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Viewpoints
Treatment of Male Pattern Baldness with
Botulinum Toxin: A Pilot Study
Sir:
W
e would like to present the results of an open-
label pilot study using botulinum toxin type A
(Botox; Allergan, Inc., Irvine, Calif.) for the treatment
of androgenetic alopecia. This form of alopecia is be-
lieved to be caused by a genetically predisposed sensi-
tivity of hair follicles to the toxic effects of dihydrotest-
osterone, a metabolite of testosterone. Medical treatment
of androgenetic alopecia has previously only beenmod-
erately effective using systemic drugs such as finas-
teride, a 5-reductase inhibitor.
1
In this ethically approved study, 50 male subjects aged
between19 and57 years withNorwood/Hamiltonratings
of II to IV participated.
2
The study was 60 weeks in du-
ration, with 12 weeks of run-in followed by two treatment
cycles of 24 weeks each. Subjects were injected with 150
units of Botox (5 units per 0.1 ml saline) into the muscles
surrounding the scalp, including frontalis, temporalis,
periauricular, and occipitalis muscles in equally divided
doses over 30 injection sites. The primary outcome mea-
sure was a change in hair count in a fixed 2-cmarea using
a method described by Canfield.
3
Secondary outcome
measures included hair loss, measured by having subjects
collect loose hair fromtheir pillowwith a sticky lint roller,
and subjective efficacy using a validated questionnaire.
Statistical analysis entailed paired t tests of group means.
Forty subjects completed the study, and no adverse
effects were reported. The treatment response rate was
75 percent. Mean hair counts for the entire group
showed a statistically significant (p 0.0001) increase
of 18 percent between baseline and week 48 (Table 1),
similar to the results reported with Propecia (Merck,
Whitehouse Station, N.J.).
1
Hair regrowth was objec-
tively visible in some subjects (Fig. 1). Secondary out-
come measures were also significantly improved. The
reduction in hair loss and increase in hair count did not
show a statistically significant correlation. This sug-
gested that longer retention of terminal hairs did not
account for the increase in hair count.
Mechanistically, the scalpbehaves like a drumskinwith
tensioning muscles around the periphery. These muscle
groupsthe frontalis, occipitalis, and periauricular mus-
cles and to a minor degree the temporaliscan create a
tight scalp when chronically active. Because the blood
supply to the scalp enters through the periphery, a re-
ductioninbloodflowwouldbemost apparent at thedistal
ends of the vessels, specifically, the vertex and frontal
peaks. Areas of the scalp with sparse hair growth have
been shown to be relatively hypoxic, have slow capillary
refill, and to have high levels of dihydrotestosterone.
4
Conceptually, Botoxloosens thescalp, reducingpres-
sure on the perforating vasculature, thereby increasing
blood flow and oxygen concentration. The enzymatic
conversion of testosterone to dihydrotestosterone is ox-
ygen dependent. In low-oxygen environments, the con-
version of testosterone to dihydrotestosterone is favored;
whereas inhigh-oxygenenvironments, more testosterone
is converted to estradiol.
4
Blood flow may therefore be a
primary determinant in follicular health. Strategically
placed Botox injections appear able to indirectly modify
this variable, resulting in reduced hair loss and new hair
growth in some men with androgenetic alopecia.
DOI: 10.1097/PRS.0b013e3181ef816d
Brian J. Freund, D.D.S., M.D.
Marvin Schwartz, D.D.S., M.Sc.
Crown Institute
Pickering, Ontario, Canada
Correspondence to Dr. Freund
49 Main Street South
Uxbridge, Ontario L9P 1J4, Canada
freund@crowninstitute.com
This clinical trial has been registered as Treatment of
Male Pattern Baldness with Botulinum Toxin at
http://www.clinicaltrials.gov/ClinicalTrials.gov
with identifier NCT00965640. Copyright 2010 by the American Society of Plastic Surgeons
www.PRSJournal.com 246e
DISCLOSURE
The investigators have received support in the form of un-
restricted educational grants from Allergan Inc. (Irvine, Calif.)
within the past 5 years. The authors hold intellectual property
rights related to the process described in this study in both the
United States and the European Union. This study was not
supported by any commercial entity or government agency.
REFERENCES
1. Kaufman KD, Olsen EA, Whiting D, et al. Finasteride in the
treatment of men with androgenetic alopecia. Finasteride
Male Pattern Hair Loss Study Group. J Am Acad Dermatol.
1998;39:578589.
2. Norwood OT. Male pattern baldness: Classification and inci-
dence. South Med J. 1975;68:13591365.
Fig. 1. Pretreatment andposttreatment photographs of subjects withandrogeneticalopeciaresponsive
to Botox therapy.
Table 1. Summary of Mean Study Data
Time (wk)
12 (Run-in) 0 (First Injection) 4 24 (Second Injection) 28 36 48 (Completion)
No.
50 43 43 43 43 43 40
Hair count (group mean)
234 235 254 276 (18%)*
Hair loss (group mean)
144 96 88 (39%)
Subjective evaluation (Kaufman)
20 21 19 19
*Statistically significant increase (p 0.0001).
Statistically significant decrease (p 0.01).
Statistically significant change (p 0.04).
Volume 126, Number 5 Viewpoints
247e
3. Canfield D. Photographic documentation of hair growth in
androgenetic alopecia. Dermatol Clin. 1996;14:713721.
4. Goldman BE. Transcutaneous PO2 of the scalp in male pat-
tern baldness. Plast Reconstr Surg. 1996;97:11091116.
Mechanisms of Blepharoptosis following
Cosmetic Glabellar Chemodenervation
Sir:
C
hemodenervation with botulinum toxin type A has
gained widespread use in various cosmetic proce-
dures. Its long-lasting but impermanent effects make it
attractive for several reasons. First-time and repeated con-
sumers alike are drawnby convenience, cost, andefficacy.
For relatively risk-averse patients, repeated chemodener-
vation is a viable alternative to the permanence and com-
plications associated with incisional cosmetic surgery.
1,2
Facial muscles of expression, especially those in the peri-
orbital region, offer high-impact results.
3
Although inev-
itable, unexpected results including brow and lid ptosis
are frustrating for patients and providers.
Two forms of botulinum toxin type A are commer-
cially available in the United States today, onabotuli-
numtoxinA (Botox; Allergan, Inc., Irvine, Calif.) and
abobotulinumtoxinA (Dysport; Medicis Aesthetics, Inc.,
Scottsdale, Ariz.). As many as 5.4 percent of glabellar
treatments with Botox, and 3 percent with Dysport,
yield undesirable blepharoptosis.
4,5
This study proposes
and validates two mechanisms by which cosmetic cor-
rugator chemodenervation may lead to blepharoptosis.
First, botulinum toxin may contact the levator palpe-
brae superioris muscle as it traverses the preperiosteal
plane in deep injections. Second, the toxin may track
along tributaries of the superior ophthalmic vein,
which courses in along the levator muscle.
A human cadaver was injected with colored latex to
define arteries (red) and veins (blue). Methylene blue
(1%, 1 cc) was injected into the right and left corru-
gator muscles, at the level of the supraorbital foramina.
On the right, the injection needle was inserted deep to
the bulk of the muscle belly, approaching the periosteal
plane. On the left, the needle was inserted into the
muscle belly, with a trajectory toward the supraorbital
foramen. The superior orbital tissues were dissected
and inspected for tracking of dye along relevant lid and
orbital structures.
Dissection through the upper lids was conducted
through a horizontal incision running 15 mm superior
to the upper lid margin. The anterior orbital septum
and anterior surface of the levator aponeurosis were
stained bilaterally. Viewed through a craniotomy ap-
proach, on the right, dye stained the orbital surface of
the periosteumandthe periorbita. Dissectionof the left
orbit revealed dye staining the superior surface of the
levator palpebrae superioris and adjacent tissues, in-
cluding the superior ophthalmic vein and some of its
tributaries (Fig. 1).
This study was limited by unavoidable use of non-
physiologic conditions. Cooling of the cadaver for pres-
ervation and latex fixation may theoretically have
altered tissue-diffusion properties. Omission of latex
fixation would, however, limit visibility of minute
vascular structures that may be inadvertently dis-
sected or destroyed.
In this study, two mechanisms of blepharoptosis
from corrugator chemodenervation have been pro-
posed. First, toxin may reach the levator muscle as it
traverses the preperiosteal plane. Second, toxin may
track along tributaries of the superior ophthalmic vein,
which travels along the levator for part of its course.
Blepharoptosis may be avoided through careful super-
ficial positioning of the injection needle, using appro-
priately low volumes. Deep injections, particularly
those overlying the bulk of the supraorbital nerve or
Fig. 1. Orbital dissection. (Left) Left orbit viewedthroughthe craniotomy approach. Dye stains the anterior body of the
levator palpebrae superioris muscle (black arrow). Tiny tributaries feeding the superior ophthalmic vein are seen lying
on the belly of the muscle (white arrow). (Right) Right orbit viewed through the craniotomy approach. The periorbita is
seen as a blue-stained, glistening structure extending posteriorly to the orbital apex.
Plastic and Reconstructive Surgery November 2010
248e
near branches of the superior ophthalmic vein, should
be avoided to prevent perineural or perivascular infil-
tration around the levator palpebrae superioris.
DOI: 10.1097/PRS.0b013e3181ef822a
Nicholas A. Ramey, M.D.
Julie A. Woodward, M.D.
Duke University Eye Center
Durham, N.C.
Correspondence to Dr. Ramey
Duke University Medical Center
Box 3802
Durham, N.C. 27710
nicholas.ramey@duke.edu
DISCLOSURE
The authors have no financial interest to declare in re-
lation to the content of this article.
REFERENCES
1. Rzany B, Dill-Muller D, Grablowitz D, Heckmann M, Caird D;
German-Austrian Retrospective Study Group. Repeated bot-
ulinum toxin A injections for the treatment of lines in the
upper face: A retrospective study of 4,103 treatments in 945
patients. Dermatol Surg. 2007;33:S18S25.
2. Macdonald MR, Spiegel JH, Raven RB, Kabaker SS, Maas CS.
An anatomical approach to glabellar rhytids. Arch Otolaryngol
Head Neck Surg. 1998;124:13151320.
3. Carruthers A, Carruthers J. Eyebrow height after botulinum
toxin type A to the glabella. Dermatol Surg. 2007;33:S26S31.
4. Brandt F, Swanson N, Baumann L, Huber B. Randomized,
placebo-controlled study of a new botulinum toxin type a for
treatment of glabellar lines: Efficacy and safety. Dermatol Surg.
2009;35:18931901.
5. Carruthers JA, Lowe NJ, Menter MA, et al. A multicenter,
double-blind, randomized, placebo-controlled study of the
efficacy and safety of botulinum toxin type A in the treatment
of glabellar lines. J Am Acad Dermatol. 2002;46:840849.
Visual Field Defect after Facial Rejuvenation
with Botulinum Toxin Type A and
Polyacrylamide Hydrogel Injection
Sir:
A
esthetic medicine has evolved rapidly. The com-
binationof dermal fillers andbotulinumtoxintype
A treatment enhanced the results and decreased the
dose required independently.
1
Complications from
each treatment have been reported
1
but have not been
reported from combination treatment.
A 57-year-old woman presented to our clinic with a
3-day history of severe headache, left eye upper visual
field darkness, nausea, and vomiting immediately after
botulinum toxin type A and Aquamid (Contura Interna-
tional A/S, Soeborg, Denmark) injections. Her underly-
ing Sjogren syndrome was well controlled. Physical ex-
amination revealed edema, erythema, and multiple
pustules from the glabella to the nasojugal folds (Fig. 1).
Her best-corrected visual acuity was 20/20 inthe right eye
and 20/70 in the left eye. Her intraocular pressure was
normal. Positive relative afferent pupillary defect, limited
extraocular movement, and mild ptosis in the left eye
were found. Ophthalmoscopy showednopenetrationbut
localized choroiditis over the inferior nasal quadrant, dif-
fuse venous stasis without thrombi, and a swelling disc in
the left eye. The visual field confirmed a superior half
scotoma; fluoresceinangiography provedgeneralizedvas-
cular delayed filling in the left eye. Laboratory evaluation
was unremarkable. An enhanced T2-weighted magnetic
resonance imaging scanrevealedleft medial andsuperior
rectus hyperintensity, andoptic nerve andintraconal soft-
tissue swelling.
Transient incomplete third-nerve palsy, anterior
ischemic optic neuropathy, and localized cellulitis were
diagnosed. Oral steroids, intravenous antibiotics, and
aspirin were prescribed. The third-nerve palsy resolved
17 days later. The patient regained best-corrected visual
acuity of 20/30, with the sequelae of the superior half
visual field defect sparing the macula, a pale inferior
disc, inferior arteriolar attenuation and sheathing, and
nasal choroidal scars in her left eye 4 months later.
Combination treatment makes the origin more diffi-
cult to determine. The visual field, angiography, and disc
findings indicated vascular hypoperfusion or ischemia.
The eyeball was approximately 2.5 cm in diameter. The
Aquamid injection with a 27- or 31-gauge needle was not
deepenoughtocause ischemic optic neuropathy because
the needle head was approximately 1.3 cm in length.
However, injection of botulinum toxin type A into the
supratrochlear or supraorbital artery couldcauserefluxto
the ophthalmic artery, causing posterior ciliary artery ir-
ritationor vasospasmthat may leadtoinsufficient vascular
supply of the optic nerve (Fig. 2). The choroiditis indi-
cated that Aquamid was left as a mass effect in the peri-
conal-preequitorial area and compressed the inferior di-
vision of the third nerve, which caused the nerve palsy.
An autoimmune disease such as Sjogren syndrome is
a relative contraindication for dermal fillers; however,
Fig. 1. At initial presentation, the patient had swelling and ery-
thema around the periocular skin and multiple tiny whitish pus-
tules at the glabella extending bilaterally through the intercan-
thal area to the nasojugal folds.
Volume 126, Number 5 Viewpoints
249e
the reasons are undetermined.
2
Aquamid has been
used in 50 patients with human immunodeficiency virus
associated lipodystrophy without any complications.
3
There have been no complications related to injection in
patients with autoimmune diseases to date.
Ischemic optic neuropathy causedby direct injection
of botulinumtoxin type Ainto the periocular artery has
never been reported. The choroiditis and transient
third-nerve palsy caused by the volume effect of Aqua-
mid was first reported. The safety of combination treat-
ments of botulinum toxin type A and Aquamid in
immunoincompetent patients requires further study.
Skills with periocular injections deserve more attention
and detailed anatomical awareness.
DOI: 10.1097/PRS.0b013e3181ef81d9
Yi-Hsing Chen, M.D.
Yueh-Ju Tsai, M.D.
An-Ning Chao, M.D.
Yih-Shiou Huang, M.D.
Ling Yuh Kao, M.D.
Department of Ophthalmology
Chang Gung Memorial Hospital
Chang Gung University
College of Medicine
Taoyuan, Taiwan
Correspondence to Dr. Tsai
Department of Ophthalmology
Chang Gung Memorial Hospital
Chang Gung University
5, Fu-Shing Street
Kuei Shan, Taoyuan 333, Taiwan
erintsai@adm.cgmh.org.tw
Presented at the 44th local meeting of the
Ophthalmological Society of Taiwan.
DISCLOSURE
The authors have no commercial associations or financial
disclosures that might pose or create a conflict of interest with
anything discussed in this article.
REFERENCES
1. Carruthers JD, GlogauRG, Blitzer A; Facial Aesthetics Consensus
Group Faculty. Advances infacial rejuvenation: Botulinumtoxin
type A, hyaluronic acid dermal fillers, and combination thera-
pies. Consensus recommendations. Plast Reconstr Surg. 2008;121:
5S30S; quiz 31S33S.
2. Bello G, Jackson IT, Keskin M, et al. The use of polyacrylamide
gel in soft-tissue augmentation: An experimental assessment.
Plast Reconstr Surg. 2007;119:13261336.
3. De Santis G, Jacob V, Baccarani A, et al. Polyacrylamide hy-
drogel injection in the management of human immunodefi-
ciency virusrelated facial lipoatrophy: A 2-year clinical expe-
rience. Plast Reconstr Surg. 2008;121:644653.
Lateral Photography of the Nasal Tip: What Is
Acceptable and Can It Be Improved?
Sir:
T
he Frankfort horizontal line is determined by the
porion (upper margin of the external auditory me-
atus) and the orbitale (lowermost point of the inferior
bony orbit). It is important in assessing preoperative pho-
tographs before rhinoplasty and mentoplasty surgery, be-
cause photographs taken in this plane allow accurate na-
sal tip and chin assessment. Photographs form an
important part of the patient record, facilitate postoper-
ative evaluation, and provide potential defense in case of
adverse outcome. Our objective was to define acceptable
error of deviationfromthe Frankfort plane and assess the
accuracy of our service frommedical photography and to
improve this.
Fig. 2. Injection of botulinum toxin type A into the supratrochlear or supraorbital artery could
cause reflux into the ophthalmic artery, causing posterior ciliary artery irritation vasospasm and
anterior ischemic optic neuropathy.
Plastic and Reconstructive Surgery November 2010
250e
Four subjects with normal noses consented to lateral
rhinoplasty photography in the Frankfort plane, fol-
lowed by 20 photographs in degree increments above
and below this plane. Photographic conditions were
identical with respect to camera focal length, magnifi-
cation, and camera optics. A standard distance of 3 m
was used, with camera angulation reduced by a com-
mercial spirit level.
Four rhinoplasty surgeons assessed these, which they
divided into three groups:
Group A: Subject has tip ptosis requiring surgical cor-
rection to increase tip projection and rotation.
