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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

© 2018, Elsevier Inc. All rights reserved.

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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
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 INTESTINAL INDIGESTION AND
OBSTRUCTION IN BIRDS.

Causes: Age, debility, atony, matting of feathers, dry or indigestible food, lack of
water, diseased oviducts, sand or gravel, lack of pebbles or power in gizzard.
Lesions: masses of egg, uric acid, or fæces in cloaca, implicating colon and cæca.
Symptoms: dullness, stupor, vertigo, staggering, erect plumage, trailing wings and
tail, bulging anus, covered with matted feathers, impaction felt by finger.
Treatment: extract mass, castor oil, laudanum, chalk, bismuth, pepper,
demulcents, phenol, exercise, silage, green food, pebbles.

Causes. These resemble those already noted for the dog. Old age,
debility, and atony of the bowel, the matting together of feathers
across the anus, dry feeding, indigestible food, scarcity of water, and
lack of exercise are especially to be noted. Malformations or other
changes lead to obstruction of the cloaca, and of defecation. Sand
and gravel passing from an atonic gizzard accumulate in the small
intestine or in the cæca distending them to great excess. Imperfect
trituration in the gizzard, from lack of pebbles, may prove a factor in
stoneless prairies.
Lesions. The most common seat of obstruction is at the cloaca, and
the impacted matter may be yellow partaking of the nature of yolk of
egg, or it may consist of feculent matters and uric acid in various
proportions, white, hard and fœtid. As in the dog this distension may
be continued forward blocking the colon and cæca as well. Lucet
mentions a case in which the impacted mass measured seven inches
long, and eight in circumference at its posterior and larger end.
Symptoms. The bird is dull, sluggish, stupid, giddy or unsteady on
its limbs, with feathers erect, wings, tail and head pendent and loses
flesh rapidly. Often a felted mass of feathers and fæces cover the
anus. In its absence there appears the rounded swelling or on
manipulation the impacted cloaca or rectum can be felt firm and
resistant.
Treatment. Soften and remove the external mass of fæces by the
aid of tepid water, clip off the feathers, which would tend to restore
it, then by the oiled finger and warm water injections break up and
extract the contents of cloaca and rectum. If impaction remains
farther forward give a teaspoonful of castor oil. If diarrhœa has
already set in, give 5 drops laudanum, and mix chalk or bismuth and
pepper in a mush to be fed to the patient. Injections of slippery elm
containing a teaspoonful of carbolic acid in the pint will prove useful.
The bird should be allowed plenty of exercise, its grain being fed
on a floor covered lightly with straw to encourage scratching, and
silage or green food should be allowed. On the prairies where pebbles
cannot be secured, imported gravel or vitrified brick broken into
small pieces should be allowed.
 COLIC IN SOLIPEDS FROM VERMINOUS
EMBOLISM. INTESTINAL CONGESTION.
Definition. Causes: presence of sclerostoma in arteries, form, habit, nature,
immature, biology, life in bowel, in submucosa, in arteries, outside the mammal,
pathogenesis, blood-sucking, verminous cysts, verminous aneurisms, seats of
latter, coagula, embolism, stagnation of blood, œdema and thickening of intestine,
mesentery, fermentations, tympany, infective inflammations, blood extravasations,
infection of liver and spleen. Symptoms: sudden attack, violent colics, reckless
movements, frequent defecation followed by its arrest, palsy of peristaltic
movement, of pain, prostration. Course: two to twenty-four hours, death from
indigestion, tympany, obstruction, hemorrhage, poisoning, recovery, sequelæ,
laminitis, intestinal catarrh or atony, debility. Treatment: aneurism worms beyond
reach, treat lesions, venesection, anodynes, stimulants of peristalsis, antiseptics,
compresses, sinapisms. Prevention: expel intestinal worms, exclude embryos,
tartar emetic, iron sulphate, arsenic, phenol, pure water, occasional vermifuges.
Definition. Congestion and spasms of the intestines in connection
with blocking (thrombus or embolism) of the mesenteric arteries,
and verminous aneurism.
Causes. The essential cause is the migration of the sclerostoma
equinum (strongylus armatus, Rud.) into the mesenteric arteries in
its agamous condition. It seems appropriate therefore to here notice
the life history of this parasite.
