muscles
Bone
Cartilage
1
Maxillary CN V
Anterior digastric, TVP, mastication,
Mandibular
Meckel’s: malleus &
mylohyoid, *tensor veli palatini
incus
Groove = external auditory meatus
Pouch = middle ear
2
Stapedial CN VII Posterior digastric, stylohyoid,
Styloid
Reichart’s: stapes
stapedius, mimetics
Groove = cervical sinus obliterated
Pouch 2 = tonsillar fossa
3
ICA
CN IX Stylopharyngeus
Groove = cervical sinus obliterated
Pouch 3 = thymus, inf PT gland
4
Aorta
CN X
Pharyngeal & larygneal muscles (LVP,
SLN/RLN
uvula, palatoglossus/pharyngeus,
Groove = cervical sinus obliterated
Pouch 4 = sup PT gland
Facial clefts
#0: midline
incomplete median nasal prominence with each other
#3: lateral incisor & canine
disrupts piriform aperture, involves orbit, uni CL
#4: lateral incisor and canine
spares piriform aperture
#6: incomplete Treacher Collins
colobomas of lower eyelid
#7: macromastia – absent z arch MC* - incomplete fusion of mand & max prominences; max 2nd molar
#8: inferior displacement of lateral canthus
Cleft lip & palate
Embryology
o Cleft lip: 5-6 weeks
cleft palate: 7-8 weeks
o Origins
 Primary palate: medial nasal prominences and maxillary prominences
 Secondary palate: lateral palatine process of max prominences
 Premaxilla, nasal tip, philtrum, columella: medial nasal prominences
 Forehead & nasal bridge: frontonasal process
 Nasal ala: lateral nasal processes
o Problems
 Cleft lip: failure of fusion of medial nasal and maxillary nasal
 Macromastia: failure of fusion of mandibular and maxillary prominences
Cleft lip
o Anatomy
 Nasal ala displaced lateral, inferior, posterior
 ANS deviated to other side
 Orbicularis oris abnormal insertion on cleft side
 MC is absence of lateral incisor
o Mustarde-rotation flap
 “L”: lateral lip – nasal lining and sidewall expansion (ADVANCEMENT)
 “M”: medial lip (ROTATION)
 “C”: columellar lengthening
o MC stigmata is short lip
o Abbe-Estlander flap to transfer lower lip tissue to upper lip
o Lateral incisor MC affected tooth
Cleft palate
o Types
 Primary: malunion of MEDIAL PALATINE and LATERAL PALATINE
 Secondary: malunion of LATERAL PALATINE with each other & with septum
 *R palatine shelf elevates before L = LEFT with more frequent clefts
o Repair
 Intravelar veloplasty: reorient LEVATOR VELI PALATINI horizontally – LENGTHENS palate
 Furlow palatoplasty: lengthens palate
 Useful as salvage procedure after straight line closure for submucous CP
 Veau-Wardill-Kiler palatoplasty: V-Y pushback to posteriorly displace soft palate
Timing of repairs
o Cleft lip: 3 months
o Cleft palate: 1 year
o Alveolar bone grafting: 7-8 years (before complete eruption of permanent canine)
o Orthognathic surgery: after 18 years
VPI
o Anatomy
 LVP: pulls 1/3 soft palate – moves pharyngeal walls medially
 Palatopharyngeus: courses down posterior tonsillar pillars
 Palatoglossus: elevates tongue against soft palate = anterior tonsillar pillars
 ALL MUSCLES innervated by CN X (except TVP)
 Passavant’s ridge: force constriction of superior pharyngeal constrictors & LVP
o Pearls
 Palatal flaps: greater palatine artery & vein
o
 ICA lies just lateral to posterior pharyngeal wall  medially displaced in VCFS
 Repairing LVP improves Eustachian tube function (repositions muscle)
Options
 Coronal closure: sphincter pharyngoplasty = lateral wall (posterior tonsillar flap =
palatopharyngeus)
 Sagittal closure: posterior pharyngeal flap = posterior wall (posterior mucosa flap =
superior constrictor)
Craniosynostosis
Timing of suture closure
o Metopic: 9 months – 2 years
o Sagittal: 22 yrs
o Coronal: 24 rs
o Lamboid: 26 yrs
o Ant fontanelle: 8-9 months
o Post fontanelle: 3-6 month
Types
o Metopic: trigonocephaly – triangle-shaped; Rx = supraorbital and lateral orbital rim advancement
