Patients seeking rejuvenation of the forehead will present with different problems and no one forehead lift procedure will be best for all patients. Foreheadplasty techniques using a coronal incision offer advantages over closed procedures and should result in an inconspicuous scar and few complications if skilfully performed. This may also be the procedure of choice for patients with low hairlines who wish their hairline to be raised. Many patients seeking rejuvenation of their foreheads are troubled by high hairlines and worry that surgery will make this worse. Hairline elevation occurs in both coronal and closed endoscopic techniques, and a high forehead appears unnatural, masculine, and detracts from an otherwise attractive appearance. Using an incision or partial incisions along the hairline allows hairline position to be maintained or lowered. Experience has shown that it is not necessary to use an endoscope to mobilize the forehead and modify the corrugator supercilii muscles if forehead anatomy is understood, the operation is appropriately planned and a transpalpebral approach to the corrugators is used. Transpalpebral corrugator myoplasty provides not only a means to perform a closed foreheadplasty without an endoscope, but a method by which medial brow elevation can be minimized or avoided.
Injuries to the fingertip, easily dismissed as minor in the busy emergency department, can be extremely debilitating and, poorly managed, can result in life-changing morbidity. With this is in mind, the hand surgeon's aim should be restoration of useful function, not simply getting the wound healed. Management must be based on careful assessment, both of the fingertip and the patient, before deciding on the appropriate choice of reconstruction. Different areas of the hand have differing functional demands, and the hand surgeon must be familiar with a wide range of reconstructive tools, both simple and complex, to gain optimum results.
Facial deformity significantly affects individuals both psychologically and functionally. Over the past six decades there have been great advances in the management of facial deformity. Developments in orthognathic surgery have been of key importance to improving the outcome for these patients. Orthognathic treatment involves teamwork. The orthodontist plays a vital role in planning and assessment, preparing the patient for surgery and detailing the occlusion post surgery. Patient assessment, including facial and dental assessment, operative technique and complications, will be discussed. The aim of treatment is to achieve a stable, functional occlusion with a desired change in facial shape without significant morbidity and to conclude with a satisfied patient.
The atypical skin lesions are a diverse group of tumours that are uncommon but clinically important. They include a spectrum from benign lesions through to those that demonstrate local invasion and/or distant metastatic potential. Since these lesions are only seen infrequently during clinical practice, it is important to have a solid grounding in the general principles of their management. We also cover some common surgically relevant lesions of the skin, including common types of cysts. A clear understanding of cysts and their aetiology is important to direct their management. We have divided the atypical lesions into benign or malignant and then by their cell/tissue of origin to provide a framework for their study. Such a framework is not perfect due to our evolving understanding of the molecular and cellular bases of these tumours, but it provides a foundation for their study.
The abdominal wall is a complex myofascial structure that prevents exenteration of the abdominal viscerae and supports numerous essential physiological processes. Defects of the abdominal wall therefore result in both localized and systemic dysfunction. The goals of abdominal wall reconstruction are to restore dynamic function and structure including skin resurfacing. It is an evolving subspecialist discipline that uses an increasing array of contemporary techniques to improve outcome.
Brachial plexus injuries are devastating and have a significant impact on quality of life and upper extremity function. Although traditionally surgical intervention has resulted in relatively poor recovery of function, the implementation of new surgical techniques such as nerve transfers, combined with significantly improved knowledge of internal nerve topography, has dramatically improved outcomes. Although there remains a role for surgical interventions such as nerve grafting and tendon transfer, especially in the obstetrical brachial plexus palsy population, nerve transfers are rapidly emerging as the standard of care for the treatment of these difficult patients. This chapter highlights the anatomy, etiologies, investigations, patterns of injury, and surgical options to manage these patients and discusses the outcomes in this emerging field.
Over the last few decades, a rise in demand for minimally invasive procedures with few side effects and little to no recovery period has led to the emergence of a plethora of products and systems designed to refresh the skin and restore the natural contours of youth. Current approaches to the ageing face include injectables – botulinum toxin and fillers – to diminish the appearance of lines and folds and replace volume lost over the years, as well as techniques designed to initiate fibroplasia and neocollagenesis, such as microdermabrasion, chemical peels, lasers and light- or energy-based devices. Increasingly used in any number of combinations, modern procedures safely and effectively lift and tighten the face and reduce the appearance of wrinkles and surface irregularities with an immediate return to normal activity and a low risk of serious complications.
There are multiple techniques that can be used to perform breast reduction with good predictable results. The excess skin and parenchyma needs to be removed and the nipple needs to be safely moved to a more appropriate location. This can only be achieved with a good knowledge of the blood supply in order to understand the design of the various pedicles to carry the nipple–areola complex. The superomedial pedicle vertical breast reduction is described in detail in this chapter. The variations used for a vertical mastopexy and vertical mastopexy-augmentation are also described.
A good neckline gives an attractive and appealing appearance and conveys a sense of youth, health, fitness and vitality. Neck improvement is of high priority to almost every patient seeking facial rejuvenation, and the results of 'facelift' procedures are often judged by the result obtained in the neck. Each patient seeking neck improvement will present with a different set of problems and the neck lift technique used must be based on the deformities present, and will vary from patient to patient. Success or failure in treating the neck lies in the diagnosis of problems and the application of a logical surgical plan. It is not enough to perform submental liposuction and tighten the skin in most patients as such an approach ignores a number of anatomical problems typically present, including platysmal laxity, platysma bands, excess subplatysmal fat, large submandibular glands and digastric muscle hypertrophy. Removing subcutaneous fat and tightening skin over these problems does not correct them, and the presence or absence of each must be looked for in order to create and apply an appropriate surgical plan.
