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29 Prophylactic Surgical Procedures inPlastic Surgery
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341
some studies indicate 30–56% transformation
rate of these lesions into invasive SCC [179,
180]. Despite the wide variety of treatment
modalities, none of them are known to be efcient on eliminating HPV infectivity. Thus, primary goal of treatment should be ameliorating
the symptom or removing the symptomatic
lesion. “Gold-standard” treatment for Buschke–
Lowenstein tumor is wide local excision with
clear margins and, if present, complementary
modalities according to histological invasion status [181]. Antiviral treatments such as interferon,
immunomodulating agents, or imiquimod may
be preferred rather surgical destruction or
removal to eliminate surgical complications.
However, surgery may still be treatment of choice
because of the advantage of immediate results
[182]. On the other hand, circumcision constitutes a prophylactic measure for prevention of the
HPV transmission [178, 183].
29.3.12 Leukoplakia
tion, betel nut chewing, and old age are the major
risk factors [184]. Since it is a clinical term only,
histopathologic evaluation is warranted to determine the severity of the lesion. Indeed, a clinical
suspicion of leukoplakia diagnosis may end up
with other conditions, such as candidiasis, bite
keratosis, or lichen planus after histopathologic
evaluation. There are several identied subtypes
of oral leukoplakia, for example, homogenous,
non-homogenous and proliferative verrucous leukoplakia, with malignant transformation risk
varying between 1 and 10% per year and overall
mortality rate up to 40% [184]. Biopsies indicating dysplasia or carcinoma in situ require surgical
removal with clear margins, although recurrence
may be up to 35%. A histopathological diagnosis
of “hyperkeratosis with no dysplasia” or “keratosis of unknown signicance” after excluding other
benign conditions warrants special attention
either for prophylactic complete removal or close
follow-up with periodic biopsies depending on
the size, multifocality, margin demarcation, and
subtype of the leukoplakia [185].
Leukoplakia is the best-known lesion of the oral
mucosa which bears malignant potential
(Fig.29.10). It can simply be dened as an oral
mucosal white lesion that cannot be considered as
any other denable lesion. Leukoplakia is thought
to start as focal hyperkeratosis or hyperplasia progressing into some degree of dysplasia and ultimately carcinoma in situ or invasive oral
SCC.Tobacco smoking, heavy alcohol consump-
Fig. 29.10 Squamous cell carcinoma arising from leukoplakia of the right gingivobuccal groove
29.4 Cancer-Unrelated Conditions
As a shining new concept, prophylactic surgery is
not only limited to cancer prevention but can also
comprise wide variety of unwanted consequences
or benign diseases that are intended to be prevented surgically. Accordingly, in addition to the
cancer prevention, this book also aimed to review
numerous cancer-unrelated and surgically preventable conditions in the specic organs and
systems. However, plastic surgery is not generally conned to an organ or system and it mostly
focuses on solving the “problem.” Interestingly,
dealing with the “problem” may conict with the
spirit of the prophylactic surgery whose
fundamental purpose is to prevent the “problem.”
But it should be considered that solving a “problem,” for example, repairing a cleft palate primarily aims to prevent more serious and irreversible
“problem,” such as speech abnormalities, as in
this instance. While reviewing the surgical procedures from the top of the head to the tip of the
toes involving patients ranging in age from new-
342
born to nonagenarian in the light of the prophylactic surgery perspective, we could identify less
than a dozen conditions adaptable to the ideal
description of the prophylactic surgery. We
believe that these conditions ranging from basic
to sophisticated are not limited to our appreciation and as the mentality of the prophylactic surgery expands and more widely adopted, the
number of examples will increase both in number
and diversity.
29.4.1 Fasciotomy/Escharotomy
A fasciotomy is a well-known and the only effective surgical treatment of the compartment syndrome (CS), which can be described as either an
acute or a chronic condition, that is resulted from
elevated pressure in a non-compliant osseofascial compartment. Elevated compartment pressure in turn gives rise to decreased circulatory
pressure gradient between the vascular bed and
tissues, and leads to ischemic necrosis of the
muscles and nerves within the compartment.
