Plastic & Reconstructive Surgery

November 2007, Volume 120, Issue 6,pg(1443-1748)

BREAST ORIGINAL ARTICLES Raising Perforator Flaps for Breast Reconstruction: The Intramuscular 1443 Anatomy of the Deep Inferior Epigastric Artery. Warren M. Rozen, M.B.B.S.; Mark W. Ashton, M.D.; Wei R. Pan, M.D.; G Ian Taylor, M.D. An Intraoperative Algorithm for Use of the SIEA Flap for Breast 1450 Reconstruction. Aldona J. Spiegel, M.D.; Farah N. Khan, M.D. Dermabond Skin Closures for Bilateral Reduction Mammaplasties: A 1460 Review of 255 Consecutive Cases. Gregory R. Scott, M.D.; Cynthia L. Carson, P.A.-C.; Gregory L. Borah, M.D. The Versatility of the Superomedial Pedicle with Various Skin 1466 Reduction Patterns. Steven P. Davison, M.D., D.D.S.; Ali N. Mesbahi, M.D.; Ivica Ducic, M.D., Ph.D.; Marc Sarcia, M.D.; Joseph Dayan, M.D.; Scott L. Spear, M.D. Immediate Postoperative Complications in DIEP versus Free/Muscle- 1477 Sparing TRAM Flaps. Constance M. Chen, M.D., M.P.H.; Eric G. Halvorson, M.D.; Joseph J. Disa, M.D.; Colleen McCarthy, M.D., M.P.H.; Qun-Ying Hu, M.D.; Andrea L. Pusic, M.D., M.H.S.; Peter G. Cordeiro, M.D.; Babak J. Mehrara, M.D. BREAST IDEAS AND INNOVATIONS Correction of Inverted Nipples by Strong Suspension with Areola-

1483 Based Dermal Flaps. Jin Sik Burm, M.D., Ph.D.; Yang Woo Kim, M.D., Ph.D. EXPERIMENTAL ORIGINAL ARTICLES Norian Craniofacial Repair System: Compatibility with Resorbable and 1487 Nonresorbable Plating Materials. David G. Genecov, M.D.; Michael Kremer, M.D.; Rajiv Agarwal, M.D.; Kenneth E. Salyer, M.D.; C Raul Barcelo, M.D.; Harold M. Aberman, D.V.M., M.S.E.; Lynne A. Opperman, Ph.D. Experimental Animal Model Proving the Benefit of Primary Defatting of 1496 Full-Thickness Random-Pattern Skin Flaps by Suppressing "Perfusion Steal". Arie Chetboun, M.D.; Alain Charles Masquelet, M.D. rhBMP-4 Gene Therapy in a Juvenile Canine Alveolar Defect Model. Joyce C. Chen, M.D.; Shelley R. Winn, Ph.D.; Xi Gong, M.D.; Wayne H. Ozaki, M.D. 1503

Influences of Preservation at Various Temperatures on Liposuction 1510 Aspirates. Daisuke Matsumoto, M.D.; Tomokuni Shigeura, M.S.; Katsujiro Sato, M.D.; Keita Inoue, M.D.; Hirotaka Suga, M.D.; Harunosuke Kato, M.D.; Noriyuki Aoi, M.D.; Syoko Murase, Ph.D.; Koichi Gonda, M.D.; Kotaro Yoshimura, M.D. RECONSTRUCTIVE HEAD AND NECK: ORIGINAL ARTICLES Impact of the SMAS on Frey's Syndrome after Parotid Surgery: A

1519 Prospective, Long-Term Study. Andrea Wille-Bischofberger, M.D.; Gunesh P. Rajan, M.D.; Thomas E. Linder, M.D.; Stephan Schmid, M.D. Reconstruction of Postburn Neck Contractures Using Free Thin

1524 Thoracodorsal Artery Perforator Flaps with Cervicoplasty. Goo-Hyun Mun, M.D.; Byeng-June Jeon, M.D.; So-Young Lim, M.D.; Won-Sok Hyon, M.D.; Sa-Ik Bang, M.D.; Kap-Sung Oh, M.D.

