WP Chung_OT in Head and Neck Reconstructive Surgery_97819751

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Operative Techniques in Head and Neck Reconstructive Surgery FIRST EDITION Publishes May 2019 SAMPLE CHAPTER PREVIEW

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When you have to be right

Operative Techniques in Head and Neck Reconstructive Surgery FIRST EDITION

ISBN 978-1-9751-2725-1 Price £195.00 / €220.00

Part of the best-selling Operative Techniques series, Operative Techniques in Plastic Surgery provides superbly illustrated, authoritative guidance on operative techniques along with a thorough understanding of how to select the best procedure, how to avoid complications and what outcomes to expect. This stand-alone book offers focused, easy-to-follow coverage of head and neck reconstructive surgery, all taken directly from the larger text. It covers nearly all plastic surgery operations for these specific areas that are in current use, and is ideal for residents and physicians in daily practice.

Features include:

Perfect for a quick preoperative review of the steps of a procedure. Comprehensively covers anesthesia, facial lacerations, scalp and calvarium, mandible, lip, eyelid, nose, facial nerves, and much more. Editors and contributors are globally renowned authorities in their respective subspecialties and are known for their surgical expertise.

Hundreds of full-color intraoperative photographs and illustrations, as well as numerous high-quality videos, capture procedures step by step and help you immediately apply your knowledge.

Publishes May 2019 Sample Chapter Preview

When you have to be right

Contributors

Cherry L. Estilo, DMD Attending Dentist Dental Service Department of Surgery Memorial Sloan Kettering Cancer Center Clinical Member Memorial Sloan Kettering Cancer Center Associate Professor of Surgery Weill Cornell Medical College Associate Attending Dentist New York Presbyterian Weill Cornell Medical Center New York, New York Adel Y. Fattah, PhD, FRCS(plast) Consultant Plastic Surgeon Director, Facial Nerve Programme Clinical Director Regional Paediatric Burns and Plastic Surgery Service Alder Hey Children’s NHS Foundation Trust Liverpool, United Kingdom Aaron Fay, MD Assistant Professor Department of Ophthalmology Harvard Medical School Boston, Massachusetts John G. Fernandez, MD, FACS Director of Plastic and Reconstructive Surgery Cancer Treatment Centers of America Philadelphia, Pennsylvania Jordan D. Frey, MD Resident Hansjörg Wyss Department of Plastic Surgery

Michael V. Chiodo, MD Plastic Surgery Resident Hansjörg Wyss Department of Plastic Surgery New York University Langone Medical Center New York, New York Ernest S. Chiu, MD, FACS Associate Professor of Plastic Surgery Director, Kimmel Hyperbaric and Advanced Wound Healing Center Assistant Professor, Plastic Surgery Washington University in St. Louis Saint Louis, Missouri Carrie K. Chu, MD, MS Assistant Professor Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, Texas Michael W. Chu, MD Kaiser Permanente Medical Group Department of Plastic & Reconstructive Surgery Los Angeles, California J. Alejandro Conejero, MD, FACS Assistant Professor of Surgery Division of Plastic Surgery Albert Einstein College of Medicine Montefiore Medical Center Bronx, New York Joseph H. Dayan, MD Division of Plastic & Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, New York J. Rodrigo Diaz-Siso, MD Postdoctoral Research Fellow Hansjörg Wyss Department of Plastic Surgery New York University Langone Health New York, New York NYU Langone Health New York, New York Gerald J. Cho, MD

Mouchammed Agko, MD Assistant Professor Section of Plastic Surgery Department of Surgery Medical College of Georgia at Augusta University Augusta, Georgia Daniel C. Baker, MD Clinical Professor Department of Plastic Surgery New York University Langone Medical Center New York, New York Robert Beinrauh, MD Head of Craniofacial Surgery Plastic and Reconstructive Surgery Department Kaiser-Permanente Hospital Downey, California Mihir K. Bhayani, MD, FACS Head and Neck Surgical Oncology NorthShore University HealthSystem NYC Prosthodontics New York, New York Richard H. Caesar, MA, MB BChir, FRCOphth Consultant Surgeon Ock Street Clinic Abingdon, England Edward I. Chang, MD, FACS Associate Professor Department of Plastic Reconstructive Surgery University of Texas MD Anderson Cancer Center Houston, Texas Hung-Chi Chen, MD, PhD, FACS Professor of Plastic Surgery Department of Plastic and Reconstructive Surgery China Medical University China Medical University Hospital International Medical Service Center Taichung, Taiwan Clinical Assistant Professor Pritzker School of Medicine University of Chicago Evanston, Illinois Lawrence E. Brecht, DDS

NYU Langone Health New York, New York

Evan S. Garfein, MD, FACS Associate Professor of Surgery Departments of Surgery and Otorhinolaryngology Albert Einstein College of Medicine Chief

