A Prospective Controlled Assessment Of.72 PDF

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standard lipectomy procedures to avoid visual loss.

We would like to stress this issue and also direct the
attention of the readers to the potential complication
of blindness as a consequence of steroid injection
into the eyelids.
Because the great majority of reported cases of visual
impairment related to blepharoplasty result from either injecting the fat compartments or applying traction on the fat during eyelid lipectomy, it follows that
the approach that would minimize or perhaps eliminate visual loss related to these causes consists of avoiding injection or traction of the intraorbital fat. The only
technique currently available that fulfills these criteria
is the use of fat-preserving techniques as described by
Sachs and Bosniak in 1986, de la Plaza in 1988, Mendelson in 1993, Camirand in 1997, and by us in 19982
and 2008.3
The concept of fat preservation is based on the
observation that intraorbital fat is an important component of an attractive appearance and therefore
should not be viewed as excessive, but as fatty hernia
that should be corrected by repositioning it to its
Viewpoints
Visual Impairment after Blepharoplasty and
after Depot Steroid Injection
Sir:
he complication that plastic surgeons and patients

dread the most following blepharoplasty is visual
impairment. Lelli and Lisman highlight the seriousness of this complication in their well-composed review article entitled Blepharoplasty Complications
in a recent issue of this Journal.1 The authors document that the final common pathway involves continued orbital bleeding leading to increased intraorbital and intraocular pressure, with resultant
ischemic damage to the retina and/or optic nerve,
and stress the importance of intraoperative control
of hemostasis and avoidance of excessive traction
during fat excision to avoid visual impairment.1 However, the authors are remiss in not discussing fatpreserving blepharoplasty as a viable alternative to
Copyright 2011 by the American Society of Plastic Surgeons
136e
Fig. 1. (Above) Intraoperative photograph shows the fatty hernia of the left lower eyelid before repair. (Below) The same lower
eyelid is shown after repair of the fatty hernia with approximation
of the capsulopalpebral fascia and the arcus marginalis with interrupted 5-0 monofilament sutures.
www.PRSJournal.com
Volume 127, Number 6 Viewpoints

original compartments.13 Correction of the lower
eyelid fatty hernia consists of repairing the weakened
supporting structures by approximating the capsulopalpebral fascia to the arcus marginalis as shown in
Figure 1, and correction of the upper eyelids consists
of plicating the attenuated orbital septum to the
superior orbital rim.4 The effectiveness of these techniques has been well documented in both short-term
and long-term follow-up studies by us and by many
other authors.2,3
Intralesional steroid injection into the eyelids also
deserves mention as a potential cause of visual impairment and blindness2 because many plastic surgeons commonly use such injections in the management of various conditions affecting the eyelids. The
resulting visual impairment after depot steroid injection is often permanent and is theorized to be
caused by retinal vascular infarction.5 The most commonly proposed mechanism for vascular occlusion
and visual impairment or blindness after such injections is felt to be intraarterial entry of the depot
steroid and its retrograde flow from excessive force
of injection. Another theorized possibility is the injection of steroids through vascular abnormalities
that may exist from previous blepharoplasties.5 This
serious complication should prompt immediate
ophthalmoscopic fundus examination to allow early
recognition of ischemic signs and immediate intervention.
DOI: 10.1097/PRS.0b013e3182131e88
Alan Ali Parsa, M.D.

Daniel Murariu, M.D.
Shannon M. Koehler, M.D.
Presper Daher, M.D.
Fereydoun Don Parsa, M.D.
John A. Burns School of Medicine
University of Hawaii
Honolulu, Hawaii
Correspondence to Dr. Parsa
Department of Surgery
John A. Burns School of Medicine
University of Hawaii
Honolulu, Hawaii 96813-2421
REFERENCES
1. Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast
Reconstr Surg. 2010;125:10071017.
2. Parsa FD, Miyashiro MJ, Elahi E, Mirzai TM. Lower eyelid
hernia repair for palpebral bags: A comparative study. Plast
Reconstr Surg. 1998;102:24592465.
3. Parsa AA, Lye KD, Radcliffe N, Parsa FD. Lower blepharoplasty
with capsulopalpebral fascia hernia repair for palpebral bags:
A long-term prospective study. Plast Reconstr Surg. 2008;121:
13871397.
4. Muhlbauer W, Holm C. Orbital septorrhaphy for the correction of baggy upper and lower eyelids. Aesthetic Plast Surg.
2000;24:418423.
5. Yagci A, Palamar M, Egrilmez S, Sahbazov C, Ozbek SS. Anterior segment ischemia and retinochoroidal vascular occlu-
sion after intralesional steroid injection. Ophthal Plast Reconstr

Surg. 2008;24:5557.
Lower Blepharoplasty with Orbital Septum

Reconstruction Using Upper Blepharoplasty
Excision Material
Sir:
rominent eyelid fat pads are a common problem

addressed by the oculoplastic surgeon. The eyelid fat pads become prominent as the orbital septum
thins and loosens with time and becomes a less effective barrier against the anterior prolapse of orbital
fat or fat pads.1
Cook et al. applied light electrocautery to the orbital
septum, causing it to shrink and tighten. Therefore, the
orbital septum became a more effective barrier against
the anterior prolapse of orbital fat, and the fat pads
receded. Bisaccia et al. described a similar technique in
the treatment of lower eyelid fat pads.2,3
In the past decade, in particular, various new techniques and technologies have emerged, altering our
ability to treat the lower eyelids. These techniques
include transconjunctival blepharoplasty, a variety of
canthopexy procedures, fat-conserving or fat-replacing methods, wedge excision, and laser resurfacing
techniques, and they allow a more individualized
approach based on variations in anatomical features
and patient goals.4 De la Plaza and Arroyo treated the
septum like a hernia repair.5
A different approach to correct flattening associated with aging in the preseptal portion was previously suggested by Lewis. In patients with blepharoplasty, the lower eyelid was elevated just anterior to
the tarsal plate as much as to cover the tarsal plate
completely without removing the orbicularis oculi
muscle segment.6
In the present study, we performed reconstruction of
the lower eyelid septum by using the excision material
during upper lid blepharoplasty and strengthened the
pretarsal portion. Thus, we achieved construction of a
wall that can be resistant to fat pad herniation.
Fourteen female patients were evaluated for lower
and upper blepharoplasty surgery. Preoperative
planning was performed before the patient was anesthetized for the operation. An upper blepharoplasty
procedure was carried out first under general anesthesia. Orbicularis oculi muscle was also elevated
following deepithelialization of the upper eyelid
(Fig. 1). After suturing the upper eyelid, access to the
lower eyelid was gained through a subciliary incision
and we descended to the inferior rim over the septum. Then, the orbicularis oculi muscle, obtained as
a graft, was stretched to cover one-half of the inferior
tarsal muscle and the whole orbital septum. Medial
and lateral inferior borders, just below the canthal
ligaments, were sutured to the rim inferior to the
periosteum (Fig. 2). The superior border was left
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Plastic and Reconstructive Surgery June 2011
Fig. 1. (Above, left) Preoperative planning. (Above, right) Deepithelialization of the upper eyelid.
(Below) The excised isolated orbicularis oculi muscle.
Fig. 2. (Above, left) Looseness of the septum and fat pad herniation in the lower eyelid. (Above, right) The stage
of inferior rim determination of the orbicularis oculi muscle graft. (Below, left) Adaptation of the orbicularis
oculi muscle on the herniated fat pad. (Below, right) Completely determined stage of the orbicularis oculi
muscle graft.
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Fig. 3. Patient 1 preoperatively (above) and 1 year postoperatively (below).
Fig. 4. Patient 2 preoperatively (above) and 1 year postoperatively (below).
unsutured to prevent the risk of ectropion. The remaining muscle graft was flapped according to the
defect size to develop a pad in patients with tear
trough deformity and the region of the sulcus was
dissected subperiosteally and fixed in the canal. Afterward, the excess material of the elevated musculocutaneous lower eyelid flap was excised and
adapted to its anatomical location.
Our results appear completely homogeneous and
natural and avoid the obviously-operated-on appearance. It is natural and youthful to have fat in the
eyelids; therefore, septo-orbitoperiosteoplasty more
naturally reverses the aging process of the eyelids
(Figs. 3 and 4).
In conclusion, it is an acceptable opinion that
prominent lower eyelid prolapse and fat pads are
caused not by excess fat but by herniation related to
the weakness of the anterior septum. To construct
the orbital septum, orbicularis oculi muscle, the excision material of upper blepharoplasty, was extended in front of the septum to support the septum
strongly. At the same time, in the presence of sufficient material, a subperiosteal pocket is generated
and muscle graft is folded and can be located in this
region for performing tear trough deformity correc-
tion. We assessed the cases of both applications after

1 year. We observed that our results were satisfactory.
Neither herniation nor recurrence was observed in
the lower fat pad.
DOI: 10.1097/PRS.0b013e318213b749
Ozan Balik, M.D.

Estetech Beauty Clinic
Plastic, Reconstructive, and Aesthetic Surgery Department
Plastic, Reconstructive, and Aesthetic Surgery
Besiktas, Istanbul 34335, Turkey
REFERENCES
1. Mendelson BC. Herniated fat and the orbital septum of the
lower eyelid. Clin Plast Surg. 1993;20:323330.
2. Cook TA, Derebery J, Harrah ER. Reconsideration of fat pad
management in lower eyelid blepharoplasty surgery. Arch Otolaryngol. 1984;110:521524.
3. Bisaccia E, Scarborough DA, Swensen RD. A technique for
blepharoplasty without incising or puncturing orbital septum. J Dermatol Surg Oncol. 1990;16:360363.
4. Spira M. Lower blepharoplasty: A clinical study. Plast Reconstr
Surg. 1977;59:3538.
5. de la Plaza R, Arroyo JM. A new technique for the treatment
of palpebral bags. Plast Reconstr Surg. 1988;81:677687.
6. Lewis JM. Augmentation blepharoplasty. Ann Plast Surg. 1988;
21:434438.
139e

The Question Mark Ear Deformity and Its
Surgical Repair
Sir:
he question mark ear is a severe malformation involving a cleft between the helix and the earlobe. It
is usually accompanied by protrusion of the upper third
of the ear and unfurling of its antihelix.
This malformation was first reported by Vincent et
al.1 in 1961. Subsequently, Cosman et al.2,3 reported two
cases and named the deformity the question mark deformity. We designed and performed a new technique
that is very simple and effective for the treatment of this
deformity: a surgical plan to correct both the cleft and
the protrusion of the upper ear (Fig. 1). A skin flap was
designed on the postauricular fold based inferiorly.
One end of the base of the flap was connected to an
incision on the posterior surface of the ear extended
upward, parallel and close to the edge of the ear crossing the cleft area to reach the upper limit of the defect.
The postauricular skin flap was raised and the incision
on the posterior surface of the ear parallel and close to
the edge of the ear was performed. Undermining of the
edges of the incision created a defect to be filled with
the postauricular skin flap. Through the wound, expo-
sure of the antihelical fold was performed (facilitated

by multiple needles inserted through the anterior surface of the ear along the antihelical fold). The amount
of the cartilage graft needed to replace the missing
cartilage at the cleft site was marked on the antihelical
fold as an ellipse. The cartilage with its perichondrium
on one side was taken as a graft. This created a prominent antihelical fold on pushing the ear backward,
which is essential for correction of the protruding ear.
The skin flap was then rotated toward the defect created by the incision along the edge of the ear. The flap
was adjusted to be bulkier at the cleft site. The skin flap
was then sutured in place, correcting the deficiency of
tissue at the cleft site. The cartilage graft was then
passed through the skin flap and sutured inside. This
created continuity between the upper and the lower
halves of the ear. The donor area of the skin was closed
primarily, helping to create the antihelical fold and
contributing to correction of the prominent upper half
of the ear. This created a normal appearing ear without
any decrease in its dimensions.
The numbers of corrective surgical procedures are
very limited in the literature. These include closing of
the cleft with Z-plasty, the V-Y technique, and rotation
Fig. 1. (Above, left) Design of the amount of skin and cartilage needed to be added (shaded
area) to correct the deformity. (Above, right) Design of the skin flap on the posterior side of the
ear. An incision near and parallel to the edge of the ear is made to receive the flap. (Below, left)
The skin flap is raised. The lateral incision is opened to create a recipient site for the skin graft.
A cartilage graft is taken from the antihelix to help restore a prominent antihelix edge. (Below,
right) Final posterior appearance after skin flap inset and the cartilage graft inside it and
primary donor-site closure correcting the protruding upper ear.
140e

advancement flaps.2,4 These techniques result in a decrease in the size of the auricle. That is why they were
recommended for bilateral deformity to prevent discrepancy of the ears. Vayvada et al.5 correct the deformity by using a skin flap based on the cleft on the
posterior side of the ear and an ipsilateral conchal
cartilage graft inserted in the cleft area and covered
with the skin graft after scoring of the anterior surface
of the antihelix.
The technique corrects the cleft and the prominence of the upper helix in the same procedure. However, the authors noticed that the definition of the
antihelical fold was not adequate. The rotational advancement flaps and local flaps from the posterior surface of the ear4,5 may correct the cleft but not the upper
ear prominence. The authors rotation chondrocutaneous flap6 could have been used, but a simpler method
of separate skin flap and cartilage graft was preferred.
This technique has the following advantages:
1. It is fast and easy.
2. The donor site can be easily closed primarily.
3. The resulting scar can be hidden easily behind
the ear.
4. Closing the donor site helps to correct the protruding ear, avoiding a second-stage operation.
5. Taking the cartilage graft from the antihelical
fold helps to create more definition for the fold
and correction of the protruding ear.
6. It can be used for both unilateral and bilateral
ear deformities, because it does not affect the size
of the ear.
DOI: 10.1097/PRS.0b013e3182131e4c
Nabil I. Elsahy, F.R.A.C.S., F.A.C.S.
Temporalis Fascia for Lip Augmentation

Sir:
he pervasiveness of the beauty of lips persists today,

with U.S. women spending almost $2.9 billion annually on cosmetics and lip products. Various surgical approaches and methods have been used in lip augmentation, including heterologous materials and autologous
tissue. We reviewed the charts of seven patients who underwent temporalis muscle fascia lip augmentation to
anecdotally evaluate the temporalis muscle fascia as a safe
and effective means of lip augmentation.
The scalp is incised and the superficial temporal fascia is
split, exposing the deep temporal fascia. The fascia is separated from the temporalis muscle and easily harvested.
Then, 1% lidocaine with epinephrine is injected into the
oral commissures bilaterally to provide vasoconstriction. A
long tenotomy scissors is used to dissect in the plane between
the orbicularis muscle and the mucosa of the lip to create a
tunnel to accept the temporalis fascia graft.
The temporalis fascia graft is then either stacked or
rolled to the appropriate cord needed to augment the
lip. Once the temporalis fascia graft is made to size, a
tendon passer is inserted into one oral commissure and
brought out the contralateral side (Fig. 1). The temporalis fascia graft is grasped and drawn through the
tunnel that was created. The oral commissure incisions
are then closed with a 4-0 chromic suture.
Seven patients underwent lip augmentation surgery
with temporalis fascia and had an average follow-up of 5
years. All patients who underwent lip augmentation were
women. The average age of the patients was 47 years
(range, 36 to 67 years). All patients were very satisfied with
the results of their surgical lip augmentation postoperatively, and no patients required any revision operations.
2 Rd 18 Maadi
Cairo, Egypt
elsahyplasticsurgery@gmail.com
DISCLOSURE
The author has no financial interest to declare in relation
to the content of this article.
REFERENCES
1. Vincent RW, Ryan RF, Longenecker CG. Malformation of ear
associated with urogenital anomalies. Plast Reconstr Surg Transplant Bull. 1961;28:214220.
2. Cosman B, Bellin H, Crikelair GF. The question mark ear. Plast
Reconstr Surg. 1970;46:454457.
3. Cosman B. The question mark ear: An unappreciated major
anomaly of the auricle. Plast Reconstr Surg. 1984;73:572576.
4. Al-Qattan MM. Cosman (question mark) ear: Congenital auricular cleft between the fifth and sixth hillocks. Plast Reconstr
Surg. 1998;102:439441.
5. Vayvada H, Karaca C, Menderes A, Yilmaz M. Question mark
ear deformity and a modified surgical correction method: A
case report. Aesthetic Plast Surg. 2005;29:251254; discussion
255.
6. Elsahy NI. Reconstruction of the ear after skin and perichondrium loss. Clin Plast Surg. 2002;29:187200.
Fig. 1. Temporalis fascia is either splayed out, rolled, stacked, or

contoured appropriately to augment the area of the lip requiring
fill. A tendon passer is inserted after a dissection plane is made
with tenotomy scissors between the mucosa of the lip and the
orbicularis oris. Once the tendon passer is placed in the appropriate position, the temporalis fascia graft is pulled through to be
appropriately placed in the dissection plane.
141e
Fig. 2. (Above) A 34-year-old woman is shown after augmentation of the upper and lower lips with temporalis fascia grafts. The
grafts remain supple and retain their augmentation at 1 year. (Below) A 28-year-old woman is shown after augmentation of the
upper and lower lips with temporalis fascia grafts. The grafts remain supple and retain their augmentation at 1 year.
There was only one minor complication related to the

temporalis fascia harvest site, where one woman developed a hypertrophic scar postoperatively that resolved.
Representative before-and-after photographs are shown
in Figure 2.
The ideal augmentation material requires certain qualities. In addition to providing consistently reproducible
results, it needs to be biocompatible, nontoxic and inert,
easy to use, and inexpensive. It should have a natural feel,
be customizable to each individual patient, and be easily
removable in the event of complication or patient dissatisfaction. Collagen and hyaluronic acid derivatives are
biological materials that are subject to degradation by the
body, and their effects last approximately 6 months before
reinjection is required.
Autologous substances have the benefit of a low risk for
infection and tissue reaction. Temporalis fascia for
lip augmentation represents a relatively underused
material.1 In our experience, temporalis fascia is a
durable and cosmetically superior option for lip augmentation. Patients reported 100 percent satisfaction, and there were no incidences of infection. Fullness was maintained at a follow-up of greater than 1
year without loss of augmentation.
142e
The senior author has had extensive experience with

reconstruction of the lower lip.2,3 Although soft-tissue defects
necessitate replacement with like tissue, the senior author
has found temporalis fascia to be reliable in the reconstructive patient and translatable to the cosmetic patient. In our
experience, lip augmentation with temporalis muscle fascia
during concurrent face-lift surgery represents a durable and
optimal option for lip augmentation, with no donor-site
morbidity and excellent patient satisfaction.
DOI: 10.1097/PRS.0b013e3182131de2
Brian P. Dickinson, M.D.

