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Scott-Brown's Otorhin laryngology,
Head and Neck Surgery
Scott-Brown's Otorhinolaryngology, Head and Neck Surgery
7th edition
Lead editor: Michael Gleeson

Volume 1 Volume 2
Part 1 Cell biology, edited by Nicholas S Jones Part 13 The nose and paranasal sinuses, edited by
Part 2 Wound healing, edited by Nicholas S Jones Valerie J Lund
Part 3 Immunology, edited by Nicholas S Jones Part 14 The neck, edited by John Hibbert
Part 4 Microbiology, edited by Nicholas S Jones Part 15 The upper digestive tract, edited by John Hibbert
Part 5 Haematology, edited by Nicholas S Jones Part 16 The upper airway, edited by John Hibbert
Part 6 Endocrinology, edited by Nicholas S Jones Part 17 Head and neck tumours, edited by John Hibbert
Part 7 Pharmacotherapeutics, edited by Martin J Burton
Part 8 Perioperative management, edited by Martin J Burton Volume 3
Part 9 Safe and effective practice, edited by Martin J Burton Part 18 Plastic surgery of the head and neck, edited by
Part 10 Interpretation and management of data, edited by John C Watkinson
Martin J Burton Part 19 The ear, hearing and balance, edited by
Part 11 Recent advances in technology, edited by George G Browning and Linda M Luxon
Martin J Burton Part 20 Skull base, edited by Michael Gleeson
Part 12 Paediatric otorhinolaryngology, edited by Ray Clarke Index
CD-ROM

George G Browning MD FRCS

Professor of Otorhinolaryngology, MRC Institute of Hearing Research, Glasgow Royal Infirmary, Glasgow, UK
Martin J Burton MA OM FRCS
Senior Clinical Lecturer, University of Oxford; and Consultant Otolaryngologist, Oxford Radcliffe NHS Trust
Oxford, UK
Ray Clarke BSc DCH FRCS FRCS (ORL)
Consultant Paediatric Otolaryngologist, Royal Liverpool University Children's Hospital, Alder Hey, Liverpool, UK
Michael Gleeson MD FRCS
Professor of Otolaryngology and Skull Base Surgery, Institute of Neurology, University College London; and Consultant, Guy's, Kings and
St Thomas' and the National Hospital for Neurology and Neurosurgery, London UK; and Honorary Consultant Skull Base Surgeon, Great
Ormond Street Hospital for Sick Children, London, UK
John Hibbert ChM FRCS
Formerly Consultant Otolaryngologist, Department of Otolaryngology, Guy's Hospital, London, UK
Nicholas S Jones MD FRCS FRCS (ORL)
Professor of Otorhinolaryngology, Queen's Medical Centre, University of Nottingham, Nottingham UK
Valerie J Lund MS FRCS FRCS (Ed)
Professor of Rhinology, The Ear Institute, University College London, London, UK
Linda M Luxon BSc MBBS FRCP
Professor of Audiovestibular Medicine, University of London at University College London, Academic Unit of Audiovestibular Medicine; and
Consultant Physician, National Hospital for Neurology and Neurosurgery; and Honorary Consultant Physician, Great Ormond Street Hospital
for Children, London, UK
John C Watkinson MSc MS FRCS (Ed, Glas, Land) DLO
Consultant Head and Neck and Thyroid Surgeon, Department of Otorhinolaryngology/Head and Neck Surgery, Queen Elizabeth Hospital,
University of Birmingham NHS Trust, Birmingham, UK
 III

c t- row's r I
e and c r

7th edition

Edited by
Michael Gleeson
George G Browning. Martin J Burton.
Ray Clarke. John Hibbert. Nicholas S Jones.
Valerie J Lund. Linda M Luxon.
John C Watkinson

Hodder Arnold
www. hod d ere due a ti 0 n. com
First published in Great Britain in 1952 by Butterworth 8: Co.

Second edition 1965

Third edition 1971
Fourth edition 1979
Fifth edition 1987
Sixth edition 1997

This seventh edition published in Great Britain in 2008 by Hodder Arnold

An imprint of Hodder Education, a part of Hachette Livre UK, 338 Euston Road, London NWl 3BH

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Contents

How to use this book xi

PART 18 PLASTIC SURGERY OF THE HEAD AND NECK - EDITED BY JOHN C WATKINSON 2811

204 The history of reconstructive surgery of the head and neck 2813
Ralph W Gilbert and John Watkinson
205 Grafts and local flaps in head and neck surgery 2819
John C Watkinson
206 Pedicled flaps in head and neck surgery 2847
John C Watkinson and Ralph W Gilbert
207 Free flaps in head and neck reconstruction 2867
Ralph W Gilbert