Division of Plastic Surgery Montefiore Medical Center Bronx, New York

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Contributors

Evan Matros, MD, MMSc, MPH Associate Member Memorial Sloan Kettering Cancer Center Associate Professor Weill Cornell Medical College New York, New York Colleen McCarthy, MD, MSc, FRCSC Associate Attending Surgeon Department of Surgery Memorial Sloan Kettering Cancer Center New York, New York Babak J. Mehrara, MD Chief, Plastic and Reconstructive Surgery Service Member, Memorial Sloan Kettering Cancer Center New York, New York Hermann Memorial City Medical Center and Memorial Hermann Sugar Land Hospital Sugar Land, Texas Andre Panossian, MD Plastic Surgeon Private Practice Los Angeles, California Staff Surgeon, Division of Plastic Surgery Shriners Hospital for Children Pasadena, California Julian J. Pribaz, MD, FRCS(Edin), FRACS(Plastics) Professor of Surgery Morsani College of Medicine University of South Florida Plastic Surgeon Moffitt Cancer Center Plastic Surgeon Tampa General Hospital Tampa, Florida Joseph D. Randazzo, DDS, FACP Assistant Attending Dental Service Department of Surgery Memorial Sloan Kettering Cancer Center New York, New York Imran Ratanshi, MD, MSc, FRCSC Microsurgery Fellow Memorial Sloan Kettering Cancer Center New York, New York Brenton R. Robinson, MD Resident Physician Department of Surgery Presence Saint Joseph Hospital–Chicago Chicago, Illinois Afshin Mosahebi, MBBS(Lon), FRCS, FRCS(Plast), PhD(Lon), MBA(Warwick) Professor of Plastic Surgery Royal Free Hospital University College London London, United Kingdom John Nguyen, MD

Michael A. Howard, MD Clinical Associate Professor of Surgery Section of Plastic Surgery Pritzker School of Medicine University of Chicago Northbrook, Illinois George N. Kamel, MD Division of Plastic Surgery Department of Surgery

Brian R. Gastman, MD Professor Cleveland Clinic Lerner College of Medicine Staff in Plastic Surgery/Taussig Cancer Center Melanoma-Soft Tissue Cancer-Head and Neck Cancer Cleveland Clinic Cleveland, Ohio Finny George, MD Long Island Plastic Surgical Group Garden City, New York Amir M. Ghaznavi, MD Staff, Department of Plastic & Reconstructive Surgery Cleveland Clinic Florida Weston, Florida Cerrene N. Giordano, MD Instructor, Micrographic Surgery and Dermatologic Oncology Mount Sinai Icahn School of Medicine New York, New York Pierre Guerreschi, MD, PhD Plastic Reconstructive and Aesthetic Surgery University Hospital of Lille Chief of Competence Center for Clefts and Craniofacial Malformations Lille, France Larissa Habib, MD Clinical Fellow in Ophthalmic Plastic and Reconstructive Surgery Department of Ophthalmology Harvard Medical School Massachusetts Eye and Ear Infirmary Halvorson Plastic Surgery Asheville, North Carolina Matthew M. Hanasono, MD Professor and Fellowship Program Director Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, Texas Boston, Massachusetts Eric G. Halvorson, MD Department of General Surgery Kasr Al-Ainy, Faculty of Medicine Cairo University Cairo, Egypt David L. Hirsch, MD, DDS, FACS Chief, Oral-Maxillofacial Surgery Department of Otolaryngology–Head & Neck Surgery Ahmed M. Hashem, MD Professor of Plastic Surgery Division of Plastic Surgery

Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York Matthew S. Kilgo, MD Plastic Surgeon Long Island Plastic Surgical Group Garden City, New York Petros Konofaos, MD, PhD Assistant Professor of Plastic Surgery and Neurology, Director of Microsurgery and Research Department of Plastic Surgery University of Tennessee Health Science Center Memphis, Tennessee Daniel Labbé, MD Plastic Reconstructive and Aesthetic Surgery Private Hospital Saint Martin Caen, France Jamie P. Levine, MD Associate Professor of Plastic Surgery Hansjörg Wyss Department of Plastic Surgery Chief of Microsurgery Microsurgery Fellowship Director NYU Langone Medical Center New York, New York Steven M. Levine, MD Aesthetic and Reconstructive Plastic Surgeon Private Practice New York, New York Brian P. Marr, MD Director Ophthalmic Oncology Service Professor Columbia University College of Physicians and Surgeons New York-Presbyterian Hospital/ Columbia University Medical Center Department of Ophthalmology Edward S. Harkness Eye Institute Columbia University Medical Center Department of Oncology Herbert Irving Comprehensive Cancer Center New York, New York

Lenox Hill Hospital New York, New York

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Contributors

Robert D. Wallace, MD Professor and Chair

Mark Sisco, MD Clinical Associate Professor of Surgery University of Chicago Pritzker School of Medicine Chicago, Illinois Chief of Plastic Surgery NorthShore University HealthSystem Evanston, Illinois David A. Staffenberg, MD, DSc, FACS Vice Chair, Hansjörg Wyss Department of Plastic Surgery Chief, Pediatric Plastic Surgery Adult & Pediatric Craniofacial Surgery Professor, Plastic Surgery, Neurosurgery & Pediatrics NYU Langone Medical Center New York, New York John T. Stranix, MD Chief Resident Hansjörg Wyss Department of Plastic Surgery

