Plastic Surgery-Craniofacial, Head and

Neck Surgery-Pediatric Plastic Surgery

4th Edition Geoffrey C. Gurtner
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 Fourth Edition

Plastic
Surgery
Craniofacial, Head and Neck Surgery
Pediatric Plastic Surgery
Volume Three
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 Fourth Edition

Plastic
Surgery
Craniofacial, Head and Neck Surgery
Pediatric Plastic Surgery
Volume Three
Part 1 Volume Editor Part 2 Volume Editor

Eduardo D. Rodriguez Joseph E. Losee

MD, DDS MD
Helen L. Kimmel Professor of Reconstructive Ross H. Musgrave Professor of Pediatric
Plastic Surgery Plastic Surgery
Chair, Hansjörg Wyss Department of Plastic Department of Plastic Surgery
Surgery University of Pittsburgh Medical Center;
NYU School of Medicine Chief Division of Pediatric Plastic Surgery
NYU Langone Medical Center Children’s Hospital of Pittsburgh
New York, NY, USA Pittsburgh, PA, USA

Editor-in-Chief Multimedia Editor

Peter C. Neligan Daniel Z. Liu
MB, FRCS(I), FRCSC, FACS MD
Professor of Surgery Plastic and Reconstructive Surgeon
Department of Surgery, Division of Plastic Surgery Cancer Treatment Centers of America at
University of Washington Midwestern Regional Medical Center
Seattle, WA, USA Zion, IL, USA

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London, New York, Oxford, Philadelphia, St Louis, Sydney 2018

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Fourth edition 2018

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Video Contents

Chapter 11: Asian facial cosmetic surgery

Volume One: 1.1: Medial epicanthoplasty
Chapter 15: Skin graft 11.2: Eyelidplasty: Non-incisional method
11.3: Rhinoplasty
15.1: Harvesting a split-thickness skin graft 11.4: Subclinical ptosis correction (total)
Dennis P. Orgill 11.5: Secondary rhinoplasty: Septal extension graft and costal
Chapter 34: Robotics in plastic surgery cartilage strut fixed with K-wire
Kyung S. Koh, Jong Woo Choi, and Clyde H. Ishii
34.1: Robotic microsurgery
34.2: Robotic rectus abdominis muscle flap harvest Chapter 12: Neck rejuvenation
34.3: Trans-oral robotic surgery 12.1: Anterior lipectomy
34.4: Robotic latissimus dorsi muscle harvest James E. Zins, Colin M. Morrison, and C. J. Langevin
34.5: Robotic lymphovenous bypass
Jesse C. Selber Chapter 13: Structural fat grafting
13.1: Structural fat grafting of the face
Sydney R. Coleman and Alesia P. Saboeiro
Volume Two: Chapter 14: Skeletal augmentation
Chapter 6.2: Facelift: Principles of and surgical 14.1: Chin implant
approaches to facelift Michael J. Yarumchuk
© Mesa J, Havlik R, Mackay D, Buchman S, Losee J, eds. Atlas of
6.2.1: Parotid masseteric fascia Operative Craniofacial Surgery, CRC Press, 2019.
6.2.2: Anterior incision 14.2: Mandibular angle implant
6.2.3: Posterior incision 14.3: Midface skeletal augmentation and rejuvenation
6.2.4: Facelift skin flap Michael J. Yarumchuk
6.2.5: Facial fat injection © Michael J. Yaremchuk
Richard J. Warren
Chapter 16: Open technique rhinoplasty
6.2.6: Anthropometry, cephalometry, and orthognathic surgery
Jonathon S. Jacobs, Jordan M. S. Jacobs, and Daniel I. Taub 16.1: Open technique rhinoplasty
Allen L. Van Beek
Chapter 6.3: Facelift: Platysma-SMAS plication
Chapter 20: Otoplasty and ear reduction
6.3.1: Platysma-SMAS plication
Dai M. Davies and Miles G. Berry 20.1: Setback otoplasty
Leila Kasrai
Chapter 6.4: Facelift: Facial rejuvenation with loop
sutures – the MACS lift and its derivatives Chapter 23: Abdominoplasty procedures
6.4.1: Loop sutures MACS facelift 23.1: Abdominoplasty
Patrick L. Tonnard Dirk F. Richter and Alexander Stoff
From Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic
Surgery, Saunders Elsevier; 2009; with permission from Elsevier
Chapter 24: Lipoabdominoplasty

Chapter 6.7: Facelift: SMAS with skin attached – the 24.1: Lipoabdominoplasty (including secondary lipo)
Osvaldo Saldanha, Sérgio Fernando Dantas de Azevedo,
“high SMAS” technique Osvaldo Ribeiro Saldanha Filho, Cristianna Bonnetto Saldanha, and
6.7.1: The high SMAS technique with septal reset Luis Humberto Uribe Morelli
Fritz E. Barton Jr. Chapter 26.2: Buttock augmentation: Buttock
© Fritz E. Barton Jr.
augmentation with implants
Chapter 6.8: Facelift: Subperiosteal midface lift
26.2.1: Buttock augmentation
6.8.1: Subperiosteal midface lift: Endoscopic temporo-midface Terrence W. Bruner, Jose Abel De la Peña Salcedo,
Oscar M. Ramirez Constantino G. Mendieta, and Thomas L. Roberts III
Chapter 9: Blepharoplasty Chapter 27: Upper limb contouring
9.1: Periorbital rejuvenation 27.1: Brachioplasty
Julius Few Jr. and Marco Ellis 27.2: Upper limb contouring
© Julius Few Jr. Joseph F. Capella, Matthew J. Trovato, and Scott Woehrle

Chapter 28: Post-bariatric reconstruction
28.1: Post-bariatric reconstruction – bodylift procedure
J. Peter Rubin and Jonathan W. Toy
© J. Peter Rubin
Volume Three:
Chapter 6: Aesthetic nasal reconstruction
6.1: The three-stage folded forehead flap for cover and lining
6.2: First-stage transfer and intermediate operation
Frederick J. Menick
Chapter 7: Auricular construction
7.1: Total auricular construction
Akira Yamada
Chapter 8: Acquired cranial and facial bone
deformities
8.1: Removal of venous malformation enveloping intraconal
optic nerve
Renee M. Burke, Robert J. Morin, and S. Anthony Wolfe
Chapter 13: Facial paralysis
13.1: Facial paralysis
Eyal Gur
13.2: Facial paralysis
13.3: Cross facial nerve graft
13.4: Gracilis harvest
Peter C. Neligan
Chapter 14: Pharyngeal and esophageal
reconstruction
14.1: Reconstruction of pharyngoesophageal defects with the
anterolateral thigh flap
Peirong Yu
Chapter 15: Tumors of the facial skeleton: Fibrous
dysplasia
15.1: Surgical approaches to the facial skeleton
Yu-Ray Chen, You-Wei Cheong, and Alberto Córdova-Aguilar
Chapter 17: Local flaps for facial coverage
17.1: Facial artery perforator flap
17.2: Local flaps for facial coverage
Peter C. Neligan
Chapter 21.2: Rotation advancement cheiloplasty
21.2.1: Repair of unilateral cleft lip
Philip Kuo-Ting Chen, M. Samuel Noordhoff, Frank Chun-Shin,
Chang, and Fuan Chiang Chan
21.2.2: Unilateral cleft lip repair – anatomic subunit
approximation technique
David M. Fisher
Chapter 24: Alveolar clefts
24.1: Unilateral cleft alveolar bone graft
24.2: Mobilized premaxilla after vomer osteotomy prior to
setback and splint application
Richard A. Hopper and Gerhard S. Mundinger
Video Contents xiii
Chapter 26: Velopharyngeal dysfunction
26.1: Velopharyngeal incompetence – 1
26.2: Velopharyngeal incompetence – 2
26.3: Velopharyngeal incompetence – 3
Richard E. Kirschner and Adriane L. Baylis
Chapter 27: Secondary deformities of the cleft lip,
nose, and palate
27.1: Abbé flap
27.2: Alveolar bone grafting
27.3: Complete takedown
27.4: Definitive rhinoplasty
Evan M. Feldman, John C. Koshy, Larry H. Hollier Jr., and
Samuel Stal
27.5: Thick lip and buccal sulcus deformities
Evan M. Feldman and John C. Koshy
Chapter 36: Pierre Robin Sequence
36.1: Mandibular distraction
Arun K. Gosain and Chad A. Purnell
Chapter 39: Vascular anomalies
39.1: Lip hemangioma
Arin K. Greene
Chapter 43: Reconstruction of urogenital defects:
Congenital
43.1: First-stage hypospadias repair with free inner preputial
graft
43.2: Second-stage hypospadias repair with tunica vaginalis
flap
Mohan S. Gundeti and Michael C. Large
Volume Four:
Chapter 2: Management of lower extremity trauma
2.1: Anterolateral thigh flap harvest
Michel Saint-Cyr
Chapter 3: Lymphatic reconstruction of the
extremities
3.1: End-to-side lymphovenous bypass technique
© Cheng M-H, Chang D, Patel K. Principles and Practice of
Lymphedema Surgery, Elsevier; 2015.
3.2: Recipient site preparation for vascularized lymph node
transfer – axilla
© Cheng M-H, Chang D, Patel K. Principles and Practice of
Lymphedema Surgery, Elsevier; 2015.
3.3: Indocyanine green lymphography
David W. Chang
3.4: Charles procedure
Peter C. Neligan
Chapter 6: Diagnosis and treatment of painful
neuroma and nerve compression in the lower
extremity
6.1: Diagnosis and treatment of painful neuroma and of nerve
compression in the lower extremity 1
6.2: Diagnosis and treatment of painful neuroma and of nerve
compression in the lower extremity 2
xiv Video Contents
6.3: Diagnosis and treatment of painful neuroma and of nerve
compression in the lower extremity 3
A. Lee Dellon
Chapter 7: Skeletal reconstruction
7.1: Medial femoral condyle/medial geniculate artery
osteocutaneous free flap dissection for scaphoid nonunion
Stephen J. Kovach III and L. Scott Levin
Chapter 10: Reconstruction of the chest
10.1: Sternal rigid fixation
David H. Song and Michelle C. Roughton
Chapter 12: Abdominal wall reconstruction
12.1: Component separation innovation
Peter C. Neligan
Chapter 13: Reconstruction of male genital defects
13.1: Complete and partial penile reconstruction
Stan Monstrey, Peter Ceulemans, Nathalie Roche,
Philippe Houtmeyers, Nicolas Lumen, and Piet Hoebeke
Volume Five:
Chapter 6: Mastopexy options and techniques
6.1: Circumareolar mastopexy
Kenneth C. Shestak
Chapter 7: One- and two-stage considerations for
augmentation mastopexy
7.1: Preoperative markings for a single-stage augmentation
mastopexy
W. Grant Stevens
Chapter 10: Reduction mammaplasty with short scar
techniques
10.1: SPAIR technique
Dennis C. Hammond
Chapter 11: Gynecomastia surgery
11.1: Ultrasound-assisted liposuction
Charles M. Malata
Chapter 15: One- and two-stage prosthetic
reconstruction in nipple-sparing mastectomy
15.1: Pectoralis muscle elevation
15.2: Acellular dermal matrix
15.3: Sizer
Amy S. Colwell
Chapter 16: Skin-sparing mastectomy: Planned
two-stage and direct-to-implant breast
reconstruction
16.1: Mastectomy and expander insertion: First stage
16.2: Mastectomy and expander insertion: Second stage
Maurizio B. Nava, Giuseppe Catanuto, Angela Pennati,
Valentina Visintini Cividin, and Andrea Spano
Chapter 19: Latissimus dorsi flap breast
reconstruction
19.1: Latissimus dorsi flap technique
Scott L. Spear†
19.2: Markings
19.3: Intraoperative skin paddles
19.4: Tendon division
19.5: Transposition and skin paddles
19.6: Inset and better skin paddle explanation
Neil A. Fine and Michael S. Gart
Chapter 20.2: The deep inferior epigastric artery
perforator (DIEAP) flap
20.2.1: The Deep Inferior Epigastric Artery Perforator (DIEAP)
flap breast reconstruction
Phillip N. Blondeel and Robert J. Allen, Sr
Chapter 21.2: Gluteal free flaps for breast
reconstruction
21.2.1: Superior Gluteal Artery Perforator (SGAP) flap
21.2.2: Inferior Gluteal Artery Perforator (IGAP) flap
Peter C. Neligan
Chapter 21.3: Medial thigh flaps for breast
reconstruction
21.3.1: Transverse Upper Gracilis (TUG) flap 1
Peter C. Neligan
21.3.2: Transverse Upper Gracilis (TUG) flap 2
Venkat V. Ramakrishnan
Chapter 23.2: Partial breast reconstruction using
reduction and mastopexy techniques
23.2.1: Partial breast reconstruction using reduction
mammoplasty
Maurice Y. Nahabedian
23.2.2: Partial breast reconstruction with a latissimus dorsi flap
Neil A. Fine
23.2.3: Partial breast reconstruction with a pedicle TRAM
Maurice Y. Nahabedian
Volume Six:
Chapter 1: Anatomy and biomechanics of the hand
1.1: The extensor tendon compartments
1.2: The contribution of the interosseous and lumbrical
muscles to the lateral bands
1.3: Extrinsic flexors and surrounding vasculonervous
elements, from superficial to deep
1.4: The lumbrical plus deformity
1.5: The sensory and motor branches of the median nerve in
the hand
James Chang, Vincent R. Hentz, Robert A. Chase, and
Anais Legrand
Chapter 2: Examination of the upper extremity
2.1: Flexor profundus test in a normal long finger
2.2: Flexor sublimis test in a normal long finger
2.3: Extensor pollicis longus test in a normal person
2.4: Test for the Extensor Digitorum Communis (EDC) muscle
in a normal hand
2.5: Test for assessing thenar muscle function
2.6: The “cross fingers” sign
2.7: Static Two-Point Discrimination Test (s-2PD Test)
2.8: Moving 2PD Test (m-2PD Test) performed on the radial or
ulnar aspect of the finger
 Video Contents xv

2.9: Semmes–Weinstein monofilament test: The patient should Chapter 14: Thumb reconstruction: Microsurgical
sense the pressure produced by bending the filament techniques
2.10: Allen’s test in a normal person
2.11: Digital Allen’s test 14.1: Trimmed great toe
2.12: Scaphoid shift test 14.2: Second toe for index finger
2.13: Dynamic tenodesis effect in a normal hand 14.3: Combined second and third toe for metacarpal hand
2.14: The milking test of the fingers and thumb in a normal Nidal F. Al Deek
hand Chapter 19: Rheumatologic conditions of the hand
2.15: Eichhoff test
and wrist
2.16: Adson test
2.17: Roos test 19.1: Extensor tendon rupture and end–side tendon transfer
Ryosuke Kakinoki James Chang
Chapter 3: Diagnostic imaging of the hand and 19.2: Silicone metacarpophalangeal arthroplasty
wrist Kevin C. Chung and Evan Kowalski

3.1: Scaphoid lunate dislocation
Alphonsus K. Chong and David M. K. Tan
3.2: Right wrist positive midcarpal catch up clunk
Alphonsus K. Chong
Chapter 4: Anesthesia for upper extremity surgery
4.1: Supraclavicular block
Subhro K. Sen
Chapter 5: Principles of internal fixation as applied
to the hand and wrist
Chapter 20: Osteoarthritis in the hand and wrist
20.1: Ligament reconstruction tendon interposition arthroplasty
of the thumb carpometacarpal joint
James W. Fletcher
Chapter 21: The stiff hand and the spastic hand
21.1: Flexor pronator slide
David T. Netscher
Chapter 22: Ischemia of the hand

5.1: Dynamic compression plating and lag screw technique 22.1: Radial artery sympathectomy
Christopher Cox Hee Chang Ahn and Neil F. Jones
5.2: Headless compression screw 22.2: Interposition arterial graft and sympathectomy
5.3: Locking vs. non-locking plates Hee Chang Ahn
Jeffrey Yao and Jason R. Kang Chapter 24: Nerve entrapment syndromes
Chapter 7: Hand fractures and joint injuries 24.1: The manual muscle testing algorithm
7.1: Bennett reduction 24.2: Scratch collapse test – carpal tunnel
7.2: Hemi-Hamate arthroplasty Elisabet Hagert
Warren C. Hammert 24.3: Injection technique for carpal tunnel surgery
Chapter 9: Flexor tendon injury and reconstruction 24.4: Wide awake carpal tunnel surgery
Donald Lalonde
9.1: Zone II flexor tendon repair 24.5: Clinical exam and surgical technique – lacertus
9.2: Incision and feed tendon forward syndrome
9.3: Distal tendon exposure Elisabet Hagert
9.4: Six-strand M-tang repair
24.6: Injection technique for cubital tunnel surgery
9.5: Extension–flexion test – wide awake
24.7: Wide awake cubital tunnel surgery
Jin Bo Tang
Donald Lalonde
Chapter 10: Extensor tendon injuries 24.8: Clinical exam and surgical technique – radial tunnel
10.1: Sagittal band reconstruction syndrome
10.2: Setting the tension in extensor indicis transfer 24.9: Clinical exam and surgical technique – lateral
Kai Megerle intermuscular syndrome
24.10: Clinical exam and surgical technique – axillary nerve
Chapter 11: Replantation and revascularization entrapment
11.1: Hand replantation Elisabet Hagert
James Chang 24.11: Carpal tunnel and cubital tunnel releases in the same
patient in one procedure with field sterility: Part 1 – local
Chapter 12: Reconstructive surgery of the mutilated anesthetic injection for carpal tunnel
hand 24.12: Carpal tunnel and cubital tunnel releases in the same
12.1: Debridement technique patient in one procedure with field sterility: Part 2 – local
James Chang anesthetic injection for cubital tunnel
Donald Lalonde and Michael Bezuhly
Chapter 13: Thumb reconstruction: Non-
microsurgical techniques Chapter 25: Congenital hand I: Embryology,
classification, and principles
13.1: Osteoplastic thumb reconstruction
13.2: First Dorsal Metacarpal Artery (FDMA) flap 25.1: Pediatric trigger thumb release
Jeffrey B. Friedrich James Chang
xvi Video Contents

Chapter 27: Congenital hand III: Thumb hypoplasia 36.2: Adult: results of one-stage surgery for C5 rupture, C6–T1
root avulsion 10 years after
27.1: Thumb hypoplasia 36.3: Nerve transfer results 1
Joseph Upton III and Amir Taghinia
36.4: Nerve transfer results 2
Chapter 30: Growth considerations in pediatric 36.5: Nerve transfer results 3
upper extremity trauma and reconstruction 36.6: Nerve transfer results 4
36.7: Nerve transfer results 5
30.1: Epiphyseal transplant harvesting technique David Chwei-Chin Chuang
Marco Innocenti and Carla Baldrighi
Chapter 37: Restoration of upper extremity function
Chapter 31: Vascular anomalies of the upper in tetraplegia
extremity
37.1: The single-stage grip and release procedure
31.1: Excision of venous malformation 37.2: Postoperative results after single-stage grip release
Joseph Upton III and Amir Taghinia procedure in OCu3–5 patients
Chapter 32: Peripheral nerve injuries of the upper Carina Reinholdt and Catherine Curtin
extremity Chapter 38: Upper extremity vascularized composite
32.1: Suture repair of the cut digital nerve allotransplantation
32.2: Suture repair of the median nerve 38.1: Upper extremity composite tissue allotransplantation
Simon Farnebo and Johan Thorfinn W. P. Andrew Lee and Vijay S. Gorantla
Chapter 35: Free-functioning muscle transfer in the Chapter 39: Hand therapy
upper extremity
39.1: Goniometric measurement
35.1: Gracilis functional muscle harvest 39.2: Threshold testing
Gregory H. Borschel Christine B. Novak and Rebecca L. Neiduski
Chapter 36: Brachial plexus injuries: Adult and
pediatric
36.1: Pediatric: shoulder correct and biceps-to-triceps transfer
with preserving intact brachialis
 Lecture Video Contents

Chapter 28: Benign and malignant nonmelanocytic

Volume One: tumors of the skin and soft tissue

Chapter 1: Plastic surgery and innovation in medicine Benign and malignant nonmelanocytic tumors of the skin and soft
tissue
Plastic surgery and innovation in medicine Rei Ogawa
Peter C. Neligan
Chapter 31: Facial prosthetics in plastic surgery
Chapter 7: Digital imaging in plastic surgery Facial prosthetics in plastic surgery
Digital imaging in plastic surgery Gordon H. Wilkes
Daniel Z. Liu
Chapter 15: Skin graft Volume Two:
Skin graft
Chapter 4: Skincare and nonsurgical skin
Peter C. Neligan rejuvenation
Chapter 19: Repair and grafting of peripheral nerve Skincare and nonsurgical skin rejuvenation
Nerve injury and repair Leslie Baumann and Edmund Weisberg
Kirsty Usher Boyd, Andrew Yee, and Susan E. Mackinnon Chapter 5.2: Injectables and resurfacing techniques:
Chapter 20: Reconstructive fat grafting Soft-tissue fillers
Reconstructive fat grafting Soft-tissue fillers
J. Peter Rubin Trevor M. Born, Lisa E. Airan, and Daniel Suissa

Chapter 21: Vascular territories Chapter 5.3: Injectables and resurfacing techniques:
Botulinum toxin (BoNT-A)
Vascular territories
Botulinum toxin
Steven F. Morris
Michael A. C. Kane
Chapter 22: Flap classification and applications
Chapter 5.4: Injectables and resurfacing techniques:
Flap classification and applications Laser resurfacing
Joon Pio Hong
Laser resurfacing
Chapter 23: Flap pathophysiology and pharmacology Steven R. Cohen, Ahmad N. Saad, Tracy Leong,
and E. Victor Ross
Flap pathophysiology and pharmacology
Cho Y. Pang and Peter C. Neligan Chapter 5.5: Injectables and resurfacing techniques:
Chemical peels
Chapter 24: Principles and techniques of
microvascular surgery Chemical peels
Suzan Obagi
Principles and techniques of microvascular surgery
Fu-Chan Wei, Nidal F. Al Deek, and Chapter 6.1: Facelift: Facial anatomy and aging
Sherilyn Keng Lin Tay Anatomy of the aging face
Chapter 25: Principles and applications of tissue Bryan Mendelson and Chin-Ho Wong
expansion Chapter 6.2: Facelift: Principles of and surgical
Principles and applications of tissue expansion approaches to facelift
Ivo Alexander Pestana, Louis C. Argenta, and Principles of and surgical approaches to facelift
Malcolm W. Marks Richard J. Warren
Chapter 26: Principles of radiation Chapter 6.3: Facelift: Platysma-SMAS plication
Therapeutic radiation: principles, effects, and complications Platysma-SMAS plication
Gabrielle M. Kane Miles G. Berry
xviii Lecture Video Contents