208 Keloids, hypertrophic scars and scar revision 2891

J Regan Thomas and Steven Ross Mobley

209 Principles of osseointegration and the role of prosthetics 2901

M Stephen Dover and Steve Worrollo
210 A combined prosthetic and surgical approach to head and neck reconstruction 2924
Steve Worrollo and M Stephen Dover
211 Aesthetics, facial proportions and digital planning in facial plastic surgery 2943
Archana Vats and David Roberts
212 Reduction rhinoplasty 2950
Julian M Rowe-Jones
213 External rhinoplasty 2959
Gilbert J Nolst Trenite and Santdeep H Paun
214 Augmentation rhinoplasty 2970
Lydia Badia and Charles East
215 Revision rhinoplasty 2979
Gerhard Rettinger and Claudia Rudack
216 The deviated nose 2987
Charles East
217 The nasal tip and nasolabial angle 2995
Michael Stearns
218 The nasal valve and its management 3006
Ullas Raghavan and Nicholas S Jones
219 Nasal reconstruction 3015
Ullas Raghavan and Nicholas S Jones
220 Total reconstruction of the pinna 3028
David Gault
 I Contents

221 Blepharoplasty 3048

Brian Leatherbarrow
222 The ageing face 3068
John M Hilinski and Dean M Toriumi
223 Facial reanimation 3077
Douglas Harrison
224 Medical negligence in facial plastic surgery 3088
Maurice Hawthorne and David Ward

PART 19 THE EAR, HEARING AND BALANCE - EDITED BY GEORGE G BROWNING AND LINDA M LUXON 3099

Section A: Basic science aspects 3103

225 The anatomy and embryology of the external and middle ear 3105
Tony Wright and Peter Valentine
226 Form and ultrastructure of the cochlea and its central connections 3126
David N Furness and Carole M Hackney
227 Anatomy and ultrastructure of the vestibular organ 3147
Helge Rask-Andersen and Dan Bagger-Sj6"bCick
228 Sound vibrations and waves 3158
Peter Haughton
229 Physiology of hearing 3173
James 0 Pickles
230 Physiology of equilibrium 3207
Floris L Wuyts and An Boudewyns
231 The perception of sound 3245
Brian CJ Moore
232 Psychoacoustic audiometry 3260
Stig Arlinger
233 Evoked physiological measurement of auditory sensitivity 3276
Hillel Pratt
234 Prevention of hearing loss: scientific principles 3298
Su-Hua Sha, Andra E Talaska and Jochen Schacht

Section B: Clinical aspects 3307

235 Clinical examination of the ears and hearing 3311
Peter-John Wormald
236 Conditions of the pinna and external auditory canal 3321
George G Browning
236a Furunculosis 3323
Malcolm P Hilton
236b Bullous myringitis 3326
Bo Tideholm
236c Granular myringitis 3328
Bo Tideholm
236d Benign necrotizing otitis externa 3332
James W Loock
236e Malignant otitis externa 3336
A Simon Carney
236f Keratosis obturans and primary auditory canal cholesteatoma 3342
Tristram HJ Lesser
 Contents I

236g Acquired atresia of the external ear 3346

Jonathan P Harcourt
236h Otitis externa and otomycosis 3351
A Simon Carney
236i Perichondritis of the external ear 3358
James W Loock
236j Relapsing polychondritis 3362
James W Loock
236k Exostosis of the external auditory canal 3366
Philip J Robinson
2361 Foreign bodies in the ear 3370
Gary Kroukamp and James W Loock
236m Haematoma auris 3373
James W Loock
236n Osteoradionecrosis of the temporal bone 3376
James W Loock
2360 Herpes zoster oticus 3379
A Simon Carney
237 Conditions of the middle ear 3383
George G Browning
237a Acute otitis media in adults 3385
George G Browning
237b Otitis media with effusion in adults 3388
Michael Chi Fai Tong and C Andrew van Hasselt
237c Chronic otitis media 3395
George G Browning, Saumil N Merchant Gerard Kelly, lain RC Swan, Richard Canter and William S McKerrow
237d Tuberculosis of the temporal bone 3446
Jose M Acuin
237e Otosclerosis 3453
Saumil N Merchant, Michael J McKenna, George G Browning, Peter A Rea and Rinze A Tange
237f Paget's disease 3486
Ian D Bottrill
237g Ear trauma 3491
Robert Mills, Desmond A Nunez and Stephen C Toynton
237h Otalgia 3526
Liam M Flood
238 Conditions of the cochlea 3537
George G Browning
238a Age-related sensorineural hearing impairment 3539
David M Baguley, Evan Reid and Andrew McCombe
238b Noise-induced hearing loss 3548
David M Baguley and Andrew McCombe
238c Autosomal dominant nonsyndromic sensorineural hearing impairment 3558
Cor WRJ Cremers
238d Ototoxicity 3567
Stephen O'Leary
238e Idiopathic sudden sensorineural hearing loss 3577
Martin J Burton and Richard J Harvey
238f Tinnitus and other dysacuses 3594
Borka Ceranic and Linda M Luxon
viii I Contents

