History of Rhinoplasty

The word rhinoplasty is derived from 2 Greek words, rhino, meaning nose, and plasikos, meaning to shape or mold. Since the beginning of recorded time, man has considered the nose to be a key feature, if not the key feature, of facial appearance, beauty, and dynamics. However, because of its central facial location and weak cartilaginous support, the nose is relatively susceptible to disfiguring infection, trauma, pathologic entities, and human-associated carnage. If a person were to be so afflicted, these potential deformities could impose serious alterations to work, social life and psyche. In fact, because the nose has been considered the “organ of reputation,” the purposeful amputation of the nose, rhinokopia, was, and is, meant to strip a person of his or her personal honor.1,2 IN THE BEGINNING A papyrus is an ancient form of paper made from the papyrus plant that grows wild in the marshes of the Nile River. The first historical annotation regarding the surgical treatment of nasal deformities is cited in a papyrus named after Edwin Smith. Smith, an American Egyptologist, bought the papyrus from a dealer in Luxor, Egypt, in 1862. The document dates back to approximately 3000 BCE. Dimensions of the papyrus measured 4.68 m long and 33 cm wide, and was divided into 17 pages. The first transliteration of the papyrus was made by James Henry Breasted in 1930. The papyrus was translated a second time in 2006 by James P. Allen, who was the then curator of Egyptian Art at the Metropolitan Museum of Art in New York, using a more modern understanding of surgical verbiage.

At times, the treatment of nasal structural mutilation was surgically attempted by using rudimentary bronze instrumentation. Mutilation was a punishment meted out for major civil offenses, for example, wives leaving the house without permission, adultery, and theft; even lack of female sexual response could lead to punishment causing the recipient visible and lasting humiliation. Captured enemies sometimes were made to suffer the same ill fate as a warning to other would-be adversaries. The treatment of medical problems involved the use of plugs, swabs, linen, and tampons. Strips of adhesive plaster were used for drawing together wound edges. More serious wounds were closed with needles made of materials such as bone, silver, and copper. Surgical sutures were fabricated from plant fibers, hair, or linen. Nasal fractures were treated with stiff rolls of linen. Other informational pieces concerning nasal deformities were addressed in the Nuzi Tablets (1600–1350 BCE), which originated in the ancient area of Nuzi, 10 miles southwest of the city of Kirkuk in modern Iraq.6 The Ebers Papyrus, which is the largest of the medical papyruses and is written in hieratic, devotes an entire section to nasal deformities and their correction. The Ebers Papyrus was also bought by Edwin Smith from an unknown source but was sold early on to Georg Ebers, a German Egyptologist. The papyrus measures 20 m long and has 110 pages. It is dated at 1534 BCE, but parts may have been copied from earlier texts dating back as far as 3400 BCE.5 At approximately the same period of time, and as an extremely dynamic, historically significant corollary, one must note with considerable respect the fifth century BCE Ayurvedic physician, Sushruta, who lived around the same period. Although born of a lowly priestly class, the Koomas (potters), he became a professor of medicine at the University of Benares. Within his series of texts, Sushruta Samhita, written in Sanskrit (a historical branch of Indo-European languages), he outlined several surgical procedures (300) and described several surgical instruments (121). However, because his writings were in Sanskrit, and the Egyptian writings were in hieroglyphics, the spread of shared medical knowledge was greatly mitigated because of expansive geographic communicative areas. In addition, there was a limited amount of commerce between the areas, even though Alexander the Great from Macedonia in Northern Greece invaded India in 327 BCE. However, his troops lasted there for less than 10 years. Since purposeful facial deformation was not exclusive to the area of the Fertile Crescent, in India also, there was much opportunity for interested physicians to attempt to repair several contemporaneous facial mutilations. One of the most famous repairs that is associated with Sushruta is the surgical correction of cutoff noses by the transfer of pedicled forehead or cheek flaps to the nasal deformity.3 Sushruta is also credited with many other surgical procedures, such as those associated with the treatment of cataracts, hernias, lithotomy, and cesarean sections.7–9 Nasal disfigurement was used not only on people who made up the average populace but also on societal members of prominent standing. Emperor Justinian II of the Byzantine Empire (circa 700) was overthrown and had his nose mutilated (rhinokopia) and his tongue slit open (glossotomia). The mutilation was performed in front of thousands of cheering former subjects in the middle of the Hippodrome, the sporting and social center of Constantinople, itself, the capital of the Byzantine Empire. The purpose of the mutilation of his nose and tongue was to permanently discourage him from future attempts to regain his throne as emperor. However, after nasal reconstruction, in the Indian manner, and a healed tongue, he was able to return to power. The effects of the mutilation and repair may be noted in his Carmagnola marble statue likeness.10 In the first century AD, Rome became a medical center. Two outstanding physicians who lived in Rome and discussed tissue transplantation and treatment of facial defects were Celsus and Galen. Interestingly enough, both physicians were Greek.


Up to this time, only reconstructive nasal surgery was performed. This concept was carried through the Medieval age and up to the Renaissance periods. Very little, if any, surgery to improve appearance was performed during the Dark Ages (fifth to fifteenth centuries).4 In 1163, Pope Innocent III and the Council of Tours proclaimed that surgery was to be abandoned by the schools of medicine and all decent physicians. The church believed that surgery was interfering with God’s plan.5 In fact, the performance of a surgical procedure (deemed a manual operation) by an educated physician was considered below his dignity. However, surgical procedures were being performed surreptitiously and were being kept alive by passing on the principles from generation to generation and from one civilization to the next.

In this manner, the status quo was maintained but not advanced to any meaningful degree. In 1442, an Italian surgeon from Sicily named Branca de’Branca introduced a method of using forehead and cheek flaps for facial reconstruction. His son Antonius modified the technique by using the arm as the primary donor site and delaying the initial transfer of the graft. The technique became known as the Italian method. But because of the potential for severe church reprisals, the surgeries that were performed were veiled in secrecy with no publications or even collegial comments.5 Pfalzpaint (1450), a German surgeon, described the suture of a biceps flap to the face, which was initially held in position with bandages for several days before the pedicle was separated to form the nasal dorsum.4 Gasparo Tagliacozzi (1546–1599) was an Italian surgeon and anatomy professor from Bologna. During this “dark intellectual era” when emphasis was placed on the mundane, he produced scientific writings about his surgical treatments and was given the most credit for the arm flap to the facial area procedures. His fame was great, and after his death, the city fathers of Bologna erected a statue holding a rose in his honor, which symbolized his artistic surgical endeavors. However, dogmatists in the contemporaneous prevailing religious faction had him excommunicated. They thought that Tagliacozzi was “imperiously interfering with the handiwork of God.” The religious faction even exhumed his body from a hallowed church burial site and reinterred him in unconsecrated grounds. For the next 2 centuries there was very little advancement in the field of rhinoplasty.

Medical Tourism in Iran

Rhinoplasty in Iran

Breast augmentation in Iran

Butt Lift in Iran

Ear Surgery in Iran



In 1794, B. Lucas, an English surgeon who was working in India reported to have witnessed the reconstruction of a cutoff nose by using a pedicled forehead flap. The operation was performed by a man from the caste of the tile and brick makers in Poona, near the Indian coast. Lucas sent a letter regarding the operation to the Gentleman’s Magazine of London for the October edition. The account was read by Joseph Carpue, a British surgeon at York Hospital in Chelsea, England. Carpue was piqued by the concept and practiced the procedure on cadavers for approximately 20 years. Finally in 1814, he performed nasal reconstructions on 2 patients. He published the cases in an illustrated monograph where it gained great recognition among European surgeons. Interestingly enough, though Carpue was elected as a Fellow to the Royal College of Surgeons, he was passed over by the same Royal College to sit on their Council. He was disdained by his own contemporaneous professional colleagues.4,5 Carl Ferdinand Von Graefe in 1818 published his famous work, Rhinoplastik. It had 208 pages and 55 citations. Although he was born in Warsaw, he was educated in Germany and was considered German. In his book, he noted 3 different surgeries: the Indian technique with the forehead flap; the delayed Italian method of Tagliacozzi; and the third, he called the German method that entailed a free graft from the arm. In addition to his rhinoplastic work, he wrote original articles on such subjects as blepharoplasty and cleft palate repair. To many, he is considered the founder of modern plastic surgery. His son became the leading ophthalmologist in Europe. In 1840, Von Graefe, the father, died while performing an operation.4,5 Johann Friedrich Dieffenbach succeeded Von Graefe in Berlin with his professorial titles. Dieffenbach was one of the first surgeons to use local anesthesia, and at a later date, ether anesthesia, while performing his rhinoplastic techniques. His book, Operative Surgery (1845), discusses nasal reconstruction for over 100 pages. He also discussed the endonasal or the subcutaneous approach to nasal surgery. Some consider him the greatest plastic surgeon of his era.4,5 Nasal reconstruction was first performed in the United States by Dr J.M. Warren in Boston, Massachusetts, in the late 1830s. He had previously visited Von Graefe. Dr Warren was related to John Collins Warren, also of Boston. It was the latter Warren who painlessly removed a tumor on a patient’s neck with the aid of ether anesthesia administered by William Thomas Green Morton, a dentist, at the Massachusetts General Hospital on October 6, 1846. Morton said to Warren, after administering the ether general anesthetic to the proper surgical depth, his famous words, “Doctor, your patient is ready.” On finishing the procedure, Warren expounded to the surgical attendees present, with his also famous remark about Morton’s ether anesthetic, “Gentlemen, this is no humbug.”9,10 Concurrently and fortuitously, 2 additional discoveries were made that had great impact in broadening the interests of both the surgical and lay communities with regard to the functional and aesthetic advancement of rhinoplastic procedures. They were the discovery of the antiseptic qualities of carbolic acid (phenol) by an English surgeon and the local anesthetic qualities of cocaine. Joseph Lister in 1867 published his seminal and patient-altering paper on antiseptic principles to reduce infection. The paper was based on the concepts of Louis Pasteur. Lister found that the use of carbolic acid (phenol) greatly mitigated wound infection. As a professor of surgery at the University of Glasgow, he instructed surgeons under his charge to wash their hands before and after operations with a 5% carbolic acid solution and to wear clean gloves. Instruments and the operating theater were sprayed with the same solution. The rate of hospital infections dramatically dropped.14 In 1455, the Spanish explorer Augustin de Zarate discovered Peruvian coca. However, it wasn’t until approximately 400 years later (1884) that Spanish soldiers while in South America as conquistadors became familiar with the native use of the coca leaf. When brought back to Europe, it was chemically refined into cocaine, which had local anesthetic properties.15 One could readily conjecture that an operative procedure that increased the aesthetic value of the face, was relatively comfortable and free of pain for the patient, and in addition, greatly mitigated the chances of infection might gain a potential universal audience. And so it did! In 1875, William Adams, a dentist, published an article on nasal fracture reduction. He divided the fractures into those associated with bone and those associated with cartilage. Although for one of his patients, initial treatment was initiated at 6 years postfracture, his treatment was earlier and more aggressive than most in an effort to avoid potential fracture-related traumatic deformities. He also fashioned forceps to reduce the fractures that are not unlike those that are still in use today. His concept of external support is also contemporaneous.16 Dr John Orlando Roe (1848–1915) was an otolaryngologist from Rochester, New York. In 1887, he published an article regarding a “pug nose.” (A pug nose is one with large lower lateral cartilages plus or minus a concavity of the dorsum.) He performed the surgery for purely aesthetic reasons, a literature first. Besides, he performed the surgery from an intranasal approach, also a first. However, within the same article, Roe divided the nose into 5 main morphologic classes. One of the classifications was flagrantly anti-Semitic with regard to its implications and the manner in which it was further defined. This classification was probably based on the notations of Robert Knox, a period physiognomist. (For the reader, physiognomy has no scientific basis.)17–20 Four years later, in 1891, Roe published a second seminal paper on the correction of angular nasal deformities with great emphasis on the subcutaneous approach. (Dieffenbach, however, is given credit for first introducing the endonasal approach in 1845.) In addition to working from the interior of the nose, he routinely used external and internal splints to keep his postoperative results in their best aesthetic position. Also, he was one of the first to use presurgical and postsurgical photographs to illustrate his results. Some call him the true father of aesthetic rhinoplasty. Dr Robert F. Weir (1838–1927) is associated with several innovations and modifications in the performance of nasal surgery. For example, he altered Adam’s forceps to make them thinner and more delicate for the reduction of fractures. In what he termed an “osteoplastic operation,” he used an osteotome to make his fracture reductions “more even.” He used osteotomes and forceps to divide the nasal bones in the midline. He also infractured them at their juncture with the maxillae to narrow bone width along with simultaneous elevation of the bony dorsum. However, Weir is probably best known for his attempts to correct nasal dorsum deformities. He inserted the sternum of a freshly killed duck to augment a saddle nose. In retrospect, as one might expect, the heterogeneous graft lasted but a few weeks. His use of a platinum strut was somewhat more successful. 21,22 However, it was James Israel, who in 1896 successfully augmented the saddle nose with a tibial graft.23 Weir innovatively removed a wedge of the lower lateral cartilages at their facial angle to reduce interalar width and thus created a greater morphologic symmetry. The latter operation is still widely used and bears his name.


Dr Jacques Lewin Joseph (1865–1934) was born and grew up in Ko¨ nigsberg, Prussia (now, Kaliningrad, Russia). He obtained his doctorate in medicine in 1890 at the University of Leipzig, practiced in Berlin for a short period of time, and then studied orthopedic surgery at the J. Wolff Clinic in Berlin. He published his first article on reduction rhinoplasty using an external approach. He later acknowledged that Roe, Weir, and Dieffenbach had preceded him with similar work. Although Joseph performed plastic procedures on other parts of the body, he is most recognized for devising nasal operations and designing inventive new instruments, which he used to achieve his techno-anatomic goals. Joseph developed a great ability to conceptualize a reshaped anatomically deficient entity and the biomechanical approach to achieve his wellthought- out goals. As an orthopedist, and for his era, he understood how to transplant osseous tissue like bone from the tibia to the dorsum to correct saddle nose deformities. He studied and classified several nasal deformities and devised individualized procedures for their correction on a scientific basis (unlike physiognomy). His artistic drawings and meticulous operative details definitively established him as a rhinoplastic surgeon par excellence. Later, he insisted that photographs and plaster molds be taken for every patient. Joseph developed a great many instruments to use for various facetsofhisdevised correctiveprocedures. For example, for rhinoplasty, he designed various saws to reduce nasal bony and cartilaginous hypertrophies and to have greater control over the lineal separation of lateral nasal fractures for width reduction. He also designed special scalpels for cartilage modification to increase aesthetic contour, external nasal splints, and headbands to hold repaired deviated septa in place. Although Dieffenbach, Roe, and Weir first discussed changes from a subcutaneous approach, it was Joseph, who for years taught and wrote scientific articles concerning the aesthetic reduction and augmentation involving rhinoplastic procedures. Even today, many people believe thatmostrhinoplastic operations are just variations of Joseph’s body of work. One might say that rhinoplasty was born “fully grown” with the emergence of his scientific articles and books. Joseph died under enigmatic circumstances, while fleeing Hitler’s Nazi Germany, in Czechoslovakia in 1934.5,24–32 Some who attended Joseph’s courses or were contemporaneous with Joseph or his pupils were such great historical names as Gustave Aufricht,33 Joseph Safian,34 Jacques Maliniac,35 John M. Converse,36 Abe Silver (Silver WE, Abe Silver, personal communication, 2010), and Sam Foman,37 who in turn gave courses that included Maurice Cottle38 and Irving Goldman.39 It has also been said that Joseph was a bit quirky. During one of his courses, his instruments were placed on an operating room table that was completely covered with a towel so that no one could discern their design. He operated gloveless. Instruments were passed to him covertly from under the towel. One night while taking one of Joseph’s courses, Foman persuaded one of Joseph’s assistants to show him his instruments. And with lightning speed, Foman drew them all. When Foman returned to the United States, he had a friend from the Klink instrument company manufacture the instruments. He later sold them at his rhinoplasty courses (Silver WE, Sam Foman, personal communication, 2010).40 Cottle and Goldman, in due course, gave their own rhinoplastic courses that influenced hundreds of future rhinoplastic surgeons. Many of these gifted surgeons created alterations and some newer rhinoplastic procedures (dome division, elevation of the upper lateral cartilages, additional instrumentation, greater aesthetic forehead flaps, improved postoperative splint dressings, and many other modifications). However, the basic concept came to them, ‘fully grown’. In addition, one cannot exclude other such names as Sir Harold Gillies,40 V.H. Kazanjian,41 D.R. Millard,42 and J.E. Sheehan.


For some surgeons, the endonasal approach had shortcomings. For example, in most instances, surgeons knew from their own formal education, or through observation of other surgeries, researched articles, and case repetitions the subcutaneous disproportionate anatomic morphology of nasal deformities. However, by not being able to directly visualize a problem in situ, the ability to intensely comprehend the anatomic nature of the problem and then treat was compromised. For example, as much subcutaneous fatty and connective tissues (the so-called superficial musculoaponeurotic system layer) as possible might not be removed from above a surgerized dome because of lack of total visualization. This, in turn, might compromise the amount of the final aesthetic acuteness of clarity and shape of tip bulbosity. Thus, a great result might have been diminished to a good result. Another example might be a visualized actual comparison of the reduction right and left lower lateral cartilages after surgery, but before closure, relative to height, width, symmetry, convexity, and so on. On a similar note, Ellsworth Toohey once said in Ayn Rand’s The Fountainhead, “The enemy of excellence is good.”44 Good is not what we want. Then, in 1970, in Zagreb, in the former Yugoslavia, at a meeting of the American Academy of Facial Plastic and Reconstructive Surgery,45 a modestly known Yugoslavian surgeon, Ivo F. Padovan, from the meeting city itself, presented a paper on the “The external approach to rhinoplasty.”46 His 10-minute presentation was based on 400 of his own cases and 500 cases of his mentor, Ante Sercer.47 Both their observations were based on the work of Aurel Rethi of Budapest.48 An attendee at the meeting, Dr Robert Simons noted, “A revolutionary shot in the rhinoplasty world had been fired, but it was neither heard nor appreciated immediately.”49 However, William Goodman, from Toronto, Canada, who was also in attendance at Padovan’s lecture, returned home to begin performing the “external approach” for several nasal deformities. He refined the “gull-wing” incision with a resultant greater patient acceptance. Goodman published several articles regarding the positive, aesthetic, and structural outcomes that he was achieving.50–52 As fate would have it, at around the same time, a young Canadian otorhinolaryngologist, Peter Adamson, who was very much in tune with Goodman’s external approach, began a facial plastic fellowship with Jack Anderson of New Orleans. During this time, Anderson had a renowned reputation for being one of the best known and most well-respected facial plastic surgeons with an unquenchable fire in his belly for the art of rhinoplastic surgery. In addition to these qualities, he was also considered to be a great teacher.53 Before the Adamson fellowship, Anderson thought that he could do basically anything endonasally that one could do via an open method. He was very passionate about nasal surgery but was not afraid to try something different if he thought it was biologically just. His practice associate at the time was Calvin Johnson, a well-known facial plastic surgeon in his own right. With Adamson’s history with William Goodman and Anderson’s scientific inquisitiveness, they started performing external approach rhinoplasties using the midcolumellar approach. In an assessment paper on open rhinoplasty, Anderson, Johnson, and Adamson performed several hundred open procedures, and one of their significant conclusions was that they could not find fault with any surgeon who chose to perform all of their rhinoplasties via the open approach.54,55 There have been several alterations in the procedure but nothing that has altered the basic rhinoplastic surgery as postulated by Joseph. Newer alloplastic materials have been used in augmentation settings.56 Some newinstrumentation was developed that made the shaping of cartilage and osseous contouring more effective. However, it is of interest to note, that one of the most inventive rhinoplastic instrument designers who also wrote and lectured on rhinoplastic surgery was a general medical practitioner and not a surgeon per se.57–59 Rhinoplasty has come a long way, and along the way many people have benefited from the many surgeons from antiquity to the present. These surgeons have tried to give their patients a more attractive face by altering the one physical anatomic structure that one usually notices first.