A Face Lift Approach for Sentinel Node Biopsy in Head and Neck 1533 Melanoma Patients. Mark L. Venturi, M.D.; Steven P. Davison, D.D.S., M.D. Anatomical and Technical Aspects of Harvesting the Auricle as a

1540 Neurovascular Facial Subunit Transplant in Humans. Betul Gozel Ulusal, M.D.; Ali Engin Ulusal, M.D.; Jeng-Yee Lin, M.D.; Bien-Keem Tan, F.R.C.S.(Ed.); Chin-Ho Wong, M.R.C.S.(Ed.); Colin Song, F.R.C.S.(Ed.); Fu-Chan Wei, M.D. RECONSTRUCTIVE HEAD AND NECK: IDEAS AND INNOVATIONS

Measuring Sensibility of the Trigeminal Nerve. A Lee Dellon, M.D.; Eugenia Andonian, M.D.; Ramon A. DeJesus, M.D. 1546 RECONSTRUCTIVE TRUNK: ORIGINAL ARTICLE

The Superior and Inferior Gluteal Artery Perforator Flaps. Reza Ahmadzadeh, B.Sc.; Leonard Bergeron, M.D., C.M., M.Sc.; Maolin Tang, M.D.; Steven 1551 F. Morris, M.D., M.Sc. RECONSTRUCTIVE TRUNK: SPECIAL TOPIC Resumption of Sexual Activity after Plastic Surgery: Current Practice

1557 and Recommendations. Marlene Rankin, Ph.D.; Gregory Borah, M.D.; Sonia Alvarez, M.D. RECONSTRUCTIVE TRUNK: IDEAS AND INNOVATIONS Treatment of Giant Omphalocele with Intraabdominal Tissue

1564 Expansion. Marissa J. Tenenbaum, M.D.; Robert P. Foglia, M.D.; Devra B. Becker, M.D.; Alex A. Kane, M.D. RECONSTRUCTIVE LOWER EXTREMITY: ORIGINAL ARTICLES Outcome of Simultaneous and Staged Microvascular Free Tissue 1568 Transfer Connected to Arteriovenous Loops in Areas Lacking Recipient Vessels. Peter M. Vogt, M.D., Ph.D.; Hans Ulrich Steinau, M.D., Ph.D.; Marcus Spies, M.D., Ph.D.; Susanne Kall, M.D.; Andreas Steiert, M.D.; Pejman Boorboor, M.D.; Bernd Vaske, Ph.D.; Andreas Jokuszies, M.D. Use of the Soleus Musculocutaneous Perforator for Skin Paddle 1576 Salvage of the Fibula Osteoseptocutaneous Flap: Anatomical Study and Clinical Confirmation. Chin-Ho Wong, M.R.C.S.; Bien-Keem Tan, F.R.C.S.; Fu-Chan Wei, M.D.; Colin Song, F.R.C.S. HAND/PERIPHERAL NERVE ORIGINAL ARTICLES Evaluation of Elbow Flexion as a Predictor of Outcome in Obstetrical

1585 Brachial Plexus Palsy. David M. Fisher, M.D.; Gregory H. Borschel, M.D.; Christine G. Curtis, P.T., M.Sc.; Howard M. Clarke, M.D., Ph.D. Intravenous Regional Anesthesia Administered by the Operating 1591 Plastic Surgeon: Is It Safe and Efficient? Experience of a Medical Center. Joseph S. Bou-Merhi, M.D.; Alain R. Gagnon, M.D.; Jean-Yves St. Laurent, M.D.; Marc Bissonnette, M.D.; Andre A. Chollet, M.D. HAND/PERIPHERAL NERVE IDEAS AND INNOVATIONS Hand Evaluation following Ulnar Forearm Perforator Flap Harvest: A

1598 Prospective Study. Eduardo D. Rodriguez, M.D., D.D.S.; Suhail K. Mithani, M.D.; Rachel Bluebond-Langner, M.D.; Paul N. Manson, M.D. PEDIATRIC/CRANIOFACIAL ORIGINAL ARTICLES Primary Grafting with Autologous Cranial Particulate Bone Prevents

1603 Osseous Defects following Fronto-Orbital Advancement. Arin K. Greene, M.D., M.M.Sc.; John B. Mulliken, M.D.; Mark R. Proctor, M.D.; Gary F. Rogers, M.D., J.D., M.B.A. Evaluation of Cleft Lip Bony Depression of Piriform Margin and Nasal 1612 Deformity with Cone Beam Computed Tomography: "Retruded-like" Appearance and Anteroposterior Position of the Alar Base. Junpei Miyamoto, M.D.; Tomohisa Nagasao, M.D.; Tatsuo Nakajima, M.D.; Hisao Ogata, M.D. Midterm Follow-Up of Midface Distraction for Syndromic

1621 Craniosynostosis: A Clinical and Cephalometric Study. Pradip R. Shetye, M.D.S., M.Orth.R.C.S.; Sean Boutros, M.D.; Barry H. Grayson, D.D.S.; Joseph G. McCarthy, M.D.