239 Management of hearing impairment 3629

George G Browning
239a Hearing aids 3631
Harvey Dillon
239b Bone-anchored hearing aids 3642
George G Browning
239c Cochlear implants 3649
Andrew Marshall and Kevin P Gibbin
239d Middle ear implants 3660
Richard M Irving and Andrew Scott
23ge Accessory devices 3666
Leo McClymont
240 Balance disorders 3673
Linda M Luxon
240a Pathology of the vestibular system 3675
Dan Bagger-Sj6bdck and Helge Rask-Andersen
240b Evaluation of balance 3706
Adolfo M Bronstein
240c Vertigo: Clinical syndromes 3748
G Michael Halmagyi, Matthew J Thurtell and Ian S Curthoys
240d Vertigo: clinical management and rehabilitation 3791
Doris-Eva Bamiou and Linda M Luxon
240e Medical negligence in otology 3826
Maurice Hawthorne
241 Retrocochlear and facial nerve disorders 3835
Linda M Luxon
241 a Retrocochlear hearing disorders, including auditory dyssynchrony 3837
Rosalyn A Davies
241 b Central auditory dysfunction 3857
Frank E Musiek and Jane A Baran
241 c Disorders of the facial nerve 3870
Thanos Bibas, Dan Jiang and Michael J Gleeson

PART 20 SKULL BASE - EDITED BY MICHAEL GLEESON 3895

242 Anatomy of the skull base and infratemporal fossa 3897

Paul O'Flynn and Martin Bailey
243 Clinical neuroanatomy 3911
John P Patten
244 Evaluation of the skull base patient 3942
Ranit De and Richard Mirving
245 Vascular assessment and management in skull base surgery 3949
Stefan Brew and Naomi Sibtain
246 Natural history of vestibular schwannoma 3957
Mirko Tos
247 Surgical management of vestibular schwannoma 3967
Richard Ramsden and Shakeel Saeed
248 Gamma knife stereotactic radiosurgery 3989
Jeremy Rowe, Matthias Radatz and Andras Armand Kemeny
249 The patient with neurofibromatosis 2 3998
o Gareth R Evans and Michael E Basert
 Contents

250 Management of nonacoustic cerebellopontine angle tumours 4007

Jacob Bertram Springborg and Jens Thomsen
4018
251 Middle fossa surgery
Richard M Irving and Sunil Narayan Dutt
4026
252 Jugular foramen lesions and their management
Kees Graamans
4046
253 Petrous apex lesions
Michael Gleeson
4054
254 Approaches to the nasopharynx and Eustachian tube
Gunesh P Rajan and Stephan Schmid
4067
255 Tumours of the temporal bone
Marcus Atlas and Peter O'Sullivan
4078
256 Tumours of the facial nerve
Patrick R Axon and Tim Price
4086
257 Squamous cell carcinoma of the temporal bone
David Moffat and Sherryl Wagstaff
4098
258 Pituitary tumours: medical and surgical management
Alan P Johnson
4119
259 Anterior and anterolateral skull base and craniofacial surgery
Christopher A Milford and Richard SC Kerr
4135
260 Complications of skull base surgery
Ravinder PS Harar and Gerald Brookes
4142
261 Medical negligence in skull base surgery
Maurice Hawthorne and Alec Fitzgerald O'Connor

4149
Index
CD-ROM

Please note: The table of contents for all three volumes can be found on the Scott-Brown website at: [Link].

The list of contributors, preface and list of abbreviations are included in the prelims for Volume 1.
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HoW to use this book

. dition of Scott-Brown's Otorhinolaryngology, Head and Neck Surgery incorporates some special features to aid the
ThIs ne~ e derstanding and navigation of the text. These are described below.
readers un

SEARCH STRATEGY
- . ·ty of the chapters feature a search strategy indicating the key words used by the author when conducting their
The maJon view in or d er to prepare t h e ch apter, so t h at t h e rea d er can repeat an d d evelop the search.
literature re

EVIDENCE SCORING
- h major sections in each chapter, the authors have used a hierarchical system to indicate the level of evidence
For t e. their statements. This is shown in the text in the form [***], with the number of stars indicating the level of
(J

Su?portlllo key to this system is shown in the table below.

eVIdence. The

Category of evidence
Level
Systematic reviews, meta-analyses of randomized controlled trials and randomized controlled trials
****
Non-randomised studies
***
Observational or non-experimental studies
**
Expert opinion
*

Wh no level is shown, the quality of supporting evidence, if any exists, is of low grade only (for example, case reports,
. ~rel xperience etc.). For more information on evidence scoring, please refer to Chapter 304, Evidence-based medicine;
c1Illlca e ..
and 305 Critical appraIsal skIlls.

CLINICAL RECOMMENDATIONS
Th thors have indicated the basis on which they have made clinical recommendations by grading them according to the
1 elau the supporting evidence. This is shown in the text in the form [Grade A], with the grade indicating the level of
f
e~ed 0 supporting the recommendation. The key to this system is shown in the table below.
eVI ence
xii I How to use this book

Grade Nature of supporting evidence

A Recommendation based on evidence from meta-analyses of randomized controlled trails

B Recommendation based on evidence from high quality case-controlled or cohort studies
C Recommendation based on evidence from low quality case-controlled or cohort studies
D Recommendation based on evidence from clinical series or expert opinion

Recommendations are graded where the author is satisfied that the literature supports such a grading; otherwise a grading
may not be given.

