Sách phẫu thuật thẩm mỹ (Grabb and Smiths: plastic surgery)

GRABB AND SMITH’S
PLASTIC SURGERY
S I X T H

E D I T I O N
Editor-in-Chief

Charles H. Thorne, MD
Associate Professor of Plastic Surgery
NYU Medical Center
New York, New York

Editors

Robert W. Beasley, MD
Professor of Surgery, New York University, New York, New York
Director of New York University Hand Surgery Services, Institute of Reconstructive
Plastic Surgery and Bellevue Hospital Center, New York, New York
Hand Surgery Consultant, Veteran’s Administration, New York, New York
Consulting Surgeon, Hackensack University Hospital, Hackensack, New Jersey
and Impartial Advisor to Chairman, New York State Workers’ Compensation Board

Sherrell J. Aston, MD
Professor of Surgery (Plastic)
New York University School of Medicine
Chairman, Department of Plastic Surgery
Manhattan Eye Ear and Throat Hospital
New York, New York

Scott P. Bartlett, MD

Professor of Surgery, University of Pennsylvania
Mary Downs Endowed Chair in Pediatric Craniofacial Treatment and Research,
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Geoffrey C. Gurtner, MD, FACS
Associate Professor of Surgery, Department of Surgery, Division of Plastic Surgery
Stanford University School of Medicine
Stanford, California

Scott L. Spear, MD, FACS
Professor and Chief
Division of Plastic Surgery
Georgetown University Medical Center
Washington, DC

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


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Printed in the USA
Library of Congress Cataloging-in-Publication Data
Grabb and Smith’s plastic surgery.—6th ed. / editor-in-chief, Charles H. Thorne . . . [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7817-4698-4
ISBN 0-7817-4698-1
1. Surgery, Plastic. I. Thorne, Charles, 1952- II. Grabb, William C. III. Title: Plastic
surgery.
[DNLM: 1. Surgery, Plastic. 2. Reconstructive Surgical Procedures. WO 600 G7265
2007]
RD118.G688 2007
617.9 5—dc22
2006033593
Care has been taken to confirm the accuracy of the information presented and to describe
generally accepted practices. However, the authors, editors, and publisher are not responsible
for errors or omissions or for any consequences from application of the information in this
book and make no warranty, expressed or implied, with respect to the currency, completeness,
or accuracy of the contents of the publication. Application of the information in a particular
situation remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection

and dosage set forth in this text are in accordance with current recommendations and practice
at the time of publication. However, in view of ongoing research, changes in government
regulations, and the constant flow of information relating to drug therapy and drug reactions,
the reader is urged to check the package insert for each drug for any change in indications
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recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug
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Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


CONTRIBUTING AUTHORS

Valerie J. Ablaza, MD, FACS

Bruce S. Bauer, MD, FACS, FAAP

Assistant Professor
Department of Surgery
Columbia University
College of Physicians and Surgeons

New York, New York

Professor of Surgery
Department of Surgery
Division of Plastic Surgery
The Feinberg School of Medicine Northwestern University
Chief
Division of Plastic Surgery
Children’s Memorial Hospital
Chicago, Illinois

Al Aly, MD, FACS
Attending
Department of Plastic Surgery
Iowa City Plastic Surgery
Coralville, Iowa

P.G. Arnold, MD
Professor of Plastic Surgery
Department of Surgery, Division of Plastic Surgery
Mayo Clinic
Rochester, Minnesota

Christopher E. Attinger, MD
Professor
Department of Plastic Surgery
Georgetown University
Medical Director
The Limb Center
Georgetown University Hospital

Washington, District of Columbia

John D. Bauer, MD
Assistant Professor, Division of Plastic Surgery
Department of Surgery
UTMB at Galveston
Galveston, Texas

Robert W. Beasley, MD
Professor of Surgery, New York University
Director of New York University Hand Surgery Services,
Institute of Reconstructive Plastic Surgery and Bellevue
Hospital Center
Hand Surgery Consultant, Veteran’s Administration
Impartial Advisor to Chairman, New York State Workers’
Compensation Board, New York, New York
Consulting Surgeon, Hackensack University Hospital,
Hackensack, New Jersey

Michael S. Beckenstein, MD, FACS
Birmingham, Alabama

Alberto Aviles, MD
Resident in Plastic Surgery
Department of Plastic Surgery
Medical College of Wisconsin
Milwaukee, Wisconsin

Stephen B. Baker, MD, DDS, FACS
Associate Professor

Associate Program Director
Department of Plastic Surgery
Georgetown University Hospital
Washington, District of Columbia
Co-Director, Craniofacial Clinic
Inova Fairfax Hospital for Children
Falls Church, Virginia

Scott P. Bartlett, MD
Professor of Surgery
University of Pennsylvania
Mary Downs Endowed Chair in Pediatric
Craniofacial Treatment and Research
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Steven J. Bates, MD
Chief Resident
Division of Plastic Surgery
Stanford University Medical Center
Stanford, California

Sean Boutros, MD
Attending Surgeon
Houston Plastic and Craniofacial Surgery
Hermann Hospital and Children’s Memorial Hermann
Hospital
Houston, Texas

James P. Bradley, MD

Associate Professor, Sarnat Craniofacial Chair
Division of Plastic Surgery
UCLA David Geffen School of Medicine
Chief Pediatric Plastic Surgery
Division of Plastic Surgery
Mattel Children’s Hospital
Los Angeles, California

Lawrence E. Brecht, DDS
Clinical Assistant Professor of Surgery
Department of Surgery
New York University School of Medicine
Co-Director of Craniofacial Prosthetics
Institute of Reconstructive Plastic Surgery
New York University Medical Center
Clinical Associate Professor of Prosthodontics
Director of Maxillofacial Prosthetics
Advanced Education Program in Prosthodontics
New York University College of Dentistry
New York, New York

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

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viii

Contributing Authors

Arnold S. Breitbart, MD, FACS

Mihye Choi, MD

Assistant Professor of Clinical Surgery
Adjunct Assistant Professor of Surgery
Columbia University College of Physicians and Surgeons
Weill Cornell University Medical College
New York, New York

Assistant Professor
Department of Surgery
New York University
New York, New York

Mark A. Codner, MD

Duc T. Bui, MD
Department of Surgery
Stony Brook University Medical Center
Stony Brook, New York

Clinical Assistant Professor
Department of Plastic and Reconstructive
Surgery
Emory University
Atlanta, Georgia