o Sagittal: scaphocephaly – boatshaped (MC); elongated, narrow cranial vault; Rx = CVR or strip
craniectomy
o Plagiocephaly: unicoronal = FGFR mutation
 Harlequin deformity: elevation of lesser wing of sphenoid on same side
 Ipsilateral ear POSTERIOR and INFERIOR, radix deviates to affected side
o Turribrachycephaly: bicoronal – conehead – Apert & Crouzon; shallow orbits, hyperteloric
o Kleeblattschadel skull: clover-leaf with bitemporal bulging
Oral Surgery
Anatomy
o Mental nerve exists at mandibular 2nd premolar
o Stensen’s duct opening at maxillary 2nd molar (also MC affected by Tessier cleft #7)
o Inferior alveolar nerve closest to lingual cortex at mandibular 1st molar
o Lateral pterygoid is main muscle for OPENING mouth
o Maxillary canine has longest root = greatest risk of injury
o Palate: hard palate - nasopalatine = anterior palate, greater palatine = posterior palate
o Tongue
 Anterior 2/3: sensation = lingual (V), taste = chorda tympani (VII)
 Posterior 1/3: sensation & taste = glossopharyngeal (IX)
Dentition
o *Usually bottom first, then in to out
o Temporary: grows from mesial to buccal (in to out); no molar teeth
o Permanent: real molar teeth grow first  in to out but canine is second to last  2nd molar
Orthognathic surgery
o Sagittal split osteotomy
 Osteotomy on buccal mandible and end on lingual cortex in region of 1 st molar
 MCC = lower lip loss of sensation
o LeFort 1
 Transverse across max sinus and piriform aperture
 Descending palatine most likely injured
 Ascending pharyngeal and ascending palatine artery provides vascularity
 Alar cinch suture decreases widening of alar base
LeFort 3
 MCC failure in midface hypoplasia = lack of midface growth compared to mandible
o Genioplasties
 Jumping genioplasty: deepens labiomental angle
 Sliding (advancement): primary blood supply is posterior muscle attachments
 Avoid “Witch’s deformity” by reapproximating mentalis muscle
Cysts/tumors
o Periapical cysts: associated with tooth infection / necrotic pulp
o Dentigerous cyst: unerupted tooth – NON-keratinized epithelium
o Keratocystic odontogenic: stratified squamous epithelium lined
o Primordial cyst: develops instead of a tooth
o Neurofibromas: typically bilateral, expansile lesions
Tumors (from odotongenic epithelium origin)
o Ameloblastoma: palisading basaloid cells with large nuclei - resection (segmental
mandibulectomy), reconstruction
o KOT (keratocystic odontogenic tumor): keratinized epithelium but no skin components (i.e.rete
ridges)- rx = curettage and chemoablation
Odontogenesis
o Ameloblasts  enamel (but ameloblastomas are from odontogenic epithelium**)
o Odontoblasts  dentin (most sensitive part)
o Cementoblasts  cementium
o
-
-
-
Facial fractures
Frontal sinus fracture
o Anterior: if nasofrontal duct involved = obliteration
o Posterior: if displaced/comminuted = cranialization
Zygomatic
o Greater wing of sphenoid (lateral orbital wall) most useful landmark for alignment
o Periosteal resuspension after ORIF
Orbital
-
o NOE: medial canthal tendon should be posterior and superior to ant lacrimal crest
o Isolated orbital fractures MC occur in MAXILLARY BONE*
o NOE fracture can AFFECFT REDUCTION of ZMC fracture
o 5% increase in orbital volume  enophthalmos
Mandible
o Condyle displaces anteriorly & medially due to lateral pterygoid
o Angle fracture: pulling of massester  posterior open bite on C/L side
Scalp reconstruction
Cervicofacial flap: anchor zygoma to reduce ectropion
Tongue flap: paired lingual arteries run laterally within ventral third of tongue
Frontal branch of facial nerve: found within superficial temporal (temporoparietal) fascia
o When raising coronal flap, incise superficial layer of DEEP TEMPORAL FASCIA to protect frontal br
Eye anatomy
Anatomy
o Upper eyelid
o Lower eyelid