Surgical fasciotomy procedure typically starts
with skin and subcutaneous tissue incisions and
is followed by deep facial splitting along with
the swollen fascial compartments (Fig.29.11).
However, an escharotomy normally does not
include deep fascial plane [186]. It typically
relaxes the full- thickness skin burns by supercial incisions, where the underlying structures
are exposed to signicant constrictive effect of
the burned skin. If even a circumferential
involvement is present, preventive value of the
escharotomy rises in importance, because these
constrictive forces sometimes can behave like a
leather tourniquet and block the distal circulation or can lead a failure in thorax expansion for
adequate ventilation [187–189]. However, concomitant injury of deep tissues after a full-thickness burn trauma can also cause inammation,
edema, and pressure increase within the fascial
compartments. In such a case, fascial splitting in
addition to escharotomy is mandatory in order to
prevent CS.
Ö. F. Dilek et al.
Fig. 29.11 Fasciotomy of a leg with a severe crush
injury. The limb was salvaged without any ischemic
sequela
Besides being a treatment modality, on the
other hand, early fasciotomy can also be considerable as a complete surgical preventive measure
if it is performed to alleviate increasing pressure
of an injured compartment by timely recognizing
the early signs of impending CS.Otherwise, latediagnosed CS not only can cause devastating
consequences, such as permanent functional
damage or extremity loss, but also may end up
with medico-legal litigations [190]. While as this
makes CS of an important feared clinical condition for orthopedic and plastic surgeons, it also
emphasizes the preventive importance of early
fasciotomy or escharotomy procedures, which
require experience, alertness, and well-directed
decision-making.
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29.4.2 Ectopic Implantation
Ectopic implantation or ectopic banking refers to
a temporary and creative surgical solution for the
amputated body parts that are unable to be readily replanted to where they anatomically belong
to, because of an insufcient recipient site availability. Life-threatening concomitant traumas,
hemodynamic instability or recipient site difculties, such as gross contamination, massive tissue loss, or severe avulsion/crush injuries can
cause a seek for a temporary adjourning of the
primary replantation that can only be achieved by
somehow ensuring the circulation of the amputated limb [191]. Marko Godina (1986) rst
described a case, in which an unperfused hand
was initially implanted into the axilla via thoracodorsal vessels because of extensive damage
and contamination of the recipient site and
replanted back to forearm after appropriate
wound care at postoperative day 66 [192]. Since
then, many attempts of ectopic implantation of
various organs such as digit, forearm, foot, scalp,
penis, and testes have been published with up to
100% survival rate following secondary replantation [193]. However, the procedure still seems to
be based on anecdotal data and has no consensus
in terms of the indications, ideal banking location, banking duration, and technical considerations. Nonetheless, ectopic implantation
constitutes a very important promising aspect of
the plastic surgery which evidently can prevent
limb loss and complex secondary reconstructive
procedures.
29.4.3 Surgical Prevention
ofLymphedema
Lymphedema of the arm is a well-known complication of the breast cancer surgery and effects
approximately 20% of the patients who undergone breast cancer surgery [194], although the
incidence highly varies depending on the breast/
axillary surgery and adjuvant radiotherapy [195–
197]. For example, while lumpectomy alone may
only cause up to 3% of breast cancer-related
lymphedema, it may reach up to 70% if modied
radical mastectomy plus regional radiotherapy is
implemented [
198]. Clinical presentation is char-
acterized by arm swelling due to disruption of
lymphatic carriers and subsequent accumulation
of the protein-rich uid, and eventually progressive edema of the effected tissue. Arm swelling
not only can cause signicant disgurement and
decreased function but can also adversely affect
the overall life quality [199–202]. Early physiotherapy [203, 204] and manual lymphatic drainage [205] are shown to be non-surgical preventive
options with variable success for this debilitating
condition. However, there are a couple of prophylactic surgical options available as well, all
can be considerable as preventive measures for
breast cancer-related lymphedema.