REFERENCE ANNOTATION

The reference lists are annotated with an asterisk, where appropriate, to guide readers to key primary papers and major
review articles. We hope that this feature will render the lists of references more useful to the reader and will encourage
self-directed learning among both trainees and practicing physicians.
 PLASTIC SURGERY OF THE HEAD AND NECK

EDITED BY JOHN C WATKINSON

204 The history of reconstructive surgery of the head and neck 2813
Ralph W Gilbert and John Watkinson
205 Grafts and local flaps in head and neck surgery 2819
John C Watkinson
206 Pedicled flaps in head and neck surgery 2847
John C Watkinson and Ralph W Gilbert
207 Free flaps in head and neck reconstruction 2867
Ralph W Gilbert

208 Keloids, hypertrophic scars and scar revision 2891

J Regan Thomas and Steven Ross Mobley

209 Principles of osseointegration and the role of prosthetics 2901

M Stephen Dover and Steve Worrollo
210 A combined prosthetic and surgical approach to head and neck reconstruction 2924
Steve Worrollo and M Stephen Dover
211 Aesthetics, facial proportions and digital planning in facial plastic surgery 2943
Archana Vats and David Roberts
212 Reduction rhinoplasty 2950
Julian M Rowe-Jones
213 External rhinoplasty 2959
Gilbert J Nolst Trenite and Santdeep H Paun
214 Augmentation rhinoplasty 2970
Lydia Badia and Charles East
215 Revision rhinoplasty 2979
Gerhard Rettinger and Claudia Rudack
216 The deviated nose 2987
Charles East
217 The nasal tip and nasolabial angle 2995
Michael Stearns
218 The nasal valve and its management 3006
Ullas Raghavan and Nicholas S Jones

-
219 Nasal reconstruction 3015
UI/as Raghavan and Nicholas 5 Jones
220 Total reconstruction of the pinna 3028
David Gault
221 Blepharoplasty 3048
Brian Leatherbarrow
222 The ageing face 3068
John M Hilinski and Dean M Toriumi
223 Facial reanimation 3077
Douglas Harrison
224 Medical negligence in facial plastic surgery 3088
Maurice Hawthorne and David Ward
The history of reconstructive surgery of the head and
neck

RALPH W GILBERT AND JOHN WATKINSON

Introduction 2813 The Great Wars 2815

The early history 2813 The modern era 2816
Roman and Hellenic 2814 Key points 2817
The Middle Ages and the Renaissance 2814 Deficiencies in current knowledge and areas for future
The seventeenth and eighteenth centuries 2814 research 2817
Skin grafting 2815 References 2818

The data in this chapter are supported by a Medline search using the key words history, reconstructive surgery, nasal
reconstruction, free tissue transfer, forearm flap, fibular flap and anterolateral thigh flap. Evidence is level 4 throughout.

INTRODUCTION reconstructive head and neck surgery with a focus on

the developments in the nineteenth and early twentieth-
To fully appreciate the current state of head and first century.
neck reconstructive surgery, it is useful to understand
its evolution and development. The word plastic is
derived from the Greek work plastikos meaning 'to THE EARLY HISTORY
mould' or 'to give form'. The origins of reconstructive
head and neck surgery likely predate this linguistic Egyptian physicians can be credited with describing some
root as the early papyri of Egypt and the Sanskrit of the first facial reconstructive efforts. The 'Edwin Smith
texts of India describe the use of reconstructive Papyrus', the origins of which are dated at approximately
procedures to correct facial deformities. Reconstructive 3000BC, contains some of the first descriptions of surgical
surgery over the past many centuries has been largely management of mandibular and nasal fractures. Arguably,
focused on the correction of deformities of the head the first documented efforts of reconstructive surgery of
and neck. Until the end of the nineteenth century the nose and ear are found in the Sanskrit texts of ancient
'plastic surgery' as Gillies described it, was focused on India written approximately 2600 years ago. During this
returning the patient to a normal state. Cosmetic or period of Indian history, reconstructive surgery of the
aesthetic surgery, which developed in the twentieth nose and ear was highly valued as invaders from
century, was essentially focused on surpassing the 'surrounding territories would often stigmatize their
normal. 1 This chapter will review the history of victims by amputating the nose or ear. The early Hindu
2814 I PART 18 PLASTIC SURGERY OF THE HEAD AND NECK