And with this wonderful circuitous medical history, how did oral and maxillofacial surgery, a dentally based specialty, become a player? During the early part of the 1980s, after regular American Association of Oral and Maxillofacial Surgeons (AAOMS) board meetings, evening blue sky sessions occurred, involving board and staff members. Nagging questions continued to arise relative to just what was our surgical scope. Had we reached our zenith? Was our surgical breadth already defined and finalized by us or, even worse, by others. Concurrently, at annual and midwinter meetings, orthognathic surgery programs were almost always assured that lecture halls would be filled to capacity. The expanded version of orthognathic surgery (or orthodontic surgery as it was then called) was developed to a great degree by European colleagues during the post–World War II era because of a lack of orthodontists and orthodontic materials. Since they could not consistently rely on orthodontic care to aid in the treatment of the many orofacial skeletal deformities, they ingeniously devised technical intraoral methods to operate simultaneously on both the maxillae, the mandible, and their segmental components. Later, definitive biologic credence for these procedures was established by Bell and Levy in 1970 with rhesus monkey angiographic studies.60 Therefore, it was obvious that facial aesthetics in the form of facial bone reconstruction was paramount in the minds of several members of the orthognathic surgical community. Serendipitously, for some, pieces of an arcane puzzle started to swirl about during this period. The author’s own awareness started when a 17-yearold patient was seen for facial aesthetic evaluation. The patient had recently had orthodontic treatment that involved 4 first bicuspid extractions. If one were to evaluate her postorthodontic models alone, the tooth alignment and achieved occlusion were excellent. However, if one assayed the face, in its entirety, it became obvious that the lower onethird of the face was severely “dished.” As oral and maxillofacial surgeons (OMS), we are well aware that a potential treatment of bimaxillary horizontal retrusion is maxillary and mandibular advancement surgery. This surgery is usually accompanied with a genioplasty. The concept was presented to the patient’s family, and the surgeries were successfully performed. Although the osteotomy sites began to heal in their normal manner and the facial edema subsided, to even a casual observer the patient’s previously veiled nasal deformity became the focal point of her face. The patient’s family sought the services of a rhinoplastic surgeon. The surgery was performed and I saw the patient several weeks later. She had become a swan! I was stunned. I thought that out of all the facial surgeries recently performed on her, the nasal alterations made, by far, the greatest significant impact in her overall facial aesthetics. Although, at the time OMS were performing rhinoplasties to only the slightest moderate degree, the thought occurred that as OMS, we operate lateral to the nose, inferior to the nose, above the nose, and on occasion, within the nose. Why should we not perform aesthetic operations on the nose in combination with other facial procedures, or as a stand-alone procedure? After all, we are OMS. And the nose is clearly in the center of the maxillofacial region. Why not? But who would teach an oral surgeon, and better yet, one without a medical degree? Enter, Dr William (Billy) Silver, an otolaryngologist by formal post–medical school residency training. After living in the same area for several years, Dr Silver and I had become geographic friends who shared ideas, techniques, generalized information, and stories about people and events in our respective specialties. Dr Silver’s brother was an orthodontist, his father, a general dentist, and his uncle, Abe Silver, a rhinoplastic surgeon. His uncle, Abe, was part of New York’s well-known Mount Sinai Hospital’s rhinoplastic teaching group along with Irving Goldman. Dr Goldman was the creator of the famous nasal dome division for greater tip definition, which bears his name (the Goldman tip). Dr Billy Silver received additional training after his formal otorhinolaryngology residency by spending much time with Drs Richard Webster of Boston, Jack Anderson of New Orleans, and Maury Parks of Los Angeles. This was the route taken by many future facial plastic surgeons even before there was an official subspecialty of facial plastic surgery and, for that matter, facial plastic fellowships. These members were indeed the pioneers of this new specialty. It was not an easy row to hoe logistically, politically, or financially for these potential members of the newest specialty in the head and neck region. There was a great deal of opposition to the formation of the specialty from anatomically regional medical competitors.61 In fact, $1.2 million was levied in a lawsuit that weighed against the Georgia Society of Plastic Surgeons regarding the professional competency of facial plastic surgeons.62,63 With this background in mind, a telephone call was made to Dr Billy Silver. When asked if he were sitting down, his answer was yes. “Billy, I would like you to teachmehow to do rhinoplasties.” There was a pause on the phone, which seemed to me like 1 hour but was actually just momentary. I thought he had fallen off the chair, fainted, or both. At the end of this pregnant pause, he answered with resolve in his voice stating that he would be more than delighted to teach me. He mentioned a book that he wanted me to read.64 He also asked me to call his receptionist for a list of rhinoplasties that he had scheduled so I could initially observe the mechanics and instrumentation. And so it began. To say the least, it was exciting! I spent time with him that year and with other surgeons, while also attending several meetings.65 The 1988 AAOMS Midwinter meeting on the topic of Esthetic Considerations in Oral and Maxillofacial Surgery held in Tucson, not an easy place to get to,was up to that time the largestmidwintermeeting everattended.Thetopicsincludedliposuction, facial augmentation, rhinoplasty, cheiloplasty, and others. The American Academy of Cosmetic Surgery was a fledgling organization devoted to cosmetic surgery. The academy consisted of a group of professionals in search of a platform to share and add to their cosmetic knowledge. I attended a few meetings and then submitted the required number of cases to become a full member. They were good to OMS. Academy presidents such as Julius Newman, Howard Tobin, and Tom Alt opened their offices to academy members for the observation of patient treatment. Their only criterion was an interest in cosmetic surgery. It was also there that I had the privilege of meeting Richard Webster while I was a member of the academy board. It was his philosophy that every specialty brings something unique to the cosmetic surgery table. Early on, for the OMS who was interested in performing cosmetic surgery, the academy was like a home away from home, but never forgetting that home was truly the AAOMS. Some books on rhinoplasty were somewhat confusing to me until I read Open Structure Rhinoplasty by Calvin Johnson and Dean Toriumi.66 The book was transforming. I read it, reread it, made flash cards, and then I was fortunate to spend a week in Dr Johnson’s office. Sheen’s 2-volume text is also a giant in the rhinoplastic literature.67 After about a year, I started to perform rhinoplastic procedures myself. First, dorsal hump removals and gradually into the more intricate dome and lateral osteotomies. These were performed, at first with orthognathic surgeries and later as standalone procedures. Over a period of time, but gradually, the local hospital staff credentialing committees were won over. Patients who formerly underwent rhinoplasty and orthognathic surgery asked if facelifts, eyes, and peels were in our specialties preview. And then the process started all over again. During this period of time, representatives of the AAOMS met with the American Board of Oral and Maxillofacial Surgery. The 2 national organizations updated the definition of the specialty to include the treatment of facial aesthetic defects. The house of delegates of the American Dental Association later ratified this change. Although some dental boards were recalcitrant in accepting the change because of several frivolous reasons, a significant number of individual states changed their definition with rapidity to coincide with the more realistic definitions of our national organizations. So we can say with assurance, that rhinoplasty and oral and maxillofacial surgery are now tightly interwoven in the future of the specialties scope. And in fact, can any other specialty routinely surgically alter the maxillae, advance it anteriorly, reduce its height, increase its height, alter the mandibular morphology, make it longer or shorter, and so forth? The same could be said for the chin and then a rhinoplasty could be performed to balance out the aesthetics of the face. And lastly, one can also state that the services of those that also perform reconstructive facial plastic surgery is still a very much needed surgical therapy.

Concepts of Skin Grafts and Skin Substitutes

Key Points
Split-thickness skin grafts contain epidermis and a portion of underlying dermis, whereas fullthickness
skin grafts contain epidermis and the entire dermis.
Split-thickness skin grafts, when compared with full-thickness skin grafts, experience less primary
contracture, more secondary contracture, may experience more pigment changes, be more
susceptible to trauma, and have a lower metabolic demand of the recipient site wound bed.
Skin grafts heal by a process of imbibition and revascularization through angiogenesis. Graft healing
is associated with swelling of the graft, increased mitotic activity leading to desquamation, and
eventual reepithelialization over a span of about 4 weeks.
Common causes of graft failure include hematoma, infection, seroma, shear forces, and a poorly
vascularized wound bed.
Skin substitutes come in a variety of forms and can be considered as biologic dressings that provide
clinicians more options in complex wound management, either as an alternative to traditional
dressings or as a bridge to more definitive treatment such as surgical closure.


Medical Tourism in Iran

Rhinoplasty in Iran

Breast augmentation in Iran

Butt Lift in Iran

Ear Surgery in Iran



Providing wound coverage for a patient through the application and grafting of skin harvested from a distinct or separate region located elsewhere on that patient’s body is a key foundational technique in the armamentarium of the plastic surgeon. Skin grafting originated in India approximately 3000 years ago, where full-thickness grafts comprising the entire dermis and epidermis layers of the skin harvested from the gluteal region were used by the Koomes tilemaker caste for nasal reconstruction after amputation, a common punishment for criminals. 1 The knowledge of this surgical technique did not make its way into Western medicine until the early 19th century. In 1817, Sir Astley Cooper used a full-thickness skin graft from a man’s amputated thumb to provide coverage for the remaining stump. This was followed by a successful nasal reconstruction using a skin graft, performed by Buenger in 1823. However, because of the difficulties his European contemporaries encountered while attempting to replicate his technique, skin grafting did not become widely popular until 1869, when Reverdin published his landmark paper reporting successful pinch grafts. Thin split-thickness grafts were popularized in the late 19th century by Ollier (1871) and Thiersch (1874), as a method to cover defects with a large surface area, becoming known as Ollier-Thiersch grafts. However, the drawbacks of these grafts quickly became evident, with several reports in the 1890s detailing the subsequent wound contractures and graft susceptibility to trauma. During the same period, surgeons and ophthalmologists were using full-thickness skin grafts to correct cases of ectropion. The technique of full-thickness skin grafting was published by Wolfe in 1874 and popularized by Krause, with full-thickness skin grafts becoming known as Wolfe-Krause grafts. 2,3 Despite the development of more advanced surgical techniques, autologous skin grafting remains a mainstay of wound coverage reconstruction, especially for burn trauma. However, the relative lack of donor site availability in patients with extensive burns and the suboptimal aesthetic and functional outcomes commonly associated with autologous skin grafts drive a search for alternatives and led to the development of skin substitutes in recent decades. Although initially intended for primary coverage, skin substitutes have been found to have a salutary impact on wounds even when they fail as permanent wound coverage options. In contemporary applications, skin substitutes have been used more commonly as biologic dressings and bridging therapies to eventual definitive closure via autologous skin grafts or other conventional plastic surgical techniques. Nonetheless, much ongoing work continues in efforts to develop an alternative to autologous skin grafts that would promote regenerative healing of wounds in a definitive fashion.

Anatomy of Skin Grafts

The skin is the largest organ in the body, accounting for 15% of total adult body weight, with a layered structure (Figure) that assists in its functions of protection, sensation, thermoregulation, control of evaporation, and absorption. 4 The epidermis, or the outermost layer of the skin, is of ectodermal origin; and its cells undergo continuous differentiation, migration, and eventual shedding. 90% to 95% of epidermal cells are keratinocytes, with the remainder including Langerhans cells, melanocytes, and Merkel cells. The epidermis is substratified into five layers (from superficial to deep)—stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum basale. The epidermis has an average thickness of 100 μm, but this can range widely, from 50 μm on the eyelids to 1 mm on the glabrous skin of the hands and feet.

The anatomy of autologous skin grafts.

The dermis is a structure of mesodermal origin comprised of collagen and elastin fibers, ground substance, and the deeper portions of the epithelial appendages (eccrine and apocrine sweat glands, and pilosebaceous follicles). Although fibroblasts are the dominant cell type in the dermis, it also contains mesenchymal dermal dendrocytes and mast cells. The papillary dermis is the thin uppermost layer of the dermis composed of loosely arranged collagen fibers, which contains a capillary network that provides nutrients to the epidermis and acts as a mechanism of heat exchange and regulation. The reticular dermis lies below the papillary dermis and is composed of dense irregular collagen fibers. It also contains most of the dermal elastin, as well as the pilosebaceous units and sweat glands. Within the dermis layer, there exist two horizontal plexuses of vessels connected by bridging vessels that traverse the dermis vertically. The superficial plexus lies at the interface of the papillary and reticular dermis, whereas the deep plexus lies adjacent to the deep border of the dermis. These plexuses are closely associated with nerve bundles and structures that help mediate sensations such as pain, temperature, itch, touch, and pressure. Below the dermis lies the hypodermis or subcutis, which is composed of adipocytes separated by fibrous septa containing fibroblasts, dendrocytes, and mast cells, and into which extend the deepest parts of the epithelial appendages, as well as vessels and nerves that contribute to the overlying dermal plexuses. In structural continuity with the underlying subcutaneous fat, this layer provides thermoregulation, insulation, energy, and mechanical protection for the skin. Split-thickness skin grafts are defined as grafts involving the epidermis and any part of the dermis, and range in thickness from approximately 0.005 to 0.030 inches. They are classified as thin (0.005–۰٫۰۱۲ inches), medium (0.012–۰٫۰۱۸ inches), or thick (0.018–۰٫۰۳۰ inches) grafts, depending on the amount of dermis included. 1 Full-thickness skin grafts are defined as grafts composed of the epidermis and the entire dermis. Many factors play into the choice between a split- and full- thickness skin graft for wound coverage. Primary contraction of a skin graft is due to elastin fibers within the dermis and occurs immediately after harvest. The amount of primary contraction that a graft experiences is proportional to the amount of dermis in the graft; therefore full-thickness grafts exhibit more primary contraction than split-thickness grafts harvested from the same site. 5 By comparison, secondary contraction is a myofibroblast-mediated process that occurs during graft healing and is more likely to occur in grafts with a thinner dermal component. Secondary contraction can cause significant limitations in the stretch and mobility of the healed graft, and therefore, full-thickness grafts are favored in areas such as wounds over joint surfaces where mobility affects function. Although both split-thickness and full-thickness grafts are vulnerable to shear forces during the healing process, once healed, grafts with a larger dermal element are less fragile to subsequent trauma. One must also take into account the size of the graft needed, as the harvest of a split-thickness graft heals the donor site by secondary intention with minimal morbidity, whereas the donor site for a full-thickness graft usually necessitates primary closure for optimal mitigation of donor site morbidity (thereby limiting the size and potential donor sites for a full-thickness skin graft). Split-thickness grafts are also more amenable to size expansion via meshing techniques, making them more suitable for large wounds. Thicker skin grafts place greater metabolic demands on the wound bed during healing because of the larger tissue component needing nutrients and eventual revascularization, with full-thickness grafts having a slightly lower chance of complete survival and healing than split-thickness grafts on an equivalent wound bed. Because they include only the most superficial portions of the dermis, splitthickness skin grafts also generally do not contain intact accessory skin structures such as hair follicles and sweat glands.

Mechanisms of Skin Graft Healing

A healthy ungrafted wound bed will typically undergo healing by secondary intention—granulation, contraction, and reepithelialization. Placing a skin graft on a wound bed fundamentally alters these processes. Skin grafts become incorporated into the wound bed by a process known as graft take, a loosely defined term generally accepted to imply graft healing and survival. This process is largely dependent on the reestablishment of vascular perfusion to the graft within a critical time frame. Skin graft take has historically been broken down into three classic phases of engraftment—imbibition (0– ۴۸ hours), inosculation (48–۷۲ hours), and revascularization (>96 hours). Much of our knowledge in this area relies on decades-old research based largely on in vitro models and histologic analysis, and there remain several competing theories of the exact mechanisms of graft revascularization. However, the recent development of in vivo models has proven enlightening in repetitive intravital microscopic analyses of the microcirculation and revascularization of a skin graft within the wound beds of live organisms. 6 With all other factors being equal, graft survival has been shown to be dependent on the vascularity of the donor site (with grafts harvested from a highly vascular area healing better than a graft from a poorly perfused area), as well as the metabolic activity of the graft at the time of placement. Freshly harvested grafts have also been shown to attract blood vessel ingrowth more rapidly than grafts that have been frozen and subsequently thawed, but they are also less tolerant of the ischemic period because of increased metabolic activity.


The first stage of skin graft healing is an ischemic phase known as plasmatic or serum imbibition, a concept first developed by Huebscher in 1888, 8 who theorized that grafts were initially nourished by fluid from the wound bed prior to restoration of perfusion. The exact duration of this phase is variable and depends on the characteristics of the wound bed. It lasts approximately 24 hours in a proliferative wound and 48 hours in a fresh wound and can last up to several days in a poorly perfused wound bed. Although it is widely accepted that imbibition allows the graft to survive the initial ischemic period until perfusion is restored, the exact effects on the skin graft of this stage are unclear. Some believe that the graft is nourished by the serum absorbed from the wound bed, 9,10 whereas others believe that the serum has no metabolic function and only serves to keep the graft moist and its vessels patent in the initial period following grafting. 8,11,12 During imbibition, plasma leaks from recipient capillaries into the wound bed-graft interface, and fibrinogen in the plasma is converted into fibrin, which serves to adhere the graft to the wound bed. As the grafts absorb serum, they become edematous and gain as much as 40% of their initial weight in the first 24 hours, starting to decrease in weight after 96 hours, as lymphatic and venous return develop. 8 During imbibition, metabolism within the graft becomes anaerobic and the pH level falls, reaching a pH of 6.8 as determined by Rous. 13 The metabolic demands of the graft also fall, with ATP levels falling 70% and glucose levels falling 80%. Historically, the second stage of skin graft healing was thought to be a process called inosculation, by which blood vessels from the underlying wound bed connect with existing vessels in the skin graft at the graft interface. This mechanism in its traditional definition is no longer considered truly valid, as it would require close approximation of the cut ends of the wound bed and graft vessels. While connections between the wound bed vessels and graft vasculature do occur, they are through the process of angiogenesis and new vessel ingrowth in a unidirectional fashion from the wound bed into the graft. Additionally, these new vascular connections do not necessarily occur at the wound interface with the graft, as inosculation would infer. Recent animal studies have shown that after 48 to 72 hours, microvascular growth of capillary-sized vessels (averaging 10–۱۱ μm in diameter) from the wound bed into the graft has been established in the fibrin interface of the wound. A peak in vessel density is seen at postgraft day 7, with the vascular density at the interface increasing 2.5-fold between postgraft days 3 and 7 before returning to levels near those of postgraft day 3 by day 10.


Historically, there have been three theories laid out to explain graft revascularization. The first proposes that anastomoses are formed between the capillaries of the wound bed and the native vessels in the skin graft, and that circulation is restored in the original skin graft vessels. 12,15–۱۷ The second theory involves new vessels originating from the wound bed growing into the skin graft and establishing a new circulation after the initial reperfusion, implying angiogenesis and vasculogenesis, with the native graft vessels eventually degenerating. 18–۲۰ The third theory also suggests reperfusion by angiogenesis from the wound bed but hypothesizes that recipient-derived endothelial cells migrating into the graft use the skin graft’s intrinsic preexisting vascular network as a conduit for ingrowth, with eventual replacement of the graft’s endothelial structure. 21 Recent development of in vivo animal models supports the third theory of skin graft healing. In 2010, an in vivo mouse model was developed by Lindenblatt et al. to model skin graft revascularization, allowing for analysis of the microcirculation of the graft and wound bed using fluorescein and intravital fluorescence microscopy during healing. 6 Microcirculatory analysis included the determination of vessel diameter, red blood cell velocity, and functional capillary density defined as length of perfused capillaries per area of observation. During the first 72 hours after grafting, there were a progressive widening of the wound bed capillaries (from 10.6 ± ۰٫۱ μm to 15.9 ± ۰٫۲ μm) and the development of small capillary protrusions representing early bud formation and angiogenesis, although the skin graft still lacked reperfusion of the dermal plexus. At 72 hours, a sluggish blood flow within the graft appeared in a pattern comparable to the original skin microcirculation at the donor site prior to graft harvest, likely representing reperfusion of preexisting graft capillaries. After 96 hours, both the wound bed and the skin graft demonstrated increased capillary diameter and functional capillary density, indicating continued angiogenesis in the wound bed, and ingrowth of newly formed vessels into the graft tissue. At 120 hours, capillary diameter and functional capillary density within the wound bed began to decrease, while still increasing within the graft. By 10 days after grafting (240 hours), the skin graft was fully revascularized, with the wound bed vessels still showing a slightly increased diameter (but without signs of ongoing angiogenesis), and the capillary diameter and functional capillary density of the graft at baseline. This model supports the theory that angiogenesis is the primary factor in skin graft revascularization, beginning as early as 24 hours after grafting, leading to vessel growth through the fibrin wound bed-graft interface, eventually leading to reperfusion of the graft’s native microcirculation within 48 to 72 hours, predominantly within the center of the skin graft. These findings are supported by previously demonstrated dermal graft vessel growth of 5 μm/h, which would mean that a skin graft 200 to 300 μm in thickness would be fully traversed by new microvessels within 48 to 72 hours. 21 Additional research by Lindenblatt et al. has demonstrated that the graft vessels demonstrate an angiogenic response to reperfusion between 3 and 8 days post grafting, suggesting that they are more than simply mechanical conduits. Buds visualized within the grafts at capillary junctions contained endothelial cells and pericytes on histology, indicating a temporary angiogenic response within the skin graft. 22 Matrix metalloproteinases MT1-MMP and MMP-2 are associated with the initiation of angiogenesis, by promoting the degradation of the endothelium and interstitial matrix. MT1-MMP enables endothelial cells to form invading tubular structures and to lyse the existing capillaries, as these invading structures connect the graft and wound bed vasculature. The temporary angiogenic buds of the graft showed increased expression of MT1-MMP on their surface and served in vivo as docking points for ingrowing capillaries. MMP-2 expression was concentrated around the vessel sprouts of ingrowing vessels as they advanced toward the deep dermal layer of the skin graft. 23 Using a crossover wild-type/green fluorescent protein (WT/GFP) skin transplantation mouse model (where WT skin was grafted onto GFP mice), GFP-positive structures appeared within the graft vessels starting 48 to 72 hours after transplantation. Preexisting vascular channels in the periphery of the skin graft were 100% replaced by vessel ingrowth from the wound bed by day 10, whereas those in the center of the graft were replaced to a much lesser extent (50%–۶۰%). ۲۴ This may be because the hypoxic stimulus for angiogenesis is no longer present after subsequent revascularization and nutrient supply in the center of the graft where the revascularization process started. 25 In conclusion, skin graft healing is a process of imbibition and revascularization, which represents a combination of angiogenic vessel outgrowth originating in the wound bed, reperfusion of the preexisting graft vasculature, and partial replacement of the existing graft vessels.