 Capsulopalpebral fascia equal to LPS, inferior tarsus equal to Muller’s muscle
 Inferior oblique divides medial and central fat pad
o Superior orbital fissure formed by greater and lesser wings of sphenoid
Ptosis
o Types
 Congenital
 Absence of eyelid crease and minimal levator function
 Neurogenic
 Horner: miosis, anhidrosis, ptosis – affects Muller muscle
 Myasthenia gravis: antibodies to ACh at NMJ  dx with Tensilon test or
neostigmine to block ACh breakdown (ACherase inhibitors)
 Senescent (senile/involutional)
 High or absent supratarsal lid due to levator dehiscence
o Patient assessment
 Schirmer’s test: measure tear film production = potential for dry eye after ptosis repair
 Hering’s law: unilateral ptosis masks C/L ptosis b/c innervation dependent on less ptotic
o Management depends on levator fx
 Poor (0-5mm): frontalis suspension
 Mod (6-10mm): levator resection
 Good (>10mm): levator advancement / repair
 Fasanella-Servat: best if phenylephrine test negative
 Muller’s resection: best if phenylehphrine test positive
Eyelid Reconstruction
Zone I (upper)
o Sliding tarsoconjunctival flap (Hughes flap): superiorly based upper eyelid flap, need FTSG on top
o Cutler-Beard flap: full thickness advancement flap from lower lid through slit
o Mustarde lower lid switch flap
Zone II (below)
o Sliding tarsoconjunctival flap + FTSG
o Mustarde cheek advancement flap (with septal cartilage and lining composite graft)
-
o Tripier flap: lid-switch flap – takes skin and muscle from upper lid as pedicled to lower lid
Zone III (medial canthus)
o Nasoglabellar flap
o Upper eyelid rotational flap
Lip Reconstruction
Pathology
o Upper lip cancer = BCC, lower lip cancer = SCC
Local flaps
o Abbe flap: central defects – inferior labial artery
o Estlander flap: commissure defects – PRESERVES FACIAL NERVE
o Karapandzic flap: musculocutaneous rotation flap for large central defects = micromastia
 Preserves innervation to orbicularis oris
o Gilles flap: modified Estlander flap with quadrilateral shape
o Bernard-Burrow cheiloplasty: Burrow’s triangle allows medial advancement of lateral cheeks 
compromises orbicularis oris
o FAMM: facial artery musculocutaneous flap (buccinator MUST be included)
o Submental artery flap: submental artery travels between submandibular gland and digastric
Nasal reconstruction
<0.5cm: primary closure
0.5-1cm: secondary intention
o Nasal tip hears POOREST vs. medial canthal area / glabella heals BEST
1-1.5cm: bilobed flap (45-50 degrees per lobe)
1.5-2cm: nasolabial flap (based on facial artery), dorsal nasal (based on angular artery) for
>2cm: forehead flap (based on supratrochlear)
If cartilage missing, need to take composite graft
Lining
o Septal pivot flap = superior labial vessels
o Septal mucoperichondrial flap = anterior ethmoid artery – nasal sidewall lining
Ear deformities and reconstruction
Innervation
o Auriculotemporal (V3): anterior surface and tragus
o Greater auricular (C2/C3): lobule / lower half
o Arnold (auricular br of vagus nerve X): concha and posterior EAC
o Lesser occipital: posterior ear
Ear deformities
o Microtia: abnormal development with 1st and 2nd branchial arches (within 5-10 weeks)
o Prominent hear: loss of antihelical fold OR conchal hypertrophy
o Stahl’s ear: 3rd crus, flattening of antihelix
o Cryptotia: upper pole buried beneath skin, superior sulcus absent
o Lop/constricted ear: hooding of helix/scapha
Otoplasty
o Mustarde: conchoscaphoid sutures – bending antihelix with mattress suture
Craniofacial Syndromes
Hemifacial microsomia: 2nd MCC congenital anomaly after CLP; heterogenous etiology (NOT completely
genetic)
MISCELLANEOUS
Anesthesia / critical care / trauma
Classes of local anesthetic
o Ester: metabolized to PABA (plasma)
o Amides: cleared in liver (contains 2 is) – NO hypersensitivity reaction