Group B: Subject has normal nasal tip projection, not
considered for change.
Group C: Subject requires tip derotation.
Assessment of photographs from four subjects sug-
gested that deviation of more than 9 degrees from the
Frankfort line results inperceived alterationof nasal tip
projection (Table 1).
After this, 100 photographs of patients before rhi-
noplasty were assessed to measure the degree of de-
viance from the Frankfort line in degrees (group 1).
National guidelines from the Institute of Medical
Illustrators
1
were distributed to the medical photog-
raphy department and a further 100 photographs
were assessed prospectively (group 2). Another audit
cycle was completed in which the photographer
marked surface landmarks and photographed pa-
tients with these marks aligned (group 3).
Marked variation was demonstrated, with 68 tilted in
a cephalad direction and six of the 100 orientated cor-
rectly. In 24 photographs, the error exceeded 9 degrees
from the horizontal plane (Fig. 1).
When national guidelines were followed, there was
a statistically significant improvement in scatter of
the data. However, there were only 13 photographs
in the correct plane and there was an error in ori-
entation by more than 9 degrees still evident in eight
cases (Fig. 2).
Table 1. Acceptable Range of Deviation fromthe Frankfort Plane (in degrees)
Subject
Surgeon 1 2 3 4
I 8 4 8 13 Acceptable tip range
4 9 9 3
II 6 4 8 11 Acceptable tip range
7 12 14 6
III 8 4 12 10 Acceptable tip range
8 14 14 10
IV 14 6 14 15 Acceptable tip range
6 12 13 9
Average acceptable range 9 4.5 10.5 12.25 9.1
6.25 11.75 12.5 7 9.4
Average acceptable range
Fig. 1. Deviation from the Frankfort plane before intervention in group A.
Volume 126, Number 5 Viewpoints
251e
Statistical analysis of the results using an unpaired
t test revealed a statistically significant difference
between groups 1 and 2 (p 0.018). Therefore, a
significant improvement in image orientation was
obtained.
Further analysis of the results revealed no difference
between group 1 and group 3 (p 0.0819) or between
group 2 and group 3 (p 0.4648). Rhinoplasty pho-
tographs within 9 degrees of rotation from the Frank-
fort plane provide an accurate representation of the
nasal tip.
Awareness and reinforcement of the use of guidelines
for preoperative photography significantly reduces, but
does not abolish, theerrors inherent inimageacquisition.
Surgeons should be aware of these deficiencies and make
allowances for them when assessing preoperative and
postoperative photographs of rhinoplasty cases. More im-
portantly, they should not regard the photographs as a
substitute for accurate and careful patient examination.
DOI: 10.1097/PRS.0b013e3181ef8181
Sukhbir Ahluwalia, M.R.C.S., M.Sc.
Vikrant Veer, M.R.C.S.
Guy S. Kenyon, M.B.A., F.R.C.S.
Whipps Cross University Hospital
London, United Kingdom
Correspondence to Dr. Ahluwalia
158 Princes Road
Buckhurst Hill
London IG9 5DJ, United Kingdom
mail@suki.org.uk
Presented in part at the British Rhinological Society
meeting, in Liverpool, United Kingdom, 2008.
DISCLOSURE
No outside funds have been used to support this work.
None of the authors has a financial interest in this work.
REFERENCE
1. Institute of Medical Illustrators (Web site). Available at: http://
www.imi.org.uk/natguidelines/IMINatGuidelinesRhinoplasty
May2006.pdf. Accessed November 2007.
A New Technique for Creating Spreader and
Septal Extension Grafts
Sir:
T
he keystone area is important bothaesthetically and
functionally, and when it is disrupted, it needs to
be reconstructed to maintain dorsal aesthetic lines,
nasal support, and natural airflow.
1,2
Controlling and
reshaping the nasal tip is another important part of
rhinoplasty procedures. A slight supratip break is
preferable, especially in women. To create a supratip
break, Byrd et al. described three types of septal
extension grafts.
1
The type 1 septal extension graft
consists of paired spreader grafts, and to create a
supratip break, the planes of the dome at the tip-
defining points and of the dorsum at the anterior
septal angle should vary 6 to 10 mm according to the
thickness of the soft tissues.
3
In this study, we aimed to define a new cartilaginous
harvesting technique to create septal extension grafts
and spreader grafts. Patients who are suitable candi-
dates for a new harvesting technique presented with
complaints of a dorsal cartilaginous hump.
Anendonasal approachcanbe usedif the patient has
an isolated dorsal hump, but more aggressive modifi-
cationto the nose requires anopenapproachandis our
favored technique. After the nasal dorsum is under-
mined, bilateral submucoperichondrial tunnels are
created and mucoperichondrium of the dorsal septum
is elevated caudal to cephalad. The upper lateral car-
tilage is separated sharply from the junction with the
Fig. 2. Deviation from the Frankfort line following intervention in group B.
Plastic and Reconstructive Surgery November 2010
252e
septum without damaging the mucosa. Using a no. 15
scalpel or septum scissors, dorsal cartilaginous reduc-
tion is performed.
4,5
At this point, the cartilaginous
septumis in three separate pieces, the septumcentrally
and the upper lateral cartilages laterally. Then, har-
vested cartilage was incised longitudinally to create a
spreader graft and the attached portion of cartilage was
used as a septal extension graft (Figs. 1 and 2).
Figure 3 shows a patient who underwent primary
rhinoplasty including humpectomy and septal exten-
sion grafts. Eight months later, the patient has appro-
priate dorsal aesthetic lines and supratip breakpoint.
Costal cartilage and the septal cartilage floor are the
primary and conventional sources of spreader and sep-
tal extension grafts. Excessive dissection is required for
these donor sites and may cause mucosal synechia, loss
of structural integrity of the L strut, avulsion of the
cribriform plate, and other disadvantages with rib car-
tilage harvest. Our new technique allows us to dissect a
minimum amount of mucoperichondrium. Another
advantage of this technique is the ability to reconstruct
the middle vault with simultaneous creation of the su-
pratip break in the same graft. Harvested graft can be
used as a columellar strut graft if the patient does not
need spreader or septal extension grafts. The attached
portion of the graft was used as a septal extension graft
if the patient needed a supratip break. If not, grafts
were incised longitudinally all the way to create
spreader grafts.
This technique was performed in 54 consecutive pri-
mary rhinoplasty patients who required dorsal reduc-
tion. Spreader grafts were used in 37 patients and septal
extension grafts were used in 17 patients who needed
a supratip breakpoint. The newharvesting technique of
the spreader and septal extension graft is a simple,
reproducible, and effective technique that can be used
to assist dorsal reduction in primary rhinoplasty while
preserving the dorsal aesthetic lines and creating a
supratip breakpoint.
DOI: 10.1097/PRS.0b013e3181ef8140
Gursel Turgut, M.D.
Ali Tufan Soydan, M.D.
Lutfu Bas, M.D.
Plastic Reconstructive and Aesthetic Surgery Department
S isli Etfal Training and Research Hospital
Istanbul, Turkey
Correspondence to Dr. Soydan
Plastic Reconstructive and Aesthetic Surgery Department
S.B. S isli Etfal Training and Research Hospital
Buyukdere Street
S isli, Istanbul, Turkey
drtufansoydan@gmail.com
PATIENT CONSENT
The patient provided written consent for the use of
her image.
REFERENCES
1. Byrd HS, Meade RA, Gonyon DL Jr. Using the autospreader
flap in primary rhinoplasty. Plast Reconstr Surg. 2007;119:
18971902.
Fig. 1. (Above) Creation of a submucoperichondrial pocket and
(below) harvesting the cartilaginous hump as a graft. Three sep-
arate pieces of harvestedcartilage, the septumcentrally andup-
per lateral cartilage laterally, were harvested.
Fig. 2. (Above) Harvested cartilage was incised longitudinally
and the attached portion was used as a septal extension graft if
the patient needed a supratip break (below).
Volume 126, Number 5 Viewpoints
253e
2. Constantian MB, Clardy RB. The relative importance of septal
and nasal valvular surgery in correcting airway obstruction in
primary and secondary rhinoplasty. Plast Reconstr Surg. 1996;98:
3854.
3. Byrd HS, Andochick S, Copit S, Walton KG. Septal extension
grafts: A method of controlling tip projection shape. Plast
Reconstr Surg. 1997;100:9991010.
4. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump
reduction: The importance of maintaining dorsal aesthetic
lines in rhinoplasty. Plast Reconstr Surg. 2004;114:12981308;
discussion 13091312.
5. Rohrich RJ, Lary HH. Rhinoplasty: Dorsal reduction and
spreader graft. Paper presented at the 17th annual Dallas
Rhinoplasty Symposium; March 24, 2000; Dallas, Texas.
Tailoring Nasal Splints to Optimize
Rhinoplasty Results
Sir:
N
o rhinoplasty surgeon would deny the contribu-
tions of nasal splinting in this challenging surgery.
It can help to stabilize structures, thus reducing edema
and improving remodeling appearances. Although
many masters in this field have emphasized this step
and introduced commodities off the shelf, better re-
sults could be achieved if nasal splints could be tailored
to fit different cases. Over the past 2 years, partly be-
cause of economic considerations, we have chosen to
fashion nasal splints ourselves for our patients. This has
Fig. 3. Preoperative and postoperative views of a patient who underwent primary rhinoplasty
using the septal extension graft. Note the smooth supratip break 8 months after surgery.
Plastic and Reconstructive Surgery November 2010
254e
proved to be a simple and effective tip that is worth
sharing.
In the preparation process, empty alloy cans were
collected. We selected those that were stronger than
aluminum cola cans, softer than lead pots, with good
flexibility, and with a smooth surface. The entire body
was cut into one metal plate and then thoroughly
cleaned and sterilized. A broad, cloth tape was placed
on one side of the metal plate for standby. Then, a reel
of double-sided adhesive foam was preparedthe se-
nior author used items found easily in supermarkets
and hardware stores, including a sewing scissors, pliers,
ballpoint pen, and ruler in the operating room for
tailoring (Fig. 1).
At the end of each rhinoplasty operation, after all
incisions have been closed and before the patient has
left the operating room, 5 minutes is spent tailoring the
splint. First, the distance between the radix point and
the anterior angle of the septum to be the height of an
isosceles trapezoid-shaped splint is measured. Then,
each projection (upper projection and lower projec-
tion) and the width between two dorsumaesthetic lines
(upper width and lower width) are measured carefully
on these two points to plan the upper and lower edges
of the trapezoid. Finally, we can draw an isosceles trap-
ezoid on the cloth tape/metal plate composite with its
bottom edge being as long as doubled lower projection
plus lower width; the upper edge is doubled upper
projection plus upper width and its height equal to the
height of an isosceles trapezoid-shaped splint (Fig. 2).
The scissors is used to cut the trapezoid off the plate
and blunt four angles into an arc form, making sure
that there is no barb on any of the edges. With the help
of a long straight pliers, it can easily be angled along the
dorsum aesthetic lines on the splint. After trying it on
the patients nose anddetermining that it is satisfactory,
we can fix it on the patients nose with the double-sided
adhesive foam to finish the work.
In our experience, the tailoring splint can replace those
commodities, be used repeatedly on the same patient, and
be adjusted at the surgeons will. It costs only 5 minutes and
almost no money to make a new one whenever we need it.
Wecaneventeachpatients todoit themselves inthekitchen,
which is often helpful for nonlocal patients. Generally, tai-
loring splints can save money and time, save patients and
surgeons sometimes, and always save the earth.
DOI: 10.1097/PRS.0b013e3181efeaaa
Zhanqiang Li, M.D.
Yongxue Xie, M.D.
Qinjian Peng, M.D.
Lin Liu, M.D.
Bo Yu, M.D.
Beijing Huangsi Aesthetical Surgery Hospital
Beijing, Peoples Republic of China
Correspondence to Dr. Li
Beijing Huangsi Aesthetical Surgery Hospital
No. 9 Anwai Huangsi Street
Beijing 100120, Peoples Republic of China
leezhanqiang@hotmail.com
Autoclave Sterilizable Pencils in
Maxillofacial Surgery
Sir:
C
ommercially available pencils have been used for
intraoperative marking in maxillofacial surgery
since the 1980s. They are versatile and inexpensive, and
offer the possibility for teaching and discussion intra-
operatively. Planning prospective cuts (Fig. 1) and eras-
ing markings is simple and can be repeated with high
precision many times. However, there are two con-
cerns: first, the safety regarding sterility applying only
very quick conventional autoclave procedures; and sec-
ond, uninvestigated health risks for the patient attrib-
utable to pencil exposure.
The objective of this article is to present a nontoxic
pencil that can be sterilized effectively by conventional
Fig. 2. Splint design: UP, upper projection; UW, upper width; LP,
lower projection; LW, lower width; H, height of an isosceles trap-
ezoid-shaped splint.
Fig. 1. Materials and splints.
Volume 126, Number 5 Viewpoints
255e
autoclave procedures. Furthermore, the literature was
reviewed to investigate the potential toxicity of the in-
dividual components of pencils and the pencil as such.
To test sterility and wear, 30 nonlacquered 2HB pen-
cils (Caran dAche SA, Geneva, Switzerland) (Fig. 2)
without labels or coloring were individually double-
wrapped in laminated sterilization bags (SPS Amcor
Flexibles, Coulommiers, France), and steam-sterilized
at 134C for 18 minutes. No visible alteration of the
pencils was observed. Then, 15 pencils each were ex-
amined 2 weeks and 3 months following sterilization by
immersion in brain-heart infusion broth (bioMerieux,
Marcy lEtoile, France), incubation at 35C for 14 days,
and testing for bacterial growth. Results were negative
for all 30 pencils.
On request, the manufacturer informed us that the
pencils are made with birch wood, graphite, and kaolin
only. We performed a MEDLINE and textbook search
(articles between 1960 and 2009) related to potential
toxicity of the pencil and its components. In brief,
results of our search showed that, today, graphite-con-
taining pencils are considered virtually nontoxic in
small to moderate exposures.
1
More specifically, birch
wood dust can induce pulmonary diseases such as al-
lergic rhinitis, chronic bronchitis, and asthma.
2
No re-
ports were found regarding toxicity when ingested or
in contact with oral mucosa. Graphite is found in soil
or rocks such as granite and marble.
3
There are no
reports proving toxicity in its pure form. However, pen-
etrating injuries with pencil graphiteparticularly in
the case of a local reactionmay require surgical
intervention.
4
Kaolin is mined and used for a variety of
goods such as paper, porcelain, and rubber.
3
In an
experimental setting, it has been used to produce se-
vere inflammation (e.g., arachnoiditis when injected
into tissue).
5
As there is no airway contact in our pa-
tients and our pencils are not used within soft tissues,
we consider pencils safe for intraoperative use.
In conclusion, we found that unlabeled, nonlac-
quered pencils have many advantages, such as im-
proved intraoperative accuracy, biocompatibility, and
low cost. Most importantly, they are easily sterilized by
standard autoclave procedures in a short time (18 min-
utes). As our pencil brand may not be available in all
countries, it canbe replaced by other products. For new
brands, we advise that there should be no labels or
coloring and that sterility testing should be performed.
DOI: 10.1097/PRS.0b013e3181ef81ed
Andrej Terzic, M.D., D.M.D.
Service of Maxillofacial and Oral Surgery
Department of Surgery
Sasi Dharan
Didier Pittet, M.D., M.S.
Infection Control Program
Paolo Scolozzi, M.D., D.M.D.
Service of Maxillofacial and Oral Surgery
Department of Surgery
University of Geneva Hospitals and Faculty of Medicine
Geneva, Switzerland
Correspondence to Dr. Terzic
Service of Maxillofacial and Oral Surgery
Department of Surgery
Geneva University Hospitals
4 Rue Gabrielle-Perret-Gentil
1211 Geneva 14, Switzerland
andrej.terzic@hcuge.ch
DISCLOSURE
None of the authors has a financial interest in any of the
products mentioned in this article. There were no outside
sources of funds.
REFERENCES
1. Olson KR, ed. Poisoning & Drug Overdose: A Lange Clinical
Manual. 2nd ed. Norwalk, Conn: Appleton & Lange; 1994.
2. Maatta J, Majuri ML, Luukkonen R, et al. Characterization of
oak and birch dust-induced expression of cytokines and che-
mokines in mouse macrophage RAW 264.7 cells. Toxicology
2005;215:2536.
3. Graphite. In: Encyclopdia Britannica. Available at: http://www.
britannica.com/EBchecked/topic/242042/graphite. Accessed
October 4, 2009.
Fig. 1. Intraoperative application during genioplasty. Note the
precise planning regarding the mental nerve.
Fig. 2. Standard pencils with no labels or coloring unwrapped
and in sterilization bags.
Plastic and Reconstructive Surgery November 2010
256e
4. Seider N, Gilboa M, Lautman E, Miller B. Delayed presenta-
tion of orbito-cerebral abscess caused by pencil-tip injury.
Ophthal Plast Reconstr Surg. 2006;22:316317.
5. Brodbelt AR, Stoodley MA, Watling AM, Tu J, Jones NR. Fluid
flow in an animal model of post-traumatic syringomyelia. Eur
Spine J. 2003;12:300306.
Broad-Vector Facial Suspension with a Zygomatic
Arch Anchor for Paralyzed Face Revival
Sir:
W
e present a simple technique that employs the
zygomatic arch as a stable point for the suspen-
sion of collapsed facial tissue, with fibrous Gore-Tex
(expanded polytetrafluoroethylene) to secure the tis-
sue in its new position.