The sclerostoma equinum (strongylus armatus) is one of the
common pin worms of the horse. It is distinguished by its dull gray
or reddish brown body, thickest at the cephalic end and tapering off
toward the caudal, but ending in a blunt point; by the round, open
mouth furnished with several firm chitinous rings, of which the outer
bears six short symmetrically arranged papillæ, an intermediate row
of rounded blunt tooth-like projections, and the innermost a row of
fine, closely aggregated and very sharply pointed teeth for
penetration of the mucosa. Male ¾ to 1½ inches long, with caudal
membranous alæ in two lateral lobes, joined by a rudimentary
central lobe: two delicate spicula. Female ¾ to 2 inches long, blunt
pointed tail, vulva in posterior half of the body. Eggs ovoid with
slightly raised ring around the centre: oviparous.
 Habitats. They are found in solipeds in two stages of existence, the
mature worms in the cæcum and colon, and the immature in the
same organs encapsuled in little pellets of manure, and in cysts in the
mucosa but also apart in the arterial system especially in the anterior
mesenteric artery and other gastric or intestinal trunks.
The mature sclerostomata are found attached to the mucosa of
the large intestine into which the head is sunk for the purpose of
sucking the blood, and they may be gray, brown or red according to
the quantity of blood which they have imbibed. The author has found
them in little hernial sacs of the mucosa hanging from the peritoneal
surface.
The sexually immature sclerostomata are found in little pill-
like masses of ingesta in the large intestines and from which they
project part of the body through a narrow opening. Another habitat
is in cysts of the mucosa of the cæcum and colon and less frequently
of the small intestine, individual cysts varying in size from a pin’s
head to a hazel nut, and containing the young worm rolled upon
itself, and varying in size but always less than the intestinal worm
and always asexual. In some cases the cyst is found empty but with a
small opening toward the lumen of the bowel showing the means of
escape of the parasite. A third habitat of the immature worm is in the
blood-vessels, especially the posterior aorta and its divisions, and
still more constantly the anterior and other mesenteric arteries.
Biology. The ova of the sclerostoma are segmented in the oviduct
but are hatched out after they have been laid. The hatching may be
effected in the intestine or in manure or water external to the body.
When hatched out in the intestine they may pass out at once with the
manure or they may envelop themselves in pellets of the finer ingesta
and remain for a time in the bowel and finally pass out in this
condition. Baillet has traced their development out of the body. In a
watery or damp medium they are hatched out in a few days as a
cylindroid worm ¼ to ⅓ mm. long, thick in front and with a filiform
tail. In moist environment but especially in damp manure they grow
to 1 mm. or 1.5 mm. and continue for months in this condition, but
remain small and asexual, until taken in, in the drink or green food
of the soliped. Reaching the intestine and especially the cæcum and
colon they bore their way into the mucosa and encyst themselves, or
if they happen to perforate a blood-vessel they make a habitat of that.
In the cyst, development proceeds and when it has reached a certain
stage the worm once more bores its way through the mucosa and
reaching the intestine becomes sexually mature.
In this last migration the young worm is liable to perforate a
blood-vessel in which case it is destined to a period of existence in
the blood. It may, however, have blundered upon a blood-vessel at an
earlier stage when seeking a temporary home in the mucous
membrane, so that the sclerostomata of aneurisms may be derived
from two separate sources. In the blood-vessels the parasite attains a
length of 1 to 8 lines, whereas in the mucous cysts it does not exceed
3½ lines. Yet Neumann holds that after leaving the blood-vessels
they may again encyst themselves in the mucosa before escaping into
the intestine.
Several moultings take place in the asexual condition.
Other views have been advanced as to the development of the
sclerostomata. Colin believed that the ova deposited in the ducts of
the mucous glands and in the perforations made by the parasite in
blood-sucking, hatched in this situation and the embryo at once
encysted itself in the mucosa.
Leuckart imagines that the embryo found in the fæces or in water
outside the body of the soliped, should pass through an intermediate
host before it can return to gain sexual maturity in the horse. But no
evidence of the existence of such intermediate host is furnished, and
the encysted intestinal worms show no indication of a special
development which would have been accomplished in such host.
Willach holds to a hermaphrodite stage passed in the intestine of
the soliped. He found in the bowel small worms apparently related to
the sclerostomata by the appearance of the head and the caudal
membrane, but not exceeding three to five lines in length. Some were
evidently females and contained not only eggs with soft shells, but in
one case embryos. Others had the caudal membrane of the male, yet
contained also a few eggs. There is no vulva and the embryos escape
by rupture of the oviducts. These embryos he supposes are developed
in the same host into the familiar mature sclerostomata.
Whatever may be said of those alleged modes, the first described
series of changes and migrations may be taken as the usual and
regular method of development.
 Pathogenesis. Lesions. These embrace perforations of the
mucosa, cysts, aneurisms, embolisms and congestions.
Irritation of the mucosa. The adult worms, like so many
leeches are continually biting and sucking blood from the mucosa
and when present in large numbers, hundreds, thousands, or a
million create an aggregate of irritation which may determine violent
indigestions and congestions.