The Septospinal Ligament in Cleft Lip Nose Deformity: Study in Adult 1633 Unilateral Clefts. Rajiv Agarwal, M.Ch., D.N.B. (Plast. Surg.); Ramesh Chandra, F.R.C.S. A Virtual Reality Atlas of Craniofacial Anatomy. Darren M. Smith, M.D.; Aaron Oliker, M.S.; Christina R. Carter, D.M.D.; Miro Kirov, M.F.A.; 1641 Joseph G. McCarthy, M.D.; Court B. Cutting, M.D. Supplemental Digital Content is available in the text COSMETIC ORIGINAL ARTICLES Anatomy of the Corrugator Supercilii Muscle: Part I. Corrugator

1647 Topography. Jeffrey E. Janis, M.D.; Ashkan Ghavami, M.D.; Joshua A. Lemmon, M.D.; Jason E. Leedy, M.D.; Bahman Guyuron, M.D. Versatility of Diced Cartilage-Fascia Grafts in Dorsal Nasal

1654 Augmentation. Martin H. Kelly, F.R.C.S.(Plast.); Neil W. Bulstrode, F.R.C.S.(Plast.); Norman Waterhouse, F.R.C.S.(Plast.) COSMETIC ORIGINAL ARTICLES: Discussion

Discussion. Rollin K. Daniel, M.D. 1660 COSMETIC ORIGINAL ARTICLES The Change of Maximum Bite Force after Botulinum Toxin Type A

1662 Injection for Treating Masseteric Hypertrophy. Ki Young Ahn, M.D., Ph.D.; Seong Taek Kim, D.D.S., M.S.D. A Comparison of Face Lift Techniques in Eight Consecutive Sets of

1667 Identical Twins. Darrick E. Antell, M.D., D.D.S.; Michael J. Orseck, M.D. One-Stage Mastopexy with Breast Augmentation: A Review of 321

1674 Patients. W Grant Stevens, M.D.; Mark E. Freeman, M.D.; David A. Stoker, M.D.; Suzanne M. Quardt, M.D.; Robert Cohen, M.D.; Elliot M. Hirsch, M.D. The Brava External Tissue Expander: Is Breast Enlargement without

1680 Surgery a Reality? Ingrid Schlenz, M.D.; Alexandra Kaider, M.Sc. COSMETIC ORIGINAL ARTICLES: Discussion

Discussion. Sumner A. Slavin, M.D. 1690 COSMETIC ORIGINAL ARTICLES

Back Contouring in Weight Loss Patients. Berish Strauch, M.D.; Christine Rohde, M.D.; Mitesh K. Patel, M.D.; Sameer Patel, M.D. 1692 COSMETIC IDEAS AND INNOVATIONS Endoscopic Brow Lift, Upper and Lower Blepharoplasty, Retinacular

1697 Canthopexy: Personal Approach. James M. Stuzin, M.D. Video Plus Content is available in the text. CME

CME Surgical Cephalometrics: Applications and Developments. 92e Craig A. Hurst, M.D.; Barry L. Eppley, M.D., D.M.D.; Robert J. Havlik, M.D.; A Michael Sadove, M.D. SPECIAL TOPIC

Operating Room Fires: Optimizing Safety. Silvia Cristina Meneghetti, M.D.; Mark M. Morgan, M.D.; Janet Fritz, C.R.N.A.; Raymond G. 1701 Borkowski, M.D.; Risal Djohan, M.D.; James E. Zins, M.D.

50th Anniversary Plastic Surgery Research Council Panel on the 1709 Future of Academic Plastic Surgery. R Barrett Noone, M.D.; Robert M. Goldwyn, M.D.; Mary McGrath, M.D.; Scott Spear, M.D.; Gregory R. D. Evans, M.D.

Bridging the Gap: The 34th Varaztad H. Kazanjian Memorial Lecture. Robert M. Goldwyn, M.D. 1722 EDITORIAL

The Lagging U.S. Health Care Information Technology Infrastructure: 1729 Parallel Challenges for Plastic Surgery. Rod J. Rohrich, M.D. Appropriate Prophylactic Antibiotic Use in Plastic Surgery: The Time

1732 Has Come. John G. Hunter, M.D., M.M.M. REVIEWS

Neck Lift. Daniel C. Baker, M.D. 1735

Reoperative Aesthetic and Reconstructive Plastic Surgery, 2nd Edition. Maurice Y. Nahabedian, M.D. 1735 LETTERS

Putting Wild Maggots on Your Head Is Not "Maggot Therapy," but It 1737 Does Suggest Pre-Existing Pathology. Ronald Sherman, M.D., M.Sc., D.T.M.&H. Putting Wild Maggots on Your Head Is Not "Maggot Therapy," but It