A 2-cm incision is made to the depth of the oral
vestibule of the involved site. Wide subperiosteal dis-
section is performed over the zygomatic area. Then, a
zygomatic awl is introduced in the anteriormost part of
the zygomatic arch and its tip is passed through toward
the oral cavity until it is easily visible in the dissected
area. A 3-0 nylon suture is passed through the hole of
the awl. Then, this instrument is withdrawn gently and
is turnedaroundthe zygomatic arch. Inthis step, we will
have a thread around the arch with two ends in the oral
cavity.
Two centimeters (or more) of a vascular Gore-Tex
(W. L. Gore and Associates, Flagstaff, Ariz.) tube is cut.
By introducing the tip of a mosquito forceps, a tunnel
is prepared and the vascular Gore-Tex is inserted in this
tunnel and secured with resorbable sutures in place.
One of the free ends of nylon suture that was pre-
pared in the first step is passed through the vascular
catheter and tied with the other end of nylon suture.
Patients are instructed in proper oral hygiene and ad-
vised to follow a soft diet for the first month.
The static suspension of facial tissue is an effective
technique that was introduced for treatment of facial
paralysis. Multivector suspension is a successful method
that was described by Alex and Nguyen. They used the
lateral orbital rim as an anchor for the suspending
sutures.
1
The fascias and periosteum have been de-
scribed for anchoring the facial tissue to drag it into a
cephalic position.
2,3
Autogenous fascia lata grafts, ex-
panded polytetrafluoroethylene, bioabsorbable poly-
lactic acid, and acellular dermal allograft have been
used to prevent tissue slipping.
4
In this technique, we use a stable point to lift the com-
missure and other tissues. After 2 months, the Gore-Tex
tube is integrated into the soft tissue and will stabilize the
tissue in the new position for facial reanimation.
The zygomatic arch can act as a pulley to drag the
Gore-Tex tube, and the Gore-Tex tube can protect
tissue fromtearing under suture tension.
5
However, the
only limitation of pulling force is the tensile strength of
the suture. The Gore-Tex tube distributes the pulling
force froma point to a line, and the pulling force could
perform as a broad vector instead of multiple tiny vec-
tors. The wider and deeper insertion of this vector
could reduce the pinched view and result in a natural
appearance (Fig. 1).
The advantages of this technique are as follows: it
uses a minimal incision, it is less time consuming, and
it is associated with a short recovery time. The suspen-
sion of paralyzed tissue can enhance the nasal breath-
ing, speech, and cosmesis of patients. We have per-
formed this technique in five patients so far, and the
Fig. 1. Schematicviewof Gore-Texsuspendedfromthezygomaticarchwithasuture(left). The
Gore-Tex tube is the origin of a broad vector in this static facial suspension technique (right).
Volume 126, Number 5 Viewpoints
257e
results have been promising (Fig. 2). All of the cases
were stable, and no complications were seen at fol-
low-up (3 months to 1 year).
DOI: 10.1097/PRS.0b013e3181ef8216
Behnam Bohluli, D.M.D.
Department of Oral and Maxillofacial Surgery
Buali Hospital
Azad University of Medical Sciences
Abass Kazemi Ashtiani, M.D.
Department of Plastic and Reconstruction Surgery
Hazrat Fatemeh Hospital
Iran University of Medical Sciences
Nima Moharamnejad, D.M.D.
Craniomaxillofacial Research Center
Shariati General Hospital
Tehran University of Medical Sciences
Correspondence to Dr. Moharamnejad
Craniomaxillofacial Research Center
Shariati General Hospital
Tehran University of Medical Sciences
P.O. Box 14515-659
Tehran, Iran
nima_mnj@yahoo.com
PATIENT CONSENT
The patient provided written consent for the use of her
image.
REFERENCES
1. Alex JC, Nguyen DB. Multivectored suture suspension: A min-
imally invasive technique for reanimation of the paralyzed
face. Arch Facial Plast Surg. 2004;6:197201.
2. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access
cranial suspension lift: A modified S-lift. Plast Reconstr Surg.
2002;109:20742086.
3. Saylan Z. Purse string-formed plication of the SMAS with
fixation to the zygomatic bone. Plast Reconstr Surg. 2002;110:
667671.
4. Humphrey CD, McIff TE, Sykes KJ, Tsue TT, Kriet JD. Suture
biomechanics and static facial suspension. Arch Facial Plast
Surg. 2007;9:188193.
5. Morgan AS, McIff T, Park DL, Tsue TT, Kriet JD. Biome-
chanical properties of materials used in static facial suspen-
sion. Arch Facial Plast Surg. 2004;6:308310.
Resorbable Suture Fixation of Neonatal
Mandibular Fractures: A Novel Technique
Sir:
W
e wish to introduce a resorbable suture fixation
technique for displaced neonatal mandibular
fracture repair. A premature girl born at 33 weeks
gestation sustained a mandibular symphysial fracture
after breech vaginal presentation necessitated forceps-
assisted vaginal delivery of this 1800-g infant. The pa-
tient was subsequently transferred to our institution for
management of her mandibular fracture. Computed
tomography demonstrated a significantly displaced
midline fracture at the symphysis (Fig. 1). After stabi-
lization, she was taken to the operating room for open
reduction and internal fixation. The airway was man-
aged by means of oral intubation, with suture ligation
of the endotracheal tube supplemented by adhesive
tapes. The inferior border of the mandible was exposed
by lower buccal sulcus incision and the fracture was
then reduced (Fig. 2, above). Because the fracture site
Fig. 2. (Left) Preoperativeview. (Right) Postoperativeviewinrestingposition, 12months after
facial suspension, of a patient with previous nerve graft failure.
Plastic and Reconstructive Surgery November 2010
258e
was through a growth plate, only very limited curettage
was performed. A 1.1-mm hole was drilled into the
inferior border of the fractured fragment and reduc-
tion was achieved with a single 3-0 polydioxanone su-
ture (Fig. 2, below). The mentalis muscle was reattached
using 4-0 Vicryl suture (Ethicon, Inc., Somerville, N.J.)
and the buccal sulcus incision was closed. The patient
did well postoperatively, tolerating oral feeding of for-
mula diet with good weight gain.
Neonatal mandibular fractures, especially those
resulting from traumatic obstetric delivery, are rare.
Prolonged second stage of labor, midforceps deliv-
ery, shoulder dystocia, surgeon inexperience, and
birth weight over 4000 g are risk factors for traumatic
obstetric delivery.
1,2
Interosseous and circumferential metallic wiring was
largely used for repair of the neonatal mandibular frac-
tures as reported by Vasconcelos et al.
1
Although it
provides an excellent reduction of the fracture, subse-
quent removal of hardware is necessary. In addition,
these metallic implants can cause growth restriction
when deployed in immature cases, necessitating re-
moval after achieving sufficient fracture healing. Im-
plant extrusion and allergic reactions are other sources
of morbidity for the neonatal patient.
3
Using resorb-
able suture fixation eliminates the need for subsequent
removal and provides excellent reduction of a dis-
placed fracture, as seen in this case. Obviously, the
residual interfragmentary strain is higher with sutures.
However, the key question is whether it is enough to
prevent redisplacement while healing is taking place.
Laster et al. described memory shape nickle-titanium
monocortical staple fixation as a semirigid, noninvasive
method of fixation that was used in a 9-month-old
infant and in a 4-year-old girl, with excellent results
and minimal morbidity. The staples were subse-
quently removed 6 months later.
4
Much like staple
fixation, resorbable sutures offer a minimally invasive
approach to fracture fixation but without the need
for subsequent removal.
Giventhe lowloaddemands of the neonatal mandible,
rigid fixation appears unnecessary. The unpredictable
growth disturbance associated with this impressionable
mandible questions even the most noninvasive manip-
ulations needed for adequate reduction and fixation.
We contend that, given the minimal load associated
with the neonatal mandible and its robust healing po-
tential, minimal exposure and fixation should be
usedjust enough to hold the reduction while healing
occurs. Overall, resorbable suture fixation appears to
be a safe, effective, and minimally invasive method of
fixation of neonatal mandible fractures, with minimal
risk of limiting future growth.
DOI: 10.1097/PRS.0b013e3181efa6e1
Nishant Bhatt, M.D.
Gerald J. Khachi, M.D. Fig. 1. Three-dimensional computedtomographic reconstruction.
Fig. 2. Exposure of mandibular fracture (above) with subse-
quent suture fixation (below).
Volume 126, Number 5 Viewpoints
259e
Jack C. Yu, D.M.D., M.D.
Section of Plastic and Reconstructive Surgery
Medical College of Georgia
Augusta, Ga.
Correspondence to Dr. Yu
Section of Plastic and Reconstructive Surgery
Medical College of Georgia
1467 Harper Street, HB 5040
Augusta, Ga. 30912
jyu@mail.mcg.edu
DISCLOSURE
The authors have no financial interest to declare in re-
lation to the content of this article.
REFERENCES
1. Vasconcelos BC, Lago CA, Nogueira RV, Gondim DG, Filho
AB. Mandible fracture in a premature infant: A case report
and review of the literature. J Oral Maxillofac Surg. 2009;67:
218222.
2. Chidzonga MM. Mandibular fracture in a neonate: Report of
a case. Int J Maxillofac Surg. 2005;35:186187.
3. Yerit KC, Hainich S, Enislidis G, et al. Biodegradable fixation of
mandibular fractures in children: Stability and early results. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:1724.
4. Laster Z, Muska EA, Nagler R. Pediatric mandibular fractures:
Introduction of a novel therapeutic modality. J Trauma 2008;
64:224229.
Magnetic Resonance ImagingBased Progress
Control after Autologous Fat Transplantation
Sir:
A
utologous fat transplantation to the female breast
is a current hot topic in plastic surgery. The initial
clinical results are encouraging. However, measure-
ment of the transplanted fat volume is hampered.
Furthermore, the potential for tumor induction dur-
ing transplantation, especially adipose-derived stem
cells in autologous fat transplantation, is a major con-
cern. To date, no evidence-based guidelines have been
available regarding safety issues as far as tumor induc-
tion and detection and clinical outcome in autologous
fat transplantation are concerned. To overcome the
aforementioned problems of patient safety and to have
an outcome analysis of the transplanted fat volume, we
would like to propose serial magnetic resonance im-
aging as a potential solution in this regard.
Magnetic resonance imaging has been used to con-
trol postoperative results up to 53 months (average, 25
months) after autologous fat transfer to the breast.
1
The diagnostic power of mammary magnetic resonance
imaging in detecting abnormalities of the breast is em-
phasized by studies about breast cancer imaging,
2
or
after failed silicone breast augmentation.
3
The high
sensitivity and specificity of magnetic resonance imag-
ing promote this method, but the higher cost of the
examinations does not.
Performing aesthetic surgery of healthy breasts or
reconstructive surgery after breast cancer by using au-
tologous, potentially adipose-derived stemcell fat trans-
fer, supports baseline imaging to exclude any abnor-
mality. Although conventional autologous fat transfer
to the breast seems to be safe, with only two breast
carcinomas described,
4
the situation using adipose-de-
rived stem cell transplantation is unclear to date.
As such, we have implemented a protocol with serial
breast magnetic resonance imaging starting with base-
line magnetic resonance imaging before autologous fat
transplantation, and subsequent serial magnetic reso-
nance imaging scans at 6 and 12 months after autolo-
gous fat transplantation. The imaging data of magnetic
resonance imaging examinations can be used for both
potential tumor detection and outcome analysis using
breast volumetry and volume-based algorithms.
5
Unless
evidence-based recommendations on the appropriate
imaging modality are available, we follow our female
patients undergoing autologous fat transplantation us-
ing serial magnetic resonance imaging to improve both
patient safety and outcome analysis.
DOI: 10.1097/PRS.0b013e3181ef938c
Christian Herold, M.D.
Karsten Knobloch, M.D., Ph.D.
Hans O. Rennekampff, M.D., Ph.D.
Department of Plastic, Hand, and Reconstructive Surgery
Hannover Medical School
Hannover, Germany
Klaus Ueberreiter, M.D.
Department of Plastic Surgery
Asklepios Klinik
Birkenwerder, Germany
Peter M. Vogt, M.D., Ph.D.
Department of Plastic, Hand, and Reconstructive Surgery
Hannover Medical School
Hannover, Germany
Correspondence to Dr. Herold
Department of Plastic, Hand, and Reconstructive Surgery
Hannover Medical School
Carl-Neuberg-Str. 1
30625 Hannover, Germany
christianherold@gmx.de
DISCLOSURE
The authors have no commercial associations that might
pose or create a conflict of interest with information on products
presented in this communication.
REFERENCES
1. Zheng DN, Li QF, Lei H, et al. Autologous fat grafting to the
breast for cosmetic enhancement: Experience in 66 patients
with long-term follow up. J Plast Reconstr Aesthet Surg. 2008;
61:792798.
2. Tozaki M. Diagnosis of breast cancer: MDCT versus MRI.
Breast Cancer 2008;15:205211.
3. Gorczyca DP, Gorczyca SM, Gorczyca KL. The diagnosis of
silicone breast implant rupture. Plast Reconstr Surg. 2007;120:
49S61S.
4. Gutowski KA. Current applications and safety of autologous
fat grafts: Areport of the ASPS fat graft task force. Plast Reconstr
Surg. 2009;124:272280.
Plastic and Reconstructive Surgery November 2010
260e
5. Herold C, KnoblochK, Stieglitz LH, Samii A, Vogt PM. Magnetic
resonance imaging-based breast volumetry in breast surgery: A
transfer from neurosurgery. Plast Reconstr Surg. 2010;125:17e19e.
Breast Cerebrospinal Fluid after
Ventriculoperitoneal Shunt Placement
Sir:
T
here are many complications in implant-based breast
reconstruction. Themost commonaremastectomy flap
necrosis, infection, implant/expander exposure, capsular
contracture, deflation, and rippling.
1
We present the fourth
report of a ventriculoperitoneal shunt complication related
to breast implant but the first to cause implant rupture.
A 66-year-old white woman presented who, 19 years
previously, hadundergone bilateral breast reconstruction
with silicone implants. She presented to the clinic with
complaints of bilateral ruptured implants, diagnosed by
means of magnetic resonance imaging. The patients his-
tory was significant for hydrocephaly with a ventriculo-
peritoneal shunt under the implant. The decision was
made to revise the shunt to an alternative route before
implant exchange, thus decreasing the chance of injury
to the shunt during the implant exchange. She under-
went an uncomplicated revision of the shunt by neuro-
surgery, and postoperative radiographs confirmed place-
ment of the peritoneal catheter. Two months after shunt
revision, the patient returned to our clinic with com-
plaints of redness and swelling of the right breast. She was
admitted to the hospital, and computed tomographic
scan showed the shunt to be within the right breast cap-
sule (Fig. 1). She was taken to the operating room, and
it was foundthat duringtheshunt change, theright breast
implant had been punctured inadvertently and had ce-
rebrospinal fluid within the capsule (Fig. 2). Exterioriza-
tion of the shunt was performed, as was removal of the
breast implant. Results of intraoperative cultures were
negative, andthe patient hadanuncomplicatedrecovery.
Six months later, the patient underwent placement of a
right breast implant and left breast implant exchange.
Many complications associated with ventriculoperi-
toneal shunts have been described, with a reported rate
of up to 25 percent. The most common complications
are obstruction and associated infections. Other com-
plications include perforations of hollow viscera, solid
viscera, ascites, and pseudocysts.
2
Displacement of the
catheter is a known complication after ventriculoperi-
toneal shunt placement, with migration to locations
such as the breast, thoracic cavity, chest wall, and
scrotum.
3
A PubMed search for ventriculoperitoneal
shuntrelated complications to the breast found 11
case reports, which involved 12 patients. Chief com-
plaints of the 12 patients included enlargement of the
breast (n 4), breast lump (n 4), nipple discharge
(n 3), and infection (n 1). Three patients had
implant-related complications after ventriculoperitoneal
shunt placement. The time between ventriculoperitoneal
shunt placement and symptoms was 1 day and 6 weeks in
two of the three patients, respectively. In both of these
cases, there was no rupture of the implant, but the cath-
eter dislodged and migrated proximally.
4,5
Another pa-
tient with a history of a ventriculoperitoneal shunt un-
derwent elective breast augmentation. She presented 10
weeks later with breast cerebrospinal fluid pseudocyst re-
sulting from migration of the catheter caused by an ep-
isode of vigorous breast manipulation.
3
This case highlights a complication of ventriculoperi-
toneal shunt and breast implants. Our case involved per-
foration of the implant during placement of the ventricu-
loperitoneal shunt and subsequent migration into the
breast. The plastic surgeon can aid the neurosurgeon by
suggesting a more lateral location for tunneling the peri-
toneal catheter, to avoid injury to any existing implant.
DOI: 10.1097/PRS.0b013e3181ef81aa
Kamlesh B. Patel, M.D.
Michael S. Wong, M.D.
Fig. 1. Computed tomographic scan showing the ventriculo-
peritoneal shunt to be within the right breast capsule.
Fig. 2. Intraoperative finding of the ventriculoperitoneal shunt
within the right breast implant.
Volume 126, Number 5 Viewpoints
261e
Thomas P. Whetzel, M.D.
Lee L. Pu, M.D., Ph.D.
Thomas R. Stevenson
Division of Plastic Surgery
University of California Davis Medical Center
Sacramento, Calif.
Correspondence to Dr. Patel
Division of Plastic Surgery
University of California Davis Medical Center
2221 Stockton Boulevard, Suite 2125
Sacramento, Calif. 95817
kamlesh.patel@ucdmc.ucdavis.edu
DISCLOSURE
The authors have no financial interest to declare in re-
lation to the content of this article.