Chapter 6.4: Facelift: Facial rejuvenation with loop Chapter 19: Secondary rhinoplasty
sutures – the MACS lift and its derivatives Secondary rhinoplasty
Facial rejuvenation with loop sutures – the MACS lift and its Ronald P. Gruber, Simeon H. Wall Jr., David L. Kaufman,
derivatives and David M. Kahn
Mark Laurence Jewell Chapter 21: Hair restoration
Chapter 6.5: Facelift: Lateral SMASectomy facelift Hair restoration
Lateral SMASectomy facelift Jack Fisher
Daniel C. Baker and Steven M. Levine Chapter 22.1: Liposuction: A comprehensive review
Chapter 6.6: Facelift: The extended SMAS technique of techniques and safety
in facial rejuvenation Liposuction
The extended SMAS technique in facelift Phillip J. Stephan, Phillip Dauwe, and Jeffrey Kenkel
James M. Stuzin Chapter 22.2: Correction of liposuction deformities
Chapter 6.7: Facelift: SMAS with skin attached – the with the SAFE liposuction technique
“high SMAS” technique SAFE liposuction technique
SMAS with skin attached – the high SMAS technique Simeon H. Wall Jr. and Paul N. Afrooz
Fritz E. Barton Jr. Chapter 23: Abdominoplasty procedures
Chapter 6.8: Facelift: Subperiosteal midface lift Abdominoplasty
Subperiosteal midface lift Dirk F. Richter and Nina Schwaiger
Alan Yan and Michael J. Yaremchuk Chapter 25.2: Circumferential approaches to truncal
Chapter 6.9: Facelift: Male facelift contouring: Belt lipectomy
Male facelift Belt lipectomy
Timothy J. Marten and Dino Elyassnia Al S. Aly, Khalid Al-Zahrani, and Albert Cram
Chapter 6.10: Facelift: Secondary deformities and Chapter 25.3: Circumferential approaches to truncal
the secondary facelift contouring: The lower lipo-bodylift
Secondary deformities and the secondary facelift Circumferential lower bodylift
Timothy J. Marten and Dino Elyassnia Dirk F. Richter and Nina Schwaiger
Chapter 7: Forehead rejuvenation Chapter 25.4: Circumferential approaches to truncal
Forehead rejuvenation contouring: Autologous buttocks augmentation with
purse string gluteoplasty
Richard J. Warren
Purse string gluteoplasty
Chapter 8: Endoscopic brow lifting
Joseph P. Hunstad and Nicholas A. Flugstad
Endoscopic brow lift
Renato Saltz and Alyssa Lolofie Chapter 25.5: Circumferential approaches to truncal
contouring: Lower bodylift with autologous gluteal
Chapter 9: Blepharoplasty flaps for augmentation and preservation of gluteal
Blepharoplasty contour
Julius Few Jr. and Marco Ellis Lower bodylift with gluteal flaps
Chapter 11: Asian facial cosmetic surgery Robert F. Centeno and Jazmina M. Gonzalez
Asian facial cosmetic surgery Chapter 26.3: Buttock augmentation: Buttock
Clyde H. Ishii shaping with fat grafting and liposuction
Chapter 12: Neck rejuvenation Buttock shaping with fat grafting and liposuction
Neck rejuvenation Constantino G. Mendieta, Thomas L. Roberts III,
and Terrence W. Bruner
James E. Zins, Joshua T. Waltzman, and Rafael A. Couto
Chapter 13: Structural fat grafting Chapter 27: Upper limb contouring
Structural fat grafting Upper limb contouring
Sydney R. Coleman and Alesia P. Saboeiro Joseph F. Capella, Matthew J. Trovato, and Scott Woehrle
Chapter 15: Nasal analysis and anatomy Chapter 30: Aesthetic genital surgery
Nasal analysis and anatomy Aesthetic genital surgery
Rod J. Rohrich Gary J. Alter

Volume Three:
Chapter 10.3: Midface reconstruction: The M. D.
Anderson approach
Midfacial reconstruction: The M. D. Anderson approach
Matthew M. Hanasono and Roman Skoracki
Chapter 12: Lip reconstruction
Lip reconstruction
Peter C. Neligan and Lawrence J. Gottlieb
Chapter 14: Pharyngeal and esophageal
reconstruction
Pharyngoesophageal reconstruction
Peirong Yu
Chapter 15: Tumors of the facial skeleton: Fibrous
dysplasia
Fibrous dysplasia
Alberto Córdova-Aguilar and Yu-Ray Chen
Chapter 17: Local flaps for facial coverage
Local flaps for facial coverage
David W. Mathes
Chapter 19: Facial transplant
Facial transplant
Michael Sosin and Eduardo D. Rodriguez
Chapter 32: Nonsyndromic craniosynostosis
Nonsyndromic craniosynostosis
Patrick A. Gerety, Jesse A. Taylor, and Scott P. Bartlett
Chapter 36: Pierre Robin Sequence
Pierre Robin sequence
Chad A. Purnell and Arun K. Gosain
Chapter 39: Vascular anomalies
Vascular anomalies
Arin K. Greene and John B. Mulliken
Volume Four:
Chapter 2: Management of lower extremity trauma
Management of lower extremity trauma
Yoo Joon Sur, Shannon M. Colohan, and Michel Saint-Cyr
Chapter 15: Surgery for gender identity disorder
Surgery for gender identity disorder
Loren S. Schechter
Chapter 16: Pressure sores
Pressure sores
Robert Kwon, Juan L. Rendon, and Jeffrey E. Janis
Chapter 17: Perineal reconstruction
Perineal reconstruction
Hakim K. Said and Otway Louie
Lecture Video Contents xix
Volume Five:
Chapter 5: Breast augmentation with autologous fat
grafting
Breast augmentation with autologous fat grafting
E. Delay
Chapter 6: Mastopexy options and techniques
Mastopexy
Robert Cohen
Chapter 9: Reduction mammaplasty with inverted-T
techniques
Reduction mammaplasty with inverted-T techniques
Maurice Y. Nahabedian
Chapter 15: One- and two-stage prosthetic
reconstruction in nipple-sparing mastectomy
Prosthetic reconstruction in nipple-sparing mastectomy
Amy S. Colwell
Chapter 20.1: Abdominally based free flaps:
Introduction
Abdominally-based autologous breast reconstruction
Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 20.2: The deep inferior epigastric artery
perforator (DIEAP) flap
Abdominally-based autologous breast reconstruction
Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 20.3: The superficial inferior epigastric
artery (SIEA) flap
Abdominally-based autologous breast reconstruction
Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 20.4: The free TRAM flap
Abdominally-based autologous breast reconstruction
Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 25: Radiation therapy considerations in the
setting of breast reconstruction
Radiation therapy in breast reconstruction
Steven Kronowitz
Volume Six:
Chapter 7: Hand fractures and joint injuries
Hand fractures and joint injuries
Joseph S. Khouri and Warren C. Hammert
Chapter 13: Thumb reconstruction: Non-
microsurgical techniques
Thumb reconstruction
Nicholas B. Vedder and Jeffrey B. Friedrich
Chapter 21: The stiff hand and the spastic hand
The stiff hand
David T. Netscher, Kenneth W. Donohue, and Dang T. Pham
xx Lecture Video Contents
Chapter 24: Nerve entrapment syndromes
Tips and pearls on common nerve compressions
Elisabet Hagert and Donald Lalonde
Chapter 30: Growth considerations in pediatric
upper extremity trauma and reconstruction
Growth considerations in pediatric upper extremity trauma and
reconstruction
Marco Innocenti and Carla Baldrighi
Chapter 33: Nerve transfers
Nerve injury and repair
Kirsty Usher Boyd, Andrew Yee, and Susan E. Mackinnon
Chapter 37: Restoration of upper extremity function
in tetraplegia
Restoration of upper extremity function in tetraplegia
Carina Reinholdt and Catherine Curtin

When I wrote the preface to the 3rd edition of this book, I
remarked how honored and unexpectedly surprised I was to
be the Editor of this great series. This time ‘round, I’m equally
grateful to carry this series forward. When Elsevier called me
and suggested it was time to prepare the 4th edition, my
initial reaction was that this was way too soon. What could
possibly have changed in Plastic Surgery since the 3rd edition
was launched in 2012? As it transpires, there have been many
developments and I hope we have captured them in this
edition.
We have an extraordinary specialty. A recent article by
Chadra, Agarwal and Agarwal entitled “Redefining Plastic
Surgery” appeared in Plastic and Reconstructive Surgery—Global
Open. In it they gave the following definition: “Plastic surgery
is a specialized branch of surgery, which deals with deformi-
ties, defects and abnormalities of the organs of perception,
organs of action and the organs guarding the external pas-
sages, besides innovation, implantation, replantation and
transplantation of tissues, and aims at restoring and improv-
ing their form, function and the esthetic appearances.” This is
an all-encompassing but very apt definition and captures the
enormous scope of the specialty.1
In the 3rd edition, I introduced volume editors for each of
the areas of the specialty because the truth is that one person
can no longer be an expert in all areas of this diverse specialty,
and I’m certainly not. I think this worked well because the
volume editors not only had the expertise to present their area
of subspecialty in the best light, but they were tuned in to
what was new and who was doing it. We have continued this
model in this new edition. Four of the seven volume editors
from the previous edition have again helped to bring the latest
and the best to this edition: Drs Gurtner, Song, Rodriguez,
Losee, and Chang have revised and updated their respective
volumes with some chapters remaining, some extensively
revised, some added, and some deleted. Dr. Peter Rubin has
replaced Dr. Rick Warren to compile the Aesthetic volume
(Vol. 2). Dr. Warren did a wonderful job in corralling this
somewhat disparate, yet vitally important, part of our spe-
cialty into the Aesthetic volume in the 3rd edition but felt that
the task of doing it again, though a labor of love, was more
than he wanted to take on. Similarly, Dr. Jim Grotting who did
a masterful job in the last edition on the Breast volume,
decided that doing a major revision should be undertaken by
someone with a fresh perspective and Dr. Maurice Nahabe-
dian stepped into that breach. I hope you will like the changes
you see in both of these volumes.
Dr. Allen Van Beek was the video editor for the last edition
and he compiled an impressive array of movies to comple-
ment the text. This time around, we wanted to go a step
further and though we’ve considerably expanded the list of
1
Chandra R, Agarwal R, Agarwal D. Redefining Plastic Surgery. Plast
Reconstr Surg Glob Open. 2016;4(5):e706.
Preface to the Fourth Edition
videos accompanying the text (there are over 170), we also
added the idea of lectures accompanying selected chapters.
What we’ve done here is to take selected key chapters and
include the images from that chapter, photos and artwork,
and create a narrated presentation that is available online;
there are annotations in the text to alert the reader that this is
available. Dr. Daniel Liu, who has taken over from Dr. Van
Beek as multimedia editor (rather than video editor) has done
an amazing job in making all of this happen. There are over
70 presentations of various key chapters online, making it as
easy as possible for you, the reader, to get as much knowledge
as you can, in the easiest way possible from this edition. Many
of these presentations have been done by the authors of the
chapters; the rest have been compiled by Dr. Liu and myself
from the content of the individual chapters. I hope you find
them useful.
The reader may wonder how this all works. To plan this
edition, the Elsevier team, headed by Belinda Kuhn, and I,
convened a face-to-face meeting in San Francisco. The volume
editors, as well as the London based editorial team, were
present. We went through the 3rd edition, volume by volume,
chapter by chapter, over an entire weekend. We decided what
needed to stay, what needed to be added, what needed to be
revised, and what needed to be changed. We also decided
who should write the various chapters, keeping many exist-
ing authors, replacing others, and adding some new ones; we
did this so as to really reflect the changes occurring within the
specialty. We also decided on practical changes that needed to
be made. As an example, you will notice that we have omitted
the complete index for the 6 Volume set from Volumes 2-6
and highlighted only the table of contents for that particular
volume. The complete index is of course available in Volume
1 and fully searchable online. This allowed us to save several
hundred pages per volume, reducing production costs and
diverting those dollars to the production of the enhanced online
content.
In my travels around the world since the 3rd edition was
published, I’ve been struck by what an impact this publication
has had on the specialty and, more particularly, on training.
Everywhere I go, I’m told how the text is an important part
of didactic teaching and a font of knowledge. It is gratifying
to see that the 3rd edition has been translated into Portuguese,
Spanish, and Chinese. This is enormously encouraging. I
hope this 4th edition continues to contribute to the specialty,
remains a resource for practicing surgeons, and continues to
prepare our trainees for their future careers in Plastic Surgery.
Peter C. Neligan
Seattle, WA
September, 2017
List of Editors
Editor-in-Chief Volume 4: Lower Extremity, Trunk, and Burns
Peter C. Neligan, MB, FRCS(I), FRCSC, FACS David H. Song, MD, MBA, FACS
Professor of Surgery Regional Chief, MedStar Health
Department of Surgery, Division of Plastic Surgery Plastic and Reconstructive Surgery
University of Washington Professor and Chairman
Seattle, WA, USA Department of Plastic Surgery
Georgetown University School of Medicine
Washington, DC, USA

Volume 1: Principles Volume 5: Breast

Geoffrey C. Gurtner, MD, FACS Maurice Y. Nahabedian, MD, FACS
Johnson and Johnson Distinguished Professor of Professor and Chief
Surgery and Vice Chairman, Section of Plastic Surgery
Department of Surgery (Plastic Surgery) MedStar Washington Hospital Center
Stanford University Washington, DC, USA;
Stanford, CA, USA Vice Chairman
Department of Plastic Surgery
MedStar Georgetown University Hospital
Washington, DC, USA

Volume 2: Aesthetic Volume 6: Hand and Upper Extremity

J. Peter Rubin, MD, FACS James Chang, MD
UPMC Professor of Plastic Surgery Johnson & Johnson Distinguished
Chair, Department of Plastic Surgery Professor and Chief
Professor of Bioengineering Division of Plastic and Reconstructive Surgery
University of Pittsburgh Stanford University Medical Center
Pittsburgh, PA, USA Stanford, CA, USA

Volume 3: Craniofacial, Head and Neck Surgery Multimedia editor

Eduardo D. Rodriguez, MD, DDS Daniel Z. Liu, MD
Helen L. Kimmel Professor of Reconstructive Plastic and Reconstructive Surgeon
Plastic Surgery Cancer Treatment Centers of America at Midwest-
Chair, Hansjörg Wyss Department of Plastic ern Regional Medical Center
Surgery Zion, IL, USA
NYU School of Medicine
NYU Langone Medical Center
New York, NY, USA

Volume 3: Pediatric Plastic Surgery

Joseph E. Losee, MD
Ross H. Musgrave Professor of Pediatric Plastic
Surgery
Department of Plastic Surgery
University of Pittsburgh Medical Center;
Chief Division of Pediatric Plastic Surgery
Children’s Hospital of Pittsburgh
Pittsburgh, PA, USA
 List of Contributors
The editors would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition would
not have been possible.

VOLUME ONE Kirsty Usher Boyd, MD, FRCSC Geoffrey C. Gurtner, MD, FACS
Assistant Professor Surgery (Plastics) Johnson and Johnson Distinguished Professor
Hatem Abou-Sayed, MD, MBA Division of Plastic and Reconstructive Surgery of Surgery and Vice Chairman,
Vice President University of Ottawa Department of Surgery (Plastic Surgery)
Physician Engagement Ottawa, Ontario, Canada Stanford University
Interpreta, Inc. Stanford, CA, USA
San Diego, CA, USA Charles E. Butler, MD, FACS
Professor and Chairman Phillip C. Haeck, MD
Paul N. Afrooz, MD Department of Plastic Surgery Surgeon
Resident Charles B. Barker Endowed Chair in Surgery Plastic Surgery
Plastic and Reconstructive Surgery The University of Texas MD Anderson Cancer The Polyclinic
University of Pittsburgh Medical Center Center Seattle, WA, USA
Pittsburgh, PA, USA Houston, TX, USA
The late Bruce Halperin†, MD
Claudia R. Albornoz, MD, MSc Peter E. M. Butler, MD, FRCSI, FRCS, Formerly Adjunct Associate Professor of
Research Fellow FRCS(Plast) Anesthesia
Plastic and Reconstructive Surgery Professor Department of Anesthesia
Memorial Sloan Kettering Cancer Center Plastic and Reconstructive Surgery Stanford University
New York, NY, USA University College and Royal Free London Stanford, CA, USA
London, UK
Nidal F. Al Deek, MD Daniel E. Heath
Doctor of Plastic and Reconstructive Surgery Yilin Cao, MD, PhD Lecturer
Chang Gung Memorial Hospital Professor School of Chemical and Biomedical Engineering
Taipei, Taiwan Shanghai Ninth People’s Hospital University of Melbourne
Shanghai Jiao Tong University School of Parkville, Victoria, Australia
Amy K. Alderman, MD, MPH Medicine
Private Practice Shanghai, China Joon Pio Hong, MD, PhD, MMM
Atlanta, GA, USA Professor
Franklyn P. Cladis, MD, FAAP Plastic Surgery
Louis C. Argenta, MD Associate Professor of Anesthesiology Asan Medical Center, University of Ulsan
Professor of Plastic and Reconstructive Surgery Department of Anesthesiology Seoul, South Korea
Department of Plastic Surgery The Children’s Hospital of Pittsburgh of UPMC
Wake Forest Medical Center Pittsburgh, PA, USA Michael S. Hu, MD, MPH, MS
Winston Salem, NC, USA Postdoctoral Fellow
Mark B. Constantian, MD Division of Plastic Surgery
Stephan Ariyan, MD, MBA Private Practice Department of Surgery
Emeritus Frank F. Kanthak Professor of Surgery, Surgery (Plastic Surgery) Stanford University School of Medicine
Plastic Surgery, Surgical Oncology, St. Joseph Hospital Stanford, CA, USA
Otolaryngology Nashua, NH, USA
Yale University School of Medicine; C. Scott Hultman, MD, MBA
Associate Chief Daniel A. Cuzzone, MD Professor and Chief
Department of Surgery; Plastic Surgery Fellow Division of Plastic and Reconstructive Surgery
Founding Director, Melanoma Program Hanjörg Wyss Department of Plastic Surgery University of North Carolina
Smilow Cancer Hospital, Yale Cancer Center New York University Medical Center Chapel Hill, NC, USA
New Haven, CT, USA New York, NY, USA
Amir E. Ibrahim
Tomer Avraham, MD Gurleen Dhami, MD Division of Plastic Surgery
Attending Plastic Surgeon Chief Resident Department of Surgery
Mount Sinai Health System Department of Radiation Oncology American University of Beirut Medical Center
Tufts University School of Medicine University of Washington Beirut, Lebanon
New York, NY, USA Seattle, WA, USA
Leila Jazayeri, MD
Aaron Berger, MD, PhD Gayle Gordillo, MD Microsurgery Fellow
Clinical Assistant Professor Associate Professor Plastic and Reconstructive Surgery
Division of Plastic Surgery Plastic Surgery Memorial Sloan Kettering Cancer Center
Florida International University School of The Ohio State University New York, NY, USA
Medicine Columbus, OH, USA
Miami, FL, USA
xxiv List of Contributors

Brian Jeffers Daniel Z. Liu, MD Riccardo F. Mazzola, MD

Student Plastic and Reconstructive Surgeon Plastic Surgeon
Bioengineering Cancer Treatment Centers of America at Department of Specialistic Surgical Sciences
University of California Berkeley Midwestern Regional Medical Center Fondazione Ospedale Maggiore Policlinico, Ca’
Berkeley, CA USA Zion, IL, USA Granda IRCCS
Milano, Italy
Lynn Jeffers, MD, FACS Wei Liu, MD, PhD
Private Practice Professor Lindsay D. McHutchion, MS, BSc
Oxnard, CA, USA Plastic and Reconstructive Surgery Anaplastologist
Shanghai Ninth People’s Hospital Institute for Reconstructive Sciences in Medicine
Mohammed M. Al Kahtani, MD, FRCSC Shanghai Jiao Tong University School of Edmonton, Alberta, Canada
Clinical Fellow Medicine
Division of Plastic Surgery Shanghai, China Babak J. Mehrara, MD, FACS
Department of Surgery Associate Member, Associate Professor of
University of Alberta Michael T. Longaker, MD, MBA, FACS Surgery (Plastic)
Edmonton, Alberta, Canada Deane P. and Louise Mitchell Professor and Vice Memorial Sloan Kettering Cancer Center
Chair Weil Cornell University Medical Center
Gabrielle M. Kane, MB, BCh, EdD, FRCPC Department of Surgery New York, NY, USA
Associate Professor Stanford University
Radiation Oncology Stanford, CA, USA Steven F. Morris, MD, MSc, FRCSC
University of Washington Professor of Surgery
Seattle, WA, USA H. Peter Lorenz, MD Department of Surgery
Service Chief and Professor, Plastic Surgery Dalhousie University
Raghu P. Kataru, PhD Lucile Packard Children’s Hospital Halifax, Nova Scotia, Canada
Senior Research Scientist Stanford University School of Medicine
Memorial Sloan-Kettering Cancer Center Stanford, CA, USA Wayne A. Morrison, MBBS, MD, FRACS
New York, NY, USA Professorial Fellow
Susan E. Mackinnon, MD O’Brien Institute
Carolyn L. Kerrigan, MD, MSc, MHCDS Sydney M. Shoenberg Jr. and Robert H. Department of Surgery, University of Melbourne
Professor of Surgery Shoenberg Professor Department of Plastic and Reconstructive
Surgery Department of Surgery, Division of Plastic and Surgery, St. Vincent’s Hospital
Dartmouth–Hitchcock Medical Center Reconstructive Surgery Melbourne, Australia
Lebanon, NH, USA Washington University School of Medicine
St. Louis, MO, USA Peter C. Neligan, MB, FRCS(I), FRCSC,
Timothy W. King, MD, PhD, FAAP, FACS FACS
Associate Professor with Tenure Malcolm W. Marks, MD Professor of Surgery
Departments of Surgery and Biomedical Professor and Chairman Department of Surgery, Division of Plastic
Engineering; Department of Plastic Surgery Surgery
Director of Research, Division of Plastic Surgery Wake Forest University School of Medicine University of Washington
University of Alabama at Birmingham (UAB) Winston-Salem, NC, USA Seattle, WA, USA
Craniofacial and Pediatric Plastic Surgery
Children’s of Alabama – Plastic Surgery; Diego Marre, MD Andrea J. O’Connor, BE(Hons), PhD
Chief, Plastic Surgery Section Fellow Associate Professor
Birmingham VA Hospital O’Brien Institute Department of Chemical and Biomolecular
Birmingham, AL, USA Department of Plastic and Reconstructive Engineering
Surgery University of Melbourne
Brian M. Kinney, MD, FACS, MSME St. Vincent’s Hospital Parkville, Victoria, Australia
Clinical Assistant Professor of Plastic Surgery Melbourne, Australia
University of Southern California Rei Ogawa, MD, PhD, FACS
School of Medicine David W. Mathes, MD Professor and Chief
Los Angeles, CA, USA Professor and Chief of the Division of Plastic Department of Plastic
and Reconstructive Surgery Reconstructive and Aesthetic Surgery
W. P. Andrew Lee, MD University of Colorado Nippon Medical School
The Milton T. Edgerton MD, Professor and Aurora, CO, USA Tokyo, Japan
Chairman
Department of Plastic and Reconstructive Evan Matros MD, MMSc Dennis P. Orgill, MD, PhD
Surgery Plastic Surgeon Professor of Surgery
Johns Hopkins University School of Medicine Memorial Sloan-Kettering Cancer Center Harvard Medical School
Baltimore, MD, USA New York, NY, USA Medical Director, Wound Care Center;
Vice Chairman for Quality Improvement
Sherilyn Keng Lin Tay, MBChB, MSc, Isabella C. Mazzola, MD Department of Surgery
FRCS(Plast) Attending Plastic Surgeon Brigham and Women’s Hospital
Consultant Plastic Surgeon Klinik für Plastische und Ästhetische Chirurgie Boston, MA, USA
Canniesburn Plastic Surgery Unit Klinikum Landkreis Erding
Glasgow Royal Infirmary Erding, Germany
Glasgow, UK
 List of Contributors xxv