Eduardo D. Rodriguez, MD Chair, Hansjorg Wyss Department of Plastic Surgery Helen L. Kimmel Professor of Reconstructive Plastic Surgery NYU Langone Medical Center New York, New York Anthony M. Rossi, MD, FAAD Assistant Attending Memorial Sloan Kettering Cancer Center Assistant Professor Weill Cornell Medical College Assistant Attending New York Presbyterian Hospital Memorial Sloan Kettering Cancer Center New York, New York Pierre Saadeh, MD Vice Chair of Education Residency Program Director Chief of Plastic and Hand Surgery Bellevue Hospital Department of Plastic Surgery School of Medicine New York University New York, New York Farooq Shahzad, MBBS, FACS, FAAP Assistant Professor of Plastic Surgery Ann & Robert H Lurie Children’s Hospital of Chicago Feinberg School of Medicine Northwestern University Chicago, Illinois Sammy Sinno, MD

Residency Program Director Department of Plastic Surgery University of Tennessee Health Sciences Center Memphis, Tennessee Robert L. Walton, MD, FACS Professor of Surgery Division of Plastic & Reconstructive Surgery Feinberg School of Medicine Northwestern University Chief of Plastic Surgery Department of Surgery Saint Joseph Hospital Chicago, Illinois George Xipoleas, MD, FACS The Long Island Plastic Surgical Group, PC Garden City, New York SaeHee Kim Yom, DDS, MPH Assistant Attending–Dental Service Department of Surgery Memorial Sloan Kettering Cancer Center New York, New York Peirong Yu, MD, FACS Professor Division of Surgery Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Bellaire, Texas Barry M. Zide, MD, DMD Professor of Plastic Surgery Hansjorg Wyss Department of Plastic Surgery

NYU Langone Health New York, New York Simon G. Talbot, MD Attending Plastic Surgeon Brigham and Women’s Hospital Associate Professor

Harvard Medical School Boston, Massachusetts Vishal Thanik, MD Assistant Professor, Plastic Surgery Associate Program Director, Residency Program Chief of Microsurgery, Bellevue Hospital Hansjörg Wyss Department of Plastic Surgery New York University Langone Medical Center New York, New York

NYU Langone Health New York, New York

Private Practice Chicago, Illinois

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Contents

12 Mandible Reconstruction With Scapula Flap 73 Mouchammed Agko and Hung-Chi Chen 13 Lateral Mandible Reconstruction With Soft Tissue Flaps 83 Afshin Mosahebi, Evan Matros, and Babak J. Mehrara 14 Maxillomandibular Fixation 88 Cherry L. Estilo, SaeHee Kim Yom, and Joseph D. Randazzo SECTION VI LIP 15 Repair of Lip Commissure Defects With Estlander Flaps 91 Simon G. Talbot and Julian J. Pribaz 16 Repair of Lip Defects With Karapandzic Flaps 95 Simon G. Talbot and Julian J. Pribaz 17 Repair of Lip Defects With the Abbe Flap 99 Robert Beinrauh and Joseph H. Dayan 18 Lower Lip Reconstruction With the Nasolabial Flap 104 George Xipoleas and Matthew S. Kilgo 19 Lip Reconstruction With Radial Forearm Free Flap 109 Vishal Thanik SECTION VII EYELID 20 Direct Closure and Lateral Cantholysis 114 Aaron Fay and John Nguyen 21 Tenzel Semicircular Rotational Flap 120 John Nguyen and Aaron Fay 22 Eyelid Reconstruction With the Hughes Flap or Cutler-Beard Flap 125 Larissa Habib and Brian P. Marr 23 Lower Eyelid Reconstruction With Palatal Grafts 130 Farooq Shahzad, Babak J. Mehrara, and Aaron Fay

Contributors vi Preface ix

SECTION I ANESTHESIA 1 Local Anesthesia of the Face 2

Cerrene N. Giordano and Anthony M. Rossi

SECTION II FACIAL LACERATIONS 2 Management of Facial Lacerations 11 John G. Fernandez

SECTION III SCALP AND CALVARIUM 3 Scalp Reconstruction With Rotation Flaps 16 Finny George and Evan Matros 4 Scalp Reconstruction With Free Flaps 20 Finny George and Evan Matros 5 Scalp Reconstruction With Tissue Expansion 26 Finny George and Evan Matros 6 Calvarial Reconstruction With Split Rib Grafts 30 David A. Staffenberg and Gerald J. Cho 7 Calvarial Reconstruction With Split Calvarial Grafts 33 David A. Staffenberg and Gerald J. Cho SECTION IV SKULL BASE AND MIDFACE 8 Free Fibula Flap for Midface Reconstruction 37 J. Rodrigo Diaz-Siso and Eduardo D. Rodriguez 9 Soft Tissue Flaps for Maxillary Reconstruction 47 Ahmed M. Hashem and Brian R. Gastman SECTION V MANDIBLE 10 Mandible Reconstruction With Fibula Free Flap Using CAD/CAM Techniques 58