REFERENCES
1. McCarthy CM, Mehrara BJ, Riedel E, et al. Predicting com-
plications following expander/implant breast reconstruction:
An outcomes analysis based on preoperative clinical risk. Plast
Reconstr Surg. 2008;121:18861892.
2. Taub E, Lavyne MH. Thoracic complications of ventriculo-
peritoneal shunts: Case report and review of the literature.
Neurosurgery 1994;34:181183; discussion 183184.
3. Iyer HP, Jacob LP, Chaudhry NA. Breast cerebrospinal fluid
pseudocyst. Plast Reconstr Surg. 2006:118:87e89e.
4. Spector JA, Culliford AT, Post NH, Weiner H, Levine JP. An
unusual case of cerebrospinal fluid pseudocyst in a previously
augmented breast. Ann Plast Surg. 2005;54:8587.
5. Torres AN. Late complication of a ventriculoperitoneal shunt
in a patient with mammary prosthesis. J Plast Reconstr Aesthet
Surg. 2008;61:212214.
Lipofilling in Breast Cancer Patients: From
Surgical Technique to Oncologic Point of View
Sir:
A
nimportant question should be raised today con-
cerning the safety of lipofilling in breast cancer
patients. Indications for lipofilling are broadening
extensively in aesthetic and reconstructive surgery.
After breast cancer treatment, lipofilling is now used
widely to improve the contour of the breast, both
after breast conservation and after breast reconstruc-
tion. Tentative techniques of total breast reconstruc-
tion without prostheses or flaps have been performed
and published.
14
In 2008, the French Society of Plastic, Reconstructive
and Aesthetic Surgery issued a recommendation to
French plastic surgeons to postpone lipofilling in the
breast with or without a history of breast cancer, unless
it is performed under a prospective controlled protocol.
5
In2009, the American Society of Plastic Surgeons set up
a fat graft task force to assess the safety and efficacy of
autologous fat grafting.
1
The task force conclusions
mentioned that no publication studied emphasized an
increasing risk of breast cancer recurrence or metas-
tasis related to the lipofilling procedure. However, no
study reached a high level of evidence as defined pre-
viously by the task force. Most studies were gathering
small series, with short follow-up, poor definition of the
cancer status of the patients, and no comparison with
a control group.
Moreover, the preparation of the fat to be trans-
ferred varies widely. The selection of adult adipocytes
by the Coleman technique using centrifugation to
discard the other components of the aspirated spec-
imen is the most frequently used. New approaches
aiming at enhancing the proportion of adult stem
cells are under study.
3
Addition of growth factors to
stimulate the survival of the adipocytes is also proposed
by some authors.
3
All of these techniques may promote
the stimulation of angiogenesis, although cancer treat-
ment research works on fighting against angiogenesis.
Moreover, experimental animal studies demonstrate a
stimulation of the cancer burden following lipofilling.
A number of publications emphasize the endocrine,
paracrine, and autocrine activity of the adipocytes. Adi-
pokines can have the tumor-stromal interaction with
breast parenchymal cell and stromal cells. For example,
a high level of adiponectin seems to have an inhibitive
effect on breast cancer, whereas leptin tends to stim-
ulate cancer growth. No definitive conclusion can be
drawn from in vitro studies, as cancer recurrence is
concerned with breast cancer patients. However, the
question of safety should be solved quickly because of
reliable statistical controlled clinical studies. Today, no
informed consent can be given to our patients stating
that lipofilling does not stimulate fueling of dormant
cancer cells or eventually induce new cancer cells. A
multicenter study is required that gathers an important
number of cases with a precise registration of the can-
cer status and that follows them prospectively for a
sufficient number of years to reach reliable statistical
results for comparison of the local recurrence rate with
a matched controlled group.
DOI: 10.1097/PRS.0b013e3181ef94a8
Jean Yves Petit, M.D.
Division of Plastic Surgery
European Institute of Oncology
Milan, Italy
Krishna Clough, M.D.
Isabelle Sarfati, M.D.
Paris Breast Center
Paris, France
Visnu Lohsiriwat, M.D.
Francesca de Lorenzi, M.D., Ph.D.
Mario Rietjens, M.D.
Division of Plastic Surgery
European Institute of Oncology
Milan, Italy
Correspondence to Dr. Petit
Division of Plastic Surgery
European Institute of Oncology
Via Ripamonti, 435
20141 Milan, Italy
jean.petit@ieo.it
Plastic and Reconstructive Surgery November 2010
262e
REFERENCES
1. Gutowski KA, Baker SB, Coleman SR, et al. Current appli-
cations and safety of autologous fat grafts: A report of the
ASPS fat graft task force. Plast Reconstr Surg. 2009;124:272
280.
2. Coleman SR, Saboeiro AP. Fat grafting to the breast revis-
ited: Safety and efficacy. Plast Reconstr Surg. 2007;119:775
785.
3. Chan CW, McCulley SJ, Macmillan RD. Autologous fat
transfer: A review of the literature with a focus on breast
cancer surgery. J Plast Reconstr Aesthet Surg. 2008;61:1438
1448.
4. Delay E, Gosset J, Toussoun G, Delaporte T, Delbaere M.
Efficacy of lipomodelling for the management of sequelae of
breast cancer conservative treatment (in French). Ann Chir
Plast Esthet. 2008;53:153168.
5. French Society of Plastic Reconstructive and Aesthetic Surgery
[Societe Francaise de Chirurgie Plastique Reconstructrice et
Esthetique (SOFCPRE)]. Available at: http://www.plasticiens.
org/. Accessed November 28, 2009.
Repeated Bilateral Reduction Mammaplasty: A
12-Year Experience
Sir:
B
ilateral reduction mammaplasty is an extremely
common operation used to decrease the size of
large breasts and relieve their many associated symp-
toms. Repeated bilateral reduction mammaplasty, in
contrast, is an infrequently performed procedure. Few
studies have investigated postoperative outcomes, and
as a result, there are no clearly established guidelines,
risk profiles, or recommendations for the preferred
operative technique.
13
From September of 1997 to May of 2009, a total of
890 patients (1780 breasts) underwent bilateral reduc-
tion mammaplasty performed by one of four surgeons
at the University of Michigan Health System. Of these,
eight cases (16 breasts) were repeated procedures (0.9
percent of all bilateral reduction mammaplasties) (Ta-
ble 1). Mean patient age at the time of the repeated
procedure was 48.8 years (range, 24 to 76 years). All
surgeons used the same technique for the repeated
bilateral reduction mammaplasty that was used for the
primary procedure, when known. However, the pri-
mary operation was unknown in four of the eight cases.
Operative procedures included inferior pedicle tech-
nique (n 5), central/superior pedicle technique
(n 1), inferior pedicle technique with a free nipple
graft (n 1), and superomedial pedicle technique with
a free nipple graft (n 1).
Three of the eight repeated reduction mammaplasties
(37.5 percent) resulted in a major complication, which
was defined as a complication that required either an
operation or hospitalization to treat, as follows: nipple
necrosis (n 1), abscess (n 1), and seroma (n 1). All
major complications occurred in cases using a pure in-
ferior pedicle technique; all of these patients had also
undergone an inferior pedicle technique as the original
procedure. As a result, there was a 100 percent compli-
cation rate for the repeated reduction cases using an
inferior pedicle when the original reduction was known
to have been performed by means of an inferior pedicle
(patients 3, 5, and 8 in Table 1). There were no major
complications in any patient undergoing a repeated re-
duction using any other technique.
Repeated bilateral reduction mammaplasty proce-
dures are associated with a major complication rate of
37.5 percent, a rate significantly higher than rates re-
ported for primary reduction, which range from4 to 26
percent.
4,5
It has been recommended that surgeons
could reduce their risk of reoperative complications by
performing the same operation for the secondary pro-
cedure as was originally performed.
3
However, on the
basis of our data, if an inferior pedicle technique was
known to have been used for the primary procedure,
and an inferior pedicle is used for the repeated pro-
cedure, there is a 100 percent complication rate. This
would suggest that surgeons should exercise caution
when selecting the technique to be used for the
repeated reduction mammaplasty. Cases using some
version of a free nipple graft technique for the re-
visional procedure did not have any major compli-
cations, and this may be the technique of choice for
repeated bilateral reduction mammaplasties.
DOI: 10.1097/PRS.0b013e3181ef94bd
Shaun P. Patel, B.S.
David L. Brown, M.D.
Table 1. Repeated Bilateral Reduction Mammaplasty Cases
Patient
Age
(yr)
First Operation
(yr previously)
First Operation
Technique
Repeated Operation
Technique
Right Breast
Tissue
Resected (g)
Left Breast
Tissue
Resected (g)
Major
Complication
1 44 10 (exact unknown) Unknown Inferior pedicle 710 700 None
2 37 20 Unknown pedicle/
free nipple graft
Central/superior
pedicle
510 600 None
3 41 15 Inferior pedicle Inferior pedicle 680 1000 Abscess
4 67 35 Unknown Inferior pedicle 250 430 None
5 55 27 Inferior pedicle Inferior pedicle 506 524 Nipple necrosis
6 76 15 (exact unknown) Inferior pedicle Inferior/free
nipple graft
1011 1042 None
7 24 4 Unknown Superomedial/
free nipple graft
762 547 None
8 46 18 Inferior pedicle Inferior pedicle 935 920 Seroma
Volume 126, Number 5 Viewpoints
263e
Paul S. Cederna, M.D.
University of Michigan Medical School
Ann Arbor, Mich.
Correspondence to Dr. Cederna
University of Michigan Medical School
Ann Arbor, Mich. 48109
cederna@umich.edu
REFERENCES
1. Pandeya NK. Inferior pedicle technique for reduction mamma-
plasty after aStrombeckreduction. Plast Reconstr Surg. 1996;97:1306.
2. Lejour M. Vertical mammaplasty as secondary surgery after
other techniques. Aesthetic Plast Surg. 1997;21:403407.
3. Hudson DA, Skoll PJ. Repeat reduction mammaplasty. Plast
Reconstr Surg. 1999;104:401408.
4. Buenaventura S, Severinac R, Mullis W, Beasley M, Jacobs W,
Wood D. Outpatient reduction mammaplasty: A review of 338
consecutive cases. Ann Plast Surg. 1996;36:162166.
5. Scott GR, Carson CL, Borah GL. Maximizing outcomes in
breast reduction surgery: A review of 518 consecutive patients.
Plast Reconstr Surg. 2005;116:16331639; discussion 16401641.
A Simple and Effective Method for Phalloplasty
in Female-to-Male Transsexuals
Sir:
P
halloplasty poses a great challenge for plastic sur-
geons. Construction of a neourethra is always con-
sidered to be a difficult part of phalloplasty, especially
for female-to-male transsexuals, on account of the high
incidence of fistulas and strictures.
1
No method has
become standardized.
Wehavesuccessfully performedonecaseof total penile
reconstruction with a prefabricated lower abdominal flap
based on the superficial iliac and epigastric vessels in a
female-to-male transsexual. During the first-stage opera-
tion, transvaginal hysterectomy, oophorectomy, vaginec-
tomy, andmastectomy was performedfirst. Then, thepars
fixaurethraewas elongatedwiththeanterior vaginal flap.
2
For the preconstruction of the pars pendulans urethrae,
the tubed graft of vaginal tunica mucosa harvested from
the vaginectomy was buried in the lower abdomen (Fig.
1). For the second stage, the actual phalloplasty was then
performed with the abdominal flap, and the prefabri-
cated urethra was anastomosed with the advanced ure-
thral orifice 5 months later.
The reconstructed penis survived completely and
allowed the patient to urinate while standing. After 6
months of follow-up, no complications developed, such
as wound infection, flap necrosis, urethral stricture, or
fistula (Fig. 2). The neophallus retained its size (14 cm
in length and 3.5 cmin diameter) and was rigid enough
so that penetrative sexual intercourse was possible with-
out a penile prosthesis. The patient had regained sen-
sation at the bottom 1 cm of the neophallus.
According to our review of the literature, this is the first
reportedcase of phalloplasty witha lower abdominal flapby
using the vaginal tunica mucosa for urethral preconstruc-
tion. Infact, constructionof theneourethrausingthevaginal
mucosa grafts has been occasionally reported,
3
but the sur-
gical techniques described were different and lack further
applications. Our methodhas several advantages, as follows.
First, compared with the traditional methods, we reused
thevaginal tunicamucosa, thus avoidinganother donor site.
Moreover, in fabrication of a neourethra, the vaginal tunica
mucosa has uniquemerits: (1) it is a wet epithelium, making
Fig. 1. (Above) The whole vaginal mucosa was harvestedduring
vaginectomy. (Below) Afull-thickness vaginal tunicamucosawas
evertedandwrappedarounda drainage tube (1 cmindiameter)
to form a 13-cm tube.
Fig. 2. Lateral view during voiding 6 months postoperatively.
Plastic and Reconstructive Surgery November 2010
264e
it more histologically similar to urethral mucosa than skin;
(2)it is smoothandhairless; and(3)it has adensesubdermal
plexus, rendering it more prone to obtain a blood supply
from the graft site and thus to healing.
Second, in our method, the vaginal mucosa grafts
could establish sufficient blood supply within a 3- to
6-month delay following prefabrication. At the same
time, the entire prefabricated urethra, especially its two
end points, could efficiently inhibit the primary cica-
tricial contracture after long-standing support. As a
result, the incidence of postoperative urethral compli-
cations could, in theory, be effectively reduced.
Third, the surgical techniques of our method are rel-
atively simple. It avoids the use of microsurgical tech-
niques. The abdominal donor site could be sutured di-
rectly, so that the postoperative scar is relatively small,
which could be more easily accepted by the patient.
In conclusion, we introduce a simple and effective
method of urethral prefabrication using a tubed graft of
vaginal tunica mucosa for phalloplasty in female trans-
sexuals. Not only is it easy toimplement but it alsoreduces
the incidence of postoperative urethral complications.
DOI: 10.1097/PRS.0b013e3181ef81c4
Yingfan Zhang, M.D.
Lixuan Lu, M.D.
Wenjun Zhang, M.D.
Hua Jiang, M.D.
Xiaohai Zhu, M.D.
Department of Plastic Surgery
Changzheng Hospital
Second Military Medical University
Shanghai, China
Correspondence to Dr. Zhu
Department of Plastic Surgery
Changzheng Hospital
415 Fengyang Road
Shanghai 200003, China
zhuxiaohai@186sh.com
ACKNOWLEDGMENT
This study was supported by the Natural Science
Foundation of Shanghai (no. 10ZR1439200).
REFERENCES
1. Hage JJ, Bloem JJ. Review of the literature on construction of
a neourethra in female-to-male transsexuals. Ann Plast Surg.
1993;30:278286.
2. Hage JJ, Torenbeek R, Bouman FG, Bloem JJ. The anatomic basis
of the anterior vaginal flap used for neourethra construction in
female-to-male transsexuals. Plast Reconstr Surg. 1993;92:102108.
3. Meyer R, Daverio PJ, Dequesne J. One-stage phalloplasty in
transsexuals. Ann Plast Surg. 1986;16:472479.
Penile Epithesis: Preliminary Study
Sir:
T
he principle of osseointegration is accepted and
used in different disciplines: ceramic teeth, silicone
ears and noses, joints and fingers, and upper and lower
extremity epitheses that can be fixed with various tita-
nium screws.
1
A possible ultimate application can be
represented by penile reconstruction.
Particularly for female-to-male transsexuals, the ulti-
mate goal is to create, in a one-stage procedure, an aes-
thetically appearing neophallus, with erogenous and tac-
tile sensation, provided with a competent neourethra, to
allow for voiding while standing, and rigidity to allow for
sexual intercourse. Minimal scarring and no functional
loss inthe donor area are further requirements.
2
No ideal
technique has been described yet.
3
Previously, Hage and Bouman
4
described a silicone
genital prosthesis for female-to-male transsexuals. Different
from Hage and Boumans prosthesis, our epithesis
wouldbeosseointegrated, allowingfor sexual intercourse,
transmission of vibration with possible stimulation of the
clitoris, and eventually voiding through the device. In this
preliminary study, we present our experimental surgery
on explanted bones and on two cadavers (one male and
one female cadaver) to fix a penile epithesis to the pubic
bones, using Branemark screws.
We analyzed anatomy of the pubic bone, implant
fixation, and soft-tissue coverage. On the two cadavers,
a U-shaped incision was positioned on the lower part of
the pubic area: this pubic flap needed major defatting.
Alternatively, complete tissue excision and full-thick-
ness skin grafting are possible.
A hole 2 mm in diameter was performed bilaterally
to the pubic symphysis, on the lowest and anterior part
of the pubic bones (depth, 12 to 15 mm). Holes were
enlarged using a Branemark Integration AB drill kit.
For clinical cases, we recommend 5-mm-wide, 20-
mm-long implants. We propose three different types of
epitheses (Table 1): type I (no urinary channel), to be
possibly used for female-to-male transsexuals without
previous surgery; type II, in which the epithesis incor-
porates an internal catheter, to be inserted in an ure-
throstomy, indicated after penile avulsion (trauma/
excision after cancer), congenital anomalies, or in
combination with urethrostomy/clitoris displacement
in female-to-male transsexuals; and type III, in which
the epithesis incorporates an internal pocket, for in-
sertion of a possible congenital or post metoidioplasty
micropenis (Fig. 1).
Apart from the simplicity of the surgical technique, an
epithesis would avoid completely donor-site disfigurement,
3
as occurs followingconventional flapsurgery.