Charles E. Butler, MD

Associate Professor
The University of Texas
M.D. Anderson Cancer Center,
Department of Plastic Surgery, Houston, Texas

Sydney R. Coleman, MD
Assistant Clinical Professor
Department of Plastic Surgery
New York University School of Medicine
New York, New York

Peter E. M. Butler, MB, BSc (Hons)
Consultant Plastic Surgeon
Royal Free Hospital
University College London
London, England

Grant W. Carlson, MD
Professor
Department of Surgery
Emory University
Chief of Surgical Services
Crawford W. Long Hospital
Atlanta, Georgia

Peter G. Cordeiro, MD
Professor of Surgery
Department of Surgery
Weill Medical College of Cornell University
Chief, Plastic & Reconstructive Surgery Service

Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, New York

Alfred Culliford IV, MD
Division of Plastic, Reconstructive and Hand Surgery
Staten Island University Hospital
Staten Island, New York

Benjamin Chang, MD, FACS
Associate Professor of Clinical Surgery
Division of Plastic Surgery
University of Pennsylvania School of Medicine
Attending Surgeon
Division of Plastic Surgery
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania

Court Cutting, MD
Professor of Surgery-Plastic Surgery
Director, Cleft Lip and Palate Program
Institute of Reconstructive Plastic Surgery
NYU Medical Center
New York, New York

Genevieve de Bese, MD

James Chang, MD
Associate Professor
Division of Plastic Surgery

Stanford University Medical Center
Attending Surgeon
Lucile Packard Children’s Hospital at Stanford
Stanford University Medical Center
Palo Alto, California

Raymond R. Chang, MD
Assistant Professor of Surgery
Department of Surgery, Division of Plastic Surgery
George Washington University
Attending
Department of Surgery, Division of Plastic Surgery
George Washington University Hospital
Washington, District of Columbia

James J. Chao, MD, FACS
Associate Professor of Plastic Surgery
Department of Surgery
University of California,
San Diego School of Medicine
San Diego, California

General Manager and Director of Research
American Hand Prostheses
New York, New York

Mark DeLacure, MD
Associate Professor of Otolaryngology and Surgery
(Plastic Surgery)
New York University Medical Center

New York, New York

Joseph J. Disa, MD, FACS
Associate Attending Surgeon
Plastic and Reconstructive
Surgery Service
Memorial Sloan-Kettering Cancer Center
New York, New York

Matthias B. Donelan, MD
Associate Clinical Professor of Surgery
Harvard Medical School
Chief of Plastic Surgery
Shriners Burns Hospital
Boston, Massachusetts

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


Contributing Authors

Ivica Ducic, MD, PhD

Robert D. Galiano, MD

Associate Professor
Chief–Peripheral Nerve Surgey
Department of Plastic Surgery
Georgetown University Hospital

Washington, District of Columbia

Institute of Reconstructive Plastic Surgery
New York University
New York, New York

Gregory A. Dumanian, MD, FACS
Associate Professor of Surgery
Department of Surgery, Division of Plastic Surgery
Feinberg School of Medicine, Northwestern University
Associate Professor of Surgery
Department of Surgery, Division of Plastic Surgery
Northwestern Memorial Hospital
Chicago, Illinois

Roy G. Geronemus, MD, PC
Laser and Skin Surgery Center of New York
Clinical Professor
Department of Dermatology
New York Medical Center
New York, New York

Giulio Gherardini, MD, PhD
Rome, Italy

Mary K. Gingrass, MD, FACS

Charles J. Eaton, MD
Hand Surgeon
Department of Surgery

Jupiter Medical Center
Jupiter, Florida

Charles R. Effron, MD
Rochelle Park, New Jersey

L. Franklyn Elliott II, MD
Atlanta Plastic Surgery, P.C.
Atlanta, Georgia

Gregory R. D. Evans, MD, FACS
Professor of Surgery and Biomedical Engineering
Chief Aesthetic Plastic Surgery
University of California Irvine
Professor of Surgery and Biomedical Engineering
Chief Aesthetic Plastic Surgery
UCI Medical Center
Orange, California

Maryam Feili-Hariri, PhD
Assistant Professor
Surgery and Immunology
University of Pittsburgh
Pittsburgh, Pennsylvania

Assistant Clinical Professor
Department of Plastic Surgery
Vanderbilt University School of Medicine
Chief of Plastic Surgery
Department of Plastic Surgery

Baptist Hospital
Nashville, Tennessee

Cornelia N. Golimbu, MD
Professor of Radiology
Department of Radiology
New York University Medical Center
New York, New York

Arun K. Gosain, MD
Professor
Department of Surgery
Case Western Reserve University
University Hospital (Lakeside)
Chief
Section of Craniofacial and Pediatric Plastic Surgery
Rainbow Babies and Childrens Hospital
Cleveland, Ohio

Barry Grayson, DDS

Derek T. Ford, MD, FRCSC
Private Practice
Toronto, Ontario, Canada

M. Felix Freshwater, MD
Miami, Florida

David W. Friedman, MD
Assistant Professor

Department of Surgery-Plastic
New York University
Fellowship Director
Hand Surgery
New York University Medical Center
New York, New York

Associate Professor of Surgery (Orthodontics)
Institute of Reconstructive Plastic Surgery
New York University School of Medicine
Tisch Hospital
New York, New York

Arin K. Greene, MD, MMSc
Craniofacial Fellow
Department of Plastic Surgery
Children’s Hospital Boston, Harvard Medical School
Boston, Massachusettes

Geoffrey C. Gurtner, MD, FACS
Associate Professor of Surgery
Department of Surgery, Division of Plastic Surgery
Stanford University School of Medicine
Stanford, California

Jeffrey D. Friedman, MD

J. Joris Hage, MD, PhD

Assistant Professor

Department of Plastic Surgery
Baylor College of Medicine
The Methodist Hospital
Houston, Texas

Chief
Department of Plastic and Reconstructive Surgery
Netherlands Cancer Institute-Antoni van Leeuwenhoek
Hospital
Amsterdam, The Netherlands

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

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Contributing Authors

Elizabeth J. Hall-Findlay, MD, FRCSC

John N. Jensen, MD

Plastic Surgeon
Mineral Springs Hospital
Banff Alberta, Canada

Department of Plastic Surgery

Medical College of Wisconsin
Milwaukee, Wisconsin

Dennis C. Hammond, MD
Center for Breast & Body Contouring
Grand Rapids, Michigan

Michael Hausman, MD
Assistant Professor
Department of Orthopaedics
Chief, Hand Service Mount Sinai Hospital
New York, New York