Cho Y. Pang, PhD Saja S. Scherer-Pietramaggiori, MD E. Dale Collins Vidal, MD, MS

Senior Scientist Plastic and Reconstructive Surgeon Chief
Research Institute Plastic Surgery Section of Plastic Surgery
The Hospital for Sick Children; University Hospital Lausanne Dartmouth–Hitchcock Medical Center
Professor Lausanne, Vaud, Switzerland Lebanon, NH, USA
Departments of Surgery/Physiology
University of Toronto Iris A. Seitz, MD, PhD Derrick C. Wan, MD
Toronto, Ontario, Canada Director of Research and International Associate Professor
Collaboration Division of Plastic Surgery
Ivo Alexander Pestana, MD, FACS University Plastic Surgery Department of Surgery
Associate Professor Rosalind Franklin University; Director of Maxillofacial Surgery
Plastic and Reconstructive Surgery Clinical Instructor of Surgery Lucile Packard Children’s Hospital
Wake Forest University Chicago Medical School Stanford University School of Medicine
Winston Salem, NC, USA Chicago, IL, USA Stanford, CA, USA

Giorgio Pietramaggior, MD, PhD Jesse C. Selber, MD, MPH, FACS Renata V. Weber, MD
Swiss Nerve Institute Associate Professor, Director of Clinical Assistant Professor Surgery (Plastics)
Clinique de La Source Research Division of Plastic and Reconstructive Surgery
Lausanne, Switzerland Department of Plastic Surgery Albert Einstein College of Medicine
MD Anderson Cancer Center Bronx, NY, USA
Andrea L. Pusic, MD, MHS, FACS Houston, TX, USA
Associate Professor Fu-Chan Wei, MD
Plastic and Reconstructive Surgery Chandan K. Sen, PhD Professor
Memorial Sloan Kettering Cancer Center Professor and Director Department of Plastic Surgery
New York, NY, USA Center for Regenerative Medicine and Cell- Chang Gung Memorial Hospital
Based Therapies Taoyuan, Taiwan
Russell R. Reid, MD, PhD The Ohio State University Wexner Medical
Associate Professor Center Gordon H. Wilkes, BScMed, MD
Surgery/Section of Plastic and Reconstructive Columbus, OH, USA Clinical Professor of Surgery
Surgery Department of Surgery University of Alberta
University of Chicago Medicine Wesley N. Sivak, MD, PhD Institute for Reconstructive Sciences in Medicine
Chicago, IL, USA Resident in Plastic Surgery Misericordia Hospital
Department of Plastic Surgery Edmonton, Alberta, Canada
Neal R. Reisman, MD, JD University of Pittsburgh
Chief Pittsburgh, PA, USA Johan F. Wolfaardt, BDS,
Plastic Surgery MDent(Prosthodontics), PhD
Baylor St. Luke’s Medical Center M. Lucy Sudekum Professor
Houston, TX, USA Research Assistant Division of Otolaryngology – Head and Neck
Thayer School of Engineering at Dartmouth Surgery
Joseph M. Rosen, MD College Department of Surgery
Professor of Surgery Hanover, NH, USA Faculty of Medicine and Dentistry;
Plastic Surgery Director of Clinics and International Relations
Dartmouth–Hitchcock Medical Center G. Ian Taylor, AO, MBBS, MD, MD(Hon Institute for Reconstructive Sciences in Medicine
Lebanon, NH, USA Bordeaux), FRACS, FRCS(Eng), FRCS(Hon University of Alberta
Edinburgh), FRCSI(Hon), FRSC(Hon Covenant Health Group
Sashwati Roy, MS, PhD Canada), FACS(Hon) Alberta Health Services
Associate Professor Professor Alberta, Canada
Surgery, Center for Regenerative Medicine and Department of Plastic Surgery
Cell based Therapies Royal Melbourne Hospital; Kiryu K. Yap, MBBS, BMedSc
The Ohio State University Professor Junior Surgical Trainee & PhD Candidate
Columbus, OH, USA Department of Anatomy O’Brien Institute
University of Melbourne Department of Surgery, University of Melbourne
J. Peter Rubin, MD, FACS Melbourne, Victoria, Australia Department of Plastic and Reconstructive
UPMC Professor of Plastic Surgery Surgery, St. Vincent’s Hospital
Chair, Department of Plastic Surgery Chad M. Teven, MD Melbourne, Australia
Professor of Bioengineering Resident
University of Pittsburgh Section of Plastic and Reconstructive Surgery Andrew Yee
Pittsburgh, PA, USA University of Chicago Research Assistant
Chicago, IL, USA Division of Plastic and Reconstructive Surgery
Karim A. Sarhane, MD Washington University School of Medicine
Department of Surgery Ruth Tevlin, MB BAO BCh, MRCSI, MD St. Louis, MO, USA
University of Toledo Medical Center Resident in Surgery
Toledo, OH, USA Department of Plastic and Reconstructive Elizabeth R. Zielins, MD
Surgery Postdoctoral Research Fellow
David B. Sarwer, PhD Stanford University School of Medicine Surgery
Associate Professor of Psychology Stanford, CA, USA Stanford University School of Medicine
Departments of Psychiatry and Surgery Stanford, CA, USA
University of Pennsylvania School of Medicine
Philadelphia, PA, USA
xxvi List of Contributors

VOLUME TWO Leslie Baumann, MD Sydney R. Coleman, MD

CEO Assistant Clinical Professor
Paul N. Afrooz, MD Baumann Cosmetic and Research Institute Plastic Surgery
Resident Miami, FL, USA New York University Medical Center
Plastic and Reconstructive Surgery New York;
University of Pittsburgh Medical Center Miles G. Berry, MS, FRCS(Plast) Assistant Clinical Professor
Pittsburgh, PA, USA Consultant Plastic and Aesthetic Surgeon Plastic Surgery
Institute of Cosmetic and Reconstructive University of Pittsburgh Medical Center
Jamil Ahmad, MD, FRCSC Surgery Pittsburgh, PA, USA
Director of Research and Education London, UK
The Plastic Surgery Clinic Mark B. Constantian, MD
Mississauga; Trevor M. Born, MD Private Practice
Assistant Professor Division of Plastic Surgery Surgery (Plastic Surgery)
Surgery Lenox Hill/Manhattan Eye Ear and Throat St. Joseph Hospital
University of Toronto Hospital North Shore-LIJ Hospital Nashua, NH, USA;
Toronto, Ontario, Canada New York, NY, USA; Adjunct Clinical Professor
Clinical Lecturer Surgery (Plastic Surgery)
Lisa E. Airan, MD Division of Plastic Surgery University of Wisconsin School of Medicine
Aesthetic Dermatologist NYC University of Toronto Western Division Madison, WI, USA;
Private Practice; Toronto, Ontario, Canada Visiting Professor
Associate Clinical Professor Department of Plastic Surgery
Dermatology Terrence W. Bruner, MD, MBA University of Virginia Health System
Mount Sinai School of Medicine Private Practice Charlottesville, VA, USA
New York, NY, USA Greenville, SC, USA
Rafael A. Couto, MD
Gary J. Alter, MD Andrés F. Cánchica, MD Plastic Surgery Resident
Assistant Clinical Professor Chief Resident of Plastic Surgery Department of Plastic Surgery
Division of Plastic Surgery Plastic Surgery Service Dr. Osvaldo Saldanha Cleveland Clinic
University of California São Paulo, Brazil Cleveland, OH, USA
Los Angeles, CA, USA
Joseph F. Capella, MD Albert Cram, MD
Al S. Aly, MD Chief Post-bariatric Body Contouring Professor Emeritus
Professor of Plastic Surgery Division of Plastic Surgery University of Iowa
Aesthetic and Plastic Surgery Institute University Hackensack University Medical Center Iowa City Plastic Surgery
of California Irvine Hackensack, NJ, USA Coralville, IO, USA
Orange, CA, USA
Robert F. Centeno, MD, MBA Phillip Dauwe, MD
Khalid Al-Zahrani, MD, SSC-PLAST Medical Director Department of Plastic Surgery
Assistant Professor St. Croix Plastic Surgery and MediSpa; University of Texas Southwestern Medical
Consultant Plastic Surgeon Chief Medical Quality Officer School
King Khalid University Hospital Governor Juan F. Luis Hospital and Medical Dallas, TX, USA
King Saud University Center
Riyadh, Saudi Arabia Christiansted, Saint Croix, United States Virgin Dai M. Davies, FRCS
Islands Consultant and Institute Director
Bryan Armijo, MD Institute of Cosmetic and Reconstructive
Plastic Surgery Chief Resident Ernest S. Chiu, MD, FACS Surgery
Department of Plastic and Reconstructive Associate Professor of Plastic Surgery London, UK
Surgery Department of Plastic Surgery
Case Western Reserve/University Hospitals New York University Jose Abel De la Peña Salcedo, MD, FACS
Cleveland, OH, USA New York, NY, USA Plastic Surgeon
Director
Daniel C. Baker, MD Jong Woo Choi, MD, PhD, MMM Instituto de Cirugia Plastica S.C.
Professor of Surgery Associate Professor Huixquilucan
Institute of Reconstructive Plastic Surgery Department of Plastic and Reconstructive Estado de Mexico, Mexico
New York University Medical Center Surgery
Department of Plastic Surgery Seoul Asan Medical Center Barry DiBernardo, MD, FACS
New York, NY, USA Seoul, South Korea Clinical Associate Professor, Plastic Surgery
Rutgers, New Jersey Medical School
Fritz E. Barton Jr., MD Steven R. Cohen, MD Director New Jersey Plastic Surgery
Clinical Professor Senior Clinical Research Fellow, Clinical Montclair, NJ, USA
Department of Plastic Surgery Professor
UT Southwestern Medical Center Plastic Surgery Felmont F. Eaves III, MD, FACS
Dallas, TX, USA University of California Professor of Surgery, Emory University
San Diego, CA; Medical Director, Emory Aesthetic Center
Director Medical Director, EAC Ambulatory Surgery
Craniofacial Surgery Center
Rady Children’s Hospital, Private Practice, Atlanta, GA, USA
FACES+ Plastic Surgery, Skin and Laser Center
La Jolla, CA, USA
 List of Contributors xxvii

Marco Ellis, MD Joseph P. Hunstad, MD, FACS Tracy Leong, MD

Director of Craniofacial Surgery Associate Consulting Professor Dermatology
Northwestern Specialists in Plastic Surgery; Division of Plastic Surgery Rady Children’s Hospital - San Diego;
Adjunct Assistant Professor The University of North Carolina at Chapel Hill; Sharp Memorial Hospital;
University of Illinois Chicago Medical Center Private Practice University California San Diego Medical Center
Chicago, IL, USA Huntersville/Charlotte, NC, USA San Diego;
Private Practice, FACES+ Plastic Surgery, Skin
Dino Elyassnia, MD Clyde H. Ishii, MD, FACS and Laser Center
Associate Plastic Surgeon Assistant Clinical Professor of Surgery La Jolla, CA, USA
Marten Clinic of Plastic Surgery John A. Burns School of Medicine;
San Francisco, CA, USA Chief, Department of Plastic Surgery Steven M. Levine, MD
Shriners Hospital Assistant Professor of Surgery (Plastic)
Julius Few Jr., MD Honolulu Unit Hofstra Medical School, Northwell Health,
Director Honolulu, HI, USA New York, NY, USA
The Few Institute for Aesthetic Plastic Surgery;
Clinical Professor Nicole J. Jarrett, MD Michelle B. Locke, MBChB, MD
Plastic Surgery Department of Plastic Surgery Senior Lecturer in Surgery
University of Chicago Pritzker School of University of Pittsburgh Department of Surgery
Medicine Pittsburgh, PA, USA University of Auckland Faculty of Medicine and
Chicago, IL, USA Health Sciences;
Elizabeth B. Jelks, MD South Auckland Clinical Campus
Osvaldo Ribeiro Saldanha Filho, MD Private Practice Middlemore Hospital
Professor of Plastic Surgery Jelks Medical Auckland, New Zealand
Plastic Surgery Service Dr. Osvaldo Saldanha New York, NY, USA
São Paulo, Brazil Alyssa Lolofie
Glenn W. Jelks, MD University of Utah
Jack Fisher, MD Associate Professor Salt Lake City, UT, USA
Associate Clinical Professor Department of Ophthalmology
Plastic Surgery Department of Plastic Surgery Timothy J. Marten, MD, FACS
Vanderbilt University New York University School of Medicine Founder and Director
Nashville, TN, USA New York, NY, USA Marten Clinic of Plastic Surgery
San Francisco, CA, USA
Nicholas A. Flugstad, MD Mark Laurence Jewell, MD
Flugstad Plastic Surgery Assistant Clinical Professor Plastic Surgery Bryan Mendelson, FRCSE, FRACS, FACS
Bellevue, WA, USA Oregon Health Science University The Centre for Facial Plastic Surgery
Portland, OR, USA Toorak, Victoria, Australia
James D. Frame, MBBS, FRCS, FRCSEd,
FRCS(Plast) David M. Kahn, MD Constantino G. Mendieta, MD, FACS
Professor of Aesthetic Plastic Surgery Clinical Associate Professor of Plastic Surgery Private Practice
Anglia Ruskin University Department of Surgery Miami, FL, USA
Chelmsford, UK Stanford University School of Medicine
Stanford, CA, USA Drew B. Metcalfe, MD
Jazmina M. Gonzalez, MD Division of Plastic and Reconstructive Surgery
Bitar Cosmetic Surgery Institute Michael A. C. Kane, BS, MD Emory University
Fairfax, VA, USA Attending Surgeon Atlanta, GA, USA
Plastic Surgery
Richard J. Greco, MD Manhattan Eye, Ear, and Throat Hospital Gabriele C. Miotto, MD
CEO New York, NY, USA Emory School of Medicine
The Georgia Institute For Plastic Surgery Atlanta, GA, USA
Savannah, GA, USA David L. Kaufman, MD, FACS
Private Practice Plastic Surgery Foad Nahai, MD
Ronald P. Gruber, MD Aesthetic Artistry Surgical and Medical Center Professor of Surgery
Adjunct Associate Clinical Professor Folsom, CA, USA Division of Plastic and Reconstructive Surgery
Division of Plastic and Reconstructive Surgery Department of Surgery
Stanford University Jeffrey Kenkel, MD Emory University School of Medicine
Stanford, CA Professor and Chairman Emory Aesthetic Center at Paces
Clinical Association Professor Department of Plastic Surgery Atlanta, Georgia, USA
Division of Plastic and Reconstructive Surgery UT Southwestern Medical Center
University of California San Francisco Dallas, TX, USA Suzan Obagi, MD
San Francisco, CA, USA Associate Professor of Dermatology
Kyung S. Koh, MD, PhD Dermatology
Bahman Guyuron, MD, FCVS Professor of Plastic Surgery University of Pittsburgh;
Editor in Chief, Aesthetic Plastic Surgery Journal Asan Medical Center, University of Ulsan School Associate Professor of Plastic Surgery
Emeritus Professor of Plastic Surgery of Medicine Plastic Surgery
Case School of Medicine Seoul, South Korea University of Pittsburgh
Cleveland, OH, USA Pittsburgh, PA, USA
xxviii List of Contributors

Sabina Aparecida Alvarez de Paiva, MD Osvaldo Saldanha, MD, PhD Ali Totonchi, MD
Resident of Plastic Surgery Director of Plastic Surgery Service Dr. Osvaldo Assistant Professor
Plastic Surgery Service Dr. Ewaldo Bolivar de Saldanha; Plastic Surgery
Souza Pinto Professor of Plastic Surgery Department Case Western Reserve University;
São Paulo, Brazil Universidade Metropolitana de Santos Medical Director Craniofacial Deformity Clinic
- UNIMES Plastic Surgery
Galen Perdikis, MD São Paulo, Brazil MetroHealth Medical center
Assistant Professor of Surgery Cleveland, OH, USA
Division of Plastic Surgery Renato Saltz, MD, FACS
Emory University School of Medicine Saltz Plastic Surgery Jonathan W. Toy, MD, FRCSC
Atlanta, GA, USA President Program Director, Plastic Surgery Residency
International Society of Aesthetic Plastic Surgery Program Assistant Clinical Professor
Jason Posner, MD, FACS Adjunct Professor of Surgery University of Alberta
Private Practice University of Utah Edmonton, Alberta, Canada
Boca Raton, FL, USA Past-President, American Society for Aesthetic
Plastic Surgery Matthew J. Trovato, MD
Dirk F. Richter, MD, PhD Salt Lake City and Park City, UT, USA Dallas Plastic Surgery Institute
Clinical Professor of Plastic Surgery Dallas, TX, USA
University of Bonn Paulo Rodamilans Sanjuan MD
Director and Chief Chief Resident of Plastic Surgery Simeon H. Wall Jr., MD, FACS
Dreifaltigkeits-Hospital Plastic Surgery Service Dr. Ewaldo Boliar de Director
Wesseling, Germany Souza Pinto The Wall Center for Plastic Surgery;
São Paulo, Brazil Assistant Clinical Professor
Thomas L. Roberts III, FACS Plastic Surgery
Plastic Surgery Center of the Carolinas Nina Schwaiger, MD LSU Health Sciences Center at Shreveport
Spartanburg, SC, USA Senior Specialist in Plastic and Aesthetic Shreveport, LA, USA
Surgery
Jocelyn Celeste Ledezma Rodriguez, MD Department of Plastic Surgery Joshua T. Waltzman, MD, MBA
Private Practice Dreifaltigkeits-Hospital Wesseling Private Practice
Guadalajara, Jalisco, Mexico Wesseling, Germany Waltzman Plastic and Reconstructive Surgery
Long Beach, CA, USA
Rod J. Rohrich, MD Douglas S. Steinbrech, MD, FACS
Clinical Professor and Founding Chair Gotham Plastic Surgery Richard J. Warren, MD, FRCSC
Department of Plastic Surgery New York, NY, USA Clinical Professor
Distinguished Teaching Professor Division of Plastic Surgery
University of Texas Southwestern Medical Center Phillip J. Stephan, MD University of British Columbia
Founding Partner Clinical Faculty Vancouver, British Columbia, Canada
Dallas Plastic Surgery Institute Plastic Surgery
Dallas, TX, USA UT Southwestern Medical School; Edmund Weisberg, MS, MBE
Plastic Surgeon University of Pennsylvania
E. Victor Ross, MD Texoma Plastic Surgery Philadelphia, PA, USA
Director of Laser and Cosmetic Dermatology Wichita Falls, TX, USA
Scripps Clinic Scott Woehrle, MS BS
San Diego, CA, USA David Gonzalez Sosa, MD Physician Assistant
Plastic and Reconstructive Surgery Department of Plastic Surgery
J. Peter Rubin, MD, FACS Hospital Quirónsalud Torrevieja Jospeh Capella Plastic Surgery
Chief Alicante, Spain Ramsey, NJ, USA
Plastic and Reconstructive Surgery
University of Pittsburgh Medical Center; James M. Stuzin, MD Chin-Ho Wong, MBBS, MRCS, MMed(Surg),
Associate Professor Associate Professor of Surgery FAMS(Plast Surg)
Department of Surgery (Plastic) Voluntary W Aesthetic Plastic Surgery
University of Pittsburgh University of Miami Leonard M. Miller School of Mt Elizabeth Novena Specialist Center
Pittsburgh, PA, USA Medicine Singapore
Miami, FL, USA
Ahmad N. Saad, MD Alan Yan, MD
Private Practice Daniel Suissa, MD, MSc Former Fellow
FACES+ Plastic Surgery Clinical Instructor Adult Reconstructive and Aesthetic
Skin and Laser Center Section of Plastic and Reconstructive Surgery Craniomaxillofacial Surgery
La Jolla, CA, USA Yale University Division of Plastic and Reconstructive Surgery
New Haven, CT, USA Massachusetts General Hospital
Alesia P. Saboeiro, MD Boston, MA, USA
Attending Physician Charles H. Thorne, MD
Private Practice Associate Professor of Plastic Surgery
New York, NY, USA Department of Plastic Surgery
NYU School of Medicine
Cristianna Bonnetto Saldanha, MD New York, NY, USA
Plastic Surgery Service Dr. Osvaldo Saldanha
São Paulo, Brazil