Histology of the Healing Skin Graft

During the first 4 days after grafting, the epidermis of the graft doubles in thickness. This has been hypothesized to be due to multiple processes, including swelling of the nuclei and cytoplasm of epidermal cells, epidermal cell migration to the surface of the graft, and accelerated mitosis of follicular and glandular cells. 26 Between the fourth and eighth days after grafting, the epithelium continues to proliferate and starts to desquamate. This increased cellular turnover does not return to baseline until 4 weeks after grafting. 27,28 The dermis of a healing skin graft also demonstrates considerable turnover of its cellular and noncellular structures. It is generally accepted that fibroblasts within the dermis of a healing skin graft are not native graft fibroblasts. In a rat model, Converse and Ballantyne noted decreased fibrocyte populations in the first 3 days after grafting, with the appearance of new fibroblast-like cells after day 3, which would also coincide with graft reperfusion. 18 Collagen turnover in the dermis parallels that of the epidermal hyperplasia, peaking at 2 to 3 weeks after grafting at three to four times faster than the collagen turnover rate for normal skin. Approximately, 85% of the original collagen in a skin graft is replaced within 5 months of grafting, although split-thickness grafts replace only half as much of their original collagen compared with full-thickness grafts of the same size. 29,30 Elastin within the graft is also replaced, with degeneration from postgraft day 3, and regeneration starting 4 to 6 weeks after grafting.

Graft Contraction

Graft contraction occurs in both split-thickness and full-thickness grafts. Primary contraction occurs immediately after graft harvest and is a result of the recoil of elastin fibers in the dermis. A full-thickness graft loses approximately 40% of its surface area after harvest because of primary contraction, whereas a split-thickness graft loses 10% to 20% of its area. Secondary contraction occurs during the healing of a skin graft and is a myofibroblast-mediated process that is inversely proportional to the amount of dermis in the graft. 31 The mechanism behind the inhibition of wound contraction by the presence of dermal elements in the graft is unclear, although multiple hypotheses have been proposed. Rudolph had suggested that increased dermis causes more rapid turnover and elimination of the myofibroblasts that mediate wound contraction. 32 However, further studies by Oliver et al. demonstrated that grafts without dermal cells and other noncollagenous dermal proteins, but possessing a collagen matrix, in fact behave much like fullthickness skin grafts in terms of inhibiting wound contraction. 33 Once wound contraction is complete, full-thickness grafts are able to grow with the surrounding tissue, whereas split-thickness grafts remain fixed.

Skin Grafting Techniques

Choosing a Donor Site

A skin graft donor site is selected based on several factors. Split-thickness grafts are commonly taken from the lateral thigh to minimize difficulties during harvest and dressing changes, although patients may prefer donor sites with less visible scarring such as the buttocks. Split-thickness grafts taken from the scalp are also successful with minimal donor morbidity and no visible scarring once hair has regrown, but are less commonly used because of the need to shave the donor area prior to taking the graft. Common full-thickness graft donor sites include the inguinal creases, the postauricular region, and the supraclavicular area. Consideration must also be taken to obtain an appropriate color match, especially with head and neck skin graft reconstruction, with grafts optimally taken from donor sites above the clavicles.

Graft Fixation

Adherence of the skin graft to the wound bed during the revascularization process is critical for graft survival. During imbibition, the graft adheres to the wound bed by a thin fibrin layer. Once revascularization begins, vascular ingrowth from the wound bed into the graft reinforces this bond. Shear forces, fluid collections (hematoma/seroma), and infection all decrease the chances of graft adherence and take. For these reasons, optimal graft fixation methods minimize movement, and gently compress the graft to reinforce hemostasis and minimize the chance of fluid collections. Tie-over bolsters using a xeroform sheet filled with mineral oil–soaked cotton balls are common, especially for the fixation of smaller grafts. For larger skin grafts, grafts in mobile areas, or grafts in areas that are difficult to bolster (e.g., the hand and axilla), negative-pressure dressing techniques such as vacuum-assisted closure therapy (KCI, San Antonio, TX) have become increasingly popular as an alternative bolster dressing for meshed skin grafts. Negative-pressure therapy allows the patient to maintain mobility; however, it does require the patient to carry and recharge the negative-pressure device unit, and the attachment of the dressing to the unit may prove to be cumbersome, especially in patients at increased risks for falls. Spray fibrin sealants such as Evicel (Ethicon, Somerville, NJ) and Artiss (Baxter Healthcare, Deerfield, IL) are also gaining popularity for both securing the edges of the graft (instead of sutures or staples) and increasing adherence of the graft surface. They offer the benefit of immediate mobility, minimal dressings, and ease of application. However, these products may be cost prohibitive in certain settings and also work optimally on thin splitthickness grafts without much primary contraction. The initial dressing over a skin graft is usually removed approximately 1 week following grafting, once adherence of the graft to the wound bed is more secure and the revascularization process has begun. However, adherence does not imply full graft survival and healing, and local wound care (typically with xeroform and gauze to keep the wound moist and minimize shear forces) is necessary in the postacute phase following the removal of the initial dressing until the skin graft has had the opportunity to mature and become more durable, usually by 3 to 4 weeks following grafting.

Causes of Graft Failure

In addition to mechanical factors in the fibrin interface between the wound bed and graft that interfere with revascularization (such as hematoma, seroma, or shear forces), other causes of graft failure include infection, medical comorbidities of the patient (such as diabetes mellitus, peripheral arterial disease, or a history of radiation), and inherent properties of both the wound bed and the graft. Meshing (performed using a hand-driven roller instrument that creates uniform slits throughout the graft) and pie-crusting (using a scalpel to create multiple small fenestrations in the graft) are common techniques intended to avoid fluid buildup under the skin graft. Skin grafts in diabetic patients with associated comorbidities often demonstrate delayed healing, with one study showing skin grafts take approximately 2 weeks longer to heal in diabetic patients than in nondiabetic patients. 34 Diabetic patients are also at increased risk for wound dehiscence, infection, and the need for revision surgery. Lower extremity peripheral vascular disease (PVD) also plays an important role in the ability of the wound bed to support a healing graft needing revascularization. In patients whose clinical pictures suggest PVD, a low threshold should be maintained for obtaining noninvasive vascular studies and arteriography. These patients may be candidates for surgical bypass or endovascular angioplasty techniques to optimize blood flow to the wound bed. A wound bed with necrotic tissue that is poorly perfused, is grossly infected, or has chronically exposed bone or tendon (without periosteum or paratenon) is not appropriate for a graft and will need to be optimized prior to graft placement to maximize the chance of graft survival. Robson and Krizek found that skin grafts are likely to fail if bacterial loads on quantitative culture are greater than 105 organisms per gram of tissue. 35 Additionally, inherent properties of the graft may also play a role in graft failure. A thin split-thickness graft will have a greater chance of engraftment than a full-thickness graft taken from the same area, because the metabolic demands of the graft are less and a thinner graft requires a shorter distance of new vessel ingrowth for full revascularization.

Management of the Skin Graft Donor Site

The optimal dressing for the split-thickness skin graft donor site continues to be a matter for debate, as multiple options exist and there are no comprehensive studies comparing all materials in a standardized manner. Generally speaking, the ideal donor site dressing encourages rapid reepithelialization, minimizes pain, decreases the risk of infection, and curtails scarring. In general, dressings that promote a moist wound environment until reepithelialization occurs (at least 7 days) have been shown to improve rates of healing and pain control. A 2013 multicenter randomized clinical trial compared six common donor site dressings and assessed both primary outcomes (time to reepithelialization and pain scores) and secondary outcomes (itching, scarring, and adverse events such as infection, allergic reaction, and hypergranulation). 36 Patients were randomly allocated to an alginate (Kaltostat; ConvaTec, Skillman, NJ; Algisite; Smith & Nephew, London, UK; or Melgisorb; Mölnlycke Health Care, Gothenburg, Sweden); a semipermeable film (Tegaderm; 3M, St Paul, Minnesota; or Opsite; Smith and Nephew); a gauze dressing (Adaptic; Acelity, San Antonio, TX; or Jelonet; Smith & Nephew); a hydrocolloid (DuoDERM; ConvaTec); a hydrofibre (Aquacel; ConvaTec), or a silicone dressing (Mepitel; Mölnlycke Health Care). Time to complete reepithelialization was 7 days (30%) shorter when hydrocolloid dressings were used (median 16 days) than with any other dressing (median 23 days). Pain scores were lowest in the semipermeable film group, but the difference did not reach statistical significance. Gauze dressings had the highest infection rates. This trial’s protocol prescribed the uniform use of gauze-based secondary dressings; therefore, the effects of other secondary dressings (such as semipermeable film) used in clinical practice could not be studied. Additionally, in clinical practice, other factors such as cost, patient compliance with wound care, and availability must be considered. Skin graft donor site dressings continue to be a matter of surgeon preference with no strong evidence directed to any one option. However, it is generally accepted that the dressing should maintain a moist wound environment for at least 1 week.

Emerging Alternatives to Conventional Skin Grafts

Cultured epidermal grafts have been used clinically since the 1980s, when burn patients were successfully grafted with cultured allografts, 37 and Phillips et al. treated refractory chronic lower extremity wounds with both cultured autografts and cultured allografts. 8 Although it seems intuitive that cultured epithelial autografts would heal on a wound, the successful engraftment of cultured epithelial allografts in the setting of complete lack of immunosuppression needed further explanation. In the 1990s, several studies demonstrated that all donor cells in the graft were replaced by recipient keratinocytes by as early as 1 week following grafting, 38–۴۰ leading to the subsequent conclusion that cultured epidermal allografts provide growth factors that lead to rapid wound healing despite the technical failure when the graft fails to survive. This concept of an epithelial graft as a pharmacologic agent to aid wound healing rather than a technical replacement of the epithelium was an important development in understanding how skin substitutes and similar products may be used to promote wound closure. The clinical applications of cultured epidermal autografts (Epicel; Genzyme, Cambridge, MA) have been limited because of variable graft take rate, limited mechanical resistance, hyperkeratosis, scar contracture, ulceration, and blister formation because of reactions to foreign fibroblasts in feeder media, as well as the lengthy culture time (3–۴ weeks) required and the high cost. Recently, there has been development of several modifications of skin grafting technique to address the drawbacks of traditional skin grafting, including dermal-epidermal grafts, fractional skin harvesting, and epidermal grafts. 41,42 In epidermal grafting, harvesting systems provide continuous negative pressure to separate the epidermis from the dermis at the dermal-epidermal junction while preserving the histological architecture of the epidermis. Although it has been used to treat vitiligo for decades, it has only recently been evaluated as a possible treatment for wound healing. Healing of epidermal grafts is associated with keratinocyte activation, growth factor secretion, and reepithelialization from the wound edge, more akin to cultured keratinocytes than full- or split-thickness grafts. 42 Dermal-epidermal grafting creates micrografts of approximately 0.8 mm × ۰٫۸ mm in size from a splitthickness skin graft using the Xpansion Micrografting system (ACell, Colombia, MD). This increases the border area and regenerative capacity of the grafts, and allows expansion by a factor of 1:100 (instead of the typical 1:5 expansion of a full-thickness skin graft and 1:9 expansion of a meshed split-thickness skin graft). Micrografts also do not need to retain their dermal orientation, thereby decreasing the procedural complexity. This minimizes the size of the skin graft required and resultant donor site morbidity, allowing the procedure to take place under local anesthetic in an outpatient setting. 41 Fractional skin harvesting requires harvesting a large number of full-thickness microscopic skin tissue columns measuring approximately 700 μm in diameter using customized hypodermic needles. The extracted skin columns are placed randomly in the wound without maintaining the dermal orientation. Advantages of this technique include minimal morbidity, faster healing of the donor site without scarring, and lack of the expanded mesh graft pattern of the healed graft. Although this is still a new technique currently only being used in experimental animal models, it shows promise for future commercial development. 41 Autologous noncultured cell therapy such as ReCell (Avita Medical, Royston, UK) isolates cells from the dermal-epidermal junction of a thin split-thickness skin graft using trypsin incubation, followed by mechanical agitation to separate the cells, and immediate suspension in a lactate solution, which then undergoes spray application on the wound. Benefits of this system include quick application and a large expansion ratio (1:80). Drawbacks include poor attachment and loss of cells secondary to mechanical pressure while spraying, as well as high cost. One promising application of this technique is potential one-stage creation of an epidermal layer when used concurrently with dermal matrices. In a pilot study, 43 ReCell was combined with the dermal substitute Integra (Integra LifeSciences Corp., Plainsboro, NJ) to treat full-thickness wounds in a porcine model. Cells isolated with the ReCell system were sprayed on the underside of the dermal matrix prior to application. The study indicated that cells stay viable, migrate through the dermal substitute, and self-organize into a differentiated epidermis.

Skin Substitutes

The scarcity of donor site availability in patients with extensive burns and the suboptimal aesthetic and functional outcomes commonly associated with autologous skin grafts have prompted the search for viable substitutes for skin grafts. The earliest skin substitutes were allografts of cadaveric human skin used to treat patients with extensive burns and limited donor sites for autograft harvest. The high antigenicity of skin allografts, in particular the epidermal layer, with subsequent graft sloughing and rejection led to the combination of cultured epidermal autografts over dermal allografts in the 1980s. 44 Observation that the formation of a neodermis comprised of healthy connective tissue is stimulated in the wound bed even though the allograft does not successfully survive, as well as concerns about disease transmission from donors and persistent scarring and contractures, has spurred continued efforts to develop bioengineered skin substitutes. 45 In 1984, Pruitt and Levine 46 detailed the attributes of an ideal skin substitute: Little or no antigenicity Tissue compatibility Lack of toxicity, either local or systemic Permeability to water vapor just like normal skin Impenetrability to microorganisms Rapid and persistent adherence to a wound surface Porosity for ingrowth of fibrovascular tissue from the wound bed Malleability to conform to an irregular wound surface Elasticity for motion of underlying tissues Structural stability to resist linear and shear stresses A smooth surface to discourage bacterial proliferation Sufficient tensile strength to resist fragmentation Biodegradability Low cost Ease of storage Indefinite shelf life Although the intervening decades have seen the development of a broad range of products that attempt to embody many of these attributes, the term skin substitute belies how these products are currently used in complex wound management. Furthermore, inconsistency in terminology and how these products are applied can make consistent classification challenging, but skin substitutes and related products may be categorized in several ways: composition of source material (e.g., synthetic versus biologic; human versus animal), intended duration (permanent versus temporary), intended tissue to be replaced (epidermal versus dermal), and number of layers (single versus bilaminate). Many products do not neatly fit into these categories, however. For example, Biobrane (Smith & Nephew) is a biosynthetic composite containing both synthetic elements comprised of silicone and a nylon mesh along with a biologic element derived from porcine collagen. Another composite product, Dermagraft (Organogenesis, Canton, MA) is created by seeding neonatal foreskin fibroblasts onto a biodegradable polyglycolic acid mesh. The fibroblasts are cryopreserved at −۸۰°C and regain their viability once the product is applied on the wound, which must be done within 30 minutes after thawing. 45 Marketed under a variety of terms including artificial skin equivalent, dermal regeneration template, wound matrix, biologic dressing, tissue scaffold, or some other permutation of these words, these bioengineered products share the similar purpose of promoting wound closure, and contrasts are only found on whether the emphasis of a product is placed on acting as an in situ replacement of skin tissue that is eventually incorporated into the recipient wound bed, or on promoting endogenous tissue repair processes within the wound bed to achieve a more optimal healing outcome. In fact, rather than evaluating these products as true substitutes for native skin and treating them as equivalent to autologous skin grafts, it is more useful when deciding whether to use them for clinical purposes to regard the role of these bioengineered skin products as constructs that may deliver growth factors and extracellular matrix components, or attract cells to the wound bed, that can stimulate endogenous healing processes to help promote wound closure and assist in preparing the wound bed for definitive surgical treatment, especially for patients with wounds such as diabetic foot ulcers that can be extremely challenging to treat. 45 One product mentioned more frequently on plastic surgery examinations is Integra, a bilaminar membrane system consisting of a porous coprecipitate of bovine tendon type I collagen and shark glycosaminoglycan (chondroitin-6-sulfate), covered by a temporary silicone epidermal substitute. The silicone layer prevents excessive moisture loss and formation of granulation tissue on the matrix surface. Chondroitin-6-sulfate provides elasticity to the matrix, controls the biodegradation rate, and maintains an open pore structure that allows cell migration into the matrix. 49 Integra heals in phases similar to skin graft healing, progressing through (1) imbibition, (2) fibroblast migration, (3) neovascularization, and (4) remodeling and maturation. During imbibition, the interstices of the matrix fill with wound fluid containing red blood cells, and the fibrin in the wound exudate fosters adherence of the matrix to the wound bed. By day 7, myofibroblasts start migrating into the matrix and start producing collagen by the beginning of week 3. The silicone epidermal layer has usually sloughed or been removed by this point in time. New blood vessels can be seen in the deep portion of the matrix by day 12 and reach the superficial surface by day 28, at which point a thin split-thickness skin graft may be applied. Recent data showed clinical effectiveness using Integra to help achieve eventual wound closure with successful skin grafting performed as early as 1 week after Integra application in combination with negative-pressure therapy. 50 However, neovascularization of the matrix at that early time point has yet to be demonstrated at the histological level. Integra can also be used without the silicone layer as a filler for contour deformities, although this does require a lengthier period of neovascularization for vessel ingrowth through a thicker matrix.

Using skin substitutes as a bridging therapy


Each year sees the introduction of new or modified products intended as advanced wound therapy. However, high-level clinical evidence, rigorous cost-benefit analyses, and other research supporting their routine use remain incomplete, with many of the products not uniformly available because of lack of regulatory approval or restrictive reimbursement and formulary policies. Nonetheless, the use of skin substitutes and related products has entered the mainstream of contemporary clinical practice. Recent reviews summarizing these products with extensive lists and tables can be found in the existing medical and scientific literature, 47,48 and therefore will not be duplicated here, given the constant flux and changes in available products and evidence. Although the full potential of skin substitutes remains yet to be achieved, with their ability to promote wound closure and act as important temporizing bridges to definitive treatment, skin substitutes and their related brethren products have become an important adjunct in complex wound management for the plastic surgeon.