Neil F. Jones, MD, FRCS
Professor
Division of Plastic & Reconstructive Surgery
Department of Orthopedic Surgery
University of California Los Angeles
Chief of Hand Surgery
UCLA Hand Center
UCLA Medical Center
Los Angeles, California

Robert J. Havlik, MD
Professor
Department of Surgery-Section of Plastic Surgery
Indiana University School of Medicine
Chief Section of Plastic Surgery
Riley Hospital for Children
Indianapolis, Indiana

Michael A. C. Kane, MD, BS

Alexes Hazen, MD

Nolan S. Karp, MD

Attending, Plastic Surgery
Department of Plastic Surgery
NYU Medical Center
Chief Plastic Surgery
Manhattan Veterans Administration Hospital
New York, New York

David A. Hidalgo, MD
New York, New York

Larry Hollier, Jr., MD
Associate Professor/Residency Program Director
Department of Plastic Surgery
Baylor College of Medicine
Texas Children’s Hospital
Ben Taub General Hospital
Houston, Texas

Richard A. Hopper, MD, MS
Associate Professor
Department of Surgery
University of Washington
Surgical Director

The Craniofacial Center
Seattle Children’s Hospital
Seattle, Washington

Christopher J. Hussussian, MD
Plastic Surgery Associates
Waukesha, Wisconsin

Alamgir Isani, MD
Clinical Assistant Professor
Plastic Surgery
New York University Medical Center
New York, New York

Jeffrey E. Janis, MD
Assistant Professor
Chief of Plastic Surgery
Parkland Health
Hospital System Co-Director
Plastic Surgery Residency Program
University of Texas Southwestern Medical Center
Dallas, Texas

Attending Surgeon
Department of Plastic Surgery
Manhattan Eye, Ear & Throat Hospital
New York, New York

Associate Professor of Plastic Surgery
NYU School of Medicine

New York, New York

Armen K. Kasabian, MD
Assistant Professor of Plastic Surgery
Department of Plastic Surgery
New York University Medical Center
Chief, Section of Microsurgery
Institute of Reconstructive Plastic Surgery
New York, New York

Henry Kawamoto, Jr., MD, DDS
Clinical Professor
Department of Surgery, Division
of Plastic Surgery
UCLA
Los Angeles, California

Patrick Kelley, MD
Medical Director
Craniofacial Center
Children’s Hospital of Austin
Austin, Texas

Amy Kells, MD, PhD
Microsurgery Fellow
Department of Plastic Surgery
University of Mississippi
Jackson, Mississippi

Karen H. Kim, MD

Director of Research
Laser and Skin Surgery Center of New York
New York, New York

Arnold William Klein, MD
Professor of Medicine and Dermatology
Department of Medicine and Dermatology
David Geffen School of Medicine at UCLA
Beverly Hills, California

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


Contributing Authors

Matthew B. Klein, MD

Otway Louie, MD

Assistant Professor
Department of Plastic Surgery
University of Washington
Associate Director
University of Washington Burn Center
Harborview Medical Center
Seattle, Washington

House Staff
Institute of Reconstructive and Plastic Surgery

NYU Medical Center
New York, New York

David M. Knize, MD
Associate Clinical Professor of Plastic Surgery
Department of Surgery
University of Colorado Health Sciences Center
Denver, Colorado
Former Chief of Plastic Surgery
Department of Surgery
Swedish Medical Center
Englewood, Colorado

David W. Low, MD
Associate Professor of Surgery
Division of Plastic Surgery
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Susan E. Mackinnon, MD
Shoenberg Professor and Chief
Division of Plastic and Reconstructive Surgery
Washington University in St. Louis
Barnes-Jewish Hospital
St. Louis, Missouri

James Knoetgen, III, MD
Consultant in Plastic Surgery
Department of Surgery, Division of Plastic Surgery
Mayo Clinic

Rochester, Minnesota

John S. Mancoll, MD
Fort Wayne, Indiana

Ralph T. Manktelow, MD, FRCS(c)
Howard N. Langstein, MD
Department of Plastic Surgery
The University of Texas
M. D. Anduson Cancer Center
Houston, Texas

W. P. Andrew Lee, MD

Professor of Surgery
University of Toronto
Staff Surgeon
Department of Surgery
Toronto General Hospital
Toronto, Ontario, Canada

Professor of Surgery
University of Pittsburgh
Chief
Division of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania

Stephen J. Mathes, MD

Salvatore C. Lettieri, MD

Lawrence D. Bell Professor of Plastic Surgery
Institute of Reconstructive Plastic Surgery
NYU School of Medicine
Director
Institute of Reconstructive Plastic Surgery
NYU Medical Center
New York, New York

Instructor
Department of Plastic Surgery
Mayo Graduate School
Rochester, Minnesota
Chief
Department of Plastic Surgery
Maricopa Medical Center
Phoenix, Arizona

Jamie Levine, MD
Assistant Professor
Division of Plastic Surgery
New York University
Chief Plastic and Microsurgery
Department of Surgery
Bellevue Hospital
New York, New York

J. William Littler, MD
Professor Emeritus of Clinical Surgery

Columbia University Department of Surgery; and Retired
Senior Attending Physician, Chief of Plastic and
Reconstructive Surgery
St. Luke’s-Roosevelt Hospital Center
New York, New York

Institute of Reconstructive Plastic Surgery
New York University Medical Center
New York, New York

Joseph G. McCarthy, MD

Babak J. Mehrara, MD
Assistant Professor
Department of Surgery
Columbia University New York Hospital-Cornell
MedicalCenter
Assistant Attending
Memorial Sloan-Kettering Cancer Center
New York, New York

Frederick J. Menick, MD
Associate Clinical Professor
Division of Plastic Surgery
University of Arizona
Staff Surgeon
Division of Plastic Surgery
St. Joseph’s Hospital
Tucson, Arizona

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

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Contributing Authors

Timothy A. Miller, MD

John A. Perrotti, MD

Professor and Chief Plastic Surgery
University of California School of Medicine
David Geffen School of Medicine at UCLA
Department of Surgery
UCLA Medical Center
Los Angeles, California