The Roxbury Clinic and Surgery Center
Beverly Hills, Calif.
Ian Roy
Malcolm A. Lesavoy, M.D.
Division of Plastic and Reconstructive Surgery
University of California, Los Angeles School of Medicine
Los Angeles, Calif.
Correspondence to Dr. Lesavoy
16311 Ventura Boulevard, Suite 555
Encino, Calif. 91436-4314
drlesavoy@aol.com

REFERENCES
1. Lassus C. Surgical vermillion augmentation: Different possibilities. Aesthetic Plast Surg. 1992;16:123127.
2. Lesavoy MA. Lip reconstruction. In: Lesavoy MA, ed. Reconstruction
of the Head and Neck. Baltimore: Williams & Wilkins; 1981:95117.
3. Lesavoy MA. Lower third of face and lip reconstruction. In:
Mathes SJ, ed. Plastic Surgery. Vol. 3: The Head and Neck, Part 2.
2nd ed. Philadelphia: Saunders Elsevier; 2006:799858.
Human Immunodeficiency VirusRelated

Lipoatrophy of the Face: Where Should We
Have to Fill?
Sir:
acial lipoatrophy, defined as flattening or indentation

of normally convex facial contours, is the major stigma
for human immunodeficiency virusinfected people. It can
have dramatic effects on their self-esteem and socialization,
and it may result in reduced antiretroviral adherence.
In a study performed by Paton et al., facial magnetic
resonance imaging scans were performed in three groups
of patients: those with lipoatrophy, wasting, and weight
gain.1 The regions of interest were temporal fat and cheek
fat (separated at the zygomatic arch level), periorbital fat,
the buccal fat pad, orbital fat, and the masseter and temporalis muscles. The magnetic resonance imaging scans
showed a great difference in cheek fat at baseline among the
lipoatrophy group (average, 17.2 ml), the weight loss group
(average, 34.3 ml), and the weight gain group (average, 44.6
ml). In contrast, very close values among the three groups
where shown at baseline in temporal fat, periorbital fat,
buccal fat pad, orbital fat, temporalis muscle, and masseter
muscle.
Davison et al. in a recent study described the defects of
facial wasting as a series of triangles.2 The first triangle is
observed above the zygomaticus major, the second is located
below it, and the last is based at the zygomatic arch, extending superiorly. The authors present a triangular area of depression identified between the nasolabial fold, the malar
arch, and the line that connect these two anatomical landmarks, and whichever restoration technique is used (nonresorbable fillers or structural fat graft) seems to give a natural and pleasant result (Fig. 1).
The study performed by Paton et al.1 seems to validate the
idea that the real change in facial lipoatrophy is a sunken
aspect in the cheek area. Several works have been published
in the literature regarding structural fat grafting and dermal
fillers for rehabilitation of facial wasting but, to the best of our
knowledge, only the study performed by Serra-Renom sand
Fontdevila3 indicates the area that was filled. Serra-Renom
and Fontdevila explained that the injection was made from
two points in the inferior and external vertices of the sunken
zone in the shape of a triangle, but they did not identify this
triangular area with anatomical landmarks as we did.
Some other studies described facial wasting rehabilitation with the use of malar implants. Mori et al. in their
work stated that submalar augmentation with lipofilling
resulted in a notable improvement of the facial contour,
whereas the cases corrected by silicone malar implants left
the surgeon not completely satisfied.4
Fig. 1. (Above) The triangular area of depression, identified between the nasolabial fold, the malar arch, and the line that
connects these two anatomical landmarks, presented by the
authors. (Below) The same area after a filling treatment.
The cases shown in the study performed by Claude et al.,

in which rehabilitation was performed by using only malar
implants, clearly let us identify that the triangular area described by ourselves still has a sunken aspect. Anyhow, the
outcomes were considered good or very good.5 From the
point of view of the authors, the area that should be filled to
restore facial wasting is a triangle identified between the
nasolabial fold, the malar arch, and the line that connects
these two anatomical landmarks.
DOI: 10.1097/PRS.0b013e3182131e38
Raffaele Rauso, M.D.

Gianpaolo Tartaro, M.D.
Unit of Maxillofacial Surgery
Head and Neck Department
II University of Naples
Gilda Cobellis, M.D., Ph.D.

General Pathology Department
Vincenzo Sangiovanni, M.D.

Infective Disease Department
Cotugno Infective Disease Hospital
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Giuseppe Colella, M.D., D.M.D.
Unit of Maxillofacial Surgery
Head and Neck Department
Naples, Italy
Correspondence to Dr. Rauso
Centro Polispecialistico Santa Apollonia
Via Martiri del Dissenso, 47
81055-S. Maria C. V. (CE), Italy
raffaelerauso@virgilio.it
DISCLOSURE
The authors have no financial interest to declare in relation to
the content of this article. No outside funding was required.
REFERENCES
1. Paton NI, Yang Y, Tha NO, Sitoh YY. Changes in facial fat in
HIV-related lipoatrophy, wasting, and weight gain measured by
magnetic resonance imaging. HIV Clin Trials 2007;8:227234.
2. Davison SP, Timpone J Jr, Hannan CM. Surgical algorithm for
management of HIV lipodystrophy. Plast Reconstr Surg. 2007;120:
18431858.
3. Serra-Renom JM, Fontdevila J. Treatment of facial atrophy related to treatment with protease inhibitors by autologous fat
injection in patients with human immunodeficiency virus infection. Plast Reconstr Surg. 2004;114:551555; discussion 556557.
4. Mori A, Lo Russo G, Agostini T, Pattarino J, Vichi F, Dini M.
Treatment of human immunodeficiency virus-associated facial lipoatrophy with lipofilling and submalar silicone implants. J Plast Reconstr Aesthet Surg. 2006;59:12091216.
5. Claude O, Domergue Than Trong E, Blanc R, et al. Treatment of
HIV facial lipoatrophy with a submalar porous polyethylene implant
(Medpor) (in French). Ann Chir Plast Esthet. 2009;54:2128.
Neovascularization following Facial Surgery:

Possible Cause and Treatment
Sir:
ngiogenesis is essential for wound healing. Normal

wound healing is associated with hypervascularization that resolves in the weeks after complete reepithelialization. We report our findings in aberrant neovascularization after facial surgical procedures, which resulted
in durable telangiectasia surrounding surgical scars, and
their brisk response to pulsed dye laser treatment.
The study was conducted in keeping with the principles outlined in the Declaration of Helsinki. The
study group consisted of 16 patients (14 women and two
men) aged 42 to 67 years who presented with telangiectasia adjacent to surgical scars, which appeared 4 to
12 weeks postoperatively. Lesions were located on the
nose (three patients) or periauricularly (11 patients).
Telangiectasias were treated with a 595-nm pulsed
dye laser (Vbeam Perfecta; Candela, Wayland, Mass.),
using a 5-mm spot size, a 6-msec pulse duration, and a
fluence of 9 to 12 J/cm2, with dynamic cooling. Treatments were repeated every 2 months until acceptable
clinical improvement was achieved.
Follow-up examinations were performed at each treatment and 3 months after completion. Lesions were photographed before treatment and at 3 months and evaluated by
two dermatologists on a five-point scale: excellent, 75 to 100
percent clearance; good, 50 to 75 percent clearance; fair, 25
to 50 percent clearance; poor, less than 25 percent clearance; or worse, results worse than pretreatment.
All 16 patients completed the study and underwent
one to three treatments (mean, 1.6 treatments). All
Fig. 1. Telangiectasia after (left) Mohs surgery for basal cell carcinoma of the nasal
bridge and (right) face lift.
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Fig. 2. Mohs surgery for basal cell carcinoma of the nasal bridge, before (left) and after
(right) two treatments with pulsed dye laser.
had minimal discomfort during treatment and mild,

transient edema and purpura after treatment. No
serious adverse events were reported. At 3 months,
outcome was rated excellent in all patients (75 to 100
percent clearance). Figure 1 illustrates the phenomenon; Figure 2 shows a typical response to pulsed dye
laser.
Our study identified a rarely reported phenomenon
of periscar telangiectasia after facial surgery. In all patients, the telangiectasia appeared 2 to 3 months after
the procedure. The vessels were fine and responded
well to pulsed dye laser.
Angiogenesis is an integral part of any wound healing process.1 In our patients who underwent face-lift or
Mohs procedures to improve cosmetic outcomes, the
angiogenic response was exaggerated and resulted in
dermal telangiectasia, interfering with the intended
optimization of the cosmetic outcome.
Several mechanisms may provoke the exaggerated angiogenic response. First, ischemic injury may up-regulate
hypoxia-sensitive pathways, primarily hypoxia inducible
factor-1, whose induction by ischemia stimulates a cascade of proangiogenic cytokines.2 Second, inflammation,
inherent in tissue manipulation, is an established trigger
for angiogenesis by means of release of cytokines with
angiogenic properties, including monocyte chemoattractant protein, colony-stimulating factor, tumor necrosis
factors, and interleukin-8.3 Stretch-induced signaling or
shear stress caused by traction after wound edges are
approximated can provoke angiogenesis by means of recruitment of shear-sensitive angiogenic cytokines such as
hypoxia inducible factor-1, monocyte chemoattractant
protein, and platelet-derived growth factor.4 Lastly, the
wound may exert a matrix effect, as suture material and
fibrin have been reported to act as triggers for angiogenesis, through direct biological activation or through recruitment of macrophages, with variable angiogenesis
with different sutures.5 Postsurgical telangiectasis is likely

caused by a combination of these factors and is likely more
prevalent than is currently appreciated. When detected,
it is easily corrected with a limited number of pulsed dye
laser treatments.
DOI: 10.1097/PRS.0b013e3182131e60
Shlomit Halachmi, M.D., Ph.D.

Laser Unit
Department of Dermatology
Rabin Medical Center
Petach Tikva, Israel
Maurice Adatto, M.D.

Skinpulse Dermatology
Laser and Beauty Centers
Geneva, Switzerland
Ran Kornowski, M.D.

Department of Cardiology
Petach Tikva, Israel, and
Sackler Faculty of Medicine
Tel Aviv University
Tel Aviv, Israel
Moshe Lapidoth, M.D., M.P.H.

Laser Unit
Petach Tikva, Israel, and
Sackler Faculty of Medicine
Tel Aviv University
Tel Aviv, Israel
Correspondence to Dr. Halachmi
Laser Unit
7 Keren Kayemet Street
Petach Tikva, Israel
shlomitha2@clalit.org.il
145e

DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article. No outside funding was
required.
REFERENCES
1. Carmeliet P. Angiogenesis in life, disease and medicine. Nature
2005;438:932936.
2. Bruick RK. Oxygen sensing in the hypoxic response pathway:
Regulation of the hypoxia-inducible transcription factor.
Genes Dev. 2003;17:26142623.
3. Ribatti D, Crivellato E. Immune cells and angiogenesis. J Cell
Mol Med. 2009;13:28222833.
4. Milkiewicz M, Doyle JL, Fudalewski T, et al. HIF-1alpha and
HIF-2alpha play a central role in stretch-induced but not
shear-stress-induced angiogenesis in rat skeletal muscle.
J Physiol. 2007;583:753766.
5. Laschke MW, Haufel JM, Scheuer C, Menger MD. Angiogenic
and inflammatory host response to surgical meshes of different mesh architecture and polymer composition. J Biomed
Mater Res B Appl Biomater. 2009;91:497507.
A Prospective Controlled Assessment of

Microneedling with the Dermaroller Device
Sir:
leven patients with posttraumatic or acne scars were

treated by microneedling therapy with the Dermaroller device (Horst Liebl, Co., France). This device is
available with different needle lengths. The model used
was MF8. The device has a 12-cm handle that holds a
drum-shaped cylinder at the endsimilar to a small
paint roller2 cm in diameter and 2 cm in width. The
surface of the cylinder holds 192 stainless steel needles
in eight rows. Each needle has a diameter of 0.25 mm
and is 1.5 mm long. They have a radial arrangement of
15 degrees in relation to the roller center. The needles
of the Dermaroller create minuscule holes. These microchannels are closed within minutes after the treatment without any visible traces in the epidermis or
stratum corneum. Eleven patients were selected with
scars that normally would be treated by dermabrasion
or laser resurfacing.
Five male and six female Caucasian patients aged
22 to 51 years participated in this study. The areas
treated were mostly in the face (four patients), lower
extremity (three patients), trunk area (three patients), and on the upper leg in a patient with stretch
marks (striae distensae). One patient failed to come
for the second punch biopsy. Altogether, 10 subjects
completed the entire study protocol. Before treatment, a punch biopsy (3 mm) on one side of the area
to be treated was performed. The microneedling was
performed under local anesthesia in a criss-cross
manner until an even pattern of punctures and microbleeding could be observed under the spectacle
loupe (Fig. 1). All patients were treated by one and
the same operator. No other internal or external
medications or dressings were used.
Six to 8 weeks later, another punch biopsy specimen was taken just 2 cm from the first biopsy site in
146e
Fig. 1. A patient with acne scarring in the forehead before

(above) and 6 weeks after (below) microneedling.
the treated area. Skin samples were fixed in formaldehyde and embedded in paraffin. The biopsy specimens were dyed by elasticavan Gieson and hematoxylin stain. All samples were numerated by random
and, at the end of the study, were evaluated for
histologic characteristics by an independent dermatologist and pathologist in a blinded study. Slides
were analyzed for epidermal thickness, total collagen
staining area, and gross organization (Fig. 2). The
slides were analyzed by color measurement, and the
relative amount of black pixels corresponding to
the stained elastic fibers was calculated in a 2560
1920-pixel picture (24 bits per pixel at 20magnification). The epidermal thickness was also measured.
Ten patients underwent the two punch biopsies
and completed the protocol. All subjects were
pleased with the results and acknowledged that they
would undergo another Dermaroller treatment
(Fig. 1). The procedure was very well tolerated. No
side effects were reported. None had to interrupt his
or her daily routine or leave work. The needled areas
showed small bruising and mild redness for 1 or 2
days; occasionally, a slight hematoma was seen on