Michael J. Yaremchuk, MD
Chief of Craniofacial Surgery
Massachusetts General Hospital;
Clinical Professor of Surgery
Harvard Medical School;
Program Director
Harvard Plastic Surgery Residency Program
Boston, MA, USA
James E. Zins, MD
Chairman
Department of Plastic Surgery
Dermatology and Plastic Surgery Institute
Cleveland Clinic
Cleveland, OH, USA
VOLUME THREE
Neta Adler, MD
Senior Surgeon
Department of Plastic and Reconstructive
Surgery
Hadassah University Hospital
Jerusalem, Israel
Ahmed M. Afifi, MD
Assistant Professor of Plastic Surgery
Department of Surgery
University of Wisconsin
Madison, WI, USA;
Associate Professor
Department of Plastic Surgery
Cairo University
Cairo, Egypt
Marta Alvarado, DDS, MS
Department of Orthodontics
Facultad de Odontología
Universidad de San Carlos de Guatemala
Guatemala
Eric Arnaud, MD
Pediatric Neurosurgeon and Co-Director
Unité de Chirurgie Craniofaciale
Hôpital Necker Enfants Malades
Paris, France
Stephen B. Baker, MD, DDS
Associate Professor and Program Director
Co-Director Inova Hospital for Children
Craniofacial Clinic
Department of Plastic Surgery
Georgetown University Hospital
Georgetown, WA, USA
Scott P. Bartlett, MD
Professor of Surgery
Surgery
University of Pennsylvania;
Chief Division of Plastic Surgery
Surgery
Children’s Hospital of Philadelphia
Philadelphia, PA, USA
List of Contributors xxix
Bruce S. Bauer, MD Edward I. Chang, MD
Chief Assistant Professor
Division of Plastic Surgery Department of Plastic Surgery
NorthShore University HealthSystem The University of Texas M. D. Anderson Cancer
Highland Park; Center
Clinical Professor of Surgery Houston, TX, USA
Department of Surgery
University of Chicago Pritzker School of Constance M. Chen, MD, MPH
Medicine Director of Microsurgery
Chicago, IL, USA Plastic and Reconstructive Surgery
New York Eye and Ear Infirmary of Mt Sinai;
Adriane L. Baylis, PhD Clinical Assistant Professor
Speech Scientist Plastic and Reconstructive Surgery
Section of Plastic and Reconstructive Surgery Weil Medical College of Cornell University;
Nationwide Children’s Hospital Clinical Assistant Professor
Columbus, OH, USA Plastic and Reconstructive Surgery
Tulane University School of Medicine
Mike Bentz, MD, FAAP, FACS New York, NY, USA
Interim Chairman
Department of Surgery Yu-Ray Chen, MD
University of Wisconsin; Professor of Surgery
Chairman Division of Plastic Surgery Plastic and Reconstructive Surgery
Department of Surgery Chang Gung Memorial Hospital
University of Wisconsin Taoyuan City, Taiwan
Madison, WI, USA
Philip Kuo-Ting Chen, MD
Craig Birgfeld, MD, FACS Professor
Associate Professor, Pediatric Plastic and Craniofacial Center
Craniofacial Surgery Chang Gung Memorial Hospital
Seattle Children’s Hospital Taoyuan City, Taiwan
Seattle, WA, USA
Ming-Huei Cheng, MD, MBA
William R. Boysen, MD Professor
Resident Physician, Urology Division of Reconstructive Microsurgery
University of Chicago Medicine Department of Plastic and Reconstructive
Chicago, IL, USA Surgery
Chang Gung Memorial Hospital
James P. Bradley, MD Taoyuan City, Taiwan
Professor and Chief
Section of Plastic and Reconstructive Surgery Gerson R. Chinchilla, DDS MS
Temple University Director
Philadelphia, PA, USA Department of Orthodontics
Facultad de Odontología
Edward P. Buchanan, MD Universidad de San Carlos de Guatemala
Division of Plastic Surgery Guatemala
Baylor College of Medicine
Houston, TX, USA Peter G. Cordeiro, MD
Chief
Michael R. Bykowski, MD, MS Plastic and Reconstructive Surgery
Plastic Surgery Resident Memorial Sloan Kettering Cancer Center;
Plastic Surgery Professor of Surgery
University of Pittsburgh Medical Center Surgery
Pittsburgh, PA, USA Weil Medical College of Cornell University
New York, NY, USA
Edward J. Caterson, MD, PhD
Director of Craniofacial Surgery Alberto Córdova-Aguilar, MD, MPH
Division of Plastic Surgery Attending Plastic Surgeon
Brigham and Women’s Hospital Surgery
Boston, MA, USA Faculty of Medicine Ricardo Palma University
Lima, Peru
Rodney K. Chan, MD
Chief Plastic and Reconstructive Surgery Edward H. Davidson, MA(Cantab), MBBS
Clinical Division and Burn Center Resident Plastic Surgeon
United States Army Institute of Surgical Department of Plastic Surgery
Research University of Pittsburgh
Joint Base San Antonio, TX, USA Pittsburgh, PA, USA
xxx List of Contributors

Sara R. Dickie, MD Patrick A. Gerety, MD Matthew M. Hanasono, MD

Clinician Educator Assistant Professor of Surgery Associate Professor
Surgery Division of Plastic and Reconstructive Surgery Department of Plastic Surgery
University of Chicago Hospital Pritzker School of Indiana University and Riley Hospital for The University of Texas MD Anderson Cancer
Medicine; Children Center
Attending Surgeon Philadelphia, PA, USA Houston, TX, USA
Section of Plastic and Reconstructive Surgery
NorthShore University HealthSystem Jesse A. Goldstein, MD Toshinobu Harada, PhD
Northbrook, IL, USA Chief Resident Professor in Engineering
Department of Plastic Surgery Department of Systems Engineering
Risal S. Djohan, MD Georgetown University Hospital Faculty of Systems Engineering
Microsurgery Fellowship Program Director Washington, DC, USA Wakayama University
Plastic Surgery Wakayama, Japan
Cleveland Clinic; Arun K. Gosain, MD
Surgery ASC Quality Improvement Officer Chief Jill A. Helms, DDS, PhD
Plastic Surgery Division of Plastic Surgery Professor
Cleveland Clinic Ann and Robert H. Lurie Children’s Hospital of Surgery
Cleveland, OH, USA Chicago Stanford University
Chicago, IL, USA Stanford, CA, USA
Amir H. Dorafshar, MBChB, FACS, FAAP
Associate Professor Lawrence J. Gottlieb, MD David L. Hirsch, MD, DDS
Plastic and Reconstructive Surgery Professor of Surgery Director of Oral Oncology and Reconstruction
Johns Hopkins Medical Institute; Department of Surgery Lenox Hill Hospital/Northwell Health
Assistant Professor Section of Plastic and Reconstructive Surgery New York, NY, USA
Plastic Surgery University of Chicago
R Adams Cowley Shock Trauma Center Chicago, IL, USA Jung-Ju Huang, MD
Baltimore, MD, USA Associate Professor
Arin K. Greene, MD, MMSc Division of Microsurgery
Jeffrey A. Fearon, MD Department of Plastic and Oral Surgery Plastic and Reconstructive Surgery
Director Boston Children’s Hospital; Chang Gung Memorial Hospital
The Craniofacial Center Associate Professor of Surgery Taoyuan, Taiwan
Dallas, TX, USA Harvard Medical School
Boston, MA, USA William Y. Hoffman, MD
Alexander L. Figueroa, DMD Professor and Chief
Craniofacial Orthodontist Patrick J. Gullane, MD, FRCS Division of Plastic and Reconstructive Surgery
Rush Craniofacial Center Wharton Chair in Head and Neck Surgery UCSF
Rush University Medical Center Professor of Surgery, Department of San Francisco, CA, USA
Chicago, IL, USA Otolaryngology - Head and Neck Surgery
University of Toronto Larry H. Hollier Jr., MD
Alvaro A. Figueroa, DDS, MS Toronto, Ontario, Canada Division of Plastic Surgery
Co-Director Baylor College of Medicine
Rush Craniofacial Center Mohan S. Gundeti, MB, MCh, FEBU, Houston, TX, USA
Rush University Medical Center FRCS(Urol), FEAPU
Chicago, IL, USA Associate Professor of Urology in Surgery and Richard A. Hopper, MD, MS
Pediatrics, Director Pediatric Urology, Director Chief
David M. Fisher, MB, BCh, FRCSC, FACS Centre for Pediatric Robotics and Minimal Division of Craniofacial Plastic Surgery
Medical Director Cleft Lip and Palate Program Invasive Surgery Seattle Children’s Hospital;
Plastic Surgery University of Chicago and Pritzker Medical Surgical Director
Hospital for Sick Children; School Comer Children’s Hospital Craniofacial Center
Associate Professor Chicago, IL, USA Seattle Children’s Hospital;
Surgery Associate Professor
University of Toronto Eyal Gur, MD Department of Surgery
Toronto, Ontario, Canada Professor of Surgery, Chief University of Washington
Department of Plastic and Reconstructive Seattle, WA, USA
Roberto L. Flores, MD Surgery
Associate Professor of Plastic Surgery The Tel Aviv Sourasky Medical Center Gazi Hussain, MBBS, FRACS
Director of Cleft Lip and Palate Tel Aviv, Israel Clinical Senior Lecturer
Hansjörg Wyss Department of Plastic Surgery Macquarie University
NYU Langone Medical Center Bahman Guyuron, MD, FCVS Sydney, Australia
New York, NY, USA Editor in Chief, Aesthetic Plastic Surgery
Journal; Oksana Jackson, MD
Andrew Foreman, B. Physio, BMBS(Hons), Emeritus Professor of Plastic Surgery Assistant Professor
PhD, FRACS Case School of Medicine Plastic Surgery
Consultant Surgeon, Department of Cleveland, OH, USA Perelman School of Medicine at the University
Otolaryngology - Head and Neck Surgery of Pennsylvania;
University of Adelaide, Assistant Professor
Royal Adelaide Hospital, Plastic Surgery
Adelaide, SA, Australia The Children’s Hospital of Philadelphia
Philadelphia, PA, USA
 List of Contributors xxxi

Syril James, MD Joseph E. Losee, MD Gerhard S. Mundinger, MD

Clinic Marcel Sembat Ross H. Musgrave Professor of Pediatric Plastic Assistant Professor
Boulogne-Billancourt Surgery Craniofacial, Plastic, and Reconstructive Surgery
Paris, France Department of Plastic Surgery Louisiana State University Health Sciences
University of Pittsburgh Medical Center; Center
Leila Jazayeri, MD Chief, Division of Pediatric Plastic Surgery Children’s Hospital of New Orleans
Microsurgery Fellow Children’s Hospital of Pittsburgh New Orleans, LA, USA
Plastic and Reconstructive Surgery Pittsburgh, PA, USA
Memorial Sloan Kettering Cancer Center Blake D. Murphy, BSc, PhD, MD
New York, NY, USA David W. Low, MD Craniofacial Fellow
Professor of Surgery Plastic Surgery
Sahil Kapur, MD Division of Plastic Surgery Nicklaus Children’s Hospital
Assistant Professor Perelman School of Medicine at the University Miami, FL, USA
Department of Plastic Surgery of Pennsylvania;
University of Texas - MD Anderson Cancer Clinical Associate Peter C. Neligan, MB, FRCS(I), FRCSC,
Center Department of Surgery FACS
Houston, TX, USA Children’s Hospital of Philadelphia Professor of Surgery
Philadelphia, PA, USA Department of Surgery, Division of Plastic
Henry K. Kawamoto Jr., MD, DDS Surgery
Clinical Professor Ralph T. Manktelow, MD, FRCSC University of Washington
Surgery Division of Plastic Surgery Professor of Surgery, Seattle, WA, USA
UCLA The University of Toronto,
Los Angeles, CA, USA Toronto, Ontario, Canada M. Samuel Noordhoff, MD, FACS
Emeritus Professor in Surgery
David Y. Khechoyan, MD Paul N. Manson, MD Chang Gung University
Division of Plastic Surgery Distinguished Service Professor Taoyuan City, Taiwan
Baylor College of Medicine Plastic Surgery
Houston, TX, USA Johns Hopkins University Giovanna Paternoster, MD
Baltimore, MD, USA Unité de chirurgie crânio-faciale du departement
Richard E. Kirschner, MD de neurochirurgie
Section Chief David W. Mathes, MD Hôpital Necker Enfants Malades
Plastic and Reconstructive Surgery Professor and Chief of the Division of Plastic Paris, France
Nationwide Children’s Hospital; and Reconstructive Surgery
Senior Vice Chair Surgery Division of Plastic and Reconstructive Jason Pomerantz, MD
Plastic Surgery Surgery Assistant Professor
The Ohio State University Medical College University of Colorado Surgery
Columbus, OH, USA Aurora, CO, USA University of California San Francisco;
Surgical Director
John C. Koshy, MD Frederick J. Menick, MD Craniofacial Center
Division of Plastic Surgery Private Practitioner University of California San Francisco
Baylor College of Medicine Tucson, AZ, USA San Francisco, CA, USA
Houston, TX, USA
Fernando Molina, MD Julian J. Pribaz, MD
Michael C. Large, MD Director Professor of Surgery
Urologic Oncologist Craniofacial Anomalies Foundation A.C. University of South Florida, Morsani College of
Urology of Indiana Mexico City; Medicine
Greenwood, IN, USA Professor of Plastic Reconstructive and Tampa General Hospital
Aesthetic Surgery Tampa, FL, USA
Edward I. Lee, MD Medical School
Division of Plastic Surgery Universidad La Salle Chad A. Purnell, MD
Baylor College of Medicine Mexico City, Distrito Federal, Mexico Division of Plastic Surgery
Houston, TX, USA Lurie Children’s Hospital of Northwestern
Laura A. Monson, MD Feinberg School of Medicine
Jamie P. Levine, MD Division of Plastic Surgery Chicago, IL, USA
Chief of Microsurgery Baylor College of Medicine
Associate Professor Houston, TX, USA Russell R. Reid, MD, PhD
Plastic Surgery Associate Professor
NYU Langone Medical Center Reid V. Mueller, MD Surgery/Section of Plastic and Reconstructive
New York, NY, USA Associate Professor Surgery
Plastic Surgery University of Chicago Medicine
Jingtao Li, DDS, PhD Oregon Health and Science University Chicago, IL, USA
Consultant Surgeon Portland, OR, USA
Oral and Maxillofacial Surgery Eduardo D. Rodriguez, MD, DDS
West China Hospital of Stomatology John B. Mulliken, MD Helen L. Kimmel Professor of Reconstructive
Chengdu, Sichuan, People’s Republic of China Professor Plastic Surgery
Department of Plastic and Oral Surgery Chair, Hansjörg Wyss Department of Plastic
Lawrence Lin, MD Boston Children’s Hospital Surgery
Division of Plastic Surgery Harvard Medical School NYU School of Medicine
Baylor College of Medicine Boston, MA, USA NYU Langone Medical Center
Houston, TX, USA New York, NY, USA
xxxii List of Contributors

Craig Rowin, MD Peter J. Taub, MD Ronald M. Zuker, MD, FRCSC, FACS,

Craniofacial Fellow Professor FRCSEd(Hon)
Plastic Surgery Surgery Pediatrics Dentistry and Medical Professor of Surgery
Nicklaus Children’s Hospital Education Department of Surgery
Miami, FL, USA Surgery Division of Plastic and Reconstructive University of Toronto;
Surgery Staff Plastic and Reconstructive Surgeon
Ruston J. Sanchez, MD Icahn School of Medicine at Mount Sinai Department of Surgery
Plastic and Reconstructive Surgery Resident New York, NY, USA SickKids Hospital
University of Wisconsin Toronto, Ontario, Canada
Madison, WI, USA Jesse A. Taylor, MD
Mary Downs Endowed Chair of Pediatric
Lindsay A. Schuster, DMD, MS Craniofacial Treatment and Research; VOLUME FOUR
Director Cleft-Craniofacial Orthodontics Director, Penn Craniofacial Fellowship;
Pediatric Plastic Surgery Co-Director, CHOP Cleft Team Christopher E. Attinger, MD
Children’s Hospital of Pittsburgh of UMPC; Plastic, Reconstructive, and Craniofacial Surgery Professor, Interim Chairman
Clinical Assistant Professor of Plastic Surgery The University of Pennsylvania and Department of Plastic Surgery
Department of Plastic Surgery Children’s Hospital of Philadelphia Center for Wound Healing
University of Pittsburgh School of Medicine Philadelphia, PA, USA Medstar Georgetown University Hospital
Pittsburgh, PA, USA Washington, DC, USA
Kathryn S. Torok, MD
Jeremiah Un Chang See, MD Assistant Professor Lorenzo Borghese, MD
Plastic Surgeon Pediatric Rheumatology Plastic Surgeon
Department of Plastic and Reconstructive University of Pittsburgh Chief of International Missions
Surgery Pittsburgh, PA, USA Ospedale Pediatrico Bambino Gesù
Penang General Hospital Rome, Italy
Georgetown, Penang, Malaysia Ali Totonchi, MD
Assistant Professor Charles E. Butler, MD, FACS
Pradip R. Shetye, DDS, BDS, MDS Plastic Surgery Professor and Chairman
Assistant Professor (Orthodontics) Case Western Reserve University; Department of Plastic Surgery
Hansjörg Wyss Department of Plastic Surgery Medical Director Craniofacial Deformity Clinic Charles B. Barker Endowed Chair in Surgery
NYU Langone Medical Center Plastic Surgery The University of Texas M. D. Anderson Cancer
New York, NY, USA MetroHealth Medical Center Center
Cleveland, OH, USA Houston, TX, USA
Roman Skoracki, MD
Plastic Surgery Kris Wilson, MD David W. Chang, MD
The Ohio State University Division of Plastic Surgery Professor of Surgery
Columbus, OH, USA Baylor College of Medicine University of Chicago
Houston, TX, USA Chicago, IL, USA
Mark B. Slidell, MD, MPH
Assistant Professor of Surgery S. Anthony Wolfe, MD Karel Claes, MD
Department of Surgery Plastic Surgery Department of Plastic and Reconstructive
Section of Pediatric Surgery Miami Children’s Hospital Surgery
University of Chicago Medicine Biological Miami, FL, USA Ghent University Hospital
Sciences Ghent, Belgium
Chicago, IL, USA Akira Yamada, MD, PhD
Professor of Plastic Surgery Mark W. Clemens II, MD, FACS
Michael Sosin, MD World Craniofacial Foundation Associate Professor
Research Fellow Dallas, TX, USA; Plastic Surgery
Department of Plastic Surgery Institute of Clinical Assistant Professor MD Anderson Cancer Center,
Reconstructive Plastic Surgery Plastic Surgery Houston, TX, USA
NYU Langone Medical Center Case Western Reserve University
New York, NY, USA; Cleveland, OH, USA Shannon M. Colohan, MD, MSc
Research Fellow Assistant Professor of Surgery
Division of Plastic Reconstructive and Peirong Yu, MD University of Washington
Maxillofacial Surgery Professor Seattle, WA, USA
R Adams Cowley Shock Trauma Center Plastic Surgery
University of Maryland Medical Center M. D. Anderson Cancer Center; Peter G. Cordeiro, MD
Baltimore, MD, USA; Adjunct Professor Chief
Resident Plastic Surgery Plastic and Reconstructive Surgery
Department of Surgery Baylor College of Medicine Memorial Sloan Kettering Cancer Center
Medstar Georgetown University Hospital Houston, TX, USA New York, NY, USA
Washington, DC, USA
Salvatore D’Arpa, MD, PhD
Youssef Tahiri, MD, MSc, FRCSC, FAAP, Department of Plastic and Reconstructive
FACS Surgery
Associate Professor Ghent University Hospital
Pediatric Plastic & Craniofacial Surgery Ghent, Belgium
Cedars Sinai Medical Center
Los Angeles, CA, USA
 List of Contributors xxxiii

Michael V. DeFazio, MD Jeffrey E. Janis, MD, FACS Michele Masellis, MD

Department Plastic Surgery Professor of Plastic Surgery, Neurosurgery, Former Chief of Department of Plastic and
MedStar Georgetown University Hospital Neurology, and Surgery; Reconstructive Surgery and Burn Therapy
Washington, DC, USA Executive Vice Chairman, Department of Plastic Department of Plastic and Reconstructive
Surgery; Surgery and Burn Therapy - ARNAS Ospedale
A. Lee Dellon, MD, PhD Chief of Plastic Surgery, University Hospitals Civico e Benfratelli
Professor of Plastic Surgery Ohio State University Wexner Medical Center Palermo, Italy
Professor of Neurosurgery Columbus, OH, USA
Johns Hopkins University Stephen M. Milner, MB BS, BDS
Baltimore, MD, USA Leila Jazayeri, MD Professor of Plastic Surgery
Microsurgery Fellow Surgery
Sara R. Dickie, MD Plastic and Reconstructive Surgery Johns Hopkins School of Medicine
Clinical Associate of Surgery Memorial Sloan Kettering Cancer Center Baltimore, MD, USA
University of Chicago Hospitals New York, NY, USA
Pritzker School of Medicine Arash Momeni, MD
Chicago, IL, USA Grant M. Kleiber, MD Fellow, Reconstructive Microsurgery
Assistant Professor of Surgery Division of Plastic Surgery
Ivica Ducic, MD, PhD Division of Plastic and Reconstructive Surgery University of Pennsylvania Health System
Clinical Professor of Surgery Washington University School of Medicine Philadelphia, PA, USA
GWU Washington Nerve Institute St. Louis, MO, USA
McLean, VA, USA Stan Monstrey, MD, PhD
Stephen J. Kovach III, MD Department of Plastic and Reconstructive
Gregory A. Dumanian, MD Assistant Professor Surgery
Stuteville Professor of Surgery Division of Plastic Surgery Ghent University Hospital
Division of Plastic Surgery University of Pennsylvania Ghent, Belgium
Northwestern Feinberg School of Medicine Philadelphia, PA, USA
Chicago, IL, USA Venkateshwaran N, MBBS, MS, DNB, MCh,
Robert Kwon, MD MRCS(Intercollegiate)
John M. Felder III, MD Southwest Hand and Microsurgery Consultant Plastic Surgeon
Fellow in Hand Surgery 3108 Midway Road, Suite 103 Jupiter Hospital
Plastic Surgery Plano, TX, USA Thane, India
Washington University in Saint Louis
St. Louis, MO, USA Raphael C. Lee, MS, MD, ScD, FACS, Rajiv P. Parikh, MD, MPHS
FAIMBE Resident Physician
Goetz A. Giessler, MD, PhD Paul and Allene Russell Professor Department of Surgery, Division of Plastic and
Professor Director Plastic Surgery, Dermatology, Anatomy and Reconstructive Surgery
Plastic-Reconstructive, Aesthetic and Hand Organismal Biology, Molecular Medicine Washington University School of Medicine
Surgery University of Chicago St. Louis, MO, USA
Gesundheit Nordhessen Chicago, IL, USA
Kassel, Germany Mônica Sarto Piccolo, MD, MSc, PhD
L. Scott Levin, MD, FACS Director
Kevin D. Han, MD Chairman of Orthopedic Surgery Pronto Socorro para Queimaduras
Department of Plastic Surgery Department of Orthopaedic Surgery Goiânia, Goiás, Brazil
MedStar Georgetown University Hospital University of Pennsylvania School of Medicine
Washington, DC, USA Philadelphia, PA, USA Nelson Sarto Piccolo, MD
Chief
Piet Hoebeke Otway Louie, MD Division of Plastic Surgery
Department of Urology Associate Professor Pronto Socorro para Queimaduras
Ghent University Hospital Surgery Goiânia, Goiás, Brazil
Ghent, Belgium University of Washington Medical Center
Seattle, WA, USA Maria Thereza Sarto Piccolo, MD, PhD
Joon Pio Hong, MD, PhD, MMM Scientific Director
Professor of Plastic Surgery Nicolas Lumen, MD, PhD Pronto Socorro para Queimaduras
Asan Medical Center, University of Ulsan Head of Clinic Goiânia, Goiás, Brazil
Seoul, South Korea Urology
Ghent University Hospital Vinita Puri, MS, MCh
Michael A. Howard, MD Ghent, Belgium Professor and Head
Clinical Assistant Professor of Surgery Department of Plastic, Reconstructive Surgery
Plastic Surgery Alessandro Masellis, MD and Burns
NorthShore University HealthSystem/University Plastic Surgeon Seth G S Medical College and KEM Hospital
of Chicago Euro-Mediterranean Council for Burns and Fire Mumbai, Maharashtra, India
Chicago, IL, USA Disasters
Palermo, Italy Andrea L. Pusic, MD, MHS, FACS
Associate Professor
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, NY, USA
xxxiv List of Contributors