Supportive agents
o Milrinone: inotropic and systemic/pulmonary vasodilator
o Dobutamine: inotropic and vasodilator
o Epi/norepi: both inotropic and vasoconstricts
o Dopamine: ionotropic, alpha vs. beta effects depending on dose
Propofol infusion syndrome
o Lactic acidosis, renal failure, rhabdomyolysis, treatment-resistant bradycardia  asystole
o Propofol inhibits b-adrenergic receptor, calcium channel function, sympathetic activity
Reversal agents
o Acetaminophen: N-acetylcysteine
o Narcotics: naloxone
o Heavy metal: dimercaprol
o Epinepherine: phentolamine
o Metheglobinemia: methylene blue
o Benzodiazepine: flumazenil
o Malignant hyperthermia: dantrolene
o Bradycardia/asystole: atropine
o Local anesthesia toxicity: fat emulsion (20% emulsion, 1-2mg/kg as bolus)
o Anaphylaxis: epinephrine INTRAMUSCULAR
o Doxorubicin: dexrazoxane IV or topical DMSO
o Vincristine: hyaluronidase
o Calcium: hyauloronidase
Bleeding disorders
o Von Willebrand: deficiency of vWF:ristocetin cofactor and factor VIII
 Rx: DDAVP (ADH derivative)
Post-op nausea and vomiting
o Arepitant: neurokinin-1 receptor antagonist blocks binding of substance P in brain emetic center
and GI tract
Core principles
 Hypersensitivity reactions
o Type I (allergy): IgE  histamine (asthma, anaphylaxis)
o Type II (cytotoxic-antibody): IgM or IgG binds target cell  MAC  destruction of cell
(thrombocytopenia, Goodpasture, membranous nephropathy)
o Type III (immune-complex mediated): IgG binds to circulating antigen  immune complex 
deposition in joints, vasculature, kidneys (rheumatoid, SLE, serum sickness)
o Type IV (delayed hypertensitivity): Th1 helper T-cells activated by APC  activated again with
macrophage mediated cellular damage (chronic transplant rejection, contact dermatitis, MS)
 Trauma
o Zones of neck: I = sternum to cricoid, II = cricoid to mandible angle, III = above mandible angle
o ABC = airway, breathing (C-spine), circulatory (control bleeding)
 Hematologic disorders
o Basics
 aPTT: assesses intrinsic system (8, 9, 11, 12) and common pathway (1, 2, 5, 10)
 PT: assess extrinsic system = Vit-K dependent factors (VII, TF) and common pathway
 Bleeding time: assess platelet number and/or function
Skin lesions
Melanoma
o Breslow thickness: <1mm = 1cm margin, 1-4mm = 2cm margin, >4mm = 3cm margin
o Types: superficial spreading (MC) > nodular (vertical growth) > lentigo maligna (sun lesions) >
acral lentiginous (dark skin)
o Must do SLNB if thickness > 1mm
o Distant mets: best prognosis = skin and SQ, intermediate = lung, worst = visceral i.e. liver or brain
Premalignant lesions
o Actinic keratoses (to SCC): 5-FU, imiquimod, 5-ALA (activated by PDL) – 10% progress to SCC
o Keratoacanthoma (to SCC): rapidly enlarges, spontaneously resolves - excision
o Lentigo maligna (to melanoma): 1cm margin resection
o Cylindroma: benign adnexal tumors (eccrine and apocrine)  progress to malignancy = resect
Basal cell carcinoma
o Best margins: 3-4mm (95% cure) up to 5mm; MC is nodular type
Squamous cell carcinoma
o Margins
 High-risk lesions: 6mm margins
 Features: >2cm in size, poor diffx, history of XRT, immunosup, reticular dermis,
NOT trunk, extremities or neck
 Low-risk lesions: 4mm margins
Merkel cell carcinoma
o Aggressive neuroendocrime tumor – if smaller than 2cm, WLE with 1cm margin + SLNB**
Miscellaneous lesions
o Dermatofibrosarcoma protuberans
 Margins: 15-20mm vs. Mohs (potentially BETTER*) + radx (close positive margins),
Gleevec (unresectable)
o Pilomatricoma: benign, calcifying tumor of hair appendages appears BLUISH– surgical excision
Mohs indication
o Recurrent tumor
o H-zones: nose, medial canthus, lip, eyelids
o Irregular border
o Within scar or radiation bed
Wound Healing
Scar revision techniques
o W-plasty: results in increased wound tension?