Table 1. Relative Number of Black Pixels at 20
Magnification
Location
Forehead
Forehead
Breast
Cheek
Striae, upper leg
Buttock
Lip
Buttock
Upper leg
Lower leg
Fig. 2. Histologic sample before (above) and 6 weeks after (below) microneedling.
bony areas such as the dorsum of the nose or the

malar eminences. All areas healed primarily. Histologic examination of the specimen showed a noticeable increase in elastic fibers in the treated biopsy
specimens. Seven of the patients had their elastic
fibers increased to a noticeable amount. The increase in elastin formation was between 1.1-fold and
2-fold (Table 1), although three patients showed no
effect or a slight decrease in the amount of elastin.
The reason for this is not clear, although correspondence to the clinical outcome was good.
One patient had a 10-fold increase in elastin and
responded especially well to the treatment. Measuring
the epidermal thickness showed no change that was
statistically relevant.
Very astonishing was the effect that the most newly
built elastin fibers could be noted just subepidermally at a depth of 0.6 mm. There were no changes
to be seen deeper than 0.6 mm or in the epidermis
itself. The needle would be penetrating approximately 1 mm in depth, so its effect is well correlated
to that.
Several methods have been introduced into plastic
surgery to enhance collagen formation and scar im-
Before
After
Relative
Response
0.18
0.02
0.12
0.16
0.08
0.12
0.06
0.1
0.14
0.18
0.2
0.18
0.07
0.35
0.13
0.13
0.04
0.14
0.16
0.14
1.11
10
0.58
2.19
1.63
1.08
0.67
1.4
1.14
0.78
provement. Histologic changes after dermabrasion are

well known, and the effect of carbon dioxide laser has
also been investigated.19
Our clinical data indicate that microneedling can
increase dermal thickness and collagen formation.
All treated subjects reported an improvement in hyperchromia and other skin characteristics such as
smoothness and texture. It was evident that the
amount of newly built elastin fiber was in one depth
of the skin, depending on the thickness of the epidermis itself. This suggests that the tip of the needle
or the depth of penetration is an important point and
may vary the results.10,11
The technique is operator-dependent and therefore depth of penetration is different. Theoretically,
round arranged needles at an angle of 15 degrees
and 1.5 mm in length penetrate the skin with 1.2 mm.
Effective treatment requires examination of these
variables. A good clinical judgment is the microbleeding visible under a spectacle-loupe with 2.3
magnification. No high pressure needs to be applied
on the Dermaroller device. The needles are extremely sharp and penetrate the skin easily. The surface of the roller head determines the depth of penetration, regardless of the pressure. Especially when
the Dermaroller is rolled over the forehead, nose,
and cheeks, pressure must be adjusted to prevent the
needles from touching the bones underneath. Also,
around the orbital area, pressure should be minimized to avoid severe hematoma. In my experience,
it is not the pressure but the number of needles on
the roller head and the number of roller movements
over the same skin area that are the decisive factors
for a good result. Theoretically, 15 Dermaroller
movements create 250 pricks per square centimeter.
The force applied to the device is not very high,
theoretically 3 N for the MF8 device and even less
for the MF4.
A very new indication is the treatment of stretch
marks by microneedling. Clinically, the results were
encouraging and, by theory, the newly built elastin
fibers can minimize the gap in the singular stretch
mark. At the moment, this is the goal of another
running study.
147e

This controlled trauma to the dermis causes an
optimal natural collagen production and deposition
of collagen on the epidermal/dermal junction. Combination with topical agents that enhance collagen
production may boost this effect. The external substance applied must be considered for this biocompatibility, as the effect of enhancing penetration
through the epidermis is already proven.
DOI: 10.1097/PRS.0b013e3182131e0f
Martin Schwarz, M.D.

Helmut Laaff, M.D.
Praxisklinik Stuehlinger and Dermatohistological
Laboratory Laaff
Freiburg, Germany
Correspondence to Dr. med. Schwarz
Stuehlingerstrasse 24
D-79106 Freiburg, Germany
schwarz@plastchir.net
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Orentreich DS, Orentreich N. Subcutaneous incisionless
(subcision) surgery for the correction of depressed scars and
wrinkles. Dermatol Surg. 1995;21:543549.
2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast
Surg. 1997;21:4851.
3. Kitzmiller WJ, Visscher M, Page DA, Wicket RR, Kitzmiller
KW, Singer JL. A controlled evaluation of dermabrasion
versus CO2 laser resurfacing for the treatment of perioral
wrinkles. Plast Reconstr Surg. 2000;106:13661372; discussion
13731374.
4. Giese SY, McKinney P, Roth SI, Zukowski M. The effect of
chemosurgical peels and dermabrasion on dermal elastic
tissue. Plast Reconstr Surg. 1997;100:489498; discussion 499
500.
5. Grossman AR, Majidian AM, Grossman PH. Thermal injuries
as a result of CO2 laser resurfacing. Plast Reconstr Surg. 1998;
102:12471252.
6. Coimbra M, Rohrich RJ, Chao J, Brown SA. A prospective
controlled assessment of microdermabrasion for damaged
skin and fine rhytides. Plast Reconstr Surg. 2004;113:1438
1443; discussion 1444.
7. Rubino C, Farace F, Dessy LA, Sanna MP, Mazzarello V. A
prospective study of anti-aging topical therapies using a
quantitative method of assessment. Plast Reconstr Surg. 2005;
115:11561162; discussion 11631164.
8. Rosenberg GJ, Brito MA Jr, Aportella R, Kapoor S. Long-term
histologic effects of the CO2 laser. Plast Reconstr Surg. 1999;
104:22392244; discussion 22452246.
9. Kligman LH. Photoaging: Manifestation, prevention and
treatment. Dermatol Clin. 1986;4:517528.
10. Davis SP, Allen MG, Prausnitz MR. The mechanics of microneedles. Proceedings of the Second Joint EMBS Conference ;
October 2326, 2002; Houston, Texas.
11. Henry S, McAllister DV, Allen MG, Prausnitz MR. Microfabricated microneedles: A novel approach to transdermal drug
delivery. J Pharm Sci. 1998;87:922925.
148e
Staged Nipple Reconstruction with Vascularized

SurgiMend Acellular Dermal Matrix
Sir:
ipple reconstruction is often the final stage of breast

reconstruction for postmastectomy patients. However, the local flaps most commonly used have a loss of
projection of up to 70 percent. Consequently, flattening
is the central point of dissatisfaction among these women.
This is particularly true when reconstruction is undertaken in the thinned dermis seen after tissue expansion.
Several authors have described the use of acellular
dermal matrix to augment nipple projection.1,2 The
matrix has been placed at the time of nipple reconstruction or as a filler for the deficient nipple. We have
developed a technique to be used where we know that
the dermis will be thin in the region of nipple reconstruction. This staged technique is designed to allow
the matrix to become vascularized, increasing the safety
of nipple creation without adding additional steps.
In a patient requiring bilateral breast reconstruction
after full expansion at the time of expander exchange,
a 5-cm circular space was undermined deep to the
dermis but superficial to the capsule after implant
placement. This was at the site of future nipple reconstruction. Into this pocket was placed a 5-cm disk of
SurgiMend (TEI Biosciences, Boston, Mass.) bovine
collagen, 2 mm thick. No sutures were required for
fixation. When the patient returned for nipple reconstruction 4 months later, a skate flap was designed on
each breast, at the site where the SurgiMend had been
placed. The flap was performed with the elevated nipple volume including the SurgiMend in addition to the
dermis and subcutaneous tissue. The SurgiMend was
noted to be well vascularized, bleeding from the cut
Fig. 1. Histologic evaluation at the time of nipple creation reveals positive immunohistochemical staining for CD31, a commonly used endothelial cell marker, demonstrating a vascular
supply in the SurgiMend sample approximately 4 months after
initial implantation.
Fig. 2. Postoperative follow-up at 7 months.
edges. A piece of the SurgiMend was sent for histologic evaluation, revealing a vascularized matrix with
positive CD31 staining (Fig. 1). The augmented volume produced a nipple 8 mm in height. Projection
was 7 mm at 4-month follow-up and 6 mm at 7-month
follow up (Fig. 2).
Previous techniques have incorporated folded biological matrices placed within thinned dermal flaps
to augment projection.13 This introduces a large
volume of foreign material compared with the compromised native tissue. We hypothesized that subdermal placement of a matrix after expansion at the
site of future nipple reconstruction would allow for
dermal augmentation by vascularization of the matrix before nipple creation.
We chose SurgiMend because, in contrast to human-derived biologic matrices, histologic evaluation
in animal models has shown a diminished inflammatory response, with persistence of the implant at 12
weeks and no chronic inflammatory responses seen.4
In our study, the SurgiMend was found both clinically
and histologically to be vascularized (Fig. 1), augmenting the native dermis. This restored the lost
dermal volume, allowing thicker flaps to be raised
and maintaining the integrity of the capsule. Ultimately, this provided a well-vascularized substrate for
improved bulk and projection. Whether the evidence
of decreased inflammation and vascularization of biological matrices results in clinically improved outcomes remains to be determined and will be measured in years rather than months.
DOI: 10.1097/PRS.0b013e3182131e74
Randall O. Craft, M.D.

James W. May, Jr., M.D.
Massachusetts General Hospital
Harvard Medical School
Boston, Mass.
Correspondence to Dr. Craft

Harvard Plastic Surgery
Boston, Mass. 02115
rcraft@partners.org
DISCLOSURE
Dr. May is a consultant for TEI Biosciences (Boston,
Mass.). There were no sources of funding for this work.
REFERENCES
1. Nahabedian MY. Secondary nipple reconstruction using
local flaps and AlloDerm. Plast Reconstr Surg. 2005;115:
20562061.
2. Garramone CE, Lam B. Use of AlloDerm in primary nipple
reconstruction to improve long-term nipple projection. Plast
Reconstr Surg. 2007;119:16631668.
3. Chen WF, Barounis D, Kalimuthu R. A novel cost-saving approach to the use of acellular dermal matrix (AlloDerm) in
postmastectomy breast and nipple reconstructions. Plast Reconstr Surg. 2010;125:479481.
4. Hwang K, Hwang JH, Park JH, Kim DJ, Shin YH. Experimental study of autologous cartilage, acellular cadaveric
dermis, lyophilized bovine pericardium, and irradiated bovine tendon: Applicability to nasal tip plasty. J Craniofac
Surg. 2007;18:551558.
How Long Does the Nipple Projection Last

after Reconstruction Using the Skate Flap
Purse-String Technique?
Sir:
ipple reconstruction is a type of tip procedure

for producing a natural impression of the reconstructed breast. Hammond et al. reported the
skate flap purse-string technique for nipple-areola
complex reconstruction in 2007.1 As compared with
other techniques, such as the star flap, skate flap,
double-opposing tab flap, and others, this method
has the great advantage that it does not produce a
scar outside the areola, because the donor for the
flap is closed with two island flaps using the circling
149e

purse-string technique. It also prevents the constriction of the shape of the breast that is usually produced by simple closure of the local flap donor in
other techniques. We report here the results of a
retrospective study to determine how the projection
lasts after reconstruction by this method.
Between August of 2004 and April of 2009, 16
female patients underwent nipple-areola complex reconstruction using this technique at the Shizuoka
Cancer Center. The women were aged 32 to 64 years
(average, 49 years). Six patients underwent breast
reconstruction with autologous tissue, and 10 received implants.
The areola diameter was designed to be equal to that
of the opposite areola, which ranged from 27 to 34 mm
(average, 31 mm), and the height of the flap was designed to be 10 to 17 mm (average, 11 mm) (Fig. 1).
Other procedures were as described in the first report
by Hammond et al.1
The projection of the nipple tended to shrink with
time (Fig. 2). In patients followed up for more than
12 months, the average size of the projection was 2.3
mm (32 percent of that of the opposite nipple), and
in patients followed up for more than 24 months, the
average was 1.9 mm (27 percent of that of the opposite nipple). There was no difference in the degree
Fig. 1. Nipple reconstruction.
150e
of shrinkage between patients who underwent

autologous reconstruction and those who received
implants.
Past reports show variations in the projection of
the reconstructed nipple depending on the technique used and the length of follow-up after surgery.
In studies in which the mean follow-up period or
minimum follow-up period was longer than 2 years,
Few et al. reported that the residual projection was
41 percent after reconstruction with the star flap as
compared with the intraoperative projection,2 and
Kroll reported a projection of 2.43 mm after reconstruction using the double-opposing tab flap method
and of 1.96 mm after using the star flap method.3
Tanabe et al. reported that the remaining projection
was 94.6 percent 1 to 3 years after reconstruction
using a bilobed flap with concha cartilage storing.4
Garramone and Lam reported that use of AlloDerm
with a modified star flap improved long-term nipple
projection, and also that there was a significant difference in the remaining projection between the
subjects undergoing reconstruction with transverse
rectus abdominis musculocutaneous flaps and those
receiving implants.5
In our study, there were no significant differences
between the patients undergoing autologous breast

3. Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple
projection with the modified double-opposing tab and star
flaps. Plast Reconstr Surg. 1997;99:16021605.
4. Tanabe HY, Tai Y, Kiyokawa K, Yamauchi T. Nipple-areola
reconstruction with a dermal-fat flap and rolled auricular
cartilage. Plast Reconstr Surg. 1997;100:431438.
5. Garramone CE, Lam B. Use of AlloDerm in primary nipple
reconstruction to improve long-term nipple projection. Plast
Reconstr Surg. 2007;119:16631668.
Bilateral Autologous Reconstruction from

Different Sites: Indications and Outcomes after
DIEP and SGAP Flaps
Sir:
Fig. 2. Nipple projection over time.
reconstruction and those receiving implants. The

modified skate flap purse-string technique was useful
in both groups, with minimum donor sacrifice and
inconspicuous scarring. The use of this technique
does not affect the shape of the reconstructed breast
and enables reconstruction of not only circular areolas but also oval areolas; however, further improvements still need to be devised for the reconstruction
of nipples with greater height.
DOI: 10.1097/PRS.0b013e3182131e24
Yoko Katsuragi, M.D.

Shuji Kayano, M.D., Ph.D.
Takuya Koizumi, M.D., Ph.D.
Takahiro Matsui, M.D.
Masahiro Nakagawa, M.D., Ph.D.
Shizuoka Cancer Center Hospital
Shizuoka, Japan
Correspondence to Dr. Katsuragi
Shizuoka Cancer Center Hospital
1007 Shimonagakubo
Naga-izumi, Shizuoka 411-8777
yoko-prs@umin.ac.jp
Presented in part at the 53rd Annual Meeting of the Japan
Society of Plastic and Reconstructive Surgery, in Kanazawa,
Japan, April 8, 2010.
DISCLOSURE
REFERENCES
1. Hammond DC, Khuthaila D, Kim J. The skate flap purse-string
technique for nipple-areola complex reconstruction. Plast Reconstr Surg. 2007;120:399406.
2. Few JW, Marcus JR, Casas LA, Aitken ME, Redding J. Longterm predictable nipple projection following reconstruction.
Plast Reconstr Surg. 1999;104:13211324.
he traditional dictum for bilateral breast reconstruction is to use the same type of reconstruction
on both sides for optimal symmetry. This can sometimes prove difficult in patients electing to have autologous reconstruction. Challenges include patients
with (1) unilateral reconstruction who subsequently
need contralateral mastectomy, (2) bilateral reconstruction who suffer unilateral flap loss, and (3) a
paucity of donor-site tissue. In such patients, autologous tissue from two different donor sites should
theoretically provide a better match compared with
autologous tissue on one side and implant on the
other. Furthermore, as many of these patients undergo irradiation, reconstruction with an implant
carries an increased risk of capsular contracture and
asymmetry.1 The long-term effects of reconstructions
using different donor sites are unclear. We present
our experience with six patients who had bilateral
reconstruction with a deep inferior epigastric artery
perforator (DIEP) flap on one side and a superior
gluteal artery perforator (SGAP) flap on the other.
Although most patients achieved satisfactory results,
in one case, postoperative changes and weight gain
created persistent asymmetry.
Two patients had unilateral breast cancer and
DIEP flap reconstruction. Both developed a primary
cancer in the contralateral breast within 3 years and
chose mastectomy with SGAP flap reconstruction.
Two patients had bilateral mastectomy and bilateral
DIEP flap reconstruction. In both patients, venous
congestion led to unilateral flap loss and tissue expander placement. They both elected to subsequently undergo expander removal and SGAP flap
reconstruction. Two patients had staged reconstruction, as there was insufficient abdominal tissue for
bilateral reconstruction (Fig. 1). Both patients had a
DIEP flap on one side and an SGAP flap on the other.
One of the patients developed a 35-lb weight gain
over 4 years. The breast reconstructed with the DIEP
flap appeared much larger despite similar initial flap
weights (Fig. 2). Five of the six patients had acceptable postoperative results based on symmetry and
volume, with a mean follow-up of 2.1 years.
Our experience suggests that bilateral autologous
reconstruction from different donor sites can be sat-
151e
Fig. 1. A 35-year-old woman with unilateral breast cancer preoperatively (left) and 2 years after staged right SGAP and
left DIEP flap surgery (right). Note the increased projection of the SGAP flap despite the similar breast volume.
Fig. 2. A 47-year-old woman with bilateral breast cancer preoperatively (left) and 4 years after staged left DIEP and right
SGAP flap surgery (right). This patient gained 35 lb and developed a subsequent asymmetry with preferential volume
increase on the left.
isfactorily performed in rare instances where warranted. However, challenges remain to achieving a
good aesthetic outcome. We found that the higher
fat content and more pronounced septation in SGAP
flaps lead to increased projection and decreased superior pole fullness. This makes symmetry difficult,
even when the flaps are closely matched in weight.
Additional revision procedures, including autologous fat grafting, may be required to achieve maximal symmetry.
Our last case highlights the potential for long-term
asymmetry with weight gain. This is of particular concern in the breast cancer patient population, as chemotherapy, hormonal therapy, and menopause are
known contributors to weight gain.2,3 Fluctuations in
body weight have been associated with changes in graft
volume after fat grafting.4 It is possible that adipocytes
transferred as part of composite tissue grafts behave as
152e
they would in their site of origin because normal stromal support and tissue architecture are preserved.
Therefore, they may exhibit different responses to systemic weight gain, just as they do in situ. If different
donor sites must be used for reconstruction, patients
should be counseled about potential asymmetry that
can occur with weight gain.
DOI: 10.1097/PRS.0b013e318213a1ea
Sashank K. Reddy, M.D., Ph.D.