Sentinel lymph node biopsy (SLNB) is a wellknown procedure for reducing the breast cancerrelated lymphedema of the arm. This technique
basically identies the rst lymph node (sentinel
lymph node) draining the certain anatomic area
just before draining to the subsequent regional
nodes. Radionuclide injected near the tumor travels and accumulates in sentinel lymph node,
which then located by surgeon with a specialized
probe. Excision of the sentinel node(s) alone lets
prevention of unnecessary removal of the remaining subsequent regional nodes and lymphatics if,
for sure, the node comes free of tumor after histologic evaluation. SLNB has radically changed the
approach in oncologic morbidity, especially in
breast cancer. While the rate of lymphedema after
axillary lymph node dissection has been estimated to range from 7 to 77%, SLNB procedure
has decreased this range as low as 1–7% [
194,
206–209].
Building on the similar principle of SLNB,
Thompson etal. (2007) described another technique, Axillary Reverse Mapping (ARM), that
identies the lymph nodes draining the arm in a
reverse fashion [210]. Herewith, they aimed to
preserve arm lymph nodes by visualizing them
intraoperatively, soon after injecting a dye into
the medial arm that travels through the lymphatic
channels towards to arm nodes of the axilla and
colors the channels along with the nodes in the
344
meantime. A radionuclide injected from breast
and a radiotracer consummate the ARM technique by allowing detection of cross-over lymph
nodes (lymph nodes draining both the arm and
breast), which are also recommended to be
removed for oncological safety [211]. Multiple
studies showed that sparing arm lymph nodes and
excising the remaining lymph nodes of axilla has
a signicant reduced risk for lymphedema development [212–217]. However, anatomical variations [210, 213, 214], cross-over lymph nodes
[218, 219], and increased arm lymph node
involvement risk in patients with heavy nodal
metastasis burden [220–222] have caused controversies about the oncological safety of this technique. Nevertheless, an ongoing prospective
randomized controlled trial aimed to estimate the
rates of lymphedema and regional recurrence
will likely help making more accurate judgements [223].
The Lymphatic Microsurgical Preventive
Healing Approach (LYMPHA) technique,
described by Boccardo [224], uses microsurgical
lymphaticovenous anastomosis after completion
of axillary lymph node dissection to prevent
lymphedema. Similar to ARM procedure, after
injection of a dye from medial arm, colored afferent arm lymphatics are traced and divided just
before they enter into the arm nodes. After axillary lymph node dissection is completed including the colored arm nodes, by performing a
microsurgical technique, 2–4 of the divided lymphatics are anastomosed into a collateral branch
of the axillary vein [224, 225]. By this technique
they also reported 4% lymphedema rate with successful lymphaticovenous patency at 4-year follow- up [225]. In 2019, Ozmen et al. was also
described an approach and named simplied
LYMPHA (S-LYMPHA) in which the lymphaticovenous anastomosis is completed without
using a surgical microscope [226].
29.4.4 Prophylactic Surgery
forWisdom Teeth
Wisdom teeth (third molars) usually erupt in
between the ages of 17 and 24years [227]. When
Ö. F. Dilek et al.
Fig. 29.12 Radiograph of an impacted left mandibular
wisdom tooth
complete eruption into the normal functioning
position of wisdom teeth is prevented despite a
fully-grown root, impaction occurs. Lack of
space, development in an abnormal position, or
obstruction by another tooth are common reasons
for impaction (Fig.29.12) [228]. More than other
teeth, wisdom teeth can fail to erupt or can erupt
only partially, with a worldwide impaction prevalence of 24% [229]. While the impaction can usually present with several signs and symptoms, for
example, painful, tender or swollen gums, bad
breath and jaw pain, associated with the pathological conditions, such as caries, cysts, tumors,
periodontal disease, pericoronitis and root resorption; a “disease-free” or “asymptomatic” impaction is called, however, if the patient does not
experience any sign or symptoms that can be
related to these pathological conditions [230].