Clinical Assistant Professor
Department of Surgery
New York Medical College
Valhalla, New York
Attending Surgeon
Department of Plastic Surgery
Manhattan Eye, Ear and Throat Surgery
New York, New York

Blake A. Morrison, MD
Private Practice
North Texas Hand Surgery
Dallas, Texas

Hannan Mullett, MD, FRCS (TR & ORTM)
Consultant Orthopaedic Surgeon
Department of Orthopaedic Surgery
Beaumont Hospital
Dublin, Ireland

John B. Mulliken, MD
Professor of Surgery
Harvard Medical School
Director Craniofacial Centre
Department of Plastic Surgery
Children’s Hospital
Boston, Massachusetts

Thomas A. Mustoe, MD
Professor
Department of Surgery, Division of Plastic Surgery
Feinberg School of Medicine, Northwestern University
Chief
Department of Plastic Surgery
Northwestern Memorial Hospital
Chicago, Illinois

Terence M. Myckatyn, MD, FRCSC
Assistant Professor

Department of Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, Missouri

Randall Nacamuli, MD
Resident
Division of Plastic and Reconstructive Surgery
Oregon Health Sciences University
Portland, Oregon

James D. Namnoum, MD
Atlanta Plastic Surgery, P.C.
Atlanta, Georgia

Peter C. Neligan, MB, FRCSC, FACS
Wharton Chair in Reconstructive Plastic Surgery
Professor and Chair, Division of Plastic Surgery
University of Toronto
Toronto, Canada

Martin I. Newman, MD
Active Staff
Department of Plastic & Reconstructive Surgery
Cleveland Clinic Florida
Weston, Florida

John A. Persing, MD
Professor and Chief Plastic Surgery, Professor of
Neurosurgery
Yale University School of Medicine

Chief
Plastic Surgery
Yale-New Haven Hospital
New Haven, Connecticut

Linda G. Phillips, MD
Truman G. Blocker Distinguished Professor and Chief
Division of Plastic Surgery
UTMB Galveston
Galveston, Texas

Michael L. Reed, MD
Associate Clinical Professor
Department of Dermatology
New York University School of Medicine
Attending Physician
Department of Dermatology
New York University Medical Center
New York, New York

Rod J. Rohrich, MD, FACS
Professor and Chairman
Department of Plastic Surgery
The University of Texas Southwestern Medical Center
Chief of Plastic Surgery
Department of Plastic Surgery
University Hospital – Zale Lipshy
Dallas, Texas

Harvey M. Rosen, MD, DMD

Clinical Associate Professor
Department of Surgery
University of Pennsylvania
Chief
Division of Plastic Surgery
Pennsylvania Hospital
Philadelphia, Pennsylvania

George H. Rudkin, MD, FACS
Clinical Associate Professor
Department of Plastic Surgery
UCLA Medical Center
Chief, Plastic Surgery
Department of Plastic Surgery
VA West Los Angeles
Los Angeles, California

Pierre B. Saadeh, MD
Assistant Professor
Attending Physician
Department of Surgery, Plastic Surgery
New York University School of Medicine
New York, New York

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


Contributing Authors

Hrayr K. Shahinian, MD, FACS

Alisa C. Thorne, MD

Director
Skull Base Institute
Cedars-Sinai Medical Office Towers
Los Angeles, California

Professor of Clinical Anesthesiology
Weil Cornell School of Medicine
Director of Ambulatory Anesthesia
Memorial Sloan Kettering Cancer Center
New York, New York

Sheel Sharma, MD
Faculty
Department of Plastic and Reconstructive Surgery
Hackensock, New Jersey

Joseph H. Shin, MD
Associate Professor of Surgery
Director Yale Craniofacial Center
Department of Plastic Surgery
Yale University School of Medicine
Attending Physician
Yale New Haven Hospital
New Haven, Connecticut

Sumner A. Slavin, MD

Division of Plastic Surgery
Beth Israel Deaconess Medical Center
Harvard Medical School
Brookline, Massachusetts

Hooman Soltanian, MD, FACS
Attending
Specialties of Plastic Surgery
Hartford, Connecticut

Scott L. Spear, MD
Chairman
Department of Plastic Surgery
Georgetown University
Professor and Chairman
Department of Plastic Surgery
Georgetown University Hospital
Washington, District of Columbia

Henry M. Spinelli, MD

Charles H. Thorne, MD
Associate Professor
Department of Plastic Surgery
NYU School of Medicine
New York, New York

John T. Tymchak, MD, FACS
Clinical Assistant Professor
Department of Surgery

SUNY Health Science Center at Brooklyn
Director, Division of Plastic Surgery and Hand Surgery
Services
Department of Surgery, Division of Plastic Surgery
The Brookdale University Hospital and Medical Center
Brooklyn, New York

Lok Huei Yap, MD
Department of Plastic Surgery
The University of Texas
M.D. Anderson Cancer Center
Houston, Texas

Michael J. Yaremchuk, MD
Clinical Professor
Department of Surgery
Harvard Medical School
Chief of Craniofacial Surgery
Department of Plastic Surgery
Massachusetts General Hospital
Boston, Massachusetts

Paul Zidel, MD, MS, FACS

Clinical Professor of Surgery
Department of Surgery
Weill Medical College of Cornell University
Attending Surgeon
Department of Plastic Surgery
New York Presbyterian Hospital – Weill Cornell

New York, New York

Clinical Faculty
Department of Surgery
Nova Southeastern University
Fort Lauderdale, Florida
Attending
Department of Surgery
University Hospital
Tamarac, Florida

G. Ian Taylor, AO

Ronald M. Zuker, MD, FRCSC, FACS

Professor
Department of Anatomy and Cell Biology
University of Melbourne
Senior Consultant
Department of Reconstructive Plastic Surgery
Royal Melbourne Hospital
Parkville, Victoria, Canada

Professor of Surgery
Department of Surgery
University of Toronto
Staff Surgeon
Division of Plastic Surgery
The Hospital for Sick Children
Toronto, Ontario, Canada

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

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Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