Salih Colakoglu, M.D.
Michael S. Curtis, M.D.
Adam M. Tobias, M.D.
Samuel J. Lin, M.D.
Bernard T. Lee, M.D.

Beth Israel Deaconess Medical Center
Boston, Mass.
Correspondence to Dr. Lee
Beth Israel Deaconess Medical Center
110 Francis Street, Suite 5A
Boston, Mass. 02215
blee3@bidmc.harvard.edu
DISCLOSURE
REFERENCES
1. Lee BT, Adesiyun TA, Colakoglu S, et al. Postmastectomy
radiation therapy and breast reconstruction: An analysis of
complications and patient satisfaction. Ann Plast Surg. 2010;
64:679683.
2. Demark-Wahnefried W, Winer EP, Rimer BK. Why women
gain weight with adjuvant chemotherapy for breast cancer.
J Clin Oncol. 1993;11:14181429.
3. Moore HC, Kim J, Rodriguez C, et al. Predictors of permanent
menopause after chemotherapy for early-stage breast cancer
in premenopausal women. J Clin Oncol. 2009;27:15s.
4. Delay E, Garson S, Tousson G, Sinna R. Fat injection to the
breast: Technique, results, and indications based on 880 procedures over 10 years. Aesthet Surg J. 2009;29:360376.
The Use of a Single Set of Internal Mammary

Recipient Vessels in Bilateral Free Flap
Breast Reconstruction
Sir:
ilateral free flap breast reconstructions are mostly

performed using two sets of internal mammary
vessels as recipients. The purpose of this article is to
present the surgical tips for bilateral free flap breast
reconstruction using a single set of recipient artery and
vein.
A 5-year retrospective review of a series of patients
who underwent bilateral breast reconstruction between
2005 and 2009, using one set of recipient vessels for
both flaps, is presented. Patient files were reviewed, and
demographics, reason for using one set of internal
mammary vessels, and operative details were recorded
(Table 1). All patients had preoperative abdominal and

thoracic computed tomographic mapping showing the
position of perforators and the patency of the thoracic
vessels.1 All patients underwent bilateral deep inferior
epigastric artery perforator flap reconstruction as described previously.2 A preoperative or perioperative decision for using only one set of internal mammary vessels was made, and the contralateral pedicle was passed
through a presternal tunnel. Anastomoses were performed as shown in Figures 1 and 2. A skin paddle was
left for flap monitoring and a Doppler probe was used
to assess the patency of the pedicle passing into the
subcutaneous tunnel when no skin paddle was left for
monitoring.
Results are listed in Table 1. A total of 10 patients
were included. No partial or complete flap losses were
observed. Only one patient (patient 5) underwent revision 5 hours after surgery. A venous thrombosis was
seen at the level of the anastomosis with internal mammary vessels, with complete recovery after revision.
The internal mammary vessels are the first-choice recipients for free flap breast reconstruction, but the thoracodorsal vessels or the internal mammary perforators
are regularly used.3 However, the internal mammary artery is also the first-choice donor vessel for coronary artery
bypass graft surgery because of its superiority compared
with other arterial or venous conducts.4
Although death resulting from an absence of an internal mammary artery donor for coronary artery bypass
graft surgery has never been described, some surgeons
believe that preservation of one internal mammary artery
in bilateral breast reconstruction should be kept in mind
in patients with coronaropathy. In addition, the internal
mammary vessels sometimes cannot be used for other
reasons, such as previous irradiation of the sternal region,
that can cause important scarring of the vascular bed and
in extreme cases thrombosis.5
The use of a single recipient pedicle can even allow
reliable monitoring of completely buried flaps (Fig. 1)
(type III). Monitoring is then performed by using a
flow-Doppler probe at the level of the presternal passage of the pedicle, but the results must be interpreted
with caution.
Obviously, using a single recipient vessel for two free
flaps has the risk of thrombosis of the main pedicle, which
Table 1. Patient Data

Patient
Age
(yr)
Type of
Reconstruction
Reason for
Single Recipient
Type of Arterial
Anastomosis
Type of Venous
Anastomosis
1
2
3
4
5
6
7
8
9
10
45
42
49
35
59
53
62
38
47
26
Bilateral immediate
Immediate and delayed
Bilateral prophylactic
Bilateral delayed
Bilateral delayed
Bilateral prophylactic
Bilateral immediate
Monitoring purposes
Scarred vessels
Scarred vessels
Coronary lesions on CT scan
Previous CABG
Coronary lesions on CT scan
Cardiac patient
Iatrogenic
Cardiac patient
Iatrogenic
II
III
IV
II
III
II
III
III
III
III
IV
III
IV
III
IV
IV
IV
III
IV
I
CT, computed tomographic; CABG, coronary artery bypass grafting.
153e
Fig. 1. Options for anastomosing the arteries of a bilateral free flap breast reconstruction. IMAp, internal mammary artery perforator, proximal; IMAd, internal mammary artery perforator, distal.
may result in failure of both flaps. Therefore, such surgical

technique should only be performed when indicated and
performed by an experienced microsurgeon.
In bilateral free flap breast reconstruction, both internal mammary sites are frequently used; however, in
selected cases, it is necessary to have an extra option for
anastomosing one of the two flaps. The use of a single
internal mammary recipient for bilateral reconstructions is a valuable microsurgical option.
DOI: 10.1097/PRS.0b013e3182131df9
Assaf A. Zeltzer, M.D.

Patricio Andrades, M.D.
Moustapha Hamdi, M.D., Ph.D.
Phillip N. Blondeel, M.D., Ph.D.
Koenraad Van Landuyt, M.D., Ph.D.
Correspondence to Dr. Van Landuyt
Department of Plastic Surgery
University Hospital Gent (UZ Gent)
154e
De Pintelaan 185
Gent B-9000, Belgium
koenraad.vanlanduyt@ugent.be
REFERENCES
1. Masia J, Clavero JA, Larran
aga JR, Alomar X, Pons G, Serret P.
Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59:594
599.
2. Blondeel PN. One hundred free DIEP flap breast reconstructions: A personal experience. Br J Plast Surg. 1999;52:104111.
3. Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm
in choosing recipient vessels for perforator free flap in breast
reconstruction: The role of the internal mammary perforators. Br J Plast Surg. 2004;57:258265.
4. Tomizawa Y, Endo M, Nishida H, et al. Use of arterial grafts
for coronary revascularization: Experience of 2987 anastomoses. Jpn J Thorac Cardiovasc Surg. 1999;47:325329.
5. Gansera B, Schmidtler F, Angelis I, et al . Quality of internal
thoracic artery grafts after mediastinal irradiation. Ann Thorac
Surg. 2007;84:14791484.
Fig. 2. Options for anastomosing the veins of a bilateral free flap breast reconstruction. IMAp, internal mammary
vein, proximal; IMAd, internal mammary vein, distal.
The Role of Pocket Dissection in

Breast Implant Contracture: A Single
Surgeons Review
Sir:
apsular contracture following breast augmentation

can be a common occurrence (5 to 25 percent
occurrence rate).1 Although its exact cause is unknown,
implant type, bacterial contamination, genetics, and
bleeding in the breast pocket region have all been
hypothesized to be instrumental in capsular contracture development.
A review of one surgeons experience evaluating 615
patients over a 5-year period was conducted to examine
any factors related to the onset of capsular contracture.
Variables, including autoimmune status and tobacco
use, were eliminated to reduce retrospective bias. Only
primary augmentation below the muscle with saline
implants using the inframammary fold incision was reviewed. The major variable was the technique used to
dissect the submuscular pocket.
In dissecting the plane below the superior retromuscular pocket of the 615 cases, 315 procedures
(51.2 percent) were performed using direct visualization dissection with complete electrocautery versus 300 procedures (48.8 percent) performed with a
Dingman blunt dissector for blind dissection. The
occurrence rate of capsular contracture with complete electrocautery dissection was two (0.64 percent) of 315 cases compared with 19 (6.4 percent) of
300 cases with blunt blind dissection (chi-square test,
13.5; p 0.001; Fishers exact test, p 0.0001). The
relative risk of capsular contracture with blunt blind
dissection compared with complete electrocautery
dissection is 10 (95 percent confidence interval, 2.5
to 38.5), indicating that procedures performed with
blunt, blind dissection are 10 times as likely to produce capsular contracture. It is therefore highly
likely that bleeding during blunt, blind dissection
promotes the higher rate of capsular contracture.
(Contingency table analysis was performed by John
155e

C. Pezzullo, Ph.D., of Georgetown University, Washington D.C., Interactive Statistical Calculations web
site maintenance.)
Microvascular bleeding that occurs more frequently with blunt, blind dissection can be attributed
to the vascular properties of the submuscular area.
Abundant and profuse microvascular networks in the
superior chest of the submuscular plane are susceptible to bleeding induced by blunt dissection. Slow,
latent bleeding could be a trigger in initiating the
onset and progression of the early phases of fibrosis
leading to capsular contracture. Measures by minimizing bleeding during operative dissection through
precise atraumatic techniques with electrocautery to
dissect the entire submuscular pocket, in addition to
antibiotic breast pocket irrigation, will likely reduce
the rates of capsular contracture.
DOI: 10.1097/PRS.0b013e318213a2d2
Jason Jacoby, B.S.

Sean T. Lille, M.D.
Scottsdale, Ariz.
Correspondence to Dr. Lille
10210 N92nd Street, Suite 203
Scottsdale, Ariz. 85258
jhjsololt1@aol.com
REFERENCE
1. Barnsley GP, Sigurdson LJ, Barnsley S. Textured surface
breast implants in the prevention of capsular contracture
among breast augmentation patients: A meta-analysis of
randomized controlled trials. Plast Reconstr Surg. 2006;117:
21822190.
Lateral Intercostal Artery Perforator Flap in

Combination with Thoracoabdominal
Advancement Flap for Correction of Contour
Deformities following Autologous
Breast Reconstruction
Sir:
n autologous breast reconstruction, partial flap loss,
scar contracture, or volume deficiency can cause
breast asymmetry. Options for filling out the lower pole
include lowering the flap, fat grafting, or local pedicle
flaps.1 All have various disadvantages.
We present the combination of lateral intercostal
artery perforator and thoracoabdominal advancement flaps as a means of repairing defects of the
breast lower pole. A transverse flap based on a lateral
intercostal artery perforator imaged with a Doppler
probe is harvested on the lateral trunk. The flap is
deepithelialized before rotation into the lower pole
of the breast by means of a subcutaneous tunnel and
fixed with absorbable sutures, and the donor site is
closed primarily.
The thoracoabdominal advancement flap is elevated
by undermining the skin past the inframammary fold
inferiorly. With progressive tension sutures, advance-
156e
ment up to 6 cm is possible. The inframammary fold is

recreated and the thoracoabdominal flap is sutured to
the superior mastectomy skin flap.
In case 1, a 62-year-old patient presented with breast
asymmetry following free transverse rectus abdominis
musculocutaneous (TRAM) flap surgery (Fig. 1, above,
left). Her reconstructed breast developed scar contracture and volume deficiency, which we corrected with a
lateral intercostal artery perforator and thoracoabdominal flap procedure. The lower skin flap was undermined to midway between the umbilicus and the
inframammary fold. The thoracoabdominal flap was
advanced 6 cm, and a 17 7-cm lateral intercostal
artery perforator flap filled in the lower pole of the
breast (Fig. 1, below). The patient was discharged the
same day and healed without complications (Fig. 1,
above, right).
In case 2, a 60-year-old patient underwent a pedicled TRAM flap that suffered a partial flap necrosis,
resulting in contour deformity and flap skin scarring.
The entire skin paddle was excised. The additional 7
cm of skin required was obtained with a thoracoabdominal flap after undermining all the way to the
umbilicus level. A 17 6-cm lateral intercostal artery
perforator flap was harvested and the thoracoabdominal flap was sutured to the superior mastectomy
skin flap.
In case 3, a 53-year-old patient underwent free TRAM
flap surgery for breast reconstruction which lacked
lower pole projection and ptosis. Her thoracoabdominal flap was advanced 5 cm, and a 20 4-cm lateral
intercostal artery perforator flap was harvested. Her
inframammary fold was too high; thus, a new one was
created by fixing the thoracoabdominal flap to the
chest wall at the corrected level.
The lateral intercostal artery perforator flap in
combination with a thoracoabdominal flap is a useful
method of local tissue rearrangement in the chest
(Figs. 2 and 3). The lateral intercostal artery perforator flap provides volume, and the thoracoabdominal flap provides skin of equivalent color and texture.
There is minimal morbidity involved. All of our patients were discharged within 24 hours and suffered
no complications. The volume created is more consistent than fat grafting because the lateral intercostal artery perforator flap is not subjected to fat resorption.
The lateral intercostal artery perforator flap has
been documented in partial breast/thoracic skin
reconstruction,2,3 breast augmentation,4 and partial
mastectomy defect correction.5 If the skin paddle is
situated over an axillary/lateral adipose tissue roll, a
large flap can be harvested and can also improve truncal silhouette.
To correct post breast reconstruction lower pole
deformities, we combine lateral intercostal artery perforator and thoracoabdominal flaps for volume and
skin replacement, respectively. Incidentally, this may
Fig. 1. Case 1. (Above, left) Oblique-lateral view of the patient, demonstrating markings for lateral intercostal
artery perforator (X marks the perforator imaged with the Doppler probe) and thoracoabdominal flap (TAF).
(Below) Intraoperative view of the lateral intercostal artery perforator (LICAP) flap being harvested. (Above,
right) The patient is shown 6 months postoperatively.
Fig. 2. Lower pole breast deformity and possible lateral intercostal artery perforator flap inset positions.
157e
Fig. 3. (Left) Corrected lower pole deformity of the breast. Dotted line shows preoperative trunk contour,
before dermal lipectomy (lateral intercostal artery perforator flap harvest). (Right) Correction of lower pole
breast deformity with lateral intercostal artery perforator and thoracoabdominal flaps.
result in improved lateral trunk contour and also allows

inframammary fold repositioning.
DOI: 10.1097/PRS.0b013e318213a1d4
Corrine Wong, M.R.C.S.

