VIEWPOINTS

GUIDELINES with the underlying bony framework that supports it,

Viewpoints, pertaining to issues and efforts should be made to respect the anatomical
of general interest, are welcome, planes of the nose.
even if they are not related to Reshaping the nasal tip by excision of a strip of
items previously published. View- cartilage from the cephalic portion of the lateral crus
points may present unique tech- is a commonly used procedure. It results in a decrease
niques, brief technology up-
dates, technical notes, and so on. of the volume of the cephalic part of the tip combined
Viewpoints will be published on with an upward rotation and an improved definition of
a space-available basis because they are typically less time- the lateral aspect of the tip.
sensitive than Letters and other types of articles. Please This technique is not completely free of risk, espe-
note the following criteria: cially when associated with hump excision, as it can lead
• Text—maximum of 500 words (not including to incompetence of the internal nasal valve.2 It also
references) causes a loss in the continuity of the cartilage that is
• References—maximum of five naturally interposed between the skin and the mucosa,
• Authors—no more than five increasing the possibility of scar formation and scar
• Figures/Tables—no more than two figures and/or one contractures that can deform this area.
table After carefully exposing the tip of the nose using a
Authors will be listed in the order in which they appear
in the submission. Viewpoints should be submitted elec- transcolumellar approach, the amount of cephalic mar-
tronically via PRS’ enkwell, at www.editorialmanager.com/ gin of alar cartilage is marked, including in the marking
prs/. We strongly encourage authors to submit figures in a triangle in the caudalmost portion of the alar carti-
color. lage. The triangle is then incised to separate it from the
We reserve the right to edit Viewpoints to meet re- rest of the alar cartilage to be excised, respecting its
quirements of space and format. Any financial interests attachment to the mucosa. The portion of alar cartilage
relevant to the content must be disclosed. Submission of to be removed is carefully separated from the under-
a Viewpoint constitutes permission for the American So- lying mucosa as is normally done. The triangular flap
ciety of Plastic Surgeons and its licensees and assignees to is pushed downward and caudally to maintain the car-
publish it in the Journal and in any other form or medium. tilaginous plane in this zone and decrease the possi-
The views, opinions, and conclusions expressed in the
Viewpoints represent the personal opinions of the indi- bility of scar formation and skin retraction, maintaining
vidual writers and not those of the publisher, the Editorial a good definition of the supratip region (Figs. 1 and 2).
Board, or the sponsors of the Journal. Any stated views, The disruption of the anatomical structures and
opinions, and conclusions do not reflect the policy of any planes of the nose leads to anarchy of the tissues of the
of the sponsoring organizations or of the institutions with soft envelope of the nose, causing prolonged edema,
which the writer is affiliated, and the publisher, the Edi- skin contractures, and thus a mediocre definition of the
torial Board, and the sponsoring organizations assume no tip of the nose. We consider that in most cases a com-
responsibility for the content of such correspondence. bination of sutures to respect the structural integrity of
the nose and resection of exceeding segments to sculpt
The Supratip Triangle
Sir:

W hen practicing resection of the cephalic portion

of alar cartilage to improve nose aesthetics, loss
of the continuity of the cartilage that is naturally in-
terposed between the skin and the mucosa increases
the possibility of scar formation and scar contractures
that can deform this area. Naturally, the tissue anarchy
created when the tissues of the soft envelope are in
contact with the underlying mucosa leads to scar tissue
formation that can eventually alter the shape of the tip.
The authors propose an alternative to avoid the inter-
action of these tissues by the interposition of a triangular
flap of cartilage sculpted from the cartilage to excise from
the cephalic portion of the alar cartilage. This technical
variation allows the preservation of the tissue planes of the
nose, avoiding secondary skin contractures.
Tissue characteristics, tissue dynamics, and anatomy
are the issues that ultimately determine the success or Fig. 1. The supratip region is covered using a bilateral cartilage
failure in aesthetic nose surgery.1 It is important to triangular flap from the alar cartilage after trimming of the medial
consider the relationship of the soft-tissue envelope crura and the triangular cartilages. The triangle is then incised to
separate it from the rest of the alar cartilage to be excised, re-
Copyright ©2008 by the American Society of Plastic Surgeons specting its attachment to the mucosa.

www.PRSJournal.com 19e
 Plastic and Reconstructive Surgery • July 2008

2. Boccieri, A. Mini spreader grafts: A new technique associated

with reshaping of the nasal tip. Plast. Reconstr. Surg. 116: 1525,
2005.

Patient Preference in Placement of the Donor-

Site Scar in Head and Neck Cancer
Reconstruction
Sir:

A lthough the radial forearm flap has become the

workhorse for soft-tissue oral reconstructive surgery
in head and neck cancer, there have been concerns re-
garding the healing and aesthetic result at the donor site.1
As there is often a choice in the selection of the free flap,
it seemed appropriate to ask patients whether they have
Fig. 2. The triangular flap is pushed downward and caudally to preferences for donor-site scar placement.
maintain the cartilaginous plane in this zone and decrease the A questionnaire was designed and piloted that
possibility of scar formation and skin retraction, maintaining a asked patients their preference for the site of a scar
good definition of the supratip region. (Fig. 1). Three different patient groups (50 patients
each) were recruited consecutively over 8 months,
with no refusals: group 1, head and neck cancer
patients treated with a free flap; group 2, head and
the nose is the best solution. In our opinion, any factor neck cancer patients without a free flap; and group
that contributes to the preservation of the anatomical 3, maxillofacial outpatients, of similar age. Group 1
planes of the nose might help in the reduction of patients were also asked how distressed they were by
postoperative complications involving the soft enve- their scar (on a 10-point scale, with 1 being least
lope. This turns out to be even more important in this distressed).
specific region, where the removal of the cephalic por- The upper thigh flap was the most favored of the
tion of the alar cartilages creates a dead space and soft-tissue flaps, with the lower abdominal flap (or
allows the direct contact of the subcutaneous tissue of iliac crest) being the most favored for composite
the skin envelope of the nose with the underlying mu- grafts (Table 1). The lower leg and chest were clearly
cosa. The addition of these factors predisposes to scar the least preferred sites for those who had had a free
formation and skin contractures. flap, and the chest was the least preferred site for
DOI: 10.1097/PRS.0b013e31817746ea other patients. Women preferred scarring less than
Franz W. Baruffaldi Preis, Prof. men for each scar site (Table 1), particularly for
lower leg and chest scars. Head and neck cancer
Victor J. Urzola Herrera, M.D. patients who had a free flap were least concerned
Alberto Mangano (scored lowest). Younger patients (younger than 60
years) scored higher for upper and lower arms and
Maurizio Cavallini, M.D.
lower legs. These sex and age differences existed
Guido Maronati, M.D. within each patient group.
Istituto Ortopedico Galeazzi Patients who had undergone free flap surgery were
University of Milan not generally distressed by their scar and scored very
Milan, Italy low on the 10-point scale (mean score, 2.0).
Correspondence to Dr. Mangano The anterolateral thigh was the most favored flap
Via Mulini 12 donor site from an aesthetic viewpoint. The lower ab-
22015 Gravedona dominal wound, which is similar for the rectus abdo-
Como, Italy minis and the iliac crest donor site, was the most fa-
alberto.surgery@libero.it vored for the composite grafts. The least favored donor
site was the chest, which was more commonly used in
DISCLOSURE the past for pectoralis major; not surprisingly, women
There are no financial interests or commercial as- preferred this donor site least. More surprisingly, the
sociations from any of the authors related to this com- lower leg was the second least preferred donor site, with
munication. women again finding this site unfavorable.
The aesthetics of cancer surgery are important to
REFERENCES patients, as is clear for breast and head and neck
1. Tebbetts, J. B. Anatomic bases and clinical implications for cancer sufferers.2,3 Very few studies have assessed
nasal tip support in open and closed rhinoplasty. Plast. Re- patient opinion regarding site or type of scar, but
constr. Surg. 104: 1571, 1999. these studies make a valid contribution to informing

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Volume 122, Number 1 • Viewpoints

Fig. 1. Patients were asked to rate their level of preference for scar placement on
a scale of 1 to 10, where 1 was most preferred and 10 was least preferred. Options
for placement were as follows: a, chest; b, lower arm; c, lower abdomen; d, upper
thigh; e, shoulder blade; f, lower back; g, upper arm; and h, lower leg.

Table 1. Mean Level of Preference Score for Placement of Scars by Sex and Age Group*
Upper Lower Lower Upper Shoulder Lower Lower Friedman
Group Thigh Back Abdomen Arm Blade Arm Leg Chest Test p
All patents (n ⫽ 150) 4.1 4.6 4.9 5.0 5.1 5.3 5.9 6.5 ⬍0.001

Group 1, head and neck

cancer: free flap
(n ⫽ 50) 3.6 4.0 3.8 3.6 4.1 4.0 5.5 5.5 ⬍0.001
Group 2, head and neck
cancer: no flap
(n ⫽ 50) 4.3 4.7 5.3 5.3 5.6 5.3 5.8 6.7 0.004
Group 3, no cancer
(n ⫽ 50) 4.4 5.2 5.5 6.0 5.6 6.6 6.4 7.3 ⬍0.001
Kruskal-Wallis test p 0.13 0.13 0.01 ⬍0.001 0.01 0.001 0.54 0.07

Male (n ⫽ 82) 4.2 4.6 4.9 4.4 4.7 5.0 4.9 5.7 0.006
Female (n ⫽ 68) 4.0 4.6 4.9 5.6 5.6 5.6 7.1 7.5 ⬍0.001
Mann-Whitney test p
(sex) 0.50 0.97 0.95 0.12 0.11 0.40 ⬍0.001 0.001

Age ⬍60 years (n ⫽ 81) 4.2 4.5 5.0 5.4 5.2 6.0 6.5 6.9 ⬍0.001
Age ⱖ60 years (n ⫽ 69) 4.0 4.8 4.7 4.5 5.0 4.5 5.1 6.0 0.001
Mann-Whitney test p
(age group) 0.71 0.53 0.48 0.07 0.74 0.006 0.02 0.22
*Where 1 is the most preferred and 10 the least preferred.

a patient’s consent when there is a choice of surgical study adds further weight in favor of this donor site.
treatment.4 Clinicians should not compromise the choice of flap
The anterolateral thigh is becoming widely used with regard to the ideal reconstruction in the primary
after being popularized in the Far East,5 and this site, but avoiding the more peripheral donor sites

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 Plastic and Reconstructive Surgery • July 2008

and the chest seems to be in the patient’s best Nasal mucosal flaps (from the nasal fossa floor or
interest. from the inferior turbinate) are the most used flaps.4
DOI: 10.1097/PRS.0b013e31817746a5 The use of forearm free flaps or oral mucosal flaps has
James S. Brown, F.R.C.S. also been described. Connective tissue grafts such as
University Hospital Aintree temporal muscle and fascia, pericranium, conchal car-
tilage, mastoid periosteum, and human acellular der-
Suraj Thomas, M.F.D.S. mal allograft are commonly interposed between the
University Hospital Aintree repaired nasal mucosal flaps.
Angela Chakrabati, M.Sc. Our technique is based on an endonasal, endoscope-
Edgehill College assisted approach, with the dissection of bilateral
Bideford monopedicled mucosal flaps from the nasal fossa floor,
North Devon without any graft interposition. The surgical approach
Derek Lowe, C.Stat., M.Sc. begins with an anterior caudal septal incision (see
University Hospital Aintree Video, Supplemental Digital Content 1, which demon-
Simon N. Rogers, F.R.C.S. strates the incision through the left nostril, http://link-
University Hospital Aintree s.lww.com/Axxx ); the cut is extended to the floor of the
Liverpool nasal fossa (Fig. 1, above, left) and as far as under the
England inferior turbinate and posteriorly (see Video, Supple-
mental Digital Content 2, which shows the incision of
Correspondence to Dr. Brown
University Hospital Aintree
the left nasal fossa floor, http://links.lww.com/Axxx).
Lower Lane The dissection is made under the perichondral layer
Liverpool L9 7AL, England of the septum all around the perforation and over the
brownjs@doctors.org.uk nasal fossa floor (see Video, Supplemental Digital Con-
tent 3, which shows the incision of the perforation
DISCLOSURE during the elevation of the flap, http://links.lww.com/
No statement of financial interest or commercial Axxx) (Fig. 1, above, right). Once elevated, the flap is
associations are relevant to this article. transposed medially and cranially to completely cover
the perforation. The nasal fossa floor is left uncovered.
REFERENCES The flap is then sutured to the mucosa of the upper
margin of the perforation with a reabsorbable suture
1. Richardson, D., Fisher, S. E., Vaughan, E. D., and Brown, J. S.
Radial forearm flap donor-site complications and morbidity:
(see Video, Supplemental Digital Content 4, which
A prospective study. Plast. Reconstr. Surg. 99: 109, 1997. demonstrates the sutures on the right side, http://links.
2. Fung, K. W., Lau, Y., Fielding, R., et al. The impact of mas- lww.com/Axxx ) (Fig. 1, below, left). The same approach
tectomy, breast-conserving treatment and immediate breast is made on the other side, without interposition of any
reconstruction on the quality of life of Chinese women. Aust. cartilage or connective graft (Fig. 1, below, right). The
N. Z. J. Surg. 71: 202, 2001. nasal package is mild, and is removed after 3 days.
3. Schain, W. S., d’Angelo, T. M., Dunn, M. E., et al. Mastectomy The results from 31 patients showed a rate of closure
versus conservative surgery and radiation therapy: Psychoso- of 96.3 percent of the perforations smaller than 3 cm
cial consequences. Cancer 73: 1221, 1994. after 1 year of follow-up (the highest rate of success
4. Coutinho, M., Southern, S., Ramakrishnan, V., Watt, D., Fou- reported in the international literature for that diam-
rie, L., and Sharpe, D. T. The aesthetic implication of scar eter). Nevertheless, according to our results, in perfo-
position in breast reconstruction. Br. J. Plast. Surg. 54: 326, rations smaller than 3 cm, the interposition of a graft
2001. between the two mucosal layers is useless.
5. Wei, F. C., Jain, V., Celik, N., et al. Have we found an ideal In perforations larger than 3 cm, results have not
soft-tissue flap? An experience with 672 anterolateral thigh been equally satisfactory. In four patients considered,
flaps. Plast. Reconstr. Surg. 109: 2219, 2002.
we had complete closure in only two.
The flaps, despite being monopedicled and often of
wide dimensions, never showed vascular suffering. The
Surgery of Septal Perforations
Sir:

A wide variety of techniques and approaches to treat

septal perforation have been described in the in-
ternational literature, but the results of surgical closure
Supplemental digital content is available for
this article. Direct URL citations appear in the
remain less than satisfactory. The open rhinoplasty
printed text; simply type the URL address into
approach1 with an external columellar incision and the any web browser to access this content. Click-
midfacial degloving approach2 (in larger perforations) able links to the material are provided in the
are often preferred for wide exposition of the septum HTML text and PDF of this article on the
and the perforation. The endonasal approach is pre- Journal’s Web site (www.PRSJournal.com)
ferred by a minority of authors.3

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Volume 122, Number 1 • Viewpoints

Fig. 1. (Above) Dissection of the nasal fossa floor flap. (Below, left) The suture at the
edge of the perforation. (Below, right) The same approach is made on the other side,
without any graft interposition.

epithelization of the nasal floor left uncovered is com- REFERENCES

plete after 30 to 40 days (see Video, Supplemental 1. Arnstein, D. P., and Berke, G. S. Surgical considerations in the
Digital Content 5, which shows complete closure of the open rhinoplasty approach to closure septal perforations.
perforation with an epithelized nasal fossa floor at 30- Arch. Otolaryngol. Head Neck Surg. 115: 435, 1989.
day follow-up, http://links.lww.com/Axxx). 2. Romo T., III, Foster, C. A., Korovin, G. S., and Sachs, M. E.
Our experience suggests that the endonasal endo- Repair of nasal septal perforation utilizing the midface de-
scope-assisted approach can allow the best precision for gloving technique. Arch. Otolaryngol. Head Neck Surg. 114: 739,
verifying all the surgical steps; the absence of external 1988.
scars and the absence of morbidity at the donor site for 3. Fairbanks, D. N. F. Nasal septal perforation repair: A 25-year
the graft represent advantages of this technique. We experience with the flap and graft technique. Am. J. Cosmet.
Surg. 11: 189, 1994.
also think that only techniques with nasal mucosal flaps
4. Woolford, T. J., and Jones, N. S. Repair of nasal septal per-
are able to achieve a normal nasal physiology, because forations using local mucosal flaps and composite cartilage
they use the normal respiratory epithelium for closure.5 graft. J. Laryngol. Otol. 115: 22, 2001.
The high rates of success for the perforations smaller 5. Kridel, R. W. H. Considerations in the etiology, treatment, and
than 3 cm seem to confirm the effectiveness of this repair of septal perforations. Facial Plast. Surg. Clin. North Am.
technique. 12: 435, 2004.
DOI: 10.1097/PRS.0b013e3181774596
Livio Presutti, M.D.
Matteo Alicandri-Ciufelli, M.D.
The “Bikini” Lip Reduction: An Approach to
Daniele Marchioni, M.D.
Oversized Lips
Angelo Ghidini, M.D. Sir:
Domenico Villari, M.D.
Policlinico di Modena
Modena, Italy
G reatly hypertrophic or oversized lips are an occa-
sionally encountered aesthetic problem, particu-
larly in the black and Asian populations. The reduction
Correspondence to Dr. Alicandri-Ciufelli of very large lips is not a new procedure but remains a
Policlinico di Modena relatively unused one and has received little attention
Via del Pozzo 71 in the literature.1– 4 The following presents a modified
Modena 41100, Italy method for lip reduction referred to as the “bikini”
matteo.alicandri@hotmail.it reduction, consisting of excising a “bikini top” (two