Jamie P. Levine, David L. Hirsch, and Lawrence E. Brecht

11 Mandible Reconstruction With Fibula Flap With Templates 66 Eric G. Halvorson

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Contents

24 Lateral Tarsal Strip Canthoplasty 135 Richard H. Caesar

SECTION XI CAVITY AND PHARYNX 39 Facial Artery Perforator Flap 224 Julian J. Pribaz and Simon G. Talbot 40 Facial Artery Musculo-Mucosal (FAMM) Flap 229 Julian J. Pribaz and Simon G. Talbot 41 Free Flap for Hemi-Tongue Reconstruction 234 Carrie K. Chu and Peirong Yu 42 Floor of Mouth Reconstruction 245 George N. Kamel, J. Alejandro Conejero, and Evan S. Garfein 43 Reconstruction of Total Glossectomy Defects 251 Mark Sisco and Mihir K. Bhayani 44 Reconstruction of Buccal Mucosal Defects 255 Imran Ratanshi and Colleen McCarthy 45 Jejunum Flap for Pharyngeal Reconstruction 265 Farooq Shahzad and Babak J. Mehrara 46 Anterolateral Thigh Flap for Pharyngoesophageal Reconstruction 272 Edward I. Chang and Matthew M. Hanasono 47 Pectoralis Major Flap for Pharyngeal Reconstruction 279 Michael A. Howard and Babak J. Mehrara 48 Supraclavicular Island Flap for Oropharyngeal Reconstruction 285 Michael W. Chu and Ernest S. Chiu SECTION XII FACIAL NERVES 49 Facial Reanimation in the Oncologic Patient Using Nerve Grafts and Nerve Transfers 291 Joseph H. Dayan 50 Temporalis Flap and Lengthening Temporalis Myoplasty for Facial Paralysis 298 Andre Panossian 51 Labbé Procedure: Lengthening Temporalis Myoplasty 308 Daniel Labbé and Pierre Guerreschi 52 Babysitter Nerves for Facial Reanimation 313 Adel Y. Fattah 53 Gold Weight Insertion for Upper Eyelid Reanimation 322 Larissa Habib and Brian P. Marr Index 325

SECTION VIII CHEEK 25 Cheek Reconstruction With Laterally or Medially Based Cervicofacial Flap 139 Sammy Sinno and Barry M. Zide 26 Cheek Reconstruction With Tissue Expanders 145 John T. Stranix and Barry M. Zide 27 Cheek Reconstruction With Free Radial Forearm Flap 152 John G. Fernandez 28 Cheek Reconstruction With Skin Grafts 158 Farooq Shahzad and Babak J. Mehrara SECTION IX EAR 29 Antia-Buch Flaps for Ear Reconstruction 165 Amir M. Ghaznavi and Brian R. Gastman 30 Postauricular Flap for Ear Reconstruction 169 Matthew M. Hanasono 31 Reconstruction of the Ear Lobe 174 Matthew M. Hanasono 32 Wedge Reconstruction of Partial Auriculectomy Defects 178 Edward I. Chang and Matthew M. Hanasono SECTION X NOSE 33 Nasal Reconstruction With Banner Flaps, Bilobed Flaps, and Nasolabial Flaps 182 Michael V. Chiodo and Pierre Saadeh 34 Nasal Reconstruction With Paramedian Forehead Flap 190 Robert D. Wallace and Petros Konofaos 35 Septal Flaps for Nasal Lining 201 Jordan D. Frey, John T. Stranix, and Pierre Saadeh 36 Radial Forearm Flap for Nasal Lining Reconstruction 207 Robert L. Walton and Brenton R. Robinson 37 Nasal Reconstruction With Skin Grafts and Composite Grafts 216 Steven M. Levine and Daniel C. Baker 38 V-Y Advancement Flaps for Nasal Reconstruction 219 Julian J. Pribaz and Simon G. Talbot

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Video Clips

Chapter 1 Infraorbital Nerve Block Chapter 6 Calvarial Graft Harvest Chapter 7 Rib Graft Harvest Chapter 12 Osteocutaneous Scapular Flap