Munique Maia, M.D.
Michel Saint-Cyr, M.D.
University of Texas Southwestern Medical Center
Dallas, Texas
Correspondence to Dr. Saint-Cyr
University of Texas Southwestern Medical Center
1801 Inwood Road
Dallas, Texas 75390-9132
michel.saint-cyr@utsouthwestern.edu
DISCLOSURE
REFERENCES
1. Saint-Cyr M, Nagarkar P, Schaverien M, Dauwe P, Wong C,
Rohrich RJ. The pedicled descending branch muscle-sparing
latissimus dorsi flap for breast reconstruction. Plast Reconstr
Surg. 2009;123:1324.
2. Hamdi M, Van Landuyt K, de Frene B, Roche N, Blondeel
P, Monstrey S. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg. 2006;59:
644652.
3. Hamdi M, Spano A, Van Landuyt K, DHerde K, Blondeel P,
Monstrey S. The lateral intercostal artery perforators: Anatomical study and clinical application in breast surgery. Plast
Reconstr Surg. 2008;121:389396.
4. Hamdi M, Van Landuyt K, Blondeel P, Hijjawi JB, Roche N,
Monstrey S. Autologous breast augmentation with the lateral
intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aesthet Surg. 2009;62:6570.
158e
5. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous

breast reconstruction for partial mastectomy defects. Plast
Reconstr Surg. 2005;116:762767.
Adolescent Breast Reduction: Indications,

Techniques, and Outcomes
Sir:
ith the rise in childhood obesity, an increase in

the number of patients seeking adolescent breast
reduction has been appreciated. The cause of macromastia in pubertal and parapubertal girls is variable and
includes endocrine changes, childhood obesity, and
juvenile (virginal) hypertrophy of the breast.1 Benefits
of reduction mammaplasty include resolution of pain,
improved quality of life, extroversion, and emotional
stability. There is a paucity of literature regarding outcomes for a growing number of adolescent girls seeking
breast reduction.2,3 We examined our experience with
presenting symptoms, techniques, and both surgical
and pathologic outcomes for reduction mammaplasty
in the adolescent population.
Medical records of 76 consecutive patients younger
than 18 years who underwent reduction mammaplasty
over a 7-year period were identified and reviewed. Operative indications included neck, back, and/or shoulder
pain (75 percent); intertrigo (8 percent); and shoulder
grooving (17 percent). Difficulty finding bras (8 percent)
and participating in sports (9 percent), and social distress
(24 percent) were noted. Average body mass index was 31
kg/m2, and 65 percent of children were obese (body mass
index 30). Surgical correction most commonly included Wise pattern reduction with inferior pedicle (91
percent) and superior pedicle (8 percent). Complications
occurred in eight patients (10.5 percent), including four

partial wound dehiscences, three seromas, two cases of
cellulitis, and one partial nipple loss. All of these patients
were managed without return to the operating room.
Pathologic examination yielded no cancers, with 80 percent normal or mildly fibrotic and 20 percent benign
histology. Based on the cost determined by our pathologic
review and incidence in the pediatric population (0.08
cases per 100,000), the resulting cost of one breast cancer
diagnosis is $147 million.
Beyond the symptoms of macromastia shared by adult
patients, there are special considerations in the young
population requiring more attention. These include emotional status, future lactation success, nipple sensation,
changes in breast morphology on subsequent pregnancy,
and weight loss or gain. Reduction mammaplasty has
been reported to greatly reduce or completely eliminate
eating disorder symptoms and markedly improved body
image.4 Although the majority of patients may demonstrate varying degrees of breast tissue regrowth, symptomatic relief and long-term patient satisfaction persist 6 years
following surgical intervention; 94 percent of patients
would undergo their procedure again.5 Whether these
issues are present in our population following breast reduction remains to be determined, but our preliminary,
short-term follow-up results are promising, with dissemination of these data to occur in the near future.
Adolescent macromastia can be a deforming, distressing, and disabling condition. Presenting symptoms, along
with complication rates, of adolescent mammaplasty patients mirror those seen in the adult population. However,
compared with their adult counterparts, the adolescent
population displays greater obesity and presents with increased social distress and comorbid psychiatric disorders. Thus, surgeons should feel comfortable and obliged
to perform reduction mammaplasty in the carefully selected adolescent patient in whom, with proper consent
and expectations for complications, surgery may help alleviate the increased social, psychological, and physical
strain caused by macromastia.
DOI: 10.1097/PRS.0b013e3182131ae4
Peter F. Koltz, M.D.

Rene P. Myers, M.D.
Robert B. Shaw, M.D.
Philip Wasicek, B.S.
John A. Girotto, M.D.
University of Rochester Medical Center
Rochester, N.Y.
Correspondence to Dr. Koltz
University of Rochester Medical Center
601 Elmwood Avenue, Box 661
Rochester, N.Y. 14642
REFERENCES
1. Denzer C, Webel A, Muche R, Karges B, Sorgo W, Wabitsch
M. Pubertal development in obese children and adolescents.
Int J Obes. 2007;31:15091519.
2. Davis GM, Ringler SL, Short K, Sherrick D, Bengston BP.

Reduction mammaplasty: Long-term efficacy, morbidity, and
patient satisfaction. Plast Reconstr Surg. 1995;96:11061610.
3. Glatt BS, Sarwer DB, OHara DE, Hamori C, Bucky LP,
LaRossa D. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast
Reconstr Surg. 1999;103:7682; discussion 8385.
4. Losee JE, Serletti M, Kreipe RE, Caldwell EH. Reduction mammaplasty in patients with bulimia nervosa. Ann Plast Surg.
1997;39:443446.
5. McMahan JD, Wolfe JA, Cromer BA, Ruberg RL. Lasting success in teenage reduction mammaplasty. Ann Plast Surg. 1995;
35:227231.
Null-Type Anaplastic Lymphoma

KinaseNegative Anaplastic Large Cell
Lymphoma Arising in a Silicone Breast
Implant Capsule
Sir:
58-year-old white woman who had undergone bilateral cosmetic breast augmentation with Inamed
McGhan smooth silicone gel breast implants 19 years
previously presented with a painful right breast and
Baker grade III capsular contracture without evidence
of breast mass or lymphadenopathy. In 2006, her device
had already been replaced in a private clinical structure
for the same complication. At admission, she was otherwise in good health. Her blood count and serum
chemistry values were normal. No local mammary or
systemic cutaneous manifestations were observed.
Mammography was unremarkable. Both implants were
removed and the submuscular pouch was explored,
with drainage of a serous-hematic fluid surrounding
the right prosthesis. Capsulectomy was performed and
the removed fibrous tissue analyzed because of its altered aspect. The pathologic findings were consistent
with a diagnosis of null-type, anaplastic lymphoma ki-
The views, opinions and techniques set forth

in this article addressing anaplastic large cell
lymphoma in women with breast implants are
those of the individual author(s) and do not
reflect the views, opinions, or recommendations of the American Society of Plastic Surgeons, the Journal or the Journal editors. Any
treatment recommendations contained in the
article are those of the individual author(s)
and are not to be considered or construed as
practice guidelines, practice standards or
practice parameters. The use of any treatment technique described in the article is at
the sole discretion of the physician in the
exercise of his or her independent medical
judgment taking into account the patients
individual circumstances.
159e

nasenegative, non-Hodgkins anaplastic large cell lymphoma (ALCL) (Figs. 1 and 2). Computed tomographic
and positron emission computed tomographic scanning
revealed no further lymphoma localization; thus, it was
classified as a stage I systemic ALCL. Because the patient
Fig. 1. ALCL slide showing large blastic cells with abundant cytoplasm and eccentric nuclei that are generally horseshoe
shaped or reniform with prominent nucleoli (hematoxylin and
eosin; original magnification, 400).
refused radiation therapy, she underwent a combined

chemotherapy regimen with cyclophosphamide, doxorubicin, vincristine, and prednisone. To date (21 months
follow-up), there is no evidence of recurrence.
The presenting symptom in virtually all cases of primary breast lymphoma is a mass-type lesion, sometimes
painful and located most often in the upper outer quadrant. In contrast, patients who developed breast lymphoma following prosthesis implantation had implant-related symptoms with or without a mass-type
lesion, including breast mass or enlargement, tenderness, capsular contracture, swelling, seroma, and
skin ulceration.1 4 Primary breast lymphoma arising
in the setting of a breast prosthetic capsule has recently been supposed to be associated with breast
implants, since 45 cases have been observed in the
literature.57 Surprisingly, even if primary breast lymphomas are commonly phenotypically B-cell, those
associated with implants are predominately T-cell
type. In particular, 45510 were ALCL, of which 33
cases were ALK-1 protein; in the remaining 12, the
status was not proven. Among four more non-ALCL
T-cell lymphomas observed,5 two patients had mycosis fungoides and two had Sezary syndrome, all arising in the skin overlying intact silicone implants.
Only four B-cell lymphomas were diagnosed further
Fig. 2. Typical immunophenotype of null-type [no expression of T-cell marker CD3 (above, right) or the B-cell
marker CD20 (above, left)] ALCL [intense expression of CD30 (below, left)] and showing no expression of anaplastic
lymphoma kinase (below, right) (original magnification, 200).
160e

and subtyped as follicular lymphoma, primary effusion lymphoma, and lymphoplasmacytic lymphoma.
ALCLs are lymphomas of activated lymphocytes.
Thus, the apparent increase in prevalence of T-cell
lymphomas must be highlighted, particularly of the
ALCL type, in patients with breast implants compared
with the overall more common B-cell lymphomas seen
in the breast. In light of this, the development of ALCL
in the proximity of breast implants might be a consequence of an immunologic reaction to the device components. Although various authors have proposed that
activation of immunologic mechanisms secondary to
exposure to silicone or toluene diamine from polyurethane covers on implants and Staphylococcus infection
may lead to the development of a malignant T-cell
clone, these hypotheses do not seem to be likely.1 4
Patients with a diagnosis of implant-related ALCL have
had implants that were either ruptured or intact, filled
either with saline or with silicone gel, and placed for either
reconstructive or cosmetic purposes; these varying circumstances have not appeared to make any difference.5,6 Although large observational epidemiological studies in North
American and Scandinavian women have disproved significant associations with breast cancer or other specific cancer
sites or with autoimmune disease,1117 currently, clinical and
histological findings of two major reviews5,6 speak in favor of
an association between breast implants and ALK-1negative
ALCL, which presumably is an indolent form of this group
of nonHodgkins lymphoma that is completely distinct
from the systemic disease with a clinical behavior more similar to primary cutaneous ALCL than to the systemic counterpart. Thus, several authors agree that implant-related
ALCL should be recognized as a separate category in the
World Health Organizations classification, with its own
diagnosis and treatment.5,6 Thus, several authors agree
that implant-related ALCL should be recognized as a
separate category in the World Health Organizations classification, with its own diagnosis and treatment.5,6
The Danish Registry for Plastic Surgery of the Breast is
the first registry in which preoperative, perioperative, and
postoperative data for women undergoing breast augmentation in Denmark since 1999 are registered. Due to
the newly emerging condition, a breast implant registry
should be introduced worldwide in every country as a
successful ongoing prospective registry of both cosmetic
and reconstructive breast implantations, as recently established in the United States by the American Society of
Plastic Surgeons in collaboration with the U.S. Food and
Drug Administration.18,19
We presented the first case of primary null-cell type
ALCL arising in a silicone breast implant capsule.
DOI: 10.1097/PRS.0b013e318213a1bd
Davide Lazzeri, M.D.

Plastic and Reconstructive Surgery Unit
Tommaso Agostini, M.D.

Burn Center Unit
Giordano Giannotti, M.D.

Hospital of Pisa
Giovanni Fanelli, M.D.

Division of Surgical, Molecular, and Ultrastructural
Pathology
Livio Colizzi, M.D.

Breast Cancer Surgical Unit
University Hospital of Pisa
Marcello Pantaloni, M.D.

Hospital of Pisa
Elisabetta Sordi, M.D.

Division of Hematology
University Hospital of Pisa
Pisa, Italy
Address correspondence to Dr. Sordi
Unita` Operativa di Ematologia
Ospedale S. Chiara
Universita` di Pisa
Via Roma 67
56100 Pisa, Italy
bettasordi@libero.it
DISCLOSURE
REFERENCES
1. Sahoo S, Rosen PP, Feddersen RM, Viswanatha DS, Clark DA,
Chadburn A. Anaplastic large cell lymphoma arising in a
silicone breast implant capsule: A case report and review of
the literature. Arch Pathol Lab Med. 2003;127:e115e118.
2. Kraemer DM, Tony HP, Gattenlohner S, Muller JG. Lymphoplasmacytic lymphoma in a patient with leaking silicone
implant. Haematologica 2004;89:ELT01.
3. Wong AK, Lopategui J, Clancy S, Kulber D, Bose S. Anaplastic
large cell lymphoma associated with a breast implant capsule:
A case report and review of the literature. Am J Surg Pathol.
2008;32:12651268.
4. Roden AC, Macon WR, Keeney GL, Myers JL, Feldman AL,
Dogan A. Seroma-associated primary anaplastic large-cell
lymphoma adjacent to breast implants: An indolent T-cell
lymphoproliferative disorder. Mod Pathol. 2008;21:455463.
5. Kim B, Roth C, Chung KC, et al. Anaplastic large cell lymphoma and breast implants: A systematic review. Plast Reconstr
Surg. 2011;127:21412150.
6. Lazzeri D, Agostini T, Bocci G, et al. ALK-1 negative anaplastic large cell lymphoma associated with breast implants:
A new clinical entity. Clin Breast Cancer (in press).
7. Lazzeri D, Agostini T, Pantaloni M, DAniello C. Further
information on anaplastic large cell lymphoma and breast
implants. Plast Reconstr Surg. (in press).
8. Mora P, Melo AC, Amorim GLS, Scheliga AA. Primary T-cell
anaplastic lymphoma associated to a breast implant: Case
report. Haematologica 2009;94:658659.
9. Popplewell L, Chang K, Olevsky O, Nademanee A, Forman S.
Primary anaplastic large cell lymphoma of the breast occurring
in patients with silicone breast implants (American Society of
Hematology: Abstract). Blood 2004;104:4563.
10. Brody G, Deapen D, Gill P, et al. T-cell non Hodgkins
anaplastic lymphoma associated with one style of breast implants. Presented at: 89th Annual Meeting of the American
Association of Plastic Surgeons, San Antonio, Texas; 2010.
161e

11. Brinton LA. The relationship of silicone breast implants and cancer at other sites. Plast Reconstr Surg. 2007;120(Suppl 1):94S102S.
12. Lipworth L, Tarone RE, Friis S, et al. Cancer among Scandinavian women with cosmetic breast implants: A pooled
long-term follow-up study. Int J Cancer 2008;124:490 493.
13. Deapen DM, Hirsch EM, Brody GS. Cancer risk among Los
Angeles women with cosmetic breast implants. Plast Reconstr
Surg. 2007;119:19871992.
14. Brisson J, Holowaty EJ, Villeneuve PJ, et al. Cancer incidence
in a cohort of Ontario and Quebec women having bilateral
breast augmentation. Int J Cancer 2006;118:2854 2862.
15. Pukkala E, Boice JD Jr, Hovi SL, et al. Incidence of breast and
other cancers among Finnish women with cosmetic breast implants, 19701999. J Long Term Eff Med Implants 2002;12:271279.
16. Brinton LA, Lubin JH, Burich MC, Colton T, Brown SL, Hoover
RN. Cancer risk at sites other than the breast following augmentation mammaplasty. Ann Epidemiol. 2001;11:248256.
17. Brinton LA, Buckley LM, Dvorkina O, et al. Risk of connective tissue disorders among breast implant patients. Am
J Epidemiol. 2004;160:619 627.
18. American Society of Plastic Surgeons. ASPS collaborates
with FDA to establish breast implant registry. Available at:
http://www.plasticsurgery.org/Media/Press_Releases/ASPS_
Collaborates-with_FDA_to_Establish_Breast_Implant_Registry.
html . Accessed February 17, 2011.
19. Haeck P, Eaves FF, Rohrich RJ. Breast implants and anaplastic large cell lymphoma: Using science to guide our patients
and plastic surgeons worldwide. Plast Reconstr Surg. Epublished ahead of print March 25, 2011.
Homodigital Dorsal Adipofascial Reverse Flap:

Clinical Applications
Sir:
he actual criterion standard of distal digital reconstruction includes a convenient nail bed, with
length preservation and an almost normal nail lamina,
making the dorsal repair as important as the pulp
repair.1 Several techniques have been suggested and,
recently, adipofascial flaps, since the first descriptions
by Ozdemir et al.,2 have also been proposed.
In our previous article,3 we concentrated our research
on the homodigital adipofascial reverse flap, based on
distal dorsal perforators coming from the main volar vessels, and pointed out some key points for a safe dissection.
In particular, we recommended first that the skin flaps
on the ulnar side of the digits be raised to avoid
visible and tender scars and to avoid undermining
the distal part of the flap, preserving at least a 10-mm
cuff of tissue proximal to the eponychial fold.3
Afterward, we began to use the homodigital dorsal
adipofascial reverse flap to revascularize the damaged nail
bed in acute apical lesions; then, after getting acquainted
with technical pearls in flap performance, we have been
extending its indications to posttraumatic deformities. In
this viewpoint, we present our cases, 11 of them trauma
patients treated on an emergency basis, and seven apical
scars treated by elective surgery. Details are in listed Table 1.
After surgical debridement in the first group and
nail-bed scar removal in the latter, skin and adipofascial
flaps were designed, dissected, and elevated according
to the description of our anatomical article.3 The adi-
162e
Table 1. Patient Summary*

Age (yr)
Sex
Dominant hand
Injured finger
Trauma
Days from trauma to surgery
No. of patients undergoing
immediate repair
(07 days after trauma)
No. of patients undergoing
secondary repair
(7 days after trauma)
Average, 37.5 (range, 469)

14 male; 4 female
16 right; 2 left
4 II; 6 III; 8 IV; 1 V
(1 patient with
2 fingers III, IV)
11 crush injuries,
3 road accidents,
1 dog bite
092
11
7
*One patient suffered from venous congestion with partial flap necrosis (40 percent of the flap), requiring debridement and a subsequent local flap advancement. However, an almost normal regrowth
of nail lamina was documented. None of our patients complained of
cold intolerance or residual joint contracture.
pofascial flaps were rotated to fill the defect and to

cover the exposed bone and sutured in place, and
topical care with moist dressings changed every other
day for the first 10 days was carried out. Figure 1 presents a representative case, in which a 37-year-old carpenter presented to our unit 5 days after sustaining a
crush injury of the right ring finger, with nail avulsion,
complete nail-bed breakdown, and comminuted fracture
of the distal phalanx. A surgical debridement was performed, with care taken to spare the matrix remnants, and
a homodigital distal adipofascial reverse flap was planned.
Under digital tourniquet, a book page skin flap was elevated and, after a careful dissection of the adipofascial
layer, starting proximally and sparing the underlying
paratenon and stopping the dissection 10 mm proximal
to the eponychium, the adipofascial flap was rotated to
cover the defect, and the skin flap was put down to cover
the adipofascial flap except for its tip. The distal part of
the flap was treated with petroleum-impregnated gauze
dressing twice during the first week and once during the
second week, undergoing complete reepithelialization on
day 13. Six-month follow-up showed good nail regrowth,
with a little swelling in correspondence with the flap pivot.
Sparing even small matrix remnants should always be
taken into consideration to achieve a satisfying nail lamina
regrowth and a nice final result.
Healing and regrowth of nail lamina, moving twopoint discrimination test; grip test; visual analogue
scale score; Italian Disabilities of the Arm, Shoulder
and Hand questionnaire; and time of return to full
occupational activity were examined. All patients showed
an uneventful postoperative recovery, with complete flap
survival. The nail lamina was observed slowly growing and
perforating the flap at a mean of 25 to 45 days; complete
regrowth occurred in 120 days (Fig. 1).
After a minimum follow-up of 6 months, static twopoint discrimination had a mean value of 9 mm. All
patients returned to full occupational activity within an
average of 4.5 weeks.

moval; and the flap is viable and perforated by the nail,
acting as a soft, concealing bed for nail growth. It does
not need microsurgical skills or skin grafts, as it heals
through spontaneous epithelialization. Scarring at the
donor site is limited and well tolerated, particularly as care
was taken to avoid placing the scars on the dorsum of the
digit, placing them in the midaxial access and in the same
digit. To our knowledge to date (except Hosnuter et al.4),
a systematic review of the use of this flap in apical scar
repair is lacking, and we propose this flap as a good
alternative also for reconstruction of the scarred nail bed.
DOI: 10.1097/PRS.0b013e318213a2ba
Gabriele Delia, M.D., Ph.D.