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 Plastic and Reconstructive Surgery • July 2008

cups and a middle strap) from the upper lip, and a then opens the lips, revealing four central dots (a, a=,
“bikini bottom” (a triangle) from the lower lip. This b, and b=).
technique is unique in that it focuses not only on lip The bikini design is now implemented (Fig. 1, center).
reduction but also on labial contouring and volume The bikini top is marked by drawing the central strap
balance. Aesthetic analysis of the lips has been de- as two parallel lines between a and b for a distance of
scribed in detail by the author5 and may be reviewed in approximately 1 cm, then diverging to form two oval
Figure 1, above. cups bilaterally. The cups’ anteroposterior dimension
The patient is asked to close the lips gently. A marker (c to d) should be approximately double that of a to b
is used to place a dot in the midline between both upper and should end in a tapered manner a few millimeters
and lower lips at the actual dry/wet junction (Fig. 1, before the commissures. The bikini bottom is drawn as
center, points a and a=). The patient is then asked to a triangle (e to b= to f), with points e and f stopping a few
open the lips slightly, as the surgeon manipulates the millimeters from the commissures.
lips with his or her fingers by rotating them inward, Infiltration of the operative field is performed using
attempting to make them appear smaller. The patient 5 to 8 cc of lidocaine 1% with epinephrine 1:100,000.
then closes the lips. This is repeated until the size of the While squeezing the upper lip between the fingers of
showing vermilion is adequately reduced, ensuring the the left hand to limit bleeding, a no. 15 blade is used
lower lip remains roughly 40 to 50 percent more vo- to excise the bikini top from the upper lip, with the
luminous than the upper one. Then, another dot is blade beveled slightly to excise a triangular wedge of
made in the midline on the newly created dry/wet tissue. The bikini bottom is excised in a similar way and
interface (Fig. 1, center, points b and b=). The patient hemostasis is achieved using fine needle tip electro-

Fig. 1. (Above) Aesthetic analysis of attractive lips. (Center) The “bikini” incision,
consisting of a “bikini top” (two cups and middle strap) from the upper lip, and a
“bikini bottom” (a triangle) from the lower lip. (Below) The expected result, show-
ing the proper reductions, contouring, and relative volumes of the upper and
lower lips.

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Volume 122, Number 1 • Viewpoints

cautery. Defects are closed with a deep layer of inter- A musculocutaneous incision is performed on the
rupted 4-0 chromic sutures, followed by a superficial medial one-third of the crease. The orbital septum is
layer of interrupted 4-0 chromic. No dressing is nec- incised horizontally to expose the aponeurotic fat. The
essary. Figure 1, below shows the expected result. nasal fat pad is then located and gently mobilized lat-
DOI: 10.1097/PRS.0b013e3181774671 erally, exposing a natural hollow area between this pad
Nabil Fanous, M.D. and the medial wall (Fig. 1). With malleable retractors,
this plane is enlarged inferiorly and medially, providing
Valérie J. Brousseau, B.Sc.H., M.D.C.M. wide access to the superior aspect of the medial wall
Adi Yoskovitch, M.D. (Fig. 2). The periorbita of the medial wall is incised and
Institute of Cosmetic Surgery elevated from the underlying lamina papyracea of the
Department of Otolaryngology–Head and Neck Surgery ethmoid bone. A small amount of dissection is per-
McGill University formed superiorly and posteriorly to localize the ante-
Montreal, Quebec, Canada rior ethmoid neurovascular bundle. The wall is thus
Correspondence to Dr. Brousseau entirely exposed from the frontoethmoidal suture to
1409-3475 de la Montagne the medial portion of the floor.
Montreal, Quebec H3G 2A4, Canada We have used this access without any difficulty to
vajulie@mac.com correct medial blowout fractures and for decompress-
ing the orbit.
DISCLOSURE We believe that Katowitz et al.2 were the first to use
None of the authors has any disclosures to make. the lid crease to approach the medial wall in a case
report of medial blowout. Their work was completely
REFERENCES overlooked, and no other report on this approach is
1. Hauben, D. J. Reduction cheiloplasty for upper lip hemangi- found in the literature. To the best of our knowledge,
omas. Plast. Reconstr. Surg. 88: 222, 1991. Pérez Moreiras from Spain is the only surgeon who has
2. Rees, T. D., Horowita, S. L., and Coburn, R. J. Mentoplasty, described the lid crease incision for orbital
prognathism and cheiloplasty. In T. S. Rees and D. Wood- decompression.3
Smith (Eds.), Cosmetic Facial Surgery. Philadelphia: Saunders, The lid crease incision is a natural approach to the
1973. Pp. 494–553.
medial wall. There is no need to retract the globe
3. Botti, G., Botti, C. H., and Cella, A. A simple surgical remedy
for iatrogenic excessively thick lips. Plast. Reconstr. Surg. 110: laterally and thus the postoperative inflammatory symp-
1329, 2002. toms related to the eye are minimized. The approach
4. Stucker, F. J. Reduction cheiloplasty: An adjunctive procedure allows an easy and complete exposure of the medial
in the black rhinoplasty patient. Arch. Otolaryngol. Head Neck wall without any difficulty. The superior oblique mus-
Surg. 114: 779, 1988. cle, which lies close to the ethmoid-frontal junction, is
5. Fanous, N. Correction of thin lips: “Lip lift.” Plast. Reconstr. the most important landmark of the superior limit of
Surg. 74: 33, 1984. the surgical field. Immediately below this muscle, the
surgeon finds the anterior ethmoid neurovascular bun-
dle. In orbital decompression, bone removal starts from
this level toward the orbital floor and posteriorly toward
Upper Eyelid Crease Approach to the Medial the apex. During the inferior dissection toward the
Orbital Wall floor, the surgeon naturally works behind the posterior
Sir:

S urgical access to the postseptal segment of the me-

dial wall is an essential step in the management of
a variety of conditions, such as fractures of the lamina
papyracea and Graves’ optic neuropathy. Although
there are many different approaches to the medial wall,
there is a strong trend among orbital surgeons to favor
the transcaruncular approach to access the deep por-
tion of the medial wall.1 This route poses no problems
for ophthalmologists who are familiar with operations
on the globe. However, for surgeons with surgical train-
ing in other specialties, the necessity of performing
incisions on the eyeball is a disadvantage of the
transconjunctival approach.
We report here our experience in accessing the
postseptal portion of the medial wall through the
upper eyelid crease. In our opinion, the lid crease offers
a natural plane to the posterior part of the medial
wall, allowing excellent exposure with virtually no Fig. 1. Lateral displacement of the medial preaponeurotic fat
globe manipulation. pad exposing a natural plane to the medial wall.

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 Plastic and Reconstructive Surgery • July 2008

Fig. 2. Exposure of the lamina papyracea of the ethmoid bone.

lacrimal crest. No harm is done to the medial canthal

ligament or the anterior insertion of the Horner muscle. Fig. 1. Preoperative view of foldover ear.
DOI: 10.1097/PRS.0b013e3181774710
Antonio A. V. Cruz, M.D., Ph.D. overall had a round outline, but the inner rim of the
Patricia M. S. Akaishi, M.D. helix was pointed because the cartilage in the upper
pole was folded over abnormally. A technique is pre-
Adriano Baccega, M.D.
sented to correct this deformity.
Craniofacial Unit
Department of Ophthalmology, Otorhinolaryngology, and The helix is adhered to the scapha, obliterating the
Head and Neck Surgery helical sulcus. Unlike the lidding deformity seen in
School of Medicine of Ribeirão Preto constricted ears, there is no intervening layer of skin
University of São Paulo between the two layers of cartilage.1 When looking at
São Paulo, Brazil the helix in profile, the normal curved roll is not seen
as the helix bends over sharply. This deformity usually
Correspondence to Dr. Cruz
Hospital das Clı́nicas-Campus involves the upper pole of the ear and can result in a
Departamento de Oftalmologia, Otorrinolaringologia e shortened vertical height of the ear. The condition
Cirurgia de Cabeça e Pescoço ranges from a mild deformity to what has been termed
Av. Bandeirantes 3900 a satyr ear.2 Embryologically, a defect in hillock 4 may
14049-900, Ribeirão Preto, São Paulo, Brasil result in this deformity.
aavecruz@fmrp.usp.br Eighteen patients (14 foldover deformities and four
lop ear deformities) were treated between March of
REFERENCES 2003 and September of 2005 (Table 1). Reconstruction
1. Chang, E., Bernardino, C. R., and Rubin, P. Transcaruncular was carried out as a primary procedure in 15 patients;
orbital decompression for management of compressive optic three patients required revision after failed surgery in
neuropathy in thyroid-related orbitopathy. Plast. Reconstr. another unit. Seven cases were unilateral. All patients
Surg. 112: 739, 2003. were treated by the senior author (J.I.O.).
2. Katowitz, J. A., Welsh, M. G., and Bersani, T. A. Lid crease The skin incision was placed between the anterior
approach for medial wall fracture repair. Ophthalmic Surg. 18:
rim of the helix and the scaphoid fossa. The skin over
288, 1987.
3. Pérez Moreiras, J. V., Sánchez, M. C. P., Bockos, J. C., et al.
the upper part of the helix was freed from the under-
Oftalmopatia distiroidea. In J. V. Pérez Moreiras and M. C. lying cartilage. The anterior part of the folded cartilage
Prada Sánchez (Eds.), Patologia Orbitária, Tomo 2, 1st Ed. was dissected free and transposed behind the posterior
Barcelona: Ferre Olsina, 2002. part as a support. In unilateral cases, the normal ear was
used as a template. The position of the transposed
cartilage was adjusted to match the vertical height of
the normal side. The two layers of cartilage were su-
The Foldover Helical Rim: Reshaping the tured together with 5-0 polydioxanone. The skin was
Contour of an Unusual Deformity redraped and sutured with 5-0 Prolene (Ethicon, Inc.,
Sir: Somerville, N.J.). Ear Buddies (splints; Ear Buddies,

E ar deformities are common, with some requiring

long and complicated procedures to recreate a nor-
mal appearing ear. We describe a deformity in which
Bucks, United Kingdom) were taped to the scaphoid
hollow for 2 weeks to maintain the new contour. Su-
tures were removed 2 weeks postoperatively and pa-
the complaint is of a pointed ear (Fig. 1). The ear tients were reviewed 3 months later.

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Volume 122, Number 1 • Viewpoints

Table 1. Patient Characteristics Our technique is straightforward and, aided by external

ear splints,5 a satisfactory ear contour can be achieved.
Age DOI: 10.1097/PRS.0b013e31817746fd
Patient (yr) Sex Operation Side
Joy I. Odili, M.R.C.S.
1 44 F Secondary Unilateral (R) lop ear
2 9 M Primary Bilateral lop ear David T. Gault, F.R.C.S.
3 12 F Primary Unilateral (R) lop ear Centre for Plastic Surgery and Reconstruction
4 10 M Secondary Unilateral (R) foldover ear Mount Vernon Hospital
5 21 M Secondary Unilateral (L) lop ear Northwood, Middlesex, United Kingdom
6 44 M Primary Bilateral foldover ear
7 29 M Primary Bilateral foldover ear Presented at Annual Congress of the European Association
8 40 M Primary Bilateral foldover ear of Plastic Surgeons, in Marseille, France, May of 2005.
9 43 M Primary Bilateral foldover ear
10 39 M Primary Unilateral (R) foldover ear Correspondence to Dr. Odili
11 45 M Primary Bilateral foldover ear 75 Windermere Avenue
12 29 F Secondary Bilateral foldover ear Finchley, London N3 3RD, United Kingdom
13 27 M Primary Bilateral foldover ear everjoyous@aol.com
14 39 M Primary Unilateral (L) foldover ear
15 32 F Primary Bilateral foldover ear
16 15 F Primary Unilateral (L) foldover ear DISCLOSURES
17 33 M Primary Bilateral foldover ear David Gault is a director of the company that produces
18 16 M Primary Bilateral foldover ear
the Ear Buddies used in this communication. The Ear
M, male; F, female; L, left; R, right.
Buddies were designed by Dr. Gault and are used routinely
in the authors’ plastic surgery unit. The work produced by
A satisfactory ear shape was achieved in all cases (Fig. this communication was not sponsored by any company.
2). Two patients complained of a sharp edge to the
helical rim where the cartilage edge showed through REFERENCES
their auricular skin. A dermal graft was used to mask 1. Cosman, B. The constricted ear. Clin. Plast. Surg. 5: 389, 1978.
this edge as a secondary procedure. There were no 2. Davis, J. Aesthetic and Reconstructive Otoplasty. New York: Springer-
complications. All patients reported improved self-es- Verlag, 1987. Pp. 251–266.
3. Horlock, N., Grobbelaar, A. O., and Gault, D. T. 5-year series
teem postoperatively.
of constricted (lop and cup) ear corrections: Development of
The folded over helical rim gives the ear a pointed, the mastoid hitch as an adjunctive technique. Plast. Reconstr.
elfin-like appearance. Our operation removes the Surg. 102: 2325, 1998.
folded over cartilage and reinserts it in a more favorable 4. Tanzer, R. C. The constricted (cup and lop) ear. Plast. Reconstr.
position. The vertical height of the ear is adjusted easily Surg. 55: 406, 1975.
without local flaps or additional cartilage grafts. This 5. Tan, S. T., Shibu, M., and Gault, D. T. A splint for correction
technique was also used successfully to treat patients of congenital ear deformities. Br. J. Plast. Surg. 47: 575, 1994.
with lop ears. With a single operation, a normal ap-
pearing ear was achieved in patients who had previously
undergone multiple procedures for their lop ears.2– 4 Surgical Correction of Cryptotia with the Three-
Flap Method
Sir:

W e1 have slightly modified the design of the square

flap method, devised by Hyakusoku and Fumiiri2 to
increase the length between two points, and used it for the
correction of severe congenital epicanthus. This method
also can also be used in the surgical correction of cryp-
totia, where it is called the three-flap method because it
consists of two triangular flaps and one square flap.
From 2001 to 2005, this technique was used on 15
ears in nine patients with cryptotia (Table 1). In every
patient, normal size and sufficient depth of the auricu-
locephalic sulcus could be obtained by the traction to
the upper part of the auricle away from the scalp.
The operation is performed under general anesthe-
sia in children or local anesthesia in elder patients.
Traction is applied to the upper part of the auricle away
from the scalp, and the shortest line is marked as the
central arm. In front of the central arm, the square
S-flap is designed, whereas the triangular T-flap and
U-flap are designed in the back.2 The angle of the tip
Fig. 2. Postoperative view of foldover ear. of the T-flap is, ideally, 45 degrees and that of the U-flap

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 Plastic and Reconstructive Surgery • July 2008

Table 1. Patient Data

Patient Sex Age (yr) Side Follow-Up (mo)
1 Male 14 Left 6
2 Male 3 Bilateral 12
3 Male 10 Right 3
4 Female 20 Bilateral 24
5 Male 5 Bilateral 18
6 Male 27 Bilateral 24
7 Female 9 Bilateral 12
8 Female 11 Left 9
9 Male 12 Bilateral 6

should be a right angle. The sides of flaps are the same

length (1.3 to 1.7 cm). After skin incision, the flaps are
freed and elevated (Fig. 1) and the posterior surface of
the upper half of the cartilage is exposed. The superior
auricular muscle should be dissected and corrected to
the normal position. In addition, the fibrous tissue and
the intrinsic transverse muscle causing the contracture
of the antihelix should be dissected. Finally, the square
flap is advanced, the two triangular flaps are rotated to
Fig. 2. An oblique view of a 9-year-old girl who had congenital
relative directions, and then the flaps are sutured.2
cryptotia of her right auricle.
In all patients, no problem with flap viability was
encountered and all healed well. The follow-up period
was 3 months to 2 years, with relatively favorable results. flaps is approximately 1.5 cm. Theoretically, the length
Satisfactory function and appearance were obtained in achieved by the method will be approximately 1.8 times
the evaluation of the patients. The auriculocephalic the original length.2 When the side length is 1.5 cm, the
sulcus was deepened, the length of the helix was ex- theoretical gain in length is 2.7 cm, and the actual gain is
tended, the width of the upper third of the auricle was over 2.0 cm. In mild to moderate cases, the gained skin
increased, and recurrence was prevented (Fig. 2). is usually large enough to cover the entire postauricular
This method is indicated in cases of mild to moderate surface without tension. This method is not suitable for
deformity of cryptotia, and the proper side length of the severe deformities, which should be treated with skin
grafting or other types of flaps.
A number of techniques have been developed for
the surgical correction of cryptotia.3–5 Compared with
conventional techniques, our method has many ad-
vantages, such as simple and easy design, provision of
sufficient skin to the upper and posterior portions
of the auricle, sufficient depth of the auriculo-
cephalic sulcus, and no additional requirement for
skin grafting.
DOI: 10.1097/PRS.0b013e3181774779

Wei-Qiang Tan, M.D.