Vinay Rawlani, MD VOLUME FIVE Robert Cohen MD, FACS

Division of Plastic Surgery Medical Director
Northwestern Feinberg School of Medicine Jamil Ahmad, MD, FRCSC Plastic Surgery
Chicago, IL, USA Director of Research and Education Scottsdale Center for Plastic Surgery
The Plastic Surgery Clinic Paradise Valley, AZ and;
Juan L. Rendon, MD, PhD Mississauga, Ontario, Canada; Santa Monica, CA, USA
Clinical Instructor Housestaff Assistant Professor of Surgery
Department of Plastic Surgery University of Toronto Amy S. Colwell, MD
The Ohio State University Wexner Medical Toronto, Ontario, Canada Associate Professor
Center Harvard Medical School
Columbus, OH, USA Robert J. Allen Sr., MD Massachusetts General Hospital
Clinical Professor of Plastic Surgery Boston, MA, USA
Michelle C. Roughton, MD Department of Plastic Surgery
Assistant Professor New York University Medical Center Edward H. Davidson, MA(Cantab), MB, BS
Division of Plastic and Reconstructive Surgery Charleston, NC, USA Resident Plastic Surgeon
University of North Carolina at Chapel Hill Department of Plastic Surgery
Chapel Hill, NC, USA Ryan E. Austin, MD, FRCSC University of Pittsburgh Medical Center
Plastic Surgeon Pittsburgh, PA, USA
Hakim K. Said, MD, FACS The Plastic Surgery Clinic
Associate Professor Mississauga, ON, Canada Emmanuel Delay, MD, PhD
Division of Plastic surgery Unité de Chirurgie Plastique et Reconstructrice
University of Washington Brett Beber, BA, MD, FRCSC Centre Léon Bérard
Seattle, WA, USA Plastic and Reconstructive Surgeon Lyon, France
Lecturer, Department of Surgery
Michel Saint-Cyr, MD, FRSC(C) University of Toronto Francesco M. Egro, MB ChB, MSc, MRCS
Professor Toronto, Ontario, Canada Department of Plastic Surgery
Plastic Surgery University of Pittsburgh Medical Center
Mayo Clinic Philip N. Blondeel, MD Pittsburgh, PA, USA
Rochester, MN, USA Professor of Plastic Surgery
Department of Plastic Surgery Neil A. Fine, MD
Michael Sauerbier, MD, PhD University Hospital Ghent President
Professor, Chair Ghent, Belgium Northwestern Specialists in Plastic Surgery;
Department for Plastic, Hand, and Associate Professor (Clinical) Surgery/Plastics
Reconstructive Surgery Benjamin J. Brown, MD Northwestern University Fienberg School of
Academic Hospital Goethe University Frankfurt Gulf Coast Plastic Surgery Medicine
am Main Pensacola, FL, USA Chicago, IL, USA
Frankfurt am Main, Germany
Mitchell H. Brown, MD, MEd, FRCSC Jaime Flores, MD
Loren S. Schechter, MD Plastic and Reconstructive Surgeon Plastic and Reconstructive Microvascular
Associate Professor and Chief Associate Professor, Department of Surgery Surgeon
Division of Plastic Surgery University of Toronto Miami, FL, USA
Chicago Medical School Toronto, Ontario, Canada
Morton Grove, IL, USA Joshua Fosnot, MD
M. Bradley Calobrace, MD, FACS Assistant Professor of Surgery
David H. Song, MD, MBA, FACS Plastic Surgeon Division of Plastic Surgery
Regional Chief, MedStar Health Calobrace and Mizuguchi Plastic Surgery Center The Perelman School of Medicine
Plastic and Reconstructive Surgery Departments of Surgery, Divisions of Plastic University of Pennsylvania Health System
Professor and Chairman Surgery Philadelphia, PA, USA
Department of Plastic Surgery Clinical Faculty, University of Louisville and
Georgetown University School of Medicine University of Kentucky Allen Gabriel, MD
Washington, DC, USA Louisville, KY, USA Clinical Associate Professor
Department of Plastic Surgery
Yoo Joon Sur, MD, PhD Grant W. Carlson, MD Loma Linda University Medical Center
Associate Professor Wadley R. Glenn Professor of Surgery Loma Linda, CA, USA
Department of Orthopedic Surgery Emory University
The Catholic University of Korea, College of Atlanta, GA, USA Michael S. Gart, MD
Medicine Resident Physician
Seoul, Korea Bernard W. Chang, MD Division of Plastic Surgery
Chief of Plastic and Reconstructive Surgery Northwestern University Feinberg School of
Chad M. Teven, MD Mercy Medical Center Medicine
Resident Baltimore, MD, USA Chicago, IL, USA
Section of Plastic and Reconstructive Surgery
University of Chicago Mark W. Clemens II, MD, FACS Matthew D. Goodwin, MD
Chicago, IL, USA Assistant Professor Plastic Surgery Plastic Surgeon
M. D. Anderson Cancer Center Plastic Reconstructive and Cosmetic Surgery
Houston, TX, USA Boca Raton Regional Hospital
Boca Raton, FL, USA
 List of Contributors xxxv

Samia Guerid, MD Albert Losken, MD, FACS Maria E. Nelson, MD

Cabinet Professor of plastic surgery and Program Assistant Professor of Clinical Surgery
50 rue de la République Director Department of Surgery, Division of Upper GI/
Lyon, France Emory Division of Plastic and Reconstructive General Surgery, Section of Surgical Oncology
Surgery Keck School of Medicine
Moustapha Hamdi, MD, PhD Emory University School of Medicine University of Southern California
Professor of Plastic and Reconstructive Surgery Atlanta, GA, USA Los Angeles, CA, USA
Brussels University Hospital
Vrij Universitaire Brussels Charles M. Malata, BSc(HB), MB ChB, Julie Park, MD
Brussels, Belgium LRCP, MRCS, FRCS(Glasg), FRCS(Plast) Associate Professor of Surgery
Professor of Academic Plastic Surgery Section of Plastic Surgery
Alexandra M. Hart, MD Postgraduate Medical Institute University of Chicago
Emory Division of Plastic and Reconstructive Faculty of Health Sciences Chicago, IL, USA
Surgery Anglia Ruskin University
Emory University School of Medicine Cambridge and Chelmsford, UK; Ketan M. Patel, MD
Atlanta, GA, USA Consultant Plastic and Reconstructive Surgeon Assistant Professor of Surgery
Department of Plastic and Reconstructive Division of Plastic and Reconstructive Surgery
Emily C. Hartmann, MD, MS Surgery Keck Medical Center of USC
Aesthetic Surgery Fellow Cambridge Breast Unit at Addenbrooke’s University of Southern California
Plastic and Reconstructive Surgery Hospital Los Angeles, CA, USA
University of Southern California Cambridge University Hospitals NHS
Los Angeles, CA, USA Foundation Trust Nakul Gamanlal Patel, BSc(Hons),
Cambridge, UK MBBS(Lond), FRCS(Plast)
Nima Khavanin, MD Senior Microsurgery Fellow
Resident Physician Jaume Masià, MD, PhD St. Andrew’s Centre for Plastic Surgery
Department of Plastic and Reconstructive Chief and Professor of Plastic Surgery Broomfield Hospital
Surgery Sant Pau University Hospital Chelmsford, UK
Johns Hopkins Hospital Barcelona, Spain
Baltimore, MD, USA Gemma Pons, MD, PhD
G. Patrick Maxwell, MD, FACS Head
John Y. S. Kim, MD Clinical Professor of Surgery Microsurgery Unit
Professor and Clinical Director Department of Plastic Surgery Plastic Surgery
Department of Surgery Loma Linda University Medical Center Hospital de Sant Pau
Division of Plastic Surgery Loma Linda, CA, USA Barcelona, Spain
Northwestern University Feinberg School of
Medicine James L. Mayo, MD Julian J. Pribaz, MD
Chicago, IL, USA Microsurgery Fellow Professor of Surgery
Plastic Surgery Brigham and Women’s Hospital
Steven Kronowitz, MD New York University Harvard Medical School
Owner, Kronowitz Plastics New York, NY, USA Boston, MA, USA
PLLC;
University of Texas, M. D. Anderson Medical Roberto N. Miranda, MD Venkat V. Ramakrishnan, MS, FRCS,
Center Professor FRACS(Plast Surg)
Houston, TX, USA Department of Hematopathology Consultant Plastic Surgeon
Division of Pathology and Laboratory Medicine St. Andrew’s Centre for Plastic Surgery
John V. Larson, MD MD Anderson Cancer Center Broomfield Hospital
Resident Physician Houston, TX, USA Chelmsford, UK
Division of Plastic and Reconstructive Surgery
Keck School of Medicine of USC Colin M. Morrison, MSc (Hons) FRCSI Elena Rodríguez-Bauzà, MD
University of Southern California (Plast) Plastic Surgery Department
Los Angeles, CA, USA Consultant Plastic Surgeon Hospital Santa Creu i Sant Pau
St. Vincent’s University Hospital Barcelona, Spain
Z-Hye Lee, MD Dublin, Ireland
Resident Michael R. Schwartz, MD
Department of Plastic Surgery Maurice Y. Nahabedian, MD, FACS Board Certified Plastic Surgeon
New York University Medical Center Professor and Chief Private Practice
New York, NY, USA Section of Plastic Surgery Westlake Village, CA, USA
MedStar Washington Hospital Center
Frank Lista, MD, FRCSC Washington DC, USA; Stephen F. Sener, MD
Medical Director Vice Chairman Professor of Surgery, Clinical Scholar
The Plastic Surgery Clinic Department of Plastic Surgery Chief of Breast, Endocrine, and Soft Tissue
Mississauga, Ontario, Canada; MedStar Georgetown University Hospital Surgery
Assistant Professor Surgery Washington DC, USA Department of Surgery, Keck School of
University of Toronto Medicine of USC
Toronto, Ontario, Canada James D. Namnoum, MD Chief of Surgery and Associate Medical Director
Clinical Professor of Plastic Surgery Perioperative Services
Atlanta Plastic Surgery LAC+USC (LA County) Hospital
Emory University School of Medicine Los Angeles, CA, USA
Atlanta, GA, USA
xxxvi List of Contributors

Joseph M. Serletti, MD, FACS Henry Wilson, MD, FACS Lesley Butler, MPH
The Henry Royster–William Maul Measey Attending Plastic Surgeon Clinical Research Coordinator
Professor of Surgery and Chief Private Practice Charles E. Seay, Jr. Hand Center
Division of Plastic Surgery Plastic Surgery Associates Texas Scottish Rite Hospital for Children
University of Pennsylvania Health System Lynchburg, VA, USA Dallas, TX, USA
Philadelphia, PA, USA
Kai Yuen Wong, MA, MB BChir, MRCS, Ryan P. Calfee, MD
Deana S. Shenaq, MD FHEA, FRSPH Associate Professor
Chief Resident Specialist Registrar in Plastic Surgery Department of Orthopedic Surgery
Department of Surgery - Plastic Surgery Department of Plastic and Reconstructive Washington University School of Medicine
The University of Chicago Hospitals Surgery St. Louis, MO, USA
Chicago, IL, USA Cambridge University Hospitals NHS
Foundation Trust Brian T. Carlsen, MD
Kenneth C. Shestak, MD Cambridge, UK Associate Professor
Professor, Department of Plastic Surgery Departments of Plastic Surgery and Orthopedic
University of Pittsburgh Medical Center Surgery
Pittsburgh, PA, USA VOLUME SIX Mayo Clinic
Rochester, MN, USA
Ron B. Somogyi, MD MSc FRCSC Hee Chang Ahn, MD, PhD
Plastic and Reconstructive Surgeon Professor David W. Chang, MD
Assistant Professor, Department of Surgery Department of Plastic and Reconstructive Professor
University of Toronto Surgery Division of Plastic and Reconstructive Surgery
Toronto, ON, Canada Hanyang University Hospital School of Medicine The University of Chicago Medicine
Seoul, South Korea Chicago, IL, USA
David H. Song, MD, MBA, FACS
Regional Chief, MedStar Health Nidal F. Al Deek, MD James Chang, MD
Plastic and Reconstructive Surgery Surgeon Johnson & Johnson Distinguished Professor
Professor and Chairman Plastic and Reconstructive Surgery and Chief
Department of Plastic Surgery Chang Gung Memorial Hospital Division of Plastic and Reconstructive Surgery
Georgetown University School of Medicine Taipei, Taiwan Stanford University Medical Center
Washington, DC, USA Stanford, CA, USA
Kodi K. Azari, MD, FACS
The late Scott L. Spear†, MD Reconstructive Transplantation Section Chief Robert A. Chase, MD
Formerly Professor of Plastic Surgery Professor Holman Professor of Surgery – Emeritus
Division of Plastic Surgery Department of Orthopedic Surgery Stanford University Medical Center
Georgetown University UCLA Medical Center Stanford, CA, USA
Washington, MD, USA Santa Monica, CA, USA
Alphonsus K. S. Chong, MBBS, MRCS,
Michelle A. Spring, MD, FACS Carla Baldrighi, MD MMed(Orth), FAMS (Hand Surg)
Program Director Staff Surgeon Senior Consultant
Glacier View Plastic Surgery Pediatric Surgery Meyer Children’s Hospital Department of Hand and Reconstructive
Kalispell Regional Medical Center Pediatric Hand and Reconstructive Microsurgery Microsurgery
Kalispell, MT, USA Unit National University Health System
Azienda Ospedaliera Universitaria Careggi Singapore;
W. Grant Stevens, MD, FACS Florence, Italy Assistant Professor
Clinical Professor of Surgery Department of Orthopedic Surgery
Marina Plastic Surgery Associates; Gregory H. Borschel, MD, FAAP, FACS Yong Loo Lin School of Medicine
Keck School of Medicine of USC Assistant Professor National University of Singapore
Los Angeles, CA, USA University of Toronto Division of Plastic and Singapore
Reconstructive Surgery;
Elizabeth Stirling Craig, MD Assistant Professor David Chwei-Chin Chuang, MD
Plastic Surgeon and Assistant Professor Institute of Biomaterials and Biomedical Senior Consultant, Ex-President, Professor
Department of Plastic Surgery Engineering; Department of Plastic Surgery
University of Texas Associate Scientist Chang Gung University Hospital
MD Anderson Cancer Center The SickKids Research Institute Tao-Yuan, Taiwan
Houston, TX, USA The Hospital for Sick Children
Toronto, Ontario, Canada Kevin C. Chung, MD, MS
Simon G. Talbot, MD Chief of Hand Surgery
Assistant Professor of Surgery Kirsty Usher Boyd, MD, FRCSC Michigan Medicine
Brigham and Women’s Hospital Assistant Professor Charles B G De Nancrede Professor, Assistant
Harvard Medical School Division of Plastic Surgery, University of Ottawa Dean for Faculty Affairs
Boston, MA, USA Ottawa, Ontario, Canada University of Michigan Medical School
Ann Arbor, Michigan, USA
Jana Van Thielen, MD Gerald Brandacher, MD
Plastic Surgery Department Scientific Director Christopher Cox, MD
Brussels University Hospital Department of Plastic and Reconstructive Attending Surgeon
Vrij Universitaire Brussel (VUB) Surgery Kaiser Permanente
Brussels, Belgium Johns Hopkins University School of Medicine Walnut Creek, CA, USA
Baltimore, MD, USA
 List of Contributors xxxvii

Catherine Curtin, MD Elisabet Hagert, MD, PhD Ryosuke Kakinoki, MD, PhD
Associate Professor Associate Professor Professor of Hand Surgery and Microsurgery,
Department of Surgery Division of Plastic Department of Clinical Science and Education Reconstructive, and Orthopedic Surgery
Surgery Karolinska Institute; Department of Orthopedic Surgery
Stanford University Chief Hand Surgeon Faculty of Medicine
Stanford, CA, USA Hand Foot Surgery Center Kindai University
Stockholm, Sweden Osakasayama, Osaka, Japan
Lars B. Dahlin, MD, PhD
Professor and Consultant Warren C. Hammert, MD Jason R. Kang, MD
Department of Clinical Sciences, Malmö – Hand Professor of Orthopedic and Plastic Surgery Chief Resident
Surgery Chief, Division of Hand Surgery Department of Orthopedic Surgery
University of Lund Department of Orthopedics and Rehabilitation Stanford Hospital & Clinics
Malmö, Sweden University of Rochester Redwood City, CA, USA
Rochester, NY, USA
Kenneth W. Donohue, MD Joseph S. Khouri, MD
Hand Surgery Fellow Isaac Harvey, MD Resident
Division of Plastic Surgery Clinical Fellow Division of Plastic Surgery, Department of
Department of Orthopedic Surgery Department of Pediatric Plastic and Surgery
Baylor College of Medicine Reconstructive Surgery University of Rochester
Houston, TX, USA Hospital for SickKids Rochester, NY, USA
Toronto, Ontario, Canada
Gregory A. Dumanian, MD, FACS Todd Kuiken, MD, PhD
Stuteville Professor of Surgery Vincent R. Hentz, MD Professor
Division of Plastic Surgery Emeritus Professor of Surgery and Orthopedic Departments of PM&R, BME, and Surgery
Northwestern Feinberg School of Medicine Surgery (by courtesy) Northwestern University;
Chicago, IL, USA Stanford University Director, Neural Engineering Center for Artificial
Stanford, CA, USA Limbs
William W. Dzwierzynski, MD Rehabilitation Institute of Chicago
Professor and Program Director Jonay Hill, MD Chicago, IL, USA
Department of Plastic Surgery Clinical Assistant Professor
Medical College of Wisconsin Anesthesiology, Perioperative and Pain Medicine Donald Lalonde, BSC, MD, MSc, FRCSC
Milwaukee, WI, USA Stanford University School of Medicine Professor of Surgery
Stanford, CA, USA Division of Plastic and Reconstructive Surgery
Simon Farnebo, MD, PhD Saint John Campus of Dalhousie University
Associate Professor and Consultant Hand Steven E. R. Hovius, MD, PhD Saint John, New Brunswick, Canada
Surgeon Former Head, Department of Plastic,
Department of Plastic Surgery, Hand Surgery Reconstructive and Hand Surgery W. P. Andrew Lee, MD
and Burns Erasmus MC The Milton T. Edgerton MD, Professor and
Institution of Clinical and Experimental University Medical Center Chairman
Medicine, University of Linköping Rotterdam, the Netherlands; Department of Plastic and Reconstructive
Linköping, Sweden Xpert Clinic, Hand and Wrist Center Surgery
The Netherlands Johns Hopkins University School of Medicine
Ida K. Fox, MD Baltimore, MD, USA
Assistant Professor of Plastic Surgery Jerry I. Huang, MD
Department of Surgery Associate Professor Anais Legrand, MD
Division of Plastic and Reconstructive Surgery Department of Orthopedics and Sports Postdoctoral Research Fellow
Washington University School of Medicine Medicine Plastic and Reconstructive Surgery
St. Louis, MO, USA University of Washington; Stanford University Medical Center
Program Director Stanford, CA, USA
Paige M. Fox, MD, PhD University of Washington Hand Fellowship
Assistant Professor University of Washington Terry Light, MD
Department of Surgery, Division of Plastic and Seattle, WA, USA Professor
Reconstructive Surgery Department of Orthopedic Surgery
Stanford University Medical Center Marco Innocenti, MD Loyola University Medical Center
Stanford, CA, USA Associate Professor of Plastic Surgery, Maywood, IL, USA
University of Florence;
Jeffrey B. Friedrich, MD Director, Reconstructive Microsurgery Jin Xi Lim, MBBS, MRCS
Professor of Surgery and Orthopedics Department of Oncology Senior Resident
Department of Surgery, Division of Plastic Careggi University Hospital Department of Hand and Reconstructive
Surgery Florence, Italy Microsurgery
University of Washington National University Health System
Seattle, WA, USA Neil F. Jones, MD, FRCS Singapore
Professor and Chief of Hand Surgery
Steven C. Haase, MD, FACS University of California Medical Center; Joseph Lopez, MD, MBA
Associate Professor Professor of Orthopedic Surgery; Resident, Plastic and Reconstructive Surgery
Department of Surgery, Section of Plastic Professor of Plastic and Reconstructive Surgery Department of Plastic and Reconstructive
Surgery University of California Irvine Surgery
University of Michigan Health Irvine, CA, USA Johns Hopkins University School of Medicine
Ann Arbor, MI, USA Baltimore, MD, USA
xxxviii List of Contributors

Susan E. Mackinnon, MD Christine B. Novak, PT, PhD Douglas M. Sammer, MD

Sydney M. Shoenberg, Jr. and Robert H. Associate Professor Associate Professor of Plastic and Orthopedic
Shoenberg Professor Department of Surgery, Division of Plastic and Surgery
Department of Surgery, Division of Plastic and Reconstructive Surgery Chief of Plastic Surgery at Parkland Memorial
Reconstructive Surgery University of Toronto Hospital
Washington University School of Medicine Toronto, Ontario, Canada Program Director Hand Surgery Fellowship
St. Louis, MO, USA University of Texas Southwestern Medical Center
Scott Oates, MD Dallas, TX, USA
Brian Mailey, MD Deputy Department Chair;
Assistant Professor of Surgery Professor Subhro K. Sen, MD
Institute for Plastic Surgery Department of Plastic Surgery, Division of Clinical Associate Professor
Southern Illinois University Surgery Plastic and Reconstructive Surgery
Springfield, IL, USA The University of Texas MD Anderson Cancer Robert A. Chase Hand and Upper Limb Center
Center Stanford University School of Medicine
Steven J. McCabe, MD, MSc, FRCS(C) Houston, TX, USA Stanford, CA, USA
Director of Hand and Upper Extremity Program
University of Toronto Kerby Oberg, MD, PhD Pundrique R. Sharma, MBBS, PhD and
Toronto Western Hospital Associate Professor FRCS (Plast)
Toronto, Ontario, Canada Department of Pathology and Human Anatomy Consultant Plastic Surgeon
Loma Linda University School of Medicine Department for Plastic and Reconstructive
Kai Megerle, MD, PhD Loma Linda, CA, USA Surgery
Assistant Professor Alder Hey Children’s Hospital
Clinic for Plastic Surgery and Hand Surgery Scott Oishi, MD Liverpool, UK
Technical University of Munich Director, Charles E. Seay, Jr. Hand Center
Munich, Germany Texas Scottish Rite Hospital for Children; Randolph Sherman, MD, FACS
Professor, Department of Plastic Surgery and Vice Chair
Amy M. Moore, MD Department of Orthopedic Surgery Department of Surgery
Assistant Professor of Surgery University of Texas Southwestern Medical Center Cedars-Sinai Medical Center
Division of Plastic and Reconstructive Surgery Dallas, TX, USA Los Angeles, CA, USA
Department of Surgery
Washington University School of Medicine William C. Pederson, MD, FACS Jaimie T. Shores, MD
St. Louis, MO, USA President and Fellowship Director Clinical Director, Hand/Arm Transplant Program
The Hand Center of San Antonio; Department of Plastic and Reconstructive
Steven L. Moran, MD Adjunct Professor of Surgery Surgery
Professor and Chair of Plastic Surgery The University of Texas Health Science Center at Johns Hopkins University School of Medicine
Division of Plastic Surgery, Division of Hand and San Antonio Baltimore, MD, USA
Microsurgery; San Antonio, TX, USA
Professor of Orthopedics Vanila M. Singh, MD, MACM
Rochester, MN, USA Dang T. Pham, MD Clinical Associate Professor
General Surgery Resident Anesthesiology, Perioperative and Pain Medicine
Rebecca L. Neiduski, PhD, OTR/L, CHT Department of Surgery Stanford University School of Medicine
Dean of the School of Health Sciences Houston Methodist Hospital Stanford, CA, USA
Professor of Health Sciences Houston, TX, USA
Elon University Jason M. Souza, MD, LCDR, MC, USN
Elon, NC, USA Karl-Josef Prommersberger, MD, PhD Staff Plastic Surgeon, United States Navy
Chair, Professor of Orthopedic Surgery Walter Reed National Military Medical Center
David T. Netscher, MD Clinic for Hand Surgery Bethesda, MD, USA
Program Director, Hand Surgery Fellowship; Bad Neustadt/Saale, Germany
Clinical Professor, Division of Plastic Surgery Amir Taghinia, MD, MPH
and Department of Orthopedic Surgery Carina Reinholdt, MD, PhD Attending Surgeon
Baylor College of Medicine; Senior Consultant in Hand Surgery Department of Plastic and Oral Surgery
Adjunct Professor of Clinical Surgery (Plastic Center for Advanced Reconstruction of Boston Children’s Hospital;
Surgery) Extremities Assistant Professor of Surgery
Weill Medical College Sahlgrenska University Hospital/ Mölndal Harvard Medical School
Cornell University Mölndal, Sweden; Boston, MA, USA
Houston, TX, USA Assistant Professor
Department of Orthopedics David M. K. Tan, MBBS
Michael W. Neumeister, MD Institute for Clinical Sciences Senior Consultant
Professor and Chairman Sahlgrenska Academy Department of Hand and Reconstructive
Division of Plastic Surgery Goteborg, Sweden Microsurgery
Springfield Illinois University School of Medicine National University Health System
Springfield, IL, USA Justin M. Sacks, MD, MBA, FACS Singapore;
Director, Oncological Reconstruction; Assistant Professor
Shelley Noland, MD Assistant Professor Department of Orthopedic Surgery
Assistant Professor Department of Plastic and Reconstructive Yong Loo Lin School of Medicine
Division of Plastic Surgery Surgery National University Singapore
Mayo Clinic Arizona Johns Hopkins School of Medicine Singapore
Phoenix, AZ, USA Baltimore, MD, USA