Maria Francesca Campolo, M.D.
Giovanni Risitano, M.D.
Benedetto Manasseri, M.D., Ph.D.
Francesco Stagno dAlcontres, M.D.
Michele R. Colonna, M.D.
Plastic Surgery Unit
Department of Surgical Specialties
Messina University Hospital
Messina, Italy
Correspondence to Dr. Colonna
Viale della Liberta` 395/Y isol 521
98121 Messina, Italy
mrcolonna@unime.it
DISCLAIMER
This article has been prepared and written conforming to the
Declaration of Helsinki; it is not a clinical trial.
REFERENCES
Fig. 1. (Above) Preoperative view of crush injury of the right ring

finger, with nail avulsion, complete nail-bed breakdown, and
comminuted fracture of the distal phalanx. (Center) A homodigital distal adipofascial reverse flap was planned. A book page skin
flap was elevated. The adipofascial layer was dissected, starting
proximally and sparing the underlying paratenon and stopping
the dissection 10 mm proximal to the eponychium. (Below) Sixmonth follow-up showed good nail regrowth, with a little swelling in correspondence with the flap pivot.
The technique itself showed several advantages: it is

easy and safe, because of a constant vascular supply
allowing also coverage of bone exposure after scar re-
1. Momeni A, Zajonc H, Kalash Z, Stark GB, Bannasch H. Reconstruction of distal phalangeal injuries with the reverse
homodigital island flap. Injury 2008;39:14601463.
2. Ozdemir R, Kilinc H, Sensoz O, Unlu RE, Baran CN. Innervated dorsal adipofascial turnover flap for fingertip amputations. Ann Plast Surg. 2001;46:914.
3. Delia G, Casoli V, Sommario M, Risitano G, DAlcontres FS,
Colonna MR. Homodigital dorsal adipofascial reverse flap:
Anatomical study of distal perforators and key points for safe
dissection. J Hand Surg Eur Vol. 2010;35:454458
4. Hosnuter M, Kargi E, Babuccu O. Is nail germinal matrix
ablation always necessary in a dorsal reverse adipofascial flap
procedure for fingertip reconstruction? Plast Reconstr Surg.
2004;114:1678; author reply 16781679.
Upper Extremity Mycobacterium chelonae

Cutaneous Infection
Sir:
ycobacterium chelonae is a rare cause of cutaneous

infections in immunocompetent individuals. We
report a case of M. chelonae infection of the upper
extremity and its surgical and medical interventions.
A 79-year-old woman presented with a 3-month history of nodular, erythematous lesions over the dorsum
of her right wrist and forearm (Fig. 1). The patient had
163e
Fig. 1. The patient had multiple erythematous nodules over the

dorsum of the right wrist and forearm.
polymyalgia rheumatica, heart disease, and hypothyroidism. Her medications included prednisone, Synthroid, estradiol, and multiple cardiac medications.
The patient also had long-standing right upper extremity lymphedema secondary to axillary lymph node dissection for breast cancer. There was no history of recent
travel, gardening, or other unusual hobbies. She did
not have any pets and could not recall any associated
trauma to her right arm.
On referral to a hand surgeon, the patient was afebrile, with several nontender erythematous nodules
over the dorsum of her right wrist and forearm. The
lesions were functionally nonlimiting; there was no
lymphadenopathy. Radiographs and basic laboratory
workup were normal. She subsequently underwent excision of the cutaneous lesions. Histologic evaluation
revealed dense neutrophilic collections within the deep
dermis and subcutaneous fat with abscess formation.
Acid-fast staining demonstrated large amounts of acidfast bacilli present throughout all the specimens obtained (Fig. 2, above). Additional Fites staining (a modified acid-fast stain, cross-reactive with M. chelonae)
corroborated these results (Fig. 2, below). The patient
continued on clarithromycin therapy for 6 months. All
wounds healed without incident.
M. chelonae is a rapidly growing acid-fast organism
that develops with an insidious course. It is most often
found in soil throughout the United States and is a rare
cause of mycobacterial cutaneous infection. Previous reports suggest that the most frequent areas of skin involvement are the extremities, which may correlate with areas
most often involved in minor traumatic injuries.1,2
Immunosuppression also appears to play a role in
the incidence and progression of the disease. Wallace
et al. identified 100 skin, soft-tissue, or bone isolates of
M. chelonae over a 10-year period.3 The most common
manifestation was disseminated cutaneous disease, followed by localized cellulitis, subcutaneous abscess, or
osteomyelitis. Among their patient population, 62 percent were receiving corticosteroids and 72 percent had
164e
Fig. 2. (Above) Photomicrograph showing multiple acid-fast bacilli, mostly in clusters. There are also bacilli scattered throughout
the specimen (acid-fast bacillus stain; original magnification,
40). (Below) Photomicrograph showing mycobacteria scattered throughout the cellular matrix. A cluster of bacilli is seen in
the specimen (Fites stain; original magnification, 40).
immunosuppressive conditions. In our patient, longterm prednisone therapy in addition to other comorbidities may have created chronic immunosuppression.
Diagnosis of M. chelonae cutaneous infection may
include chronic ulcerations, with expression of a caseous material. An antecedent penetrating traumatic injury may also be present, in addition to a history of
immunosuppressive conditions (e.g., acquired immunodeficiency syndrome) or drug therapy. Symptoms
may be vague, and there are no pathognomonic physical examination findings for M. chelonae. As a result,
diagnosis is often made late and usually follows other
empiric medical interventions that were unsuccessful.
M. chelonae infections of the upper extremity are rare.
Its incidence is associated with immunosuppression and
penetrating traumatic injuries. Surgical procedures may
also be associated. Early detection may be difficult, but
surgical excision is usually curative. In addition, the organism is largely sensitive to clarithromycin, and long-

term therapy may be required to eradicate disease.4
DOI: 10.1097/PRS.0b013e318213a27b
Andre Panossian, M.D.

Keck School of Medicine
University of Southern California
Myles J. Cohen, M.D.

Irving Posalski, M.D.
Cedars-Sinai Medical Center
Los Angeles, Calif.
Correspondence to Dr. Panossian
Division of Plastic Surgery
Childrens Hospital Los Angeles
4650 Sunset Boulevard, MS Suite 96
Los Angeles, Calif. 90027
drpanossian@gmail.com
REFERENCES
1. Mateo L, Rufi G, Nolla JM, Alcaide F. Mycobacterium chelonae tenosynovitis of the hand. Semin Arthritis Rheum. 2004;34:617622.
2. Kozin SH, Bishop AT. Atypical Mycobacterium infections of the
upper extremity. J Hand Surg Am. 1994;19:480487.
3. Wallace RJ Jr, Brown BA, Onyi GO. Skin, soft tissue, and bone
infections due to Mycobacterium chelonae chelonae: Importance
of prior corticosteroid therapy, frequency of disseminated
infections, and resistance to oral antimicrobials other than
clarithromycin. J Infect Dis. 1992;166:405412.
4. Franck N, Cabie A, Villette B, Amor B, Lessana-Leibowitch M, Escande JP. Treatment of Mycobacterium chelonae-induced skin infection with clarithromycin. J Am Acad Dermatol. 1993;28:10191021.
nerve structures. We propose a new technique to modify the shape of the needle, transforming it into a 90degree-angled needle and allowing the injector to stop
the needle insertion when it is introduced vertically
into firm palmar skin. This prevents the liquid from
penetrating into the deeper dermis, which may result
in muscle weakness (Figs. 1 and 2).
In the axilla, this technique allows for parallel introduction of the needle. It even allows the injector to
use the needle as a hook to raise the skin to make sure
that the injection is superficial, thereby minimizing the
subsequent loss of effect of the product.
To modify the needle, sterile clamps and sterile surgical gloves are used. The depth at which the injection
is intended is calculated (approximately 2.5 to 3 mm
for the palm of the hand and 5 mm for the armpit), and
the caudal end of the needle is bent without reducing
the caliber or damaging the cutting edge.
In our experience, this technique has simplified the
work significantly, resulting in reduced pain when the
Our Trick to Control the Depth of Injection of

the Botulinum Toxin in the Treatment
of Hyperhidrosis
Sir:
he efficiency of the treatment of hyperhidrosis with

botulinum toxin has previously been demonstrated.1 The main technical inconvenience reported
consists of difficulty injecting the product at an even
depth and avoiding diffusion into the dermis, which in
the case of palmar hyperhidrosis may lead to diffusion
toward the muscles of the hands. The most frequent complication in palmar hyperhidrosis is loss of muscle
strength, which has been reported in 6 to 77 percent of
patients.1
Zaiac et al. described the use of special ADG needles
with adjustable tops to control the depth of penetration.2
Unfortunately, these needles are not available in all countries, and they add an extra cost to the procedure. De
Almeida et al. reported the addition of a plastic top obtained by modifying the protective cap included in the
needle, leaving only 2.5 mm of the needle tip exposed.3
The main inconvenience with these modifications is that
direct vision of the needle tip is lost, which results in a
blind injection procedure.
In treating the palm of the hand, it has also been
suggested that physicians inject obliquely into the skin,
but this technique is more painful and produces more
bleeding by coursing through more capillaries and
Fig. 1. The needle is bent with a sterile clamp. The finished appearance of the modified needle is shown on the right.
Fig. 2. The modified needed can be used on the palm, entering

at a 90-degree angle to the skins surface. In the axilla, it enters
parallel to the skin and raises it.
165e

needle is inserted into deeper areas by mistake, fewer
complications, and significantly better outcomes,
which result in better patient satisfaction.
DOI: 10.1097/PRS.0b013e318213a292
Guillermo Blugerman,
Diego Schavelzon,
Honorio Labaronnie,
Andrea Markowsky,
Jorge DAngelo,
M.D.
M.D.
M.D.
M.D.
M.D.
B & S Clinic
Buenos Aires, Argentina
Correspondence to Dr. Blugerman
B & S Clinic
Buenos Aires, Argentina
blugerman@clinicabys.com
REFERENCES
1. Glaser DA, Hebert AA, Pariser DM, Solish N. Palmar and
plantar hyperhidrosis: Best practice recommendations and
special considerations. Cutis 2007;79:1828.
2. Zaiac M, Weiss E, Elgart G. Botulinum toxin therapy for palmar hyperhidrosis with ADG needle. Dermatol Surg. 2000;26:
230.
3. de Almeida AR, Kadunc BV, de Oliveira EM. Improving botulinum toxin therapy for palmar hyperhidrosis: Wrist block
and technical considerations. Dermatol Surg. 2001;27:3436.
Free Flap Skin Temperature Correlates to

Microcirculatory Free Flap Capillary Blood Flow
Sir:
n case of free flap failure, time is of utmost importance, as salvage rates have been reported to be inversely related to the time interval between the onset of
ischemia and its clinical recognition.1 The more rapid the
assessment and decision-making, the more likely the
Fig. 1. Blood flow temperature correlation.
166e
failed free flap will be salvaged. Besides clinical inspection

and capillary refill testing, various technical methods have
been suggested to be useful.2 However, to date, the
majority have certain limitations as far as practicability, availability, and financial issues are concerned.
Inspired by the technical tip of Robert Allen
published in Plastic and Reconstructive Surgery using
temperature strips to determine free flap skin temperature, we thought to underscore the clinical observation that a skin temperature difference of more
than 1C is supportive for flap malperfusion.3
As such, we used laser Doppler imaging to determine
microcirculation of free flaps to determine its correlation with flap temperature. A total of 54 free flaps were
monitored using a regular digital infrared surface thermometer (Medisana FTD, Germany) simultaneous
with microcirculatory assessment using combined laser
Doppler and photospectrometry (Oxygen to See; Lea
Medizintechnik, Giessen, Germany).
We found a positive correlation between free flap temperature and free flap capillary blood flow (Pearson correlation, r 0.44, p 0.001) in 54 free flaps (Fig. 1). A
1F less free flap temperature decreased the mean microcirculatory capillary blood flow by 20.8 relative units.
One free flap showed a temperature drop to 78.8F
caused by postoperative combined arterial and venous
malperfusion. After consecutive revision, the flap temperature was 97.1F at regular microcirculatory blood
flow. We therefore postulate an acute temperature drop
of 3F at the center of the skin island as indicative of
arterial thrombosis, whereas a 1 to 2F uniform drop of
the flap is indicative of venous compromise.
Despite meeting ideal monitoring criteria, surface
temperature monitoring is still regarded to be of
value only in monitoring replantation and small free
flap reconstruction by some authors.2 A recent study
proved laser Doppler flowmetry to be a useful investigative tool with which to monitor microcirculatory

blood flow changes in free flap transfer.4 Our study
demonstrates the free flap skin temperature is closely
related to microcirculatory capillary blood flow of a
given free flap assessed by a regular digital infrared
surface thermometer. In the future, free flap skin
temperature assessment might be a validated and
inexpensive adjunct monitoring method in plastic
and reconstructive surgery to improve patient safety.
DOI: 10.1097/PRS.0b013e318213a2a6
Robert Kraemer, M.D.

Karsten Knobloch, M.D., Ph.D.
Plastic, Hand, and Reconstructive Surgery
Johan Lorenzen, M.D.

Department of Nephrology
Stephan Papst, M.D.