justice system also imposed harsh penalties on those The period of Renaissance in the fourteenth century
found guilty of being unfaithful to a spouse by signalled a rebirth of science, medicine and the world of
amputating either the genitalia or the nose. It is therefore surgery. In the fifteenth century, the Branca family
logical that the nose, a structure of dignity and unique became prominent in wound reconstruction and the
personal identity, would become a focus of reconstructive reintroduction of the Indian method of nasal reconstruc-
efforts in the early history of reconstructive surgery. tion. 3 The family apparently zealously protected the
In his Sushruta Samhita (Sushruta's compendium),l techniques they had developed from outside observers
Sushruta, regarded as the father of Indian surgery, and the surgical techniques were passed down through
described a variety of surgical techniques for reconstruc- family members. Branca's son Antonius inherited this
tion of head and neck defects. Considerable controversy technique and modified it through the use of a delayed
exists over the time period of his contributions with dates skin flap from the arm. This Italian method, as it became
ranging from 600BCE to 1000AD. He contributed to many known, was eventually transferred to other families of
fields of medicine, but is said to have laid the foundations surgeons.
for a variety of pedicled and rotation flaps and was the Descriptions of these various techniques may have
pioneer of reconstructive rhinoplasty having described contributed to Gasparro Tagliacozzi's interest in nasal
more that 15 methods of nasal reconstruction, similar to reconstruction. Tagliacozzi, incorrectly referred to as the
many of the techniques utilized in the nineteenth and originator of the Italian method, made significant
twentieth centuries. contributions to facial reconstructive surgery. Working
in Bologna in the latter half of the sixteenth century,
Tagliacozzi described and refined the use of distant
ROMAN AND HELLENIC pedicled flaps for a variety of facial reconstructions. 4

Whether Hellenistic or Roman physicians were exposed to

the Indian techniques through Alexander the Great's THE SEVENTEENTH AND EIGHTEENTH
expedition to India in the fourth century BCE is of debate. CENTURIES
Certainly Roman and Hellenistic physicians described
similar techniques to those described in India. Aulus In the late 1600s, reconstructive surgery entered into a
Cornelius Celsus,2 considered to be the greatest of the period of significant decline. This was largely based on
Roman medical authors and surgeons, also described a misconceptions about transferred tissues, superstition
variety of techniques similar to those practised in India in and a lack of belief or understanding of the sciences.
his medical text of the first century, De Medecina. Reconstructive surgery began to emerge in the late
The royal Byzantine physician Oribasis wrote exten- eighteenth century. An often cited impetus of this renewal
sively about facial and nasal reconstruction in the fourth was a letter published in London in 1984 in the
century. His comprehensive medical encyclopaedia entitled Gentleman's Magazine by a British surgeon named Lucas.
Synagogue Medicae followed Celsus. He described in detail In this account Lucas described the reconstruction of the
the use of bipedicle advancement flaps for skin defects of nose of a British bullock driver whose nose was mutilated
the eyebrow, ala, cheek, nasal dorsum and columella. He by the enemy for transporting supplies for the British
described the concept of undermining of advancement forces. In the account, Lucas describes a forehead flap
flaps. His technique of alar reconstruction may have been being performed by an Indian man of the brickmaker
the first description of the superiorly based nasolabial flap. caste. Lucas's account was read by Carpue, a British
surgeon who reasoned that if the procedure could be
undertaken in India then it could be easily done in
THE MIDDLE AGES AND THE RENAISSANCE Britain. Carpue described his experience with two British
soldiers in Restoration of a lost nose in 1816 and interest in
The development of facial reconstruction certainly nasal reconstruction and the Indian technique was
continued in the Middle Ages. However, following the renewed in Europe. 5
fall of Rome in the fifth century and the diffusion of In 1818, the German surgeon Carl Von Graefe
Barbarians and Christianity throughout the Middle Ages, published his major work Rhinoplastik. 6 Von Graefe's
a significant decline in the advancement of all surgery, in book described a variety of reconstructive approaches
particular reconstruction, occurred. This decline was including the Indian and Italian methods, as well as his
certainly aided by Pope Innocent III who prohibited own method utilizing a free skin graft from the arm. He
surgical procedures of all types. It is interesting to note also described techniques for palate reconstruction and
that physicians of the time considered surgery to be a blepharoplasty and, because of the breadth of his
manual skill and below their intellectual and societal contributions, is regarded as one of the fathers of modern
stature. The development of the concept of the 'Barber' plastic surgery.
surgeon appeared and the decline of the role of surgery Johann Dieffenbach began his practice in Berlin in
and surgeons began. 1823 with a great interest in plastic surgery and nasal
 Chapter 204 The history of reconstructive surgery of the head and neck III 2815