When an impacted wisdom tooth resulted with a
pathological change causing sign or symptoms of
a local disease, clinicians and researches mostly
agree on the surgical removal. However, on the
other hand, regarding to knowledge indicating
that this dentition plays no signicant role in the
oral cavity, extraction in the absence of an obvious pathological condition remains highly controversial among the global clinicians in dental
surgery, researchers, and oral and maxillofacial
surgeons [231–234]. Many systematic reviews
have shown the lack of evidence to support or
refute the prophylactic removal of the asymptomatic wisdom teeth [235–242]. The debate mostly
centers on whether the health really needs such a
surgical intervention bearing postoperative dis-
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comfort and complication risks, as well as costs
and economic burden. To clarify the arguments, it
seems there is a need for research investigating
the oral health-related quality of life, in the context of managing impacted wisdom teeth.
However, aside from the arguments, current
trends of the prophylactic removal tend to be
practiced in a more individualized fashion based
on clinical expertise, which involves case selection according to clinical and radiographic surveillance and patient-tailored risk assessments
[242–245].
Impacted wisdom teeth are also focus of controversies resulted from their likely roles in the
etiology of angle fractures, which constitute
16–35% of all mandible fractures [246, 247].
Systematic reviews showed the presence of mandibular third molars, possibly due to disruption of
the cortical layer or occupation of bony space
because of complete impaction, make the mandibular angle weaker and increases the fracture
risk 3.7-fold [248, 249]. While several studies
recommend the prophylactic removal of wisdom
teeth to reduce the risk of possible angle fractures, especially in the athletes of contact sports
[250–252], others disagree because the resultant
increased strength in the angle region also
increases the risk of condylar fracture, which has
more serious complication potential [253–256].
29.4.5 Babysitter Procedure
Cross-facial nerve grafting (CFNG), rst introduced in 1970s, is a method of importing motor
axons from the unaffected side of the patient with
unilateral facial paralysis that can be resulted
from various conditions, such as head and neck
cancer surgery, trauma, or radiotherapy [257–
259]. In CFNG procedure, several cables of nerve
grafts, interposed between the distal facial nerve
branch of the unaffected side and the proximal
facial nerve stump of the affected side, are aimed
to convey regenerating axons from the unaffected
contralateral facial nerve branches to the motor
units of the paralyzed fascial musculature. Using
the contralateral facial nerve and its nucleus as a
motor source was not only an important break-
through for coordinated muscle animation and
emotional expression which could not be
achieved by other sacriced motor axon options
(e.g., hypoglossal, accessory, trigeminal and
phrenic nerves), but also was a worthwhile
chance for avoiding the signicant donor morbidities associated with these motor sources.
However, since the regenerating axons normally
proceed approximately only 1 mm/day and
require a total of 8–12months for reinnervation
to begin, the relative long distance created by
nerve grafts has been one of the important shortcomings of the CFNG procedure [
260]. The elon-
gated denervation of target fascial musculature
and the risk of irreversible muscle atrophy limit
the use of CFNG procedure unless it is performed
within the 6 months from the onset of the facial
nerve injury [260].
Babysitter procedure, introduced rst by
Terzis in 1984, aimed to overcome this limitation
with two-stage surgical concept for facial reanimation [261, 262]. Although various modications have been described since its inception
[263–268], the procedure is simply performed as
described [260]. In the rst stage, as distinct from
the routine CFNG procedure, following the coaptation of the proximal ends of the nerve grafts to
the selected contralateral facial nerve branches,
the distal ends are carefully secured in a labeled
place in the affected side of the face. Then, a
powerful motor donor nerve (masseteric or partial hypoglossal) coaptation is performed to the
proximal nerve stump in the affected side with or
without nerve grafts. This alternate motor source
attached to the close proximity of the affected
facial musculature prevent them from irreversible
atrophy while awaiting appropriate, spontaneous
and synchronous innervation through the nerve
grafts from contralateral side. The second stage is
performed after 8–12 months. This time, distal
ends of the labeled nerve grafts lled with sprouting motor axons in the affected side are identied
and coapted to the fascial nerve branches distal to
the prior masseteric or partial hypoglossal nerve
coaptation zone. While waiting the appropriately
targeted, far “mother” reinnervation, prevention
of irreversible atrophy of the fascial musculature
by prompt reinnervation using a temporary motor
346
Ö. F. Dilek et al.