Chapter 24 Tarsal Strip Canthoplasty Chapter 43 Glossectomy Chapter 46 Anterolateral Thigh Flap Chapter 51 Labbé Procedure

xii

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Section I: Anesthesia

Local Anesthesia of the Face

C H A P T E R

Cerrene N. Giordano and Anthony M. Rossi

DEFINITION

■■ The trigeminal nerve is divided into three main components— V1 (ophthalmic nerve), V2 (maxillary nerve), and V3 (man- dibular nerve) with further smaller divisions. ■■ V1 is composed of the supraorbital, supratrochlear, infratrochlear, external nasal, and lacrimal nerve branches and is primarily responsible for the sensory innervation of the upper eyelids, glabella, forehead, dorsal nose, and anterior portion of the scalp. ■■ V2 is composed of the zygomaticotemporal, zygomati- cofacial, and infraorbital branches and supplies innerva- tion to the central face including the lower eyelids, medial cheeks, temples, lateral nasal sidewall and alar rim of the nose, and the upper cutaneous and mucosal lip. ■■ V3 is composed of the auriculotemporal, buccal, and mental nerves and innervates the lateral and lower halves of the face including the preauricular region, portions of the anterior ear, jawline, chin, and lower lip. ■■ The supraorbital, infraorbital, and mental nerves exit their respective foramen all located in the midpupillary line. ■■ Cervical nerves C2 and C3 form the great auricular and lesser occipital nerves that complete the innervation of the lateral and anterior neck, the ear, and the postauricular scalp.

■■ Local or regional anesthesia involves the injection or appli- cation of a medication to a specific area of the body to mini- mize procedural-related pain. ■■ Various types of local anesthesia exist including topical, infiltrative, nerve block, and tumescent. ■■ The number of office-based procedures utilizing local anes- thesia continues to rise, particularly in the dermatologic setting. ■■ In-office procedures performed under local anesthesia have reduced recovery time, decreased cost, and improved safety relative to those performed under general anesthesia or intravenous sedation. ANATOMY ■■ Effective local anesthesia for the face, particularly with peripheral nerve blocks, requires a complete understanding of the underlying nervous anatomy. ■■ The 11 branches of the trigeminal nerve (cranial nerve V) and 2 branches of the cervical plexus (C2, C3) are primar- ily responsible for the cutaneous sensory innervation of the face and neck ( FIG 1 ).

CN V

Supra-orbital Supratrochlear Infratrochlear Lacrimal External nasal

S p i n a l n e r v e s T r i g e m i n a l n e r v e ( C N V )

CN V

Supra-orbital Supratrochlear Lacrimal External nasal Infratrochlear Zygomatico- temporal Infra-orbital Zygomaticofacial CN V 2 Auriculotemporal Mental Buccal CN V 3

CN V

Zygomaticotemporal Zygomaticofacial

Greater occipital (C2) Third occipital (C3) Lesser occipital (C2, C3) Great auricular (C2, C3)

Infra-orbital

Auriculotemporal Buccal Mental CN V 3

Great auricular (C2, C3)

Anterior Rami

Posterior Rami

FIG 1 • Trigeminal and cervical plexus nerve distribution.

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Chapter 1 Local Anesthesia of the Face

■■ The great auricular and lesser occipital nerves emerge from Erb point in the posterior cervical triangle, located approximately at the midpoint of the posterior border of the sternocleidomastoid muscle. ■■ The greater occipital (C2) and third occipital (C3) nerves supply the posterior scalp and neck. MECHANISMS OF ACTION ■■ All local anesthetics share a similar molecular structure composed of a hydrophilic amine and a lipophilic aromatic ring linked together by an intermediate chain that classifies the agent as an ester or amide. ■■ Both esters and amides cause reversible inhibition of volt- age-gated sodium channels within affected nerves, thereby blocking depolarization and inhibiting action potential propagation and ultimately sensation. 1 ■■ Esters, such as tetracaine, procaine, and chloroprocaine, are hydrolyzed by plasma cholinesterases and excreted by the kidneys (Table 1). ■■ In contrast, amides such as lidocaine, mepivacaine, and bupivacaine are metabolized by microsomal enzymes in the liver. 2 ■■ The structural components of the local anesthetic agent determine various parameters for clinical efficacy. ■■ The lipid solubility of the aromatic ring influences the diffusion and potency of the product, with more lipid- soluble molecules possessing greater diffusion through the nerve cell membrane resulting in higher potency. ■■ Agents that are highly protein-bound have a longer dura- tion of action as they possess a stronger affinity for the sodium-gated ion channels. ■■ Speed of onset is determined by the drug dissociation constant (pKa), defined as the pH at which the ionized and nonionized forms of the drug are present in equal amounts. ●● All local anesthetics have a pKa higher than physiologic pH. ■■ The closer the pKa is to physiologic pH, the more nonion- ized form of the medication is present, and the more rap- idly the drug penetrates the nerve cell membrane creating its clinical effect.

■ Ropivacaine is a newer amide anesthetic that has been shown to have a rapid onset and longer duration of action compared to lidocaine.