Peter M. Vogt, M.D., Ph.D.
Hannover Medical School
Hannover, Germany
Correspondence to Dr. Kraemer
Carl-Neuberg-Str. 1
30625 Hannover, Germany
kraemer.robert@mh-hannover.de
DISCLOSURE
REFERENCES
1. Siemionow M, Arslan E. Ischemia/reperfusion injury: A review in relation to free tissue transfers. Microsurgery 2004;24:
468475.
2. Smit JM, Zeebregts CJ, Acosta R, Werker PM. Advancements
in free flap monitoring in the last decade: A critical review.
Plast Reconstr Surg. 2010;125:177185.
3. Chiu ES, Altman A, Allen RJ Jr, Allen RJ Sr. Free flap
monitoring using skin temperature strip indicators: Adjunct to clinical examination. Plast Reconstr Surg. 2008;122:
144e145e.
4. Booi DI, Debats IB, Boeckx WD, van der Hulst RR. A study of
perfusion of the distal free-TRAM flap using laser Doppler
flowmetry. J Plast Reconstr Aesthet Surg. 2008;61:282288.
Diastasis as a Cause of Recurrence in Ventral

Herniorrhaphy with Porcine Acellular Dermal
Collagen Implant
Sir:
n recent years, several new biological implants have
been introduced for ventral herniorrhaphy and are
proposed for clinical use in infected fields.1,2 Most of
these materials are well incorporated into the host
tissue and show high overall success rates. However,
because long-term outcomes on biological materials
are unavailable, the overall high success rate may be
partly explained by the relatively short duration of

follow-up and the high rate of loss to follow-up in
some studies.2 The exact cause of recurrence in such
patients remains unknown. Although words such as
diastasis and bulge have been used to describe
the failure of biomaterials, to our knowledge, accurate descriptions of what actually occurs are not available. We report a case of recurrent incisional hernia
that had previous repair with porcine acellular dermal collagen implant (Permacol) and discuss the
cause of recurrence.
A 67-year-old, 89-kg woman with end-stage diabetic
renal failure on hemodialysis presented with a recurrent midline abdominal incisional hernia. She previously had a left nephrectomy for tuberculosis, a radical
cystectomy with ileal conduit formation for urinary
bladder carcinoma, a right nephrectomy for recurrent
sepsis, and suture repair of a parastomal hernia. She
presented with a large midline incisional hernia (12
10 cm) which, because of an intraoperative enterotomy
during adhesiolysis, was repaired using a 15 10-cm
biological graft (porcine acellular dermal collagen implant) to reconstruct the abdominal wall. Postoperatively, the patient developed a methicillin-resistant
Staphylococcus aureus wound infection that was managed
with local dressings. At 6 weeks, the wound was healed
completely and there was no evidence of herniation in
the abdominal wall.
Six months later, she presented with recurrence of
swelling at the site of the previous incisional hernia.
Physical examination revealed a 12 8-cm nontender swelling at the site of the previous incisional
hernia repair (Fig. 1, above). A computed tomographic scan confirmed the presence of an incisional
hernia containing small bowel (Fig. 1, below). A second repair was undertaken. The previous skin wound
was excised and extensive skin flaps were elevated.
The hernial sac comprised stretched porcine acellular dermal collagen implant that was intact and still
attached to the margins of the abdominal wall defect.
(Fig. 2, above). The sac (i.e., bulging porcine acellular
dermal collagen implant) was opened and doublebreasted to close and narrow the defect (Fig. 2, center)
and a 30 30-cm polypropylene (Premilene) mesh
was placed in an onlay fashion onto the anterior
abdominal wall deep to the skin flaps (Fig. 2, below).
The patient had an uneventful recovery, and at
6-month follow-up the wound was well healed and
there was no recurrence of the hernia.
Permacol is a biological implant made from a sheet
of acellular cross-linked porcine dermal collagen. It
is nondegradable and cross-linked with hexamethylene diisocyanate, which provides added stability and
resistance to collagenase degradation, thus conferring the benefits of longevity and durability.3 The
indication for use of porcine acellular dermal collagen implant in our case was the potential for infection associated with bowel perforation. This was further justified when the patient developed wound
infection postoperatively. However, she started to
167e
Fig. 1. Patient had recurrence of hernia with previous repair of

incisional hernia showing the positive cough impulse (above).
Computed tomographic scan of her abdomen shows the recurrence of incisional hernia (stretch of Permacol) 3 months after
porcine acellular dermal collagen implant repair (below).
develop recurrent herniation at approximately 3

months after repair. At reoperation, there was no
true sac present, but the implant had appeared to
weaken and had stretched (diastasis). It may be possible that the wound infection contributed to the
development of this diastasis, perhaps by increased
breakdown of the implant or by an unknown effect
on the cross-linking of collagen. Cross-linking sterically limits collagenase degradation and controls
temporal remodeling in the normal environment.4
The remodeling of the material is the other possible
cause of the weakness and diastases; however, we do
not know the exact rate of this remodeling process,
nor do we know which factors influence this rate.
Our current knowledge of the long-term outcome
using biological materials in abdominal wall reconstruction is limited; however, it seems reasonable to
expect that these grafts help to avoid major complications, especially in the early postoperative period, and
help to achieve successful closure of complex abdom-
168e
Fig. 2. Perioperative images of the previous porcine acellular

dermal collagen implant (Permacol) in the center with the bulge
causing the recurrence of hernia. Arrows indicate the interrupted
polypropylene sutures of previous repair to fix the porcine acellular dermal collagen implant in position (above). Perioperative
photograph showing the double-breasted porcine acellular dermal collagen implant sac to close the defect (center) and a 30
30-cm polypropylene (Premilene) mesh as an onlay mesh onto
the anterior abdominal wall (below).
inal wounds. Further studies are needed to show the

long-term durability, stability, and recurrence rate with
the use of these biological materials.
DOI: 10.1097/PRS.0b013e318213a3ca

Faisal M. Shaikh, M.D.
Thomas E. Kennedy, M.B., B.A.O.
Peter Coyle, M.B., B.A.O.
Eamon G. Kavanagh, M.D.
Pierce A. Grace, M.Ch.
Mid-Western Regional Hospitals and University of
Limerick
Limerick, Ireland
Correspondence to Dr. Grace
Department of Vascular Surgery
Mid-Western Regional Hospital
Dooradoyle, Limerick, Republic of Ireland
pagrace@eircom.net
orthopedic shoulder holders are locked onto the

sides of the operating table with their pulley systems
facing the panniculus. Traction bows are attached to
the hooks of the pulley system. Adequate weight is
attached to the ropes to lift the panniculus vertically
up and expose the inferior portion clearly (Fig. 1).
A large curvilinear incision from one iliac crest to the
other approximately two fingerbreadths above the
pubic symphysis is made and carried down through
the subcutaneous tissue to the abdominal fascia with
electrocautery without undermining. The panniculus is mobilized in the cephalad direction up to the
xiphoid. We used tenaculae at this stage to suspend
the mobilized panniculus by connecting them to traction bows (Fig. 2). The panniculus is laid down after
releasing the Kirschner wires from the traction bows.
REFERENCES
1. Shaikh FM, Giri SK, Durrani S, Waldron D, Grace PA. Experience with porcine acellular dermal collagen implant in onestage tension-free reconstruction of acute and chronic abdominal wall defects. World J Surg. 2007;31:19661672;
discussion 16731674, 1675.
2. Hiles M, Record Ritchie RD, Altizer AM. Are biologic grafts
effective for hernia repair? A systematic review of the literature. Surg Innov. 2009;16:2637.
3. Hammond TM, Chin-Aleong J, Navsaria H, Williams NS. Human in vivo cellular response to a cross-linked acellular collagen implant. Br J Surg. 2008;95:438446.
4. Jarman-Smith ML, Bodamyali T, Stevens C, Howell JA, Horrocks M, Chaudhuri JB. Porcine collagen crosslinking, degradation and its capability for fibroblast adhesion and proliferation. J Mater Sci Mater Med. 2004;15:925932.
Panniculectomy as a PreBariatric
Surgery Procedure
Fig. 1. Elevation of the panniculus.
Sir:
large hanging panniculus is a significant health

problem in morbidly obese patients. Most of the
panniculectomies are performed either concurrently
with or subsequent to bariatric procedures. Patients with
a grade 5 panniculus,1 where it extends to the knees and
beyond, are candidates for pre bariatric surgery panniculectomy. Several case reports and series describe different
techniques, including tourniquets, towel clips, hover lift,
and floor cranes for panniculus exposure.25 We have
developed a new technique of exposure of tissue during
panniculectomy in select morbidly obese patients before
they undergo definitive bariatric surgery.
The patient is positioned supine on a wide-based
operating table used for bariatric surgery. General
anesthesia is administered along with muscle relaxation. Two large Kirschner wires are inserted
through the most dependent part of the panniculus
using an orthopedic drill approximately along the
midclavicular line. The depth of insertion depends
on the size of the panniculus. Traction bows are
attached to the two ends of the Kirschner wires. Two
Fig. 2. Further mobilization of the panniculus with tenaculae

and traction bows.
169e

The superior incision is made from one iliac crest to
the other. This incision is deepened down until the
abdominal fascia and panniculus is removed along
with the Kirschner wires. The superior and inferior
edges are approximated without tension. JacksonPratt drains are placed in the lateral aspects of the
wound. The subcutaneous tissue is brought together
with interrupted absorbable sutures and skin with
subcuticular running absorbable suture.
Our technique has several advantages. The Kirschner
wires can be easily drilled into the panniculus and to a
considerable depth, so the system is very stable. Shoulder
holders are connected to the operating table, which provides flexibility for patient positioning and does not interfere
with the surgeons maneuverability. By adjusting the weights
on the pulley and using tenaculae, the same system
can be used for different sizes of panniculi. Kirschner
wires can be easily detached, allowing panniculus to
be laid down for superior dissection.
Panniculectomy before a definitive bariatric procedure is a viable option in patients with grade 5 panniculus, allowing them to live a more mobile and productive life while waiting for definitive bariatric surgery.
Our technique helps the procedure, with minimal
strain on the operating surgeon.
DOI: 10.1097/PRS.0b013e3182131eb5
Bala Natarajan, M.B.B.S.

Pradeep K. Pallati, M.B.B.S.
Robert P. Bertellotti, M.D.
Robert Armour Forse, M.D., Ph.D.
Creighton University
Omaha, Neb.
Correspondence to Dr. Natarajan
Department of General Surgery
Creighton University
2500 California Plaza
Omaha, Neb. 68178
balanatarajan@creighton.edu
DISCLOSURE
REFERENCES
1. Igwe D Jr, Stanczyk M, Lee H, Felahy B, Tambi J, Fobi MA.
Panniculectomy adjuvant to obesity surgery. Obes Surg. 2000;
10:530539.
2. Reichenberger MA, Stoff A, Richter DF. Dealing with the mass:
A new approach to facilitate panniculectomy in patients with
very large abdominal aprons. Obes Surg. 2008;18:16051610.
3. Manahan MA, Shermak M. Massive panniculectomy after massive weight loss. Plast Reconstr Surg. 2006;17:21912197; discussion 21922193.
4. Daw JL, Mustoe TA. Use of tourniquet in panniculus resection. Plast Reconstr Surg. 1997;99:20822084.
5. Jensen PL, Sanger JR, Matloub HS, Yousif NJ. Use of portable
floor crane as an aid to resection of the massive panniculus.
Ann Plast Surg. 1990;25:234235.
170e
Extended Dermal Apposition: A Simple

Technique for the Closure of Irradiated
Perineal and Sacral Wounds
Sir:
he irradiated perineal or sacral wound is frequently encountered by reconstructive surgeons.

Unfortunately, these are difficult wounds because of
location and radiation-induced damage to the vasculature, fibroblasts, and the regulatory growth factors of wound healing.1 The damage to fibroblasts
may be particularly important in wounds subjected
to high tensile forces. Irradiated fibroblasts exhibit
reduced proliferation, abnormal migration, decreased quality of synthesized collagen, impaired
proline hydroxylation, and decreased collagen gene
expression.1 As a result, the tensile strength of the
surgical wound is decreased.2
We present our experience with these traditionally
challenging wounds using an extended dermal apposition technique for closure. The technique is simple,
requires no distant donor site, fills dead space, and is
universally applicable.
Nine patients (six men and three women) underwent
this procedure from 2004 to 2009 (Table 1). Five patients
had a sacral chordoma and required sacrectomy. The
remaining four patients suffered from rectal cancer and
had undergone abdominoperineal resection. All patients
had preoperative radiation therapy (average, 44.2 Gy;
range, 19.8 to 54 Gy). Five patients also had postoperative
radiation therapy (average, 27.4 Gy; range, 19.8 to 57.6 Gy).
If needed to fill dead space, the gluteus musculature is
mobilized and its fascial layer sutured together. The tissue
edges are pushed together manually and the lateralmost
area of contact is marked. An ellipse is then defined and
drawn around these markings. The ellipse is then deepithelialized with scissors or a knife. Typically, we deepithelialize a distance of 1.5 to 4 cm on each side of the wound.
We extend the deepithelialization the length of the irradiated field and where tension is maximal. Often, this is
not the entire length of the wound (Fig. 1).
The leading dermal edges are then brought together in the midline and sutured with interrupted
absorbable sutures. Once this is done, the ellipse is
advanced toward the midline with subsequent layers
of absorbable suture (usually three additional layers)
driving the leading edges into the depth of the
wound (Fig. 1). Ultimately, the epidermal edges are
brought together in the midline with cutaneous nylon
sutures and a liquid skin adhesive. The patient is instructed to avoid pressure to the wound for 4 weeks and
an air-fluidized bed is often used. The nine patients in this
series all had completely healed wounds (Fig. 2).
Preoperative radiotherapy is important in the
treatment of rectal cancer and sacral chordomas,
promoting successful resection and allowing bladder, anal sphincter, and nerve preservation.3,4 Unfortunately, it results in a higher rate of wound
complications.3,4 Not only do these nonhealing
wounds use time and resources, they can also delay
60
43
51
72
73
46
43
80
35
Initial
Operation
Crohn disease,
tobacco
abuse
None
Hepatitis C
Comorbidities
Sacral
chordoma
Sacral
chordoma
Sacral
chordoma
Sacral
chordoma
Sacral
chordoma
Sacrectomy
Sacrectomy
Sacrectomy
Sacrectomy
Sacrectomy
Concurrent
prostate
cancer (with
radiation of
79.2 Gy)
None
None
None
None
Rectal cancer APR with distal None

sacrectomy
and
coccygectomy
Rectal cancer APR
Rectal cancer APR
Rectal cancer APR
Underlying
Disease
APR, abdominoperineal resection; M, male; F, female.
Sex
Age
(yr)
Table 1. Patient Characteristics
19.8
(postoperative,
57.6 )
50.4
(postoperative,
19.8 )
50.4
(postoperative,
19.8 )
50.4
(postoperative
19.8 )
50.4
21.6
50.4
54
Radiation before
Dermal
Apposition (Gy)
Closure done at
50.4
time of primary
(postoperative,
resection
19.8)
Draining sinuses,
infection,
nonhealing
wound for 33
mo
Abscess, draining
sinuses,
nonhealing
wound for 23
mo
Abscesses, sinus
tracts, positive
margins, open
wound for 1
mo
Sacral wound
breakdown
with
nonhealing for
12 mo
Closure done at
time of primary
resection
Closure done at
time of primary
resection
Closure done at
time of primary
resection
Closure done at
time of primary
resection
Complications
from Cancer
Resection
Size of
Deepithelialization
(cm2)
100
40
64
24
36
60
160
90
60
Size of
Wound
(cm)
25 7
42
96
32
16 5
25 6
30 9
18 7
17 6
None
None
None
None
None
None
None
None
None
Complications
from Dermal
Apposition
11
11
33
33
56
18 (died with
healed
wound)
39
Follow-Up
(mo)
171e
Fig. 1. Posterior view of a typical patient in the series demonstrating original wound extending
into the peritoneal cavity (left). The deepithelialized dermis is advanced into the wound and
closedinlayers(right).Thesuperiorportionofthewoundwasclosedwithoutdeepithelialization.
Fig. 2. Preoperative (left) and 6-week postoperative (right) photographs after wound closure using the extended dermal
apposition technique. This patient received 50.4 Gy of preoperative and 19.8 Gy of postoperative irradiation. He also received 79.2 Gy directed to his prostate for concomitant prostate cancer before the dermal invagination closure.
the onset of life-saving adjuvant chemotherapy or

postoperative irradiation.3,4 Muscle flaps are frequently used in these situations.5
The benefit of the extended dermal apposition
technique is that it is simple and quick, allows for
some dead-space filling, and is performed with a
minimal donor defect. It leaves other reconstructive
options available. It can be performed at the time of
cancer resection or after wound breakdown. Most
importantly, we have found it to be durable.
DOI: 10.1097/PRS.0b013e318213a3e2
172e
Tristan L. Hartzell, M.D.

Miguel Medina, M.D.
Francis J. Hornicek, M.D.

Department of Orthopedic Surgery
William G. Austen, Jr., M.D.

Boston, Mass.