o Z-plasty: 30 degree = 25% increase in scar length, 45 degree = 50% increase, 60 degree = 75%
increase, 75 degree = 100%, 90 degree = 125%
Skin physiology
o Maximum tensile strength of wounds: 80% in 60 days (5% in 1 week, 10% in 2 wks, 20% in 3
wks, 40% in 4 wks, 80% in 8 wks)
o Normal skin: type 1 to type 3 collagen is 4:1 vs. hypertrophic scar is 2:1, keloid (more type 3)
Wound healing adjuncts
o Vit A inhibits phospholipase A2 (esp when steroid use)
o Vit C: collagen synthesis
o Pressure garment: local tissue ischemia
o Corticosteroids: incr tissue proteinases
o Silicone sheet: skin hydration, negative charge
Keloids vs. hypertrophic scars
o Hypertrophic: MYOfibroblasts, defect within scar
o Keloids: FIBROblasts (incr proliferation), less blood vessel density, defect beyond original scar,
decreased type 3 to 1 collagen
-
TGF-B most potent stimulator of collagen & ECM synthesis
Chronic wound has increased MMP
Cutis laxa with normal wound healing but increased risk of hernias
Transplantation
Natural killer (NK) cells regulate APC to induce tolerance
Types of rejection
o Hyperacute: preformed antibodies
o Acute: humoral = antibodies after exposure to graft, cellular = T-cell mediated
o Chronic: antibody and T-cell mediated
Immunosuppressive agents
o Calcineurin inhibitors: tacrolimus / cyclosporine – IL2 inhibition (T-cell)
 Renal toxicity
o Antimetabolites: AZA / mycophenolate mofetil – inhibits DNA synthesis
 Increased malignancy
o Antibodies: basiliximab, anti-CD25/3 – target cells or cytokines
 Anti-CD3: post-transplant lymphoproliferative disorder (EBV)
Tissue expansion
Mechanism
o Increased cell division of expanded skin
o Epidermis thicker, dermis thinner, flattening of rete ridges
o Amount of advancement: distance of arc of skin overlying expander – diameter of TE base
Place between galea and periosteum (or frontalis and periosteum) - SUBGALEAL
Rectangular or crescent shaped more expansion than circular
Osmotic tissue expander is self-filling, decr rate of infection but CANNOT overfill or stop
Skin, cartilage, fat grafts
Skin grafts
o FTSG has decreased contracture due to entire dermis; grows with child
o STSG takes by imbibition  inosculation  angiogenesis; reharvest from back
o Sensation return: pain  light touch  temp  vibration
Cartilage grafts
o WARPING is MCC – worst with intact perichondrium
o Harvest in subperichondrial plane
Fat grafting
o MCC is resorption – 60% survival at 6 months
o Adipocytes in muscle survive better than those in dermis
Bone grafts
o Mechanisms
 Osteogenesis: vascularized bone grafts – produce new bone
 Osteoconduction: cortical / cancellous bone / hydroxyapatite – resorption &
replacement of new bone; cortical bone grafts revascularized in 2 months
 Osteoinduction: cancellous bone / demineralized bone / BMP – cells stimulated to
differentiation
 Endochondral ossification: fracture callus forms into bone
o Specifics
 Iliac crest: both cancellous and cortical = osteoinductive and conductive
 Calvarial bone: do not split until diploic space forms at 4 years (from parietal)
 Rib graft: best to take ribs 5-7; split rib allows bone regrowth
Hair Transplantation
Minoxidil and finasteride effective medications
-
Stages: ? – most are in telogen (resting), anagen (adding or growth phase)
o Androgenetic alopecia – MC (X-linked)
o Anagen effluvium: chemotherapy (affects hair mitosis)
o Telogen effluvium: due to stress, pregnancy, etc (halts in resting phase)