Jing-Hong Xu, M.D.
Wei-Hua Wu, M.D.
Department of Plastic Surgery
The First Affiliated Hospital
College of Medicine
Zhejiang University
Hangzhou Plastic Surgery Hospital
Hangzhou, P. R. China

Correspondence to Dr. Xu
Fig. 1. Depiction of the surgical technique. In front of the central Department of Plastic Surgery
arm, the square S-flap is designed, whereas the triangular T-flap The First Affiliated Hospital
and U-flap are designed in the back. After skin incision, the flaps College of Medicine
Zhejiang University
are freed and elevated. Finally, the square flap is advanced, the 79 Qing-Chun Road
two triangular flaps are rotated to relative directions, and the Hangzhou 310003, P. R. China
flaps are sutured. tanweixxxx@163.com

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Volume 122, Number 1 • Viewpoints

DISCLOSURES
No special products, devices, or drugs were used in
this study. There is no conflict of interest, commercial
associations, or intent of financial gain for any of the
authors.

REFERENCES
1. Wu, W., Xu, J., Yan, S., et al. Correction of severe congenital
epicanthus using the modified square-flap method. Br. J. Plast.
Surg. 53: 667, 2000.
2. Hyakusoku, H., and Fumiiri, M. The square flap method. Br. J.
Plast. Surg. 40: 40, 1987.
3. Uemura, T., Matsumoto, N., Tanabe, T., et al. Surgical cor-
rection of cryptotia combined with intraoperative distention
using isotonic saline injection and rotation flap method.
J. Craniofac. Surg. 16: 473, 2005.
4. Hodgson, E. L., and McGregor, A. D. Correction of cryptotia Fig. 1. Completely broken palate with narrow palatal shelves
using full-thickness skin grafts. Ann. Plast. Surg. 47: 471, 2001. and scarred, short soft palate.
5. Cho, B. C., and Han, K. H. Surgical correction of cryptotia with
V-Y advancement of a temporal triangular flap. Plast. Reconstr.
Surg. 115: 1570, 2005.
lining of the soft palate. This continued as a repair
of the nasal mucoperiosteum of the hard palate. It is
essential that this repair be continued anteriorly be-
Salvaging Procedure for Mutilated Cleft Palate yond the alveolus if there is a cleft of alveolus, to
by Simultaneous Tongue and Pharyngeal Flap prevent retraction of the flap, which may result in a
Surgery postalveolar fistula. Adequate mobilization of mus-
Sir: cles as described by Sommerlad4 will help to approx-

M ultiple failed attempts at cleft palate repair leave

behind a mutilated palate, with minimal tissue avail-
able for closure at a later date. The problem becomes
imate the muscles in the center. Occasionally, the
tethered, scarred oral layer of the soft palate needed
a horizontal incision behind the hard palate to move
more challenging because of added scarring, which leaves the oral mucosa medially. An anteriorly based tongue
tissue unrelenting. The superiorly based pharyngeal flap flap of adequate size was raised and the defect was
has often been used to augment the nasal lining of the closed primarily. Special attention was given to the
scarred, contracted soft palate; similarly, the tongue flap most posterior part of the defect while fitting the
has been used for hard palate closure.1,3 However, a si- tongue flap. None of the patients needed blood
multaneous pharyngeal flap with tongue flap surgery has transfusion. After ensuring that there was no active
never been reported, probably because of expected air- bleeding, patients were extubated. They were kept in
way problems.2 A simultaneous pharyngeal flap with the postoperative recovery room for 4 to 5 hours with
tongue flap surgery also lengthens the palate and retains pulse oximetry and then transferred to the ward. All
its length postoperatively. these patients were given maintenance intravenous
Since 2001, I have had six patients with a mutilated fluid on the day of surgery and encouraged to take
and severely compromised palate with little tissue sips of water after 6 hours postoperatively. These
available after previous repairs. These patients had patients were started on a liquid and semisolid diet
either a completely broken palate with very narrow from the second day of surgery, and all patients man-
palatal shelves or a very large anterior fistula with a aged to have a semisolid to soft diet by 3 to 4 days.
broken or severely scarred soft palate (Fig. 1). The Antibiotics were given only intraoperatively and oral
profiles and other details of these six patients are hygiene was emphasized by continuous drinking of
listed in Table 1. water and mouth washes. The tongue flap was divided
During the procedures, the paring incision was after 12 to 15 days under local anesthesia (Fig. 2).
made on the hard palate 2 to 3 mm away from the The cut edge on the palate was cauterized but not
edge to create a turndown flap. These flaps were sutured. The base of the tongue flap was returned to
dissected in continuity with the nasal mucoperios- the tongue. Although we had concerns about the
teum of the nasopharynx. Posteriorly, these incisions airways, surprisingly, none of the patients had an
continued on to the junctional area to the soft palate. episode of hypoxia in the recovery room or later.
As one progresses on the soft palate, the paring in- None of the patients has any residual fistula.
cision is moved onto the edges or a little on the nasal Of the six patients, we did not have postoperative
side to preserve as much of the oral layer as possible. speech samples for two patients. Of four patients, two
A superiorly based pharyngeal flap (moderately did not have any improvement in speech. Two patients
wide) of adequate length was sutured to the nasal had postoperative improvement in speech (nasal emis-

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Table 1. Patient Profiles and Details

Patient

1 2 3 4 5 6
Patient age, years 20 10 20 11 10 23
Diagnosis Left UCLP Left UCLP Left UCLP Right UCLP Complete cleft Left UCLP
of SP
Age at first
attempt at palate
repair, years 19 6 18 8 2.5 21
No. of palate
repair attempts 1 2 3 1 2 1
Finding Large fistula Totally broken Large fistula Totally broken Totally broken Large fistula
and scarred, with little and scarred, with little with little and scarred,
broken soft palatal shelf broken soft palatal shelf palatal shelf broken soft
palate tissue palate tissue tissue palate
Division of tongue
flap, days 21 15 16 13 15 12
UCLP, unilateral cleft lip– cleft palate; SP, soft palate.

2. Eipe, N., Pillai, A. D., Choudhrie, A., and Choudhrie, R. The

tongue flap: An iatrogenic difficult airway? Anesth. Analg. 102:
991, 2006.
3. Guzel, M. Z., and Altintas, F. Repair of large, anterior palatal
fistulas using thin tongue flaps: Long term follow-up of 10
patients. Ann. Plast. Surg. 45: 109, 2000.
4. Sommerlad, B. A technique for cleft palate repair. Plast. Re-
constr. Surg. 112: 1542, 2003.

Tumescent Steroid Infiltration Reduces

Postoperative Eye Closure after Craniofacial
Surgery
Sir:

C raniofacial surgery results in postoperative swell-

ing. Elevation of a coronal scalp flap and subse-
quent bony remodeling leads to significant edema and
Fig. 2. Palate reconstructed by tongue and pharyngeal flap. ecchymosis. This is frequently severe enough to prevent
eye opening for a number of days postoperatively. In
pediatric patients, this adds to the distress suffered by
patients and their caregivers, and makes postoperative
sion disappeared), with marginal improvement in monitoring difficult. Evidence for systemic steroids in
articulation. reducing this postoperative swelling is mixed,1 but this
DOI: 10.1097/PRS.0b013e318177463d has not prevented their common use in craniomaxil-
lofacial surgery.2 This study aims to confirm the ben-
Jyotsna Murthy, M.S., M.Ch., D.N.B. eficial effect of tumescent steroid infiltration of the
Department of Plastic Surgery scalp in reducing postoperative eyelid swelling.
Cleft & Craniofacial Center From January of 2001 to February of 2006, 20 con-
Sri Ramachandra Medical College and Research Institute secutive patients undergoing fronto-orbital advance-
(Deemed University) ment for craniosynostosis without preoperative tumes-
Porur, Chennai 600 116, India cent steroid infiltration were compared with 20
jmurthy@satyam.net.in
subsequent patients undergoing the same operation
with infiltration of triamcinolone acetonide (Kena-
ACKNOWLEDGMENT cort-A 10; Bristol-Myers Squibb Pharmaceuticals, New
All patients were operated on for free under the Smile York, N.Y.). The historic control group had a solution
Train Project. containing ropivacaine with 1:200,000 adrenaline in-
filtrated in the region of the incision only. In the treat-
REFERENCES ment group, the tumescent solution was made up to a
1. Boo-Chai, K. Repair of difficult anterior palate fistulae using total volume of 7 ml/kg body weight and contained
anteriorly based tongue flap. Plast. Reconstr. Surg. 100: 812, 1997. triamcinolone, 0.1 mg/ml; ropivacaine, 3 to 5 mg/kg

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Table 1. Grade of Eye Closure in the treatment group (p ⫽ 0.0003). No complications

of the surgery or steroid infiltration were observed in
Grade Description
the median follow-up period of 29 months (range, 3 to
0 No closure, no lid edema 62 months). In particular, there was no effect on wound
1 Lid edema with mild lag, over the limbus not healing5 or dermal or soft-tissue atrophy. There was no
covering pupil
2 Lid edema, pupil covered by lid, lower significant difference in the length of hospital stay after
limbus visible the operation.
3 Lid edema, entire limbus covered, manual In the steroid infiltration group, the average grade of
retraction easily exposes pupil for closure at each postoperative day is charted in Figure 1.
neurologic observation Tumescent infiltration of triamcinolone into the
4 Lid edema severe, eye tightly closed scalp before raising scalp flaps in pediatric craniofacial
surgery reduces postoperative eyelid swelling and has
been a welcome addition to our operative protocol.
DOI: 10.1097/PRS.0b013e31817745d3
body weight; hyaluronidase, 3 units/ml; and adrena- Wai-Ting Choi, M.B., B.S.
line, 5 to 10 ␮g/kg body weight, in normal saline.3 This
solution was administered in a subgaleal plane by Andrew L. Greensmith, F.R.A.C.S.
means of a 23-gauge needle beneath the planned in- Chalermpong Chatdokmaiprai, M.D.
cision and then anteriorly over most of the forehead Anthony D. Holmes, F.R.A.C.S.
except for the inferiormost 1 cm of the supraorbital bar
to avoid inadvertent injection into the supraorbital and John G. Meara, M.B.A., F.R.A.C.S.
supratrochlear vessels. Intravenous dexamethasone Department of Plastic and Maxillofacial Surgery
Royal Children’s Hospital
was given to all patients at induction and 6 hours post-
Melbourne, Australia
operatively for its antiemetic effect.4
Data for total intraoperative transfusion require- Correspondence to Dr. Greensmith
ment (crystalloid, colloid, and blood products), length Department of Plastic and Maxillofacial Surgery
of surgery, postoperative eyelid closure, length of stay, Royal Childrens’ Hospital
and postoperative complications both local and sys- Flemington Road
Parkville, Melbourne
temic were collected and compared between the two
Victoria 3052, Australia
groups. Data for the first control group were collected andrew.greensmith@rch.org.au
retrospectively. A scale for grading postoperative eyelid
swelling is proposed (Table 1). ACKNOWLEDGMENT
A significant reduction in postoperative eyelid clo- Dr. Susan Donath of the Department of Biostatistics
sure on the second postoperative day was shown with
tumescent steroid infiltration (75 percent of patients in
and Epidemiology, University of Melbourne, Royal Chil-
the steroid infiltration group had eyes open compared dren’s Hospital, performed the statistical analysis.
with 9.5 percent of the control group; p ⬍ 0.0005). This
was carried out using bivariate analyses with each of the DISCLOSURES
variables of duration of operation, volume of fluid No financial support or benefits have been received
transfused, age, and steroid infiltration using t tests and by any author, or by any member of our existing families
chi-square analysis. This difference occurred despite an or any individual or entity with whom or with which we
average 510 ml more fluid transfused intraoperatively have a significant relationship from any commercial

Fig. 1. Average grade of eyelid closure in the steroid infiltration group.

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 Plastic and Reconstructive Surgery • July 2008

source that is related directly or indirectly to the scientific

work reported on in the article.
REFERENCES
1. Rapaport, D. P., Bass, L. S., and Aston, S. J. Influence of
steroids on postoperative swelling after facialplasty: A pro-
spective, randomized study. Plast. Reconstr. Surg. 96: 1547,
1995.
2. Assimes, T. L., and Lessard, M. L. The use of perioperative
corticosteroids in craniomaxillofacial surgery. Plast. Reconstr.
Surg. 103: 313, 1999.
3. Neil-Dwyer, J. G., Evans, R. D., Jones, B. M., et al. Tumescent
steroid infiltration to reduce postoperative swelling after
craniofacial surgery. Br. J. Plast. Surg. 54: 565, 2001.
4. Steward, D. L., Welge, J. A., and Myer, C. M. Steroids for
improving recovery following tonsillectomy in children. Co-
chrane Library Syst. Rev. 1: CD003997, 2006.
5. Fleischli, J. W., and Adams, W. R. Use of postoperative steroids
to reduce pain and inflammation. J. Foot Ankle Surg. 38: 232,
1999.
Fig. 1. Preoperative view of the patient.

Aquamid: Where Is the Reality? the same preauricular incision was used that had been
Sir: used during one of the previous operations. After a
W hen we read the numerous accounts of the as-
tonishing results obtained by so many colleagues
through the use of Aquamid (Ferrosan, Soeborg, Den-
brief, blunt subcutaneous dissection, an area was
reached that appeared fluctuant; it was lined by an
easily lacerable membrane of reactive tissue and con-
mark) infiltrations, to treat depressed areas, for exam- tained some pasty liquid material, exactly correspond-
ple, or to raise deep wrinkles of the face for aesthetic ing to the methacrylate placed previously (Fig. 2). We
purposes, it occurs to us to think that the cases that removed the methacrylate together with the lining cap-
sometimes come to our attention are absolutely rare. sule, which appeared, however, to be tenaciously ad-
Aquamid is a soft-tissue filler, a transparent poly- herent to the underlying tissue planes. Taking into
acrylamide gel consisting of approximately 2.5% cross- consideration the patient’s need to maintain adequate
linked polyacrylamide and 97.5% apyrogenic water. It filling of the area (which intraoperatively was deprived
is used for soft-tissue augmentation and contour cor- of the polyacrylamide support and again appeared de-
rection, with minimal reports of significant complica- pressed), we proceeded to prepare a dermoadipose
tions after injection into the face.1–5 After discussing graft, by drawing from the inguinal region and fixing
personal experience with other colleagues who report it in the subcutaneous site. The patient had an optimal
an increasing number of such cases, multiplied by the
large number of practicing surgeons just in Rome, we
think that many cases, really, have not been reported,
certainly not intentionally, possibly because the pa-
tients did not return for follow-up.
Just to give an example, we present the case of a
30-year-old woman who presented with a swollen area
that included the entire right cheek as far as the inferior
palpebral region (Fig. 1). The patient had sustained an
injury to the face years earlier and had already under-
gone numerous reparative operations, with results, ac-
cording to the patient, that were not completely ac-
ceptable. Consequently, to correct a depression of the
operated area, the patient had undergone treatment by
infiltration of an indeterminate quantity of injectable
polyacrylamide. Approximately 3 years after the oper-
ation, however, the patient noticed swelling that was
fluctuant and, as time passed, tended to increasingly
move into a dependent position. A magnetic resonance
imaging study confirmed the presence of the material
previously infiltrated and revealed no other noteworthy Fig. 2. Intraoperative view of the product being removed from
findings. The patient underwent surgery, during which the right cheek.