Verminous Cysts. These are like a pin’s head, a pea or hazel nut,
containing the asexual worm in a mass of purulent debris, or if
empty, presenting a small orifice where it made its exit.
Verminous Aneurisms. These are perhaps the most important
lesions caused by the sclerostome as they are the steppingstone to
the dangerous embolisms, and too often fatal colics and congestions
of the intestines. They are very common in some localities, and rare
in others following the distribution of the sclerostomata. Bollinger
found them in 90 to 94 per cent. of adult horses, and Ellenberger in
84 out of 85 horses dissected. They are found in all ages from six
months up, and are nearly always in the short, stubby trunk of the
anterior mesenteric artery. Often two or three exist in the same
animal, the whole length of the posterior aorta showing patches of
disease, exudations, neoplastic elevations alternating with
depressions, and aneurisms and thrombosis in its different branches.
In 100 horses Bollinger found 168 aneurisms, 153 in the anterior
mesenteric, and its divisions, 4 in the cœliac axis and its divisions, 3
in the hepatic artery, 3 in the posterior mesenteric artery, 3 in the
renal arteries and 2 in the posterior aorta.
The special predisposition of the anterior mesenteric artery is
variously accounted for: 1st. There is the obvious fact that its
branches are distributed to the cæcum and double colon, the home of
the mature parasite, and to the small intestines which are first
reached by the young parasites that are taken in with the water and
the food. These are therefore most likely to get into the branches of
this vessel and to follow them up toward its origin. 2nd. The anterior
mesenteric artery distributes its branches to the small intestines the
most motile portion of the intestinal tract, and the cæcum and colon
the most heavily loaded with solid ingesta, it is therefore the most
subject to traction, and distensions, and the more so that the parent
trunk is extremely short and the divisions pass in all directions and
to a large extent at right angles, so that there is a dragging of the
walls apart as well as an obstruction to the blood flow and an
increase of internal tension. The distension, laceration, inflammation
and softening of the internal coat have accordingly been regarded as
the starting point of an endarteritis upon which the parasites have
been implanted as a further cause of trouble. We must not forget,
however, that the sharp circle of teeth of the parasite, by which it
fixes itself on the intima of the vessel are quite enough to produce
initial endarteritis, without any assistance from distension, traction
or laceration.
The irritation of the intima from whatever cause determines here
as elsewhere exudation, and coagulation, and the inflamed walls
losing their tone yield more and more readily to the internal tension.
Sometimes the coagulum lines the aneurism or vessel all round,
leaving a narrow central passage through which the blood still flows;
in other cases the clot extends into the adjacent smaller vessels,
completely blocking them and disturbing circulation and innervation
in the parts which they supply. As a rule the parasites are found in
galleries hollowed out in the clot, and heads or tails may be seen to
project into the circulating blood. Sometimes they are found
imbedded in the arterial coat, or in an adjacent small abscess. The
formation of aneurisms in the other arterial trunks may follow the
same method.
Embolisms. These come very naturally from the formation of
thrombi in the various arteries. The coagulum determined by the
presence of the worms, tends to undergo retrogressive changes
notably fatty degeneration, to which germs brought on the worms or
in their alimentary canals contribute. This together with the
movements of the parasites tends to break up the mass, and minute
portions are washed on into the different smaller vessels. Soon these
reach divisions which are too small to admit them, which are
accordingly occluded and the circulation through them abolished.
The presence of microbes as well as fibrine contributes to cause
further coagulation, more absolute embolism and arrest of the
circulation.
It is further alleged that the sexual instinct in the summer months
(May to August) leads the worms to leave the aneurisms, to pass
through the smaller divisions to the cæcum or colon where alone full
sexual evolution is possible. In these migrations they cause the
thrombosis of the smaller trunks and determine the verminous
congestions of the bowels which are especially common in these
months.
Disturbances of the Intestinal Circulation. As these usually
occur in the lines of distribution of the anterior mesenteric artery a
knowledge of its divisions and their destination and anastomosis, is
essential to an intelligent understanding of the pathogenesis and
lesions. As first pointed out by Lecoq the anterior mesenteric artery
is divided into three primary bundles: (a) a left of 15 to 20 trunks
which are destined to the small intestine; (b) a right which gives off
cæcal branches, one to the double colon, and one to the ilium to
anastomose with the last trunk of the left bundle; and (c) an anterior
which gives one branch to the second division of the double colon
and anastomosis with the colic branch of the right bundle at the
pelvic flexure; and a second branch to the floating colon to
anastomose with the posterior mesenteric artery.