PREFACE

Although I can vouch that the editors are humble, our task was
not: to produce a comprehensive text covering all of plastic
surgery in a single volume. Grabb and Smith’s Plastic Surgery
is now the only single-volume text that attempts such a feat. In
fact, the book was based on the belief that with proper editing,
our single volume could contain all the essential information
of any multiple-volume text.
The second challenge was to make the book sufficiently
new to justify calling it a “new” edition. Of the 93 chapters,
over two thirds (64) are completely new, with new authors.
The remaining 29 chapters were re-written, in many cases
completely. The number of topics covered increased in all areas
except Hand, with the largest expansion in the Breast and Cosmetic sections. We grouped ten chapters within a newly titled
section, Congenital Anomalies and Pediatric Plastic Surgery.
Every chapter is shorter than its counterpart in the previous
edition, and references were limited to 15. Our authors are
experts in their fields, and their skills in surgery are equaled by

their writing skills. I am grateful that they accepted my editing,

some of which was quite deep in my attempts to keep chapters
pithy.
The downside of a single volume that is comprehensive
enough for examination preparation is its weight! As our senior
co-editor Dr. Beasley warned, “It should be light enough to take
to bed with you.” In this regard, we may have failed, but we
feel comfortable blaming the scope of the field rather than the
competence of the editors.
The book is intended for medical professionals and
trainees at all levels: Practicing plastic surgeons, surgeons in
related fields such as Ophthalmology, Otolaryngology, Oral
Surgery, Orthopedics and General Surgery, surgery residents
in all subspecialties, medical students, physicians assistants,
nurses, and nurse practitioners.
My thanks to the co-editors, authors, Lippincott Williams
and & Wilkins, and Dovetail Content Solutions for their contributions to this worthy endeavor.

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

Charles H. Thorne, MD

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Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

CONTENTS

Contributing Authors vii
Preface xv

PART I ■ PRINCIPLES, TECHNIQUES,
AND BASIC SCIENCE

14

Mohs Micrographic Surgery 115
Karen H. Kim
Roy G. Geronemus

15

Congenital Melanocytic Nevi 120
John N. Jensen
Arun K. Gosain

1

Techniques and Principles in Plastic Surgery 03
Charles H. Thorne

2

Wound Healing: Normal and Abnormal 15
Geoffrey C. Gurtner

16

Malignant Melanoma 124
Christopher J. Hussussian

3

Wound Care 23
Robert D. Galiano
Thomas A. Mustoe

17

Thermal, Chemical, and Electrical Injuries 132
Matthew B. Klein

4

The Blood Supply of the Skin 33
G. Ian Taylor

18

Principles of Burn Reconstruction 150
Matthias B. Donelan

5

Muscle Flaps and Their Blood Supply 42

Stephen J. Mathes
Jamie Levine

19

Radiation and Radiation Injuries 162
James Knoetgen III
Salvatore C. Lettieri
P. G. Arnold

6

Transplant Biology and Applications to Plastic
Surgery 52
W.P. Andrew Lee
Maryam Feili-Hariri
Peter E. M. Butler

20

Lasers in Plastic Surgery 169
David W. Low

7

Implant Materials 58
Arnold S. Breitbart
Valerie J. Ablaza

8

Principles of Microsurgery 66
Lok Huei Yap
Charles E. Butler

9

Microsurgical Repair of Peripheral Nerves and Nerve
Grafts 73
Terence M. Myckatyn
Susan E. Mackinnon

10

Tissue Expansion 84
Bruce S. Bauer

11

Local Anesthetics 91
Alisa C. Thorne

12

21

Embryology of the Head and Neck 179
Arun K. Gosain
Randall Nacamuli

22

Vascular Anomalies 191
John B. Mulliken

23

Cleft Lip and Palate 201
Richard A. Hopper
Court Cutting
Barry Grayson

24

Nonsyndromic Craniosynostosis and Deformational
Plagiocephaly 226
Joseph H. Shin
John A. Persing

25

Craniosynostosis Syndromes 237
Scott P. Bartlett

26

Craniofacial Microsomia 248
Joseph G. McCarthy

27

Orthognathic Surgery 256
Stephen B. Baker

Principles of Craniofacial Distraction 96
Joseph G. McCarthy

PART II ■ SKIN AND SOFT TISSUE
13

PART III ■ CONGENITAL
ANOMALIES AND PEDIATRIC
PLASTIC SURGERY

Dermatology for Plastic Surgeons 105
Alfred Culliford IV
Alexes Hazen

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

xvii


xviii

Contents

28

Craniofacial Clefts and Hypertelorbitism 268
James P. Bradley
Henry Kawamoto, Jr.

29

Miscellaneous Craniofacial Conditions: Fibrous
Dysplasia, Moebius Syndrome, Romberg’s Syndrome,
Treacher Collins Syndrome, Dermoid Cyst,
Neurofibromatosis 281
Robert J. Havlik

PART V ■ AESTHETIC SURGERY
44

Cutaneous Resurfacing: Chemical Peeling,
Dermabrasion, and Laser Resurfacing 459
John A. Perrotti

45

Filler Materials 468
Arnold William Klein

46

Botulinum Toxin 475
Michael A.C. Kane

47

Structural Fat Grafting 480
Sydney R. Coleman

48

Blepharoplasty 486
Mark A. Codner
Derek T. Ford

49

Facelift 498
Charles H. Thorne

50

Forehead Lift 509
David M. Knize

51

Skull Base Surgery 347
Hrayr K. Shahinian

Rhinoplasty 517
Jeffrey E. Janis
Rod J. Rohrich

52

34

Craniofacial and Maxillofacial Prosthetics 350
Lawrence E. Brecht

Liposuction 533
Mary K. Gingrass

53

35

Reconstruction of the Scalp, Calvarium,
and Forehead 358
Lok Huei Yap
Howard N. Langstein

Abdominoplasty and Lower Truncal Circumferential
Body Contouring 542
Al Aly

54

Facial Skeletal Augmentation With Implants 551
Michael J. Yaremchuk

55

Osseous Genioplasty 557

Harvey M. Rosen

56

Hair Transplantation 562
Michael L. Reed

30

Otoplasty and Ear Reconstruction 297
Charles H. Thorne

PART IV ■ HEAD AND NECK
31

Soft Tissue and Skeletal Injuries of the Face 315
Larry Hollier, Jr.
Patrick Kelley

32

Head and Neck Cancer and Salivary
Gland Tumors 333
Pierre B. Saadeh
Mark D. DeLacure

33

36

Reconstruction of the Lips 367
Sean Boutros

37

Reconstruction of the Cheeks 375
Babak J. Mehrara

38

Nasal Reconstruction 389
Frederick J. Menick

39

Reconstruction of the Eyelids, Correction of Ptosis, and
Canthoplasty 397
Martin I. Newman
Henry M. Spinelli