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postoperative period and at 3 months after the oper- eridemia, insulin resistance with increased C-peptide
ation showed an optimal result even in terms of aes- levels, type 2 diabetes, lactic acidemia, and elevated
thetic appearance. A certain degree of reabsorption of hepatic transaminases.1
the inserted graft is probably to be expected, but this Lipodystrophy, primarily a result of protease inhib-
can be remedied by lipofilling over the next few years. itor therapy, has a prevalence ranging from 20 to 80
We wish, therefore, to emphasize the possible prob- percent.2,3 The syndrome can be disfiguring and stig-
lems related to the use of so many foreign materials that matizing to patients, threatening the confidentiality of
perhaps are too easily used ever more frequently be- their HIV serostatus and leading to hindered adher-
cause of statistics and results that may overstate their ence and reduced efficacy or even failure of treatment.1
success. Elective plastic surgery is an effective and increasingly
DOI: 10.1097/PRS.0b013e3181774619 sought after treatment for the clinical manifestations of
Fabio M. Abenavoli, M.D. this syndrome.2 However, the metabolic components of
the syndrome, namely, dyslipidemia and insulin resis-
Andrea Servili, M.D. tance, lead to hypertension, accelerated atherosclero-
Roberto Corelli, M.S. sis, endothelial dysfunction, and a prothrombotic state,
“San Pietro” Hospital all of which predispose these patients to an increased
Fatebenefratelli risk of perioperative cardiovascular events and postop-
Rome, Italy erative complications.1– 4
Correspondence to Dr. Abenavoli We report the case of a 49-year-old white woman with
Via Savoia 72 a 10-year history of HIV (CD4 count ⱖ500, undetect-
00198 Rome, Italy able viral load) on highly active antiretroviral therapy
f.abenavoli@mclink.it who presented with facial lipoatrophy and fat accumu-
lation in the abdomen and dorsocervical spine. Under
general anesthesia, the patient underwent ultrasonic
REFERENCES liposuction of the buffalo hump, an abdominoplasty,
1. von Buelow, S., von Heimburg, D., and Pallua, N. Efficacy and and microfat injections for the facial lipoatrophy. The
safety of polyacrylamide hydrogel for facial soft-tissue aug- patient tolerated all the procedures without complica-
mentation. Plast. Reconstr. Surg. 116: 1137, 2005. tion. On postoperative day 2, the patient began to ex-
2. Christensen, L., Breiting, V., Janssen, M., Vuust, J., and Hog-
perience worsening dyspnea, tachypnea, and desatura-
dall, E. Adverse reactions to injectable soft tissue permanent
fillers. Br. J. Dermatol. 154: 755, 2006. tions requiring intubation and transfer to the intensive
3. Amin, S. P., Marmur, E. S., and Goldberg, D. J. Complications care unit. Chest computed tomography revealed flash
from injectable polyacrylamide gel, a new nonbiodegradable pulmonary edema, which cardiology consultation con-
soft tissue filler. Dermatol. Surg. 30: 1507, 2004. cluded was secondary to diastolic hypertension. By
4. De Cassia Novaes, W., and Berg, A. Experiences with a new postoperative day 5, with aggressive diuresis and car-
nonbiodegradable hydrogel (Aquamid): A pilot study. Aes- diovascular monitoring, the patient was extubated.
thetic Plast. Surg. 27: 425, 2003. Postoperative outcome measurements were otherwise
5. Breiting, V., Aasted, A., Jorgensen, A., Opitz, P., and Rosetzsky, similar to those reported in lipodystrophy patients
A. A study on patients treated with polyacrylamide hydrogel treated with elective plastic surgery.
injection for facial corrections. Aesthetic Plast. Surg. 28: 45,
The effect of highly active antiretroviral therapy on
2004.
surgical outcomes remains undetermined.5 However,
the increase in cardiovascular risk in patients receiving
highly active antiretroviral therapy is undeniable. It is
imperative, therefore, that HIV-positive patients receiv-
Correction of Lipodystrophy in HIV-Positive ing highly active antiretroviral therapy undergo in-
Patients on Highly Active Antiretroviral creased surveillance of cardiovascular risk factors and
Therapy: Surgeon Beware potential complications in the preoperative, perioper-
Sir: ative, and postoperative periods.

H ighly active antiretroviral therapy in the treatment

of human immunodeficiency virus (HIV) has led
to significant decreases in morbidity and mortality and
Complete assessment would include patient his-
tory, physical examination, and a preoperative
workup, including CD4 cell count, HIV RNA (viral
is now considered the standard of care.1 However, the load), serum glucose, lipid panel, electrocardiogra-
therapy is responsible for a commonly encountered phy, chest radiography, stress echocardiography, pul-
constellation of body fat and metabolic abnormalities monary function tests, and arterial blood gases if
known as lipodystrophy. Manifestations of this syn- indicated. Traditional cardiovascular risk factors, in-
drome include peripheral lipoatrophy of the face, cluding smoking, hypertension, hyperglycemia, and
limbs, or buttocks and central fat accumulation in the dyslipidemia, should also be addressed. For risk fac-
abdomen and dorsocervical fat pad, with the latter tors that cannot be modified, perioperative beta
commonly referred to as a “buffalo hump.” The met- blockade, continuous perioperative and postopera-
abolic abnormalities include hypercholesterolemia tive cardiovascular monitoring, and serum glucose
with decreased high-density lipoprotein, hypertriglyc- control should be considered.

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 Plastic and Reconstructive Surgery • July 2008

Plastic surgeons should have a heightened awareness mities that include flexion contractures of the extrem-
when treating patients receiving highly active antiret- ities, pseudosyndactyly, microstomia, esophageal stric-
roviral therapy. Elective procedures in these patients tures, and adhesions of various skin surfaces.2 We
necessitate a comprehensive preoperative assessment describe anesthetic management in six patients aged 3
and vigilant postoperative management. With such to 14 years with recessive dystrophic epidermolysis
measures, plastic surgery in HIV-positive patients bullosa.
receiving highly active antiretroviral therapy can be Most of the surgical operations were for release of
performed safely. syndactyly and dressing changes. On physical exami-
DOI: 10.1097/PRS.0b013e31817745f7 nation, they had multiple bullae and erosions on their
Neil Tanna, M.D. body surfaces. All patients had growth retardation
caused by malnutrition and chronic anemia. Two pa-
Samir Rao, B.A. tients had restricted mouth opening because of scar-
Division of Plastic and Reconstructive Surgery
George Washington University
ring around the mouth. Anesthesia was provided by
axillary brachial plexus block in five patients. In addi-
Mark L. Venturi, M.D. tion to axillary block, spinal anesthesia was performed
Department of Plastic and Reconstructive Surgey in three of them to harvest a split-thickness skin graft.
Georgetown University In a patient undergoing circumcision, penile block was
Michael Olding, M.D. performed by the pediatric surgeon. In all patients,
Division of Plastic and Reconstructive Surgery anesthesia was induced with ketamine, 3 mg/kg body
George Washington University weight, administered intramuscularly to facilitate se-
Washington, D.C. curing an intravenous line and monitoring devices. For
Poster presented at Plastic Surgery 2005: Annual Meeting electrocardiographic monitoring, adhesive pads were
of the American Society of Plastic Surgeons, in Chicago, removed and well-lubricated electrodes were placed
Illinois, September 24 through 28, 2005. beneath the patients. Petroleum jelly–impregnated
Correspondence to Dr. Tanna
gauze was laid under the blood pressure cuff to avoid
2475 Virginia Avenue, N.W., Apartment 907 skin trauma. A silicone pad was placed under the pa-
Washington, D.C. 20037 tients. Axillary block was performed with a 50-mm, 22-
ntanna@gwu.edu gauge needle using the nerve stimulator. The needle
direction was adjusted until flexion of the wrist at the
DISCLOSURES lowest current value. At this point, 0.25% bupivacaine,
None of the authors has any conflict of interest to 2 mg/kg body weight, was injected. Spinal anesthesia
report. was administered with the patient in the lateral decu-
bitus position, and bupivacaine 0.5%, 0.3 to 0.4 mg/kg
REFERENCES body weight, was injected intrathecally at the L4-5 in-
1. Carr, A., and Cooper, D. A. Adverse effects of antiretroviral
terspace. Operating conditions were satisfactory for all
therapy. Lancet 356: 1423, 2000. patients, and sufficient analgesia was provided during
2. Schiller, D. S. Identification, management, and prevention of surgery. The severity of pain was measured by means of
adverse effects associated with highly active antiretroviral ther- a visual analogue scale in the postoperative period. The
apy. Am. J. Health Syst. Pharm. 61: 2507, 2004. durations of analgesia provided by axillary block and
3. Carr, A., Samaras, K., Burton, S., et al. A syndrome of periph- spinal anesthesia were 8.7 ⫾ 2.1 hours and 3.2 ⫾ 1.3
eral lipodystrophy, hyperlipidaemia, and insulin resistance in hours, respectively.
patients receiving HIV protease inhibitors. AIDS 12: F51, 1998. The anesthetic management of patients with epider-
4. Barbaro, G. Cardiovascular manifestations of HIV infection. molysis bullosa is particularly difficult because of oro-
Circulation 106: 1420, 2002. pharyngeal and cutaneous involvement. Perioral scar-
5. Jones, S., Schechter, C. B., Smith, C., and Rose, D. N. Is HIV
ring restricts opening of the mouth, resulting in airway
infection a risk factor for complications of surgery? Mt. Sinai
J. Med. 69: 329, 2002. difficulty.3 Scarring of the oral cavity occurred in 51
percent of cases in the major series of epidermolysis
bullosa patients reported, and 6 percent of these pa-
tients could not be intubated.4 The principal advantage
Anesthesia in Children with Epidermolysis of the use of regional anesthesia in patients with epi-
Bullosa dermolysis bullosa is the avoidance of manipulation of
Sir: the airway. In addition, struggling during emergence

D ystrophic epidermolysis bullosa is an inherited

mechanobullous disorder caused by mutations in
the type VII collagen gene and perturbations in an-
from anesthesia is not seen during regional anesthesia.
Postoperative pain and excessive movement of the pa-
tient in an attempt to eliminate the painful stimuli can
choring fibrils.1 It has two genotypes: an autosomal easily be avoided.5
dominant form and an autosomal recessive form. The In summary, we have provided safe and effective
autosomal recessive form of dystrophic epidermolysis anesthesia with sufficient postoperative analgesia by
bullosa is the most severe form of the disease. Healing using regional techniques in our patients with epider-
occurs with scarring and results in characteristic defor- molysis bullosa. New bullae formation was not observed

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Volume 122, Number 1 • Viewpoints

around the site of axillary block in any of the patients. 5. Culpepper, T. L. Anesthetic implications in epidermolysis
When the surgical site, the procedure, and the condi- bullosa dystrophica. A.A.N.A. J. 69: 114, 2001.
tion of the patient are suitable, regional techniques
should be considered.
DOI: 10.1097/PRS.0b013e3181774722
Ozlem Serpil Cakmakkaya, M.D. Use of Patient Body Mass Index as a Rationing
Tool in Breast Reduction Surgery
Fatis Altindas, Asst. Prof.
Sir:
Guner Kaya, Prof.
Department of Anesthesiology and Reanimation
Semih Baghaki, M.D.
B reast reduction surgery, although regarded as a
low-priority cosmetic procedure by most National
Health Service trusts, has been shown to result in high
Department of Plastic, Reconstructive, and patient satisfaction and better quality of life.1 Most
Aesthetic Surgery health trusts have set the upper body mass index limit
Cerrahpasa Medical Faculty of between 26 (overweight) and 30 (obese) as a selec-
University of Istanbul tion tool for patients considering surgery. It remains
Istanbul, Turkey unclear whether these limits are based purely on op-
Correspondence to Dr. Cakmakkaya erative complications or as a rationing tool.
Cevizlibag Tercuman Sitesi Our aim was to assess whether overweight patients
A-4 Blok D.78 with a body mass index greater than 26 have higher
34015 Zeytinburnu, Istanbul, Turkey complication rates after breast reduction and should
serpilcakmakkaya@yahoo.com thus be excluded from surgery. Two hundred six con-
secutive patients in one tertiary plastic surgery center
DISCLOSURE who underwent breast reduction surgery were reviewed
None of the authors has a financial interest in any retrospectively.
of the products, devices, or drugs mentioned in this Of all patients, 38 percent had a body mass index less
article. than 26 and 62 percent had a body mass index of 26 or
more (range, 21 to 32; mean, 26.3) (Fig. 1). Mean age
REFERENCES was 36 years (range, 14 to 65 years). The most common
1. Chen, M., Costa, F. K., Lindvay, C. R., et al. The recombinant risk factors were the use of oral contraceptive pills (26
expression of full-length type VII collagen and characteriza- percent) and smoking (22 percent). Most operations
tion of molecular mechanisms underlying dystrophic epider- (82 percent) were performed using the inferior pedicle
molysis bullosa. Biol. Chem. 277: 2118, 2002. technique, half of which were performed by a consultant.
2. Crowley, K. L., and Shevchenko, Y. O. Anesthetic manage- Overall, 72 complications were noted in 56 patients,
ment of a difficult airway in a patient with epidermolysis with wound infection, wound breakdown, hematoma,
bullosa: A case report. A.A.N.A. J. 72: 261, 2004.
and fat necrosis accounting for 89 percent of the com-
3. Katz, J., and Steward, D. L. (Eds.). Anesthesia and Uncommon
Pediatric Diseases, 2nd Ed. Philadelphia: Saunders, 1987. Pp. plications. Twenty-eight of the complications were in
384–387. the lower body mass index group (35 percent) and 44
4. James, I., and Wark, H. Airway management during anesthesia were in the higher body mass index group (35 percent)
in patients with epidermolysis bullosa dystrophica. Anesthesi- (Table 1). There was no statistically significant difference
ology 56: 323, 1982. between the two groups (p ⬎ 0.05). In addition, there was

Fig. 1. Distribution of body mass index among the 206 patients in the study.

35e
 Plastic and Reconstructive Surgery • July 2008

Table 1. Incidence of Major Complications in Presented at the British Association of Plastic Surgeons
Patients with a BMI < 26 and a BMI between 26 Winter 2005 meeting.
and 32 Correspondence to Dr. Tadiparthi
BMI BMI Flat 59, The Symphony
<26 26 –32 2 Stowell Street
Complication (%) (%) p Liverpool, Merseyside L7 7DL, United Kingdom
tadiparthi@hotmail.co.uk
Wound infection 6 (8) 11 (9) 0.7868
Wound breakdown 13 (16) 11 (9) 0.09 REFERENCES
Hematoma 3 (4) 10 (8) 0.2592
Fat necrosis 5 (6) 7 (5.5) 0.8076 1. Klassen, A., Fitzpatrick, R., Jenkinson, C., and Goodacre, T.
Skin and nipple necrosis 1 (1) 5 (4) 0.4098 Should breast reduction surgery be rationed? A comparison
Total 28 (35) 44 (35) 0.6235 of the health status before and after treatment: Postal ques-
BMI, body mass index. tionnaire survey. B.M.J. 313: 454, 1996.
2. Platt, A., Mohan, D., and Baguley, P. The effect of body mass
index and wound irrigation on the outcome after bilateral
no difference in length of hospital stay (mean, 2.5 days) breast reduction. Ann. Plast. Surg. 51: 552, 2003.
or postoperative follow-up noted (p ⬎ 0.05). 3. Zubowski, R., Zins, J. E., Foray-Kaplon, A., et al. Relationship
Obesity is becoming one of the fastest growing public of obesity and specimen weight to complications in reduction
mammaplasty. Plast. Reconstr. Surg. 106: 998, 2000.
health problems, with 32 percent of women in the
4. Wagner, D. S., and Alfonso, D. R. The influence of obesity and
United Kingdom being overweight and 23 percent volume of resection on success in reduction mammaplasty: An
obese. Our study is the largest to date investigating the outcomes study. Plast. Reconstr. Surg. 115: 1034, 2005.
risk of postoperative complications following breast re-
duction surgery in patients with a body mass index of
less than 26 and in those with a body mass index be-
tween 26 and 32. It confirms that overweight patients Sonographic Assessment on Breast
are not at increased risk of any complications, and the Augmentation after Autologous Fat Graft
length of hospital stay and postoperative follow-up are Sir:
not prolonged as a result. Our study, however, did not
have patients with a body mass index greater than 32.
The literature investigating the postoperative com-
I n 1991, in our hospital, Dr. Keming Qi1 improved the
procedure of breast augmentation by repeatedly in-
jecting (one to five times) a low volume of autologous
plication rates after breast reduction surgery in relation fat (50 to 60 ml per time) into each breast, achieving
to body mass index is sparse and shows contradicting a satisfactory cosmetic effect with fewer complications.
outcomes. Platt et al.,2 in a study of 30 patients, noted Since 2003, we have used breast ultrasound as an ob-
an increased wound breakdown rate in those with a jective method of calculating the absorbance index of
body mass index greater than 26.3 (10 percent versus grafted fat and to classify the necrotic fat nodules by
33 percent; p ⬍ 0.05). Similarly, Zubowski et al.3 found sonographic changes after each operation.
a statistically significant increase in local complications Thirty-three patients aged 25 to 45 years were in-
in obese patients (11.3 percent versus 7.2 percent). jected one to five times in both breasts with a low
However, Wagner and Alfonso,4 in a study of 186 pa- volume (50 to 60 ml) of autologous fat. The autologous
tients, found that obese patients achieved as much fat was harvested from the abdominal wall or the tro-
symptom relief and with similar complication rates as chanteric area using the tumescent technique.1 The
the nonobese group. mixture of fat and anesthetic fluid obtained was placed
Breast reduction surgery is becoming increasingly re- in a stationary state for 30 minutes, and then the fat was
stricted by the National Health Service, with variability in collected from the top layer. The fat was injected into
rationing across the United Kingdom. Reasons for restric- the retromammary layer at the middle point of the
tion of surgery should be clear and based on good clinical inframammary fold or the axillary tail of the breast.
evidence; otherwise, it represents inequality in the provi- Then, the breast was massaged softly until the lump
sion of health care. This study showed that overweight induced by the injection disappeared. The interval be-
patients did not suffer from a higher rate of postoperative tween the two operations was more than 1 month.
complications following breast reduction surgery. Over- Breast sonographic examination was performed to eval-
weight patients are not at increased risk of surgical com- uate the grafted fat tissues. The thickness of the retro-
plications after breast reduction surgery, and a body mass mammary fat layer before and after each injection was
index less than 26 should not be used as a rationing tool measured at four points (Fig. 1) to calculate the ab-
with which to restrict surgery. sorbance index. The fat absorbance index was calcu-
DOI: 10.1097/PRS.0b013e3181774767
lated as [1 – (C – A)/(B – A)] ⫻ 100 percent, where A,
Sujatha Tadiparthi, M.R.C.S. B, and C represent the retromammary fat thickness
S. H. Liew, F.R.C.S.(Plast.) measured before the operation, the same day after the
Department of Plastic and Reconstructive Surgery operation, and 1 month after the operation, respec-
Whiston Hospital tively. The size and evolution of each necrotic fat nod-
Liverpool, United Kingdom ule were followed up every 3 months.