The divisions of the left bundle anastomose so freely with each
other in the mesentery and immediately above the intestine that the
blocking of any one branch cannot entirely arrest the circulation in
the corresponding part of the intestine. It may however produce a
partial local stagnation in the vessels of a short loop of intestine,
resulting in œdematous infiltration and thickening with resulting
induration and stricture of the gut. Chronic and permanent lesions
are produced by such blocking, but only rarely acutely fatal ones.
Acute and fatal congestive lesions of the small intestine from
verminous embolism, occur only when several adjacent divisions of
the artery are blocked at once, and this is a rare occurrence.
The right bundle of branches furnishes the only two arteries which
are supplied to the cæcum and the only artery furnished to the first
half of the double colon. The ileo-cæcal branch is less involved, first,
because being less dependent and smaller, it is less likely to receive
an embolus, and, second, because any lack of blood supply is
counterbalanced by the free anastomosis with the last iliac division
of the left bundle. When the embolus blocks the undivided trunk of
the right bundle this same principle comes into play, the free supply
of blood from the posterior branch of the left bundle supplying blood
through its anastomosis with the iliac and cæcal branches of the
right.
But when the emboli are lower down, in the cæcal branches of the
right bundle, or in these and the colic branch, arrest of the
circulation in the intestinal walls ensues, followed by paresis, passive
congestion and hemorrhage. The cæcum and double colon thus
become the seats of the grave and fatal lesions of verminous
embolism.
The resulting lesions are to be variously accounted for. The
stagnation of blood in the vessels below the embolus, determines a
speedy exhaustion of its oxygen and increase of its carbon dioxide, so
that it is rendered unfit to maintain the normal nutrition and
functions of the part, and the capillary and intestinal walls are alike
struck with atony or paresis. The blood filters into the stagnant
vessels slowly from adjacent anastomosing trunks, and the liquor
sauguinis exudes into the substance of the tissues and lumen of the
intestine, leaving behind the greater part of the blood globules so
that the stagnant blood is rendered more and more abnormal in
composition. The walls of the capillaries soon lose their cohesion as
well as their contractility, and giving way at different points, allow
the escape of blood into the tissues, bowels and peritoneal cavity. It
has been further claimed that the emboli already infected and in
process of degeneration communicate this to the walls of the vessels
and to the stagnant blood, hastening the process of degeneration and
rupture.
Another series of circulatory disorders are liable to take place. The
blocking of the vessels of the right bundle, tends to increase the
blood pressure in the left bundle and the anterior one, and thus to
determine congestions, paresis and inflammations in the small
intestines, the second division of the double colon and the floating
colon. The resulting inflammation and increased vascular tension
may lead indirectly to implications of the brain and lung.
Extravasations so extensive as to appear like blood clots may be
present between the layers of the mesentery or in the mucosa and
submucosa, and blood, liquid or coagulated, may have accumulated
in the abdominal cavity. Blood effusion into the intestine gives a dark
red coloration to the contents which are further mixed with distinct
clots.
 The atonic bowels are always the seat of extensive fermentations
and tympany. The microbes engaged in these fermentations and
their toxins, are accountable for toxic changes occurring in the locally
diseased parts and in distant organs. To this may be attributed the
congestion and softening of the liver and the engorgements and
hemorrhagic centres in the spleen.
Symptoms. An animal, perhaps known to harbor the sclerostoma
equinum, is suddenly attacked with violent and persistent colic. He
trembles, paws, moves his hind feet uneasily, kicks the abdomen,
throws anxious looks at the flanks, crouches, lies down, rolls, gets up,
and at once gets down again. The intensity of the suffering rapidly
increases, the face is drawn and pinched, the eye is extremely
anxious, the patient no longer lies down, but throws himself down
reckless of consequences, when down he is not quiet for an instant,
but now on his breast, then on his side, then on his back, the limbs
struggling and jerked violently, the head turned first to one side and
then to the other, he is a picture of extreme agony. If made to walk
the same indications continue; he walks with head down and limbs
semiflexed ready to drop at any moment, and often he will drop
suddenly in spite of every effort to keep him on his feet. The pulse is
at first strong and full, but as extensive effusion takes place into the
bowels or abdomen, or as the animal is poisoned by toxins, it
becomes small, weak, and it may be imperceptible. Breathing is
quick and catching, and the mucous membranes are dark red.
Sweating which shows first about the elbows or flanks or back of the
ears finally becomes general, the surface cold and the limbs
especially so. Fæces may be passed at first, a few dry balls at a time
from the floating colon or rectum, but soon they are suppressed
entirely. Some patients strain frequently to micturate but pass little
at a time.