Correspondence to Dr. Hartzell
55 Fruit Street
Boston, Mass. 02114
thartzell@partners.org
DISCLOSURE
REFERENCES
1. Tibbs M. Wound healing following radiation therapy: A review. Radiother Oncol. 1997;42:99106.
2. Gorodetsky R, McBride WH, Withers HR, Miller GG. Effect of
fibroblast implants on wound healing of irradiated skin: Assay
of wound strength and quantitative immunohistology of collagen. Radiat Res. 1991;125:181186.
3. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary
perineal wound closure after preoperative radiotherapy and
abdominoperineal resection has a high incidence of wound
failure. Dis Colon Rectum 2005;48:438443.
4. Zileli M, Hoscoskun C, Brastianos P, Sabah D. Surgical treatment of primary sacral tumors: Complications associated with
sacrectomy. Neurosurg Focus 2003;15:18.
5. Chessin DB, Hartley J, Cohen AM, et al. Rectus flap reconstruction decreases perineal wound complications after pelvic
chemoradiation and surgery: A cohort study. Ann Surg Oncol.
2005;12:104110.
Use of a Retrograde Pedicled Double-Barreled

Osteocutaneous Fibula Flap for Reconstruction
of Distal Tibia and Soft-Tissue Defects
Sir:
fter trauma or oncologic surgery, distal lower

extremity reconstruction is often challenging.
Although microsurgery allows composite transfer of
bone, muscle, and skin, free tissue transfer to the
lower extremity is marred by high failure rates.1 Traditionally, free osteocutaneous fibula flaps have been
the workhorse flaps for reconstructing dual bone and
Fig. 1. (Above, left) A 7-cm distal tibia defect (filled with antibiotic bone spacer) had loss of overlying soft tissue following surgical
debridement. Intraoperative marking of the tunnel site for skin paddle was marked with a checkerboard pattern. (Above, left) A
retrograde osteocutaneous fibula flap was mobilized on the distal pedicle after ligation of the peroneal vessels at their takeoff.
(Below, left) After contouring osteotomy, a double-barreled vascularized fibula and a single strut of nonvascularized fibula were
cerclage-wired together to fill the distal tibial defect. (Below, right) After final inset, the skin paddle appeared viable.
173e

soft-tissue defects.2,3 In 1986, Chen et al. described a
pedicled, osteocutaneous fibula flap for distal femur
reconstruction.4 Later, Minami et al. described the
retrograde fibula flap based on communicating
branches between the peroneal and posterior tibial
vessels for reconstruction of distal tibia defects.5
To our knowledge, no retrograde, pedicled fibula
flap has been harvested with an overlying soft-tissue
component supplied by underlying peroneal septocutaneous perforators. Such a skin paddle allows reconstruction of accompanying soft-tissue defects and serves
as a marker for total flap viability. Furthermore, cutaneous harvest has not been reported in a retrograde,
pedicled fibula flap in which the fibula is osteotomized.
A patient suffered an open tibia-fibula fracture complicated by osteomyelitis and nonunion. After debridement, she had a 7-cm distal tibia and soft-tissue defect
(Fig. 1). We used a retrograde, pedicled, osteocutaneous fibula flap for reconstruction.
Intraoperatively, the fibula was traced from the lateral condyle of the knee to the lateral malleolus. The
area between the defect and harvest sites (checkerboard pattern) marks where the flap would be tunneled. We used Doppler ultrasonography to identify
peroneal perforators and accordingly designed a
12 6-cm skin paddle. Using both anterior and
posterior approaches, the osteocutaneous fibula flap
was harvested in situ in the standard fashion.3 Next,
we dissected cephalad to the tibial-peroneal trunk,
ligating the peroneal vessels at their takeoff. This

converted the in situ flap into a retrograde flap mobilized on its distal pedicle (Fig. 1). The recipient site
was prepared by elevating fasciocutaneous edges and
the previously marked tunnel. A reconstruction plate
was presecured in the anteromedial tibia (spanning
the defect) with five proximal and four distal screws,
and then removed. The fibula was osteotomized into
thirds: the distal segment was used as the main bony
bridge and was telescoped into the proximal and
distal ends of the tibia, the middle third was buttressed alongside this segment, and the proximal
portion was osteotomized off at the original fibula
fracture site and used as a nonvascularized bone
graft. This left a vascularized double-barreled fibula
and a nonvascularized third strut acting as a fibula
graft. These three struts were cerclage-wired together
using 16-gauge wires and the reconstruction plate
was resecured (Fig. 1). A drain was placed in the
recipient bed. The proximal donor site was closed
primarily and a meshed split-thickness skin graft was
used distally. The skin paddle was inset in layers
(Fig. 1). A posterior resting splint was fashioned to
maintain the ankle at 90 degrees. At 12-month followup, the patient could bear weight, had radiographic
evidence of good bony union, and had an acceptable
final soft-tissue contour (Fig. 2). The retrograde,
pedicled fibula osteocutaneous flap advances previously described variations of the fibula free flap to
Fig. 2. (Left) Lateral radiograph shows the reconstructed tibia at 20-month follow-up.
(Right) At 12-month follow-up, the patient was able to bear weight and had stable
soft-tissue coverage and acceptable final contour.
174e

safely provide autogenous reconstruction of distal
tibia and soft-tissue defects.
DOI: 10.1097/PRS.0b013e3182131e9e
Raj M. Vyas, M.D.

John E. Ready, M.D.

Department of Orthopedic Surgery
Lifei Guo, M.D., Ph.D.

Brigham and Womens Hospital
Boston, Mass.
Correspondence to Dr. Guo
Brigham and Womens Hospital
75 Francis Street
Boston, Mass. 02115
lguo@partners.org
DISCLOSURE
The authors have no financial interests in or commercial
associations with any product or technique advocated in this
article.
REFERENCES
1. Khouri RK, Shaw WW. Reconstruction of the lower extremity
with microvascular free flaps: A 10-year experience with 304
consecutive cases. J Trauma 1989;29:10861094.
2. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004;114:14571466.
3. Mathes SJ, Nahai F. Fibula flap. In: Reconstructive Surgery: Principles, Anatomy, and Technique. Vol. 2, 1st ed. New York:
Churchill Livingstone; 1997:13531370.
4. Chen ZW, Chen LE, Zhang GJ, Yu HL. Treatment of tibial
defect with vascularized osteocutaneous pedicled transfer of
fibula. J Reconstr Microsurg. 1986;2:199203, 205.
5. Minami A, Itoga H, Suzuki K. Reverse-flow vascularized fibula
graft: A new method. Microsurgery 1990;11:278281.
Randomized Controlled Trials and

Consolidated Standards of Reporting Trials
Reporting Quality: An Evidence-Based Analysis
of the American Society of Plastic Surgeons,
American Burn Association, and American
Society for Surgery of the Hand
Conference Meetings
Sir:
fter the initiative by Plastic and Reconstructive Surgery

and the American Society of Plastic Surgeons to
promote evidence-based medicine1 and to strive for
high levels of reporting quality,2 it is current belief that
randomized controlled trials are the key to guiding and
helping clinical decision making. The broad field of
plastic surgery with its subdisciplines reconstructive surgery, burn surgery, aesthetic surgery, and hand surgery
often lacks a fair amount of published randomized
controlled trials. However, to date, there is no com-
parative analysis on the recent developments of randomized controlled trials in reconstructive, burn, aesthetic, and hand surgery. Furthermore, reporting
quality of randomized controlled trials was addressed
by the Consolidated Standards of Reporting Trials
group first in 1996, and was updated in 2001 and very
recently in 2010.3 The Consolidated Standards of Reporting Trials items aim to improve the reporting quality of randomized controlled trials in full article and in
abstract form.4 Using the Consolidated Standards of
Reporting Trials items, one can compare the reporting
quality of randomized controlled trial conference abstracts, which was a second aim of this analysis. To
analyze up to date, we decided to analyze various conferences rather than full articles, given the fact that not
all randomized controlled trials presented as abstracts
will find their way to a full article within the next 5 years.
We analyzed 65 oral abstracts and 94 poster abstracts from the 2008 meeting of the American Society of Plastic Surgeons by two independent researchers. In addition, 152 oral and 100 poster
presentations from the 2008 meeting of the American Burn Association were analyzed, as were102 abstracts from the American Society for Surgery of the
Hand annual meeting. We determined the evidencebased medicine level of evidence for study design.
Furthermore, the level of reporting quality according
to the Consolidated Standards of Reporting Trials
recommendations was determined with a maximum
score of 17 of 17 points.
We found that at the American Society of Plastic
Surgeons 2008 meeting, 9 percent (5 percent oral and
4 percent poster abstracts) of presentations were randomized controlled trials. Reporting quality at the
American Society of Plastic Surgeons meeting was 6.7
1.2 for oral randomized controlled trials and 7.3 1 for
poster randomized controlled trials (p 0.498; 95 percent confidence interval, 2.62 to 1.46) of 17 achievable
points according to Consolidated Standards of Reporting Trials criteria. At the American Burn Association
Annual Meeting, 7 percent randomized controlled trials were presented, with 5 percent oral and 2 percent
poster presentations. Reporting quality according to
Consolidated Standards of Reporting Trials criteria was
not significantly different for oral versus poster randomized controlled trials (7.2 1.4 versus 6.5 1 of
17 points, p 0.552; 95 percent confidence interval,
1.78 to 3.06). We identified 10 percent randomized
controlled trials at the American Society for Surgery of
the Hand meeting. Consolidated Standards of Reporting Trials reporting quality was 8.2 1.4 of 17, somewhat higher than for randomized controlled trials presented at the American Society of Plastic Surgeons
meeting.
Our results indicate that the amount of randomized controlled trials presented either in oral or
poster abstract form at American Society of Plastic
Surgeons, American Burn Association, and American
Society for Surgery of the Hand meetings is still below
10 percent of all presentations. Given the fact that
175e

not every conference abstract will be followed by a
full article, these numbers should be discussed. In
1996, Amadio and colleagues studied the rate of full
article randomized controlled trials from volume 1 to
volume 19 (1994) of The Journal of Hand Surgery. From
3107 articles, letters, and abstracts, they identified 25
controlled clinical trials and eight randomized controlled trials (0.26 percent).5 A 10-year analysis of
publications in Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and Aesthetic Surgery Journal revealed a randomized controlled trial publication rate
of 3.2 percent.6 A 16-year analysis of all articles published in Aesthetic Plastic Surgery revealed only a 1
percent randomized controlled trial publication rate
(11 of 1048 original articles).7 In Plastic and Reconstructive Surgery, the number of randomized controlled trials published increased from 1983 to 2003
from 0 percent to 7 percent.8 As far as reporting
quality is concerned, all conference abstracts presented at American Society of Plastic Surgeons,
American Burn Association, and American Society
for Surgery of the Hand meetings have plenty of
room for improvement, with the Consolidated Standards of Reporting Trials statement to be endorsed
substantially.
DOI: 10.1097/PRS.0b013e3182131af9
Karsten Knobloch, M.D.

Uzung Yoon
Peter M. Vogt, M.D., Ph.D.
Hannover, Germany
Correspondence to Dr. Knobloch
Carl-Neuberg-Str. 1
30625 Hannover, Germany
knobloch.karsten@mh-hannover.de
8. Loiselle F, Mahabir RC, Harrop AR. Levels of evidence in

plastic surgery research over 20 years. Plast Reconstr Surg. 2008;
121:207e211e.
Narcissism, Perfectionism, and Interest in

Cosmetic Surgery
Sir:
ultural commentators argue that we live amid an

age of narcissism, where narcissistic self-absorption and perfectionistic striving encourage interest in
cosmetic surgery.1 Case studies and media reports also
suggest that narcissism (vanity, exhibitionism, superiority, and entitlement) and perfectionism (ceaselessly
demanding perfection of oneself) foster interest in cosmetic surgery.2 Such observations, although provocative, have yet to be subjected to empirical scrutiny.
To address this shortcoming, we recruited 305 undergraduate women (mean SD age, 19.48 3.26
years) who completed reliable and valid self-report
questionnaire measures of narcissism,3 perfectionism,4
and interest in cosmetic surgery.5 Our study was approved by an institutional ethics committee, and participants provided informed consent in writing. A moderated multiple regression analysis predicting interest
in cosmetic surgery explained a moderate amount of
variance (R 2 0.05, p 0.05) and indicated that
narcissism ( 0.07, p 0.05) and perfectionism (
0.10, p 0.05) were unrelated to interest in cosmetic
surgery. However, narcissism interacted with perfectionism ( 0.14, p 0.05) such that interest in cosmetic
surgery was greatest among individuals with high levels of
both narcissism and perfectionism (Fig. 1).
REFERENCES
1. Chung KC, Swanson JA, Schmitz D, Sullivan D, Rohrich RJ.
Introducing evidence-based medicine to plastic and reconstructive surgery. Plast Reconstr Surg. 2009;123:13851389.
2. Hopewell S, Clarke M, Askie L. Reporting of trials presented
in conference abstracts needs to be improved. J Clin Epidemiol.
2006;59:681684.
3. Schulz KF, Altman DG, Moher D; CONSORT Group.
CONSORT 2010 statement: Updated guidelines for reporting
parallel group randomised trials. BMJ. 2010;340:c332.
4. Hopewell S, Clarke M, Moher D, et al. CONSORT for reporting randomised trials in journal and conference abstracts.
Lancet 2008;371:281283.
5. Amadio PC, Higgs P, Keith M. Prospective comparative clinical trials in The Journal of Hand Surgery (American). J Hand
Surg Am. 1996;21:925929.
6. Chang EY, Pannucci CJ, Wilkins EG. Quality of clinical studies
in aesthetic surgery journals: A 10-year review. Aesthetic Surg J.
2009;29:144147; discussion 147149.
7. Becker A, Blumle A, Antes G, et al. Controlled trials in aesthetic plastic surgery: A 16-year analysis. Aesthetic Plast Surg.
2008;32:359362.
176e
Fig. 1. Individuals characterized by high levels of both narcissism and perfectionism appear especially interested in cosmetic surgery.

Our results lend credence to observations implicating narcissism and perfectionism in cosmetic surgery1,2
and refine this literature by suggesting that a synergistic
relation between narcissism and perfectionism may underlie and motivate interest in cosmetic surgery. Narcissistic perfectionists (individuals characterized by extreme levels of both narcissism and perfectionism) may
strive to perfect their bodies through cosmetic surgery in
an effort to garner attention, demonstrate superiority, or
augment a grandiose but unstable sense of self.3,4
Although not all cosmetic surgery patients are narcissistically pursuing bodily perfection, important implications for cosmetic surgeons nevertheless arise from our
results. Narcissistic perfectionists may be particularly challenging and potentially hostile patients. Indeed, a vain,
entitled, and grandiose patient demanding a perfect (and
therefore unrealistic) outcome may be nearly impossible
to satisfy even if an objectively successful and aesthetically pleasing surgical outcome is obtained. Pairing surgical
procedures with psychological interventions may assist narcissistic perfectionists in overcoming barriers to a satisfying
surgical experience.
DOI: 10.1097/PRS.0b013e3182131ec9
Skye Fitzpatrick
Simon Sherry, Ph.D.
Nikola Hartling
Paul Hewitt, Ph.D.

Gordon Flett, Ph.D.
Dayna Sherry, Ph.D.
Department of Psychology
Dalhousie University
Halifax, Nova Scotia, Canada
Correspondence to Dr. Sherry
Department of Psychology
Dalhousie University
1355 Oxford Street
Life Sciences Centre
Halifax, Nova Scotia B3H 4J1, Canada
simon.sherry@dal.ca
REFERENCES
1. Twenge J, Campbell W. The Narcissism Epidemic. New York: Free
Press; 2009.
2. Goldwyn R. The Patient and the Plastic Surgeon. Boston: Little,
Brown; 1991.
3. Raskin R, Terry H. A principle-components analysis of the
Narcissistic Personality Inventory and further evidence of its
construct validity. J Pers Soc Psychol. 1988;54:890902.
4. Hewitt P, Flett GL. Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. J Pers Soc Psychol. 1991;60:456470.
5. Sherry S, Hewitt P, Lee-Baggley D, Flett G, Besser A. Perfectionism and thoughts about having cosmetic surgery performed. J Appl Biobehav Res. 2004;9:244257.
177e

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VIEWPOINTS

Viewpoints, pertaining to issues

standard lipectomy procedures to avoid visual loss.

he complication that plastic surgeons and patients

Volume 127, Number 6 Viewpoints

Alan Ali Parsa, M.D.

sion after intralesional steroid injection. Ophthal Plast Reconstr

Lower Blepharoplasty with Orbital Septum

rominent eyelid fat pads are a common problem

Plastic and Reconstructive Surgery June 2011

Volume 127, Number 6 Viewpoints

Fig. 3. Patient 1 preoperatively (above) and 1 year postoperatively (below).

Fig. 4. Patient 2 preoperatively (above) and 1 year postoperatively (below).

tion. We assessed the cases of both applications after

Ozan Balik, M.D.

Plastic and Reconstructive Surgery June 2011

sure of the antihelical fold was performed (facilitated

Volume 127, Number 6 Viewpoints

Nabil I. Elsahy, F.R.A.C.S., F.A.C.S.

Temporalis Fascia for Lip Augmentation

he pervasiveness of the beauty of lips persists today,

Fig. 1. Temporalis fascia is either splayed out, rolled, stacked, or

Plastic and Reconstructive Surgery June 2011

There was only one minor complication related to the

The senior author has had extensive experience with

Brian P. Dickinson, M.D.

Volume 127, Number 6 Viewpoints

Human Immunodeficiency VirusRelated

acial lipoatrophy, defined as flattening or indentation

The cases shown in the study performed by Claude et al.,

Raffaele Rauso, M.D.

Gilda Cobellis, M.D., Ph.D.

Vincenzo Sangiovanni, M.D.

Plastic and Reconstructive Surgery June 2011

Neovascularization following Facial Surgery:

ngiogenesis is essential for wound healing. Normal

Volume 127, Number 6 Viewpoints

had minimal discomfort during treatment and mild,

with different sutures.5 Postsurgical telangiectasis is likely

Shlomit Halachmi, M.D., Ph.D.

Maurice Adatto, M.D.

Ran Kornowski, M.D.

Moshe Lapidoth, M.D., M.P.H.

Plastic and Reconstructive Surgery June 2011