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Volume 122, Number 1 • Viewpoints

Fig. 1. The retromammary fat thickness was measured at the four points as
shown by the asterisks, namely, the middle points of the lines between the
nipple and the points of the outer edge of the gland at the 3-, 6-, 9-, and
12-o’clock positions. RB, right breast; LB, left breast.

The average fat absorbance index 1 month after each

operation was between 34 and 66 percent (Table 1).
Although the results are similar to those reported in the
literature,2– 4 the current data are directly from human
patients for the first time. The average thickness of the
retromammary fat layer increased from 0.2 cm before
the operation to 1.0 cm after the fifth operation. As
every patient in the present study had a slim figure with
a thin original thickness of the retromammary layer,
the cosmetic effect of the breast augmentation was very
satisfactory.
Fifty-one nodules in 14 patients (42.4 percent) were
detected after the fat graft. Forty-nine nodules were
found in the retromammary fat layer and two nodules
were found in the mammary gland layer, and their
connection with the retromammary layer could be Fig. 2. A cystic fat nodule shows an anechoic oval area with a
found by turning the probe during the examination.
well-defined margin and posterior acoustic enhancement on ul-
Forty-four nodules were nonpalpable and sonographi-
trasonography.
cally proved to be completely cystic with regular mar-
gins (Fig. 2), could be certainly diagnosed as benign
nodules composed mainly of oil released from free Only one nodule was surgically removed because of
lipid without eliciting a surrounding reaction,5 and patient anxiety, and its pathologic diagnosis was fat
needed no further treatment other than sonographic necrosis. The solid components of these nodules likely
follow-up. The other seven nodules (13.7 percent) were resulted from inflammation or a fibrotic response of
palpable and showed a complex or solid appearance on the necrotic grafted fat, and there was a trend toward
ultrasound images, all of which were followed up every an increase of cystic components, which might be ex-
3 months. No nodule increased in size, and three nod- plained by the liquefaction or absorbance of the in-
ules showed a more cystic component at follow-up. flammatory tissue.5

Table 1. Average Retromammary Fat Thickness and Average Absorbance Index 1 Month after Each Operation*
D D1 D2 D3 D4 D5
No. of patients 33 31 30 23 16 6
No. of breasts 66 62 60 46 32 12
No. of points 264 247 240 181 124 48
Average retromammary fat thickness, cm 0.20 ⫾ 0.10 0.48 ⫾ 0.12 0.64 ⫾ 0.23 0.85 ⫾ 0.17 0.92 ⫾ 0.21 1.02 ⫾ 0.39
Average fat absorbance index, % — 33.80 ⫾ 1.21 56.46 ⫾ 1.13 53.31 ⫾ 3.24 65.30 ⫾ 1.28 57.10 ⫾ 4.31
*D was the thickness before the first operation; D1, D2, D3, D4, and D5 was the thickness 1 month after the first, second, third, fourth, and
fifth operations, respectively.

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 Plastic and Reconstructive Surgery • July 2008

In summary, breast augmentation by repeated au- preoperative imaging is essential.1 The standard imag-
tologous fat grafting with low-volume injection each ing modality of the deep inferior epigastric artery
time is applicable and satisfactory: the absorbance in- (DIEA) has been either Doppler or color duplex
dex is acceptable, most of the necrotic fat nodules are ultrasonography,2 with both used extensively for trans-
easily diagnosed as benign lesions, and there is no need verse rectus abdominis musculocutaneous (TRAM)
for further surgery. Also, breast ultrasound is an accu- and DIEA perforator flaps. However, inconsistencies
rate and simple method of evaluating the absorbance with operative findings have perpetuated the search for
index and following up the temporal changes of the fat improved imaging modalities.
nodules after autologous fat injection. Computed tomographic angiography is a noninva-
DOI: 10.1097/PRS.0b013e3181774732 sive and effective investigation for mapping vasculature
Hongyan Wang, M.D. that has been used previously in various body regions.3,4
To our knowledge, computed tomographic angiogra-
Yuxin Jiang, M.D. phy has not been described for preoperative imaging in
Hua Meng, M.D. breast reconstruction.
Department of Diagnostic Ultrasound In 2006, a 54-year-old woman undergoing bilateral
Yuan Yu, M.D. TRAM flap breast reconstructions underwent preop-
erative abdominal wall imaging with both Doppler ul-
Keming Qi, M.D. trasonography (Philips HDI 5000 unit; Phillips Elec-
Department of Plastic Surgery
Peking Union Medical College Hospital
tronics Company, Eindhoven, The Netherlands) and
Chinese Academy of Medical Sciences helical computed tomographic angiography (Siemens
Beijing, China Somatom Sensation 64-slice computed tomographic
scanner; Siemens Medical Solutions, Malvern, Pa.) with
Correspondence to Dr. Meng 100 ml of intravenous Ultravist 370 contrast (Berlex
Department of Diagnostic Ultrasound Canada, Montreal, Quebec, Canada).
Peking Union Medical College Hospital
Chinese Academy of Medical Sciences
Doppler imaging revealed a single-trunk DIEA, with
Beijing 100730, China no major perforators or branches identified. Com-
menghua_pumch@yahoo.com puted tomographic angiographic reconstructions re-
vealed a bifurcating DIEA with two large trunks and
ACKNOWLEDGMENT several large perforators, with at least one large 2.5-mm-
The authors gratefully acknowledge Dr. Fuhai Li for diameter perforator (Figs. 1 and 2).
help with editing this communication. At the time of writing, computed tomographic an-
giography had not previously been described for pre-
DISCLOSURE
None of the authors has any financial interests or
commercial associations to disclose.
REFERENCES
1. Qi, K., and Chen, J. Breast augmentation of the autologous fat
granule injection grafting. Chin. J. Plast. Surg. Burns 13: 222, 1997.
2. Karacaoglu, E., Kizilkaya, E., Cermik, H., et al. The role of
recipient sites in fat-graft survival: Experimental study. Ann.
Plast. Surg. 55: 62, 2005.
3. Konanas, T. C., Bucky, L. P., Hurley, C., and May, J. W., Jr. The
fate of suctioned and surgically removed fat after reimplan-
tation for soft-tissue augmentation: A volumetric and histo-
logic study in the rabbit. Plast. Reconstr. Surg. 93: 763, 1993.
4. Dolsky, R. L., Newman, J., Fetzek, J. R., et al. Liposuction: History,
techniques, and complications. Dematol. Chin. 5: 313, 1987.
5. Bilgen, I. G., Usun, E. E., and Memis, A. Fat necrosis of the
breast: Clinical, mammographic and sonographic features.
Eur. J. Radiol. 39: 92, 2001.

A New Preoperative Imaging Modality for Free

Flaps in Breast Reconstruction: Computed Fig. 1. Computed tomographic angiogram of the abdominal
Tomographic Angiography wall vasculature, with coronal views highlighting the DIEA sys-
Sir: tem. Lateral images demonstrated the precise location and size

A bdominal donor-site free flaps are increasingly

used for autologous breast reconstruction. With
significant variation in individual vascular anatomy,
of several large periumbilical perforators (Fig. 2). The recon-
structed images also identified the location, size, and course of
the superficial inferior epigastric arteries.

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Volume 122, Number 1 • Viewpoints

Computed tomographic angiography is noninva-

sive but associated with some radiation exposure,
equivalent to or less than that of a staging abdominal
computed tomographic scan.5 The two scans can be
performed simultaneously, to avoid multiple presen-
tations and facilitate shorter preoperative investiga-
tion times.
In subsequent studies, we have obtained more than 70
computed tomographic angiograms for the preoperative
imaging of the DIEA and its perforators. These have been
compared with Doppler ultrasound and magnetic reso-
nance angiography scans. Computed tomographic an-
giography has remained the most accurate imaging mo-
dality and the one with the highest resolution of those
available. We have instituted improvements in computed
tomographic angiography technique, maximizing the ar-
terial phase for perforator filling. This eliminates rectus
abdominis and venous filling interference. This can be
achieved by timing the contrast bolus to the DIEA and
scanning from caudal to cranial.
Computed tomographic angiography is a suitable
alternative to Doppler ultrasonography for the preop-
erative imaging of the abdominal wall vasculature for
TRAM and DIEA perforator flaps. It is effective at dem-
onstrating both the deep and superficial epigastric ar-
Fig. 2. Computed tomographic angiogram of the abdominal terial anatomy and was superior to ultrasonography in
wall vasculature, with lateral reconstructions highlighting the its anatomical account. Its use facilitated rapid intra-
periumbilical perforators. operative dissection times and avoided surgical error.
DOI: 10.1097/PRS.0b013e318177462b
Warren M. Rozen, M.B.B.S., P.G.Dip.Surg.Anat.
Jack Brockhoff Plastic and Reconstructive Surgery
operative imaging in breast reconstruction. However, Research Unit
its effectiveness in other free flap operations certainly University of Melbourne
suggests its suitability.3,4 We demonstrate this applica- Timoth J. Phillips, M.B.B.S., P.G.Dip.Surg.Anat.
tion of computed tomographic angiography, compar- Department of Radiology
ing findings to conventional Doppler ultrasonography. Royal Melbourne Hospital
Computed tomographic angiography was highly ef-
Mark W. Ashton, F.R.A.C.S.
fective at mapping the course of the DIEA, highlighted
Jack Brockhoff Plastic and Reconstructive Surgery
by the branching pattern revealed on computed tomo- Research Unit
graphic angiography but missed on Doppler imaging. University of Melbourne
In addition, the computed tomographic angiography
was presented in a manner more suitable to the sur- Damien L. Stella, F.R.A.N.Z.C.R.
Department of Radiology
geon in the operating theater. These factors facilitated
Royal Melbourne Hospital
reduced intraoperative dissection times and the avoid-
ance of surgical error in our case. G. Ian Taylor, F.R.C.S., F.R.A.C.S.
Computed tomographic angiography was proficient Jack Brockhoff Plastic and Reconstructive Surgery
at identifying large perforators of the DIEA, with no Research Unit
University of Melbourne
perforators identified on Doppler imaging, despite
Parkville, Victoria, Australia
large perforators confirmed during surgery. This sug-
gests that even if perforators were identified on Dopp- Correspondence to Dr. Taylor
ler imaging, larger perforators may still be missed, con- Jack Brockhoff Plastic and Reconstructive Surgery
firming the high false-negative rates and interobserver Research Unit
variability for Doppler imaging in previous studies. University of Melbourne
Computed tomographic angiography also effectively Parkville, Victoria, Australia
g.taylor@medicine.unimelb.edu.au
identified the superficial inferior epigastric arteries, fur-
ther enhancing preoperative decision making, for con-
sideration of superficial inferior epigastric artery per- DISCLOSURE
forator flaps. In addition, it took less time to perform, The authors declare that there is no source of finan-
taking approximately 15 minutes, compared with 2 hours cial or other support, or any financial or professional
for perforator mapping with Doppler imaging.2,5 relationships that may pose a competing interest.

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 Plastic and Reconstructive Surgery • July 2008

REFERENCES
1. Boyd, J. B., Taylor, G. I., and Corlett, R. J. The vascular ter-
ritories of the superior epigastric and deep inferior epigastric
systems. Plast. Reconstr. Surg. 73: 1, 1984.
2. Giunta, R. E., Geisweid, A., and Feller, A. M. The value of
preoperative Doppler sonography for planning free perfora-
tor flaps. Plast. Reconstr. Surg. 105: 2381, 2000.
3. Bluemke, D. A., and Chambers, T. P. Spiral CT angiography:
An alternative to conventional angiography. Radiology 195:
317, 1995.
4. Nagler, R. M., Braun, J., Daitzman, M., and Laufer, D. Spiral
CT angiography: An alternative vascular evaluation technique
for head and neck microvascular reconstruction. Plast. Recon-
str. Surg. 100: 1697, 1997.
5. Fishman, E. K. CT angiography: Clinical applications in the
abdomen. Radiographics 21: S3, 2001.

Utility and Anatomical Examination of the

DIEP Flap’s Three-Dimensional Image with
Multidetector Computed Tomography
Sir:
Fig. 2. Sagittal section. View from the umbilicus. P1, right-side
M odern reconstructive surgery has increased the
importance of perforator flaps. However, there
are many variations in the position of perforators, and
main perforator; U, umbilicus; SEV, superficial epigastric vein.

it is difficult to perform effective surgical planning.

Thermography, Doppler ultrasound, and supersonic
rectus abdominis muscle and uses surplus adipose tis-
color Doppler imaging have been used for preoperative
sue. For this reason, it has been used for reconstructive
detection of perforators; these methods have both mer-
mammaplasty by Allen and Blondeel; subsequently, an-
its and disadvantages but ultimately do not always pro-
terolateral thigh, gluteal artery perforator, thoracodor-
vide definitive results. In contrast, enhanced multide-
sal artery perforator, and tensor fasciae latae flaps have
tector computed tomography allows accurate detection
been developed for use over much of the body.4 How-
of perforators before surgery case by case, and is a very
ever, it is often difficult to predict the positions of
useful tool in preoperative planning for surgery using
perforators before surgery because of the variation in
perforator flaps.
these positions. In this communication, we show that
The three-dimensional image supplies the exact lo-
multidetector computed tomography can be used to
cation of perforators (Fig. 1), and we compose a three-
plan an operation in detail; in this sense, multidetector
dimensional image using computed tomographic data
computed tomography can perhaps be understood to
(Fig. 2).
illuminate reconstructive surgery in a manner analo-
The deep inferior epigastric perforator (DIEP) flap
gous to Edison’s development of the light bulb in 1879.
was developed by Koshima et al. in 19891–3 and is par-
Many anatomical reconstructions are performed us-
ticularly useful because it retains the function of the
ing perforator flaps as standard medical practice. In
1987, Taylor and Minabe5 reported a detailed exami-
nation of the angiosome in the context of nourishment
perforators of the abdominal wall based on obduction
data. Determination of accurate positions for perfora-
tors is difficult; for example, in blood vessel anatomy
performed in cadavers, correspondence of individual
build differences and vascular variation cannot be
achieved based on the mean anatomical position of
each blood vessel relative to the previous vessel.
The number of perforators depends on sex and the
thickness of the abdominal wall: the physical features of
women require more perforators, and patients with a
thick abdominal wall panniculus adiposus also tend to
have more perforators. One further characteristic of
the examination is that the microvasculature is not
easily recognized in a thin panniculus adiposus.
DIEP flaps are used for reconstructive mammaplasty
Fig. 1. Computed tomographic image of the abdominal wall. in patients with breast cancer, and presurgical planning
P1, right-side main perforator; P2, left-side main perforator. with knowledge of the position of perforators is useful

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Volume 122, Number 1 • Viewpoints

in this procedure. Both preoperative and postoperative 4. Blondeel, N., Boeckx, W. D., Vanderstraeten, G. G., et al. The
multidetector computed tomography is particularly ap- fate of the oblique abdominal muscles after free TRAM flap
propriate in breast cancer patients, who also require surgery. Br. J. Plast. Surg. 50: 315, 1997.
this procedure for diagnostic purposes, and simulta- 5. Taylor, G. I., and Minabe, T. The angiosomes of the mammals
and other vertebrates. Plast. Reconstr. Surg. 89: 181, 1992.
neous scanning from the thoracic region to the ab-
dominal region is possible. Multidetector computed
tomography is particularly useful in breast cancer pa-
tients because it is also used for preoperative and Salvage of a Congested DIEP Flap: A New
follow-up cancer diagnostic testing and therefore serves Technique
two simultaneous purposes in these patients. Sir:
DOI: 10.1097/PRS.0b013e3181774607
Makoto Mihara, M.D. V enous congestion of free flaps is a major cause of
flap failure. We discuss the use of a new operative
technique of a reverse-flow anastomosis of a deep in-
Misa Nakanishi, M.D.
ferior epigastric vein to an intrinsic flap vein for salvage
Miho Nakashima, M.D. of a deep inferior epigastric perforator (DIEP) flap.
Mitunaga Narushima, M.D. A 52-year-old woman underwent delayed left breast
reconstruction with a DIEP flap 4 years after mastec-
Isao Koshima, Ph.D.
tomy, chemotherapy, and radiotherapy for ductal car-
Department of Plastic and Reconstructive Surgery
Tokyo University cinoma. She had no other significant medical history,
Tokyo, Japan and her body mass index was 27. The 440-g flap was
raised on one perforator of the lateral row identified by
Correspondence to Dr. Mihara preoperative duplex scan, with end-to-end anastomosis
Department of Plastic and Reconstructive Surgery of the deep inferior epigastric artery and one comitans
Tokyo University
7-3-1, Hongo, Bunkyo-ku
vein to the internal mammary vessels. A 2-mm Synovis
Tokyo 113-8655, Japan coupler was used for the venous anastomosis. No sig-
mihara@keiseigeka.name nificant superficial vein was found, and no other sig-
nificant perforator was present in the flap. The isch-
DISCLOSURE emia time was 34 minutes. In the second postoperative
The authors have no financial or other commercial hour, the flap was reexplored because of clinical evi-
interest in the work described in the communication. dence of a hematoma. A 300-ml hematoma was evac-
uated. The flap remained congested over the next
REFERENCES hour, demonstrating insufficient venous outflow. This
outflow was augmented by anastomosis of an intrinsic
1. Koshima, I., and Soeda, S. Inferior epigastric artery skin flaps
flap vein to a segment of the remaining unused vena
without rectus abdominis muscle. Br. J. Plast. Surg. 42: 645, 1989.
2. Koshima, I., Moriguchi, T., Fukuda, H., et al. Free, thinned, comitans of the deep inferior epigastric artery. This
paraumbilical perforator-based flaps. J. Reconstr. Microsurg. 7: segment was dissected from the pedicle until the first
313, 1991. large communicating branch between the two comi-
3. Koshima, I., Moriguchi, T., Soeda, S., et al. Free thin paraum- tans veins. The flow through this segment was in a
bilical perforator-based flaps. Ann. Plast. Surg. 29: 12, 1992. reverse direction (Fig. 1).