In some instances the acute pain seems to suddenly cease, but
there is no general improvement, the patient stands with head
depressed, eyes sunken and expressionless, ears lopped, cold
perspiration, chilly limbs, unsteady gait and imperceptible pulse. It
implies merely a paralysis of the affected bowels in connection with
the extensive congestion and extravasation.
Course. Duration. The more acute cases reach their acme with
great rapidity, death may occur after two hours illness, and in other
cases it may be delayed ten or even twenty-four hours. It may be
caused by indigestion and tympany, by volvulus or invagination, by
excessive hemorrhage, or by poisoning with toxic matters.
Recovery occurs when the vessel blocked is an unimportant one as
a branch of the left bundle so that circulation may be reëstablished
from collateral trunks; or when a more important trunk has been but
partially blocked, and after a time it either clears itself, or collateral
circulation comes in with sufficient compensation. There is a more or
less rapid disappearance of the colics and other symptoms, a free
passage of urine, the rejection of fæces, it may be in a liquid, semi-
liquid or sanguineous condition, yet enough to indicate the
restoration of intestinal tone. The patient begins to pick morsels of
food and soon acquires his former appetite.
In some instances, however, the recovery is not complete. Trasbot
has noted a case of laminitis occurring within fifteen hours after the
improvement, and in other cases there remain chronic debility and
catarrh of the intestines. The appetite remains poor, there are
occasional colics, the bowels are irregular, loose or costive, and the
fæces are dry, glossy and covered with mucus. The back is arched,
the belly tucked up, strength and vigor are both lacking, and the
patient spends much time in the recumbent position.
Complications of various kinds may follow as in other diseases of
the intestines. After even the best recoveries, a relapse is always to be
apprehended as the original cause remains and the animal is liable to
be cut off at any time.
Treatment. This is very unsatisfactory as the original source of
trouble, the worms, being in the blood-vessels, cannot be reached by
vermifuges that would be harmless to the host, and clots blocking the
smaller intestinal vessels, cannot be dissolved and removed.
Moreover, although we could compass the death of the worms in the
aneurisms, we would leave their dead bodies as sources of septic
change, blood coagulation and embolism.
A certain number of cases, however, are not necessarily fatal, and
the worms of the blood-vessels have not an indefinite period of life,
so that there is some encouragement for both therapeutic and
preventive treatment. During the attack we must be content to treat
symptoms. French veterinarians still trust largely to general
bleeding, adopted at the very outset and to the extent of 6 to 10
quarts. It will temporarily lessen the vascular tension, more
permanently dilute the blood, and calm nervous excitement, and in
the most violent cases, as a kind of forlorn hope, it might be tried
with the view of tiding over the acute stage until a freer collateral
circulation could be established.
The use of anodynes will be more generally acceptable to American
practitioners. Two to four grains of sulphate of morphia or codeine
may be given hypodermically in combination with 1½ gr. eserin, 7
grs. barium chloride, or 2 grs. pilocarpin, to secure a speedy
movement of the bowels.
To counteract intestinal fermentation perhaps no better agent can
be got than chloral hydrate, ½ oz. of which may be given by the
mouth in water, and ½ oz. more by the rectum.
Wet compresses to the abdomen, or fomentations with water
rather hotter than the hand can bear or even the application of
mustard is sometimes useful as a soothing or derivative agent.
In the absence of morphia or chloral, laudanum, ether,
chloroform, camphor or assafœtida have been recommended.
It is important to keep the patient on a soft, littered floor to
prevent injury from his throwing himself down, and walking him
around may be resorted to for the same purpose.
Prevention. After a non-fatal attack and in every case in which a
horse is found to harbor the sclerostoma equinum in quantity,
measures should be taken to expel those present in the bowels and to
prevent the entry of embryos. The infested horse may be purged and
put on two drachms each of tartar emetic and sulphate of iron every
morning in a handful of feed half an hour before the first meal. After
six doses he may take a second active purgative. In case of need the
addition of 6 grains arsenious acid and a drachm of carbolic acid to
each dose will render them much more effective. All water must be
withheld that comes from streams running by farm-yards, from
ponds or open wells in barn-yards, from uncovered cisterns and from
any source which receives drainage or leaching from land occupied
by solipeds or spread with their manure.
A course of vermifuge medicine should be given at intervals of two
or three months to get rid of the worms which have passed in the
interval from the cysts of the colon, into the intestine.
 NON-VERMINOUS INTESTINAL
CONGESTION IN SOLIPEDS.
Causes: sudden changes to green food, or leguminous fodder, newly harvested
fodder, frosted food, iced water, microbian infection, toxin poisoning, intestinal
fermentations, experiments, volvulus, invagination, strangulation, compression,
atony. Symptoms: as in verminous aneurisms. Diagnosis: absence of worms,
presence of other causes. Treatment.