Autologous skin grafts are a key foundational technique of plastic surgeons and remain a mainstay of reconstructive surgery for wounds despite the development of more advanced surgical techniques. Surgeons may choose between split-thickness and full-thickness skin grafts depending on various factors including graft characteristics (color match, size, amount of primary and secondary contraction), donor site availability and morbidity, and recipient site requirements. Once applied to a wound bed, skin grafts heal by a process of imbibition and revascularization, which is a combination of angiogenic vessel outgrowth originating in the wound bed, reperfusion of the preexisting graft vasculature, and partial replacement of the existing graft vessels. To minimize shear forces and fluid collecting at the interface, both of which can lead to graft loss, skin grafts are typically immobilized during the postoperative period with bolster dressings, which in recent years are more frequently comprised of negative-pressure wound dressings. Limitations of conventional skin grafts spur the development of biologic and synthetic skin substitutes. Although the goal of using skin substitutes for definitive wound coverage remains elusive, skin substitutes and similar products have established a role in providing temporary wound coverage and assisting in the healing and preparation of wound beds until definitive coverage can be obtained.

Principles of Microsurgery

  • Microsurgical techniques are used to repair blood vessels, nerves, and lymphatics; applications include free tissue transfer, nerve repair, replantation, and transplantation.
  • Surgical precision is the key factor in anastomotic patency.
  • Microsurgical techniques are used to repair blood vessels, nerves, and lymphatics; applications There is no difference in patency rate based on suture technique (simple interrupted versus continuous) or anastomotic technique (end-to-end versus end-to-side).
  • Routine use of antithrombotic agents in the postoperative period is optional.
  • Thrombosis is most common within 24 hours of surgery. Early failure is often related to anastomotic imperfections or pedicle positioning. If a problem is detected early, the flap can be salvaged by exploration and revision of the anastomosis.

Microsurgery is a discipline that requires magnification, precision instruments, and specialized surgical techniques. Magnification, using surgical loupes or an operating microscope, makes it possible to repair tiny, delicate structures that exceed the limits of normal human eyesight. Microsurgical techniques are used to repair blood vessels, nerves, and lymphatics; transplant tissue from one area of the body to another; and reattach amputated parts.


The origin of microsurgery can be traced back to the late 1890s when surgeons began repairing blood vessels both in laboratory animals and humans without the use of magnification. The first successful endto- end anastomosis was performed on the carotid artery of a sheep in 1889 by Jassinowski. 1 In 1902, Carrel described the triangulation method of anastomosis that is still routinely used today. 2 The following year, Höpfner performed the first experimental extremity replantation on a canine hind limb. 3 The introduction of the operating microscope in Sweden by Nylen 4 and Holmgren 5 in the early 1920s revolutionized the field of microsurgery; it was used successfully in ear and eye procedures in centers throughout Europe. Fine surgical instruments specifically designed for use under magnification were adapted from those used by watchmakers and jewelers. The development of fine sutures swaged on suitably fine needles followed thereafter. Jacobson and Suarez are credited with the first successful microsurgical anastomosis using an operating microscope on a canine carotid artery in 1960. 6 They encountered significant difficulty while attempting the procedure with the unaided eye, and after trying multiple forms of magnification, were successful with a microscope previously used in otology. Throughout the 1960s, Buncke experimented with replantation and transplantation in laboratory animals. In 1966, he performed rabbit ear replantation with the anastomosis of vessels approximately 1 mm in diameter. Buncke developed many important principles and techniques and is often called the founding father of microsurgery. 7 Technological improvements such as coaxial illumination, motorized and optical zoom, binocular viewing, and independent focus controls made small anastomoses more reliable. With flap failure rates less than 2%, 8 microsurgical techniques are now used with confidence.


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Basic Science Concepts in Microsurgery

To optimize outcomes, microsurgeons must understand the basic mechanisms of vessel injury and regeneration, the clotting mechanism, and how tissues respond to ischemia and reperfusion.

Vessel Injury and Regeneration

Microvascular anastomoses disrupt all three layers of a vessel wall. Exposure of subendothelial collagen to the bloodstream results in platelet aggregation and the formation of thrombotic plugs. Full-thickness sutures provide intimal continuity at the anastomosis site and result in the highest rates of patency. 9 Soon after anastomosis, a layer of platelets adhere to the denuded endothelium at the suture line— provided there is no exposed media or extensive vessel damage, fibrin deposition and thrombosis will not occur. Platelets gradually dissipate over the next 24 to 72 hours. As the vessel wall heals, a pseudointima forms. Dissipation of platelets in the vessel lumen and formation of the pseudointima correlates clinically with the critical period of thrombus formation within the first 3 to 5 days.

Clotting Mechanism

Platelet adherence and aggregation is the first step in thrombus formation. Platelets do not adhere to undamaged endothelium; however, collagen within the subendothelium is highly thrombogenic. If the intima is damaged, exposed collagen within the media triggers platelet adhesion to the vessel wall. Platelets contain alpha and dense granules that secrete von Willebrand factor, fibrinogen, ADP (adenosine diphosphate), calcium, and serotonin. Together, these factors promote the recruitment and adherence of additional platelets through the formation of proteinaceous bridges. Activated platelets stimulate the conversion of fibrinogen to fibrin to strengthen the growing clot. Eventually, a critical mass is reached, resulting in thrombus formation by either occlusion of the vessel lumen or activation of the extrinsic pathway of coagulation. 11 Antithrombotic drugs intervene at various steps in the clotting cascade with the aim to reduce platelet aggregation and clot formation. Heparin increases antithrombin-3 activity, which inactivates thrombin. Aspirin causes irreversible inactivation of cyclooxygenase (COX) and, subsequently, blocks the formation of thromboxane A2. Dextran decreases red blood cell aggregation through both antiplatelet and antifibrin effects; its exact mechanism of action is unknown. Despite widespread use, evidence on the benefit of antithrombotics in microsurgery is equivocal. 12 Dextran has been shown to have no effect on flap survival but a 3.9- to 7.2-fold increase in systemic complications including renal failure, pulmonary edema, and congestive heart failure. 13 Heparin and aspirin continue to be commonly used.

Tissue Response to Ischemia and Hypoxia

Free tissue transfer requires a period of flap ischemia while the vascular anastomosis is performed. The main mechanism of ischemic injury is hypoxia, which leads to anaerobic glycolysis. Cellular acidosis is particularly severe because the absence of blood flow results in the accumulation of local metabolic byproducts (lactic acid). Coagulative necrosis will ensue if ischemia is not promptly reversed. Tissues have varying levels of tolerance to ischemia based on their composition and metabolic requirements. Skin and subcutaneous tissue remain viable for approximately 24 hours. 14 Muscle is less tolerant; irreversible damage to the microcirculation occurs at approximately 6 hours without blood flow. 15 Connective tissue has very low metabolic requirements and can withstand prolonged periods of hypoxia. 16 Cooling prolongs tolerance to ischemia for all types of tissues. 17 Restoration of blood flow to ischemic tissues may cause additional damage owing to the production of free radicals and reactive oxygen species. The localized inflammatory response leads to leakage of intravascular fluid into the interstitial space and cellular swelling. Despite excellent anastomotic technique, it may be difficult or impossible to restore flow in flaps subjected to prolonged ischemia. Brisk inflow immediately after the anastomosis is followed by a sharp decline in flow rate shortly thereafter. The low flow state triggers intravascular thrombosis and flap ischemia. The process is termed the noreflow phenomenon.

Technical Factors

Many variables contribute to the success of a microvascular anastomosis: patient selection, operative planning, and technical setup, including magnification, instrumentation, and exposure. Meticulous technique and surgeon experience play the greatest role in success.


Instrumentation Basic microsurgical instruments include jeweler’s forceps, smooth-tipped dilating forceps, micro needle drivers, straight and curved microscissors, and single and double microvascular clamps. Instruments should be of the highest quality—glare-free, nonmagnetic, and ergonomic. Heparinized saline irrigation should be available in a 3 mL syringe with a 26-gauge angiocatheter tip. A microsurgical background of contrasting color (yellow, blue, or green) provides improved visualization. Additional necessary instruments include bipolar electrocautery, micro clips and appliers, suction, and a sterile Doppler ultrasound.



Magnification in the form of surgical loupes or an operating microscope is required for microsurgical anastomoses; the choice depends on the clinical scenario, availability of equipment, and individual surgeon preference. The operating microscope provides wide-field, adjustable magnification with excellent depth perception. A halogen or xenon light source projects bright, even light throughout the field, and cool fiber optic systems prevent tissue desiccation. Beam-splitting devices and multiple eyepieces allow surgeons to operate together with the same, full stereoscopic view. Video capability enables the operative field to be displayed on a large monitor, which is helpful for the scrub team. Magnification ranges from 6× to 40×. Low magnification (6–۱۲×) may be used for vessel preparation and suture tying; medium magnification (10–۱۵×) is used for suture placement; and high magnification (>15×) is helpful in performing smallcaliber anastomosis and for careful inspection at the completion of the procedure. Surgical loupes range from 2 to 8× magnification and are available in expanded viewing field options. Generally, 3.5× or higher magnification is recommended for microsurgery. Loupes offer an ergonomic advantage when the anastomosis is performed in a deep cavity or at an odd angle. Loupes-only microsurgery reduces operative time (microscope setup is eliminated), 19 provides an opportunity to perform microsurgery when a scope is not available, and results in equally high patency rates in vessels over 1 mm diameter.


Nonabsorbable, monofilament suture (prolene or nylon) is used to perform anastomoses. Suture size depends on vessel caliber and typically ranges from 8-0 to 11-0. Microneedles are 50 to 130 μm in diameter with a sharp, tapered tip to pierce the tissue and a flat body to improve stability when held in the needle driver.

Automatic Suturing Devices

Anastomotic couplers are commonly used to simplify and expedite end-to-end venous anastomoses. Patency rates are equivalent to hand-sewn anastomoses. 22 After matching the bushel size to the vessel diameter, vessel ends are passed through a polyethylene ring, everted, and evenly secured on pins. Once both donor and recipient vessels are prepared, the coupling device is used to approximate the vessel ends and the rings are held together by interdigitating pins. The result is an automated anastomosis that is stented open by a soft, plastic ring (Figure). This technique provides flexibility in tailoring the anastomosis when vessel size mismatch is present by differential placement of the everted vessel wall on the pins. Coupling devices may also be used on soft-walled arteries over 1 mm in diameter 23 but should not be used on irradiated vessels.

Use of an anastomotic coupling device

Preoperative Planning

A multitude of flap options are available to the skilled microsurgeon. Donor site choice is dependent on the size, location, and type of defect; the availability of recipient vessels; and functional needs of the patient. Donor site morbidity should be considered and minimized. Preoperative angiography (traditional or image-based) is sometimes required at the defect or donor site; it is particularly helpful when physical examination findings are abnormal or if diseased or injured vessels are suspected. When microsurgical reconstruction is needed for traumatic or infected wounds, adequate debridement of the recipient site is required. Ideally, patients should be medically and nutritionally optimized prior to free tissue transfer.

Patient Considerations

It is essential to consider the patient’s general state of health and mindset when considering microsurgical options. Patients must be fit enough to tolerate prolonged general anesthetic and willing to participate in the lengthy recovery process. Active comorbidities, such as diabetes mellitus (DM), obesity, and nicotine use, should be documented and optimized. Age alone is not a contraindication for microsurgical reconstruction. Studies show that microsurgery can be safely performed in children 24 and elderly patients 25 without an increase in flap failure or surgical complications. Macrovascular and microvascular diseases are known sequelae of diabetes; however, it is controversial as to whether DM affects free flap outcomes. Animal models show poor intimal healing at the anastomotic site and reduced venous patency, 26–۲۸ but clinical studies show no difference in the rate of flap failure. 29 Strict perioperative glycemic control reduces overall surgical complications in diabetic patients. Obesity is a known risk factor for flap and donor site complications. Free flaps in obese patients are twice as likely to fail 30 ; however, the overall rate of flap failure is still very low, 31 especially when compared with nonmicrosurgical alternatives (i.e., implant-based breast reconstruction). 32 The risks of seroma, delayed wound healing, and mastectomy flap necrosis increase in obese patients. 30,33 Patients should be advised to quit smoking at least 4 weeks before surgery to reduce perioperative complications. 34 Smoking impairs oxygenation, causes vasoconstriction, and introduces free radicals. 35,36 Studies indicate that smoking does not reduce anastomotic patency but does affect wound healing, skin graft take over flaps, infection risk, flap necrosis, hernia formation, and length of hospital stay.

Microsurgical Techniques

Surgical precision is the key factor in anastomotic patency. Ergonomic setup is the first step to success. The surgeon should be seated or standing in a comfortable position with the shoulders and neck relaxed and the forearms and wrists adequately supported. Ideally, the surgeon should position his or her body parallel to the long axis of the vessel to allow for ergonomic intubation of the vessel lumen and forehand suture placement. Wide surgical exposure is important; it may be necessary to extend the incision, further mobilize recipient vessels, or reposition retractors to avoid operating in a hole. Recipient vessels are prepared prior to division of the flap pedicle to minimize ischemia time. Adventitia and periadventitial tissue is sharply excised to prevent it from becoming interposed between the donor and recipient vessels, which is highly thrombogenic (Figure). Side branches are sealed with bipolar electrocautery or micro clips. The vessels are then clamped, divided, and irrigated with heparinized saline to remove intraluminal clot.

Donor and recipient vessel preparation

The flap pedicle is likewise prepared and divided. Immediately after division, the flap is flushed through with heparinized saline and transferred to the recipient site. It is positioned and secured in close proximity to the defect, paying careful attention to the pedicle to ensure that it is not twisted, kinked, compressed, or under tension. Both donor and recipient arteries are dilated by inserting smooth-tipped forceps into the lumen. Repeated dilation is avoided, as it weakens the vessel wall and causes vasospasm. A forward-flow test is performed by releasing the clamp on the recipient artery to check inflow. This is often done in replantation when vasospasm in injured vessels leads to the loss of the spurt sign in which the blood flows intensely from the cut end of the vessel. The clamp is then replaced and the vessel end is irrigated with heparinized saline. A double-opposing clamp is applied to approximate the donor and recipient vessels.

Principles of Flap Design and Application

  • A flap is a body of tissue with its own inherent blood supply that can be elevated and moved to reconstruct defects.
  • Thorough knowledge of blood supply to tissue is critical for safe and reliable flap elevation and transfer.
  • Use of two- and three-dimensional templates will assist with proper flap design.
  • Attempt to minimize residual donor site deformity. Consider the consequences of scar contracture, contour deformity, and functional loss.
  • For a complex defect, consider staged reconstruction with methodical planning of each stage. Always have a backup plan.
  • The primary goal of flap reconstruction is to maintain adequate flap vascularity. Plan for secondary revisions to improve contour and appearance.

The word principle stems from the Latin princeps meaning a beginning. Tenets of practice should begin with the principles, yet these should be subject to change as knowledge of the subject increases. 1 There has been significant evolution of our knowledge of flaps in recent years, primarily due to improvements in the understanding of vascular anatomy. This has led to noteworthy advances in the reconstructive options available. The simplest definition of a flap is a body of tissue with its own original inherent blood supply that can be elevated and moved to repair and reconstruct defects. In this way, a flap differs from a graft, which does not carry its own blood supply. Flaps, in one form or another, serve as the basis of reconstructive surgery.


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Flap Blood Supply and Physiology

A thorough knowledge of blood supply to the skin and accompanying tissue is critical in safe and reliable flap elevation and transfer of flaps. The skin, because of its role in thermoregulation to maintain homeostasis and its immunological function, has a rich blood supply, far greater than what is needed for its own inherent metabolic demand. This is an important fact in facilitating skin flap survival. The blood reaches the skin from deeper named vessels, via multiple perforating arteries and their accompanying veins that course through overlying muscles, septa, and fascia to supply the more superficial vascular plexuses, creating a continuous three-dimensional (3D) network of vessels supplying all layers of tissues. For the skin, the blood supply is concentrated at the suprafascial and subdermal levels, from which smaller vessels branch to supply the intervening tissues.

Vascular plexuses of the skin and subcutaneous tissue

In 1987, Taylor and Palmer rediscovered and further elaborated on the work of Manchot and Salmon on the blood supply of the skin and underlying tissue, and proposed the concept of the angiosome, which they defined as a 3D body of tissue supplied by a source (segmental or distributing) artery and its accompanying vein(s) that span between the skin and bone. 3 Each angiosome could be subdivided into a matching arteriosome (arterial territory) and venosome (venous territory). Angiosomes can vary in size and interdigitate with adjoining angiosomes via true small anastomotic bidirectional arterioles and venules by reduced-caliber choke (retiform) anastomotic vessels.

More recent work by Saint-Cyr et al. 5 advanced the angiosome concept to provide additional and more practical insight into vascular territory and flow characteristics that are important in flap design. They studied both 3D (static) and 4D (dynamic) blood flow through multiple single perforators and mapped out the territory supplied, calling this a perforasome.

They found greater complexity and variability than was initially anticipated, and they confirmed that each perforasome is connected to an adjacent perforasome by both direct (fascial) and indirect (subdermal) linking vessels.

Perforators have a distinct arterial and venous vascular territory

Interperforator flow occurs by means of direct and indirect linking vessels

Nomenclature and Classification

The nomenclature of flap classification is somewhat imperfect and fluid. As Converse stated, “There is no simple and all-encompassing system which is suitable for classifying skin flaps.” This is true for skin flaps as well as flaps of other tissue types. Although the nomenclature is imperfect and overlapping, it is important to develop a vocabulary of terms to describe flaps for improved understanding and communication with other medical professionals.

Flaps can be classified in multiple ways. Classification occurs according to flap content and tissue type, mechanics of movement or transfer, blood supply, and manipulation prior to harvest.

Flap Content

Flap classification begins with the content of the planned flap. The simplest flap contains skin and subcutaneous tissue. These are referred to as cutaneous flaps. Cutaneous flaps can be harvested relatively thinly to fit a similar defect. Generally, the blood supply in a cutaneous flap is random in nature and located within the subdermal plexus. As defects become more complex, so can the harvested flap. Flaps containing skin, subcutaneous tissue, and fascia are referred to as fasciocutaneous flaps. 7 Fascial flaps devoid of the overlying skin can also be harvested if a very thin flap that is easily contoured is desired. These are known as fascial and adipofascial flaps and are usually accompanied by an overlying skin graft to maintain a thin contour. Fasciocutaneous flaps were described and further classified by their pattern of blood supply by Cormack and Lamberty in 1984 8. The temporoparietal and anterolateral thigh fasciocutaneous flaps are excellent examples.

Cormack and Lamberty Classification of Fasciocutaneous Flaps

Muscle flaps are a staple of reconstructive surgery. They may be used in stand-alone fashion, or with an overlying skin graft. These flaps can be harvested with overlying skin and soft tissue for added bulk and are called myocutaneous flaps. Muscle and myocutaneous flaps were classified by Mathes and Nahai in 1981 based on their inherent blood supply 9. Often in cases of lower extremity trauma with exposed bone or hardware, well-vascularized muscle tissue is desired for coverage and has the advantage of conforming to an irregular wound bed to minimize dead space. However, recent literature shows that muscle and fasciocutaneous flaps achieve comparable rates of limb salvage and functional recovery.

Mathes and Nahai classification


When structural support at the defect is required, flaps containing bone can be used. Vascularized bone flaps, or osseous flaps, can be harvested free from surrounding tissue. For example, a bone-only free fibula can be harvested on the peroneal artery and is a workhorse of head and neck bony reconstruction. Conversely, overlying soft tissue and skin can be included. In this case, the flap is categorized as osteomyocutaneous and osteocutaneous. In a separate category are omental and intestinal flaps. The omental flap can be raised on the gastroepiploic vessels and utilized in pedicled fashion to fill sternal or other chest wall defects. The omentum has angiogenic and immunogenic properties that make it ideal for reconstruction of sternal wound infections. As a free flap, it is extremely useful as thin vascularized tissue that can be covered with skin grafts for defects in the head and neck or lower extremity. 11 Various intestinal flaps can be harvested to reconstruct laryngopharyngeal and esophageal defects. Composites of any of the above categories are used frequently and can include other local tissue such as cartilage, tendon, or mucosa.

Movement and Proximity to Defect

The type of movement or transfer required to inset a flap provides an additional system of classification. Based on proximity to the defect to be reconstructed, flaps are described as local, regional, or distant. Local flaps are moved into an adjacent defect by a process of advancement, transposition, rotation, and interpolation, or combinations of these basic movements.

Regional flaps such as pedicled muscle flaps require larger movements than those seen in local flaps. These often still include rotations, advancements (Figure 4.6), and transpositions. Distant flaps include tubed flaps and free flaps. Tubed flaps are the oldest known type of flaps, first described in the literature in 1917 by Filatov.These involve harvest of a pedicled flap followed by a series of transpositions known as walking. After inset of each transposition, the flap obtains new blood supply from the surrounding tissue by neovascularization and vessel ingrowth. At the subsequent stage, the opposite end is transposed, allowing for movement of the flap and maintenance of blood supply. In this way, the flap is walked or waltzed to its final destination for inset, often necessitating several stages. The advent of free tissue transfer has reduced the use of tubed flaps; however, a distant tubed flap may still play a role in patients who are poor candidates for free tissue transfer.