Fig. 1. Schematic representation of the operative technique.

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 Plastic and Reconstructive Surgery • July 2008

Richard Haywood, F.R.C.S.(Plast.)

Stoke Mandeville Hospital
Norwich, England
Correspondence to Dr. Shamsian
10 Victoria Drive East
Odstock, Salisbury
Wiltshire SPR 8BJ, England
neginshamsian@yahoo.com

REFERENCE
1. Hallock, G. G., and Rice, D. C. Efficacy of venous supercharg-
ing of the deep inferior epigastric perforator flap in a rat
model. Plast. Reconstr. Surg. 116: 551, 2005.

Perioperative Management of Patients with

Glycogen Storage Disease Type Ia
Sir:

W ith an incidence of approximately one in 20,000

live births and a phenotype described for almost
every enzyme involved in the processing of glycogen, it
Fig. 2. The flap immediately after anastomosis of the intrinsic is not uncommon to encounter a patient with one of
flap vein. the various glycogen storage diseases. A 13-year-old boy
presented with an abdominal wound around the site of
a gastrostomy tube. Formal closure was required, yet
Reverse flow was confirmed before anastomosis by the patient’s care was complicated by his history of von
gentle irrigation with saline. The flap recovered im- Gierke disease (glycogen storage disease type Ia). He
mediately and the patient made an uneventful re- required no special medication but could not be with-
covery (Fig. 2). out nutrition for more than 2 to 3 hours because of
It is well documented that some DIEP flaps drain uncontrolled hypoglycemia. At home, his mother fed
dominantly by means of the superficial veins, and this him small portions throughout the day and night sup-
is a common cause of venous congestion and flap plemented by frequent doses of uncooked cornstarch.
failure,1 but such was not the case here. However, the The glycogen storage diseases result from a defect in
venous outflow of the single perforator chosen was an enzyme required for either glycogen degradation or
clearly insufficient even in this relatively small flap. This storage. Glycogen storage disease type Ia refers to a
needed to be augmented without sacrifice of the cur- deficiency in glucose-6-phosphatase, which is required
rent venous drainage. A recipient vein was needed for for conversion of glucose-6-phosphate to glucose. Gly-
the intrinsic flap vein that we had dissected. cogen storage disease type Ia is specifically character-
We considered the following options: ized by severe fasting hypoglycemia, fatty infiltration of
the liver, hepatomegaly, hyperlacticacidemia, hyperuri-
1. Grafting the intrinsic flap vein to the cephalic cemia, and an increased amount of glycogen storage.
vein. This would have required additional scar- As a result of the rapid fall in glucose level with
ring on the arm and resulted in a significant fasting, careful management of the patient’s electrolyte
discrepancy of lumen size for anastomosis. levels is critical to any surgical plan. Strict avoidance
2. Using a vein graft anastomosed end to side onto the of catabolic periods is important, because even brief
first vena comitans draining into the internal mam- episodes can lead to profound hypoglycemia, lactic
mary vein. This may have jeopardized the flow acidosis, and seizure development. Several recom-
through this vein and required two anastomoses. mendations have been proposed as a guide for the
3. Anastomosing the intrinsic flap vein to the second perioperative management of patients with a glycogen
comitans vein end to end. This allowed drainage storage disease. The patient should be admitted to the
from the flap by retrograde flow through the sec- hospital the night before the procedure so that a con-
ond vena comitans. This required only one anasto- tinuous supply of glucose can be provided as soon as the
mosis, with minimal size discrepancy, and proved to patient is placed on nothing-by-mouth status. The spe-
be a much quicker and simpler solution. cific fluid should be 10% dextrose in half normal saline
We recommend that this technique for salvaging a solution run at roughly 1.25 to 1.5 times maintenance.
congested DIEP free flap. The intravenous fluids should run uninterrupted and
DOI: 10.1097/PRS.0b013e31817745c1 be replaced expeditiously if lost, because even a brief
period without glucose can result in severe hypoglyce-
Negin Shamsian, M.R.C.S. mia and seizures as a result of the high insulin state.
Elaine Sassoon, F.R.C.S.(Ed.), F.R.C.S.(Eng.) Other solutions, such as the standard 5% dextrose in

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Volume 122, Number 1 • Viewpoints

half normal saline and lactated Ringer’s solution, was marked on the skin with a pen. The melanoma was
should not be used. The patient’s blood glucose should excised. The exact localization of the sentinel lymph
be checked on arrival and be assessed at least hourly node was determined preoperatively using a hand-held
until the blood glucose level is stable. Thereafter, it may gamma counter. The most radioactive node was dis-
be checked every 2 hours while fasting. The intravenous sected, as were the nodes with radioactivity greater than
fluid rate should also be titrated to keep the blood 70 percent compared with the hottest node. Once the
glucose concentration above 75 mg/dl. sentinel lymph node was removed, it was sent imme-
Intraoperatively, surgical stress may result in profound diately to the pathologist. Three cuts from both sur-
lactic acidosis. It is important that the dextrose be con- faces were stained with hematoxylin and eosin and
tinued at the aforementioned rate even if hyperglycemia examined microscopically for metastatic localization.
is occurring. Lowering of the infusion rate can result in After they were preserved in formaldehyde, six sections
unopposed counterregulatory hormones, which lead to were stained by an immunocytochemical method with
severe lactic acidosis from glycogen degradation. In the anti-protein S100 serum, anti-HMB45, and anti-MelanA
face of severe acidosis, bicarbonate may be administered. antibodies. We analyzed the characteristics of the mela-
Postoperatively, the dextrose infusion should not be noma, the success rate of the procedure, how many nodes
stopped until the patient is tolerating adequate food were removed, and how many had micrometastases.
and starch intake. Once enteral intake has been toler- Ninety patients were included. Their mean age was
ated, the dextrose infusion should be weaned slowly 62.8 years (range, 25 to 90 years). The mean tumoral
over 2 to 3 hours. Rapid discontinuation may similarly thickness was 2.96 mm (range, 0.3 to 20 mm). The sites
result in hypoglycemia because of the inability to coun- of the primary melanoma were the trunk (14 percent),
terregulate high insulin concentrations. By following head and neck (14 percent), upper extremities (26
these recommendations, it is possible to minimize com- percent), and lower extremities (46 percent). One
plications in this challenging population of patients. lymph node basin per patient was mapped. Sentinel
DOI: 10.1097/PRS.0b013e31817746da nodes were identified in 100 percent of cases. One
Justin Lipper, B.A. hundred five sentinel lymph nodes were identified
Mount Sinai Medical Center (mean, 1.3 per patient; range, one to three per pa-
David A. Weinstein, M.D., M.M.Sc. tient). In 74 percent of patients, only one lymph node
University of Florida College of Medicine was removed; in 22 percent, two sentinel lymph nodes
Gainesville, Fla. were identified; and in three patients (4 percent), three
Peter J. Taub, M.D. sentinel lymph nodes were removed.
Mount Sinai Medical Center Metastasized melanoma was detected in 19 sentinel
New York, N.Y. lymph nodes from 19 patients (22 percent). All of these
patients went on to have a complete dissection of the
Correspondence to Dr. Taub
Division of Plastic and Reconstructive Surgery
involved basin, and additional positive nodes were
Mount Sinai Medical Center found in only one patient.
New York, N.Y. During the follow-up (mean, 18.8 months; range, 8
peter.taub@mountsinai.org to 32 months), one patient with a negative sentinel
lymph node had a basin recurrence (2.5 percent),
Validation of a Method to Reduce the Number whereas two patients with positive sentinel lymph nodes
of Sentinel Nodes Removed in Melanoma had distant metastases (18.18 percent).
Patients: A Preliminary Prospective Survey As a preliminary evaluation in this communication,
Sir: these results were compared with those of two literature

S entinel lymph node biopsy1,2 has become a widely

accepted method of staging lymph nodes for pa-
tients with melanoma. The current literature points out
studies.3,4 There was no significant difference with re-
spect to the success rate of the procedure, detection of
metastatic nodes, or recurrence rate after negative sen-
an increasing number of nodes removed for each pro- tinel lymph node biopsy. However, we point out a sig-
cedure, leading to a higher human and economic cost nificant difference with regard to the number of sen-
for the procedure. The objective of the current study tinel lymph nodes removed.
was to show that the number of sentinel lymph nodes DOI: 10.1097/PRS.0b013e3181774650
removed could be minimized without influencing the Alain Danino, M.D., Ph.D.
reliability of tumor staging. Gabriel Malka
A single-arm prospective study was conducted be- Sophie Dalac, M.D.
tween January of 2002 and September of 2004. Patients Department of Plastic and Reconstructive Surgery
older than 18 years of age with cutaneous melanoma of Dijon University Hospital
greater than or equal to 1 mm Breslow thickness and Dijon, France
clinically negative regional lymph nodes were eligible Correspondence to Dr. Danino
after providing informed consent. Department of Plastic and Reconstructive Surgery
An intradermal injection of 0.2 ml (10 to 15 MBq) Dijon University Hospital
of colloidal particles labeled with technetium-99m was Dijon, France
administered. The location of the sentinel lymph node alain.danino@chu-dijon.fr

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 Plastic and Reconstructive Surgery • July 2008

REFERENCES
1. Morton, D. L., Wen, D. R., Wong, J. H., et al. Technique details
of intraoperative lymphatic mapping for early melanoma.
Arch. Surg. 127: 392, 1992.
2. Morton, D. L., Thompson, J. F., Essner, R., et al. Validation of
accuracy of intraoperative lymphatic mapping and sentinel
lymphadenectomy for early stage melanoma: A multicenter
trial. Ann. Surg. 230: 453, 1999.
3. McMasters, K. M., Reintgen, D. S., Ross, M. I., et al. Sentinel
lymph node biopsy for melanoma: How many radioactive
nodes should be removed. Ann. Surg. Oncol. 8: 192, 2001.
4. Porter, G. A., Ross, M. I., Berman, R. S., et al. How many lymph
nodes are enough during sentinel lymphadenectomy for pri-
mary melanoma. Surgery 128: 306, 2000.

Multiple V-Y Advancement Flaps: A New

Method for Axillary Burn Contracture Release Fig. 2. Eight months postoperatively, full abduction of the left
Sir: shoulder joint is accomplished. Notice the M-type release of two

T he axilla is a frequent site of adduction contracture

after deep thermal injury. The hair-bearing part of
the axilla is usually spared from the thermal injury
scar bands with no undermining of the injured side.

because of the unexposed and hidden axillary skin of or type 2 according to the Kurtzman classification, with
the arm pit. The common pattern of scar formation in more than 45 degrees of abduction limitation (⬍45
this region is contracture of anterior, posterior, or both degrees usually demands skin graft). The active range
axillary folds, with a normal axillary pit. Anterior axil- of shoulder abduction before the operation was deter-
lary skin fold contracture is the most common defor- mined in these patients (45 to 90 degrees) and com-
mity occurring at the shoulder.1 Shoulder deformities pared with the postoperative measurements (110 to 180
have been classified by Kurtzman and Stern into three degrees). Patients were followed for 5 to 18 months
subgroups.2 (mean follow-up, 11.5 months), and the desired scar
During axillary burn scar release, using transposition lengthening was attained in all patients (Fig. 2). Wound
flaps such as the Z-plasty technique, problems such as morbidity was low, and no contracture recurrence was
tip necrosis and hair-bearing skin transfer to visible noted during the follow-up period. Two patients de-
areas of the axilla were noticed. This led the authors to veloped hypertrophic scar on the incision line.
reintroduce a multiple V-Y advancement flap (V-M The results of this study show that the multiple V-Y
plasty) technique (Fig. 1). From September of 2004 to advancement flap (M-plasty) procedure promises to be
April of 2006, 12 cases of anterior and and/or posterior a good alternate technique in the treatment of axillary
axillary fold contractures were treated by using the V-M contracture bands in terms of rate of elongation, pre-
advancement technique, with acceptable contracture vention of flap tip necrosis, and inhibition of hair-
release and scar lengthening. Cases were either type 1 bearing skin transfer to visible areas of the axilla. A

Fig. 1. A 5-year-old boy had axillary and anterior chest wall contracting
bands. A wider flap was designed on the scar area to prevent ischemia.
More movement and undermining are anticipated on the normal arm pit
skin.

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Volume 122, Number 1 • Viewpoints

variety of surgical treatments have been used for re- 5. Lewis, R. C., Nordyke, M. D., and Duncan, K. H. Web space
construction of axillary contracture defects. In the ma- reconstruction with a M-V flap. J. Hand Surg. (Am.) 13: 40,
jority of these techniques, flap transposition and un- 1988.
dermining in previously damaged skin are mandatory
because the flaps are prone to ischemic necrosis as a
result of compromised blood supply, especially at the The Lower Trapezius “Reverse-Turnover” Flap
tips of the flaps.3 Sir:
Scar interruption and lengthening can be achieved
by single or multiple M-type V-Y plasty,4,5 without the
need for undermining and transposition; thus, there
S ince its introduction,1 the “reverse-turnover” latis-
simus dorsi flap has been established as a reliable
muscle flap for coverage of lower midspinal wounds.2
are relatively few postoperative complications. Distor- Based on its “reversed” secondary segmental blood sup-
tion of the surrounding skin or displacement of ana- ply, a medially based flap can be turned over for cov-
tomical landmarks is less frequent and the technique is erage of midline posterior trunk defects. This same
simple, efficient, and versatile. The design and perfor- concept is used when “turnover” pectoralis major mus-
mance of the procedure are easy and the operative time cle flap surgery is performed. It is now recognized that
is short. Early mobilization and short-term hospital stay the lower trapezius muscle has a dominant dorsal scap-
are the benefits of this procedure. ular pedicle and secondary segmental pedicles arising
None of our patients developed ischemic necrosis or from the intercostal system.3 We present a novel use of
contracture recurrence or needed further surgery dur- the lower trapezius muscle as a reverse-turnover flap,
ing the follow-up period. With regard to conventional based on secondary segmental posterior intercostal ar-
multiple V-Y flaps, in the V-M plasty procedure, three tery perforators, for coverage of a midline midthoracic
convergent flaps are used in a small area and spread out wound.
to achieve a wider scar band release. The approach has A 44-year-old man underwent resection of a midline
its own limitations and is not applicable for severe in- posterior trunk fibrosarcoma at the midthoracic level,
juries and contractures. followed by primary closure and postoperative irradi-
DOI: 10.1097/PRS.0b013e31817745e5 ation. He later presented with a nonhealing wound
Mohammad Pegahmehr, M.D. despite aggressive local therapy (Fig. 1). This was
Motahary Burn and Reconstructive Center treated with a reverse-turnover lower trapezius flap
Iran University of Medical Sciences based on two segmental posterior intercostal artery
Farhad Hafezi, M.D. perforators (Fig. 2). The patient’s trapezius muscles
Department of Plastic Surgery had an abnormally high origin, terminating at the
St. Fatima Hospital ninth vertebra (Fig. 1), which precluded the use of a
Iran University of Medical Sciences traditional trapezius turnover flap as previously de-
Bijan Naghibzadeh, M.D. scribed by the senior author (J.J.D.).4 Skin closure was
Department of Otolaryngology, Head and Neck Surgery
Loghman Hospital
Shahidbeheshty University of Medical Sciences
Tehran, Iran
Amirhossein Nouhi, M.D.
Correspondence to Dr. Hafezi
No. 15 Esmaeeli Street
Keyhan Avenue
Zaferanieh, Tehran 1986884813, Iran
info@drhafezi.com

DISCLOSURE
None of the authors has any financial interest in the
writing of this communication.
REFERENCES
1. Ngim, R. C., Lee, S. T., and Tang, A. Rehabilitation of burns
of the upper limb. Ann. Acad. Med. Singapore 12: 350, 1983.
2. Kurtzman, L. C., and Stern, P. J. Upper extremity burn con-
tractures. Hand Clin. 6: 261, 1990.
3. Mathes, S. J. Plastic Surgery, 2nd Ed., Vol. 1. Philadelphia:
Saunders Elsevier, 2006. P. 255.
4. Alexander, J. W., MacMillan, B. G., and Martel, L. Correction
of postburn syndactyly: An analysis of children with introduc- Fig. 1. Intraoperative exposure after wound debridement.
tion of the VM-plasty and postoperative pressure inserts. Plast. Dotted line indicates the inferolateral edge of the right trape-
Reconstr. Surg. 70: 345, 1982. zius muscle.