57

Facial Paralysis Reconstruction 417
Ralph T. Manktelow
Ronald M. Zuker
Peter C. Neligan

Augmentation Mammoplasty and Its
Complications 575
Sumner A. Slavin

Arin K. Greene

58

Mastopexy and Mastopexy Augmentation 585
Nolan S. Karp

59

Breast Reduction: Inverted-T Technique 593
Scott L. Spear

60

Vertical Reduction Mammaplasty 604
Elizabeth J. Hall-Findlay

61

Gynecomastia 616
Nolan S. Karp

62

Breast Cancer for the Plastic Surgeon 621
Grant W. Carlson

63

Breast Reconstruction: Prosthetic Techniques 625

Joseph J. Disa

40

41

42

43

Mandible Reconstruction 428
Joseph J. Disa
David A. Hidalgo
Reconstruction of Defects
of the Maxilla and Skull Base 438
Duc T. Bui
Peter G. Cordeiro
Reconstruction of the Oral Cavity, Pharynx,
and Esophagus 447
Giulio Gherardini
Gregory R.D. Evans

PART VI ■ BREAST

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Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


Contents

xix

64

Latissimus Dorsi Flap Breast Reconstruction 634
Dennis C. Hammond

79

Soft-Tissue Reconstruction of the Hand 771
John Tymchak

65

Breast Reconstruction: Tram Flap Techniques 641
James D. Namnoum

80

66

Breast Reconstruction—Free Flap Techniques 648
L. Franklyn Elliott

Fractures and Ligamentous Injuries of the Wrist 781
Hannan Mullett
Michael Hausman

81

Fractures, Dislocations, and Ligamentous Injuries
of the Hand 790
David W. Friedman
Amy Kells
Alberto Aviles

82

Tendon Healing and Flexor Tendon Surgery 803
Paul Zidel

83

Repair of the Extensor Tendon System 810
Steven J. Bates
James Chang

84

Infections of the Upper Limb 817
James J. Chao
Blake A. Morrison

85

Tenosynovitis 826
Hooman Soltanian

86

Compression Neuropathies in the Upper Limb
and Electrophysioiogic Studies 830
Charles R. Effron
Robert W. Beasley

87

Thumb Reconstruction 835
Charles J. Eaton

88

Tendon Transfers 847
Robert W. Beasley

89

Congenital Hand Abnormalities 856
Mihye Choi
Sheel Sharma
Otway Louie

90

Dupuytren’s Disease 864
M. Felix Freshwater

PART VIII ■ HAND

91

Replantation in the Upper Extremity 868
Neil F. Jones

76

Plastic Surgeons and the Development of
Hand Surgery 737
J. William Littler

92

Upper Limb Arthritis 884
Alamgir Isani

77

Principles of Upper Limb Surgery 741
Benjamin Chang

93

Upper Limb Amputations and Prostheses 892
Robert W. Beasley
Genevieve de Bese

78

Radiologic Imaging of the Hand and Wrist 746
Cornelia N. Golimbu

67

Nipple Reconstruction 657
Michael S. Beckenstein

PART VII ■ TRUNK AND LOWER
EXTREMITY
68

Thoracic Reconstruction 665
Raymond R. Chang

69

Abdominal Wall Reconstruction 670
Gregory A. Dumanian

70

Lower-Extremity Reconstruction 676
Armen K. Kasabian
Nolan S. Karp

71

Foot and Ankle Reconstruction 689
Christopher E. Attinger
Ivica Ducic

72

Reconstruction of the Perineum 708
Jeffrey D. Friedman

73

Lymphedema 717
George H. Rudkin
Timothy A. Miller

74

Pressure Sores 722
John D. Bauer
John S. Mancoll
Linda G. Phillips

75

Reconstruction of the Penis 730
J. Joris Hage

Index 901

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.

Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


GRABB AND SMITH’S
PLASTIC SURGERY
S I X T H

E D I T I O N

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


PART I ■ PRINCIPLES, TECHNIQUES,
AND BASIC SCIENCE

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


CHAPTER 1 ■ TECHNIQUES AND
PRINCIPLES IN PLASTIC SURGERY

CHARLES H. THORNE

Plastic surgery is a unique specialty that defies definition, has
no organ system of its own, is based on principles rather than
specific procedures, and, because of cosmetic surgery, is the
darling of the media.
What is plastic surgery? No complete definition exists. Joe
McCarthy defines it as the “problem-solving specialty.” My
wife, an anesthesiologist, calls plastic surgeons the “finishers”
because they come in when “the other surgeons have done all
they can do and the operation has to be finished.” An even more
grandiose definition is the following from a plastic surgery resident: “Plastic surgery is surgery of the skin and its contents.”
There is no way to define this specialty that has acquired “turf”
through a combination of tradition and innovation. What is the
common denominator between craniofacial surgery and hand
surgery? Between pressure sore surgery and cosmetic surgery?
Unlike other surgical specialties, plastic surgery is not organized around a specific organ system. Plastic surgery has only
traditional areas of expertise and principles on which to rely
for its existence and future. Because plastic surgery has loose
boundaries and no specific anatomic region, it faces competition from regionally oriented specialties. Traditional areas of
expertise can be lost as other specialties acquire the skills to
perform the procedures developed by plastic surgeons. Consequently, plastic surgery has both freedom and vulnerability. It
is this vulnerability that makes plastic surgery dependent on
both the maintenance of superiority in the traditional areas of
expertise and on continued innovation and acquisition of new
techniques, new procedures, new problems to solve—that is,
new turf.
Plastic surgery is based more on principles than on the details of specific procedures. This allows the plastic surgeon to
solve unusual problems, to operate from the top of the head
to the tip of the toe, to apply known procedures to other body

parts, and to be innovative.
No specialty receives the attention from the lay press that
plastic surgery receives. At the same time, no specialty is lesswell understood. Although the public equates plastic surgery
with cosmetic surgery, the roots of plastic surgery lie in its
reconstructive heritage. Cosmetic surgery, an important component of plastic surgery, is but one piece of the plastic surgical
puzzle.
Plastic surgery consists of reconstructive surgery and cosmetic surgery but the boundary between the two, like the
boundary of plastic surgery itself, is difficult to draw. The more
one studies the specialty, the more the distinction between cosmetic surgery and reconstructive surgery disappears. Even if
one asks, as an insurance company does, about the functional
importance of a particular procedure, the answer often hinges
on the realization that the function of the face is to look like
a face (i.e., function = appearance). A cleft lip is repaired so
the child will look, and therefore hopefully function, like other
children. A common procedure such as a breast reduction is
enormously complex when one considers the issues of appear-

ance, self-image, sexuality, and womanhood, and defies categorization as simply cosmetic or necessarily reconstructive.
This chapter outlines basic plastic surgery principles and
techniques that deal with the skin. Cross-references to specific
chapters providing additional information are provided. Subsequent chapters in the first section will discuss other concepts
and tools that allow plastic surgeons to tackle more complex
problems. Almost all wounds and all procedures involve the
skin, even if it is only an incision, and therefore the cutaneous
techniques described in this text are applicable to virtually every procedure performed by every specialty in surgery.