3
Theurethra/
clitoris transposition in female-to-male transsexuals might
enhance the chance for orgasm during sexual intercourse,
as it is normally performed with other flap techniques.
5
The penile epithesis canbe a versatile surgical method,
not precluding flaps in case it will not work clinically as a
first-choice technique, or it can be used after flap failure.
Our anaplastologists proposed different variations of the
penile epithesis such as a silicone malleable type, and a
telescopic type than can be enlarged when the patient is
planningsexual intercourse. Clinical pilot cases shouldbe
started by experienced gender reassignment surgery cen-
ters, for selected groups of patients.
DOI: 10.1097/PRS.0b013e3181ef8196
Volume 126, Number 5 Viewpoints
265e
Gennaro Selvaggi, M.D.
Anna Elander, M.D., Ph.D.
Department of Plastic Surgery
Rickard Branemark, M.D., Ph.D.
Department of Orthopedics
Sahlgrenska University Hospital
Gothenburg, Sweden
Correspondence to Dr. Selvaggi
Department of Plastic Surgery
Abbey Pines Hospital
192 Altrincham Road
Manchester M22 4RZ, United Kingdom
selvaggigennaro@yahoo.it
Presented at the 21st Biennial Symposium of the World
Professional Association for Transgender Health, in Oslo,
Norway, June 17 through 20, 2009.
ACKNOWLEDGMENTS
The authors gratefully thank the European Society of
Plastic and Reconstructive Surgery (EURAPS), because
this work started under the EURAPS Fellowship (winner,
Gennaro Selvaggi, M.D.; sponsor, Prof. S. Monstrey;
receiving institution/tutor, Sahlgrenska University Hos-
pital, Gothenburg University Hospital, Prof. Holm-
strom). The authors thank Professor Johansson for help
in the cadaver laboratory; Kerstin Bergstrom and Stewe
Jonsson, anaplastologists, for their contribution in de-
veloping the penile epithesis; and John Brooks for the
artwork preparation.
DISCLOSURE
Gennaro Selvaggi, M.D., has filed a temporary applica-
tion, entitled Penile Epithesis, with the U.S. Patent and
Trademark Office. The other authors have no financial in-
terest to declare in relation to the content of this article.
REFERENCES
1. Eriksson E, Branemark PI. Osseointegration from the per-
spective of the plastic surgeon. Plast Reconstr Surg. 1994;93:
626637.
2. Hage JJ, Bouman FG, de Graaf FH, Bloem JJ. Construction of
the neophallus in female-to-male transsexuals: The Amster-
dam experience. J Urol. 1993;149:14631468.
3. Selvaggi G, Elander A. Penile reconstruction/formation. Curr
Opin Urol. 2008;18:589597.
4. Hage JJ, Bouman FG. Silicone genital prosthesis for female-
to-male transsexuals. Plast Reconstr Surg. 1992;90:516519.
5. Selvaggi G, Hoebeke P, Ceulemans P, et al. Scrotal recon-
struction in female-to-male transsexuals: The novel scroto-
plasty. Plast Reconstr Surg. 2009;123:17101718.
Prefabricated Cadaveric Osseous Flap Results
in Viable Bone for Penile Autoaugmentation
Sir:
A
n unfortunate complication of sickle cell disease is
postpriapism erectile dysfunction. Although not
all episodes of priapism lead to erectile dysfunction,
priapism tends to occur in young adults, with a quoted
figure of 75 to 89 percent of patients having the first
episode before their twentieth birthday.
1
Where un-
treated, prolonged priapism events of less than 12
hours duration have been reported to result in de-
creased erectile rigidity, whereas events of more than
36 hours duration led to permanent loss of spontane-
ous erections.
2
Venoocclusive disease results in irre-
versible ischemic penile injury, leading to fibrosis, im-
Fig. 1. Prototype of a type III penile epithesis. Aninternal pouch
intheepithesis is accommodatingacongenital, or postmetoido-
ioplasty, micropenis. Eventually, the internal channel can drain
urine up to the tip of the epithesis.
Table 1. Different Types of Penile Epitheses
Penile
Epithesis
Urinary
Channel
Possibility of
Voiding While
Standing
Possibility of
Sexual Intercourse
Possibility of Orgasm
during Masturbation
or Sexual Intercourse Indication
Type I No No Yes Possible FTM transsexuals
Type II Yes Yes Yes Possible Penile avulsion/excision;
congenital anomalies;
FTM transsexuals
Type III Yes Yes Yes Possible Micropenis; metoidioplasty;
FTM transsexuals
FTM, female-to-male.
Plastic and Reconstructive Surgery November 2010
266e
potence, and penile shortening. Treatment of ischemic
priapism refractory to medical management relies on
implantation of a penile prosthesis. If the prosthesis
becomes infected and has to be removed, however, no
good alternative exists.
A 32-year-old African American man with a history
of sickle cell disease and prior refractory priapism
with subsequent erectile dysfunction presented to
our institution. He had three previous failed penile
prostheses over a 6-year period and was considered
an implant cripple because of these failures. The
patient was devastated by his condition, and had
considered self-harm because of the inability to
achieve an erection. We prefabricated a segment of
cadaveric fibula and transferred it as a pedicled flap
for autologous penile augmentation.
In the first phase of surgery, the descending branch
of the lateral circumflex femoral artery and its accom-
panying venae comitantes was dissected out inthe usual
fashion as for an anterolateral thigh flap. This vascular
pedicle was harvested together with a segment of fascia
overlying the vastus intermedius. A segment of cadav-
eric fibula bone from the Musculoskeletal Transplant
Foundation (Edison, N.J.) was concurrently prepared
with a trough created in the bone to allow for place-
ment of the vascular pedicle. Numerous 2- to 3-mm
holes were drilled in the side of the fibula construct to
allow for vascular ingrowth. The prefabricated flap was
then placed within an enveloping silicone sheet (In-
votec International, Inc., Jacksonville, Fla.) and se-
cured in place.
Before the second phase of surgery, a bone scan
confirmed the viability of the prefabricated osseous
construct. A selective angiogram of the right lower ex-
tremity was also obtained and showed patency of the
artery and its distal branches within the flap. Two and
a half months after the initial surgery, the osseous flap
was elevated and the enveloping silicone sheet re-
moved. Gross vascularization of the flap, in the form of
arborizing vessels on the surface and within the drill
holes of the bone segment, was evident (Fig. 1). The
prefabricated osseous flap was then placed within a
space created within the corpora cavernosa (Fig. 2).
The osseous flap continues to be viable 1 month after
surgery, as seen on a follow-up bone scan.
To decrease the risk of flap failure associated with
sickle cell disease, we elected not to perform a free
tissue transfer, and instead chose to prefabricate a seg-
ment of cadaveric fibula for transfer as a pedicled flap.
The use of perioperative exchange transfusions has
been reported to be useful when performing free tissue
transfer in patients with sickle cell disease,
3
and these
were performed to keep the hemoglobin S level below
30 percent, which would prevent sickling in the micro-
circulation of the flap.
Applications for use of prefabricated cadaveric bone
flaps might be found in a variety of other circumstances
where autologous bone is insufficient or unavailable.
This would represent a powerful technique in the ab-
sence of other reconstructive options.
DOI: 10.1097/PRS.0b013e3181ef8201
Christopher J. Salgado, M.D.
Harvey Chim, M.D.
Department of Plastic Surgery
Case Western Reserve University
Cleveland, Ohio
Julian J. Pribaz, M.D.
Division of Plastic Surgery
Harvard Medical School
Brigham & Womens Hospital
Boston, Mass.
Fig. 1. Prefabricated cadaveric fibula flapfor penile autoaugmen-
tation. In second-stage surgery, arborizing vessels are noted over
thesurfaceof thebonesegment, withpreviouslydrilledholesalong
the sidewalls of the bone filled with vascularized tissue.
Fig. 2. Schematic depiction of penis with prefabricated cadav-
eric fibula within the corporal body.
Volume 126, Number 5 Viewpoints
267e
Samir Mardini, M.D.
Division of Plastic Surgery
Mayo Clinic
Rochester, Minn.
Correspondence to Dr. Salgado
Department of Plastic Surgery
Case Western Reserve University
University Hospitals of Cleveland, MS 5044
11100 Euclid Avenue
Cleveland, Ohio 44106
christopher.salgado@uhhospitals.org
DISCLOSURE
The authors declare that they had no financial interests
or commercial associations during the course of this study. This
article did not require any sources of funding.
REFERENCES
1. Bennett N, Mulhall J. Sickle cell disease status and outcomes
of African-American men presenting with priapism. J Sex Med.
2008;5:12441250.
2. Adeyoju AB, Olujohungbe AB, Morris J, et al. Priapism in
sickle-cell disease: Incidence, risk factors and complications.
An international multicentre study. BJU Int. 2002;90:898902.
3. Weinzweig N, Schuler J, Marschall M, Koshy M. Lower limb
salvage by microvascular free-tissue transfer in patients with
homozygous sickle cell disease. Plast Reconstr Surg. 1995;96:
11541161.
Communicating Branch of Toe Web Veins as a
Venous Return Pathway in Free Toe Pulp Flaps
Sir:
T
he free toe pulp flap has been considered a compar-
atively ideal flap for repairing soft-tissue defects of
finger pulp. However, its widespread has been somewhat
limited by the difficulty of dissecting the superficial dorsal
digital vein of the toe.
1,2
To solve this problem, we used a
communicating branch of toe web veins as a venous re-
turn pathway of the free toe pulp flap and achieved sat-
isfactory success, that is, a pathway fromthe accompanying
veins of the plantar digital artery to the communicating
branch between the deep and superficial toe web veins to
the superficial dorsal metatarsal veins.
3,4
From 2006 to the present, in resurfacing 14 cases of
finger pulp defect with free toe pulp flaps, a commu-
nicating branch of the toe web veins was taken as a
venous return pathway. Dimensions of those finger
pulp defects varied from 2.0 1.5 cm to 4.0 1.5 cm.
Exposure of flexor tendons or phalangeal bones could
be found in all of these tissue defects. Of these defects,
12 were covered with great toe pulp flaps and two were
repaired with second-toe pulp flaps. Dorsal metatar-
sal veins on the flap were anastomosed with dorsal
digital veins of the recipient hand, and the plantar
digital artery and nerve of the free toe pulp flap were
anastomosed, respectively, with the proper digital ar-
tery and nerve of the recipient site. Of these cases
studied, three flaps had a dark red color postopera-
tively, which turned into a normal color after 3 days of
intermittent small-incision bloodletting. The rest of the
flaps all had good blood circulation without venous
crisis. Fourteen cases of toe pulp flap survived success-
fully, with satisfactory contour and texture (Fig. 1).
In clinical practice, accompanying veins have always
been taken as return veins of pedicled toe pulp flaps,
57
which indicates that accompanying veins are compe-
tent for acting as return veins of free toe pulp flaps. In
the communicating branch return pathway described
here, accompanying veins of the plantar digital artery
are taken as return veins of free toe pulp flaps, and the
relatively larger dorsal metatarsal vein is taken as the
one for anastomosis. These two parts are connected
smoothly by communicating branches (Fig. 1), and
direct anastomosis of thinaccompanying veins is avoided.
In this pathway, only communicating branches and su-
perficial dorsal metatarsal veins need to be dissected in
the toe web, and accompanying veins are freed to-
gether with the nerve-artery pedicle, without the need
to directly dissect superficial veins as in traditional op-
erations; thus, the flap operation is simplified. There-
fore, in free toe pulp flaps, the communicating branch
of toe web veins as a venous return pathway can be a
helpful and potent supplement to the superficial vein
return pathway, and in free toe pulp flaps, when the
condition of the communicating branch is good, this
pathway can be selected positively to replace the su-
perficial vein return pathway.
DOI: 10.1097/PRS.0b013e3181ef8158
Wenhai Sun, B.S.
Zengtao Wang, B.S.
Shenqiang Qiu, M.M.
Shuyuan Li, Ph.D.
Shibing Guan, M.D.
Yong Hu, M.M.
Lei Zhu, M.M.
Hand and Foot Surgical Center
Provincial Hospital Affiliated to Shandong University
Jinan, China
Correspondence to Wenhai Sun
Hand and Foot Surgical Center
Provincial Hospital Affiliated to Shandong University
Jinan 250021, China
sunwsea@126.com
REFERENCES
1. Dautel G, Gouzou S, Vialaneix J, Faivre S. PIP reconstruction
with vascularized PIP joint from the second toe: Minimizing
the morbidity with the dorsal approach and short-pedicle
technique. Tech Hand Up Extrem Surg. 2004;8:173180.
2. Gu YD, Zhang GM, Chen DS, Cheng XM, Xu JG, Wang H.
Vascular anatomic variations in second toe transfers. J Hand
Surg (Am.) 2000;25:277281.
3. Xu YQ, Zhong SZ, Xu DC. The relationship between the struc-
tures and the blood vessels of the first metatarsal web space and
its clinical significance. Chin J Hand Surg. 1999;15:50.
Plastic and Reconstructive Surgery November 2010
268e
4. May JW Jr, Chait LA, Cohen BE, OBrien BM. Free neurovas-
cular flapfromthe first webof the foot inhandreconstruction.
J Hand Surg (Am.) 1977;2:387393.
5. Koshima I, Etoh H, Moriguchi T, Soeda S. Sixty cases of partial
or total toe transfer for repair of finger losses. Plast Reconstr
Surg. 1993;92:13311338; discussion 13391341.
6. Guo JX, Xu DC, Zhong SZ. Applied anatomy of hallux plantar
flap for repairing the defect in the palmar region of thumb.
Chin J Clin Anat. 1994;2:105.
7. Ellis PR, Hanna D, Tsai TM. Vascularized single toe joint
transfer to the hand. J Hand Surg (Am.) 1991;16:160168.
Autologous Platelet-Rich Plasma: Guidelines in
Plastic Surgery
Sir:
T
he objectives of this article are to describe the
guidelines for the use of platelet-rich plasma in
plastic surgery. The authors report exclusion criteria,
potential risk associated with the use of platelet-rich
plasma, and the methods of preparation.
Platelet-rich plasma can be prepared using Harvest
SmartPrep Platelet Concentrate System (Harvest Tech-
nologies, Plymouth, Mass.), the 3i Platelet Concentrate
Collection System(3i Implant Innovations, PalmBeach
Gardens, Fla.; BTI (Biotechnology Institute, Vitoria,
Spain), the Vivostat System(Vivolution, Birkerd, Den-
mark), the Cascade-Esforax System (Cascade Medical
Enterprises, Devon, United Kingdom), the RegenPRP-
Kit (RegenLab, Mollens-VD, Switzerland), and Platel-
tex (Bratislava, Slovakia). In all cases in Italy, it is nec-
essary that a medical doctor of the transfusional service
is present.
The preparation and processing of platelet-rich
plasma is quite similar in most of the platelet-concen-
trating systems, although the anticoagulant used and
the speed and duration of centrifugation may differ
with different systems. A recent study by Mazzucco et
al.
1
evaluated four systems providing platelet-rich
plasma with platelet concentration in a range consid-
ered clinically effective.
The aim of their study was to evaluate using in vitro
analysis the release of platelet-derived factors from plate-
let-rich plasma gels. Mazzucco et al. concluded that the
methods evaluated in this study were substantially similar.
Fig. 1. Atypical case: (above, left) acommunicatingbranchof thetoewebveins, (above, right) thetoepulpflapbeingfreed,
(below, left) theflaphavingturnedpinkafter reperfusion, and(below, right) thecontour of theflap1.5years postoperatively.
Volume 126, Number 5 Viewpoints
269e
Exclusion criteria consisted of the following. The
authors have published many articles
2,3
regarding the
use of platelet-rich plasma in plastic surgery and actu-
ally suggested exclusion criteria divided into two types
for platelet-rich plasma application: systemic and local.
The systemic criteria include platelet disorders, throm-
bocytopenia, antiaggregating therapy, bone marrow
aplasia, uncompensated diabetes, sepsis, and cancer.
The local criteria include osteomyelitis and loss of sub-
stance of more than 50 percent of the segments treated
in the case of chronic or posttraumatic wounds. The
authors did not consider tobacco use and genetic dis-
orders to be exclusion criteria.
Sanchez et al.
4
have elaborated on the potential risks
associated with the use of platelet-rich plasma. The
preparation of platelet-rich plasma involves the isola-
tion of platelet-rich plasma, after which gel formation
is accelerated using calcium chloride and bovine
thrombin. It has been discovered that the use of bovine
thrombin may be associated with the development of
antibodies to the factors V and XI and thrombin,
resulting in the risk of life-threatening coagulopa-
thies. Bovine thrombin preparations have been
shown to contain factor V, which could result in
stimulation of the immune system when challenged
with a foreign protein. Other methods for safer prep-
aration of platelet-rich plasma include the use of
recombinant human thrombin, autologous throm-
bin, or perhaps extrapurified thrombin. Landesberg
et al.
5
have suggested that alternative methods of
activating platelet-rich plasma need to be studied and
made available to the dental community. The authors
suggest platelet-rich plasma activating with calcium
chloride without the use of bovine thrombin associ-
ated with the development of antibodies to factors V
and XI and thrombin, resulting in a high risk of
life-threatening coagulopathies.
Therefore, the commercially available adhesives
constitute an infinitely small risk of disease transmis-
sion. Platelet-rich plasma is an autologous modifica-
tion of fibrin glue, which has been described and
used in various applications with clinical success. Af-
ter this description, the new aim of the authors is to
apply a single part of growth factors, specifically,
platelet-derived growth factor for chronic or post-
traumatic wound prevalently, and epidermal growth
factor and fibroblast growth factor for skin damage
(for burns outcomes).