reconstruction. In 1840, following the death of Von THE GREAT WARS

Graefe, he assumed the chair at the University of Berlin
and published extensively on reconstructive plastic The two world wars in the first half of the twentieth
surgery and in particular nasal reconstruction and century played a key role in the development of
reconstructive rhinoplasty.? He also made significant reconstructive head and neck surgery, particularly in
contributions in cleft palate repair. He was one of the plastic surgery, dentistry and maxillofacial surgery. The
first surgeons to advocate the use of anaesthesia. Based on First World War presented a unique challenge for medical
all accounts, Dieffenbach was a gifted technical surgeon care because of the volume of injured combatants and the
and a charismatic communicator. His charm and nature of the wounds (high velocity projectiles and
humanitarian spirit captivated the hearts of his patients, explosions). On the first day of the Battle of Somme, the
colleagues and students. He died in his clinic while British expeditionary force suffered 60,000 casualties, of
preparing for an operative procedure. whom 21,000 were killed.
Jacques Joseph, a German orthopedic trained surgeon, A number of surgeons had prominent roles in the
is widely regarded as the father of modern rhinoplasty. primary management and reconstruction of these
His book Nasenplastik und Sonstige Gesichtplastik, patients. Prominent among the French surgeons was
published in 1928, remains one of the most comprehen- Hippolyte Morestin. Born in Martinique, Morestin
sive texts written on the subject. 8 Joseph developed a worked at the French army's surgical unit at the Val-
number of techniques and instruments that are still in use de-Grace military hospital in Paris. He became well
today. known for expertise in local flaps, advocating the concept
of wide undermining, as well as developing techniques in
z-plasty. Because of the nature of his work and
prominence, many surgeons observed his [Link]
SKIN GRAFTING Perhaps most prominent among these was Harold
Gillies (1882-1960) (Figure 204.1). Gillies was born in
As applies to many of the reconstructive techniques used Dunedin, New Zealand and graduated in medicine from
in head and neck surgery, the idea and practice of skin
grafting appears to have originated in India as the Hindus
reported the use of free skin grafts along with the use of
forehead and other facial flaps for reconstruction. The
modern interest in skin grafting probably began near
the end of the eighteenth century when Barionio reported
the use of skin grafts on sheep.
The first human skin graft was probably performed by
Astley Cooper in 1817. 9 In 1869, Reverdin reported on his
experience with small 2-3-mm epidermic grafts for
serious burns he was treating at the Necker hospital in
Paris. lo
OIlier, who studied the work of Reverdin, emphasized
the importance of the dermal component and coined the
term skin graft. In 1872, he performed the first successful
full-thickness autograft to treat ectropion. l l
In 1875, Wolfe described the concept of full-thickness
skin grafting over a fresh surgical wound. Wolfe, an
ophthalmologist by training, was given credit along with
Krause for bringing this technique to clinical practice.
The term 'Wolfe graft' is still used in the UK to describe a
full-thickness skin graft. l2
In 1929, Blair and Brown l3 described the use of large
split thickness skin grafts of various thicknesses for
different types of wounds characterizing the features of
donor site morbidity and contraction.
One of the greatest developments in reconstructive
surgery was the development of the dermatome. A
surgeon, Padgett, along with Hood, a mechanical
engineer, developed the dermatome in 1939 which Figure 204.1 Sir Harold Gillies. Reproduced with kind
revolutionized the harvesting and application of skin permission from Andrew Bamji, Curator of Archives at the
grafting techniques. l4 Frognal Centre, Queen Mary Hospital, Sidcup, UK.
2816 PART 18 PLASTIC SURGERY OF THE HEAD AND NECK

Cambridge. He trained initially in otolaryngology and in

1915 volunteered his services to the Red Cross and was
sent to France. Fascinated by the reputation of Hippolyte
Morestin, he went to observe his surgery. The nature of
the work convinced Gillies to advocate for a specialty
hospital for the treatment of facial and jaw injuries for
British combatants. Interestingly, when Gillies made a
return visit to observe Morestin he was refused entry into
the operating theatre.
In 1916, the British War Office established a unit
at the Cambridge Military Hospital, Aldershot. The
Aldershot facilities proved inadequate and in 1917 the
unit was moved to Queen's Hospital (subsequently
named the Queen Mary's Hospital in 1927) at Sidcup in
Kent. Gillies treated and documented the care of
numerous patients and developed his craft at Sidcup.
Significant among his developments were the refinement
of the tubed flap and skin grafting for defects of the
eyelid (Figure 204.2). Gillies' wartime experiences
provided the material for his classic book entitled
Plastic surgery of the face published in 1920. 16 This text,
which is beautifully illustrated, set down Gillies rules to
reconstructive surgery and certainly cemented his reputa-
tion as one of the fathers of modern twentieth century
plastic surgery. Gillies and Sidcup played a major role in
the training of surgeons from around the world. Ferris
Smith, also originally an otolaryngologist, became a
prominent American plastic surgeon. Other prominent
surgeons included Pickerill from New Zealand and
Risdon from Canada. Gillies was knighted in 1930 for
his care of the injured and his major contributions to
the field.
Between the wars, plastic and reconstructive Figure 204.2 Life-size wax model of the head and upper
surgery flourished in North America. In 1919, John torso, constructed for teaching purposes, illustrating surgical
Staige Davis published the first American plastic surgery techniques including forehead and tubed pedicle flaps. Part of
textbook Plastic surgery - its principles and practice, which the New Zealand records returned to Sidcup in 1989 and
became a classic in the field. I? The 1920s and 1930s saw subsequently restored at Madame Tussaud's. Reproduced with
the development of many professional societies dedi- kind permission from Andrew Bamji, Curator of Archives at the
cated to plastic surgery in North America and rapid Frognal Centre, Queen Mary Hospital, Sidcup, UK.
expansion of the number of plastic surgeons in the United
States.
The Second World War facilitated further develop- THE MODERN ERA
ments in reconstructive surgery of the head and neck.
In England there were only four plastic surgeons (The The expertise in soft tissue and bone reconstruction that
Big Four: Gillies, Kilner, Mowlem and Mcindoe). evolved and developed during and after the Great Wars
At the beginning of the Second World War, the emer- changed its focus in the last 40 years of the twentieth
gency medical services in England set up nine centres century. The emphasis in plastic and reconstructive
for facial and jaw injuries. McIndoe was appointed surgery moved to the correction of congenital and
to the Queen Victoria Hospital, East Grinstead in secondary deformities and the reconstruction of defects
Sussex, and Gillies was sent to head the unit at following oncologic resections. Many plastic surgeons
Rooksdown House, Park Prewett Hospital, Basingstoke. became increasingly interested in aesthetic surgery. In the
Gillies continued to develop his expertise in facial 1950s and early 1960s, the majority of oncologic and
reconstruction and McIndoe became famous for post-traumatic reconstruction still utilized the techniques
developing innovative treatment approaches for pioneered by Gillies and his contemporaries. In the 1960s,
severe burns, including the face, and was well known a number of surgical innovations changed the morbidity
during and after the war for his expertise and compas- of head and neck reconstruction. The increasing use of
sionate care. axial pattern flaps made reconstruction of large oral cavity
 Chapter 204 The history of reconstructive surgery of the head and neck II 2817