Lymphedema
Types
o Milroy’s disease: congenital – at birth (VEGFR-3 mutation)
o Meige’s disease: hereditary form of lymphedema praecox manifests at puberty
o Lymphedema praecox: adolescents
o Lympphedema tarda: adulthood (after age 35)
o Filriasis: Wucheria bancrofti infection
Genes
o Lympangiogenesis: VEGF-C – stimulate reconnections in obstructed lymphatic system
o FLT4 and FOXC2 linked to primary lymphedema – autosomal dominant
Evaluation
o Lymphoscintigraphy using technetium Tc-99
Treatment
o Non-surgical: pneumatic compression, elevation, weight loss
o Liposuction: mild cases for extremity (does NOT work for penile/scrotal lymphedema)
o Staged excision of skin and SQ: severe, if excess skin
 Charles procedure: radical resection of extremity including skin, SQ down to fascia
Stewart-Treves syndrome: lymphangiosarcoma from long-standing UE lymphedema after mastectomy
Infections
Hidradenitis: MC organism = strep viridans
Septic arthritis: MC organism = S. aureus
Infectious folliculitis: S. aureus
Impetigo / erysipelas / lymphangitis: strep pyogenes
Open tibial fractures: ceftriaxone
Mucormycosis: non-septate (“mucous-y”) right angle hyphae
Pressure sores
Anatomy
o Conus medullaris: L2
o Cauda equina: S2-S3 (bony debridement up to here)
Risk factors for failure
o HbA1c > 6%, younger age, albumin < 3.5, ischial ulcers
o MC of death for pressure ulcer patients = renal failure
Reconstruction pearls
o If ambulatory, do NOT USE MUSCLE FLAPS (fasciocutaneous flaps)
o Sacrum: superior gluteal artery
o Ischium: gluteal or posterior thigh fasciocutaneous
o Trochanter: TFL, vastus; girdlestone procedure = resection of femoral head
o NO sitting for 3 weeks
Autonomic dysreflexia (AD)
o Paralysis above T6
o Sxs: bradycardia, hypertension, headache, flushing
o Primary treatment: remove stimulus (i.e. bladder or rectal distension)
Burn Reconstruction
Pathophysiology
o Increased: SVR, integrins, cytokines, T-SUP lymphocytes, complement activation
-
-
-
o Decreased: CO, plasma volume, B-lymphocytes, IGs, T-helper lymphocytes
Formulas
o Rule of 9s: anterior trunk, posterior trunk, LE = 18%, head and each UE = 9%, neck = 1%
o Parkland (fluid resuscitation): weight (kg) x % BSA x 4  give ½ over 8 hours, rest over 16 hrs
 ONLY include 2nd and 3rd degree burns
o Curreri nutrition: weight (kg) x 25 + % BSA x 40 = kcal / day needed
Topical agents
o Silvadene: neutropenia
o Silver nitrate: hyponatremia (“lyte” for nitrate)
o Sulfamylon: metabolic acidosis (carbonic anhydrase inhibition) – Pseudomonas
Frostbite
o Ice crystal formation  draws water out  cell death
o Technetium-99 bone scan used to detect tissue viability
o NSAIDs, rapid rewarming in bath, anti-tetanus, PCN, thrombolytics*
RECONSTRUCTION
Microsurgery principles
Agents
o Aspirin: COX inhibitor  inactivates TXA and prostacyclin
o Dextran: decrease platelet aggregation by incr electronegativity, modify fibrin, volume expansion
 Acute renal failure, anaphylaxis, pulmn edema
o Heparin: anti-thrombin III activator  helps inactivate thrombin, clotting factors 9-12
o Hirudin: directly inhibits thrombin
o Streptokinase: activates plasminogen to plasmin  breaks down fibrin
o Papaverine: phosphodiesterase (PDE) inhibitor
o Nifedipine: calcium channel blocker
Lower Extremity
Anatomy
o Nerves
 Thigh
 Obturator: medial thigh adductors, medial thigh sensation
 Femoral: anterior thigh, sartorius