Rotation flap

V-Y advancement flapTransposition flapBlood Supply

A flap can be further classified by the orientation of its blood supply. The pattern of blood supply to cutaneous flaps is generally described as either axial or random. An axial pattern flap has a known or named artery coursing along its longitudinal axis. A random-pattern flap is designed without a known vessel at its core and relies on the random subdermal plexus for perfusion. 15 Random-pattern flaps must generally be limited to a 3:1 length to width ratio to remain viable at the tip. Axial pattern flaps can be designed with a longer length to width ratio and may carry a random extension with the same limitations described earlier.

Flaps containing muscle or fascia can also be classified further by the type of blood flow that supplies them. The Mathes and Nahai classification of muscle flaps and the Cormack and Lamberty classification of fascial flaps are mentioned above.

The blood supply of a flap can additionally be classified as either pedicled or free. Pedicled flaps remain attached to a known native vascular pedicle and are limited to the arc of rotation or advancement that these vessels afford. The pedicle can be dissected free from surrounding tissues and the flap islandized for maximizing transfer distance. Conversely, a free flap is one that is raised on a known vascular pedicle that is transected and anastomosed to a new blood supply at the recipient site, largely requiring microsurgical techniques. 18 Free flaps allow for true freedom of tissue transfer. A flap harvested in one location can reconstruct a defect that is distant from it, assuming adequate blood flow exists at the recipient site.

Perforator flaps are those based on a perforating artery from a named vessel and include the surrounding 3D area of tissue perfused by that perforator, also known as the perforasome 5,19 (see earlier). Perforating vessels can be thought to travel in a plane perpendicular to that of the skin surface and the axial vessels beneath. Perforators are frequently identified by use of a handheld Doppler on the skin, and one or more perforators can be included in any given flap. Blood flow then arborizes and fills vessels linking one perforasome to the next. Flaps designed around a perforator often also include proximal dissection of the named vessel from which the blood flow originates, and this allows for longer pedicle length or larger caliber of vessels for free tissue transfer. Perforator flaps have become increasingly popular as local flaps for reconstructing both difficult small and larger defects that previously had required a free tissue transfer.

The keystone perforator island flap was described by Behan and has been used throughout the body as an island flap designed adjacent to a defect, and typically based on one or more smaller perforators. The flap has the shape of a keystone-like arch that is designed parallel to the defect and is at least as wide as the defect. It extends beyond each end of the defect, completing the archlike design. The dissection extends through the skin, subcutaneous tissue, and fascia, thus mobilizing the flap to advance into the defect. The closure borrows tissue from all directions, as each end is repaired as a V-Y advancement.

Keystone flap

Another local use of a perforator flap is as a propeller flap. This was first described by Hyakusoku et al. in 1991 21 and is based on a single large perforating vascular pedicle close to the defect that is rotated up to 180°. The main perforator is identified with a handheld Doppler and will be the pivot point for flap rotation. Careful measurement and precise flap design to reach the distal end of the defect is mandatory. The perforator can be visualized early in the dissection and the flap design confirmed prior to circumscribing the island flap. It is important to dissect the perforator through the fascia and free up the adventitia so that there is no venous kinking.

Propeller flap

Modifications to flap blood flow have resulted in added classifications such as the reverse-flow flap, the venous flap, and the supercharged flap. A reverse-flow flap is one in which the native direction of flow through the main pedicle is reversed at inset. An example is the reverse radial forearm flap, in which the radial artery is transected proximally, and the flap must rely on reverse blood flow in the radial artery across the palmar arch 23. A venous flow-through flap is composed of skin, subcutaneous tissue, and a plexus of veins. It is devoid of arterial tissue within the flap. A linear vein is anastomosed to an artery proximally and a vein distally, allowing for both inflow and outflow. These are generally small flaps and can be prone to congestion and partial necrosis. A supercharged flap is one in which the arterial inflow or venous outflow is augmented by using microsurgical techniques to perform a second anastomosis, bringing in an additional inflow or outflow capabilities.


A discussion of classification of flaps would be incomplete without mention of the different types of flap manipulation that can occur prior to harvest. First, tissue that is desired for a planned flap can undergo tissue expansion. An expanded flap allows for greater reach and coverage and can minimize the donor site defect. Furthermore, the mechanical force of stretching tissues has also been shown to enhance tissue neovascularity, and the accompanying thinning of the flap can be an additional bonus in reconstruction.

In situations where there is concern for the ultimate perfusion of the flap, flap delay can be employed. A delayed flap is one in which a preliminary surgical stage is planned to partially raise the flap and divide a portion of the blood supply, delivering a sublethal ischemic insult that stimulates vessel dilation, ischemic preconditioning, and neovascularization. This allows for axialization of blood flow and conditioning of the flap tissues to lower oxygen levels in anticipation of flap transfer at a second stage.

Diagrammatic representation of the same flap

The techniques of flap prefabrication and prelamination are other more recent additions to our armamentarium and can greatly expand the functional capacity of the flap.

Flap Design and Application

The reconstructive surgeon must be familiar with the full spectrum of reconstructive options and select the flap or method of repair that will give the best outcome. The optimal reconstructive strategy may involve multiple modalities of treatment and/or multiple staged procedures. One must take care not to burn bridges and compromise the final result. The flap options available have increased greatly in recent years, and the focus has shifted from ensuring flap survival to limiting the number of flaps required to close a defect and ultimately to enhanced flap selection and refinements. Refinements are achieved by careful preoperative and intraoperative assessment of the defect, determining the reconstructive requirements, and then selecting the donor tissue that gives the best functional and aesthetic result.

Assessing the Defect

For successful flap reconstruction, an accurate diagnosis of the defect, its underlying causes, and reconstructive requirements is needed. The surgeon should consider what tissues are missing (e.g., skin, functional muscle, bone). Precise measurements of shape and size should be taken, including consideration of the 3D depth of the defect for appropriate contour restoration. Photos, templates, and 3D moulages are of great assistance in defect assessment and should be used liberally 29. Modern image-guided planning, especially in planning bony flaps, is also advantageous and can reduce operative time.

One of the most important steps in reconstruction is satisfactory preparation of the defect. The wound bed should be debrided of necrotic material, granulation tissue, and attenuated or scarred tissue. In some cases, quantitative cultures are beneficial to verify the wound is free from infection and bacterial balance has been achieved. 31 In oncologic defects, pathology should ensure clear margins prior to reconstruction. Despite excellent flap selection and harvest technique, inadequate preparation of the wound can lead to flap compromise and reconstructive failure. Patient selection is also a consideration when planning reconstruction. Inherent patient factors such as diabetes, clotting disorders, and poor compliance can hamper flap success. Modifiable factors such as smoking and patient weight should also be contemplated. If risk factors for flap failure are high, a simple method of wound closure may be better than complex multistage reconstruction. In free tissue transfer, the presence of recipient vessels must be evaluated. Ideal recipient vessels are in close proximity (either deep or adjacent) to the wound to be reconstructed. The quality of these vessels should be assessed. If the planned recipient vessels appear injured either on preoperative angiogram or during direct inspection intraoperatively, consider use of different vessels. Use of vessels outside the zone of injury during free flap reconstruction leads to increased rates of lower extremity limb salvage. Additionally, recipient vessels should be of adequate caliber to anastomose easily to the flap vessels and provide adequate perfusion. If there are no adequate recipient vessels near the defect, consideration can be given to vein grafts or creation of an AV loop from a regional blood supply source. In the extremities, flow-through flaps should be considered if perfusion of the hand or foot would otherwise be compromised by anastomosis of a flap.

Selection and Management of the Donor Site

The full extent of the reconstructive ladder is contemplated for each wound, preferably from simplest to most complex. Local tissue will often provide better color match and appearance but may be limited depending on the location of the wound. Many local, regional, and distant donor sites are available. Consider the suitability of each donor site to fulfill the goals of reconstruction and the logistics and positioning on the operating table, avoiding positional changes if possible. Attempt to minimize residual donor site deformity.

Site and Content Selection

In selecting the appropriate donor site, first consider the skin surrounding the defect. Color match, texture, thickness, and special characteristics such as hair growth should be taken into account. Design the flap to be slightly larger than the defect for adequate skin coverage. This will help account for the thickness of the flap, avoid tight closure over the vascular pedicle, and facilitate donor site closure. Often significant edema of the flap occurs during the procedure that will make closure tight if some excess tissue is not included in flap design. After assessment of skin requirements, flap thickness and content can be selected. Can adequate thickness be reconstructed with skin and subcutaneous fat? Is muscle bulk needed to fill the defect, or is a functional muscle needed to restore movement? Is bone or cartilage support of the soft tissues necessary? For complex reconstructions of the head and neck, lining may be required in addition to external skin coverage. Mucosal lining can be fashioned from skin, skin graft, mucosa, or raw muscle surface, which will mucosalize with time.

Pedicle Considerations

Once content requirements of the flap have been determined, decisions can be made concerning the pedicle. The surgeon should consider both caliber and length required, especially in the case of free tissue transfer. The caliber should approximate that of the recipient vessels; however, if significant size mismatch exists, end-to-side anastomosis is an option. 34 Concerning pedicle length, the surgeon should consider the ergonomic constraints of microsurgical vessel anastomosis. Free tissue transfer can be made significantly easier with slight slack in the pedicle for creation of a tension-free anastomosis that occurs in an orientation that is comfortable for the operating surgeon’s hands. Appropriate length can be obtained either by initial selection or by dissection proximally on the flap pedicle to its origin.

Manipulation of Donor Site Tissue

Manipulation of donor site tissue at the time of flap transfer is utilized for complex reconstruction to provide a better-tailored flap and minimize donor defects. For a complex wound, two (or more) flaps can be carried on one pedicle. These flaps are known as compound or chimeric flaps. 35 An example is the latissimus dorsi, parascapular, scapular bone, serratus anterior flap, which can be one complex compound flap based on the subscapular vascular system.

Conversely, a very large flap may benefit from a double pedicle. A simple example of this is the bipedicled advancement flap. However, in more complex cases, very large flaps, such as double pedicle TRAM (transverse rectus abdominis myocutaneous) flaps, may be raised and left pedicled, or transferred as a double pedicle free flap if the volume of tissue required exceeds the amount that can be transferred on a single pedicle. Flaps can be designed to be folded on themselves to create added bulk or can be employed in reconstruction of a lamellar surface such as the lower lip. In this case, a donor site with a thin subcutaneous layer should be selected. Complex central facial defects often require reconstruction of the multiple external and internal epithelial surfaces. As mentioned earlier, the use of a 3D intraoperative alginate moulage to facilitate flap planning and folding to accurately repair the multiple epithelial defects has been found to be very useful.

Management of the Donor Site

Inherent in flap design is management of residual donor site defects. Commonly the donor site of a flap is repaired primarily, or in cases of undue tension, skin grafted. Attempts should be made to minimize donor site deformity as much as possible. Consider the consequences of scar contracture such as decreased range of motion and pain. When possible, orient incisions within resting skin tension lines. Contour deformity may be considered cosmetic; however, functional issues with hygiene may occur in severe cases. Functional loss from muscle or nerve transfer must be contemplated preoperatively and discussed with the patient. Choose muscle flaps that have redundant function when possible. Revision of donor site deformities should be offered when a functional problem exists and a solution is apparent.

Staging Reconstruction in Complex Defects

Staged reconstructions are often required for complex defects. In such cases, it is important to plan ahead and perform the best possible surgery at each stage, keeping in mind the opportunity cost of additional procedures and time for maturation at each stage. Avoid burning bridges and consider adjunct techniques, including delay, expansion, prelamination, and prefabrication. Delay of a flap involves a preliminary surgical stage to partially raise the flap and divide a portion of the blood supply. This allows for axialization of blood flow and conditioning of the flap tissues to low oxygen levels in anticipation of flap transfer at a second stage. Delay can increase survival of a larger surface area on a given pedicle. As discussed previously, tissue expansion of the donor flap provides more tissue and a thinner flap and alleviates tension at the donor site, resulting in easier closure and improved scarring. Prefabrication of a flap involves transferring a vascular pedicle into a desired block of tissue, then waiting 8 weeks for spontaneous neovascularization, thus creating a new vascular territory not previously found in nature. After maturation, the neovascularized tissue is transferred based on the implanted pedicle. This technique has been used to provide thin axial flaps and to transfer tissue with enhanced color and texture match.

Options in Case of Flap Compromise

Despite the surgeon’s best efforts, some flaps will inevitably experience decreased arterial perfusion or venous congestion after elevation and inset. In pedicled or free flaps, inadequate arterial flow is usually recognized early and may be the result of poor flap design or pedicle kinking. In a free flap, the arterial insufficiency represents thrombosis of the new anastomosis until proven otherwise. These cases require revision on the table or urgent return to the operating room to revise the anastomosis. Venous insufficiency of a flap is more common and the onset more insidious than that of arterial insufficiency. This phenomenon is multifactorial. In elevating a flap, longitudinal venous channels in the flap are disconnected. Additionally, the low pressure in the venous system is more vulnerable to extrinsic pressure because of compression from inset and flap edema. Numerous methods have been described to improve flap survival in the case of venous congestion. First, the surgeon should attempt to release insetting sutures causing tension or kinking. The flap may be pricked with a needle serially to reduce the venous burden. Deepithelialization of a portion of the flap, or removal of the nail plate in the case of a digit, with periodic application of heparin solution may increase venous outflow. Use of Hirudo medicinalis or medicinal leeches can ensure ongoing flap outflow until venous microanastomoses form. Finally, augmenting outflow by cannulation of a vein with an angiocatheter and periodically draining the flap may be useful.


Flaps are the mainstay of reconstructive surgery. In the words of Gillies, always consider “blood supply before beauty.” Remember to maintain adequate flap vascularity and plan for secondary revision to improve contour and appearance. When performing staged reconstructions for complex defects, plan ahead and do not burn bridges.

Management of Scars

  • Keloids: Heaped scars that extend beyond the margins of the original wound; rarely spontaneously regress; frequently result from minor trauma; familial predisposition common.
  • Hypertrophic scar: Raised; erythematous; pruritic; remains confined to the limits of the original wound.
  • Fibroproliferative scars/healing describe a state of excessive healing with collagen formation imbalance.
  • TGF-beta excess contributes to fibroproliferative scar formation (keloids and hypertrophic scar).
  • A combination of treatment modalities may be required for scar improvement management.

With the exception of fetal healing, the end result of wound healing is a scar. In terms of evolution, this process developed as a necessity to traumatic injury and as a response to the alternative—failure to survive.

Scars can pose numerous problems and complications: seizures (brain scar), intestinal obstruction (bowel scar), loss of range of motion (soft tissue, skin, muscle, joint scar), etc. Although normal scarring is beneficial, as it achieves a healed wound, the site and extent of scar, as related to plastic surgery, may pose both aesthetic and/or functional problems. Normal wound healing is a complex series of dynamic interactive processes that begin at the moment of wounding and involves soluble mediators, many cell types, and extracellular matrices. The process follows a specific time sequence and includes coagulation, inflammation, deposition and differentiation of extracellular matrix, fibroplasia, epithelialization, contraction, and remodeling with the end result— formation of a healed wound, by scar. 3,4 The end result of normal scar is an equilibrium between collagen synthesis/deposition and collagen lysis/degradation; the mature scar, which has approximately 80% of the tensile strength of normal unwounded skin, occurs between 6 and 18 months after wounding. 5 Proliferative healing has been described by Dvorak as a spectrum with normal healing on one end and tumor cell proliferation at the other. 6 Proliferative scar formation describes a series of events resulting in overhealing as if an equilibrium point between collagen deposition and collagen lysis has never been reached.

Types of proliferative scar formation include the following:

  • Keloids

Familial predisposition

Enlarged heaped-up scar that extends beyond the margins of the original wound

Rarely regress

Frequently result from relatively minor injury or insult

Elevated TGF-beta

  • Hypertrophic scars




Remain at the site or confines of the original wound

Partial or total resolution or regression can spontaneously occur

Result from trauma, incision, burns

Result from prolonged wound healing

Increased epidermal/dermal thickness

Lack of epithelial ridges

Random orientation of collagen fibrils

Decreased collagen content

Elevated TGF-beta

Increased number of mast cells

Decreased collagen production

Keloid scarring of the ear after ear piercing

Hypertrophic burn scar of the hand with thumb web space contracture

Related fibroproliferative disorders, all of which demonstrate similarities to proliferative scar:

  • Periprosthetic capsules—capsular contracture
  • Dupuytren contracture—palmar fascia contractures
  • Rhinophyma—tissue fibrosis

The Problem

Aesthetic Problems

Scarring may create a variably noticeable abnormality because of the direction, quality, position, size, or orientation of the scar. Beauty is in the eye of the beholder. Assessing scars can be problematic, and subjective measures sometimes determine the aesthetic problem for the patient, significant others, professionals, or casual observers. Validated scar measures are described and used; however, what one may declare acceptable, another may deem unsightly and unacceptable. 14-20 The displeasing scar is no less problematic for some patients as functionally impairing scars.



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Functional Problems

Scarring can limit functional capability, and the mere presence of scar can be symptomatic, in and of itself. Pain and pruritus are common symptomatic complaints. Scar contractures leading to diminished range of motion at joints, or other structures dependent upon mobility for their function, can cause variable disability. Scar bulk can also lead to pain, decreased function, and aesthetic concerns (as with keloids).


As with most problems, an ounce of prevention is worth a pound of cure. The use of sound, meticulous surgical wound closure technique to optimize operative incisional and traumatic wound closures to minimize tension, adequately debride nonviable tissue, remove foreign bodies, approximate layers, fill dead space, prevent hematoma and seroma, and prevent infection, and removing sutures at appropriate time intervals, can contribute to minimizing scarring. Adequate undermining with deep dermal suturing creating wound edge eversion can aid to reduce wound tension and diminish/minimize scar width.

Reducing chronic inflammation by alleviating foreign bodies, infection, and/or prolonged time to healing can improve eventual wound/scar outcomes. Adequate debridement, minimization of foreign materials (including sutures), and wound closure timing (especially as with burn wound grafting) are all advantageous to improve scarring outcomes.

Incision placement and orientation are of prime concern to eventual scar formation/noticeability and also to relieve incisional tension. The noticeable scar is a function of light reflection that catches attention. Placing scars in natural creases, in junctions between contours, and at the edges of hair-bearing skin can camouflage to produce more inconspicuous scar lines. Working within the relaxed skin tension lines, as described by Borges, Kraissl, and Langer, allows scars to lie in planes and directions of less obvious orientation, and reduces the tension on incisions to produce less widened scars.

Scar Management

Medical Management


Frequently advised for postoperative scarring, this noninvasive, inexpensive method of scar manipulation/reduction does have evidence of effectiveness. Although its usefulness is generally limited, massage can aid in the flattening and softening of scars and limiting some scar contractures (e.g., after lower eyelid procedures). Reported to be of benefit in the scenario of burn scarring, improvements in scar appearance, pruritic pain, and psychologic effects have been shown. Professional massage therapists appear to be of benefit in scarring related to burn.

Silicone Gel

Application of silicone gel has been shown to benefit the appearance of hypertrophic scar, keloids, and surgical incisions. The mechanism of action appears to be the occlusive nature of silicone dressing and epithelial hydration, not that of temperature increase, nor by any chemical effects of absorbed silicone. Likely the effect is an influence in the collagen remodeling phase of wound healing. There is differing evidence as to the efficacy of silicone gel as a preventative treatment measure as compared with good evidence to indicate effective management after scarring. Recommendation for treatment is to wear the silicone gel dressing for 12 to 24 hours per day for 2 to 3 months at the onset of visible scar abnormality.

Compression, Pressure, and Mechanomodulation

Pressure garments are commonly utilized after burn injury/treatment to aid in hypertrophic scar control. 28,42 Compression garments are recommended prophylactically in burn injury after extensive skin grafting and/or if spontaneous wound healing requires longer than 10 to 14 days. The exact mechanism that pressure garments influence hypertrophic scarring is not completely understood; however, influence on collagen synthesis and remodeling is a likely effect. Pressure requirements for effectiveness have not been established, although 15 to 25 mm Hg is the target pressure reported by many authors. The appearance, discomfort, texture, and heat reflection/generation (especially in warm climates) of pressure garments limit patient compliance and therefore their effectiveness. Pressure therapy is also effective for keloid treatment/therapy, generally as a postoperative adjunctive measure. Compression earrings (for ear lobe keloids) are commercially available for postoperative application but require patient compliance. Effectiveness may be up to 80% following complete surgical excision.