and neck defects more reliable and less costly

to the patient in terms of prolonged hospitalization. KEY POINTS
Foremost among these were the descriptions of the
forehead flap for oral reconstruction popularized by • The term 'plastic' is derived from the Greek
McGregor and McGregor 18 and the deltopectoral flap work plastikos, meaning to mould or give
described in the United States by Bakamjian and form.
Littlewood. 19 In the late 1970s, the description of the • Nasal reconstruction likely dates back to
pectoralis major myocutaneous flap by Ariyan20 trans- 600BCE, and was described by an Indian
formed head and neck oncologic surgery as patients physician called Sushruta.
could be offered a single-stage, reliable reconstruction • The Branca family and Gasparro Taggliacozzi
with minimal donor site morbidity. In addition, popularized nasal reconstruction using the
the ease of harvest and transfer of the pectoralis major Italian method in the fifteenth and sixteenth
flap made it a technique that any head and neck-trained centuries.
surgeon could perform, broadening the scope of recon- • Reverdin first described skin grafting in 1869
structive surgery to other disciplines outside plastic and Wolfe popularized full thickness skin
surgery. grafting in 1875.
The late 1960s and early 1970s heralded the era of • Sir Harold Gillies, one of the fathers of
reconstructive microsurgery. The concept of free tissue modern plastic surgery, developed his
transfer had been developed years earlier, but was limited surgical expertise during the First and
by the quality and availability of microvascular sutures, Second World Wars and popularized the use
quality instruments and magnification. Jacobsen and of tubed flaps for head and neck
Suarez21 first described the repair of vessels under 2 mm reconstruction.
in 1960. The first free tissue transfer of a composite of • Reconstruction of the head and neck
skin was performed by Taylor and Daniels in 1973. 22 developed quickly in the 1950s and
Subsequent developments in reconstructive microsurgery 1960s with the introduction of the forehead
have resulted in the description of a plethora of free tissue flap for oral reconstruction, the deltopectoral
transfers available for head and neck reconstruction, flap for oral and neck reconstruction
championed by a number of extremely gifted reconstruc- and the introduction of the pectoralis
tive micro surgeons including Harii, Buncke, Manktelow major myocutaneous flap in 1979.
and many others. • The modern era has been defined by the
The more notable among these flaps are the free development and description of free
forearm flap described by Yang in 1983 23 and popularized tissue transfer with first composite tissue
for oral cavity and oromandibular reconstruction by transfer described by Taylor and Daniels in
Soutar et al.;24 the free fibular transfer, originally 1973. 22
described by Taylor in 1977 25 and popularized by Hidalgo
and Rekow26 for mandibular reconstruction in 1995; and
the anterolateral thigh flap described by Song et al.27 in
1984 and popularized for head and neck reconstruction
by Wei et a1. 28 in 2002. Deficiencies in current knowledge and
The community of specialties performing head and areas for future research
neck reconstruction has changed dramatically over the
past 40 years. Head and neck oncologic surgery in the In the next ten years, further refinements will occur in
1950s and 1960s was largely the domain of general and the application and evaluation of the various
plastic surgeons, with the majority of reconstruction reconstructive microsurgical techniques. The areas of
performed by plastic surgeons. In the last three decades of major innovation are clearly tissue engineering and
the twentieth century, however, some major changes in transplantation. Tissue engineering may offer the
the specialties treating defects of the head and neck have potential to create composite tissue constructs
evolved. Increasingly in Europe and North America, that will replace the current approaches,
otolaryngologists with subspecialty training in head and including free tissue transfer and the associated
neck surgery and reconstructive microsurgery began to donor site morbidity. Composite tissue allografts (CTA) or
develop an interest and expertise in head and neck transplantation clearly has the potential to
surgery that extended beyond the treatment of laryngeal dramatically change the field of reconstructive
cancer. At the same time in Europe, maxillofacial surgery surgery of the head and neck. Certainly, the recent
began its evolution as a specialty and increasingly experience with partial facial transplantation in
maxillofacial surgeons treated and reconstructed conge- France 29 has highlighted the opportunities of this
nital, traumatic and oncologic defects of the head technology, as well as the ethical dilemma it poses.
and neck.
2818 II PART 18 PLASTIC SURGERY OF THE HEAD AND NECK