NATURAL HISTORY

■ The Inca populations were the first to discover the pain- reducing property of the Erythroxylum coca plant. 2 ■■ In the late 1880s, cocaine was isolated from the plant and used initially in ophthalmologic surgeries. ■■ Safer alternatives were developed early in the 20th century followed by widespread acceptance within the medical community. ■■ Lidocaine was the first amide anesthetic to undergo clinical testing in the 1940s, with a faster onset, longer duration, and lower toxicity compared to the ester formulations avail- able at the time. ■■ Eliciting relevant patient history and performing a physical exam prior to the use of any anesthetic agent are crucial to ensure patient safety and minimize complications. ■■ Patient history ■■ Determine medication allergies and prior exposure to injectable or topical anesthetics. ■■ Obtain an up-to-date list of the patient’s medications including over-the-counter herbs and agents to avoid potential interactions, particularly with drugs metabo- lized through the liver. ■■ A detailed medical history should be elicited, with par- ticular attention to cardiac, renal, liver, and neurologic diseases. ■■ Relative contraindications ■■ Hypersensitivity to the agent (particularly esters) ■■ Application of a topical agent to the skin with impaired barrier function ■■ G6PD (glucose-6-phosphate dehydrogenase) enzyme defi- ciency with the use of EMLA (eutectic mixture of local anesthetics) ■■ Significant cardiac or hepatic disease ■■ Use of class I antiarrhythmic (tocainide, mexiletine) PATIENT HISTORY AND PHYSICAL FINDINGS

Table 1 Anesthetics Used for Local Infiltration

Duration (min) Max Recommended Dose (Adults) Without Epinephrine With Epinephrine Without Epinephrine With Epinephrine

Anesthetic

Onset (min)

Amides

Articaine

2–4

30–120 120–240

60–240 240–480 240–360 60–400 60–400 60–400

5.0 mg/kg or 350 mg 2.5 mg/kg or 175 mg 4.5 mg/kg or 300 mg 4.5 mg/kg or 300 mg 6.0 mg/kg or 400 mg 7.0 mg/kg or 400 mg

7.0 mg/kg or 500 mg 3.0 mg/kg or 225 mg 6.5 mg/kg or 400 mg 7.0 mg/kg or 500 mg 7.0 mg/kg or 550 mg 10.0 mg/kg or 600 mg

Bupivacaine Etidocaine

2–10

3–5

200

30–120 30–120 30–120

Mepivacaine

3–20

Prilocaine

5–6

Esters

Chloroprocaine

5–6

30–60 15–90

N/A

11.0 mg/kg or 800 mg 14.0 mg/kg or 1000 mg

Procaine Tetracaine

5 7

30–180 240–480

10.0 mg/kg 2.0 mg/kg

14.0 mg/kg

120–240 2.0 mg/kg Reprinted from Kouba DJ, LoPiccolo MC, Alam M, et al. Guidelines for the use of local anesthesia in office-based dermatologic surgery. J Am Acad Dermatol. 2016;74: 1201-1219; copyright © 2016, with permission from Elsevier.

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Operative Techniques in Plastic Surgery: Head and Neck Reconstruction

■■ Use of EMLA in infants under 1 month of age (increased risk of methemoglobinemia) ■■ Lidocaine is pregnancy category B; however, lidocaine is excreted in breast milk ; therefore, caution is advised for use in breast-feeding mothers. ■■ Ocular exposure with EMLA should be avoided due to the presence of sodium hydroxide and the potential for alkaline injury. ■■ Caution is advised with concomitant use of EMLA and certain methemoglobinemia-inducing medications such as acetaminophen, anesthetics (prilocaine and benzocaine), anticonvulsants, antimalarials, nitrates, sulfonamides, and aniline dyes. ■■ Physical examination ■■ Ensure there is no skin breakdown or signs of infection or inflammatory lesions in areas where the agent will be applied/injected. ■■ Selection of agent ■■ Based on the anticipated procedure, the anesthetic is selected by taking into account the need for topical vs injectable modality, duration of the agent, and location of the procedure. ■■ The level of preprocedure patient anxiety should also be assessed and may determine the agent and application type used. SURGICAL MANAGEMENT ■■ Facial anesthesia is necessary for a variety of different cuta- neous procedures, including skin biopsies, excisions, Mohs micrographic surgery, surgical reconstruction, and laser and light-based therapies for facial resurfacing, scar revision, or lesion ablation. ■■ The decision to use an anesthetic and the selection of the agent is dependent partially on the type of procedure per- formed and the anticipated degree of discomfort. ■■ Facial nerve blocks are commonly implemented for abla- tive laser resurfacing of the entire face; however, there are reports of regional cutaneous nerve blocks for larger pig- mented or vascular facial lesions as well. ■■ Regional nerve blocks hold the advantage of minimizing significant tissue distortion, using less total volume of medi- cation, and less patient discomfort, but they are more chal- lenging to administer. ■■ Tumescent anesthesia is a form of local anesthesia using large volumes of highly dilute anesthetic delivered subcu- taneously, first described by Dr. Jeffrey Klein in the 1980s. ■■ It can be used alone or with various levels of sedation based on the intended procedure. ■■ While there is a wide range of usages for tumescent anes- thesia, face and neck uses generally include liposuction, face and neck lifts, dermabrasion, and full-face laser resurfacing. ■■ Lower volumes of fluid are infiltrated into the face (100– 150 mL per side) when compared with body infiltration, so the concentration of lidocaine may be higher for facial procedures. 3 Preoperative Planning ■■ Obtain an accurate patient weight to calculate the maxi- mum allotted anesthetic dose especially for procedures requiring larger volumes.