DOI: 10.1097/PRS.0b013e3181ef9518
Pietro Gentile, M.D.
Valerio Cervelli
University of Tor Vergata
Rome, Italy
Correspondence to Dr. Gentile
University of Tor Vergata
Via Laquila 7
Rome, Italy 00100
REFERENCES
1. Mazzucco L, Balbo V, Cattana E, Guaschino R, Borzini P. Not
every PRP-gel is born equal. Evaluation of growth factor avail-
ability for tissues through four PRP-gel preparations: Fibrinet,
RegenPRP-Kit, Plateltex andone manual procedure. Vox Sang.
2009;97:110118.
2. Cervelli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gentile
P. Autologous platelet-rich plasma mixed with purified fat
graft in aesthetic plastic surgery. Aesthetic Plast Surg. 2009;33:
716721.
3. Cervelli V, Gentile P, Scioli MG, Grimaldi M, Spagnoli LG,
Orlandi A. Application of platelet-rich plasma to fat grafting
during plastic surgical procedures: Clinical and in vitro eval-
uation. Tissue Eng Part C Methods 2009;15:625634.
4. Sanchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the
perfect enhancement factor? A current review. Int J Oral Max-
illofac Implants 2003;18:93103.
5. Landesberg R, Moses M, Karpatkin M. Risk of using platelet-
rich plasma gel. J Oral Maxillofac Surg. 1998;56:11161117.
The Impact of the Medicare Sustainable Growth
Rate Formula on Reconstructive Plastic Surgery
Sir:
T
his year, as Congress contemplates a 21.2 percent
reductioninMedicare physicianfees, the American
Society of Plastic Surgeons and other major medical
organizations have criticized the cutbacks, arguing that
such a reduction is a short-sighted and short-termfix to
a fundamentally flawed model.
1
It is important that
plastic surgeons, particularly those in reconstructive
surgery, demand a permanent, sustainable solution
from their congressmen and congresswomen.
Congress recent health care bill has provoked con-
siderable debate over its attempt to allow the sustain-
able growth rate to cut physician reimbursements un-
der Medicare.
2
Enacted in 1997, the sustainable growth
rate sets a target rate for physician compensation based
on the relationship between Medicare part B expen-
ditures and the gross domestic product. If expenditures
exceed target rates, the sustainable growth rate calls for
a reduction in the following years physician reimburse-
ments to recoup the loss. Since 2003, Congress has
declined to enforce the sustainable growth rate reim-
bursement cutbacks, resulting in a growing deficit.
Reconstructive plastic surgeons and their patients
may suffer the most from these reimbursement cuts.
The sustainable growth rate adjustments would reduce
their fees despite generally long operative and hospital
courses, changing the economic landscape of recon-
structive surgery. The financial incentives, or disincen-
tives, created by the sustainable growth rate may di-
rectly impact surgical management decisions. For
example, under the influence of sustainable growth
ratemediated cutbacks, a surgeon may elect to per-
form prosthetic breast reconstruction over autologous
free-flap reconstruction based on its better reimburse-
ment-tooperative time ratio. The sustainable growth
rate has clear ramifications beyond simple reimburse-
ment, with repercussions that will be felt in the areas of
patient care and surgical decision making.
Plastic and Reconstructive Surgery November 2010
270e
Economic factors already disfavor reconstructive sur-
gery, especially when compared with the profitability of
out-of-pocket elective procedures. Reconstructive sur-
gery generally yields lower fees and greater adminis-
trative overhead, often requiring the surgeon to spend
an exorbitant amount of time negotiating reimburse-
ments withinsurance companies. Because of the nature
of plastic surgery, unique or specialized techniques are
poorly differentiated in the reimbursement structure,
making claims more difficult to file as well. Despite
involving often more time-consuming and labor-inten-
sive procedures, reconstructive practices are not com-
pensated financially as well as elective, outpatient aes-
thetic procedures. The sustainable growth rate would
only stress this imbalance, making reconstructive sur-
gery a more unfavorable field to pursue for financially
indebted medical students, residents, and fellows.
3
These incentives may explain, at least in part, why
fewer plastic surgery residents are actively seeking out
careers in reconstructive surgery. Already, the Ameri-
can Society of Plastic Surgeons anticipates a shortage in
the plastic surgery workforce over the next 10 to 15
years.
4
Many academic centers have observed that fewer
plastic surgery residents are pursuing microsurgery and
reconstructive fellowships, let alone full-time careers,
highlighting the expected shortage of reconstructive
surgeons in the future.
Congress should consider the effects of the incentives
it creates, particularly when there has been no greater
need for the reconstructive surgeon than now. With the
growing elder population and advances in cancer treat-
ment, patients are undergoing more aggressive resections
than ever before. Furthermore, advances in medical
care have made patients with formerly nonsurvivable
traumatic injuries candidates for complex reconstruc-
tion. There is a growing need for reconstructive sur-
geons at the same time that these economic incentives
discourage surgeons from performing these proce-
dures. Policymakers should not create incentives that
direct physicians to choose, for example, negative-pres-
sure therapy to treat a complex wound that would be
better managed with a flap. Instead, policymakers
should create incentives to provide patients with opti-
mal care, not merely cost-based care.
Rather than seek short-term fixes and struggle with
annual health care budget shortages, Congress needs
to reform the entire cost structure. It is our duty as
plastic surgeons to ensure that our patients with com-
plex deformities are treated appropriately regardless
of the complexity of care or surgical requirements. It
is important for American plastic surgeons to follow
the national health care reform process, as it will
significantly mold the scope of our field and future
practice environment.
DOI: 10.1097/PRS.0b013e3181ef952b
Anup Patel, M.D., M.B.A.
James E. Clune, M.D.
Antonio Forte, M.D.
Christopher C. Chang, M.D.
Section of Plastic and Reconstructive Surgery
Yale University School of Medicine
New Haven, Conn.
Correspondence to Dr. Patel
Section of Plastic and Reconstructive Surgery
Yale University School of Medicine
109 Church Street
New Haven, Conn. 06510
REFERENCES
1. The American Society of Plastic Surgeons Health Policy and
Advocacy. Available at: http://www.plasticsurgery.org/
x1028.xml. Accessed February 15, 2010.
2. The American Medical Association Medicare & The Sustain-
able Growth Formula. Available at: http://www.ama-assn.org/
ama1/pub/upload/mm/15/cola_medicare_pres.pdf. Accessed
February 15, 2010.
3. Ariyan S. The rising level of medical student debt: Potential
risk for a national default. Plast Reconstr Surg. 2000;105:1457
1464.
4. Rohrich RJ, McGrath MH, Lawrence WT, Ahmad J; American
Society of Plastic Surgeons Plastic Surgery Workforce Task
Force . Assessing the plastic surgery workforce: A template for
the future of plastic surgery. Plast Reconstr Surg. 2010;125:736
746.
Pathophysiologic Changes in a Patient with
Early-Onset Extensive Keloid Disease and a
20-Year Follow-Up
Sir:
K
eloids are a manifestation of a malfunctioning cu-
taneous wound-healing process and pose not only
an aesthetic but also a functional burden on the
patient.
1,2
In contrast to hypertrophic scars, keloids are
benign tumors that continuously infiltrate beyond the
confines of the original wound margins. They are often
pruritic and painful, and rarely regress after time.
3
In-
terestingly, this disease occurs only in humans. Avail-
able treatment options are often very unsatisfactory,
because surgical excision is associated with a high re-
currence rate and other treatment regimens including
intralesional steroid injections and radiation therapy
show only limited benefits.
Despite intensive research into the pathophysiology
of keloids, a clear mechanism explaining the patho-
genesis remains unsolved. The interaction between ke-
loid fibroblasts and the extracellular matrix is consid-
ered to be one of the keystones in keloid development.
However, because of the broad spectrum of changes
observed in keloids, identification of particular candi-
date genes responsible for the initiation of the cascade
is difficult.
In this article, we report about an otherwise healthy
39-year-old Caucasian man who had been suffering
from extensive keloid formation since his early child-
hood. Every injury to the skin, either inducedby trauma
or caused by an operative procedure, resulted in scar-
ring and subsequent tissue proliferation. Keloid for-
Volume 126, Number 5 Viewpoints
271e
mation was markedly localized to the hands and feet,
causing debilitating lumpy contractures and an almost
complete loss of functionality. Keloids in the left ear
canal and cornea resulted in partial hearing and vision
loss. Over a 20-year follow-up period, multiple surgical
interventions and subsequent revisions had been per-
formed to restore mobility but provided only transient
improvement because of rapid recurrence. Alternative
treatments included interferon and radiation therapy,
which did not yield beneficial results (Figs. 1 and 2).
The early age of onset and severity of the disease
suggest a genetic cause. However, family members en-
compassing three generations were free of symptoms,
revealing no evidence for inheritance. A form of the
Ehlers-Danlos syndrome was assumed in early child-
hood but was not confirmed in later diagnostics. Fur-
thermore, syndromes associated with keloid formation
could diagnostically be excluded.
To analyze local pathophysiologic changes on a mo-
lecular basis, skin biopsy specimens fromkeloid and non-
affected sites were subjected to RNA microarray and pro-
teome analyses. Microarray using a GeneChip (U133 Plus
2.0 Array) revealed that components of the extracellular
matrix were strongly up-regulated in the keloid tissue
(Table 1). Collagen expression was increased by up to
160-fold (type XI). Matrix metalloproteinases and ada-
malysins that are partially responsible for collagen pro-
cessing and subsequent degradation were also elevated.
Tissue inhibitors of metalloproteinases that balance ma-
trix metalloproteinase function, however, remained at a
normal level. In contrast, keratins and stratifin, which are
markers of differentiating epithelial cells, were strongly
down-regulated, hinting at a metabolic state favoring pro-
liferation. This is further emphasized by a reduced ex-
pression of the transcription factor p53, which is respon-
siblefor cell cycleregulationandtumor suppression. Also,
components of the Wnt signaling pathway, which plays a
pivotal role in oncogenesis, were overexpressed in the
keloid tissue.
Interestingly, transforming growth factor (TGF)-1
and TGF-2, which are strong inducers of tissue prolif-
eration and growth, were only marginally affected in ex-
pression. Furthermore, immunoglobulins were strongly up-
regulated in keloid tissue, hinting at an involvement of the
immune system in disease pathophysiology.
Aproteomic analysis involving the multidimensional
protein identification technology was performed in
combination with a GeneTrail analysis, confirming el-
evated extracellular matrix proteins. Collagen type I
was up-regulated in keloid tissue, and the differentia-
tion marker keratin was detected only in nonaffected
skin. This protein expression partially correlates with
results on the mRNA level, supporting a reduced dif-
ferentiation and increased proliferation.
Genetic factors play a major role inkeloid formation.
Familial clustering
4
and its increased prevalence in cer-
tain races, and also several syndromes such as Rubin-
stein-Taybi and Goeminne syndromes,
5,6
which are as-
sociated with keloid formation, have been described.
However, no evidence for either familial inheritance or
association with previously described syndromes could
be detected after clinical diagnostics.
A regulated balance between extracellular matrix pro-
duction and degradation is essential for normal scar for-
mation. In this patient, strongly elevated levels of collag-
ens, fibronectin, and proteoglycans were detected.
Although matrix metalloproteinases were also up-regu-
lated, the existence of an overshooting and imbalanced
metabolism can be presumed. Growth factors such as
TGF- and platelet-derived growth factor are considered
to be key effectors of extracellular matrix proliferation
and have further been associated with keloid pathogen-
esis. However, their expression was only marginally in-
creased in the keloid tissue. This may be explained by the
fact that keloid fibroblasts were found to have a reduced
growth factor requirement for proliferation.
7
Gradual proliferation in tumors is often associated
with dysregulated apoptosis. The p53 tumor suppressor
Fig. 1. Progressing keloid formation and subsequent contrac-
tures of the chest leading to deformities (patient age, 39). This
process was characterizedby delayedwoundhealingandslowly
healing ulcers.
Fig. 2. The patient also experienced contractures of the feet.
Plastic and Reconstructive Surgery November 2010
272e
is a nuclear transcription factor, which is implicated
in the regulation of the cell cycle and is often asso-
ciated with carcinogenesis.
8
Expression of p53 and its
effectors was strongly down-regulated. Furthermore,
effectors of the Wnt signaling pathway, which also
has a pivotal role in neoplasia and embryonic
development,
9
showed increased expression levels in
keloid tissue. These results suggest an involvement of
these pathways in the pathogenesis promoting a pro-
liferative metabolic state.
There is a strong immunologic component to ke-
loids, suggesting that keloid formation might be influ-
enced by systemic immunologic mechanisms rather
than just being a local phenomenon.
10
We found an
elevated expression of immunoglobulins in the keloid
tissue, emphasizing this hypothesis. This is further em-
phasized by the fact that fetal wounds healing without
scarring show only minimal inflammatory infiltration.
11
Other factors that showed strong regulation in keloid
tissue in this patient included asporin, thrombospondin,
and syndecans, all of which are associated with extra-
cellular matrix metabolism.
In this article, we report a patient with an abnor-
mality not previously described that shows no associa-
tion with related syndromes, suggesting a novel disor-
der supposedly caused by a newmutation leading to the
phenotypic appearance. The genes identified hint at a
dysregulation of proliferation in keloid tissue. Further
genetic analyses will be required to clearly identify a
gene responsible. These results may further elucidate
the pathogenesis of general keloid disease.
DOI: 10.1097/PRS.0b013e3181ef8129
Lars Steinstraesser, M.D.
Michael Sorkin, M.D.
Hans-Ulrich Steinau, M.D.
Table 1. Selected Regulated Genes
Gene Title Gene Symbol Fold Change* Chromosomal Location
ECM receptor interaction
Collagen, type I, alpha 1 COL1A1 12.8 chr17q21.33
mRNA 3= region for pro-alpha1(III)
collagen COL3A1 7.8 chr2q31
Collagen, type V, alpha 2 COL5A2 17.5 chr2q14-q32
Collagen, type V, alpha 1 COL5A1 20.1 chr9q34.2-q34.3
Collagen, type VI, alpha 1 COL6A1 13.73 chr21q22.3
Collagen, type VIII, alpha 2 COL8A2 9.51 chr1p34.2
Collagen, type X, alpha 1 COL10A1 27.5 chr6q21-q22
Collagen, type XI, alpha 1 COL11A1 191.3 chr1p21
Fibronectin 1 FN1 8.2 chr2q34
Thrombospondin 4 THBS4 13.2 chr5q13
Epithelial differentiation
Laminin, alpha 3 LAMA3 4.1 chr18q11.2
Keratin 10 KRT10 9.6 chr17q21
Keratin 1 KRT1 315.1 chr12q12-q13
Stratifin SFN 233.9 chr1p36.11
ECM proteinases and inhibitors
ADAM metallopeptidase with
thrombospondin type 1 motif, 2 ADAMTS2 6.7 chr5qter
Matrix metallopeptidase 14
(membrane-inserted) MMP14 5.4 chr14q11-q12
TIMP metallopeptidase inhibitor 3 TIMP3 2.5 chr22q12.1-q13.222q12.3
TIMP metallopeptidase inhibitor 4 TIMP4 2.9 chr3p25
Plasminogen activator, tissue PLAT 1.5 chr8p12
Growth factors
Transforming growth factor, beta 1 TGFB1 1.8 chr19q13.219q13.1
Transforming growth factor, beta 3 TGFB3 8.3 chr14q24
Transforming growth factor,
beta receptor 1 TGFBR1 2.9 chr9q22
Platelet-derived growth factor
alpha polypeptide PDGFA 1.5 chr7p22
Fibroblast growth factor 2 (basic) FGF2 3.7 chr4q26-q27
Fibroblast growth factor receptor 2 FGFR2 3.3 chr10q26
Insulin-like growth factor 1
(somatomedin C) IGF1 3.7 chr12q22-q23
Hepatocyte growth factor
(hepapoietin A; scatter factor) HGF 1.6 chr7q21.1
Other
Thrombospondin 4 THBS4 13.2 chr5q13
Asporin ASPN 26.4 chr9q22
Syndecan 2 SDC2 2.6 chr8q22-q23
ECM, extracellular matrix; ADAM, adamalysin.
*Fold change is the factor of regulation in mRNA expression in keloid tissue compared with nonaffected control tissue.
Volume 126, Number 5 Viewpoints
273e
Frank Jacobsen, Ph.D.
Department of Plastic Surgery
BG University Hospital Bergmannsheil
Ruhr University Bochum
Bochum, Germany
Correspondence to Dr. Steinstraesser
Department of Plastic Surgery and Burn Centre
BG University Hospital Bergmannsheil
Ruhr-University Bochum
Burkle-de-la Camp Platz 1
44789 Bochum, Germany
lars.steinstraesser@ruhr-uni-bochum.de
DISCLOSURE
The authors have no financial interest to declare in re-
lation to the content of this article.
REFERENCES
1. Seifert O, Mrowietz U. Keloid scarring: Bench and bedside.
Arch Dermatol Res. 2009;301:259272.
2. Bock O, Schmid-Ott G, Malewski P, Mrowietz U. Quality of
life of patients with keloid and hypertrophic scarring. Arch
Dermatol Res. 2006;297:433438.
3. Al-Attar A, Mess S, Thomassen JM, Kauffman CL, Davison SP.
Keloid pathogenesis and treatment. Plast Reconstr Surg. 2006;
117:286300.