Non-melanomatous skin cancers (NMSCs) are the most common cancers affecting humans. Basal cell (BCC) and squamous cell carcinomas (SCC) make up the vast majority of NMSCs and both increase in incidence with age. As populations age worldwide, NMSC rates are continuing to increase, emphasizing the importance of a thorough understanding of these two tumours, their presentation, clinicopathologic variants, classification, management and follow-up in modern clinical practice. Recent developments in mutational profiling and improved understanding of the molecular mechanisms underlying the aetiology of these tumours has led to the development of targeted therapies. Novel therapies showing early promise such as systemic inhibitors of the Hedgehog pathway in BCC are reviewed in light of existing treatments so as to provide an evidence-based approach to their management.
The mammary gland is an organ of ectodermal origin whose structure reflects its function: the production of milk for lactation. In humans, the breast has both an aesthetic value and an erotic relevance. The size and shape of women's breasts vary considerably. True symmetry does not exist in reality. Often one breast is slightly larger or smaller, higher or lower or shaped differently than the other. The inner structure of the mammary gland is made of an epithelial component that consists of lobules, where milk is made, which connect to ducts that lead out to the nipple. These lobules and ducts are located spread throughout the background fibrous tissue and adipose tissue that form the main mass of the breast.
Dupuytren disease is an incurable fibromatosis of the palmar fascia with variable phenotype and disease course. Abnormal fibroblast activity leads to the formation of nodules and myofibroblast activity to the formation of skin pits and cords that may cause flexion contractions. It affects predominantly white males of over 50 years of age and is caused by a combination of genetic and environment causes. Treatment is indicated for painful nodules and progressive finger flexion deformities and can be injection (steroids for nodules; collagenase for cords), radiotherapy (for nodules and very early cords) or surgical (percutaneous or open fasciotomy, limited fasciectomy or dermofasciectomy). Skin defects can be closed by full-thickness skin grafts or left to heal secondarily. The surgical treatment modalities show an inverse relation between degree of invasiveness and durability. This chapter gives an overview of the current knowledge on this subject.
We present a rational approach to managing common eyelid defects. Techniques including lamellar closure, Tenzel flap, Hughes flap, cheek rotation and grafting are described in detail. The need to tailor the approach to the patient is emphasized, considering factors such as patient comorbidity and tissue laxity. A detailed description of eyelid anatomy and discussion of aesthetics is presented to help surgeons provide patients with an optimal outcome.
The treatment of permanent facial paralysis presents a challenge to the clinician. When embarking on facial reanimation, the surgeon is attempting to reproduce the efforts of the 17 muscles involved with facial expression with only one. The primary goal is to restore function, so that the eye can be protected, oral continence restored, speech improved and symmetry of the face made more aesthetic. In order to reanimate the face, spontaneous symmetrical movement is desired and is typically achieved by free functional muscle transfer; however this is not always possible. Facial paralysis can affect all age groups and treatment must be tailored to the individual, taking into consideration patient needs, modalities available and the underlying cause. This chapter covers the relevant anatomy, aetiology, clinical examination, diagnostic investigations and management of facial palsy in all age groups, including the static options for when reanimation is not possible.
The mandible is essential to eating, communication and facial proportions. Generally, ablative segmental mandibulectomy defects are best reconstructed with microsurgical free tissue transfer of the fibula osteoseptocutaneous flap in isolated bone, compound and composite defects. Extensive composite defects may benefit from an additional soft tissue free flap with minimal donor site morbidity, such as from the anterolateral thigh. Osseointegrated dental implants in select patients complete total mandibular rehabilitation.
The modern management of fractures of the craniofacial skeleton involves the multidisciplinary approach. Technological advances in imaging have made accurate and detailed diagnosis possible in the early stages of treatment. Advances in resuscitation and anaesthesia have made it possible to perform corrective surgery in a well-planned safer setting. Wide exposure of the craniofacial skeleton enables a direct approach to fractures which can be reduced and secured with metallic plates and screw of ever-increasing elegance and sophistication. When necessary, primary bone grafting from multiple donor sites enables maximum restoration of function and form at the time of the first surgery. These principles apply to fractures of isolated bone of the face and skull and, most importantly, to those complex panfacial fractures.
A variety of traumatic ear defects are observed after amputation, be it partial, subtotal or total with all resulting defects requiring complex contour reconstruction. The guiding principle is to template the normal ear, and transpose this to the affected ear to appreciate the extent of the defect and map which ear contours are missing. If the defect is less than a quarter and two planes of the ear are missing then a fibrocartilage graft can be used to reconstruct the defect. If greater than two planes or more than a quarter of the ear is missing then costal cartilage is required for reconstruction. In cases of subtotal and total amputation costal cartilage is required for reconstruction. The availability and quality of local skin will determine if any fascia, indirect tissue expansion and number of stages are required to reach the desired end result. In summary, there are multiple causes of ear amputations and this chapter aims to define some principles and guidelines that permit a precise surgical management plan.
Vascular anomalies are disorders of the endothelium, which can be subclassified into tumours and malformations, distinguished by proliferating and quiescent endothelium, respectively. The most common vascular tumour is haemangioma, which is divided into infantile and congenital tumours. Infantile haemangiomas have a characteristic growth pattern, appearing within the first few weeks of life, proliferating for several weeks to months, stabilizing between 6 and 12 months of age and finally gradually regressing over a period of several years. In contrast, congenital haemangiomas are completely developed at birth and are divided into rapidly involuting or non-involuting congenital haemangiomas (RICH and NICH). Vascular malformations are grouped into fast flow (arterial) versus slow flow (capillary, lymphatic and venous) types. These lesions, although present at birth, typically only become evident in childhood or, in adult life, do not undergo involution and grow commensurate with the child. Vascular anomalies necessitate multidisciplinary care by a dedicated team with expertise in the management of such lesions.