■■ Lidocaine toxicity is dose dependent, and it is critical to remain below the calculated maximum dose. ■■ It is also important to take into consideration individual patient characteristics as frail, elderly patients or those with underlying liver malfunction may require lower dosages. ■■ The maximum allotted dose of plain lidocaine for an adult patient is 4.5 mg/kg for whom the addition of epinephrine allows for up to 7 mg/kg 4 (see Table 1). ■■ The WiMP formula may also be used for ease of calculating maximum allotted dosages as long as the patient’s weight, maximum dosage, and percentage concentration of the agent are known. 5 ■■ V (mL) = (weight (kg) × 0.1 × maximum dose (mg/kg))/ percentage concentration Positioning ■■ Positioning is key to establishing both patient and provider comfort during the procedure. ■■ Ideally, the patient should be comfortably seated on the exam table with the table leaning back and the feet propped up to minimize a vasovagal reaction. ■■ The patient’s head should be firmly rested against the back of the table to allow for stabilization and minimize sudden movements when the needle is injected. ■■ It is best when injecting if the patient’s eyes are closed so they do not unintentionally pull away if they visualize the needle. ■■ For the surgeon, the table needs to be at an appropriate height, and the patient needs to be positioned closer to the surgeon’s side of the table to avoid excessive bending or reaching. ■■ The patient’s skin is held taut by either the surgeon’s non- dominant hand or an assistant. ■■ The surgeon’s nondominant hand may be used to stabilize the dominant hand during the injection. Alternatively, the surgeon may rest a few fingers of his or her dominant hand on other parts of the patient’s face to stabilize self. ■■ If an assistant is present, care must be taken to ensure the assistant is far enough from the anticipated injection tar- get to avoid accidental needlestick injury should a sudden movement occur. ■■ Additionally, the surgeon should be positioned so the needle is facing away from critical anatomic structures such as the globe of the eye to avoid an accidental puncture with unan- ticipated patient movement. Approach The topical anesthetic agents encompass a wide variety of noninvasive, painless products, which are commonly used prior to minimally invasive cosmetic procedures. ■■ Topical lidocaine and EMLA (eutectic mixture of local anesthetics) are the two most commonly used topical agents. ■■ Lidocaine is available in many formulations including cream, viscous solution, jelly, ointment, spray, and patches. ■■ Due to its unique liposomal delivery system to enhance penetration through the stratum corneum, lidocaine 4% cream (LMX-4, Ferndale Laboratories, Ferndale, MI) has the advantage of ease of application without occlusion, more rapid onset compared to EMLA (Astra Pharmaceuticals, Westborough, MA), and availability without a prescription. ■■ Topical agents ■■

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Chapter 1 Local Anesthesia of the Face

from 30 to 120 minutes, longer with the addition of epinephrine. 4 ■■ Bupivacaine is a slower-acting agent, with a 2- to 10-minute onset; however, it has one of the longest durations of action, lasting 120 to 240 minutes without epinephrine. Because of the longer duration of action, bupivacaine is commonly used in lengthy surgical pro- cedures, but its risk of cardiac and neurologic toxicity remains a concern. ■■ Ropivacaine and levobupivacaine are two newer amide anesthetics that have a similar duration of action to bupi- vacaine with fewer cardiotoxic and central nervous sys- tem effects and less pain on injection when compared to lidocaine with epinephrine. ■■ Infiltrative anesthesia may be combined with other forms of anesthesia such as topical, nerve block, or tumescent for larger or more complex cutaneous procedures. ■■ Smaller needle sizes, such as 30 or 32 gauge, should be used, and needles should be replaced frequently to reduce pain on injection. ■■ Additions to injectable anesthetics such as epinephrine, hyaluronidase, and bicarbonate that can enhance efficacy and/or improve patient comfort will be discussed in another section. ■■ Advance the needle tip deep/subdermally first and deposit about 0.5 mL of anesthetic agent. ■■ Be sure to inject slowly as rapid infiltration and cutane- ous distention contribute to increased pain. ■■ Pause for about 30 seconds, and move the needle more superficially while injecting more volume. 7 ■■ The needle may be slightly withdrawn and advanced subcutaneously in a fanlike fashion to continue anesthetizing while minimizing the number of painful injection points. ■■ Once that region is complete, the needle may be fully withdrawn from the skin and reinserted within 1 cm of the blanched border to continue injecting along the established area. 7 ■■ Anterograde injection is recommended to keep the wheal before the needle tip to minimize further pain of the needle. 7 ■■ For larger excisions, it is generally recommended to perform a ring block with infiltrative anesthesia around the outside of the ellipse, and supplemental anesthesia may be added centrally only where needed upon testing of the area. ■■ Using a longer needle to inject deep into the fascial plane or having additional syringes on hand intraop- eratively may be necessary for supplementation based on the depth of the procedure planned. ■■ The lowest possible dose to achieve an anesthetic effect should be used to avoid toxicity.