4. Marneros AG, Norris JE, OlsenBR, Reichenberger E. Clinical
genetics of familial keloids. Arch Dermatol. 2001;137:1429
1434.
5. Roelfsema JH, Peters DJ. Rubinstein-Taybi syndrome:
Clinical and molecular overview. Expert Rev Mol Med. 2007;
9:116.
6. Esquenazi S, Eustis HS, Bazan HE, Leon A, He J. Corneal
keloid in Lowe syndrome. J Pediatr Ophthalmol Strabismus
2005;42:308310.
7. Russell SB, Trupin KM, Rodriguez-Eaton S, Russell JD,
Trupin JS. Reduced growth-factor requirement of keloid-
derived fibroblasts may account for tumor growth. Proc Natl
Acad Sci USA. 1988;85:587591.
8. Ventura A, Kirsch DG, McLaughlin ME, et al. Restoration of
p53 function leads to tumour regression in vivo. Nature 2007;
445:661665.
9. Sato M. Upregulation of the Wnt/beta-catenin pathway
induced by transforming growth factor-beta in hypertro-
phic scars and keloids. Acta Derm Venereol. 2006;86:
300307.
10. Kischer CW, Shetlar MR, Shetlar CL, Chvapil M. Immuno-
globulins in hypertrophic scars and keloids. Plast Reconstr
Surg. 1983;71:821825.
11. Buchanan EP, Longaker MT, Lorenz HP. Fetal skin wound
healing. Adv Clin Chem. 2009;48:137161.
Widespread Disregard of Photographic
Documentation Standards in Plastic Surgery: A
Brief Survey
Sir:
R
eliable photographic documentation is funda-
mentally based on photographic documentary
standards that were defined decades ago.
1,2
In this
article, we raise the question of whether articles pub-
lished in the top plastic surgery journals adhere to
these standards.
We analyzed all publications showing photographic
documents published in Plastic and Reconstructive Sur-
gery (Lippincott Williams & Wilkins), the Journal of Plas-
tic, Reconstructive & Aesthetic Surgery (Elsevier) and Aes-
thetic Plastic Surgery (Springer) in 1 year. Overall, 249
publications with patient photographs were analyzed
keeping the following photographic documentary stan-
dards in view (Table 1).
Camera angles: Obvious deviations from the stan-
dard camera angles described previously
1,3
were
marked as faulty. Special emphasis was put on
comparability between preoperative and postop-
erative photographs.
Posing position: Obvious deviations from the standard
posing position described previously
1,3
were marked
as faulty. In case of differing photographic docu-
mentary standards such as the upper limb position-
ing in breast photographic documentation, each
standard was accepted as correct, provided that the
standard was consistent between preoperative and
postoperative photographs.
Background: Each type of monochrome background
was accepted.
Clothes: Absence of any piece of clothing in the pho-
tographed area was assessed as correct.
Hairdo: Hair hiding parts of the face, especially the
forehead, was marked as faulty.
Jewelry: Absence of any piece of jewelry including
watches, glasses, and hearing devices was assessed
as correct.
Makeup: Each obvious makeup product including lash
mascara and lipstick was marked as faulty.
Mimic: Each visible tension of the mimic muscles,
especially smiling, was assessed as a deviation from
the photographic documentary standards.
Photographic section: For facial photography, we
analyzed whether attention was paid to the mini-
mal photographic section, in particular, whether
the whole face, and not only close-ups, was
photographed.
The most important element of photographic
documentation is the patient positioning and the
angles of photography. Slight deviations from the
standards, in particular, differences between preop-
erative and postoperative photographs, lead to se-
vere distortions of the result. This point has been
demonstrated by photographs of a photographic
neck lift and a photographic rhinoplasty.
4,5
Facial
photographic documentation is most challenging.
Any deviation from complete relaxed mimic mus-
culature would clearly affect the result of the pho-
tographic documentation. Although it is not easy to
detect deviations from the standard mentioned
above, we still observed them in 11.3 percent of the
publications. Moreover, we were astonished that in
one-third of all publications, facial photographic
documents with obvious makeup are shown.
Plastic and Reconstructive Surgery November 2010
274e
Of course, photographic documentary stan-
dards with regard to absence of any jewelry and
clothes are more a matter of taste. Nevertheless,
we observed gross negligence of style in photo-
graphic documents of the buttock with the pants
partly pulled down, of the abdomen with the pa-
tient wearing over-the-knees boots, and of a pa-
tients face with colored contact lenses with dif-
ferent colors in different photographs.
Although standards of photographic docu-
mentation were established years ago, there ap-
pears to be a lack of adherence to them in general
practice. The importance of following the stan-
dards cannot be emphasized enough (Fig. 1).
DOI: 10.1097/PRS.0b013e3181ef830e
Stefan Riml, M.D.
Agnieszka T. Piontke
Lorenz Larcher, M.D.
Peter Kompatscher, M.D.
Department of Plastic, Aesthetic, and Reconstructive Surgery
Academic Teaching Hospital Feldkirch
Feldkirch, Austria
Correspondence to Dr. Riml
Department of Plastic, Aesthetic, and Reconstructive Surgery
Academic Teaching Hospital Feldkirch
Feldkirch, Austria
stefan.riml@lkhf.at
REFERENCES
1. Zarem A. Standards of photography. Plast Reconstr Surg. 1984;
74:137144.
2. Persichetti P, Simone P, Langella M, Marangi G, Carusi C.
Digital photography in plastic surgery: How to achieve rea-
sonable standardization outside a photographic studio. Aes-
thetic Plast Surg. 2007;31:194200.
3. Meneghini F. Clinical facial photography in a small office:
Lighting equipment and technique. Aesthetic Plast Surg. 2001;
25:299306.
Table 1. Number of Articles Split into Anatomical Regions with Correct Standardized Photographic
Documentation
Region No. Angles Posing Section Mimic Makeup Screen Hair Clothes Jewelry
Face 124 88 96 104 110 85 104 97 22 65
Breast 75 62 42 64 59 33 27
Abdomen 24 22 13 19 16 5 9
Upper limb 12 11 10 11 10 7 10
Lower limb 7 6 7 7 6 6
Buttock 7 6 5 6 6 5
Total 249 195 173 211 110 85 201 97 78 111
Fig. 1. Percentages of articles with deficient photographic documentation in the
different categories.
Volume 126, Number 5 Viewpoints
275e
4. Dickason W, Hanna D. Pitfalls of comparative photography in
plastic and reconstructive surgery. Plast Reconstr Surg. 1976;
58:167175.
5. Sommer D, Mendelsohn M. Pitfalls of nonstandardized pho-
tography in facial plastic surgery patients. Plast Reconstr Surg.
2004;114:1014.
The Plastic Surgeons Role in Multispecialty
Group Practice: A Recipe for Success
and Longevity
Sir:
A
s the authors attended the senior residents con-
ference this past year (2009), they were surprised
that their fellow trainees did not express interest in
multispecialty group practices. Although 67 percent of
graduates plan to enter private practice with no further
specialty training, only 9 percent planned to join a
hospital or multispecialty group practice.
1
The majority
(76.3 percent) plan to enter solo or small plastic sur-
gery practices. Both of the authors chose the road less
traveled and joined multispecialty groups composed
mainly of primary care physicians, but also specialists.
Sixty-five percent of practicing plastic surgeons are
currently in solo practice, in contrast to 26.7 percent of
all physicians.
2
As Zook suggests, this individualismmay
be correlated with plastic surgery residents past inter-
est in individual rather than team sports and an overall
desire to do their own thing.
3
This inclination is also
in contrast to a recent trend among all physicians to
seek out larger medical groups.
4
Despite these findings,
the authors have found plastic surgeon participation in
multispecialty practice beneficial to the plastic surgeon
and the specialty itself.
Rohrich et al. noted that among the top reasons for
career dissatisfaction influencing the decision to retire
were the stress of practice and malpractice cost.
2
The
authors have found that multispecialty group practice
can mitigate these challenges of solo or smaller prac-
tices in many ways, as follows:
1. There is less need to seek referrals, particularly for
reconstruction, because of the groups network.
2. Advertising and marketing costs are funded by
the multispecialty group and managed by a team
of experts.
3. Malpractice costs are often subsidized, or the
group may be self-insured.
4. A billing department reduces (but does not elim-
inate) stress and time associated with coding and
correspondence with third-party payers.
5. Physicians share medical records, increasing effi-
ciency and decreasing time in correspondence.
6. The plastic surgeon can avoid substantial buy-in
costs, preventing excess early practice debt (over
half of senior residents in plastic surgery esti-
mated greater than $100,000 in existing educa-
tional debt).
1
7. The production component of compensation is
often implemented early and can be competitive
with a similar solo or small group practice, at simi-
lar overhead rates, using a percentage of collections
or a relative value unitbased calculation.
8. With relative value unitbased compensation, each
patient is seen as equal, with less incentive to make
clinical decisions based on reimbursement.
The specialty itself benefits by inclusion of
plastic surgeons into the health care team in a
tangible way, as follows:
1. The plastic surgeons participation raises
awareness of the importance of plastic sur-
gery as a specialty and its complementary
role to other specialties in the group. The
plastic surgeon is viewed as a team player
involved in group and/or hospital activities.
2. The plastic surgeon is viewed as useful to
the team in an immediate, concrete way.
Finally, the authors are pleasantly surprised
that these benefits did not require unreasonable
compromises. Specifically, the authors are invited
to decide on recruitment of management and of-
fice staff, marketing, and strategic growth. The
specialty can be practiced the way it should: giving
maximal attention to patients; optimizing out-
comes; and allowing time for research, teaching,
or family. Newgraduates woulddo well to consider
the multispecialty model. As the authors have
found, being part of a team can be immensely
satisfying and surprisingly liberating.
DOI: 10.1097/PRS.0b013e3181ef94d0
Jeffrey R. Scott, M.D.
Plastic and Reconstructive Surgery
Providence Physicians Group
Everett, Wash.
Scott D. Imahara, M.D.
Plastic and Reconstructive Surgery
Palo Alto Foundation Medical Group
Palo Alto Medical FoundationSanta Cruz
Santa Cruz, Calif.
Correspondence to Dr. Scott
Plastic and Reconstructive Surgery
Providence Physician Group
12800 Bothell-Everett Highway, Suite 260
Everett, Wash. 98208
jeffrey.scott@providence.org
REFERENCES
1. Imahara SD, Scott JR, Neligan PC. Career plans of graduating
plastic surgery trainees in 2009: The impact of an uncertain
economic climate. Plast Reconstr Surg. 2009;124:21732178.
2. RohrichRJ, McGrathMH, Lawrence TW; ASPS Plastic Surgery
Workforce Task Force; AAMC Center for Workforce Studies
. Plastic surgeons over 50: Practice patterns, satisfaction, and
retirement plans. Plast Reconstr Surg. 2008;121:14581474; dis-
cussion 14751477.
3. Zook EG. Resident selection. Plast Reconstr Surg. 2006;118:
12681269.
Plastic and Reconstructive Surgery November 2010
276e
4. Liebhaber A, Grossman JM. Physicians moving to mid-sized,
single-specialty practices. Track Rep. 2007;18:15.
Fascia Lata Harvesting: Minimal Access for
Maximum Harvest. A New Technique
Sir:
F
ascia lata is a versatile source of graft material for a
variety of surgical specialties. Its use has been de-
scribed both as an allograft
1
and as an autograft.
2,3
The
size of graft required often determines the surgical
incision required to obtain it. In the literature, various
techniques have been described to make the scar less
obvious, including endoscopic harvest, but still either
they result in a significant scar and make the harvest
more difficult or require access to expensive endo-
scopic equipment.
4,5
We present two new instruments that are both
simple in design and easy to use for the harvest of
fascia lata. They allow rapid and controlled harvest of
large segments of fascia through two small transverse
skin incisions.
The two new instruments developed are called the
fascial dissector and the fasciotome (Fig. 1). The fascial
dissector has a flat blunt end and is used to dissect fascia
from adjacent soft tissues on either side of the fascia
lata. The fasciotome has a movable, U-shaped, sharp
blade (Fig. 1). This sharp blade cuts the fascia in the
desired direction.
The technique was first carried out on cadavers to
check the effectiveness of the instruments. It was then
applied to live patients. The technique can be modified
according to the size of fascia required. In our practice,
we normally use fascia lata for static support in facial
palsy. For this reason, we normally require a rectangu-
lar piece of fascia (5 15 cm). The required size is
marked on the thigh. Two transverse skin incisions are
made up to the fascia. The distal end of the fascia is cut
and held in position with forceps and the dissector is
passed above and below the fascia to release it from the
skin and the muscle. Then, the superior and inferior
ends of the rectangle are cut with the fasciotome. We
normally place the fasciotome at the distal incised end
of the fascia and cut it from distal to proximal, which
is easier because the subcutaneous fat layer is thinner.
The fascia needs to be held with forceps to stabilize it
before placing the fasciotome at the distal incision
(Fig. 2). This is pushed firmly until the sharp end of the
fasciotome is visible at the proximal incision. The same
process is repeated at the inferior end of the scar. Now,
the three-sided divided fascia is reflected out through
the proximal incision. The size is confirmed with the
template and the proximal end is cut. Usually, it does
not require hemostasis, but if there is some oozing, we
place a drain and then both incision sites are closed in
two layers.
The prototype instrument has subsequently been
used on 11 patients with success. The patients were
satisfied with the functional and cosmetic outcome.
We have also successfully used these instruments to
carry out fasciotomies through smaller incisions. The
major advantage is the blunt dissection of the fascia
from the muscle and from the skin, reducing the risk
of bleeding.
We have found these instruments easy and safe to
handle. This technique has a quick learning curve and
is easily reproducible.
DOI: 10.1097/PRS.0b013e3181ef82fa
Ahmad F. Bhatti, F.R.C.S.I.(Plast.)
Plastic Surgery
Countess of Chester Hospital
Chester, United Kingdom
Ali Soueid, M.R.C.S.
Plastic Surgery
Birmingham Children Hospital
Birmingham, United Kingdom
James M. Baden, F.D.S., M.R.C.S.
Plastic Surgery
Royal Devon and Exeter Hospital
Exeter, United Kingdom
Fig. 2. The forceps stabilize the distal end of the fascia before it
is cut with the fasciotome.
Fig. 1. Fascial dissector and the fasciotome.
Volume 126, Number 5 Viewpoints
277e
Antonio Orlando, F.R.C.S.
Frenchay Hospital
Bristol, United Kingdom
Correspondence to Dr. Bhatti
Plastic Surgery
Countess of Chester Hospital
Chester, United Kingdom
afbhatti1@yahoo.co.uk
DISCLOSURE
The authors have no financial interest to declare in re-
lation to the content of this article.
REFERENCES
1. Noyes FR, Barber SD, Mangine RE. Bone-patellar ligament-
bone and fascia lata allografts for reconstruction of the an-
terior cruciate ligament. J Bone Joint Surg (Am.) 1990;72:1125
1136.
2. Matsumoto K, Nakanishi H, Urano Y, Kubo Y, Nagae H. Lower
eyelid reconstruction with a cheek flap supported by fascia
lata. Plast Reconstr Surg. 1999;103:16501654.
3. Disa JJ, Goldberg NH, Carlton JM, Robertson BC, Slezak S.
Restoring abdominal wall integrity in contaminated tissue-
deficient wounds using autologous fascia grafts. Plast Reconstr
Surg. 1998;101:979986.
4. Drever JM. A simple method for obtaining fascia lata grafts.
Plast Reconstr Surg. 1972;50:196197.
5. Tucker JG, Choat D, Zubowicz VN. Videoscopically assisted
fascia lata harvest for correction of recurrent ventral hernia.
South Med J. 1997;90:399401.
Microsurgical Training Using a Pulsatile
Membrane Pump and Chicken Thigh: A
New, Realistic, Practical, Nonliving
Educational Model
Sir:
M
icrosurgery requires practice, skill, and patience.
Numerous microsurgical training models are
available that can impart skill, given an appropriate
level of rehearsal. Models can range from basic (e.g.,
Silastic tubing) to live animal models. Increasingly,
more realistic nonlive models have been developed
that provide a high-fidelity training experience. We
propose a pulsatile nonvital chicken thigh model for
use in training.
The core technology of this model is the mem-
brane pump. The pump is a commercially available
Rietschle-Thomas (Sheboygan, Wis.) membrane
pump model FZ 5002. Standard intravenous 0.9%
normal saline is used to perfuse the model. Our
microsurgical training setup is shown in Figure 1.
The pump provides a pulsatile pressure wave com-
parable to normal human parameters (60 to 120
mmHg). The pumps flow parameters simulate a nor-
mal peripheral pulsatile arterial flow ranging from 0
to 0.85 liters/minute. (See Video, Supplemental Dig-
ital Content 1, demonstrating pulsatile flow through
a transected chicken femoral artery attached to the
membrane pump, http://links.lww.com/PRS/A232.)
Fresh chicken thighs are used. The femoral artery is
cannulated using a 22-gauge cannula. An H-shaped
incision is made over the iliotibialis, iliofibularis, gas-
trocnemius, and peroneus longus muscles. Flaps are
raised and the muscles either reflected or resected until
the neurovascular plane is identified, as shown in Fig-
ure 2. Bipolar diathermy is required for cautery of the
tributaries of the artery and vein, adding to the realismof
the model. Dissection requires delicate handling of the
tissues and respect for branching and perforating vessels.
(See Video, Supplemental Digital Content 2, which dem-
onstrates arterial side branches arising from the chicken
femoral artery, http://links.lww.com/PRS/A233.) Poor
technique will result in simulated bleeding. A num-
ber of anastomotic techniques can now be pre-
formed. (See Video, Supplemental Digital Content 3,
which demonstrates a pulsatile arterial anastomosis,
http://links.lww.com/PRS/A234.)