Jin Bo Tang, MD
Professor and Chair
Department of Hand Surgery;
Chair, The Hand Surgery Research Center
Affiliated Hospital of Nantong University
Nantong, The People’s Republic of China
Johan Thorfinn, MD, PhD
Senior Consultant of Plastic Surgery, Burn Unit;
Co-Director
Department of Plastic Surgery, Hand Surgery
and Burns
Linköping University Hospital
Linköping, Sweden
Michael Tonkin, MBBS, MD, FRACS(Orth),
FRCS(Ed Orth)
Professor of Hand Surgery
Department of Hand Surgery and Peripheral
Nerve Surgery
Royal North Shore Hospital
The Children’s Hospital at Westmead
University of Sydney Medical School
Sydney, New South Wales, Australia
Joseph Upton III, MD
Staff Surgeon
Department of Plastic and Oral Surgery
Boston Children’s Hospital;
Professor of Surgery
Harvard Medical School
Boston, MA, USA
List of Contributors xxxix
Francisco Valero-Cuevas, PhD Fu-Chan Wei, MD
Director Professor
Brain-Body Dynamics Laboratory; Department of Plastic Surgery
Professor of Biomedical Engineering; Chang Gung Memorial Hospital
Professor of Biokinesiology and Physical Taoyuan, Taiwan
Therapy;
(By courtesy) Professor of Computer Science Julie Colantoni Woodside, MD
and Aerospace and Mechanical Engineering Orthopedic Surgeon
The University of Southern California OrthoCarolina
Los Angeles, CA, USA Gastonia, NC, USA
Christianne A. van Nieuwenhoven, MD, PhD Jeffrey Yao, MD
Plastic Surgeon/Hand Surgeon Associate Professor
Plastic and Reconstructive Surgery Department of Orthopedic Surgery
Erasmus Medical Centre Stanford Hospital & Clinics
Rotterdam, the Netherlands Redwood City, CA, USA
Nicholas B. Vedder, MD
Professor of Surgery and Orthopedics
Chief of Plastic Surgery Vice Chair
Department of Surgery
University of Washington
Seattle, WA, USA
Andrew J. Watt, MD
Attending Hand and Microvascular Surgeon;
Associate Program Director, Buncke Clinic Hand
and Microsurgery Fellowship;
Adjunct Clinical Faculty, Stanford University
Division of Plastic and Reconstructive Surgery
The Buncke Clinic
San Francisco, CA, USA
 Acknowledgments
My wife, Gabrielle Kane, has always been my rock. She not
only encourages me in my work but gives constructive criti-
cism bolstered by her medical expertise as well as by her
knowledge and training in education. I can never repay her.
The editorial team at Elsevier have made this series possible.
Belinda Kuhn leads the group of Alexandra Mortimer, Louise
Cook, and the newest addition to the team, Sam Crowe. The
Elsevier production team has also been vital in moving this
project along. The volume editors, Geoff Gurtner, Peter Rubin,
Ed Rodriguez, Joe Losee, David Song, Mo Nahabedian, Jim
Chang, and Dan Liu have shaped and refined this edition,
making vital changes to keep the series relevant and up-to-
date. My colleagues in the University of Washington, headed
by Nick Vedder, have provided continued encouragement
and support. Finally, and most importantly, the residents and
fellows who pass through our program keep us on our toes
and ensure that we give them the best possible solutions to
their questions.
Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
Driven by constant innovation, the field of head, neck, and
craniofacial surgery has truly evolved and made notewor-
thy advances over the last several decades. The diverse
expertise of the renowned contributors has provided the
latest clinical evidence and surgical techniques to facilitate
the decision-making process, which ultimately impacts the
outcomes of patients with conditions involving congenital,
oncologic, traumatic, and acquired deformities. This volume
is a comprehensive resource for specialists of all levels. It
has been a true privilege to work with such a distinguished
faculty willing to share their vast experience and insights
in their respective fields. It is with great admiration that I
sincerely thank the contributors for their generous donation
of time, commitment to excellence, dedication to education,
and advancement of the field.
Eduardo D. Rodriguez, MD, DDS
This volume represents the expertise of the current leaders
within pediatric plastic surgery; and I am grateful for their
dedication and efforts in making this “labor of love” a reality
and the standard within the field. This work is dedicated to
my families – at work and at home – and serves as a living
example of work–life integration for me. “Thank you” to my
work family – my colleagues, staff, patients and their families;
and, to my home family – Franklyn P. Cladis, MD and our son
Hudson. You all have and continue to provide significant
meaning to my life.
Joseph E. Losee, MD, FACS, FAAP
Dedicated to future plastic surgeons. Take up the torch
and lead us forward!
 1
Anatomy of the head and neck
Ahmed M. Afifi, Ruston J. Sanchez and Risal S. Djohan
SYNOPSIS
■ The superficial fascial layer of the face and neck is formed by the
superficial cervical fascia (enclosing the platysma), the superficial
facial fascia (synonymous with the superficial musculo-aponeurotic
system (SMAS)), the superficial temporal fascia (often called the
temporoparietal fascia), and the galea.
■ The deep fascial layer of the face and neck is formed by the deep
cervical fascia (or the general investing fascia of the neck), the deep
facial fascia (also known as the parotideomasseteric fascia), and the
deep temporal fascia. The deep temporal fascia is continuous with the
periosteum of the skull.
■ The deep temporal fascia splits into two layers at the level of the
superior orbital rim. The two layers insert into the superficial and deep
surfaces of the zygomatic arch.
■ The facial nerve is initially deep to the deep fascia, eventually
penetrating it towards the superficial fascia. The fat and connective
tissue filling the space between the superficial temporal fascia and the
superficial layer of the deep temporal fascia is a subject of significant
debate. Its importance stems from the temporal branch of the facial
nerve crossing from deep to superficial in this layer.
■ Most surgeons believe that it is the superficial temporal fat pad that
fills this space. Others believe there is a distinct fascial layer in this
region, named the parotideomasseteric fascia.
■ The facial nerve is at significant risk of injury in the area right above
the zygomatic arch.
■ Pitanguy’s line describes the course of the largest branch of the
temporal division of the facial nerve.
■ The marginal mandibular nerve can be located above or below the
level of the mandible. It is usually located between the platysma and
the deep cervical fascia and is always superficial to the facial vessels.
■ There are multiple fat pads in the face. They can be superficial to the
SMAS, between the SMAS and the deep fascia, or deep to the deep fascia.
■ Knowledge of the sensory nerves is important, especially within the
context of evaluating and treating migraine headaches.
Aesthetic and reconstructive surgery of the head and neck
depends on appreciating the three-dimensional anatomy and
the functional and cosmetic methods of rearranging the dif-
ferent structures. This chapter is not intended to be a detailed
description of the head and neck anatomy, which is beyond
such a limited space. It rather offers a different perspective on
the anatomy that is more relevant to the plastic surgeon and
highlights certain anatomical regions that have fundamental
importance or are more controversial.
The fascial planes of the head and
neck and the facial nerve
A peculiar feature of the anatomy of the head and neck is the
concentric arrangement of the facial soft tissues in layers.
These layers have different names and characteristics from
one area of the head and neck to the other, but they maintain
their continuity across boundaries (Fig. 1.1). Unfortunately,
inconsistent nomenclature has been used to describe these
layers leading to significant confusion among readers. The
facial nerve usually passes in defined planes in between these
layers, crossing from one layer to the other only in specific
well-described zones. Knowledge of these planes and their
relation to the facial nerve is vital if plastic surgeons are to
safely access the soft tissues and bony structures of the head
and neck.1,2 In the following discussion, we will not only
describe the anatomy and nomenclature of these layers as
mostly agreed upon, but also try to elucidate the sources of
deliberation and confusion in describing this crucial anatomy.3
The bordering regions of neck, cheek (lower face), temple,
and the scalp are arbitrarily divided by the lower border of
the mandible, the zygomatic arch, and the temporal line,
respectively. Topographically, there are two layers of fascia
covering the face, a superficial and deep, which cover these
regions and extend over other structures, such as the eyelid
and the nose (see Fig. 1.1).
The superficial layer of fascia is formed by the superficial
cervical fascia (platysma), the superficial facial fascia (SMAS),
the superficial temporal fascia (temporoparietal fascia), and
 The fascial planes of the head and neck and the facial nerve 3

Galea

Skin
Periosteum
Subcutaneous Temporal bone
fat

Temporalis
Superficial temporal
(temporoparietal) fascia

Deep temporal fascia

Zygomatic
arch

Coronoid
process
Deep facial fascia

Parotid gland

Superficial facial fascia, Deep

enclosing mimetic cervical fascia
muscles of face (SMAS)
Mandible

Superficial cervical fascia

(enclosing platysma) Fig. 1.1 The facial layers of the scalp, face, and neck.

the galea aponeurotica (Figs. 1.1 & 1.2). To be more precise,
this superficial fascia splits to enclose many of the facial
muscles. This is a consistent pattern seen all over the head and
neck region; e.g., the superficial cervical fascia splits into a
deep and superficial layer to enclose the platysma, the super-
ficial facial fascia splits to enclose the midfacial muscles, and
the galea splits to enclose the frontalis. The two layers of the
superficial fascia then rejoin at the other end of the muscle,
before splitting again to enclose the next muscle and so on.
The deep layer of fascia is formed by the deep cervical fascia,
the deep facial fascia (parotideomasseteric fascia), the deep
temporal fascia, and the periosteum. This layer is superficial
to the muscles of mastication, the salivary glands and the
main neurovascular structures (see Figs. 1.1 & 1.2). Over bony
areas, such as the skull and the zygomatic arch, this deep
fascia is inseparable from the periosteum.
The facial fat pads are localized collections of fat present
deep to the superficial layer of fascia. These are anatomically
4 CHAPTER 1 • Anatomy of the head and neck
A
STF SMAS
Superficial layer reflected
Zygomatic
ligament
and nerve
C facial fascia (SMAS), and the superficial temporal fascia
The nerves penetrate the deep fascia towards their
innervation of the SMAS and platysma
and histologically distinct structures from the subcutaneous
fat present between the skin and the superficial fascia (which
will be discussed later). These fat pads include the superficial
temporal fat pad, the galeal fat pad, suborbicularis oculi fat
pad (SOOF), the retro-orbicularis oculi fat pad (ROOF), and
the preseptal fat of the eyelids. Deep to the deep fascia are
several other fat pads: the deep temporal fat pads, the buccal
fat pads, and the postseptal fat pads of the eyelids.4
The fascia in the face
The first layer the surgeon encounters in the face deep to
the skin and its associated subcutaneous fat is the SMAS
(superficial musculo-aponeurotic system) (see Figs. 1.1 &
1.2).5 The SMAS varies in thickness and composition between
individuals and from one area to another, and it can be fatty,
fibrous, or muscular.6 The muscles of facial expression, e.g.,
STF
B
SMAS Platysma
Platysma
Mandibular
ligament
and
buccal
nerve
Fig. 1.2 The different fascial layers of the face and neck.
(A) Dissection in the superficial plane, between the skin and the
superficial fascia. (B) Elevation of the superficial fascial layer,
formed of the superficial cervical fascia (platysma), the superficial
(temporoparietal fascia). (C) Note the proximity of the nerve (on
the blue background) to the zygomatic and mandibular ligaments
(at the tips of the left and right surgical instruments, respectively).
orbicularis oculi, oris, zygomaticus major and minor, frontalis,
and platysma, are enclosed by (or form part of) the SMAS.
The SMAS is often referred to as the superficial facial fascia.
In reality, the superficial facial fascia covers the superficial
and deep surfaces of the muscles. However, these layers are
hard to separate intraoperatively (except in certain areas such
as the neck). Dissection superficial to the superficial facial
fascia (just under the skin) will generally avoid injury to
the underlying facial nerve. However, such dissection can
compromise the blood supply of the overlying skin flaps.
Often, the surgeon can safely maintain this superficial fascia
in the lower face and neck (whether it is the platysma or
the SMAS) with the skin, allowing a secure double layer
closure and maintaining skin vascularity (e.g. during a neck
dissection). In the anterior (medial) face, the facial nerve
branches become more superficial just under or within the
SMAS layer.
 The fascial planes of the head and neck and the facial nerve
The next layer in the face is the deep facial fascia, which is
also known as the parotideomasseteric fascia (see Figs. 1.1 &
1.2). Over the parotid gland, this layer is adherent to the
capsule of the gland. The facial nerve is initially (i.e., right
after it exits the parotid gland) deep to the deep facial fascia.
Most of the muscles of facial expression are superficial to the
planes of the nerve. The nerve branches pierce the deep fascia
to innervate the muscles from their deep surface, with the
exception of the mentalis, levator anguli oris, and the buccina-
tors (see Fig. 1.2). These three muscles are deep to the facial
nerve and are thus innervated on their superficial surface.
The fascia in the temporal region
The cheek and lower face are separated from the temporal
region by the zygomatic arch. There are two layers of fascia
in the temporal region (below the skull temporal lines): the
superficial temporal fascia (also known as the temporoparietal
fascia (TPF)) and the deep temporal fascia (Figs. 1.3 & 1.4A).7–9
The deep temporal fascia lies on the superficial surface of the
temporalis muscle. Between the superficial and deep temporal
fascia is a loose areolar plane that is relatively avascular and
easily dissected. However, the frontal branch of the facial
nerve is within or directly beneath the superficial temporal
Subcutaneous fat
Deep temporal fascia
Hair
Superficial
temporal
Temporal bone
fascia
Frontal branch Temporalis
of facial nerve
Sentinel vein
Middle temporal fat pad
Zygomatic
arch
Ear
Coronoid process
of mandible
Facial nerve Masseter
Parotidomasseter
fascia
Skin
SMAS
Fig. 1.3 The facial layers of the temporal region. The fat/fascia in the
subaponeurotic plane (arrow; between the temporal fascia and deep temporal
fascia) is intimately related to the facial nerve. Some authors believe that there is a
separate fascial layer in this space, referred to as the parotideomasseteric fascia.
5
fascia (see Fig. 1.4A).5 Therefore, dissection in this plane
should be strictly on the deep temporal fascia, which can be
identified by its bright white color and sturdy texture. To
ensure that the surgeon is in the right plane, he or she can
attempt to grasp the areolar tissues over the deep temporal
fascia using an Adson forceps; if in the right plane, one will
not catch any tissue. Once deep enough and right on the deep
temporal fascia, dissection can proceed quickly using a peri-
osteal elevator hugging the tough deep temporal fascia
(Fig. 1.5).
In the region right above the zygomatic arch the space
between the superficial TPF and the deep temporal fascia
(sometimes referred to as the subaponeurotic space) and the
fat/fascia it contains is both a debatable and an important
subject (see Fig. 1.4). Its importance stems from the facial
nerve crossing this space from deep to superficial right above
the zygomatic arch. A third layer of fascia has been described
in this space (between the superficial and deep temporal
fascia) and is referred to as the parotidotemporal fascia, the
subgaleal fascia, or the innominate fascia.10,11 The term “fascial
layer” is used loosely, as there is no general consensus as to
how thick connective tissue must be before it can be consid-
ered a “fascial layer”. What some authors refer to as “loose
connective tissue” may be called a “fascial layer” or a “fat
pad” by others. Our own cadaver dissection showed that this
third fascial layer could often be identified. It extends for a
short distance above and below the arch. Directly superficial
to the arch, the facial nerve is deep to this layer, piercing it to
become more superficial 1–2 cm cephalad to the arch (see
below).
Above the zygomatic arch and at the same horizontal level
as the superior orbital rim, the deep temporal fascia splits into
two layers: the superficial layer of the deep temporal fascia
(sometimes referred to as the middle temporal fascia, inter-
mediate fascia, or the innominate fascia) and the deep layer
of the deep temporal fascia (see Fig. 1.3).7 The deep and
superficial layers of the deep temporal fascia attach to the
superficial and deep surfaces of the zygomatic arch. There are
three fat pads in this region.7,12 The superficial fat pad is
located between the superficial temporal fascia and superficial
layer of the deep temporal fascia and, as described above, is
analogous with the parotidotemporal fascia, subgaleal fascia,
and/or the loose connective tissue between the superficial
and deep temporal fascia. The middle fat pad is located
directly above the zygomatic arch between the superficial and
deep layers of the deep temporal fascia. Finally, the deep fat
pad (also known as the buccal fat pad) is deep to the deep
layer of the deep temporal fascia, superficial to the temporalis
muscles and extends deep to the zygomatic arch. It is consid-
ered an extension of the buccal fat pad.
Most of the controversy in describing the fascial layers in
the temporal region arises from confusing the superficial tem-
poral fascia with the superficial layer of the deep temporal fascia.
This is very significant since the facial nerve is deep to or
within the former and superficial to the latter. The second
point is the location of the deep temporal fascia superficial to
the temporalis muscle. There is another fascial layer on the
deep surface of the muscle; this is not the deep temporal fascia
and is of little significance from a surgical standpoint. The
final controversy is what exactly is the innominate fascia? This
term is often used to describe the superficial layer of the deep
temporal fascia above the arch. Other surgeons reserve the
 6 CHAPTER 1 • Anatomy of the head and neck
Facial nerve
Superficial
temporal
fascia
Galea
A
Temporalis muscle
Superficial
layer
C superficial layer of the deep temporal fascia. (C) Dissection deep to the temporalis
Deep layer
term to the areolar tissue between the superficial layer of the
deep temporal fascia and the superficial temporal fascia (i.e.,
the innominate fascia can be synonymous with the paroti-
dotemporal fascia or subgaleal fascia or the superficial tem-
poral fat pad).13
The plane of dissection in the temporal region depends on
the goal of the surgery (see Fig. 1.4). In general, the surgeon
should avoid the superficial temporal fascia as it harbors the
frontal branch of the facial nerve. During surgery to expose
the orbital rims and the forehead musculature, the dissection
plane is between the superficial temporal fascia and deep
temporal fascia (see Fig. 1.4A). To expose the arch, the super-
ficial layer of the deep temporal fascia is divided and dissec-
tion proceeds between it and the middle fat pad (the superficial
layer of the deep temporal fascia will act as an extra layer
protecting the nerve) (see Fig. 1.4B). Finally, when a coronal
approach is used, but the arch does not need to be exposed,
dissection can proceed deep to the temporalis muscles, elevat-
ing them with the coronal flap (see Fig. 1.4B). Using this
avascular plane avoids potential traction or injury to the
frontal nerve and ensures good aesthetic results as it prevents
possible fat atrophy or retraction of the temporalis muscle.
Superficial layer of deep
temporal fascia Middle temporal fat pad
Deep
temporal
fascia
Periosteum
B
Fig. 1.4 The different planes of dissection in the temporal region. (A) Dissection
between the superficial temporal fascia (temporoparietal fascia) and the deep
temporal fascia. In this plane, the surgeon should try to stay right on the deep
temporal fascia. (B) Dissection deep to the deep temporal fascia. This is a safe plan
that will lead to the zygomatic arch. The facial nerve will be protected by the
muscle. The muscle can be left as part of the skin flap. This is a safe and easy plan
if no exposure of the arch is needed.
While the fascial layers in the temporal region are well
described, there is more debate and variability of the anatomy
of the fascial layers and the facial nerve directly superficial to
the arch.12,14,15 The superficial facial fascia (SMAS) is continu-
ous with the TPF, but it is not clear if the deep facial and deep
temporal fasciae are continuous to each other or attach and
arise from the periosteum of the arch separately. In addition,
the thickness of the soft tissues from the periosteum to skin is
minimal and the tissues are tightly adherent, making identi-
fication of the fascial planes and the facial nerve hazardous in
this region.16 The frontal branch of the facial nerve pierces the
deep temporal fascia to become more superficial near the
vicinity of the upper border of the arch, and this area consti-
tutes one of the danger zones of the face (see below).
The fascia in the neck
The nomenclature used to describe the different fascial layers
in the neck also creates significant confusion. There are two
different fascias in the neck: the superficial and the deep (Figs.
1.3 & 1.6). The latter is composed of three different layers: (1)
the superficial layer of the deep cervical fascia, also known as