REFERENCES 18. McGregor lA, McGregor FM. Cancer of the face and
mouth. pathology and management for surgeons.
1. Converse JM. Reconstructive plastic surgery. Philadephia: Reconstruction. New York: Raven Press, 1986.
W.B. Saunders Company, 1977. * 19. Bakamjian V, Littlewood M. Cervical skin flaps for
2. Pardon M. Celsus and the Hippocratic Corpus: the intraoral and pharyngeal repair following cancer
originality of a 'plagiarist'. Studies in Ancient Medicine. surgery. British Journal of Plastic Surgery. 1964; 17:
2005; 31: 403-11. 191-210.
3. Branca A. Ersatz der nose aus der haut des oberarms. Cited * 20. Ariyan S. The pectoralis major myocutaneous flap. A
in Hirsch, Biographisches Lexikon. Berlin: Urban 8 versatile flap for reconstruction in the head and neck.
Schwarzenberg, 1929. Plastic and Reconstructive Surgery. 1979; 63: 73-81.
4. Tagliocozzi G. De curtorum chirugia per insitionem libri * 21. Jacobson JH, Suarez EL. Microsurgery in anastomosis of
duo. Venice: Gaspar Bindonus Jr., 1597. small vessels. Surgical Forum. 1960; 11: 243.
5. Carpue JC. An account of two successful operations for * 22. Taylor IG, Daniels R. The free flap: composite tissue
restoring a lost nose. Plastic and Reconstructive Surgery. transfer by vascular anastomosis. Australia and New
1969; 44: 175-82. Zealand Journal of Surgery. 1973; 43: 1-3.
6. Graefe CFv. Rhinoplastik oder die kunst den verlust der nose 23. Yang GF. Free grafting of a lateral brachial skin flap.
organisch zu ersetzen. Berlin: Realschuulbuchhandlung, Zhonghua Wai Ke Za Zhi. 1983; 21: 272-4.
1818. * 24. Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial
7. Dieffenbach JF. Die operative chirurgie. Leipzig: Brockhaus, forearm flap: a versatile method for intra-oral
1845. reconstruction. British Journal of Plastic Surgery. 1983;
8. Joseph J. Nasenplastik und sonstige gesichsplastik. 36: 1-8.
Leipzig: Kabitsch, 1928. 25. Taylor GI. Microvascular free bone transfer: a clinical
9. Cooper AP. Surgical essays. London: Cox, 1818. technique. Orthopedic Clinics of North America. 1977; 8:
10. Reverdin JL. Greffe epidermique. Bulletin et Memoires de 425-47.
10 Societe des Chirurgiens de Paris. 1869; 10: 511. 26. Hidalgo DA, Rekow A. A review of 60 consecutive fibula
11. Oilier L. Greffes cutanees ou autoplatiques. Bulletin de free flap mandible reconstructions. Plastic and
I'Academie Nationale de Medecine. 1872; 1: 243. Reconstructive Surgery. 1995; 96: 585-96.
12. Wolfe JR. A new method of performing plastic operations. 27. Song YG, Chen GZ, Song YL. The free thigh flap: a new free
British Medical Journal. 1875; 32: 360. flap concept based on the septocutaneous artery. British
13. Blair VP, Brown JB. The use and uses of large split skin Journal of Plastic Surgery. 1984; 37: 149-59.
grafts of intermediate thickness. Surgery Gynecology and 28. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have
Obstetrics. 1929; 49: 82. we found an ideal soft-tissue flap? An experience with
14. Padgett EC. Skin grafting. Springfield: Thomas, 1942. 672 anterolateral thigh flaps. Plastic and Reconstructive
15. Roger BO. Hippolyte Morestin (1869-1919). Part I: A brief Surgery. 2002; 109: 2219-26.
biography. Aesthetic Plastic Surgery. 1982; 6: 141-7. * 29. Kanitakis J, Badet L, Petruzzo P, Beziat JL, Morelon E,
16. Gillies HD. Plastic surgery of the face. New York: Oxford Lefrancois N et 01. Clinicopathologic monitoring of the
University Press, 1920. skin and oral mucosa of the first human face allograft:
17. Davis JS. Plastic surgery - Its principles and practice. Report on the first eight months. Transplantation. 2006;
Philadelphia: Blakistons, 1919. 82: 1610-5.
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