OBTAINING A FINE-LINE SCAR
“Will there be a scar?” Even the most intelligent patients ask
this preposterous question. When a full-thickness injury occurs
to the skin or an incision is made, there is always a scar. The

question should be, “Will I have a relatively inconspicuous fineline scar?”
The final appearance of a scar is dependent on many factors,
including the following: (a) Differences between individual patients that we do not yet understand and cannot predict; (b)
the type of skin and location on the body; (c) the tension on
the closure; (d) the direction of the wound; (e) other local and
systemic conditions; and, lastly, (f) surgical technique.
The same incision or wound in two different patients will
produce scars that differ in quality and aesthetics. Oily or
pigmented skin produces, as a general rule, more unsightly
scars (Chapter 2 discusses hypertrophic scars and keloids).
Thin, wrinkled, pale, dry, “WASPy” skin of patients of English
or Scotch-Irish descent usually results in more inconspicuous
scars. Rules are made to be broken, however, and an occasional
patient will develop a scar that is not characteristic of his or
her skin type.
Certain anatomic areas routinely produce unfavorable scars
that remain hypertrophic or wide. The shoulder and sternal
area are such examples. Conversely, eyelid incisions almost always heal with a fine-line scar.
Skin loses elasticity with age. Stretched-out skin, combined
with changes in the subcutaneous tissue, produces wrinkling,
which makes scars less obvious and less prone to widening
in older individuals. Children, on the other hand, may heal
faster but do not heal “better,” in that their scars tend to be
red and wide when compared to scars of their grandparents. In
addition, as body parts containing scars grow, the scars become
proportionately larger. Beware the scar on the scalp of a small
child!
Just as the recoil of healthy, elastic skin in children may lead
to widening of a scar, tension on a closure bodes poorly for
the eventual appearance of the scar. The scar associated with a

simple elliptical excision of a mole on the back will likely result

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.

3


4

Part I: Principles, Techniques, and Basic Science

FIGURE 1.1. Relaxed skin tension lines. (Reproduced with permission
from Ruberg R. L. In: Smith DJ, ed. Plastic Surgery, A Core Curriculum.
St. Louis: Mosby, 1994.)

in a much less appealing scar than an incisional wound. The
body knows when it is missing tissue.
The direction of a laceration or excision also determines
the eventual appearance of the scar. The lines of tension in the
skin were first noted by Dupuytren. Langer also described the
normal tension lines, which became known as “Langer lines.”
Borges referred to skin lines as “relaxed skin tension lines”
(Fig. 1.1).
Elective incisions or the excision of lesions are planned when
possible so that the final scars will be parallel to the relaxed skin
tension lines. Maximal contraction occurs when a scar crosses
the lines of minimal tension at a right angle. Wrinkle lines are
generally the same as the relaxed skin tension lines and lie
perpendicular to the long axis of the underlying muscles.

Other issues, which are not related to the scar itself but
to perception, determine if a scar is noticeable. Incisions and
scars can be “hidden” by placing them at the junction of aesthetic units (e.g., at the junction of the lip and cheek, along
the nasolabial fold), where the eye expects a change in contour (Chapter 38). In contrast, an incision in the midcheek or
midchin or tip of the nose will always be more conspicuous.
The shape of the wound also affects ultimate appearance.
The “trapdoor” scar results from a curvilinear incision or laceration that, after healing and contracture, appears as a depressed
groove with bulging skin on the inside of the curve. Attempts at
“defatting” the bulging area are never as satisfactory as either
the patient or surgeon would like.
Local conditions, such as crush injury of the skin adjacent
to the wound, also affect the scar. So, too, will systemic conditions such as vascular disease or congenital conditions affecting elastin and/or wound healing. Nutritional status can
affect wound healing, but usually only in the extreme of malnutrition or vitamin deficiency. Nutritional status is probably
overemphasized as a factor in scar formation.
Technique is also overemphasized (by self-serving plastic
surgeons?) as a factor in determining whether a scar will be
inconspicuous, but it is certainly of some importance. Minimizing damage to the skin edges with atraumatic technique,
debridement of necrotic or foreign material, and a tension-free
closure are the first steps in obtaining a fine-line scar. Ultimately,

however, scar formation is unpredictable even with meticulous
technique.
Two technical factors are of definite importance in increasing the likelihood of a “good” scar. First is the placement of sutures that will not leave permanent suture marks or the prompt
removal of skin sutures so disfiguring “railroad tracks” do not
occur. In other words, removing the sutures may be more important than placing them! Plastic surgeons have been known
to mock other specialists for using heavy-gauge suture for skin
closure, but the choice of sutures is irrelevant if the sutures are
removed soon enough. Sutures on the face can usually be removed in 3 to 5 days and on the body in 7 days or less. Except
for wounds over joints, sutures should rarely be left in for more
than 1 week. A subcutaneous layer of closure and Steri-Strips

are usually sufficient to prevent dehiscence.
The second important technical factor that affects the appearance of scars is wound-edge eversion. In wounds where
the skin is brought precisely together, there is a tendency for
the scar to widen. In wounds where the edges are everted, or
even hypereverted in an exaggerated fashion, this tendency is
reduced, possibly by reducing the tension on the closure. In
other words, the ideal wound closure may not be perfectly flat,
but rather bulging with an obvious ridge, to allow for eventual
spreading of that wound. Wound-edge eversion ALWAYS goes
away. The surgeon need not ever worry that a hypereverted
wound will remain that way; it will always flatten over time.