Deep temporal fascia
Temporalis
Superficial temporal fascia Loose areolar tissue
(temporoparietal fascia)
Fig. 1.5 Dissection in the temporal layer.
1
2 changes. Knowledge of their anatomy is important for both
3
4 the craniofacial surgeon, the zones of adherence represent
5 reconstruction or face transplants, reconstructing or maintain-
Cross section
Fig. 1.6 Fascial layers of the neck. 1, Investing layer of deep cervical fascia; 2,
pretracheal fascia; 3, carotid sheath; 4, superficial fascia; 5, prevertebral fascia.
(Reprinted with permission from www.netterimages.com © Elsevier Inc. All rights
reserved.)
the general investing layer of deep cervical fascia; (2) the
middle layer, commonly named the pretracheal fascia; and (3)
the deep layer, or the prevertebral fascia (see Figs. 1.3 & 1.6).
The pretracheal fascia encircles the trachea, thyroid, and the
esophagus, while the prevertebral fascia encloses the prever-
tebral muscles and forms the floor of the posterior triangle of
the neck. For practical purposes, it is the superficial cervical
fascia and the superficial layer of the deep cervical fascia that
the plastic surgeon encounters.17,18
The superficial cervical fascia encloses the platysma muscle
and is closely associated with the subcutaneous adipose
tissue. The platysma muscle and its surrounding superficial
Retaining ligaments and adhesions of the face 7
cervical fascia represent the continuation of the SMAS into the
neck. In general, when skin flaps are raised in the neck, the
platysma muscle is maintained with the skin to enhance its
blood supply (e.g. during neck dissections). However, in
necklifts the skin is raised off the platysma to allow platysmal
shaping and skin redraping. Tissue expanders placed in the
neck could be placed either deep or superficial to the platysma.
Placing them superficially will create thinner flaps that are
more suitable for facial resurfacing, while placing them deeper
allows a more secure coverage of the expander.19,20
The superficial layer of deep cervical fascia, or the general
investing layer of deep cervical fascia, is what plastic surgeons
commonly refer to simply as the “deep cervical fascia”. It
encircles the whole neck and has attachments to the spinous
processes of the vertebrae and the ligamentum nuchae poste-
riorly. It splits to enclose the sternocleidomastoid and the
trapezius muscles. It also splits to enclose the parotid and the
submandibular glands. The deep facial fascia, or parotideo-
masseteric fascia, is therefore considered the continuation of
the deep cervical fascia into the face.
Retaining ligaments and adhesions
of the face
The ligaments of the face maintain the skin and soft tissues of
the face in their normal positions, resisting gravitational
the craniofacial and the aesthetic surgeon for several reasons.
For the aesthetic surgeon, these ligaments play an important
role in maintaining facial fat in its proper positions. For ideal
aesthetic repositioning of the skin and soft tissues of the face,
numerous surgeons recommend releasing the ligaments. For
coalescence between different fascial layers, possibly luring
the surgeon into an erroneous plane of dissection. In facial
ing these ligaments is important to prevent sagging of the soft
tissues with its functional and aesthetic consequences.
Various terms have been used to describe these ligamen-
tous attachments. Moss et al. classified them into ligaments
(connecting deep fascia/periosteum to the dermis), adhesions
(fibrous attachments between the deep and the superficial
fascia), and septi (fibrous wall between layers).21
In the periorbital and temporal region, various ligaments
and adhesions have been described with numerous names
given to each (Fig. 1.7). Along the skull temporal line lies the
temporal line of fusion, also known as the superior temporal
septum, which represents the coalition of the temporal fascia
with the skull periosteum. These adhesions end as the tem-
poral ligamentous adhesions (TLA) at the lateral third of the
eyebrow.21 The TLA measure approximately 20 mm in height
and 15 mm in width and begin 10 mm cephalad to the supe-
rior orbital rim. Both the temporal line of fusion and the TLA
are sometimes referred to collectively as temporal adhesions.
The inferior temporal septum extends posteriorly and inferi-
orly from the TLA on the surface of the deep temporal fascia
towards the upper border of the zygoma. It separates the
upper temporal region superiorly from the lower temporal
region inferiorly and represents the upper boundary of the
parotideomasseteric fascia (the fascial layer between the
superficial and the deep temporal fascia in the region just
8 CHAPTER 1 • Anatomy of the head and neck

Temporalis

Superior temporal septum

Temporal ligamentous adhesion

Supraorbital ligamentous adhesion

Corrugator supercilii

Lateral brow thickening

Sentinel vein

Lateral orbital thickening

Zygomaticotemporal nerve

Attachment of orbicularis retaining ligament

Zygomaticofacial nerve

Inferior temporal septum

Frontal branch of facial nerve

Fig. 1.7 The ligaments of the periorbital region.

above the zygomatic arch).22 The supraorbital ligamentous
adhesions extend from the TLA medially along the eyebrow.
The orbicularis retaining ligament (ORL) lies along the
superior, lateral, and inferior rims of the orbit, extending from
the periosteum just outside the orbital rim to the deep surface
of the orbicularis oculi muscle (Fig. 1.8).23,24 This ligament
serves to anchor the orbicularis oculi muscle to the orbital
rims. The orbicularis oculi muscle attaches directly to the bone
from the anterior lacrimal crest to the level of the medial
limbus. At this level the ORL replaces the bony origin of the
muscle, continuing laterally around the orbit. Initially short,
it reaches its maximum length centrally near the lateral
limbus.25 It then begins to diminish in length laterally, until it
finally blends with the lateral orbital thickening (LOT). The
LOT is a condensation of the superficial and deep fascia on
the frontal process of the zygoma and the adjacent deep
temporal fascia. The ORL and the orbital septum both attach
to the arcus marginalis, a thickening of the periosteum of the
orbital rims.24 The ORL is also referred to as the periorbital
septum and, in its inferior portion, as the orbitomalar liga-
ment. The ORL attaches to the undersurface of the orbicularis
oculi muscle at the junction of its pretarsal and orbital
components.
In the midface, the retaining ligaments have been divided
into direct, or osteocutaneous, ligaments and indirect liga-
ments. Direct ligaments run directly from the periosteum to
the dermis, and include the zygomatic and mandibular liga-
ments. Indirect ligaments represent a coalescence between the
superficial and deep fascia and include the parotid and
the masseteric cutaneous ligaments (Fig. 1.9; see Fig. 1.2C).
The retaining ligaments indirectly fix the mobile skin and its
intimately related superficial fascia (SMAS) to the relatively
immobile deep fascia and underlying structures (masseter
and parotid).
The zygomatic and the masseteric ligaments together form
an inverted L, with the angle of the L formed by the major
zygomatic ligaments (Fig. 1.9; see Fig. 1.2C). These ligaments
are typically around 5–15 mm wide and are located 4.5 cm in
front of the tragus and 5–9 mm behind the zygomaticus minor
muscle.26–30 Anterior to this main ligament are multiple other
bundles that form the horizontal limb of the inverted L. There
have been different descriptions of the anatomy of these

Skin
Orbicularis oculi
Orbicularis retaining
ligaments
Orbital septum
Upper tarsus
Lower tarsus
Orbicularis oculi
Orbital septum
Orbicularis retaining
ligaments
Orbital rim
Fig. 1.8 The orbicularis retaining ligaments.
zygomatic ligaments, likely related to the variability in their
thickness and location, as well as the different criteria used by
different authors to define what is truly a “ligament”. Often
the surgeon will encounter these ligaments along the whole
length of the zygomatic arch.30 The vertical limb of the L is
formed by the masseteric ligaments, which are stronger near
their upper end (at the zygomatic ligaments), and extend
along the entire anterior border of the masseter as far as the
mandibular border.5,31 The parotid ligaments, also referred to
as preauricular ligaments, represent another area of firm
adherence between the superficial and deep fascia.26,28,29 The
mandibular ligaments originate from the parasymphyseal
region of the mandible around 1 cm above the lower man-
dibular border.28,29 There are several descriptions of other
retaining ligaments in the face, most notably the mandibular
septum and the orbital retaining septum.32,24
The prezygomatic space
The prezygomatic space is a glide plane space overlying the
body of the zygoma, deep to the orbicularis oculi and the
suborbicularis fat (see Fig. 1.8).33 Its floor is formed by a fascial
layer covering the body of the zygoma and the lip elevator
muscle (namely the zygomaticus major, zygomaticus minor,
and the levator labii superioris). This fascial layer extends
caudally over the muscles, gradually becoming thinner and
allowing the muscle to be more discernible. The superior
The buccal fat pad 9
boundary of the prezygomatic space is the orbicularis retain-
ing ligament, which separates it from the preseptal space.
The more rigid inferior boundary is formed by the reflection
of the fascia covering the floor as it curves superficially to
blend with the fascia on the undersurface of the orbicularis
oculi. This inferior boundary is further reinforced by the
zygomatic retaining ligaments. Medially, the space is closed
by the origins of the levator labii and the orbicularis oculi
muscle from the medial orbital rim. Finally, the lateral
boundary is formed superiorly by the LOT over the frontal
process of the zygoma and more inferiorly by the zygomatic
ligaments.34 The facial nerve branches cross in the roof of
(i.e., superficial to) this space. The only structure traversing
the prezygomatic space is the zygomatic branch of the facial
nerve, emerging from its foramen located just caudal to
the ORL.
The malar fat pad and the
subcutaneous fat compartments
of the face
Rohrich and Pessa, in an extensive study of the facial subcu-
taneous fat, found the cheek to be partitioned into multiple,
independent anatomical compartments superficial to the
superficial fascia.35 These subcutaneous fat compartments
(also referred to as fat pads) are separated by distinct facial
condensations that arise from the superficial fascia and insert
into the dermis of the skin.36–38 These superficial fat pads
include the nasolabial, jowl, malar, or cheek (subdivided into
medial, middle, and lateral-temporal compartments); perior-
bital (subdivided into inferior, superior, and lateral compart-
ments); and forehead (subdivided into central and medial
compartments).36 This anatomy is important because elements
of facial aging may be characterized by how these compart-
ments change relatively in both position and volume with
time.38 Elevation of the malar fat pad, which is triangular in
shape with its base at the nasolabial crease and its apex more
laterally towards the body of the zygoma, is important for
facial rejuvenation and in facial palsy.39 During facelift dissec-
tion, septal transition zones between these superficial fat
compartments are regions of potential injury to deeper struc-
tures, including branches of the facial nerve as well as the
greater auricular nerve.38
The buccal fat pad
The buccal fat pad is an underappreciated factor in post-
traumatic facial deformities and senile aging and is frequently
overlooked as a flap or graft donor site.40,41 Senile laxity of the
fascia allows the fat to prolapse laterally, contributing to the
square appearance of the face.42 With many traumatic injuries
the fat herniates, either superficially, towards the oral mucosa,
or even into the maxillary sinus.25,43–45 This fat is anatomically
and histologically distinct from the subcutaneous fat. It is
voluminous in infants to prevent indrawing of the cheek
during suckling, and gradually decreases in size with age.46 It
functions to fill the glide planes between the muscles of
mastication.
10 CHAPTER 1 • Anatomy of the head and neck
Zygomatic cutaneous ligament
Preauricular parotid cutaneous ligament
parotideomasseteric cutaneous ligament
Platysma cutaneous ligament
Mandibular ligament
Fig. 1.9 The retaining ligaments of the face. (Reproduced with permission from Gray’s Anatomy 40e, Standring S (ed), Churchill Livingstone, London, 2008.)
It is usually described as being formed of a central body
and four extensions, the buccal, pterygoid, and superficial and
deep temporal. The body is located on the periosteum of the
posterior maxilla (surrounding the branches of the internal
maxillary artery) overlying the buccinator muscle and extends
forwards in the vestibule of the mouth to the level of the
maxillary second molar. The buccal extension is the most su-
perficial, extending along the anterior border of the masseter
around the parotid duct. Both the body and the buccal exten-
sion are superficial to the buccinator and deep to the deep
facial fascia (parotideomasseteric fascia) and are intimately
related to the facial nerve branches and the parotid duct. The
buccal extension is in the same plane as the facial artery, which
marks its anterior boundary. The pterygoid extension passes
backwards and downwards deep to the mandibular ramus to
surround the pterygoid muscles. The deep temporal extension
passes superiorly between the temporalis and the zygomatic
arch. The superficial temporal extension is actually totally
separate from the main body and lies between the two layers
of the temporal fascia above the zygomatic arch.47
The facial nerve
During most facial plastic surgeries, whether congenital,
reconstructive, or aesthetic, there are one or more branches
of the facial nerve that are at risk for injury. Although
there is abundant literature on the anatomy of the facial
nerve branches, the majority of publications describe two-
dimensional anatomy, depicting the trajectory of the nerve
and its surface anatomy in relation to anatomic landpoints
(see Fig. 1.3).9,16,48–55 However, it is the third dimension, the
depth of the facial nerve in relation to the layers of the face,
that is most relevant to the practicing surgeon. In spite of
the significant variability in the branching patterns, the facial
nerve consistently passes in defined planes, crossing from one
plane to another in certain zones.1 It is in these “danger zones”
that dissection should be avoided or done carefully. In the rest
of the face, the dissection can proceed relatively quickly by
adhering to a certain plane, either superficial or deep to the
plane of the nerve.
 The facial nerve 11

Temporal branches

Zygomatic branches

Posterior
auricular nerve

Zygomaticotemporal division
Cervicofacial division

Parotid gland

Buccal branches

Marginal mandibular
branches

Cervical branch

Fig. 1.10 The facial nerve.

The facial nerve nucleus lies in the lower pons and is
responsible for motor innervation to all the muscles derived
from the second branchial arch. A few sensory fibers originat-
ing in the tractus solitarius join the facial nerve to supply the
skin of the external acoustic meatus. The nerve emerges from
the lower border of the pons, passes laterally in the cerebel-
lopontine angle, and enters the internal acoustic meatus. The
facial nerve then traverses the temporal bone (being liable to
injury in temporal bone fractures) to exit the skull through the
stylomastoid foramen. Just after its exit it is enveloped by a
thick layer of fascia that is continuous with the skull perios-
teum and is surrounded by a small aggregation of fat and
usually crossed by a small blood vessel. This makes its iden-
tification in this area a challenging task. Several methods for
identification of the facial nerve trunk have been described:
1. If the tragal cartilage is followed to its deep end, it
terminates in a point. The nerve is 1 cm deep and
inferior to this “tragal pointer”. There is an avascular
plane anterior to the surface of the tragus that allows a
safe and quick dissection to this tragal pointer.
2. By following the posterior belly of the digastric
posteriorly, the nerve is found passing laterally
immediately deep to the upper border of the posterior
end of the muscle.
3. If the anterior border of the mastoid process is traced
superiorly, it forms an angle with the tympanic bone.
The nerve bisects the angle formed between these two
bones (at the tympanomastoid suture).
4. By feeling the styloid process in between the mastoid
bone and the posterior border of the mandible. The
nerve is just lateral to this process.
5. By following the terminal branches of the nerve
proximally.
The nerve passes forwards and downwards to pierce the
parotid gland. In the parotid gland the nerve divides into the
zygomaticotemporal and the cervicofacial divisions, which in
turn divide into the five terminal branches of the facial nerve:
frontal, zygomatic, buccal, marginal mandibular, and cervical
(Fig. 1.10). However, the zygomatic and buccal branches show
significant variability in their location and branching patterns,
as well as a significant overlap in the muscles they innervate
– they are sometimes grouped together and referred to as
“zygomaticobuccal”. The temporal and the mandibular
branches are perhaps at the highest risk for iatrogenic injury,
especially as the muscles they innervate show little if any
cross-innervation, making injury to these branches much
more noticeable.
Frontal (temporal) branch
This consists of 3–4 branches that innervate the orbicularis
oculi muscle, the corrugators and the frontalis muscle. Several
anatomic landmarks are used to describe their surface
anatomy. The most common description is Pitanguy’s line,
extending from 0.5 cm below the tragus to a point 1 cm above
the lateral edge of the eyebrow (or 1 cm lateral to the lateral
canthus).9,56 Ramirez described the nerve as crossing the
zygomatic arch 4 cm behind the lateral canthus.57 However,
other surgeons describe the area spanning the middle two-
thirds of the arch as the territory of the nerve. Gosain et al.
found frontal nerve branches are found at the lower border of
the zygomatic arch between 10 mm anterior to the external
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and provide for my wife and remaining daughter. As to the title-deeds
of my property, I implore you to keep them until I am released, for, as
you know, it is the practice of the authorities to take possession of
the property of a prisoner who is a criminal such as I am. You have
often lent me small sums of money—for I have been your hunter—
and you have not asked to be repaid. Should there be any attempt
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title-deeds, I have directed them to say the “Bashador” is in
possession of all our property as a guarantee for repayment of
money advanced by him. This will check extortion. The Basha is of
my tribe, and will be just and merciful to a poor Rifian in misfortune.
He knows that death is better than dishonour and disgrace. Oh! my
unhappy child!’ he exclaimed; ‘your life has been taken, and I long
for the day when Allah may take mine!’ and again the old man wept
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I took charge of his papers; he presented himself that day before
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on this man; his family may visit him.’
Hadj Kassim remained a year in prison, and on his release
presented himself to me to recover his papers, informing me that no
steps had been taken to seize his property, but, on the contrary, the
Basha had shown him kindness in prison, sending him occasionally
a little present in money; and that when he was brought before him,
on being let out of prison, the Basha said, ‘We are Rifians. The most
High and Merciful God forgives the sins of men. I also forgive thee.’
 The wretched man never hunted again or associated with his
fellow-villagers, whose esteem and regard he had regained. His
spirit was broken; he wandered about, pale and emaciated—
speechless even—amongst his friends. A few months after his
release from prison I learnt that he had died.

The interest which Mr. Hay took in the natives was not entirely
confined to the Rifians. The needs and sufferings of his poorer
neighbours—whether Christian, Hebrew, or Moslem—always met
with his sympathy, and, so far as lay in his power, he sought to assist
them in times of distress. In December, 1857, after a severe famine,
he writes to his wife, then in England:—

My farm has yielded wheat plentifully: I have enough for the house, for seed,
and some hundred almuds over, which I shall give in your name to the poor
Christians, Jews, and Moors this winter—equally divided—as there is, I fear, great
misery. The poor peasants had no seed to sow this year, so there is a lack of
wheat. I have asked the Sultan to lend seed gratis to the poorer farmers, and, to
practise what I preach, I shall lay out £100 for the same object. If something is not
done we shall have fever and famine again this year. At present the general health
is excellent and there are no fevers, but I fear the winter, and poor folk flocking into
the town, will bring typhus again.
Only think of a rascally Jew trying to sell me some $10,000 worth of stolen
jewels for $2,000. From the stupidity of the Governor’s soldiers, the accomplices in
the robbery made off with the jewels before they were seized, though I had given
notice. The only person seized was the Jew who tried to bribe me into committing
the roguery.
Curiously enough, since my return, there have been two other attempts made
to impose upon me gifts to large amounts to secure my good-will. Of course I have
declined to receive them, but I am almost ashamed to think that people should
have such a poor opinion of my character as to venture upon making me such
offers.

In proof that his kindness was not unrecognised by the natives,

the following anecdote is told by Mrs. Chapman, Sir John’s only
surviving sister:—
 Two or three years after the famine in Morocco, one of the tribes from the
interior sent a deputation of chiefs who asked to speak to John.
During the great scarcity, he had sent for corn from Spain, and dispatched
camels laden with grain to the different tribes who were suffering from starvation,
to relieve their distress and supply them with seed to sow their land.
The chiefs, fine hill-men, were received by my brother and unfolded the
purpose of their mission. They said, ‘We have heard a report that you are about to
dig a well in one of your gardens. We come to entreat you to allow us to do this
thing for you, as a slight proof of our gratitude for your generosity. You heard that
we and our families were starving; you did not know us, but you believe in the one
God and Father of us all, and you would not let your brothers want; you sent your
gold across the sea and caused a ship to come, laden with grain, and sent camels
with sacks of corn for our food and to sow our land. God will reward you!—but let
us do this little thing. We will come with our families and encamp around your
garden, we will dig your well and tend your fruit and flowers and take nothing. We
will bring our cattle and our sheep for food, and you shall be at no cost on our
account. This will partly satisfy our desire to show our gratitude, and you, when
you drink of the water of this well, will remember your poor brethren whom you
saved from death, for love of the one God.’
John consented, and gave them leave to do as they wished.
When the report spread that these wild people were coming within a mile of
Tangier, the alarmed townsfolk sent a messenger to beg my brother to dissuade
the tribe from coming, declaring that they were much to be feared, and that their
proximity would endanger the peace of the town. My brother told the messenger
he would be responsible for the orderly conduct of the tribe.
They came and dug the well, the garden and grounds were left in perfect order,
and the strangers quitted the neighbourhood in peace, going quietly back to their
hills.

Another instance of the gratitude of which these wild people are

capable may be inserted here, though the actual occurrence took
place a few years later, and after another and similar bad season
with failure of crops in the Rif.
In the stress of famine the starving mountaineers crowded, with
their families, to Tangier in search of work and food. Strenuous
efforts were made by the people of Tangier and the foreign
Representatives to assist these unhappy folk. In reply to an appeal
from Sir John, a large subscription was raised in Gibraltar, and
expended in flour, which was sent for distribution to the care of the
British Legation at Tangier.
Some of these unfortunate Rifians found work near Tangier;
others, their immediate wants relieved, as tidings came from Rif that
rain had fallen and prospects were better, returned to their homes in
small detachments; but many remained. Cholera and smallpox broke
out amongst these, and numbers died, leaving orphan children, too
young, in many instances, to be able to give any account of
themselves or their families. These were adopted by charitable
townsfolk, and are now many of them prosperous, well-to-do
individuals. But when the cholera and famine were ended, several
hundred Rifians, with their families, remained. These poor people
were finally dismissed in a body to their own country, provided with
the means of purchasing seed-corn, and with clothing and food for
their journey. When leaving Tangier they assembled at daybreak
outside the gates of the town. There, raising their hands to heaven,
they called down a blessing from God on the town and people, and
more especially on the Christians who had shown them such charity
and kindness.
Not long after they gave good proof of their gratitude. A ship was
wrecked on the coast inhabited by some of these very Rifians. The
crew were succoured and sheltered by them, and a contingent
personally conducted them in safety to Tangier.
 CHAPTER XII.

SECOND MISSION TO MARÁKESH. 1855.

Trade in Morocco had not always laboured under the

disadvantages which existed in 1855. So far back as 1725 Sultan
Mulai Abdallah encouraged commerce by imposing a system of
moderate duties, free of all monopolies and contracts—and with
regard to the garrison of Gibraltar and the British fleet, frequently
granted supplies free of all duties.
In 1801 Great Britain entered into a commercial Treaty with
Morocco—renewed in 1845—but without any express stipulations as
to duties; the Treaty merely confirming to Great Britain all privileges
granted to Spain in a Treaty made between that country and
Morocco in 1799. Contrary, however, to the spirit of this Treaty a
system had gradually arisen of monopolies, confiscation of products,
high duties, and a constant alteration of tariffs, and the prohibition of
articles of export without any cogent reason for such prohibition
being given. A serious decline in commerce since 1801 had
therefore ensued.
In pressing on the Sultan the necessity for a new Convention, Mr.
Hay pointed out that the proposals he had to make were as much for
the benefit of the Moorish Government as for that of his own. The
Sultan reigned over a country equal to any in resources, and
inhabited by a hardy and intelligent race. There was therefore no
reason, urged Mr. Hay, why, under wise direction, it should not equal
any other in prosperity. Yet, so far from being prosperous, scarcity of
coin and great poverty prevailed throughout the country.
The population of Morocco, a country as large as France,
contained a bare 7,000,000 of inhabitants as against 36,000,000 in
France and 28,000,000 in Great Britain.
The sale of monopolies might have, in the first instance, increased
the revenues of H.S.M.; but any such increase could only be
temporary, and the benefits derived from the system fell to the
limited number of unscrupulous persons who obtained these
concessions. The continual alterations of the tariff were most
injurious to foreign traders, who in consequence could place no
dependence on the security of a royal mandate fixing any particular
tariff. Again, the high duties offered a premium on smuggling. Even if
contraband trade could be checked by careful precautions at all the
ports, it would soon prevail along the unguarded coasts. Once firmly
established, such a trade would be extremely difficult to check.
Mr. Hay argued that the export of grain and agricultural produce
would powerfully promote increased production. He alluded, in proof
of his argument, to various foreign countries where a large, free
export of grain had greatly extended agricultural operations.
Especially he instanced Algeria, which before the French occupation
had only produced grain and oil sufficient for home consumption; but
since then had, in addition, exported largely to France.
Mr. Hay combated the superstitious objections of the Moors to
selling food stuffs to the Nazarenes by reminding the Sultan that his
subjects were clothed in materials manufactured by Christians, his
soldiers armed and their horses shod with weapons and shoes made
of European iron, and declared that persons who argued in such a
sense were ‘rebels against God,’ since He had not denied the
Christian and the Jew any privileges granted by Him to the Moslem.
Finally Mr. Hay suggested that it would be desirable that the
advantages of such a Convention should be shared by other Powers
in common with Great Britain, and ventured to warn the Sultan that a
Treaty of Commerce made in time of peace by a friendly Power
would be preferable to the risk of having to make such a Treaty at a
more critical moment, when the opportunity might arise for one of the
Powers to enforce its demands; for assuredly the present
Convention would not be renewed under its old conditions.
 It was to press upon the Moorish Government the advisability of a
Commercial Convention on the lines above indicated, that, in 1855,
by the direction of the British Government, Mr. Hay left Tangier for
Marákesh. The mission set out in March, 1855. On his way Mr. Hay
everywhere met with a courteous reception. Azamor, however, a
town contiguous to Rabát, proved an exception. There he
experienced very different treatment.