Microsurgical skill is best attained by exposure
through a graduated progression from simple to more
advanced training models.
1,2
There are numerous be-
ginner and advanced models
3
but a real paucity of
realistic, intermediate level, nonliving models.
The technique of using a pulsatile membrane pump
in microsurgical training was first described by Schoffl
et al.
4
using porcine coronary arteries. We have found
Supplemental digital content is available for
this article. Direct URL citations appear in the
printed text; simply type the URL address into
any Web browser to access this content. Click-
able links to the material are provided in the
HTML text of this article on the Journals Web
site (www.PRSJournal.com).
Fig. 1. The microsurgical training workstation, including mi-
crosurgical instruments, microscope, liquid crystal display
monitor, DC power supply, membrane pump, drip tray, and
operative field.
Plastic and Reconstructive Surgery November 2010
278e
that there are two significant drawbacks with this original
method. First, coronary vessels are intimately adherent to
the myocardium and have numerous side branches that
complicate the dissection. Second, pig hearts do not tol-
erate refrigeration well, becoming firm and wooden.
Chicken thighs, in comparison, are still supple and real-
istic to dissect even days after their harvest.
The standard means of microsurgical teaching is still
live animal training. Anastomoses can be assessed me-
chanically (i.e., checking for leaks), but also hemodynam-
ically by assessing for thrombosis.
5
However, animals are
expensive to keep, operate on, and dispose of. Animal
ethics approvals are oftendifficult andtime-consuming to
obtain. Premature exposure of microsurgical trainees to
advanced live animal models can be wasteful if the train-
ees have not mastered basic technique first.
There has been a growing movement toward high-
fidelity, nonvital surgical and microsurgical training for
some time. A nonliving pulsatile microsurgical model
is in keeping with this paradigm. We believe that the
pulsatile chicken thigh is the best current adaptation of
this model, as it is realistic, easy to obtain, cheap, and
lasts well. In the current form, it will not obviate the
need for live animal training. However, it will advance
trainees skill levels to a point at which will derive the
most benefit when they progress to live animal models.
DOI: 10.1097/PRS.0b013e3181ef82e2
Alexander F. Phoon, M.B.B.S.
Graham J. Gumley, F.R.A.C.S., F.A.Orth.A.
Michael A. Rtshiladze, M.B.B.S.
Sydney Hospital Microsurgical Laboratory
Sydney Hospital Hand Unit, and
University of Sydney
Sydney, New South Wales, Australia
Correspondence to Dr. Phoon
Microsurgical Training Laboratory
North Block, Level 3
Sydney Hospital 8 Macquarie Street
Sydney, New South Wales 2000, Australia
dralexphoon@gmail.com
Presented at the Australian and New Zealand Plastic
Surgical Registrars Annual Scientific Conference, in
Melbourne, Australia, 2009, and awarded the prize for best
clinical paper presentation.
DISCLOSURE
The authors have no financial interest to declare in re-
lation to the content of this article.
REFERENCES
1. Lorenzo AR, Alvarez A, Garcia-Barreiro J, Centeno A, Lopez
E, Martelo F. Designandcreationof anexperimental program
of advanced training in reconstructive microsurgery. Micro-
surgery 2006;26:421428.
2. Livingston CK, Ruiz-Razura A, Cohen BE. Guidelines for a
successful microsurgery training center and research fellow-
ship. Plast Reconstr Surg. 1999;104:15551558.
3. Sidhu RS, Park J, Brydges R, MacRae HM, Dubrowski A. Lab-
oratory-based vascular anastomosis training: A randomized
controlled trial evaluating the effects of bench model fidelity
and level of training on skill acquisition. J Vasc Surg. 2007;45:
343349.
4. Schoffl H, Hager D, Hinterdorfer C, et al. Pulsatile perfused
porcine coronary arteries for microvascular training. Ann Plast
Surg. 2006;57:213216.
5. Ilie V, Ilie V, Ghetu N, Popescu H, Grosu O, Pieptu D. As-
sessment of the microsurgical skills: 30 minutes versus 2 weeks
patency. Microsurgery 2007;27:451454.
The Ideal Donor-Site Dressing: Are We
Clear Yet?
Sir:
M
any articles have lookedat donor-site dressings over
the past few years,
13
yet there still has not been
universal agreement on the ideal dressing. As in many of
these articles, we suggest that the ideal qualities of a do-
nor-site dressing include the following: promotion of
Video 1. Supplemental Digital Content 1 demonstrates pulsa-
tileflowthrougha transectedchickenfemoral artery attachedto
the membrane pump, http://links.lww.com/PRS/A232.
Fig. 2. Neurovascular bundle following dissection.
Volume 126, Number 5 Viewpoints
279e
healing and comfort; prevention of infection; low cost;
and ease of management, application, and removal.
At present intheUnitedKingdom, therearenumerous
different dressings in use for dressing donor sites. Geary
and Tiernan
4
found that the commonest dressings in
overall use in United Kingdomplastic surgery centers are
alginates (e.g., Kaltostat). Other popular dressings in-
clude Biobrane, Mepitel, paraffin gauze, and Mefix. At
the Burns Service at Chelsea and Westminster Hospital,
London, our current practice is to use either Telfa
Clear (a transparent, nonadherent dressing manufac-
tured by Covidien) or Jelonet as a donor-site dressing
depending on consultant preference. We note that a
letter by Bhatti
5
was the only publication that primarily
addressed Telfa as a donor-site dressing, and even this
was only in a pediatric setting. Furthermore, this letter
did not specify which type of Telfa was being used. We
are currently in the process of evaluating both Telfa
and Jelonet to identify which possesses most of the
attributes of an ideal donor-site dressing.
A pilot study was designed to identify which of the
two dressings scored best with regard to pain and ease
of removal. Interestingly, we noted a definite anecdotal
trend of quicker relative healing time in the donor-site
areas dressed with Jelonet. The 30 patients recruited
were selected based on a number of criteria. Patients
with donor sites between 1 and 5 percent were selected
and randomized into proximally versus distally as to
which half was dressed with which dressing. We excluded
five patients fromthe study, as they were unable to attend
follow-up at the designated times. As we expected, the
study revealed that in 19 of the 25 patients the Jelonet was
more painful to remove than the Telfa Clear and that in
17 of the 25 cases Telfa Clear was easier to remove than
Jelonet. In three cases, the ease of removal was the same.
In summary, it was found that although Telfa Clear was
easier to remove and less painful, the Jelonet-dressed
donor sites appeared to heal faster.
Considering the two criteria of pain and ease of re-
moval, Telfa Clear appears to be the preferred dressing.
However, to fully evaluate the suitability of Telfa Clear as
a donor-site dressing, other parameters will need to be
studiedan accurate randomized study of time to heal-
ingwouldalsobe appropriate. We are currently collecting
data regardingthe ideal properties of donor-site dressings
to obtain evidence to establish a departmental protocol.
It is important to note that although it is useful to have a
standard dressing for donor sites, the dressing should be
tailored to the health economics of the unit and the
individual needs of the patient.
DOI: 10.1097/PRS.0b013e3181ef94e2
Koushik Ghosh, M.R.C.S.
Allan J. Ponniah, M.R.C.S.
Isabel Jones, F.R.C.S.Plast.
Jorge Leon-Villapalos, F.R.C.S.Plast.
Chelsea and Westminster Hospital
London, United Kingdom
Greg Williams, F.R.C.S.(Plast.)
Correspondence to Dr. Ghosh
Burns Unit
Chelsea and Westminster Hospital
269 Fulham Road
London SW10 9NH, United Kingdom
koushikghosh@hotmail.co.uk
REFERENCES
1. Terril PJ, Goh RC, Bailey MJ. Split-thickness skin graft donor
sites: A comparative study of two absorbent dressings. J Wound
Care 2007;16:433438.
2. Dornseifer U, Fichter AM, Herter F, Sturtz G, Ninkovic M. The
ideal split-thickness skin graft donor site dressing: Rediscovery
of polyurethane film. Ann Plast Surg. 2009;63:198200.
3. Melandri D, De Angelis A, Orioli R, et al. Use of a new hemi-
cellulose dressing (Veloderm) for the treatment of split-thick-
ness skin graft donor sites: A within-patient controlled study.
Burns 2006;32:964972.
4. Geary PM, Tiernan E. Management of split skin graft donor
sites: Results of a national survey. J Plast Reconstr Aesthet Surg.
2009;62:16771683.
5. Bhatti AZ. Telfa as donor-site dressing. Plast Reconstr Surg.
2005;116:1578.
Moral Hazard and Modern Health Care
Sir:
T
he inequalities of health care delivery systems stem
from several sources, one of which is inflexibility
of human behavior. Patients unmotivated to invest in
their own health consume a huge proportion of the re-
sources as compared with health-conscious patients with
healthier lifestyles. Termed moral hazard, this behavior
affects outcomes and cost and has been well recognized
as a key factor by nonhealthcare insurance systems (life,
automobile, renters, and home insurance) for decades.
In health care, however, this principle is only now being
seen as an important predictor of cost.
15
Moral hazard
varies with type of insurance coverage. The further a
health care system strays from a direct fee-for-service
model, the closer it comes to a universal model, the less
accountable an individual is for his or her health care
actions, and the higher the moral hazard.
In this article, we examine how physicians could apply
the principle of moral hazard to modernize the current
health care system to enable accurate risk prediction,
proactive intervention, targeted prevention, better resource
allocation, and potentially better outcomes with cost con-
tainment. Solutions explored here are completely nonpo-
litical and are uniquely physician driven: this is perhaps one
of the few physician-driven efforts in a highly charged envi-
ronment of stakeholders jockeying for their lot.
Some suggestions include the following:
1. Encourage patients to embrace measures that
promote better health. Incentivize healthy
choices (e.g., food, exercise, weight loss, stress
reduction, and smoking cessation).
2. Incentivize employers that provide in-house gym
facilities, dietary changes in cafeterias, and
Plastic and Reconstructive Surgery November 2010
280e
health-screening programs through discounts in
their health-insurance premiums.
3. Chart individual progress and link it with a cash-
back rewards program for demonstrating im-
provement in health status. Conversely, dissuade
noncompliance by means of education and en-
rollment in preventive programs.
4. Create easily accessible interactive programs to enable
individuals to understand the consequences of non-
compliance on health and insurance premiums.
5. Actuate overall level of health by generating a
scoring system that includes weight, comorbidi-
ties, and healthy/unhealthy behaviorsthe
health score, which is a uniform, easily measur-
able yardstick of individual health status. Im-
provement in score measures success. Modifica-
tion of expectations, ongoing assessment, and
quality improvement become goals that give pa-
tients positive participation in their health needs.
6. Increase our involvement with our patients by
means of screening, surveillance, education, and
measures to prevent posttreatment morbidity. The
initial time spent in making these changes will pay
rich dividends in terms of better outcomes.
7. Advocate for better reimbursement for eliciting
behavior modification. The promise of fewer
complications stemming from patient-related fac-
tors, better outcomes, fewer hospital days, and
improved efficiency could add up to significant
savings that could justify the increase in physician
reimbursements for preventive services.
Critics might argue that this methodseems imper-
sonal, akin to a credit score rating. This is true, but
these changes to the health care systemare inevitable.
Costs must be reducedandoutcomes must improve.
Solutions delineated here are timely and imminent.
Integrating the concept of moral hazard to improve
risk-based resource allocation builds a robust system
that finds its foundation on promoting healthier be-
haviors. It empowers patients by encouraging auton-
omy and makes themaccountable for their choices. It
could help design a health care system that suspends
the noisy political drama and actually cuts costs
through a novel strategypromote better health. Intuitive
and innovative!
DOI: 10.1097/PRS.0b013e3181ef94f4
Brian Allen, M.D.
Rajiv Y. Chandawarkar, M.D.
Division of Plastic Surgery
Department of Surgery
University of Connecticut School of Medicine
Farmington, Conn.
Correspondence to Dr. Chandawarkar
University of Connecticut Health Center, MC 1601
263 Farmington Avenue
Farmington, Conn. 06030-1601
chandawarkar@uchc.edu
REFERENCES
1. Wong IO, Lindner MJ, Cowling BJ, Lau EH, Lo SV, Leung GM.
Measuring moral hazard and adverse selection by propensity
scoring in the mixed health care economy of Hong Kong.
Health Policy 2010;95:2435.
2. Frick KD, Chernew ME. Beneficial moral hazard and the
theory of the second best. Inquiry 2009;46:229240.
3. Zweifel P, Breuer M. The case for risk-based premiums in
public health insurance. Health Econ Policy Law 2006;1:171
188.
4. Barros PP, Machado MP, Sanz-de-Galdeano A. Moral hazard
and the demand for health services: A matching estimator
approach. J Health Econ. 2008;27:10061025.
5. Nyman JA. American health policy: Cracks in the foundation.
J Health Polit Policy Law 2007;32:759783.
Clinical Trial Quality and Reporting Quality in
American Society of Plastic Surgeons and
German Conference Abstracts: A
Transatlantic Perspective
Sir:
T
ransatlantic Innovations: New Frontiers in Plastic
Surgery, involving both the United States and Eu-
rope, were initiated in a combined kickoff meeting in
February of 2009.
1
The transatlantic communication in
plastic surgical innovations is endorsed by the afore-
mentioned conference. Clinical trials, at best using a
randomized controlled design, are warranted in plastic
surgery to elucidate the value of novel technologies or
surgical refinements in plastic surgery. However, to
date, no scientific analysis has been performed on the
clinical trial quality and reporting quality of transat-
lantic plastic surgery conferences. As such, we sought to
evaluate the clinical trial quality and reporting quality
of the annual meetings of the American Society of
Plastic Surgeons (ASPS) and the Deutsche Gesellschaft
der Plastischen, Rekonstruktiven und Asthetischen
Chirurgen (German Society of Plastic, Reconstructive and
Aesthetic Surgeons). We hypothesized that the clinical
trial and reporting quality differs between the Ameri-
can and German national meetings.
We analyzed 159 (65 oral and 94 poster) abstracts
from the ASPS conference 2008 and 326 (163 oral and
163 poster) abstracts fromthe German2008 meeting by
means of two independent examiners. Main outcome
measures were the evidence-based type of study design,
the scores of 17 Consolidated Standards of Reporting
Trials
2
criteria for randomized controlled trials, or 22
Strengthening the Reporting of Observational Studies
in Epidemiology
3
criteria for observational studies.
As far as randomized controlled trials are concerned,
we found no significant difference between the ASPS
meeting and the German plastic surgery meeting (4
percent versus 2 percent, p 0.06; 95 percent confi-
dence interval, 0.93 to 8.9). Observational studies were
presented significantly more often at the ASPS meeting
versus the German meeting (53 percent versus 30 per-
cent, p 0.01; 95 percent confidence interval, 1.41 to
2.19), although more case series and other nonobser-
Volume 126, Number 5 Viewpoints
281e
vational and nonrandomized controlled trials were
published at the German meeting compared with the
ASPS meeting (68 percent versus 42 percent, p 0.01;
95 percent confidence interval, 0.51 to 0.75). Notably,
no differences in reporting quality were observed in
abstracts of randomized controlled trials for both oral
(ASPS versus German, 6.7 1.2 versus 5 0 of 17,
p 0.07; 95 percent confidence interval, 0.22 to 3.62)
and poster presentations (7.3 1 versus 7 0 of 17,
p 0.854; 95 percent confidence interval, 3.03 to
2.63). In observational studies, the reporting quality
was not different transatlantically, for either oral (8.52
2.48 versus 7.7 1.7, p 0.462; 95 percent confi-
dence interval, 0.014 to 1.62) or poster presentations
(8.07 2.29 versus 7.5 1.6, p 0.223; 95 percent
confidence interval, 0.35 to 1.5). Furthermore, we
found no difference in the reporting quality of ran-
domized controlled trials or observational studies for
poster versus oral presentations at the ASPS meeting
(randomized controlled trials, 6.7 1.2 versus 7.3 1,
p 0.498; 95 percent confidence interval, 2.62 to 1.46;
observational studies, 8.52 2.48 versus 8.07 2.29;
p 0.387; 95 percent confidence interval, 0.58 to
1.48) and the German meeting (randomized con-
trolled trials, 5 0 versus 7 0, p 0.54; observational
studies; 7.7 1.7 versus 7.5 1.6, p 0.575; 95 percent
confidence interval, 0.5 to 0.91).
We conclude that although clinical trial quality is
shifted toward higher evidence-based level designs in
ASPS versus German national plastic surgery meeting
abstracts, the reporting quality of randomized con-
trolled trials and observational studies does not differ
transatlantically. Endorsement and substantial adop-
tion of the Consolidated Standards of Reporting Trials
and the Strengthening the Reporting of Observational
Studies in Epidemiology criteria for clinical trials might
further increase the conference abstract reporting
quality on both sides of the Atlantic.
DOI: 10.1097/PRS.0b013e3181ef9506
Karsten Knobloch, M.D., Ph.D.
Uzung Yoon, M.D., M.P.H.
Peter M. Vogt, M.D., Ph.D.
Plastic, Hand, and Reconstructive Surgery
Hannover Medical School
Hannover, Germany
Correspondence to Dr. Knobloch
Plastic, Hand, and Reconstructive Surgery
Hannover Medical School
Carl-Neuberg-Str. 1
30625 Hannover, Germany
kknobi@yahoo.com
DISCLOSURE
The authors have no financial interests to disclose and
received no internal or external funding.
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