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 Plastic and Reconstructive Surgery • July 2008

trapezius muscle flap to treat a midthoracic wound,

with excellent results. Further clinical use of this flap is
warranted and should prove its reliability for coverage
of midthoracic midline wounds.
DOI: 10.1097/PRS.0b013e31817745af
Eric G. Halvorson, M.D.
Ronen Avram, M.D.
Joseph J. Disa, M.D.
Plastic and Reconstructive Service
Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, N.Y.
Submitted for presentation at the Annual Meeting of the
American Society of Microsurgeons, January of 2007.
Correspondence to Dr. Disa
Plastic and Reconstructive Service
Department of Surgery
Memorial Sloan-Kettering Cancer Center
1275 York Avenue
New York, N.Y. 10021
disaj@mskcc.org

DISCLOSURE
Fig. 2. Schematic of the lower trapezius reverse-turnover flap, No funds were used or received in the preparation of
based on secondary segmental posterior intercostal artery per- this communication.
forators.
REFERENCES
1. Bostwick, J., Scheflan, M., Nahai, F., and Jurkiewicz, M. J. The
achieved primarily, and the patient’s wound healed “reverse” latissimus dorsi muscle and musculocutaneous flap:
uneventfully. Stable wound coverage was confirmed at Anatomical and clinical considerations. Plast. Reconstr. Surg.
6-month follow-up, and no functional disability was 65: 395, 1980.
noted. 2. Stevenson, T. R., Rohrich, R. J., Pollock, R. A., et al. More
As early as 1933, Salmon performed lead injection experience with the “reverse” latissimus dorsi musculocuta-
studies and recognized that the dorsal scapular and neous flap: Precise location of blood supply. Plast. Reconstr.
Surg. 74: 237, 1984.
posterior intercostal arterial systems formed anastomo-
3. Haas, F., Weiglein, A. H., Schwarzl, F., and Scharnagl, E. The
ses in the lower trapezius muscle.5 Despite this work, the lower trapezius musculocutaneous flap from pedicled to free
vascular anatomy of the trapezius muscle has only been flap: Anatomical basis and clinical applications based on the
clarified in recent years. On the basis of earlier efforts dorsal scapular artery. Plast. Reconstr. Surg. 113: 1580, 2004.
to clarify the arterial anatomy and nomenclature for 4. Disa, J. J., Smith, A. W., and Bilsky, M. H. Management of
the trapezius muscle, Haas et al. performed bilateral radiated reoperative wounds of the cervicothoracic spine: The
dissections in 124 cadavers.3 This comprehensive study role of the trapezius turnover flap. Ann. Plast. Surg. 47: 394,
demonstrated that the trapezius muscle can be divided 2001.
into thirds, with each third deriving its blood supply 5. Salmon, M. Arteries of the muscles of the trunk. In G. I. Taylor
from distinct sources. The upper third is supplied by and R. M. Razaboni (Eds.), Arteries of the Muscles of the Extremities
branches of the occipital artery, the middle third by and the Trunk. St. Louis: Quality Medical Publishing, 1994. Pp.
117–119.
the superficial cervical artery (or superficial branch
of the transverse cervical artery), and the lower third by
the dorsal scapular artery (or deep branch of the trans-
verse cervical artery) and secondary segmental poste-
rior intercostal artery perforators. Posterior Rectal Hernia after Vacuum-Assisted
The lower trapezius can thus be conceptually con- Closure Treatment of Sacral Pressure Ulcer
sidered a Mathes-Nahai type V muscle, with one dom- Sir:
inant and multiple secondary segmental pedicles (Fig.
2). Haas et al. found that the lower trapezius was always
supplied by such secondary segmental branches of the
A 73-year-old patient with multiple recurrent pres-
sure ulcers over her buttocks presented for eval-
uation of a stage IV sacral pressure ulcer with extensive
posterior intercostal vessels, which were derived from tissue necrosis. She had previously undergone surgical
the fourth through sixth intercostal spaces more than debridement and local wound care treatment. Exten-
75 percent of the time.3 On the basis of these anatom- sive debridement of the sacral ulcer, which extended
ical findings, we used a distally based, reverse-turnover over an area of 19 ⫻ 13 cm and was approximately 2 cm

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Volume 122, Number 1 • Viewpoints

deep, was performed; the specimen included necrotic

skin, subcutaneous tissue, and remainders of sacrococ-
cygeal bone and necrotic muscle. Postoperatively, vac-
uum-assisted closure therapy of the defect resulting
from debridement of the sacral pressure ulcer was ini-
tiated with a negative pressure of 125 mmHg in inter-
mittent cycles of 5 minutes on and 2 minutes off. Dress-
ing changes were performed every 3 days.
Six weeks after initiation of treatment with the vac-
uum-assisted closure device, the plastic surgery team
was asked to reassess the patient for a new mass in the
wound. On examination, the patient had developed a
posterior rectal hernia (Fig. 1). The diagnosis was con-
firmed by computed tomographic scan.
We decided to proceed with surgical closure of the
defect to prevent injury to the rectum and expedite
closure of the wound. Given the contaminated nature Fig. 2. Final result after reconstruction with tensor fasciae latae
of the area, we elected to avoid any synthetic mesh and graft and flap closure.
chose to use a tensor fasciae latae graft for onlay closure
of the defect, followed by a local fasciocutaneous pos-
terior thigh flap repair (Fig. 2). The patient tolerated earlier than in the other reported cases. It is conceiv-
the procedure well and has not presented recurrence able that the negative pressure adjacent to the posterior
of the hernia or the sacral ulcer at 1-year follow-up. rectal wall could have contributed to forming the pro-
The case presented here has many features in com- trusion of rectum into the wound. Vacuum-assisted clo-
mon with the only two other reported cases.1,2 All pa- sure therapy has been used successfully to expedite
tients had a history of previous surgical coccygectomies healing of sacral pressure ulcers,3 and no previous her-
and developed herniation of the rectum at the poste- nia complications have been reported. We certainly
rior midline through the existing scar. All three cases cannot establish causality in this previously unreported
were treated differently: there was one primary closure complication of vacuum-assisted closure for treatment
of the fascial defect, one repair with synthetic mesh, of sacral pressure ulcers with loss of sacral bone.
and one repair with an autologous fascial graft. None DOI: 10.1097/PRS.0b013e3181774682
of the patients presented postoperative complications Pirko Maguina, M.D.
or recurrence of the hernia.
Unlike the other two patients, our patient had been Ramasamy Kalimuthu, M.D.
University of Illinois at Chicago Medical Center
undergoing treatment with a vacuum-assisted closure
Chicago, Ill.
device before appearance of the hernia. It is unclear to
us whether the use of vacuum-assisted closure was re- Correspondence to Dr. Maguina
lated to this complication. The hernia appeared much University of Illinois at Chicago
820 South Wood Street, Suite 520
Chicago, Ill. 60613
pmaguina@uic.edu

REFERENCES
1. Baynham, S., Kohlman, P., and Katner, H. P. Treating stage
IV pressure ulcers with negative pressure therapy: A case re-
port. Ostomy Wound Manage. 45: 34, 1999.
2. Balkenede, U. Hernia through a scar on the posterior rectal
wall. Eur. J. Surg. 162: 347, 1996.
3. Garcia, F. Posterior hernia of the rectum after coccygectomy.
Eur. J. Surg. 164: 793, 1998.

Treatment of the Chronic Pilonidal Sinus

Wound with a Local Perforator-Assisted
Transposition Flap
Sir:

Fig. 1. Rectal hernia seen after 6 weeks of treatment with vacu-

T reatment of chronic pilonidal sinus wounds is as-
sociated with a high failure rate. Transposition and
perforator-assisted transposition flaps can be useful for
um-assisted closure. closure of chronic pilonidal sinus wounds, providing

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 Plastic and Reconstructive Surgery • July 2008

well-vascularized skin with tension-free margins and a

flattening of the buttock cleft. We present two cases of
successful closure of chronic pilonidal sinus wounds
with a local transposition flap, the first of which was
augmented in its vascular supply with two superior glu-
teal artery perforators.
A 40-year-old man was referred for treatment of a
pilonidal sinus chronic wound that had developed a
biopsy-proven 4 ⫻ 4-cm squamous cell carcinoma at the
superior margin of the wound. The wound extended
from the top of the buttock cleft to 2 cm above the anus.
The cancer and the pilonidal sinus wound were excised
with clear margins, and the defect was reconstructed
with a superiorly based transposition flap (15 cm su-
perior to inferior, and 8 cm at its widest at the superior
portion), with two intact perforators from the superior
gluteal artery to augment the blood supply to the flap. Fig. 2. Complete survival without postoperative complications
The very tip of the flap had excellent bleeding. The flap with a simple transposition flap of a pilonidal sinus wound that
survived entirely and healing was complete primarily had been operated on twice.
(Fig. 1). There have been no complications at 2 years
postoperatively. ination rates, and difficulty with skin graft take and
In our second case, a 27-year-old woman was referred instability in this region.
after two previous unsuccessful attempts at excision and Gluteal island perforator flaps have been used for
closure of a pilonidal sinus wound. The wound was successful repair of sacral defects for more than a
excised and closed with a simple transposition flap decade.1–3 The provision of extremely well-vascularized
smaller and similar in construction to the flap in Figure skin with a tension-free closure provides a logical so-
1, which healed completely. Although we could have lution to some of the problems of pilonidal disease. In
included them, no perforators were required in this a large wound such as in the first case, the blood supply
flap, as it was smaller and quite well vascularized with- to such a large flap (8 ⫻ 15 cm) would have been less
out perforator augmentation. There have been no post- robust if either the base of the flap (venous outflow) or
operative complications at 3 years (Fig. 2). the perforators (arterial inflow and venous outflow)
Successful outcome in chronic pilonidal wound had been severed. Keeping the base of the transposi-
management is difficult because of a number of factors, tion flap intact not only provided increased venous
including high tension and shearing forces with exci- outflow to the perforator flap but also prevented kink-
sion and primary closure, high moisture and contam- ing of the perforators themselves, which can lead to
island perforator flap necrosis and failure. The orien-
tation of the transposition flap allows for tension-free
closure on either side of the midline and flattening of
the buttock cleft; both of these factors decrease the risk
of pilonidal sinus wound recurrence.
DOI: 10.1097/PRS.0b013e31817746c8
Rebecca Nelson, M.D.
Don Lalonde, M.D.
Dalhousie University
Saint John, New Brunswick, Canada
Presented at the Atlantic Society of Plastic Surgeons
Meeting, in Digby, Nova Scotia, Canada, September of
2004, and at the Canadian Society of Plastic Surgeons
Meeting, in Nanaimo, British Columbia, Canada,
June of 2005.
Correspondence to Dr. Lalonde
400 University Avenue
Saint John, New Brunswick E2L 4L2, Canada
drdonlalonde@nb.aibn.com
Fig. 1. Complete survival without complications after recon-
struction with two superior gluteal artery perforators assisting a DISCLOSURES
transposition flap (15 ⫻ 8 cm) after excision of a 4 ⫻ 4-cm squa- This project was not commercially funded and uses
mous cell cancer arising at the superior part of a chronic pilonidal no commercial products. There are no commercial or
sinus wound extending to 2 cm above the anus. financial affiliations or gains.

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Volume 122, Number 1 • Viewpoints

REFERENCES has improved the reconstructive strategy during the

1. Koshima, I., Moriguchi, T., Soeda, S., Kawata, S., Ohta, S., and past decade. The posteromedial thigh skin flap pedi-
Ikeda, A. The gluteal perforator-based flap for repair of sacral cled on the cutaneous perforator of the adductor mag-
pressure sores. Plast. Reconstr. Surg. 91: 678, 1993. nus muscle was described in 2001 by Angrigiani et al.3
2. Coskunfirat, O. K., and Ozgentas, H. E. Gluteal perforator Our experience with this flap is presented.
flaps for coverage of pressure sores at various locations. Plast. Between December of 2001 and May of 2003, seven
Reconstr. Surg. 113: 2012, 2004. flaps were used in six paraplegic patients who had grade
3. Garrido, A., Ali, R., Ramakrishnan, V., Spyrou, G., and Stanley, IV ischial pressure sores (Table 1). The primary disease
P. R. W. Reconstruction of the natal cleft with a perforator-
was spinal trauma in all patients. The patient in case 1
based flap. Br. J. Plast. Surg. 55: 671, 2002.
was also diabetic. After thorough debridement, rect-
angular transposition flaps based on the cutaneous per-
forator of the adductor magnus muscle were elevated.
A cutaneous paddle ranging between 2 and 3 cm over the
Long-Term Outcome with the Adductor perforator was always preserved and the perforator was
Perforator Flap for Ischial Pressure Sores not skeletonized. A distal deepithelialized triangular por-
Sir: tion was needed to obliterate the debrided cavity. Donor

I schial pressure sores have been a significant problem

for the reconstructive surgeon. Despite various flap
alternatives, the rate of recurrence is high.1 Muscle and
sites were skin grafted in five cases. The patients were
followed up for a mean period of 42 months.
Healing was uneventful in all cases, and no compli-
musculocutaneous flaps remain the most preferred cations were encountered. Recurrence was seen in
and reliable options.2 Introduction of perforator flaps two patients 30 and 49 months after the procedure.
to the reconstructive surgeon’s choice of techniques A grade IV sacral pressure sore was also noted in one
patient (Fig. 1, left). The hamstring muscle flap with
a skin graft for the ischial defect and a gluteus maxi-
Table 1. Patient Data mus musculocutaneous flap for the sacral defect were
used concomitantly. No recurrence was noted after
Ulcer Follow-Up
Patient Sex Age Location Recurrence (mo)
an 8-month follow-up period (Fig. 1, right). In the
other patient, the recurrence was bilateral, grade IV
1 M 42 Right No 55 on the left and grade I on the right side. Recon-
2 M 41 Bilateral Yes 51
3 M 53 Left No 50 struction was achieved with reelevation and read-
4 F 38 Right No 39 vancement of the flap on the left side. Healing was
5 M 37 Right Yes 38 uneventful in the early period.
6 F 24 Left No 23 Ischial repair differs from the others (sacral and
M, male; F, female. trochanteric) by means of two pitfalls: higher pressure

Fig. 1. Patient 5. (Left) Recurrence with an additional sacral ulcer. (Right) Eight-month
postoperative view after reconstruction with additional flap options.