Significant wound tension leads to widened scarring. Mechanomodulation to relieve scar tension at the time of incision closure can positively affect incisional scar formation and improve scar appearance. 23,25,26 Available as a commercial device and placed to redistribute and relieve tension across an incision line, the device is well tolerated by patients, is effective, and has a minimal complication rate. This device is recommended for truncal incisions such as abdominoplasty.


Injection of steroids (triamcinolone) is widely used as an initial treatment for keloids and hypertrophic scars and is commonly applied in conjunction with other modalities including surgical excision to decrease scar recurrence rates. Dosage may range from 2.5 to 40 mg either as primary solo treatment or prior to surgical excision and can be injected with a mixture of xylocaine + epinephrine to diminish local pain and to decrease steroid dispersion, to maximize its effect. Solo steroid therapy for hypertrophic scars can be repeated at 4-week to 6-week intervals until the desired effect is observed, side effects are observed, or if surgical excision is expected. Steroid pretreatment for keloids followed by surgical excision and follow-up postoperative injections produce reported cure rates of up to 80%.Complications and side effects arising from the use of injectable corticosteroids include skin atrophy, hypopigmentation, and pain with injection.

Radiation Therapy

Radiation therapy can be utilized as an adjunct therapeutic with surgical excision in the treatment of keloids. Keloid excision followed by radiation therapy within 24 to 48 hours either as a single dose or as multiple doses can reduce recurrence and lead to cure rates between 67% and 98%, depending on the anatomic area. Although there is no overwhelming prospective evidence to indicate definitive effectiveness of radiation therapy after surgical excision in keloid treatment, retrospective data from relatively large clinical patient series indicate it as a worthwhile treatment. 52-55 Radiation damages keloid fibroblasts, affecting collagen production and structure. 45,53,56 Radiation monotherapy is not effective. Concern for generation of malignancy due to radiation therapy is advisable, especially in the pediatric age patient or in areas prone to radiation-induced carcinomas, such as thyroid and breast. 57 The reported rates for carcinogenesis are low, with few cases associating radiation therapy for treatment of keloids with malignant tumor generation. Recommendations are for adequate shielding of vulnerable areas from radiation and careful patient selection.

Radiation therapy for refractory/intractable hypertrophic scarring has been reported as effective; however, there are few data to support its use.

Side effects of hyperpigmentation, hypopigmentation, and transient erythema have been reported. Few wound healing problems have been attributed to the low-dose radiation, and soft tissue fibrosis as encountered with higher doses of radiation therapy is not likely.


Topical cryotherapy may achieve initial positive results in hypertrophic scars and keloid treatment; subsequent recurrence rates are high, making this therapy less than optimal, unless repetitive treatments/sessions are utilized. Intralesional cryotherapy requiring a specialized cryoprobe does show effectiveness, but this method is not widely used.

Molecular Therapies

There is experimental (and some clinical) evidence to indicate that treatment of hypertrophic scar and/or keloids with agents such as 5-fluorouracil, bleomycin, mitomycin C, tamoxifen, paclitaxel, methotrexate, TGF-beta 3, and interferon may be of benefit. Likely the mechanisms of antiscarring action are due to their interaction with TGF-beta receptors and downregulation of fibroblast function. 59-63 The current utility of these agents is limited because of a lack of adequate clinical evidence.

Botulinum Toxin

Botulinum toxin has recently been reported to improve surgical incisional scars. 64 Although only reported as a small case series, final scar outcome improved with intraoperative injection of botulinum toxin type A, 10 U/cm in a split-scar randomized trial. The presumed mechanism of action of botulinum toxin is inhibition of TGF-beta 1 and cell cycle interaction, diminishing fibroblast cell functions/regulation.

Other Modalities

Vitamin E and onion extract have little clinical evidence to recommend their use for treatment. Reviews of over-the-counter products with claims to scar treatment and scar improvement provide little evidence for these products’ effectiveness beyond the earlier discussions.

Surgical Management

Scar revision surgery can vary from excision(re-excision) and closure to more complex modalities and combinations of modalities. The type of scar, extent of scarring, size, orientation, location, etiology, symptomatology, and patient preferences are all factors to consider when planning surgical scar treatments. Surgical adjuvants (corticosteroid injection, laser therapy, radiation therapy) deserve consideration in planning scar treatment/management for their possible benefits (versus risks and side effects).

Excision and Direct Closure

Considered in instances where local tissue conditions warrant, minimal/no tension and optimal orientation would be prime considerations. The etiology of unsatisfactory scar in this instance should be considered so that results similar to the initial scarring problem are not repeated.

Excision and Z-Plasty or W-Plasty Closure

Redirecting the orientation and tension of the scar to a more favorable or more optimal direction can produce less tension, more proper alignment, and improved appearance. Borges 29,30 described extensively the relaxed skin tension lines and the utilization of Z-plasty and W-plasty for the revision of scars to improve their appearance as well as to describe the placement of incisions in orientations for improved primary outcomes.

Z-plasty can be considered to realign tissue in instances of scar creating functional deficits such as joint contracture. Functional reorientation and scar lengthening may improve limitation of motion and decrease scar tension. A standard Z-plasty with equivalent length sides and an angle of 60 degrees provides lengthening along the central limb of approximately 75% of its original length. A longer central limb provides (theoretical) linear increase, as does increasing the Z-plasty angle. 29 Multiple in-series Zplasties can be used for longitudinal gain and reorientation. Adequate skin laxity lateral to the original scar is necessary for adequate Z-plasty flap closure. W-plasty serves to break up the scar outline and camouflage the appearance, producing less light reflection and less noticeability.

Excision and Skin Grafting

This is helpful in instances of hypertrophic/widened scars with poor appearance and/or scars causing functional limitations, such as with cicatricial ectropion of the eyelid or minor axillary contracture with minimal linear banding. Attention to recreating the original tissue deficiency with adequate scar release to the point of allowing full range of motion and overgrafting the original area of scarring can help to minimize tension on the newly created site. Once skin grafting is complete, compression garments, range of motion therapy, and scar massage may contribute to eventual improved outcomes.

Excision, Dermal Replacement, and Grafting

Recent reports of improved scar revision outcomes have described the use of dermal replacement after scar excision as a basis for secondary skin grafting as an adjuvant to scar and keloid surgical revisions. Acellular dermal matrix products allow for vascular ingrowth from contact of matrix edges with normal tissue. These matrices are used over nonvascularized and minimally vascularized structures such as exposed bones and tendons. As opposed to the time-limited nature of skin autografts, which require relatively immediate revascularization for survival, dermal matrices time line of wound bed preparation are longer but provide immediate wound coverage until second-stage grafting can be successfully accomplished.

Excision/Flap Closure

Flap closure after scar excision is worthy of consideration. Flaps including cutaneous, myocutaneous, and fasciocutaneous, whether local, random, pedicled, perforator, or a free tissue transfer, can serve to relieve tension in the area of original scar, fill dead space, and improve aesthetics and/or function. The more severe the scar contracture, especially across major joints such as the knee, elbow, and axilla, the more likely flap closure is indicated and beneficial. Maximal scar release, dead space filling, and tension-free closure are required for adequate results.

Combination Surgical Revision With Adjuvants

Excision with radiation therapy, excision with corticosteroids, and excision with pressure garments have been discussed earlier.

Laser Treatment

Laser has been successfully utilized and shown to improve scar appearance, although further investigations are warranted. Much of the positive supporting data are reported for hypertrophic burn scarring utilizing pulsed dye 585/595-nm wavelength as treatment for pruritus and erythema.  Treatments for scar prevention as well as established hypertrophic scar therapy indicated response rates in the range of 70%. Other hypertrophic scarring etiologies such as median sternotomy and inframammary scars have been reported to respond to, with good results.  Results concerning the timing of pulsed dye laser treatments on hypertrophic burn scars appear to indicate that earlier treatment with pulsed dye laser may lead to improved outcomes.  Hypertrophic scars, treated when early, less than 1-year while still erythematous, responded better than those of more mature age. Pulsed dye laser therapy works by destruction of scar microvasculature via photothermolysis, and possibly collagen modulation by reducing TGF-beta expression. CO2 laser is ablative, causing tissue vaporization due to selective absorption by water in the tissues.

Fat Grafting

Recent enthusiasm for fat grafting as scar treatment appears to have merit and effectiveness. Effects of fat grafting include filling and elevating of depressed scars, improvement in the quality and pliability of scar, and improvement and pliability in radiated soft tissue. The exact effects and mechanism of action on scars and scarring are unknown. There appears to be more effects than simple volumetric filling, and a tissue regenerative effect may occur. 82-86 Adipose-derived stem cells may stimulate local cytokine growth factors leading to increased vascularization, collagen remodeling, and inflammatory response modulation. Positive results in studies using fat grafting in the treatment of scar and fibrosing entities are found, although there are few controlled trial and quantitative data. There is growing subjective evidence to suggest that fat grafting may become a mainstay for scar treatment.


Scar tissue is the end result of the normal healing process. Abnormal scarring is enhanced healing or overhealing, usually with resulting aesthetic unacceptability and/or functional impairment. Exact mechanisms of unfavorable scarring are not well elucidated, although excess TGF-beta receptor activity appears to have a major molecular influence. Many treatment options are available either surgically or in combination; however, problematic recurrence remains high. There is no single good therapeutic option in all situations, and individual treatment is advised based on the clinical scenario, available modalities, and patient preference.

Basic Science of Wound Healing and Management of Chronic Wounds

  • Wounds present with a discontinuity of tissue and rely on complex processes for healing to occur. Most wound healing research focuses on molecular and cellular pathways, but we now appreciate the importance of the extracellular matrix (ECM) and mechanical forces. Classically, wound healing has been summarized into four phases: (1) hemostasis, (2) inflammation, (3), proliferation, and (4) remodeling.
  • Aberrant wound healing occurs when normal pathways are disrupted, most commonly in the inflammatory or proliferative phases leading to chronic wounds.
  • The most common chronic wounds are arterial ulcers, pressure injuries, venous stasis ulceration, and diabetic foot ulcers.
  • Other factors that adversely affect wound healing include radiation therapy, nutrition, and microorganisms.
  • Healing strategies involve keeping the wound moist, platelet-derived wound healing techniques, biological skin equivalents, topical growth factors, stem cells, scaffolds, and the application of biophysical forces.

Basic Science of Wound Healing

Wound healing is a complex and highly coordinated biological process. A sound understanding of the traditional stages of wound repair underpins many aspects of wound healing research. The four phases of wound healing—hemostasis, inflammation, proliferation, and remodeling—do not follow a simple and linear chronological order but overlap in time and are densely interconnected. Importantly, increasing research has demonstrated the importance of mechanical forces and the extracellular matrix (ECM) in wound healing biology.

Factors involved in wound healing

Classic Stages of Wound Healing


Tissue injury and the consequent damage to capillary blood vessels initiates the coagulation cascade through the activation of fibrinogen. This activation results in the formation of platelet aggregation and fibrin scaffold that stems blood loss and allows for the migration of cells. Platelets play a critical role in the stages of wound healing and in particular are the chief effector cells during hemostasis. In addition to contributing to the hemostatic plug, their cytoplasm contains α-granules that release several growth factors and cytokines, such as platelet-derived growth factor (PDGF) and transforming growth factor-β (TGF-β), which facilitate wound healing by attracting neutrophils, macrophages, and fibroblasts. 1,2 Platelets are also responsible for releasing several proangiogenic and antiangiogenic growth factors that are critical for revascularization of wounds, such as vascular endothelial growth factor (VEGF) and platelet-derived stromal cell–derived factor 1 (SDF-1).


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The coagulation cascade, the activation of complement, and bacterial degradation facilitate and trigger the inflammatory phase, which typically lasts 48 hours. 3 These pathways produce various chemotactic factors (such as TGF-β) and complement components (such as C3a and C5a) to attract inflammatory cells to the scaffold. Neutrophils invade the wound and phagocytose foreign debris, followed by monocytes that eventually differentiate into macrophages and further consume debris in their paths. 2 Macrophages are responsible for releasing a whole host of mediators primarily through binding to integrin receptors on the ECM, such as tumor necrosis factor α and interleukin-1 (IL-1) 4. These proinflammatory cytokines stimulate fibroblast infiltration from the surrounding healthy ECM. It is important to note that macrophage invasion is critical to the inflammatory phase because macrophage-defective or macrophagedepleted animals undergo abnormal wound healing.

Inflammatory phase of wound healing


From approximately 48 hours to 10 days after tissue injury, healing enters the proliferation phase. Keratinocytes migrate to eventually proliferating enough to create an epithelial layer that covers the wound. This is directly stimulated by epidermal growth factors, heparin-binding epidermal growth factor (HB-EGF), and transforming growth factor-alpha (TGF-α), which are the main members of the epidermal growth factor family involved in wound healing. 6 Fibroblasts are also critical to this stage of wound healing, as they produce collagen that acts as a scaffold for a vascular network. The hypoxic environment increases expression of hypoxia-inducible factor 1 (HIF-1α) protein to serve as the primary stimulus of angiogenesis. 7 HIF-1α activates several target genes such as VEGF and SDF-1 to induce neovascularization. 7 Fibroblasts and macrophages replace the fibrin mesh to form granulation tissue. Granulation tissue, also known as new stroma, consists of new connective tissue (specifically hyaluronic acid, procollagen, elastin, and proteoglycan) and blood vessels. It owes its granular appearance to the new capillary network. 1 The formation of blood vessel networks increases oxygen supply to the wound surface. Finally, fibroblasts that have differentiated into myofibroblasts have contractile ability to assist in bringing the wound edges together in a process known as wound contraction.

Proliferative phase of wound healing



The fourth and final stage of wound healing is the remodeling phase, which starts at approximately 2 weeks and can last for years. Throughout this stage, many of the cells contained in the wound undergo apoptosis or exit the wound, to eventually leave collagen and ECM proteins. This entire matrix is remodeled and strengthened from type III collagen into mainly type I collagen by matrix metalloproteinases (MMPs). MMPs are produced by fibroblasts as well as other cell types. The wound eventually forms scar tissue and never fully regains complete strength comparable to undamaged skin, at approximately 80% normal strength. 9 The ECM is also implicated in the formation of scarring. Cutaneous scar tissue is composed of the same ECM macromolecules as normal tissue but contains different ratios of these macromolecules and typically an absence of hair follicles or fat. 10 Increased levels of TGF-β۱ have been implicated in hypertrophic adult scars.

Mechanical Forces in Wound Healing

Human cells and tissues are subjected to many biophysical forces such as electrical, magnetic, and mechanical forces. These forces have various biological effects, and here we specifically discuss mechanical forces. Mechanical forces on cells include but are not limited to tension, shear force, gravity, and osmosis. 12 It is now clear that all phases of wound healing are affected by mechanical forces. In a process known as mechanotransduction, cells have the ability to detect mechanical stimuli in its microenvironment and respond by activating specific cellular pathways. These pathways can modulate cell functions such as proliferation, migration, and differentiation.

Focal adhesion (FA) complexes that are transmembrane proteins to anchor the cell cytoskeleton to other cells or the ECM are key to understanding mechanotransduction. FA complexes contain integrins, which act as primary receptors for the ECM. 13 This process of anchorage generates intracellular mechanical tension and serves not only to sense the wound microenvironment but also to modify its behavior and the surrounding ECM.

Cell migration is of critical importance in wound healing and mechanical forces are key to this. Tension generated by the cytoskeleton-integrin connections pulls the cell cytoplasm of the leading edge forward in a process known as protrusion. At the same time protein complexes of the trailing edge must disconnect from the ECM, resulting in the entire cell body moving forward and the cell producing traction forces. 13 Fibroblasts are thought to generate cell traction forces that are much greater than needed for cell migration, and this excess force deforms the ECM contributing to collagen reorganization in wound healing. 14 Similarly, mechanical forces involved in cellular migration also occur during epithelial repair and restoration.

It is also known that cell proliferation is influenced by mechanical stress, which can be defined as the force per unit area. Keratinocytes respond to mechanical stress by changing morphology, such as stretching, and these mechanotransduction pathways regulate cell proliferation. For example, cells without mechanical stress or stimuli adopt a spherical shape and enter cell-cycle arrest and apoptosis. 15 Electric fields also play an important role in wound healing. Transepithelial electric potentials are created by the movement of ions across pumps in the epithelium, termed the skin battery. Damage to the continuous epithelium generates a current of injury whereby electric potential is directed toward the wound to signal cell migration, termed electrotaxis. 16 Studies have demonstrated that influencing such electric fields can alter wound healing in vivo.

The effect of mechanical stimuli on the wound microenvironment is utilized by treatments, such as negative-pressure wound therapy (NPWT) and extracorporeal shock wave therapy (ESWT), which are explained in later sections.

Extracellular Matrix in Wound Healing

The ECM is a meshlike dynamic structure composed of different macromolecules and proteolytic enzymes. These macromolecules include collagen, elastin, glycosaminoglycans, glycoproteins, and proteoglycans. The ECM plays an important role in wound healing. Its function includes providing organization for cells as a physical scaffold, storage for growth factors, controlling cell shape, cell metabolism, and influences many cell behaviors such as migration, proliferation, and differentiation

Biophysical forces in wound healing

The composition, density, and stiffness of the ECM influence the wound microenvironment. In newly injured tissue, ECM is soft and fibrin-rich and this change initiates a repair process of fibroblast differentiation into myofibroblasts that contract and exert tension on the surrounding ECM. After cutaneous tissue injury, mechanical forces activate the focal adhesion kinase pathway. This pathway is known to be the main regulator of FAs. The focal adhesion kinase pathway has been shown to potentiate the secretion collagen, as well as monocyte chemoattractant protein-1, which has been linked to human fibrosis.

The most prominent glycosaminoglycan, hyaluronic acid (hyaluronan) is known to interact with cell surface receptors, mainly CD-44 and RHAMM (receptor for hyaluronan-mediated mobility) to trigger a cascade of processes involved in wound healing, such as modulation of inflammation, chemotaxis, cell migration, collagen secretion, and angiogenesis.

Aberrant Wound Healing

Chronic Wounds

Chronic wounds can be defined as a loss of continuity of the skin secondary to injury that persist for longer than 6 weeks. Chronic wounds are classified into vascular ulcers (arterial and venous), diabetic ulcers, and pressure ulcers. Despite each type of wound having different underlying pathologies, they all share common features such as an excessive and persistent inflammatory phase, impaired cell proliferation, abnormal cell migration, microbial colonization, the presence of biofilms, and ultimately an inability to complete all four phases of wound healing within the normal timeframe. However, they each have distinct pathophysiologies, which are further discussed in this section.

Vascular Ulcers

Vascular ulcers include venous, arterial, or mixed etiology. It has been reported that ulcers related to venous insufficiency constitute 70%, arterial disease 10%, and ulcers of mixed etiology 15% of leg ulcer presentations. The remaining 5% of leg ulcers result from less common pathophysiological causes.

Venous Ulcers

Chronic venous leg ulceration is common and is thought to occur in up to 5% of the population older than 65 years. 20 Venous ulcers are classically distributed in the gaiter area on the medial aspect between the knee and ankle. They occur secondary to venous insufficiency where there is valvular incompetence in veins, and the resulting backflow of blood results in increased venous pressure. This leads to capillary leakage of plasma constituents into the surrounding perivascular area, such as fibrin, which is known to decrease collagen production.

The primary pathological events leading to venous disease and therefore venous ulceration are changes in the vein wall and vein valve environment. Elevated venous pressures change shear stress and mechanical forces, which are then detected by endothelial cell intercellular adhesion molecule-1 (ICAM-1, CD54) and the mechanosensitive transient receptor potential vanilloid channels. The endothelial cells respond by secreting vasoactive molecules to begin an inflammatory cascade, ultimately leading to the progression of venous disease.

Arterial Ulcers

Arterial ulcers occur because of arterial insufficiency where there is narrowing of the arterial lumen most commonly secondary to atherosclerosis. They are classically located over bony prominences including the toes, heels, and ankles. Apart from atherosclerosis, other conditions that cause arterial obstruction include embolism, diabetes mellitus, vasculitis, pyoderma gangrenosum, and hematological disorders of sickle cell disease and thalassemia.