donor in the close proximity serve as “babysitting” and constitute a good example for a preven-
tive surgical measure.
Successful preservation of the reinnervation
capability of fascial musculature has also led the
consideration of the use of babysitter procedure
in peripheral nerve injuries [269–271]. Proximal
ulnar nerve injuries are well-known with their
poor motor functional return despite the proper
repair because of the long distance regenerating
axons must travel to reach denervated motor endplates [272]. In such injuries, anterior interosseous nerve can play a babysitting role as the
masseteric or hypoglossal nerve does in the facial
reanimation and prevent irreversible motor endplate changes until the regenerating axons arrive
from the injury site above the elbow [273, 274].
29.4.6 Prophylactic Tendon Surgery
Tendon surgeries are mostly based on causation,
such as repair of a torn or otherwise damaged
tendon or restoration of the decient functionality via transfer. However, there are also some
other specic occasions in that prophylactic surgery can be relevant.
Rheumatoid arthritis (RA) is a chronic disease
of unknown cause, which is characterized by progressive and systemic inammation that shows a
tendency to erode and destroy both articular cartilage and subchondral bone, thereby leading to
functional limitations and disability [275].
Progressive damage involving wrist joints and
synovial structures in the rheumatoid hand can
increase the spontaneous rupture risk of the
extensor tendons [276]. Symptoms of wrist tenosynovitis are obvious, including pain, swelling,
and difculty moving the affected joint.
Spontaneous rupture, on the other hand, is characterized with sudden, painless inability to extend
associated ngers. Several studies have shown
that several pathologic signs on the imaging
modalities can indicate an increased risk for
spontaneous extensor tendon rupture risk [277–
280]. Early recognition of these signs in patients
with long-lasting tenosynovitis can suggest that
these patients can benet of prophylactic tenosynovectomy to prevent spontaneous extensor
tendon rupture [281].
Extensor pollicis longus tendon (EPL), by the
way, warrants special attention since its propensity for spontaneous rupture risk in some occasions that are not associated with RA.Mechanical
factors, such as repetitive trauma resulting from a
sharp bony edge (Lister tubercle or distal radius
fracture) or the intrinsic bony anatomy of the
third extensor compartment, as well as inammatory etiologies, such as local/oral steroids or
tenosynovitis so far have been hypothesized for
the likely pathogenesis [282, 283]. However,
there are also reports without any reasonable risk
factors explaining the gradual weakening and the
rupture of the EPL [284–289]. Some reports recommend prophylactic decompression of the contralateral EPL that presents with tendinopathy
ndings in case of spontaneous rupture of the
other side [290, 291].
29.4.7 Prophylactic Surgery
inPressure Sores
As an almost complete preventable condition by
non-surgical measures, pressure sores also have
some prophylactic surgical procedures in the
management. It is well-known that pressure sores
mostly develop over the areas that have underlying bony prominences, such as trochanter, sacrum,
ischial tuberosity, occiput, and heel. After rst
suggestion of removal of the underlying bony
prominences as an adjunct to the surgical treatment of pressure sores [292], Arregui etal. (1965)
reported “good” results in the 81% of 94 patients
over a 10-year period who underwent total ischiectomy [293]. Subsequently, authors offered contralateral ischiectomy on a prophylactic basis
since 28% of the patient with unilateral ischiectomy also developed contralateral ulcer. However,
bilateral ischiectomy was later shown to be associated with high incidence of perineal ulcers and
urethrocutaneous stulas that resulted from
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347
weight transfer to the pubic rami and perineum.