Kaid Ben Tahir, he writes, Governor of Azamor—a great fanatic—

hated the sight of Europeans, but in pursuance of express orders
received from the Sultan, came out with the chief officials of Azamor
and some troops to meet me some distance from the town and
conducted me to our camp.
The following day, according to etiquette, I called on the Kaid at
his residence. As I entered the porch, the ‘m’haznía’ (military
guards), about forty in number—instead of being drawn up standing
in line to receive me—were squatting on the ground, forming a
double rank, reaching close to the kiosk in which the Governor was
seated, thus leaving only a narrow passage for me to pass through.
Some even had their legs sprawled out in my way. These I trod upon
heavily, or kicked aside, much to their dismay.
The Governor, who was seated, counting the beads of a rosary,
on a small divan, remained seated as I approached, without
attempting to rise or salute me; neither had he any chair or other
resting-place to offer me, and merely held out his hand saying ‘You
are welcome.’ Taking his hand with a firm grip I lifted him gently from
his divan and said, ‘I am glad to see you.’ When I got his astonished
Excellency well on his legs, I wheeled him round suddenly and
dropped on the middle of the divan where he had been seated,
leaving him standing.
 Kaid Ben Tahir looked bewildered, gazed first at me and then at
his guards, and I think was still meditating whether to bolt or to call
his scowling attendants to seize and bastinado me, when I
addressed him—‘How thoughtful and attentive of you to have
prepared this comfortable divan for me to sit upon without providing
for yourself a chair or even a stool where you could sit to entertain
me.’
He murmured, ‘The divan is my seat.’
‘Ah!’ I said, ‘So you intended to remain seated whilst the
Representative of the greatest Sovereign in the world, accredited to
your Lord the Sultan as Envoy, came to call on you! How do you like
the position in which you desired to place me? I shall report your
conduct to the Sultan, as also the behaviour of your guards, for I
consider your and their conduct a marked insult.’
Kaid Ben Tahir faltered out, ‘I have erred through ignorance. You
are the first European Representative whom I have received and I
never offer a seat to Moorish officials who call upon me—I ask your
pardon.’
Moving a little aside on the divan, I said, ‘Come, there is room for
us both to sit down and I hope we shall be able to understand each
other.’
The Governor sat down and we made friends, so I told him I
should not report the occurrence to his Lord and Master the Sultan.
As I left, he rose and accompanied me to the threshold, the
guards were all standing at attention, looking aghast at the Nazarene
who had treated their tyrannical master with such ignominy; but the
chief Kaid (or captain of the guard) whispered, as I passed, ‘Andek el
hak’ (you are right), ‘respect is due to the Envoy sent to our Lord the
Sultan.’

Further on the way to Marákesh Mr. Hay traversed the province of

Shawía, where a curious incident of a more pleasing character took
place, which he describes as follows.

Orders had been given by the Sultan that the Governor of each
province through which we passed should meet the Mission with a
body of cavalry, and escort us until we were met by the Governor of
the adjoining province.
I found these ceremonial meetings very tedious, so frequently left
my Tangier escort and, taking a man on foot to carry my gun,
wandered from the beaten track towards the next encampment, in
pursuit of game. As I was clad on such occasions in shooting attire,
an ample cloth cloak was borne by one of the troopers of my escort,
and this I donned when a Basha or other officer came in sight.
‘Buena capa, todo tapa’ (‘a good cloak covers all’)—the Spaniards
say—and as the Moorish officials present themselves with their
followers on these occasions, en grande tenue, it was not seemly
that the British Representative should have the appearance of a
second-class gamekeeper.
One morning, whilst thus shooting in a field of corn, the man who
was leading my horse came running to say he could see within half a
mile the Governor of Shawía, with a body of cavalry, approaching.
Mounting my nag, I directed him to call the trooper who carried my
cloak—but he could not be found.
As the Governor approached, riding with his Khalífa (Lieutenant-
Governor) and two sons in front of the Arab cavalry, who formed two
lines, I observed the chief was beautifully dressed, as were also his
followers, and their horses richly caparisoned.
They advanced till within fifty yards of where I had taken my
stand, for, as my Queen’s Representative, I always required that
these Governors should, according to Moorish etiquette on
encountering a superior, advance first towards me, and when within
a few yards I would move forward to meet them.
The Governor had halted, waiting for me to approach, so I
directed my attendant to say that I was very desirous to have the
pleasure of making his acquaintance, therefore would the Governor
come forward.
This staggered the great man, who, for the first time during his
Governorship, had been sent to meet a European Envoy, and I
overheard the following dialogue:—
My Attendant. ‘The Envoy says that he will have much pleasure in
making your Excellency’s acquaintance, if you will have the
goodness to approach.’
Governor Reshid. ‘Is that shabbily-clad Nazarene, whom I see
mounted on a “kida” (pack horse), the Envoy, and does he expect
me to go to him?’
Attendant. ‘Yes, my Lord.’
‘Mashallah!’ exclaimed the Governor, and spurring his horse
rather angrily, which made it bound forward, curvetting, he
approached and held out his hand.
I then advanced also, and we shook hands. The Governor,
looking rather amazed at my appearance, bid me welcome in flowery
language, and, placing me between himself and his Khalífa, we
commenced the march towards the camp, which he informed me
was distant about a two hours’ ride.
Kaid Reshid was dressed in a caftan of pale unicoloured cloth,
embroidered in silk, over which hung gracefully a transparent white
‘haik’; a fez and huge turban covered his head. The red saddle on
which he rode, and the horse’s breastplate, were beautifully
embroidered in gold on red velvet. The bridle and trappings were of
red silk, also embroidered with gold. His massive iron stirrups were
engraved in gold arabesques. By his side walked a slave carrying a
long Moorish gun.
The Kaid was a handsome man, with Caucasian features,
complexion olive, but not darker than that of the inhabitants of
Southern Europe. He kept eyeing me and my horse from head to
foot. After a pause he addressed me in polite language, though
evidently much amused at my shabby appearance and English
saddle, and said, ‘I am sure our Lord the Sultan will present you with
a better horse to replace the “kida” you are now riding.’
As the Moors are generally big men, horses below 15 hands are
not used by the cavalry; and Bashas, Kaids, and other officers ride
horses standing about 16 hands. My mount was a small Barb of
about 14.2, well bred and very fast. Ponies of this size are called
‘kidas,’ and are never used as saddle-horses, but merely as pack
animals.
‘I thank you much, Kaid Reshid,’ I replied, ‘for your good wishes
that I may enjoy the favour of the Sultan. Allow me to tell you that,
from the moment I had the pleasure of riding alongside of your
magnificent charger, I have been wrapt in admiration both of your
own appearance and of the trappings of your high-bred steed,
reminding me of the paintings and sculptures I have seen of the
ancient people of the East and of the early Christians.’
With a haughty, angry expression, Kaid Reshid replied, ‘Are you
mocking me, saying I am like a Nazarene? What resemblance can
there be between us Mussulmans and the Románi[29]?’
‘I said not that your appearance resembled that of the modern, but
of the ancient Christian. The graceful, flowing robes you now wear,
are like those depicted in pictures of the early Christians. Your
“haik”—a garment without seam—is such as it is described our
Saviour, “Sidna Aisa” (our Lord Jesus), whom you call the “Spirit of
God,” wore on earth. Your saddle and stirrups are precisely of the
form of those which Christians used in early times, and even two
centuries ago, before the invention of fire-arms, when the lance was
their chief weapon on horseback. Your bridle and the trappings about
the neck of your horse are precisely those I have seen depicted in
ancient Greek sculptures. Know you not, Basha, by the respective
dates of the Christian and Mohammedan era, that the former are the
more ancient people who believe in God Almighty? The Christian as
well as the Mohammedan religion, and I may add, art and science
came from the East. It is no shame, therefore, that your costume
should be like unto that of the early Christians. As to my present
garb, I gather from your expression that you find it very uncouth as
compared with that of the Moslem; and my saddle and bridle no
doubt appear to you scrimp and mean; but Europeans, when they
progressed in warfare and manufactures, cast aside the flowing
robes, which encumbered their movements, and adopted this tight-
fitting clothing, by which they obtain greater freedom for the use of
their limbs. They found the saddle, such as the Moslem now uses,
too heavy, and that the breastplate, large stirrups, &c., needlessly
overweighted the horse and hindered his speed. I am not surprised
you regard with contempt my “kida,” and that you express a hope the
Sultan may give me a better mount. Now, in order that I may give
you proof of the truth of what I have said, I challenge the best
horseman you have amongst your chiefs to race with me to yonder
rock in our path (about a quarter of a mile distant), go round it, and
return to you. I see the Khalífa and your sons are mounted on
magnificent steeds—I challenge them.’
One of the Basha’s sons spurred his horse angrily, so that it
reared and curvetted, and said, ‘Oh! my father, the Envoy is making
fun of us.’
‘No,’ I replied, ‘that is not my intention. Let us have the race, and I
swear that if this “kida” does not win, I dismount and make it a
present to the winner.’
‘The Envoy is in earnest,’ said Kaid Reshid, and, turning to his
sons and the Khalífa, added, ‘You are to gallop to that rock, go round
it, and return. Whoever reaches me first wins. I remain here with the
troops in line.’
Our four horses were placed in a row, and at a signal from the
Basha we all started. My three opponents dashed off at full speed,
ramming in their long spurs till the blood streamed, whilst I held in
hand my swift little nag, riding about six yards behind one of the
sons, who, turning round as we galloped, and holding out his hand,
said, ‘Shall I help you along?’ I laughed and replied, ‘Thanks, I am
coming.’
As we approached the rock I closed on them and my nag, having
a good mouth, turned sharply round it and we were all four abreast,
their horses being much blown as they had been ridden at full speed.
I had no spurs, but merely pressing my little Barb and giving him his
head drew well in front, leaving the three horses twenty yards behind
and had time to reach the Basha, wheel round by his side and see
them finish, spurring furiously.
‘The Envoy has won,’ said the Basha, with a dejected
countenance.
‘Yes,’ said one of his sons, who was second in the race. ‘He has
deceived us. That animal he rides is no doubt a Saharáwi (a horse
from the Sahara desert), who has been bought for his weight in gold,
or sent him by the Sultan as a “Shrab Reb[30].”’
‘You are mistaken, my friends,’ I replied. ‘This “kida” is not a
Saharáwi horse; he was bought by me in the market at Tangier for
$22 (£4 8s.), when he was two years old. He was then like a sack of
bones, but, as you see, has capital points. My saddle and bridle are
light compared with yours and do not encumber his movements. He
is too in good training, being the horse I usually hunt.’
Along the line of troopers there was much excitement and talking,
but many of them looked very troubled and dejected.
‘Can you use your gun on horseback?’ inquired the Basha. ‘Can
you shoot a bird or animal?’
I replied that I did not often shoot from the saddle at a bird on the
wing; but that I could do so, as my nag stood fire capitally.
The Basha then requested me to shoot from my horse any game
that might be started. The cavalry formed a long line—we were riding
over a stony plain, clad with grass and other herbage. The day was
very hot; game therefore lay close, and every now and then
partridges or other birds rose, but were too far for me to shoot. At
length, fortunately, a ‘hobar,’ or great bustard, rose about twenty-five
yards off. I put my horse at a gallop, and before the huge bird could
get into full swing to soar away, I was beneath it and brought it down.
 A shout of admiration was raised by all the troopers, and their
shrill cries of joy were repeated, as I also had the good fortune to
knock over a partridge which happened to rise immediately after I
had reined in my horse.
The Basha came up, holding out his hand and shook mine
warmly, saying, ‘You have won our hearts. All you have said about
dress, horse, &c., you have proved to be true. God forbid that we
should ever have to fight against warriors like yourself.’
I replied that neither as a horseman nor as a marksman could I
compare myself with many of my countrymen, and that I felt
persuaded if only the Moors would adopt the saddles and firearms of
Europeans, they would not only be able to do all that we could, but
that, as a grand race of men, blessed by God with muscular power
and great intelligence, they might surpass us, as their forefathers
had done in Spain a few centuries ago, when they taught the world
literature, science, and warfare.
The Basha and I became great friends. He invited me to his tent,
where he had prepared a feast. Many of the chiefs crowded round
me when I dismounted and asked to shake hands with me. They
examined my horse, saddle, and bridle with interest.
The Basha and I had a long conversation, and I told him of the
wonders of Christendom. Before we parted next day, when we were
about to meet the Governor of Dukála, I put on my fine cloak, and
told Kaid Reshid that it was the garment I had intended to have worn
the day we met, and thus to have hidden beneath its folds myself
and my ‘kida,’ but that the trooper who should have attended me had
failed to accompany me.
‘It is better as it happened,’ said the good-natured Basha, ‘we
have learnt much and part good friends. You have taught me and my
followers a lesson we shall never forget.’

On March 18 Mr. Hay reached Marákesh, and writes to his wife ‘I

do not despair of doing some good, but shall have up-hill work.’
Days passed, still the promised interview with the Sultan had not
been suggested.

Here we are still, and have not yet seen the Sultan, but expect the audience to-
morrow.
I have had some disagreeable business, even been compelled to return the
Minister’s letters. They have conceded some of the points I had demanded
regarding etiquette, though little is gained towards the negotiations; but without
proper respect in form we could never get any result in deeds.
We are all well, but rather tired of waiting here. Our weather is beautiful and not
too hot. We have been amusing ourselves with sights of dwarfs, snake charmers,
and a stone that talked (ventriloquism) and told me I had two little girls in Tangier,
&c.!
If I have the audience to-morrow I shall try and push on the negotiation and
hope in three weeks to set off again.

It was while he was thus waiting at the Moorish Court that Mr. Hay
witnessed a curious performance of the ‘Hamadsha,’ a sect which in
some respects resembles that of the Aisawa—or snake charmers—
described in Western Barbary. The origin of this sect is remote and
obscure, and probably its rites date from pagan times.
The Hamadsha, like the Aisawa, have a curious dance of their
own; but the votaries of the former sect, unlike the Aisawa, cut
themselves with knives and hatchets, run swords into various parts
of their persons, and generally mutilate themselves when under the
excitement of their fanatical rites. A large iron ball is carried in their
processions, and this is constantly thrown in the air and caught on
the heads of the Hamadsha as it falls. The dances of this sect are
accompanied by ‘ghaiatta’ (pipes) and curious drums in the form of
large earthenware cylinders with skin stretched over one end, that
give out when struck a peculiarly pleasant, deep note. These drums
are borne on one shoulder and beaten in that position by the bearer.
Like the Aisawa, they dance in a circle, linked closely together by
placing each an arm over the next man’s neck. Their Sheikh and
fugleman stands with the musicians in the centre of the circle and
directs their movements, as they jump in the air, rocking their bodies
forward with a peculiar sidelong stamp of their feet.
No doubt these Hamadsha are more or less under the influence of
‘majun’ (a preparation of hemp), but there is also little doubt that the
votaries of the sect are carried away by excitement when they hear
the sound of the drums, or see their fellows jumping, and Mr. Hay
related the following anecdote of what occurred at one of these
performances when a passing body of Hamadsha entered the
precincts of the house where the Mission was quartered.
Mr. Hay and his friends assembled in an upper gallery to watch
the curious rites of the sect in the courtyard below, where were
gathered the native attendants and the escort with their Kaid, a
grave, elderly man, always scrupulously attired in rich clothing and of
an obese habit, being much addicted to ‘siksu.’
The Hamadsha, in a closely woven circle, gyrated and rocked to
the sound of their sonorous drums, much to the delight of the
natives, but somewhat to the perturbation of the Kaid, who, it
appeared, was himself a member of the sect. The respectable old
gentleman, reclining on his cushioned divan, presently sat up
straight and gravely nodded his head in time to the beat of the
drums. The music quickened. The Kaid’s agitation increased;
unconsciously his body swayed in time to the movements of the
Hamadsha.
Quicker and yet quicker moved the measure of the drums. The
Kaid dashed aside his turban, exposing his bare skull. A few more
moments passed and the strain became too great: the fat
commander leapt to his feet, and, casting his garments from him,
naked to the waist, he joined the circling, rocking fanatics.
 At one side of the courtyard, near a fountain which spouted from
the wall, were placed several monster earthen jars, intended for
keeping drinking water clear and sweet. After jumping with his
fellows for a short time, the Kaid cast his eye on these and, springing
aside he seized one of them, and pitched it into the air, catching it as
it fell on his shaven crown where it was dashed to pieces. He would
have proceeded to do the same with the remaining jars, had not Mr.
Hay called out and protested against further destruction. The Kaid
therefore returned to his exercise of jumping till he was exhausted;
when he retreated to another fountain, which spouted in a marble
basin in the middle of the court, and sat on the top of it, in the midst
of the spray, until cooled after his exertions.
Delay after delay occurred, and a man less experienced than Mr.
Hay in the dilatory tactics of the Moslem might have been baffled by
the ‘feather-bed resistance’ that encountered him at every turn.
Again and again he writes to his wife in the same strain, ‘I do not
despair of doing some good, but there are some sad rascals here.’ ‘I
am riding them with a tight hand and spurs. What a faithless set they
are.’ And after an even more discouraging day than usual, he comes
to the conclusion that ‘In Morocco a man can be certain of nothing.’
Of the ignorance, combined with cunning, of the generality of
Moorish officials, Mr. Hay frequently related the following story.
On this Mission to the Court of Morocco, he took with him a large
map of Great Britain, her possessions and colonies, also maps of
France, Germany, &c., as a present to the Uzir, with the idea of
impressing that functionary with the extent and importance of the
British Empire.
Having presented them to the Uzir, he proceeded to explain the
different maps, and proved, as he thought, to that dignitary, the fact
that our Sultana reigned over the largest territories and was
therefore the greatest Sovereign in the world.
‘Sebarkallah,’ said the Uzir, ‘God is great. And you say all these
countries belong to Great Britain?’
 ‘Yes,’ replied Mr. Hay, ‘Our Queen rules over them all.’
The Uzir stroked his beard, considered for a while and resumed,
‘These are very beautiful maps. Where was that one made?’—
pointing, as he spoke, to the map of Great Britain and her foreign
possessions.
‘In London,’ was the reply, ‘and it has received the approval of the
British Government.’
‘Ah,’ said the Uzir, ‘if we made a map of Morocco, we might also
make out, on paper, that we possessed immense territories!’
At last, however, Mr. Hay’s resolution triumphed over all
obstacles.

‘Thank God,’ he writes to his wife from the camp at El Kántara on April 18, just
a month after his arrival, ‘we have started from Marákesh. The Sultan has
requested us to remain here the first night; but to-morrow we move on a good
day’s journey, and please God we shall reach Tangier on the sixteenth day. I am
altogether pleased with the result of my mission. I have, entre nous, obtained one
thousand oxen annually for our troops, in addition to the two thousand which are
now exported, and also the abolition of the monopoly of sale of oxen. The
negotiation of the Treaty is to be commenced in a few months; in the meantime
some reforms are to be brought forward. The basis of the Treaty, which is abolition
of monopolies and reduction of duties, is acknowledged; but time is to be given for
these slow folk to make alterations in the fiscal system.
‘Apologies have been made for past folly and discourtesy. Everything done to
please. A number of small affairs have been arranged. The Sultan gave me an
audience yesterday to take leave and was most kind.’

Yet early in the following year H.S.M. repudiated his

engagements.

‘Only think,’ Mr. Hay writes in January, 1856, ‘of this Government, after all its
solemn engagements to me at the Moorish Court, pretending now to ignore all that
has passed and been promised. I have been compelled to enter a protest against
them; which has been done in the presence of all my colleagues. Forty days are
given to the Sultan to act up to his engagement, and then, nous verrons if these
barbarians think they can lie with impunity. After my experience of the past and of
various affairs, I expect that, as naughty people say of the ladies, though always
denying and refusing to accede, they will give way even when so doing.
“Vederemos.”’

Six months later he is still engaged in negotiating the Treaty with

Sid Mohammed Khatíb, the special Commissioner appointed to draw
up the Treaty. He writes on July 11, 1856, to his wife who had left for
England:—

Another letter from Khatíb making fair promises, but treaties are in statû quo.
Next week, or about the end of the month, I think we must be at Tetuan to sign, or
else tell the Sultan he is a liar. The cholera is about over. I shall do my best to get
home in August, for Tangier is a dreary hole to be alone in.

But his hopes were premature. On August 10, he writes again:—

I give up all hope of coming home this year, for I have fresh trouble. After all my
labour in settling the Treaty with Khatíb, the Sultan refuses to ratify what his own
Plenipotentiary agreed to! And he puts forward fresh propositions.
I go to Tetuan in one of Her Majesty’s steamers as soon as the wind changes,
to see Khatíb, and perhaps shall touch at other ports in Morocco.

Ten days later, the goal was still distant.

Tangier, August 21, 1856.

Since I last wrote I have been to Tetuan in H.M.S. Vesuvius; not, alas! to sign
the Treaty, but solely to discuss the fresh and stupid propositions put forward by
this Government. It is not impossible that I may have to make a trip to Mogador
and the other ports; if so, of course I shall go by sea.
Khatíb expects the Sultan will give way after the present reference. I am less
sanguine and am heartily tired of Moorish trickery.
Khatíb was excessively civil, and had prepared me a nice house, with a garden,
in the Moorish quarter. The house was furnished splendidly in the Moorish style.
The walls covered with velvet hangings embroidered in gold; Persian carpets
covered the floor. There was also a magnificent brass bedstead with damask and
gold hangings.