Diabetic Foot Ulcers

The prevalence of diabetic foot ulcers in individuals with diabetes mellitus is common and occurs in approximately 15% of patients over their lifetime. 23 There are several pathophysiological factors that contribute to aberrant healing in diabetic individuals. These include abnormal and chronic inflammatory response, hyperglycemia, microvascular abnormalities, hypoxia, and changes of the ECM scaffold. Peripheral neuropathy, peripheral arterial disease, and trauma also contribute to diabetic ulceration. Chronic inflammation and an impaired inflammatory response is also the hallmark of diabetic wounds. Studies have demonstrated persistent and raised levels of proinflammatory cytokines, such as IL-1, IL-6, and tumor necrosis factor α. ۲۴ Wounds also typically have imbalances in protease production and their inhibitors, which stop normal matrix synthesis and remodeling.

Hyperglycemia leads to nonenzymatic binding of sugar residues to proteins through free amino acid groups, and further alterations lead to advanced glycation end-products. Advanced glycation endproducts are known to decrease the solubility of the ECM and exacerbate the inflammatory changes. 26 Glycation of the ECM is linked to cell apoptosis and disruption of normal wound healing processes such as angiogenesis, cell migration, and proliferation. 27 High levels of glucose induce expression of MMP by fibroblasts, endothelial cells, and macrophages to break down the matrix. Oxygen supply to a wound is also essential for healing, and hypoxic environments adversely affect wound healing. Chronic hyperglycemia prolongs inflammation and delays wound healing by increasing the levels of free radicals.

Pressure Injuries

The pathophysiology underlying pressure injury is a combination of pressure, friction, shearing forces between tissue planes, and moisture. Pressure exceeding arteriolar pressure results in tissue hypoxia, the creation of free radicals, an ischemic reperfusion injury, and consequent tissue necrosis. 28 Factors contributing to the development of pressure ulcers include prolonged immobility, patient position, neuropathy, and existing arterial or venous insufficiency. 28 The National Pressure Ulcer Advisory Panel (NPUAP) staging system defines four stages of severity to pressure injuries: stage 1 pressure injury is nonblanchable erythema of intact skin, stage 2 pressure injury is a partial-thickness skin loss with exposed dermis , stage 3 pressure injury involves full-thickness skin loss , and stage 4 pressure injury involves full-thickness skin and tissue loss .

Pressure injury staging

Factors That Adversely Affect Wound Healing

Radiation Therapy

Radiation therapy such as those used as part of oncologic therapies disrupts the complex pathways of wound healing. Ionizing radiation produces both acute and late effects on tissues. Acutely, basement membrane is damaged, and increased vascular permeability introduces edema to reduce neovascularization of wounds. 30 During the inflammatory phase, there is excess expression of several growth factors, leading to tissue fibrosis. Fibroblasts are also injured and contribute to the late effects of radiation injury such as fibrosis and contraction.


Nutrition has long been known to affect wound healing and chronic wounds. This includes a general malnutrition state, inadequate caloric intake, and deficiencies in vitamins, micronutrients, and macronutrients. Malnutrition is known to prolong the inflammatory phase of wound healing through reducing the proliferation of fibroblasts and the formation of collagen. 31 It can also increase the risk of infection of wounds by altering the function of immune cells, such as reducing phagocytosis and decreasing complement levels. 31 Micronutrients such as copper, zinc, and magnesium are elements and minerals that are essential to bodily chemical processes and, in particular, in wound healing. Deficiencies in these micronutrients can adversely affect wound healing, for example, in copper deficiency. Macronutrients include protein, amino acids, carbohydrates, fiber, water, and fats. These are required at sufficient levels to promote optimal wound healing. Significantly reduced protein intake is associated with increased rates of wound infection and wound strength. 31 Similarly, lipid deficiencies are associated with altered wound healing.


Microorganisms have long been known to influence the healing of chronic wounds, and all open wounds contain microbes. Bacteria predominantly exist in biofilms in clinical and natural settings, as opposed to planktonic states (single organisms/free-floating). Biofilms describe adherent populations of microbes that form three-dimensional populations and are organized on extracellular polymers. Over time, chronic wounds are known to develop biofilms, as complex interactions between the host wound microenvironment and heterogeneous bacterial populations mean they are able to proliferate unchecked. Biofilm bacterial populations delay and inhibit wound healing by not only producing toxins and damaging enzymes, but also promoting the complex chronic inflammatory pathways. 32 Proteases released from bacteria impede growth factors and wound healing proteins. Large levels of microbial exudate have also been shown to affect cell proliferation and wound healing.

Biofilm-infected chronic wounds are clinically challenging to manage and are resistant to elimination by antimicrobials and by the immune system. The current mainstay management of dealing with microorganism-related complications in chronic wounds includes pressure off-loading, appropriate dressings, systemic antibiotics, tissue debridement, and the instillation of NPWTs such as vacuumassisted closure devices.

Similarly, antiseptic dressings such as those containing chlorhexidine, silver, or iodine and topical antimicrobials (e.g., fusidic acid creams) have been developed over the years to a limited degree of success. Topical antimicrobials have promoted bacterial resistance, and several studies concluded that antiseptic dressings are not significantly better than saline gauze alone. 33 However, there are special situations when topical antimicrobials are proven beneficial. They are particularly useful in burn injuries (especially second-degree burn injuries) to treat infection and therefore prevent sepsis.

Systemic antibiotics are beneficial in infected chronic wounds but are not indicated for most chronic wounds that are merely colonized with bacteria. Antibiotics should have high tissue bioavailability and should be targeted to the specific organisms from deep wound cultures. Studies demonstrate that superficial cultures do not represent the diverse populations of bacteria of the biofilm.

Debridement involves the removal of necrotic tissue and debris at the wound edges and is often surgical, although other mechanical modes and enzymatic and autolytic methods are also utilized. The current theory is that debridement reduces biofilm. It is thought to promote wound healing and decrease the biofilm load. Recolonization of the wound after debridement is common, and often sequential debridements are required for successful healing. NPWTs, such as vacuum-assisted closure devices, are known to aid wound healing. Several studies have investigated their effect on the microorganisms within chronic wounds, and observational data of NPWT with adjunctive topical dressings have demonstrated decreased biofilm load. 33 A recent small randomized trial (n = 20) of NPWT with instillation and adjunctive sodium hypochlorite solution was effective at reducing both planktonic and nonplanktonic (biofilm) microorganisms.

Obesity and Metabolic Syndromes

Obesity is correlated with increased rates of wound complications such as wound infection, impaired wound healing, pressure injuries, venous ulcers, hematoma, and seroma formation. Hypovascularity, difficulty in repositioning, and friction between skin-to-skin contact points in skin folds are all known to contribute to the formation of pressure injuries in obese individuals. On a molecular level, obesity is related to lower levels of lymphocyte proliferate, altered cytokine levels and peripheral immune function which improves upon weight loss.

Advanced Wound Healing Strategies

Nonsurgical, advanced would healing strategies can briefly be categorized into those that employ biological therapeutics, use or enhance the matrix, and exploit biophysical forces. Although these modalities are important, basic and simple strategies still form the foundation of wound care. These measures are manifold and include optimizing the management of primary pathological conditions that lead to wound formation, such as optimal lifestyle measures (e.g., nutrition), medication, and patient education. Other measures include debridement of necrotic tissue, local ulcer care, mechanical off-loading, mechanical compression (for venous ulcers), and infection control.

Biological Therapies

Biological therapies have been of great interest in wound healing therapies, and we specifically discuss the use of cadaveric skin and xenografts, placental constructs, growth factors, hyperbaric oxygen therapy (HBOT), biological skin equivalents, and stem cells.

Growth Factors

Growth factor–related wound repair has been of immense interest in wound healing science. Commercially marketed growth factors currently available include recombinant human fibroblast growth factor, recombinant human platelet-derived growth factor, and recombinant human epidermal growth factor. Several other growth factors are also being developed. Recombinant human epidermal growth factor is a well-known growth factor that can be applied topically or injected and has been shown to improve wound healing in small clinical trials worldwide. 36 Fibroblast growth factor has also shown promising results, in particular an isoform known as recombinant human keratinocyte growth factor-2 to be applied as a topical spray. The trial showed significantly increased wound healing compared with placebo.

Platelet-Derived Growth Factors and Platelet-Rich Plasma

Several studies shown the efficacy of platelet-rich plasma (PRP) and PDGFs obtained from centrifugation of blood.

PDGF has been demonstrated to be effective when compared with placebo, with 7 studies totaling 685 patients that showed a statistically significant percentage of ulcers healed compared with sham therapy. 39 The first commercially available topical PDGF in the United States is becaplermin gel (Regranex®), which was studied in chronic diabetic foot ulcers. It is important to note that becaplermin gel contains the US Food and Drug Administration (FDA) black box warning, whereby consumers are cautioned to the increased risk of rate of mortality secondary to malignancy if several tubes are used. 40 Conversely, the evidence for PRP has been scant, with randomized controlled trial (RCT) data showing no significant difference in the percentage of ulcers healed when compared with placebo or platelet-poor plasma therapy.

Stem Cells

There has been significant interest in the use of stem cells to address the defective pathways in aberrant wound healing. Stem cells are undifferentiated cells that possess the ability to mature into differentiated cells of either one embryonic germ layer (multipotent) or all three embryonic germ layers (pluripotent). 41 Perhaps one of the most widely studied multipotent adult stem cells in wound healing research has been mesenchymal stem cells (MSCs). In several animal-based studies, MSCs have demonstrated the ability to migrate to areas of cutaneous injury, secrete angiogenic and immune-mediating factors, and differentiate into skin cells. 41 There are now several ongoing and published clinical trials using MSCs in wound healing as well as a few commercial products. 41 Multiple clinical trials have shown promising outcomes with regard to wound closure rates; however, they have been limited by small sample sizes and lack of controls. 41 At the time of writing, several clinical trials in the United States are recruiting patients to study the use of MSCs in healing cutaneous wounds.

However, challenges remain with stem cell technologies. Firstly, there are numerous ethical concerns surrounding its use, in particular, pluripotent stem cells; hence, much of the research has focused on multipotent stem cells. 41 Secondly, there are still many questions that need to be answered in the field. Two important questions posited by Sorice et al are which population of stem cells are the most effective in healing wounds and what is the best method to deliver stem cells into a wound? 41 These are important considerations if stem cells are to move into clinical translation.

Hyperbaric Oxygen Therapy

HBOT utilizes compression chambers to deliver high levels of oxygen concentration at raised atmospheric pressures. HBOT aims to promote oxygen-dependent wound healing pathways and has particularly been a treatment strategy when revascularization in vascular insufficiency has been unsuccessful. 42 Systematic review evidence of four long-term studies totaling 233 patients concluded that there was a significant difference in percentage of healed ulcers compared with sham therapy when HBOT was used adjunctively, with one short-term study finding no significant difference. However, strength of evidence was deemed low for all studies. One study of poor quality found HBOT less effective compared with ESWT (n = 84).

Cell Cultured Products

Cell cultured products, also known as tissue-engineered constructs, include Apligraf, Epicel, and Dermagraft. Apligraf (Organogenesis, Canton, MA) utilizes a bovine collagen matrix incorporated with human neonatal fibroblasts and neonatal keratinocytes to act as a scaffold as well as providing cells that produce growth factors and ECM components. Similarly, Dermagraft (Organogenesis, Canton, MA) comprises a polyglactin scaffold with dermal neonatal fibroblasts. A large Apligraf RCT (n = 309) found a significant increase in the number of healed ulcers and a reduced length of time to complete healing compared with standard therapy with compression. 39 Furthermore, cultured epithelial autografts using patients’ own keratinocytes, such as Epicel, have been utilized to treat large burns and take 2 to 3 weeks in culture to grow. 43 Genetic manipulation of keratinocytes has recently been reported to regenerate an entire fully functional epidermal layer in junctional epidermolysis bullosa.


Scaffolds act as a platform for cell migration and angiogenesis and are a key therapeutic modality. Scaffolds can be of human origin (donated tissue or cadaveric) and nonhuman origin (porcine or synthesized through extraction and cross-linking). Several such scaffolds are commercially available. Integra™ (Integra LifeSciences) is a bilayer matrix of bovine collagen and glycosaminoglycan derived from shark skin that is lyophilized to form a highly porous scaffold. Integra™ has been used with considerable success in burns, and clinical trial data have attested its use in the healing of chronic wounds, specifically decreasing time to wound closure in diabetic foot ulcers. 45 Allopatch®, which is a decellularized scaffold derived from human cadaveric tissue, has demonstrated efficacy in closure of nonhealing diabetic foot ulcers. 46 Placental constructs, such as Grafix, which is a cryopreserved placental membrane, have shown to significantly improve diabetic foot ulcer healing and reduce related complications.

Biophysical Forces

Negative-Pressure Wound Therapy

NPWT effectively ensures wound drainage, aids granulation tissue development, and expedites wound contraction. RCT data have shown improved healing of ulcers as well as reduced second amputations.

Extracorporeal Shock Wave Therapy

ESWT delivers high-energy acoustic pulses to tissues and is the standard of care in treating nephrolithiasis and various musculoskeletal conditions. It has been reported to improve cutaneous wound healing through increasing cell proliferation and stimulating angiogenesis.

Electromagnetic Therapies

Electromagnetic therapies, such as pulsed electromagnetic field therapy, have effectively been used in orthopedic practice, and numerous in vitro and animal studies have demonstrated improved cutaneous wound healing. These therapies are thought to interact with endogenous electric fields in the skin to increase expression of growth factors and nitric oxide and also promote angiogenesis 50. However, RCT data showed mixed results, with one showing no difference between placebo and electromagnetic therapy and another reporting a significant increase in the percentage of healed ulcers between the two groups.

Knowledge Gaps

There has been an explosion in therapeutic options for wound healing in the last 30 years, as the number of wounds has increased because of our aging population, increases in the incidence of type 2 diabetes, and increases in obesity. Currently, there is a lack of clinical data in well-controlled prospective studies to document the clinical efficacy of several of the modalities now used clinically including HBOT, PRP, antimicrobial dressings, topical oxygen therapy, and pulsed electromagnetic stimulation. There is also almost a complete lack of comparative studies on advanced wound healing modalities. Prospective RCTs are challenging in wound healing because of the difficulty in binding both the patient and practitioner as well as the desire by both to achieve a healed wound. Registry studies may provide a powerful method to look at comparative advanced healing modalities and also allow us to better assess the cost-effectiveness of these therapies.


Fundamental Principles of Plastic Surgery

  • Plastic surgery is a diverse surgical specialty and its practice is guided by a set of fundamental
  • There is an inexorable connection between cosmetic surgery and reconstruction surgery because
    every plastic surgery operation aims to restore both form and function.
  • Elective surgeries should be pursued only after considering whether the benefits of surgery will
    outweigh the risks.
  • Outcomes in plastic surgery can be enhanced by addressing modifiable patient factors, adequately
    preparing wounds prior to reconstruction, replacing lost structures with tissues of similar quality,
    ensuring optimal vascularity, minimizing donor site morbidity, and deliberately protecting the
    surgical site.
  • A plastic surgeon is always prepared to confront complications with a series of surgical backup
  • Plastic surgeons must continually innovate new solutions to clinical problems and will remain at the vanguard of surgical innovation.

Plastic surgery is an incredibly diverse specialty that is challenging to define because its scope cannot simply be characterized by patient age, gender, organ system, or pathology. The purview of plastic surgery extends from neonatal to end-of-life care and is inclusive of a myriad of conditions that affect every single area of the human body. Plastic surgeons possess unique and versatile skills for reconstructing defects relating to cancer extirpation, cosmetically enhancing normal anatomy, salvaging limbs after trauma, rehabilitating burn patients, ameliorating childhood deformities, and performing autotransplantation as well as allotransplantation. This expertise is also critical in devising creative solutions to a variety of problems faced by other physicians, and for this reason, plastic surgeons are frequently consulted by their colleagues in other specialties. How is it possible for one surgical specialty to encompass this enormous breadth and depth of practice?


Medical Tourism in Iran

Rhinoplasty in Iran

Breast augmentation in Iran

Butt Lift in Iran

Ear Surgery in Iran



The unifying trait of all plastic surgeons is a comprehensive understanding of a set of important
fundamental principles. Every plastic surgeon abides by these principles to successfully execute the many complex assessments, judgment calls, and technical decisions in the daily practice of plastic surgery. Therefore, the specialty of plastic surgery is exceptional because it is distinguished not by its association to a particular patient population or anatomic region, but by a dedication to imperative principles that enable plastic surgeons to provide effective and individualized care. These principles were conceptualized through centuries of plastic surgery evolution and formalized in recent history by Gillies and Millard, who outlined a collection of philosophical yet practical principles in their text The Principles and Art of Plastic Surgery. 1 Years later, Millard published an expanded set of tenets in Principalization of Plastic Surgery. 2 This chapter modernizes and expounds on 10 of the most essential fundamental principles of plastic surgery and provides relevant examples of how plastic surgeons utilize these principles in a wide range of clinical scenarios.

Principle I: Make an Informed Decision to Operate or Not Operate

Some types of plastic surgery are mandatory. A wound resulting from resection of a sarcoma with exposed bone requires a reconstructive operation that provides soft tissue coverage over the defect durable enough to withstand the infliction of adjuvant radiation therapy. However, in many situations, the plastic surgeon must make an informed decision whether to perform an operation or not based on a thorough evaluation of the potential benefits against the potential risks. Although this is conspicuously germane to cosmetic surgery, the same thought process is necessary for reconstructive surgery. For example, a large but clean traumatic wound on a patient’s thigh could be treated reasonably with one of several options, from nonsurgical strategies such as dressing changes to surgical intervention such as local tissue rearrangement. A multitude of factors must be carefully pondered to select the most appropriate treatment. If dressing changes are used, the wound may be healed eventually but at what burden to the patient? Does the patient have the patience or ability to perform satisfactory dressing changes? Would a definitive surgery result in a healed wound more efficiently? How feasible is the surgery, and what is the likelihood of specific complications? Ultimately, the surgeon must decide if the benefits of surgery will outweigh the risks and predict that the expected outcomes of surgery will enhance the patient’s overall health status.

This determination is made more difficult because of the inherently subjective nature of plastic surgery outcomes. Success in plastic surgery is not measured solely on binary scales, such as patency versus occlusion or union versus nonunion. Instead, success is also subjectively gauged by patient satisfaction and is influenced by patient expectations. 3 Consider a consultation between a plastic surgeon and a woman interested in postmastectomy breast reconstruction, an elective operation with substantial psychosocial advantages. In a relatively short amount of time, the plastic surgeon needs to educate the patient regarding the available surgical choices for breast reconstruction and provide an individualized assessment of her candidacy for each option. To guide the patient to the most suitable decision for her, the surgeon must shrewdly evaluate the patient’s expectations and her level of understanding of the desired reconstructive surgery. Are her expectations consistent with what is possible from a technical standpoint? Does the patient seem ready to make this decision amidst the other stresses associated with a breast cancer diagnosis? Does the patient understand the possible setbacks that may occur with the surgery? The answers to these types of questions will greatly affect the patient’s perception of the success of reconstruction and her reported satisfaction with both the surgery and the plastic surgeon.

Principle II: Optimize Modifiable Patient Factors

Deliberate identification and management of patient risk factors will decrease the chances of complications and increase the likelihood of successful surgical outcomes. For example, smoking is a commonly encountered modifiable risk factor. Nearly 20% of Americans are smokers and cigarette smoking remains the leading cause of preventable disease and death in the United States. 4,5 The noxious components of cigarette smoke are known to cause vasoconstriction, induce endothelial injury, cause thrombogenesis, diminish oxygen transport, and hinder cellular repair mechanisms. 6 Together, these detrimental processes work synergistically to impair wound healing and will directly confer additional risk to plastic surgery patients. Other modifiable medical risk factors that also exacerbate poor wound healing include uncontrolled diabetes, obesity, infection, steroid use, certain homeopathic medications, and malnutrition. 7 These treatable comorbidities should be recognized during preoperative screening and sufficiently addressed prior to any operation. Social risk factors should also be carefully considered during the preoperative evaluation. After surgery, patients will frequently need assistance with their activities of daily living and comply with strict restrictions. The plastic surgeon should inquire about the social support available to the patient and ensure that the patient’s postoperative safety is entrusted to either family members or a rehabilitation center.
The importance of risk factor optimization is demonstrated in the care of body contouring patients. During the preoperative consultation, a thorough history is taken to solicit all modifiable risk factors that would impair the patient’s ability to heal long incisions and wide dissection planes. 8 For a majority of plastic surgeons, smoking is an absolute contraindication to any body contouring operation. Cessation of smoking for at least 4 weeks and confirmation with a urine cotinine test is a common requirement before surgery is scheduled. Frequently, collaboration with the patient’s primary care physician is critical in correcting hyperglycemia, anemia, or vitamin deficiencies. Patients who would benefit from additional weight loss may be referred to a nutritionist or a bariatric surgeon. After the operation, the patient will have considerable activity restrictions and will need to care for the wounds; therefore, a detailed preoperative discussion with the patient about postoperative care and limitations will serve to set expectations and to establish a social support system for the patient.