 Sciatic: posterior thigh
 Leg
 Tibial: plantar flexion, plantar foot sensation
 Deep peroneal: ant compt (dorsielxion), 1st webspace sensation
 Sup peroneal: lat compt, plantar flexion; lateral leg, dorsal foot sensation
 Sural: pure sensory – tibial n. and peroneal n. – sensation to lateral foot / ankle
o Arteries
 Saphenous: branch of desc genicular from SFA
 Post tibial: btwn medial malleolus and Achilles
 Dorsalis pedis: btwn tibialis anterior and EHL  EDL and EHL
 Calcaneal (med and lat): from peroneal
 Plantar: from posterior tibial
 Medial plantar: btwn abductor hallucis and flexor digitorum brevis
 Lateral plantar: btwn abductor digiti minimi and flexor digitorum brevis
Recon options
o Proximal 1/3
 Gastrocnemius
 Pedicle: sural artery (medial and lateral) fromm popliteal
 Lateral gastroc with risk of common peroneal n. injury
o Middle 1/3
 Soleus
 Proximally based: popliteal and peroneal
 Distally based: posterior tibial
o Lower 1/3
 Reverse sural artery
 Peroneal artery perforators – pivot point is 5cm proximal to lat malleolus
 MCC is partial flap necrosis 2/2 venous congestion
 Lesser saphenous vein and sural nerve bisects flap
 Propeller type flaps are based on peroneal artery perforators (laterally), PT (medially)
 Free flaps
o Foot
 Medial plantar: sensate flap for plantar weight bearing surfaces
 Abductor hallucis brevis: small medial malleolus and heel flaps
-
Nerve outcomes
o When graft > 12cm, almost no M4 motor recovery
Chest Wall Reconstruction
Indications to reconstruct bony chest wall
o 4 or more ribs
o Diameter of total defect > 5cm
Sternotomy wound classification – prefer immediate reconstruction
o Type 1: 1st week – no bony involvement
o Type 2: 2-4th week – usually bony involvement
o Type 3: months-years – osteomyelitis, costochondritis, retained foreign bodies
Infection requires debridement and wound closure with flaps
o Pectoralis
 Advancement based on thoracoacromial arteries
 Turnover based on internal mammary
o Omental flap based on gastroepiploic
o Rectus flap based on superior epigastrics from IMA – often harvested in CABG
Congenital syndromes
o Poland Syndrome: absence of pectoralis sternal head, absent rib
o Marfan: pectus excavatum
o Anterior thoracic hypoplasia: ant chest wall depression, rib posteriorly displaced, breast
hypoplasia
Abdominal wall reconstruction
Anatomy
o Intercostal NVB runs between inferior oblique and transversalis fascia
o Below arcuate line, posterior rectus sheath only contains transversalis fascia
o Zones
 Zone 1: midabdomen – deep epigastric
 Zone 2: lower abdomen – superficial epigastrics, DCIA
 Zone 3: flanks & lateral abdomen – intercostal, subcostal and lumbar
Embryology
o Somites
 Dorsolateral: dermomyotome  musculature
 Ventromedial: sclerotome  skeletal
o Congenital
 Poland: absent sternal head of pec major, syndactyly, rib anomalies
 Jeune syndrome (asphyxiating thoracic dystrophy): short ribs, short limbs
 Spinal cord
 Myelomeningocele: spinal cord AND meninges – no skin covering
 Meningocele
 Myelocele
Component separation (bilateral)
o Epigastrium: 10cm
o Mid-abdomen: 20cm
o Low abdomen: 6cm
o Division of ext oblique oblique fascia lateral to linea semilunaris
GU reconstruction
Anatomy
o Dorsal nerve of clitoris (fr pudental n.) analogous to dorsal nerve of penis
Options
o
-
Pudendal thigh flap: thin, sensate – based on posterior labial arteries and superficial perineal n.