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 Plastic and Reconstructive Surgery • July 2008

over the ischial area during the sitting posture and Educating Students about Plastic Surgery:
tension exerted across it with different leg positions. A Program for Grade School Outreach
The gluteus maximus musculocutaneous flap pro-
vides sufficient bulk and can be designed in various Sir:
forms based on superior and/or inferior gluteal
vessels.4 However, the procedure is invasive and the
effort to spare the perforators for future flap options
A s plastic surgeons, we recognize that the public’s
perception of our specialty is limited to the idea
that we are primarily cosmetic surgeons, with reconstruc-
may further complicate it. Perforator fasciocutane- tive surgery being considered an afterthought.1 The im-
ous flaps from the gluteal region5 have been good pression of the layperson is that plastic surgeons prey on
alternatives for ischial sores and for other locations, the desires of insecure people who are trying to “nip and
although long-term outcome data are not yet avail- tuck” their way to eternal youth. The popular media do
able. We tend to preserve the gluteal region for fu- little to dissuade the public from these misconceptions.
ture flap options, which was the case in patient 5. Television programs such as “Nip/Tuck,” MTV’s “I Want
Although lacking bulk, posterior thigh skin, which a Famous Face,” and “Dr. 90210” reinforce the negative
can be transferred based on several different vascular bias people have toward plastic surgery. The problem
sources, provides abundant tissue for coverage of plastic surgeons have is the relative glut of cosmetic sur-
ischial defects. Considering the inevitable recur- gery coverage associated with the specialty and the paucity
rence, the aim should be to lengthen the sore-free of reconstructive surgery exposure.
survival in these patients. The versatility in flap de- With this in mind, a program was developed to teach
sign, the long-term durability, the possibility of read- children about plastic surgery. Schoolchildren repre-
vancing the flap, and the sparing of other potential sent an impressionable population that is enthusiastic
flaps for future reconstruction constitute the major and enjoys learning. To design the program, several
benefits of the adductor perforator flap for recon- educational resources were used. The first was the Plas-
struction of ischial pressure sores. tic Surgery Education Campaign from the American
DOI: 10.1097/PRS.0b013e31817746b6 Society of Plastic Surgeons. The next was a local pro-
Gozu Aydin, M.D. gram through the Medical College of Wisconsin that
provides science education to area schoolchildren. Fi-
Kul Zekeriya, M.D. nally, two plastic surgery faculty heavily involved in
Ozsoy Zafer, M.D. plastic surgery education (Drs. David L. Larson and
Vakif Gureba Research and Education Hospital Michael L. Bentz) were consulted.
Plastic and Reconstructive Surgery Department The program was delivered to a local fifth grade class
Istanbul, Turkey in Elm Grove, Wisconsin (Fig. 1). The objectives of the
Presented in part at the 24th Annual Congress of the presentation were as follows: to expose the children to the
Turkish Society of Plastic, Reconstructive and reconstructive aspect of plastic surgery and to introduce
Aesthetic Surgeons, in Ankara, Turkey, surgical principles. After the presentation, a question-
October 18 through 20, 2002. naire was used to assess the students’ learning.
Correspondence to Dr. Gozu
The presentation was opened with a PowerPoint (Mi-
Sakacı sok., Inmak sit. crosoft Corp., Redmond, Wash.) presentation of several pa-
Sena ap., D:5 tients. Throughout the PowerPoint presentation, it was
Kozyatagı mah. stressed that plastic surgeons “take something that is not
34742 Istanbul, Turkey normal and make it normal.” They do this by “taking skin
aydinseye@yahoo.com from an area of the body where it is available and transferring
it to an area of the body where it is needed.” The cases were
a patient with a cleft lip, another with a large hairy nevus, and
REFERENCES a third with radiation damage after cancer treatment, with
1. Rimareix, F., and Lortat-Jacop, A. Comparative study of 2 the subsequent reconstructions in each case.
surgical techniques in the treatment of ischial pressure ulcers After the PowerPoint demonstration, a surgical ac-
in paraplegic patients: Retrospective study of 90 cases. Ann. tivity involving the students changing into scrub ap-
Chir. Plast. Esthet. 45: 589, 2000. parel and repairing incisions in bananas using surgical
2. Foster, R. D., Anthony, J. P., Mathes, S. J., and Hoffman, W. staplers completed the hour-long program.
Y. Ischial pressure sore coverage: A rationale for flap selection. After the activity, a questionnaire was distributed to
Br. J. Plast. Surg. 50: 374, 1997. identify information learned. All of the students en-
3. Angrigiani, C., Grilli, D., and Thorne, C. H. The adductor flap: joyed the program. The two most popular answers for
A new method for transferring posterior and medial thigh
what they learned about plastic surgery were that (1)
skin. Plast. Reconstr. Surg. 107: 1725, 2001.
plastic surgery does not have anything to do with plastic
4. Scheflan, M., Nahai, F., and Bostwick, J., III. Gluteus maximus
island musculocutaneous flap for closure of sacral and ischial
and (2) plastic surgery involves moving skin from one
ulcers. Plast. Reconstr. Surg. 68: 533, 1981. area of the body to another.
5. Coskunfırat, O. K., and Ozgentas, H. E. Gluteal perforator We believe this program is effective on several fronts.
flaps for coverage of pressure sores at various locations. Plast. First, it is an easy and effective educational tool plastic
Reconstr. Surg. 113: 2012, 2004. surgeons can use to reach the youngest generation. Sec-

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Volume 122, Number 1 • Viewpoints

Fig. 1. Mrs. Rebecca Larson’s fifth grade class, Heritage Christian Elemen-
tary School, Elm Grove, Wisconsin.

ond, it is an excellent outreach tool for medical students and scudded across the operating room floor. I mused
interested in plastic surgery. Finally, and most impor- Prufrockian:
tantly, we believe it represents a much needed means of
positive exposure for this proud surgical specialty. Let us go then, you, and I
DOI: 10.1097/PRS.0b013e3181774694 When the evening is spread out against the sky
Jeffrey D. Larson, M.D. Like a patient etherized upon a table.
Division of Plastic Surgery
University of Wisconsin This patient, an introverted young man, now lay
David L. Larson, M.D. under general anesthesia surrounded by a team
Department of Plastic Surgery composed of skilled oral and maxillofacial surgeons,
Medical College of Wisconsin anesthesiologists, and scrub technicians, all of whose
Milwaukee actions were orchestrated by the lead surgeon. As
Michael L. Bentz, M.D. remarkable as is the team members’ planning, co-
Division of Plastic Surgery operation, and unspoken communication, the re-
University of Wisconsin sults wrought by the lead surgeon are even more so:
Madison, Wis. he sculpts—artistically reminiscent of Ghiberti—the
Correspondence to Dr. Larson graft taken from the boy’s hip and incorporates it
Division of Plastic Surgery, G5/361 into his hemifacial microsomia. Observing this use of
Department of Surgery human bone and tissue as artistic media, despite the
University of Wisconsin Hospitals
600 Highland Avenue
healing process yet to come, I was awed at the pa-
Madison, Wis. 53792 tient’s physical transformation.
jd.larson@hosp.wisc.edu Months earlier, I was privileged to sit in on the
consultation of this patient, who hoped some med-
ical procedure could transform his life by improving
REFERENCE
his appearance. Innately shy, he had affected a dis-
1. Rosen, C. The democratization of beauty. New Atlantis Spring:
interest in social interactions. His life’s aspirations
19, 2004.
were not unreasonable: he did not aspire for per-
fection; he aspired for completeness. Completeness,
Psychosocial Changes Realized in not only in the sense of correcting his facial defor-
Reconstructive Surgery Patients as a Motivator mity, but also, as I later realized, a psychosocial com-
for the Next Generation of Plastic and pleteness that allowed him to participate normally in
Reconstructive Surgeons society for the first time. I witnessed his physical
Sir: transformation from preoperatively to postopera-
tively. Although his transformation epitomizes the
W hile perched on a stainless steel stool above the
multispecialty surgical team I was observing, a
shard of bone ricocheted off my protective face mask
restorative nature of medicine, it was unique among
the more than 70 operations I have shadowed for its

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 Plastic and Reconstructive Surgery • July 2008

ensuing, and for me, more importantly, psychosocial life; my every thought—the first when I awake and
transformations. In his subsequent postoperative vis- the last before sleep. Why? There are too many
its, I observed his transformation from a perennially reasons to fit here, but mainly because I want to
sad and socially awkward adolescent to one imbued live forever. Not for self-aggrandizement: I could
with a newfound happiness and confidence. care less if my name was forgotten, but my life must
His transformation precipitated a sea change have meaning emanating from dedication to med-
in me, too. Whereas, for him, the surgical proce- icine in which I touch and enrich others’ lives by
dure culminated his life’s aspirations over a period ameliorating their suffering.
of several months; for me, his operation gave a new So, as the patient’s psyche evolved, so did I.
perspective to my lifelong desire to enter medi- Although I had always wanted to be a surgeon, my
cine–-a life whose earliest memories, from age 2½, motivations evolved with my ever-changing expe-
when my parents enrolled me in the Suzuki violin riences. For years since I observed the masterful
program, involved admiration for my violin part- plastic surgeon perform that hemifacial microso-
ner’s parents, who were doctors. On many occa- mia, I have felt my calling has been in reconstruc-
sions, I remember standing alone on stage in front tive surgery. I am less interested in the aesthetic
of hundreds of strangers. In later years, I remem- aspects of plastics than in its life-altering aspects,
ber arriving only moments before from a soccer where the surgeon’s masterful hands blend pro-
game (in which we “played up” against older, cedure with artistry, producing dramatic psycho-
stronger kids to prepare us for the challenges of logical improvement but also improvement in pa-
our regular league competition; those kids did not tients’ everyday quality of life.
want to be shown up and usually brutalized us). I DOI: 10.1097/PRS.0b013e3181774661
used wet washcloths in the car to remove mud Charles Stalnaker Brown, B.S.
before I put on a suit for my violin recital. The University of Louisville
recital program would read: “Charlie Brown will Louisville, Ky. 40292
be playing Vivaldi’s Concerto in A Minor” (aside: csbrow02@gmail.com
one can imagine how the name “Charlie Brown”
may have contributed to my ability to be comfort-
able in any situation). As I grew and moved beyond A Simple and Safe Method of Ruling Out
the Red Priest’s music, so too had my reasons for Pulmonary Embolism in Postoperative Plastic
wanting to become a doctor, all of which were Surgery Patients
enhanced by my love for learning: after all, I am Sir:
the son of self-made parents, a librarian and a
middle school teacher. Learning at my grade
school was hell: of 30 students, two committed
P ulmonary embolism is one of the most feared com-
plications of plastic surgery, and as authors have
stated, preventive measures are the best way to mini-
murders and several committed suicide. I learned mize this potentially fatal complication. However, even
no math in grade school and could not even find with all the possible prophylactic measures, pulmonary
pi on the unit circle when I entered college embolism may be unavoidable and necessitates prompt
diagnosis and aggressive treatment. A plastic surgeon is
(through my own efforts, I now am at the top of
usually not the one who treats the pulmonary embo-
my class). These and other experiences molded lism, but he or she should be the one who diagnoses it
me into a compassionate individual who is com- first to get appropriate help in a timely manner to
fortable with people of any ethnicity and socio- prevent a deadly outcome. In this communication, we
economic status. My father worked 16-hour days share a simple, noninvasive, bedside algorithm that we
every day for years, when I was young: then, I did have been using in our clinical practice to diagnose
not know how he did it, but I knew why he did it: pulmonary embolism in postoperative plastic surgery
he did it for me. He wanted me to have better patients.
opportunities than he had had. Now, I also know The diagnosis of pulmonary embolism is challenging
how he did it: out of love. This is the same passion in the postoperative period. If it is unrecognized or left
I have for medicine, the pursuit of which explains untreated, it may result in a mortality rate as high as 30
percent in hospitalized patients; this rate can be de-
why I have faded from my friends’ photographs,
creased to 8 percent with early diagnosis and proper
which were once full of me. My life is no longer treatment.1,2 Thus, it is imperative to establish a bedside
about me: that is why I study and work in the diagnostic algorithm to diagnose and treat this deadly
laboratory for hours and return home to study complication.
more, while my friends socialize. Everyone I meet Wells et al. established a simplified clinical scoring
is astounded by my work ethic, which is simple to model,3 which was derived from their original study,4 to
me: as I toil for many, he toiled for me. This is my eliminate some of the disadvantages of the complex

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Volume 122, Number 1 • Viewpoints

Table 1. Simplified Clinical Scoring Model for determined by the institution policy, availability, and
Diagnosis of Pulmonary Embolism* physician’s preference.
The simplified clinical scoring system (Table 1)
Score†
and blood D-dimer levels are readily available, can be
Clinical signs and symptoms of DVT performed at the bedside, and can safely exclude the
(minimum of leg swelling and pain with pulmonary embolism when both are negative. If ei-
palpation of the deep veins) 3 ther one is positive, more sensitive and specific di-
An alternative diagnosis is less likely than PE 3
Heart rate ⬎100 beats/min 1.5 agnostic modalities, such as spiral computed tomog-
Immobilization or surgery in the previous 4 raphy and nuclear scanning, should be considered
weeks 1.5 to rule in or rule out the diagnosis of pulmonary
Previous DVT/PE 1.5 embolism.
Hemoptysis 1 DOI: 10.1097/PRS.0b013e3181774756
Malignancy (on treatment, treated in the last
6 months, or palliative) 1 Adil Ceydeli, M.D., M.S.
PE, pulmonary embolism; DVT, deep venous thrombosis. Jack Yu, M.D., D.M.D., M.S.
*Data from Wells, P. S., Anderson, D. R., Rodger, M., et al. Derivation Division of Plastic and Reconstructive Surgery
of a simple clinical model to categorize patients’ probability of pul-
Medical College of Georgia
monary embolism: Increasing the models utility with the SimpliRED
D-dimer. Thromb. Haemost. 83: 416, 2000. Atlanta, Ga.
†Pulmonary embolism unlikely, ⱕ4 points; pulmonary embolism Correspondence to Dr. Ceydeli
likely, ⬎4 points.
Division of Plastic and Reconstructive Surgery
Medical College of Georgia
1467 Harper Street, HB-5040
Augusta, Ga. 30912
adilc@excite.com
scoring systems. In their simplified model, they gave
points to various clinical signs, symptoms, and risk fac-
tors, and categorized the patients into two groups: pul- REFERENCES
monary embolism unlikely and pulmonary embolism
1. Young, V. L., and Watson, M. E. The need for venous throm-
likely (Table 1). This is a relatively simple scoring sys-
boembolism (VTE) prophylaxis in plastic surgery. Aesthetic
tem that can be applied at the bedside to any patient
Surg. J. 26: 157, 2006.
with suspected pulmonary embolism. This simplified 2. Carson, J. L., Kelley, M. A., Duff, A., et al. The clinical course
model is particularly helpful when combined with D- of pulmonary embolism. N. Engl. J. Med. 326: 1240, 1992.
dimer blood levels of patients with suspected pulmo- 3. Wells, P. S., Anderson, D. R., Rodger, M., et al. Derivation of
nary embolism. a simple clinical model to categorize patients’ probability of
D-dimer is a degradation product of a cross-linked pulmonary embolism: Increasing the models utility with the
fibrin blood clot. The elevated D-dimer levels are typ- SimpliRED D-dimer. Thromb. Haemost. 83: 416, 2000.
ically seen with acute venous thromboembolism, but it 4. Wells, P. S., Gingsberg, J. S., Anderson, D. R., et al. Use of a
is not a specific test, because elevated levels may also be clinical model for safe management of patients with suspected
seen with recent surgery, malignancy, pregnancy, in- pulmonary embolism. Ann. Intern. Med. 129: 997, 1998.
fections, and in the older population. 5. Kline, J. A., Nelson, R. D., Jackson, R. E., et al. Criteria for the
A pulmonary-embolism-unlikely result from the sim- safe use of D-dimer testing in emergency department patients
plified clinical scoring model (Table 1) and a negative with suspected pulmonary embolism: A multicenter United
D-dimer value can safely exclude the diagnosis of pul- States study. Ann. Emerg. Med. 39: 144, 2002.
monary embolism without the need for further diag-
nostic studies with a 2 percent false-negative rate, which
is similar to standard pulmonary angiography.5 This
approach is particularly helpful in free flap patients,
because transport of these patients to nuclear medicine Nonsurgical Delay of Dorsal Rat Cutaneous
or computed tomography suites is cumbersome, and Flap Using Botulinum Toxin Type A
when both simplified clinical scoring and D-dimer lev- Sir:
els are negative, an unnecessary and potentially dan-
gerous trip may be avoided.
If pulmonary embolism is likely based on the sim-
W e aimed to investigate nonsurgical delay by using
botulinum toxin type A (Botox; Allergan Phar-
maceuticals, Westport, Ireland) in skin flaps. Twenty
plified clinical scoring system and/or the D-dimer Wistar rats were divided into two equal groups: a con-
level is positive, further diagnostic studies are usually trol group and a nonsurgical delay group.
needed to rule in or rule out the diagnosis of pulmo- On the distal half of the possible flap-raising area,
nary embolism. The most commonly used diagnostic eight points were marked as injection points (Fig. 1).
studies are spiral computed tomography and ventila- Botox was diluted with 4 ml of saline, which yields a
tion-perfusion nuclear scanning. Both studies have ad- solution with 2.5 IU of toxin per 0.1 ml. A dose of 1
vantages and disadvantages, and either one is accept- IU/kg was administered intradermally at each point
able as a first-line diagnostic study, which is usually marked. The total dose was 8 IU/kg for each rat

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 Plastic and Reconstructive Surgery • July 2008

Fig. 1. Eight injection points in the distal half of the rat dorsal flap.

in the delay group. No injection was given to the ther experimental investigations are needed to explore
control group. the pathophysiology and mechanism in detail.
Two weeks after injection, dorsal, random-pattern, 7 ⫻ DOI: 10.1097/PRS.0b013e3181774745
2-cm, cranial-based flaps that contained panniculus Alpagan M. Yildirim, M.D.
carnosus were elevated and sutured. One week after Ihsan Okur, M.D.
flap surgery, viable flap areas were calculated. Means ⫾ Zübeyir Örter, M.D.
SD were derived from these data. Department of Plastic and Reconstructive Surgery
Statistical significance was defined as p ⬍ 0.05. The School of Medicine
t test and analysis of variance test were used. Firat University
For the control group, the mean viable flap area Elazig
was 62.95 ⫾ 3.37 percent. One rat in the control Ata Uysal, M.D.
group died and was excluded from the study. For the ONEP
nonsurgical delay group, the mean viable flap area Istanbul, Turkey
was found to be 95.93 ⫾ 2.67 percent. Two rats from Presented at the 27th Annual Congress of the Turkish
this group died during anesthesia and were excluded Society of Plastic Surgery, in Konya, Turkey, 2005.
from the study. The difference between the viable
areas of the two groups was statistically significant (p Correspondence to Dr. Yildirim
⬍ 0.05). Flap delay with Botox may be useful for the Firat Universitesi Tıp Fakültesi
Plastik Cerrahi
survival of skin flaps because it is easy to administer Elazig, Turkey
in one session. alpagan@gmail.com
In our experimental investigation, surgical delay ac-
complished by means of Botox injections increased flap
viability, and this was statistically significant (p ⬍ 0.05). ACKNOWLEDGMENT
Botox-induced delay of skin flaps seems to be practical, This study was funded by Firat University Scientific
and it is possible to use it in clinical applications. Fur- Research Projects.

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