Principle III: Perform Adequate Debridement Prior to Reconstruction
Debridement is performed to physically remove any barriers to tissue growth, such as infection, biofilm, and senescent cells. 9 The plastic surgeon may choose one of many forms of debridement, from dressing changes to operative excision of the wound, but the critical concept is that the debridement must be adequate to remove all elements hindering wound healing. In many instances, this objective is accomplished only after the wound is debrided serially in the operating room. Chronic wounds are often associated with some degree of necrotic tissue that must be sharply and completely debrided away before definitive reconstruction can be performed. Failure of reconstruction is often attributed to inadequate debridement of the wound. Although adequate debridement is usually a term associated with the management of chronic wounds, this essential principle also applies to acute wounds. Acute traumatic wounds, such as open fractures of the lower extremity or lacerations from bite injury, are notoriously contaminated, and adequate debridement in this setting is also critical to the success of reconstruction. In fact, this principle of adequate debridement is so relevant to all forms of plastic surgery that it may even be applied to clean surgical wounds. For example, during reduction mammoplasty, there is often a widespread accumulation of devitalized globules of fat and clots scattered throughout the surgical field. Prior to closure, meticulous removal of this biologic debris facilitates wound healing by decreasing the risks of fat necrosis and infection.

Certain situations will complicate the plastic surgeon’s ability to perform adequate debridement. For example, in some traumatic wounds, exposed orthopedic hardware cannot be removed because doing so would result in unacceptable fracture instability. 10 In these challenging cases, debridement serves to decrease the microbial burden of the wound, and deep tissue cultures are taken to help guide antimicrobial therapy. However, the persistent presence of contaminated material will be a major risk factor for infection, and therefore the patient may need suppressive antibiotic therapy until the hardware can be removed. This necessary adaptation of the principle of adequate debridement is also exemplified in the treatment of pressure ulcers with underlying osteomyelitis. These chronic wounds exhibit many deleterious factors that impede wound healing. 11 The first step in surgical treatment is completely excising the soft tissue bursa surrounding the wound. If the osteomyelitis is limited to a small focus of bone at the base of the pressure ulcer, it is possible to remove the area of bone infection entirely during debridement. However, if the osteomyelitis is extensive, complete resection of this bone is not feasible, and the patient will often need suppressive antibiotic therapy guided by intraoperative bone cultures. In this situation, aggressive excision of the bursa is still beneficial because this promotes healing of the soft tissues after surgery and results in a smaller, cleaner, and more manageable chronic wound.

Principle IV: If Possible, Replace Like With Like; If Not Possible, Create It

One of the most famous plastic surgery principles is that lost tissues should be replaced in kind. The plastic surgeon examines the defect carefully and determines the best donor tissues necessary to optimally achieve both a durable reconstruction and an optimal aesthetic outcome. For instance, when primary skin closure is not possible after excision of a cutaneous tumor from an upper eyelid, a frequently chosen donor site is full-thickness skin from the opposite upper eyelid. 12 This option is elegant because it replaces the missing tissue with tissue of the same thickness, color match, pliability, and elasticity. In addition, donor site morbidity is acceptably low when relatively excess skin from one eyelid is used to reconstruct the other eyelid. When such an ideal donor site is unavailable, the next most similar tissue substitute is selected; in this example, skin for eyelid reconstruction can be harvested from postauricular skin or supraclavicular skin. This principle can also be applied to substantially more challenging wounds. An extensive mandibular tumor may necessitate the removal of bone, muscle, mucosa, and skin, and successful reconstruction is predicated on the replacement of these tissues with appropriately similar donor tissues. In these complex cases, reconstruction often requires the use of free flaps that are transferred to the defect, such as a fibula bone flap with associated skin based on the peroneal vascular system.

In some cases, no suitable donor sites exist, and innovative strategies must be employed to create sufficient replacement tissues of similar quality. One example of this is the use of tissue expanders to induce growth of tissues through cellular proliferation. 14 Tissue expansion has revolutionized the treatment of various conditions and given plastic surgeons another tool to better replace like with like in clinical scenarios that were previously impossible because of the severity of tissue deficiency. Tissue expanders now serve a critical role in the replacement of hair-bearing skin for large scalp defects, the creation of additional abdominal wall tissue for the closure of large hernias, the expansion of mastectomy skin for breast reconstruction, and the resurfacing of skin affected by giant congenital nevi. This concept of cellular response to force is also the mechanism behind distraction osteogenesis in craniofacial surgery. 15 This technique leverages the natural processes of fracture healing to yield outcomes superior to those achievable through other means such as nonvascularized bone grafting or free tissue transfer. For example, distraction osteogenesis is an excellent strategy for treating micrognathia in children with Pierre Robin sequence. 16 Internal or external distractors are placed surgically around the site of mandibular osteotomies, and a tensile force is slowly delivered to gradually elongate the intervening callus. One major advantage of distraction osteogenesis is that during the process of new bone formation, the overlying soft tissue envelope is also expanded incrementally. This reduces the constrictive effects of the soft tissue on the growing bone and consequently results in a stable reconstruction that is less prone to relapse. These powerful techniques to grow living structures outside of the laboratory setting have completely transformed the plastic surgeon’s ability to replace missing tissues and are often principal options for many complex clinical problems.

Principle V: Optimize Vascularity at Every Opportunity

Plastic surgeons are obsessed with blood supply. Vascularity is paramount to tissue viability and therefore to the success of healing. The plastic surgeon must possess an unparalleled comprehension of the blood supply to various types of tissues and methods to preserve this blood supply during surgery. For example, knowledge of the vastness of the subdermal plexus allows a plastic surgeon to reliably raise thin flaps of skin during a facelift operation. In reconstructive surgery, donor tissues must remain wellvascularized to transfer from one location to another. A detailed understanding of the vascular anatomy of these flaps permits their use for definitive closure of any wound. When vascularity to a surgical site is insufficient, the plastic surgeon must strive to improve it. For instance, surgery may be postponed to await smoking cessation or time may be given for other specialists to help optimize blood flow. An illustration of the latter is when a patient with arterial insufficiency and a chronic lower extremity wound is referred to a vascular surgeon for revascularization prior to surgical treatment of the wound. Vascularity of a particular flap may also be enhanced by performing a delay procedure, which is a staged operation whereby the plastic surgeon partially raises the flap and then waits 1 to 2 weeks before fully elevating the flap for reconstruction. A delay period allows choke vessels to physiologically dilate within the flap and results in greater flap reliability.

This respect for blood supply is also evident in many intraoperative decisions that are made by plastic surgeons. Judicious placement of incisions, especially in the context of unfavorable previous incisions, requires a careful consideration of blood supply. Additionally, at many points during an operation, the plastic surgeon will tailor numerous surgical techniques to maximize vascularity. For example, when a local flap such as a V-Y flap or a rotational flap is used for closure of a wound, minimal undermining is performed during flap elevation to reduce disruption of the flap’s underlying blood supply. Any sizable perforating vessels that are encountered during dissection of these local flaps are deliberately preserved if possible. During flap inset, pickups and retractors are handled thoughtfully to prevent iatrogenic tissue injury, and undue tension of the closure is avoided to minimize tissue ischemia. Even the selection of sutures and suturing technique is weighed against the effects on vascularity. For instance, placement of too many deep dermal sutures may cause relative ischemia of the edge of a cutaneous flap, and the choice of horizontal mattress suturing may lead to more ischemia compared with vertical mattress suturing. Each of these intraoperative decisions may influence the quality of the blood supply to the closure and may make a meaningful difference in the functional or cosmetic outcome of the surgery.

Principle VI: Preserve Form and Function

Every plastic surgery operation seeks to restore and preserve form and function. In many instances, the goals of surgery are both cosmetic and reconstructive. Patients with excess upper eyelid skin, for example, may describe dissatisfaction with their appearance as well as visual field deficits. During the preoperative consultation, the plastic surgeon must establish that the objectives of upper lid blepharoplasty are to both rejuvenate the upper eyelids and expand the visual field. A more challenging consideration of form and function occurs in children presenting with congenital facial nerve paralysis. In these patients, abnormalities of the facial nerve result in severe facial asymmetry that leads to devastating psychological consequences such as social isolation and difficulties with eating, speech articulation, emotional expression, and control of saliva. Frequently, the optimal solution for these cases is facial reanimation using a microsurgical transfer of an innervated muscle. 18 This reconstruction elevates the corner of the mouth and nasal ala on the paralyzed side to enhance resting facial symmetry and improve the dynamics of mastication, speech, and oral competence. Furthermore, because the muscle is innervated by a functional donor nerve at the recipient site, this operation can achieve animation of the paralyzed face, and in many instances, continued rehabilitation will result in spontaneous smiling.

In some situations, restoration of form and function is accomplished through a surgical solution that replaces multiple tissue deficiencies. An illustrative example of this is reconstruction after pelvic exenteration for advanced colorectal cancer. 20 Removal of organs such as the bladder and rectum will result in a void in the pelvis, and occasionally, the extent of tumor invasion mandates resection of other structures such as the vagina and perianal skin. The goals of reconstruction in these cases are to recreate normal anatomy, obliterate dead spaces within the pelvis, and supply additional vascularity to a surgical site that often is subject to neoadjuvant radiation. One exceptionally suitable choice that fulfills many of these reconstructive needs is the oblique rectus abdominis myocutaneous (ORAM) flap. 21 The ORAM flap has long reach for a pedicled flap, comprises a large amount of soft tissue bulk, and possesses a highly reliable blood supply. Furthermore, the flap is capable of supporting a large skin paddle that can be used for resurfacing vaginal defects as well as perianal skin deficits. With proper surgical planning, the ORAM flap can achieve excellent form and function by filling the pelvic dead space with vascularized tissue after tumor resection, providing sufficient lining for vaginal reconstruction, and decreasing the tension of closure in the perineum to optimize wound healing.

Principle VII: Minimize Donor Site Morbidity

When donor tissues are required, the plastic surgeon must focus on minimizing the functional and cosmetic sacrifices to the patient. Each operation already possesses inherent risks relating to the surgical site, such as hematoma, infection, or abnormal scarring. The donor site adds an additional anatomic area where complications may arise, and the plastic surgeon must weigh the possibility of donor site morbidity against the benefits of the use of that tissue for reconstruction. Often, several suitable donor sites exist, and a surgeon’s ultimate decision will be based upon careful consideration of the potential complications with each site. For example, during a rhinoplasty operation, structural support can be augmented by performing autologous cartilage grafting to the nasal framework. 22 Cartilage grafts can be harvested from the nasal septum, from the conchal bowl of the ear, or from the cartilaginous portion of a rib. The nasal septum would be an ideal donor site if septoplasty is also being performed, but use of this cartilage may cause further destabilization of the nasal framework and has a small risk of septal perforation. Harvest of conchal cartilage can provide adequate grafting material but may be complicated by hematoma, keloid formation, or ear asymmetry. The rib donor site offers an abundance of high-quality cartilage, but its indications must warrant the additional scar and added potential for pneumothorax. Ultimately, the plastic surgeon must choose the most appropriate donor site for reconstruction and justify the unique risks associated with that donor site.

To reduce donor site morbidity, plastic surgeons avoid unnecessary sacrifice of important adjacent anatomic structures. This focus on preservation of function during the harvest of donor tissues contributed to the advent of perforator flaps. For example, breast reconstruction using transverse rectus abdominis myocutaneous flaps commonly results in considerable abdominal wall morbidity, including bulges, hernias, and the need for mesh placement. 23 This morbidity is directly related to the removal of one or both rectus abdominis muscles from their native position, which weakens core strength and the integrity of the anterior abdominal wall. In contrast, the use of deep inferior epigastric perforator flaps for breast reconstruction is associated with lower morbidity to the abdominal donor site. During harvest of a deep inferior epigastric perforator flap, the perforating vessels supplying the skin and fat overlying the abdominal wall are meticulously dissected out of the rectus abdominis muscle, and every effort is made to maintain the continuity of the muscle. Segmental nerves are identified and protected whenever possible to preserve innervation to the rectus abdominis muscle, and a minimal amount of fascia is taken to reduce the tension of fascial closure. A continued ambition to limit donor site morbidity and extensive recent experience with perforator flap techniques have now led to the widespread use of many other workhorse perforator flaps for reconstruction, such as the anterolateral thigh (ALT) flap, the superior gluteal artery perforator flap, the thoracodorsal artery perforator flap, and the internal mammary artery perforator flap.

Principle VIII: Protect the Surgical Site Postoperatively

In plastic surgery, an operation cannot be deemed fully successful at the time of its completion; instead, this evaluation can only be made several weeks to months after the operation. This interval allows for preliminary healing to occur, subsidence of postsurgical swelling, initiation of rehabilitation therapy, and management of any complications. During this critical time, the surgical site must be protected diligently to facilitate recovery and to prevent injury to the healing tissues. The plastic surgeon must actively counsel patients to follow strict activity restrictions and help patients understand the rationale behind the necessary postoperative protocols. Strenuous activity, for example, may increase the likelihood of bleeding, seroma, or wound dehiscence and should be avoided for a period of time that commensurates with the magnitude of the operation and its associated risks. Clear postoperative instructions are provided to patients and may include customized information on various relevant issues such as wound care, splinting, compression garments, weight-bearing status, or limb elevation. Regular follow-up visits are also necessary to ensure that wounds are healing appropriately and to recognize the development of any complications. All of these efforts are directed at protecting the surgical site. Failure to do so may jeopardize the final outcome.

Complex lower extremity reconstruction exemplifies the importance of this principle. 25 An open tibial fracture with a large soft-tissue defect can be reconstructed with a free muscle flap and skin grafting to provide durable coverage of the underlying bone and orthopedic hardware. However, postoperative protection of the surgical site is as influential to successful salvage of the limb as the reconstructive surgery itself. 26 After surgery, the free flap is safeguarded from compression, especially when the muscle extends posteriorly where it would be crushed by the weight of the limb without proper elevation. This can be done using pillows, blankets, or foam; alternatively, if the patient has an external fixator in place, attachments can be added to prop up the leg much like the kickstand of a bicycle. Limb elevation also opposes venous congestion and facilitates the resolution of postsurgical edema. Immobilization is also a critical component of the postoperative protocol because it safeguards the reconstruction from any shearing forces that might disrupt either the muscle or the skin graft. Plaster or plastic splints are useful adjuncts to aid in immobilization of joints after surgery. Although each clinical scenario is unique, soft tissues generally require several weeks of protected healing time before being able to sustain any significant challenges. Therefore, once this initial healing period has occurred, a gradual and supervised release of these restrictions is commenced until complete return to normal activities is possible.

Principle IX: Have a Backup Plan (and a Backup Plan for THAT Backup Plan)

Complications will always arise, and the prepared plastic surgeon will be ready with multiple contingency plans. Most commonly, complications such as wound infection, marginal flap necrosis, or dehiscence can be successfully managed with straightforward and standardized treatment protocols. However, occasionally, the first operative plan fails to adequately address the goals of surgery, and a new plan is necessary. In reconstructive surgery, an old paradigm known as the reconstructive ladder advocates for a linear, stepwise approach to surgical problems whereby less-complicated surgical techniques are initially attempted, and progression up the ladder to more complex strategies is pursued only when needed. More recently, significant advancements in the field of plastic surgery have led to a shift away from this paradigm in favor of a treatment algorithm that encourages selection of the most definitive method for reconstruction even if it means picking a more complex one first. 27 If a backup plan is necessary, the plastic surgeon may either choose an alternative surgical plan from another rung of the reconstructive ladder or decide to try the previous plan again. Despite the antiquated adage in plastic surgery that instructs: “Make sure that plan B is not the same as plan A,” the same approach may in fact be attempted if careful consideration is given to the reasons why the prior surgery resulted in a failed reconstruction. If these factors can be readily identified and appropriately corrected, the same operative strategy may be performed another time and a successful outcome can be expected.

Reconstruction of upper extremity defects frequently exemplifies this fundamental principle. For example, a dorsal hand wound from a full-thickness burn injury with several exposed extensor tendons and metacarpal bones can be reconstructed by numerous techniques. 28 Although less-sophisticated approaches such as dermal substitutes and skin grafting may ultimately result in a closed wound, these options would not provide sufficiently durable soft tissue coverage over gliding tendons and therefore would result in unacceptable hand stiffness. A superior first choice for reconstruction might be a reverse radial forearm flap from the ipsilateral extremity or another regional flap. Should the plastic surgeon encounter insurmountable complications with the reverse radial forearm flap, a reasonable backup plan might entail the use of a free gracilis muscle flap. If the free flap reconstruction fails, the next backup option might be another free tissue transfer as long as the problems that led to loss of the previous flap are elucidated and the surgeon is confident that these issues can be sufficiently overcome prior to performing another free flap. Alternatively, the plastic surgeon might choose to reconstruct the dorsal hand wound with a pedicled groin flap. This fundamental principle of having a series of sensible backup plans guides the plastic surgeon to prepare for any number of potential setbacks during the reconstructive process and serves to optimize the chances of successful surgical outcomes.

Principle X: Innovate New Solutions to Old Problems

Innovation drives the practice and progress of plastic surgery. Plastic surgeons possess an inherent ambition to improve surgical approaches to existing clinical problems. For this reason, rarely is the exact same operation ever performed twice. Each surgery is individualized according to the clinical situation and specific patient needs. Thus, the plastic surgeon must strive to tailor every operation and often makes numerous adjustments to the accepted standard techniques. For example, a cleft lip repair for one child is never precisely the same as that for another child. 29 Although the basic tenets are constant, such as restoring continuity of the orbicularis oris and re-establishing labial subunits, the surgeon must remain flexible during the operation and modify the repair technique to account for the unique abnormalities present in each patient.

This spirit of adaptation and creative problem-solving is a large part of what distinguishes plastic surgery from other surgical disciplines and contributes to the constant evolution of the specialty. Over the course of the last century, plastic surgery has undergone enormous cycles of change that has resulted in significant paradigm shifts in patient care. One of the most profound examples is the advent of microsurgery. Previously, wounds resulting from tumor extirpation, infection, or trauma were reconstructed with either devascularized grafts that were often too thin to provide reliable soft tissue coverage or pedicle flaps that were frequently limited in reach or size. With the development of the operating microscope in the 1960s and a concomitant surge in our understanding of the vascular anatomy of muscle and myocutaneous flaps, 30-33 plastic surgery experienced an explosion of innovation and growth. The ability to raise and transfer a variety of tissue types as free flaps opened an entire realm of reconstructive solutions for problems that were once deemed impossible. For instance, distal third injuries of the lower extremity that commonly resulted in amputation could now be reconstructed with a free flap. Free tissue transfer quickly became the primary reconstructive choice after head and neck cancer resection. Hand surgery was completely revolutionized by the ability to replant amputated parts and reconstruct challenging defects of the upper extremity through the use of free flaps consisting of a variety of tissues including skin, muscle, fascia, and bone. More recently, microsurgical techniques have made vascularized composite allotransplantation a reality, and replacement of an entire complex anatomic structure such as a face, hand, or abdominal wall is now being performed at multiple centers around the world.

Plastic surgery will no doubt continue to be at the vanguard of innovating solutions to surgical problems. Plastic surgeons are spearheading ongoing research and development in a variety of emerging fields that are gaining increasing momentum, including tissue engineering, 37 transplant immunosuppression, 38 supermicrosurgery, 39 prosthetic interfaces, 40 perforator flap surgery, 41 and robotic surgery. 42 The ensuing chapters of this textbook will illustrate the persistent evolution of plastic surgery and demonstrate how numerous critical innovations in the field have completely transformed the care of our patients. Additionally, while each chapter will focus on a different aspect of plastic surgery, the reader will appreciate frequent allusions to the themes presented in this introduction and understand that plastic surgery is truly a specialty characterized by a devotion to a set of fundamental principles that guides its practice.