CLOSURE OF SKIN WOUNDS
While the most common method of closing a wound is with
sutures, there is nothing necessarily magic or superior about
sutures. Staples, skin tapes, or wound adhesives are also useful
in certain situations. Regardless of the method used, precise
approximation of the skin edges without tension is essential to
ensure primary healing with minimal scarring.
Wounds that are deeper than skin are closed in layers. The
key is to eliminate dead space, to provide a strong enough
closure to prevent dehiscence while wound healing is occurring,
and to precisely approximate the skin edges without tension.
Not all layers necessarily require separate closure. A closure
over the calf, however, is subject to motion, dependence, and
stretching with walking, requiring a stronger closure than the
scalp, which does not move, is less dependent, and not subject
to tension in daily activities.
Except for dermal sutures, which are placed with the knot
buried to prevent it from emerging from the skin during the

healing process, sutures should be placed with the knot superficial to the loop of the suture (not buried), so that the tissue
layers can be everted (Fig. 1.2A).
Buried dermal sutures provide strength so the external sutures can be removed early, but do not prevent the scar from
spreading over time. There is no technique that reliably prevents a wound that has an inclination to widen from doing so.

Suturing Techniques
Techniques for suturing are illustrated in Figure 1.2 and are
listed below.

Simple Interrupted Suture
The simple interrupted suture is the gold standard and the most
commonly employed suture. The needle is introduced into the
skin at an angle that allows it to pass into the deep dermis at
a point further removed from the entry of the needle. This allows the width of suture at its base in the dermis to be wider

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


5

Chapter 1: Techniques and Principles in Plastic Surgery

A

B

D

C

E

F

H

G

FIGURE 1.2. Types of skin closure. A: Simple interrupted. B: Vertical mattress. C: Horizontal mattress.
D: Subcuticular continuous. E: Half-buried horizontal mattress. F: Continuous over-and-over. G: Staples.
H: Skin tapes (skin adhesive performs a similar function).

than the epidermal entrance and exit points, giving the suture
a triangular appearance when viewed in cross section and everting the skin edges. Care must be taken to ensure that the
suture is placed at the same depth on each side of the incision
or wound, otherwise the edges will overlap. Sutures are usually
placed approximately 5 to 7 mm apart and 1 to 2 mm from
the skin edge, although the location and size of the needle and
caliber of the suture material make this somewhat variable.

Horizontal Mattress Suture
Horizontal mattress sutures also provide approximation of the
skin edges with eversion. They are particularly advantageous
in thick glabrous skin (feet and hand). In the author’s opinion, horizontal mattress sutures are superior to their vertical
counterparts.

Subcuticular Suture
Vertical Mattress Suture
Vertical mattress sutures may be used when eversion of the

skin edges is desired and cannot be accomplished with simple
sutures alone. Vertical mattress sutures tend to leave the most
obvious and unsightly cross-hatching if not removed early.

Subcuticular (or intradermal) sutures can be interrupted or
placed in a running fashion. In a running subcutaneous closure, the needle is passed horizontally through the superficial
dermis parallel to the skin surface to provide close approximation of the skin edges. Care is taken to ensure that the sutures
are placed at the same level. Such a technique obviates the need

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.


6

Part I: Principles, Techniques, and Basic Science

for external skin sutures and circumvents the possibility of suture marks in the skin. Absorbable or nonabsorbable suture
can be used, with the latter to be removed at 1 to 2 weeks after
suturing.

Half-Buried Horizontal Mattress Suture
Half-buried horizontal mattress sutures are used when it is desirable to have the knots on one side of the suture line with no
suture marks on the other side. For example, when insetting the
areola in breast reduction, this method leaves the suture marks
on the dark, pebbly areola instead of on the breast skin.

Continuous Over-and-Over Suture
Continuous over-and-over sutures, otherwise known as running simple sutures can be placed rapidly but depend on the
wound edges being more-or-less approximated beforehand. A

continuous suture is not nearly as precise as interrupted sutures.
Continuous sutures can also be placed in a locking fashion to
provide hemostasis by compression of wound edges. They are
especially useful in scalp closures.

Skin Staples
Skin staples are particularly useful as a time saver for long
incisions or to position a skin closure or flap temporarily before
suturing. Grasping the wound edges with forceps to evert the
tissue is helpful when placing the staples to prevent inverted
skin edges. Staples must be removed early to prevent skin marks
and are ideal for the hair-bearing scalp.

Skin Tapes
Skin tapes can effectively approximate the wound edges, although buried sutures are often required in addition to skin
tape to approximate deeper layers, relieve tension, and prevent
inversion of the wound edges. Skin tapes can also be used after skin sutures are removed to provide added strength to the
closure.

Skin Adhesives
Skin adhesives have been developed, and may have a role in
wound closure, especially in areas where there is no tension on
the closure, or where strength of closure has been provided by a
layer of buried dermal sutures. Adhesives, by themselves, however, do not evert the wound edges. Eversion must be provided
by deeper sutures.

FIGURE 1.3. Elliptical excision. A: If the ellipse is too short, dog-ears
(arrows) form at the ends of the closed wound. B: Correct method with
length of ellipse at least three times the width.

Elliptical Excision
Simple elliptical excision is the most commonly used technique
(Fig. 1.3). Elliptical excision of inadequate length may yield
“dog-ears,” which consist of excess skin and subcutaneous fat
at the end of a closure. There are several ways to correct a dogear, some of which are shown in Figure 1.4. Dog-ears are the
bane of plastic surgical existence and one must be facile with
their elimination. Dog-ears do not disappear on their own.

Wedge Excision
Lesions located at or adjacent to free margins can be excised
by wedge excision. In some elderly patients, one third of the
lower lip and one fourth of the upper lip can be excised with
primary closure (Fig. 1.5)

Circular Excision

Methods of Excision
Lesions of the skin can be excised with elliptical, wedge, circular, or serial excision.

When preservation of skin is desired (such as the tip of the nose)
or the length of the scar must be kept to a minimum (children),
circular excision might be desirable. Figure 1.6 shows some closure techniques. Figure 1.6 is included because these techniques

FIGURE 1.4. Three methods of removing a dog-ear
caused by making the elliptical excision too short.
A: Dog-ear excised, making the incision longer, or converted to a “Y”. B: One method of removing a dog-ear
caused by designing an elliptical excision with one side
longer than the other. Conversion to an “L” effectively
lengthens the shorter side.

Copyright © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
Grabb and Smith's Plastic Surgery, Sixth Edition by Charles H. Thorne.