Causes. Acute intestinal congestion apart from verminous
aneurisms is ascribed to a variety of causes. Sudden changes of food
especially to green food, in spring, or to some of the leguminous
fodder plants (alfalfa, cowpea, clover, tares, vetches), newly
harvested grain or hay, fodders covered with hoarfrost, iced water,
and microbian infection or poisoning with toxins or other irritant
products of intestinal fermentations. Experimentally the injection
into the circulation of pyogenic toxins and putrid matters has
determined intestinal congestion and hemorrhage. In the same way
musty hay or grain have proved the occasion of these attacks. Finally
mechanical blocking of the circulation of the intestine as by volvulus,
invagination, strangulated hernia, or even compression by bulky
food has seemed to operate in this way.
It ought to be borne in mind that the habitual microbes of the
healthy bowel may become pathogenic when brought in contact with
a mucosa which is the seat of irritation, atony or any condition of
debility.
Symptoms and Lesions. The verminous aneurisms and thrombosis
aside, the symptoms and lesions of this form of congestion so closely
resemble those of the verminous affection that it seems needless to
repeat them.
Diagnosis is difficult but the absence of worms in the affected
animals and their fellows, and the presence of some one of the other
recognized causes may lead to a fair conclusion.
Treatment of the affection is more hopeful than in the verminous
affection, and may be conducted on the same general lines.
 PSEUDOMEMBRANOUS (CROUPOUS)
ENTERITIS IN SOLIPEDS.
Definition. Causes: As in ordinary enteritis, with added infections or toxins.
Symptoms: As in enteritis, nervous symptoms, diarrhœa. Lesions: Congested
mucosa, whitish or grayish false membranes, in patches or tubular casts, granular,
mucous, albuminoid, fibrinous. Diagnosis: False membranes in stools. Treatment:
Glauber salts, calomel, alkaline carbonates or tartrates, oils, antiferments,
demulcents, careful diet, bitters.
Definition. An inflammatory affection of the bowels characterized
by the ejection with the fæces of false membranes.
Causes. It has been long attributed to the causes which produce
other forms of enteritis and indigestions, as youth, rich stimulating
feeding, sudden change to green food in spring, sudden chills, over-
fatigue, confinement indoors, and prolonged costiveness. In man it is
found as a sequel of infectious diseases (pneumonia, pyæmia), in
Bright’s disease, cirrhosis of the liver and cancer, and in poisoning by
lead, mercury or arsenic (Osler). Cadeac, who found great numbers
of streptococci in the false membranes in animals, is certain it is a
microbian disease, and this is doubtless true, if qualified by the
statement that the microbe as is so often the case with other
intestinal affections, requires an occasion in the form of a diseased or
debilitated condition of the mucosa to enable it to become
pathogenic. The disease is not known to propagate itself indefinitely
or without such a predisposing occasion.
Symptoms. There are dullness, prostration, langor, hyperthermia,
accelerated pulse, and colics which may be slight or very severe. In
some cases nervous symptoms have been observed, such as
irritability or stupor and somnolence with icterus and fœtid stools.
The fæces are usually semi-liquid, implying an excessive liquid
secretion as well as the exudation of the membranous matter.
Lesions. There is a pink congestion of the intestinal mucosa more
or less generally distributed. Whitish false membranes cover patches
chiefly on the terminal portion of the small intestine, but frequently
also on the cæcum and colon, covering an especially red and angry
mucosa. They may occur as simple patches, as ribbon shaped pieces,
or as hollow cylinders lining the entire circumference of the
intestine. They appear as if fibrillated, but contain abundance of
granular matter and seem to be composed mainly of mucus with
albuminoid matter and probably a little fibrine. The deeper layers, in
contact with the inflamed surface are soft and gelatinoid. It is alleged
that coexisting wounds on other parts of the body become covered by
a soft pultaceous false membrane.
Diagnosis is based on the presence of the false membranes of a
considerable thickness, so that they can be distinguished from the
film of mucus which covers the fæcal balls in constipation or enteric
catarrh.
Treatment. Facilitate the secretion from the mucosa, and the
separation of the false membrane by giving 1 lb. Glauber salts, or give
this agent in doses of 5 or 6 ozs. per day. Calomel 1 dr. may be used
instead and has the additional advantage of acting as a disinfectant.
The alkaline carbonates or tartrates or even olive or castor oil may be
used as substitutes. Antiferments like salol, naphthol, salicylic acid,
and salicylate of soda have been prescribed to check the
multiplication of the germ. Flaxseed tea, elm bark, and other
mucilaginous agents may also be given. An easily digestible and
laxative diet and a course of bitters may follow.