 Results in endovaginal hair growth  use hair
o Gracilis flap: pedicle lies between adductor longus and adductor brevis
o Inferior gluteal artery perforator flaps
 Perforator located ½ between ischial tuberosity and PSIS
Penile reconstruction
o Deep dorsal arteries and vein requires reanastomosis (from internal iliac system)
o Replantation steps: suprapubic urinary diversion, urethral anastomosis, corporal body
coaptation, microsurgical anastomosis of dorsal vessels and nerves
Other miscellaneous
Back reconstruction
o Transverse cervical artery typically divided during radical neck dissection
o Criteria for spinal met resection is minimum life expectancy of 3-6 months, not responsive to
non-operative therapy
o Sacral reconstruction: trans-sacral VRAM + free fibula flap spanning lumbar spine / iliac bones
SGAP: draw line from PSIS to greater trochanter – emergence of perforator is at junction of upper and
middle 1/3 of this line
RANDOM
Orthopedic Surgery
Biopsy lesion
o If initial biopsy does not match initial pathology results, defer final resection
o Biopsy should be done at the treating institution
o Intraoperative frozen section is to make sure adequate viable tissue has been obtained
If lytic lesion, PREVENT weightbearing
Smoking causes vasodilation and alters biology of fracture healing
Bone healing
o Primary: intramembranous healing – ABSOLUTE stability constructs (compression plates)
o Secondary: endochondral healing: non-rigid fixations (cast, ex-fix, IM nail)
Vascular Surgery
Characteristics of atherosclerosis
o Fatty streak
o Smooth cell hypertrophy
o Macrophages (foam cells) filled with cholesterol deposits
Compartment syndrome
o Anterior compartment is MOST prone
Bypass pearls
o Distal bypass (below knee) should always use autograft (NO PTFE)
o Best predictor of long-term patency is vein quality
Venous insufficiency
o Characteristic: induration with brown pigmentation, medial malleolus
o Poor prognostic factors: older age, increased BMI, DVT (reflux and obstruction), large ulcer
o Compression therapy CANNOT be used if ABI < 0.7
Genetics
Gorlin syndrome: PTCH1 gene
Saethre-Chotzen: TWIST
Branchio-oto-renal (BOR): EYA1 and SIX1 (AD)
-
Osler-Weber-Rendu (hereditary hemorrhagic telangiectasia): AV shunting in mucosa with high riskfor
bleeding and anemia – ENG, SMAD4
CLOVES syndrome: spinal MRI to r/o CNS AVM – PIK3CA
Random
Lesion excision CPT code
o Measure diameter of lesion + NARROWEST margin required for excision
o ALL adjacent tissue rearrangement codes include an excision
Medical photography
o F/stop: regulates amt of light passing through shutter during exposure
 Larger number = smaller aperture = greater depth of field = sharper focus = stronger
flash
o Shutter speed: controls length of exposure
o *f/stop and shutter speed are RECIPROCAL
o Higher focal length better for close-ups (90-100mm for face)
o Flash provides neutral skin tones
o Frankfort horizontal: top of tragus to infraorbital rim*
Safety
o Tourniquet safety: optimal inflation pressure is 100mg greater than systolic; usually no more
than 120 minutes
 If 30 minutes  reperfusion 5 min, 60 min  5-10 min, 90 min  10-15 min, 120 min
 15-20 min
 If patient has AVF, use tourniquet DISTAL to the shunt
o Current standard for diagnosis of inhalation injury is fiberoptic bronchoscopy
o Universal Protocol mandated by Joint Commission
 Pre-operative marking of surgical site
 Proper preoperative identification of patient by surgeon, anesthesia, nursing
 Time-out just prior to surgery
o Cardiac clearance
 Four metabolic equivalents (MET > 4) is common threshold to clear for surgery
Evidence-based practice
o Types of questions: therapeutic, prognostic, diagnostic, economic/decision
o PICO: patient/problem, intervention, comparison, outcome
o Level of evidence
 I: multi-centered or single-centered cohort or systematic review
 II: lesser quality RTC, prospective cohort study or comparative study
 III: retrospective cohort or comparative study, case-control study
 IV: case-series with pre/post test
 V: expert opinion
Insurance
o Reconstruction after lumpectomy defects are NOT covered