■■ EMLA is a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine hydrochloride. EMLA is applied to intact skin, under occlusion, for a minimum of 1 hour to facilitate absorption. ■■ The depth of anesthesia is directly proportional to the duration of time the product is left in place, with maxi- mum clinical anesthesia achieved at 2 to 3 hours and clin- ical effect remaining around 1 to 2 hours post removal of product. 6 ■■ EMLA is safe for use in pediatric and adult popula- tions, and the dosing is largely based on weight and surface area. The manufacturer recommends a dose of 2 g of EMLA per 10 cm 6 for 2 hours. The maximum recommended dose is 60 g applied to 400 cm 6 of nor- mal skin. ■■ Caution with either product should be exercised with use over large surface areas as prolonged application, large surface area, occlusion, and high concentrations increase the risk for cardiotoxicity and central nervous system toxicity. ■■ Injectable agents ■■ Lidocaine and bupivacaine are the two most commonly used injectable agents. Lidocaine has a rapid onset of action, generally less than 1 minute, and lasts on average ■■ Prep the surrounding skin with an antiseptic agent such as alcohol, Betadine, or chlorhexidine immediately prior to injection. ■■ Stretch the surrounding skin and stabilize the needle with the nondominant hand. ■■ Quickly pierce the skin with the tip of the needle at a 90-degree angle ( TECH FIG 1 ). ■■ Injection through an enlarged pore or follicle may minimize patient-perceived pain. ■■ Aspirate the needle prior to product infiltration to avoid intravascular injection and minimize risk for toxicity. 4 ■■ Local Infiltration

T E C H N I Q U E S

TECH FIG 1 • Piercing the skin at a 90-degree angle irritates fewer nerve fibers, thereby reducing injection pain.

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T E C H N I Q U E S 6 Operative Techniques in Plastic Surgery: Head and Neck Reconstruction ■■ Facial Nerve Blocks

nasal ala. 8 The patient may feel a slight discomfort with palpation, which assists in identification. ■■ The injection is placed 1 cm inferior to the foramen, and the needle is tangentially directed and slowly advanced upward until the approximate location of the foramen is reached. ■■ A small wheal (approximately 0.2 mL) of anesthesia can be placed subdermally prior to advancing the nee- dle to minimize pain. ■■ Alternatively, topical anesthetic agents can be used to reduce injection-related pain. ●● After negative aspiration, a 0.5- to 2.5-mL bolus of anesthetic solution is very slowly deposited just out- side of the foramen. ●● It may be helpful for the injector to leave a finger of the nondominant hand pressed over the foramen for ease of location/identification. ■■ Extreme caution is advised to avoid needlestick injury. ●● The infraorbital nerve has a slower onset of anes- thesia, so it is recommended that this nerve is anes- thetized first. 8 ■■ The intraoral approach to the infraorbital nerve ( TECH FIG 3 ) involves first locating the foramen by gentle palpa- tion of the overlying skin as described above. ■■ The area is then marked and/or the injector’s finger is kept in place as a guide. ■■ A small wheal (approximately 0.2 mL) of anesthe- sia is placed in the mucobuccal fold over the second premolar. ■■ The needle is then advanced further upward toward the marked foramen, remaining parallel to the long axis of the second premolar until the foramen is reached. ■■ After negative aspiration, a 0.5- to 2.5-mL bolus of anesthetic is slowly placed just outside of the foramen.

■■ There are a number of facial nerve blocks that can be performed, including supraorbital, supratrochlear, infra- orbital, infratrochlear, mental, zygomaticofacial, zygo- maticotemporal, and external nasal. The most commonly used are supraorbital, supratrochlear, infraorbital, and mental. ■■ Many authors cite the use of 4% articaine hydrochloride with epinephrine as the preferred agent for facial nerve blocks, but 1% lidocaine with or without epinephrine or mixtures of 1% lidocaine and 0.25% bupivacaine may also be used. ■■ Generally, 3-mL syringes with small-gauge needles such as 25 or 30 are used to reduce pain. Occasionally, longer needles such as 30 mm may be used to ensure product deposition at the targeted foramen. Supraorbital and Supratrochlear Nerves ■■ The supraorbital foramen is located in the mid-pupillary line and is palpated along the orbital rim. ■■ The needle is inserted perpendicular to the skin above the foramen and advanced until contact is achieved with the supraorbital ridge, with care not to enter the foramen and cause damage to the nerve ( TECH FIG 2 ). ■■ The supratrochlear nerve can be blocked with periosteal injection at the medial eyebrow and nasal root junction, about 1 cm medial to the supraorbital foramen. ■■ About 0.5 to 3 mL of anesthetic solution is deposited periosteally to each location after negative aspiration. Infraorbital Nerve (Video) ■■ The percutaneous approach for the infraorbital nerve involves palpation of the infraorbital foramen, located in the mid-pupillary line about 1 cm lateral to the ipsilateral

TECH FIG 2 • Supraorbital nerve block.

TECH FIG 3 • Intraoral approach to infraorbital nerve block.

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