 PSEUDOMEMBRANOUS (CROUPOUS)
ENTERITIS IN CATTLE.

Causes: as in solipeds, youth, overfeeding, plethora, dietetic blunders,

temperament, over-exertion, chill when heated, gestation, foul water, irritants,
drastics, infections. Symptoms: as in enteritis with false membranes,
complications. Duration. Lesions: false membranes, extent, color, structure,
composition, congested mucosa. Treatment: Glauber and other salts, pilocarpin,
potassium iodide, antiseptics, sulphites, sulphides, borax, bismuth, naphthol,
creolin, muriatic acid, bitters.

Causes. The same causes are quoted as in solipeds, youth, extra

high condition, rich feeding, sudden change to the green food of
spring, climatic vicissitudes of the same season, a sanguineous
(Reynal) or lymphatic (Friedberger and Fröhner) temperament,
overwork, exhausting travel, suppressed perspiration, gestation,
plethora, foul drinking water, special irritant plants (chicory,
Huzard), and drastic purgatives. Cadeac suggests bacteria, quoting
instances of a fifth or a fourth of a herd suffering at once. The same
would come from any other cause acting on the whole herd and it
seems probable that a microbian factor is present but can find
occasion for its pathogenesis only in given morbid conditions of the
mucous membrane. This would explain the failure of the affection to
propagate itself like a plague, and at the same time its tendency to
manifest itself extensively in given herds with a common
predisposing condition.
Symptoms. There are indications of enteric inflammation and
fever, rigors, slight hyperthermia, drying up of the milk secretion,
impaired or suspended appetite and rumination, constipation, colicy
pains, increasing dullness and prostration. As the disease advances
the excrements become soft, pultaceous or watery, with floating hard
baked pieces, dark and even glistening on the surface and more or
less false membranes. These are sometimes stained with blood,
which may also be mingled with the liquid debris. As in solipeds
these membranes constitute the only true diagnostic symptom. They
may appear as shreds, bands or complete cylindroid casts of the
intestine.
Other complications, like pseudomembranous exudate on wounds,
abortions and profound weakness are sometimes noted. The disease
may last eight days before ending in recovery. When death takes
place it is about the fourth or sixth day.
Lesions. The false membranes are found on the ilium and colon, in
thin films or in thick masses, or tubular casts. In extreme cases the
membrane has covered an extent of 24 feet in length, and if recent it
is soft and friable. If older it may be firm, consistent and yellow or
stained by the blood or ingesta. As in solipeds it shows a reticulated
network and a fine granular structure, and is composed mainly of
inspissated mucus with albuminoids and fibrine. The exudate covers
a surface of extreme redness, with points of darker blood-staining
and even abrasion or ulceration. The surrounding mucosa is also
congested, the villi hypertrophied, the mucous follicles swollen.
Treatment. In the early stages a laxative of soda sulphate is of
especial value in depleting from the inflamed mucosa, liquefying the
secretions and dissolving and loosening the false membranes. Epsom
salts, cream of tartar, Rochelle salts, calomel, and pilocarpin are
more or less valuable substitutes. Iodide of potassium is most
valuable in dissolving the exudate and acting as a microbicide (dose
3–4 drs.).
Other alkaline salts may be substituted or as antiseptics the
sulphites, hyposulphites, or sulphides of potash or soda. Borax,
bismuth, naphthol and creolin have also been recommended.
Enemata of warm water are desirable.
In very adynamic conditions, muriatic acid (½ dr. doses) may be
given with vegetable bitters and the same may be allowed during
convalescence.
 PSEUDOMEMBRANOUS (CROUPOUS)
ENTERITIS IN SHEEP.
Causes: As in cattle, draughts in folds, overfeeding. Symptoms: fever,
inappetence, weakness of hind parts, diarrhœa, tenesmus, false membranes, blood
in stools, tympany. Treatment: change diet of dam, exercise, Glauber salts,
potassium iodide, bismuth, flaxseed, elm bark, mallow, gum, carminatives, bitters,
antiseptics.
Causes. The same causes are claimed as for cattle. Clavel
attributed it to too rich milk, and exposure to cold draughts, in
folded lambs.
Symptoms. To the general symptoms of fever are added refusal of
the teat, weakness or paresis of the hind limbs, looseness of the
bowels and the ejection of false membranes with an unusual amount
of straining. The dejections may be watery and mixed with blood. In
some cases defecation is suppressed, the intestines being blocked by
the membranes, and then acute indigestion and fatal tympany may
follow.
The pathological anatomy and lesions resemble those seen in the
ox.