Given the high incidence of these serious complications, total ischiectomy has been later recommended to be reserved for deep and recurrent
ischial pressure sores [294, 295].
Resolving spasticity in patients who are prone
to developing pressure ulcer may not only reduce
the incidences but may also improve the life quality [296]. Besides the non-surgical therapies, surgical procedures such as local tenotomies, tendon
transfers, rhizotomy, or myelotomy can be preferred for the prevention of the pressure sores
associated with spastic malposition of the limbs
[297–300].
29.4.8 Surgical Prevention
ofDiabetic Foot Ulcers
Diabetic foot ulcers (DFUs) are one of the most
common and serious complications of diabetes
and affect 15% of all diabetic patients [301].
While the lifetime risk to a person with diabetes
for developing a foot ulcer could be as high as
25% [302], the individual recurrence rate could
reach up to 70% after 5years [303]. The primary
factors in the development of these lesions are
vascular insufciency and peripheral neuropathy.
Unperceived repetitive mechanical stress resulted
from neuropathy is a major contributor in the
development of the DFU, if especially the pedal
pulses are also present. It is generally accepted
that motor neuropathy-related foot deformities
within diabetes usually occur as a combination of
several pathologic scenarios. These scenarios
involve atrophy of intrinsic foot muscles [304],
stiffness of the exor and extensor tendons leading to muscle imbalance [305], limited joint
mobility caused by thickening of the ligaments
and joint capsules [306], subluxations/dislocations, and gait abnormalities [304, 307]. As a
result, these pathologic conditions lead to the
structural foot deformities that are commonly
reported as claw and hammer toes, prominent
metatarsal heads, pes cavus, equinus deformity,
and hallux valgus [304]. Various surgical tech-
niques used for correcting these deformities, with
only few exceptions, are primarily used in the
context of ulcer treatment. However, because
these interventions often change the structure,
biomechanics, and pressure points of the foot, in
addition to treating the DFU, they may have an
enduring preventive effect for recurrences. One
systematic review questioning the preventive
effects of various surgical interventions that are
normally preferred in correction of diabetic foot
deformities and related DFUs found less recurrent ulceration risk in some techniques, such as
Achilles tendon lengthening, single or pan metatarsal resection, and metatarsophalangeal joint
arthroplasty when compared to the non-surgical
treatment modalities. The authors also reported
that procedures such as plantar fascia release and
digital exor tendon tenotomy may have promising value in preventing ulcer recurrence [308].
Well-designed controlled studies emphasizing
the preventive importance of these procedures
may lead to better understanding of their prophylactic potential.
The idea of the use of operative nerve decompression (surgical decompressing of nerves
within the bro-osseous tunnels in the leg) to
treat clinical consequences of diabetic neuropathy in the lower extremity was rst suggested
over 30 years ago [309]. The pioneers of this
approach advocated that diabetes mellitusdependent metabolic effects may cause physical
nerve enlargement leading to nerve trunk compressions in bro-osseous tunnels of lower
extremity, thereby causing local conduction
blocks that can be attributable to the sensorimotor consequences of diabetic neuropathy. This
has been followed by accumulating numerous
clinical [310–318] and animal [319–323] studies
testing the associated hypotheses: “symptoms of
sensorimotor diabetic neuropathy may be due
partly to compression of multiple peripheral
nerves” and “surgical decompression of such
nerves may result in symptomatic improvement.”
Although studies mostly belong to limited number of research groups and have been criticized
for the high bias risk, inappropriate designs, and
348
Ö. F. Dilek et al.
being scientically “unproven” [308, 324, 325],
plus despite the fact that the procedure has not
been fully adopted, there are, indeed, many clinical studies indicating the success of nerve decompression not only in the symptomatic treatment
of diabetic neuropathy [326] but also in the prevention of DFU recurrences [314, 317,
326–330].
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