Treatment. Change the diet of the ewe, and allow more outdoor
exercise. Give the lamb Glauber salts (½ to 1 oz.) with potassium
iodide (10 grs.), and bismuth (1 dr.). Decoctions of flaxseed, or
solutions of elm bark, mallow or gum arabic are desirable, and
infusions of aromatic plants or oils of peppermint, anise, or fennel
may be added with quinia. As in the other animals such antiseptics
as salol, naphthol, naphthalin, boric acid, or salicylate of soda may be
administered.
 PSEUDOMEMBRANOUS (CROUPOUS)
ENTERITIS IN DOGS.
Complication of other diseases like distemper. Symptoms: fever, retching,
vomiting, tense, tender, tympanitic abdomen, irregular bowels, false membranes.
Lesions: stomach empty, congested, croupous exudate, extravasations. Treatment:
sodium sulphate, boric acid, sodium salicylate, salol, bismuth, by mouth or enema,
strychnia, vermifuges.
In dogs the formation of false membranes on the intestinal mucosa
seems to have less of an individual character, and is found associated
with other affections, like canine distemper and parasitism. In the
absence, however, of accurate knowledge of the specific cause of
croupous enteritis in other animals it seems permissible for the
present, to arrange the whole in one class characterized by the
presence of false membranes.
Symptoms. Along with the general symptoms of fever and the
special ones of the existing specific disease there is more or less
disturbance of the digestive organs, anorexia, vomiting, tense,
tender, perhaps tympanitic abdomen, irregularity of the bowels and
the passage of the false membranes. A morose disposition and
tendency to snap has been noticed by Röll.
Lesions. The stomach is empty with red or dark mottled mucosa,
the intestinal mucosa is congested covered with a layer of
mucopurulent exudate, and at intervals patches of false membranes
which are also found in shreds floating in the glairy contents. The
exudates are of a yellowish gray color, more or less streaked with
blood, and the mucosa infiltrated, swollen, highly congested and with
spots of extravasation of blood.
Treatment. Small doses (1 to 2 drachms) of sulphate of soda may
be given by the mouth, or boric acid (1 scruple), salicylate of soda (10
grains), salol (5 grains), or bismuth nitrate (½ drachm). Injections of
boric acid, borax, sodium hyposulphite, or even Glauber salts prove
useful, and powdered nux vomica (1 grain twice daily) may be added.
In case of intestinal parasites vermifuges must be resorted to.
 PSEUDOMEMBRANOUS (CROUPOUS)
ENTERITIS IN BIRDS.
In pigeons: Ærobic, non-motile bacillus, in lesions, membrane and internal
organs, pathogenesis, in chickens pathogenesis differs, also in man, parts attacked,
exudate, other symptoms, mortality early and late in outbreak, American form,
pathogenesis to rabbits and Guinea-pigs. Prevention: Avoidance of infection,
quarantine of birds, separation of sick, disinfection, accidental bearers of infection,
pigeons, buzzards, carrion crows, dogs, men, cleanliness. Treatment: Locally
antiseptics, phenol, boric acid, generally, phenol.
This has been especially seen in pigeons in which it has been
studied by Löffler, Cornil and Megnin, and Babes and Puscarin.
Löffler found an ærobic, non-motile, non-liquefying bacillus in the
false membranes, inflamed tissues, liver, lungs and blood, even in
the leucocytes. It formed irregular masses, and grew in nutrient
gelatine, blood serum and potato. It proved pathogenic to pigeons,
linnets, rabbits and mice, but not to hens, Guinea-pigs, rats or dogs.
Chickens, however, suffer from an acute diphtheritic affection caused
by a nearly allied bacillus, and it remains to be seen whether the
varying pathogenesis may not be due to the habit of long continued
growth in a particular genus and an acquired unfitness for growing
in the other. The pathogenesis is also different from the bacillus of
diphtheria of man, and the two diseases are not usually inter-
communicable, in spite of the fact that in rare instances infection has
appeared to have taken place from man to birds.
In pigeons and fowls the upper parts of the air passages and
digestive tract are mainly involved, the tongue, fauces, corners of the
mouth, nares, larynx, and conjunctiva. The bowels suffer less
frequently and mostly concurrently with the mouth, nose and throat.
The mucosa is deeply congested and in part covered by a yellowish
exudate which may accumulate in masses, and dry into a firm
substance. The disease affects particularly high bred birds, kept in
close warm houses, and is often imported by prize animals returned
from a show. There may be dullness, listlessness, sunken head,
trailing wings and tail, erect plumage, diarrhœa, and, if the nose and
throat are affected, a modification of the voice as in roup. Death may