1738 Does Suggest Pre-Existing Pathology: Reply. Ilteris Murat Emsen, M.D.

Maggot Debridement Therapy. Kosta Y. Mumcuoglu, Ph.D. 1738

Maggot Debridement Therapy: Reply. Ilteris Murat Emsen, M.D. 1739

Surgical Treatment of Partial Defects of the External Ear. Nabil I. Elsahy, F.R.C.S. 1739

Surgical Treatment of Partial Defects of the External Ear: Reply. Fabio M. Abenavoli, M.D. 1739

Medial Epicanthoplasty Using the Skin Redraping Method. Michael T. Yen, M.D. 1740

Augmentation Mentoplasty with Diced High-Density Porous 1740 Polyethylene. Manolis Heliotis, F.D.S.R.C.S., F.R.C.S.; Ashraf Messiha, M.F.D.S., M.R.C.S.

Augmentation Mentoplasty with Diced High-Density Porous 1741 Polyethylene: Reply. Ali Gurlek, M.D.; Cemal Firat, M.D.; Göktekin Tenekeci, M.D.; Ahmet T. Eren, M.D.

Securing Nasal Tip Rotation through Suspension Suture Technique. 1741 Juan Carlos Cardenas, M.D.; Jenny Carvajal, M.D.; Alvaro Ruiz, M.D.

Securing Nasal Tip Rotation through Suspension Suture Technique: 1743 Reply. Bahman Guyuron, M.D. Anatomical Study of Factors Contributing to Zygomatic Complex

1743 Fracture Instability in Human Cadavers. Conor P. Barry, M.F.D.(R.C.S.I.), M.B.; William J. Ryan, F.R.C.S., M.A.; Leo F. Stassen, F.R.C.S., R.D.S.(R.C.S.I.), M.A.

Anatomical Study of Factors Contributing to Zygomatic Complex 1743 Fracture Instability in Human Cadavers: Reply. Larry Hollier, M.D. The Double Opposing Periareola Flap: A Novel Concept for Nipple-

1744 Areola Reconstruction. Gottfried Wechselberger, M.D.; Heinrich M. Schubert, M.D.; Petra Pülzl, M.D.; Thomas Schoeller, M.D.

BREAST

Raising Perforator Flaps for Breast Reconstruction: The Intramuscular Anatomy of the Deep Inferior Epigastric Artery

Warren M. Rozen, M.B.B.S. Background: The deep inferior epigastric artery (DIEA) perforator flap is used Mark W. Ashton, M.D. increasingly for breast reconstruction, preferred as a muscle-sparing operation Wei R. Pan, M.D. over traditional transverse rectus abdominis musculocutaneous (TRAM) flaps. G. Ian Taylor, M.D. Complications related to the inclusion of rectus abdominis include abdominal Parkville, Victoria, Australia wall weakness and a predisposition to ventral abdominal wall hernias. DIEA perforator flaps still present this complication, with clinical experience demonstrating frequent transection of rectus fibers during dissection of perforators. Despite this, published descriptions of the DIEA in the literature describe a “direct” course through rectus abdominis. This study interprets these clinical findings by analyzing the intramuscular course of the perforators. Methods: The investigation was performed on 31 hemiabdominal walls from both fresh and embalmed cadavers, using a combination of dissection and radiography of multiple cross-sectional planes. Intramuscular distances were measured using the distances between entry and exit points of perforators from rectus abdominis muscle, allowing characterization of the intramuscular course. Results: Substantial longitudinal (mean, 1.52 cm; range, 0.2 to 4.1 cm) and transverse (mean, 1.32 cm; range, 0.3 to 3.5 cm) distances were traversed by each of the 76 perforators within the muscle. Conclusions: A significant transverse distance was shown to be traversed by perforators, confirming the need for division of rectus abdominis fibers during operation. This information may help explain the clinical findings of abdominal wall morbidity following perforator flaps, and may pave the way for improved preoperative selection of patients for DIEA perforator flaps. (Plast. Reconstr. Surg. 120: 1443, 2007.)

he need for breast reconstructive options Breast reconstruction has thus become a signifi- with minimal morbidity has become in- cant part of the management of breast cancer. Tcreasingly important. Breast cancer is cur- Breast reconstruction can be achieved by ei- rently the most common cause of cancer-related ther implant or autologous reconstruction, with death in women of developed nations, and 99 an increasing trend toward autologous percent of women affected will be treated surgi- techniques.3 The search for a reconstructive op- cally, with 25 percent having a mastectomy.1 tion with minimal morbidity has seen a range of Through increased community awareness and techniques used for this purpose, and so the improved screening programs, there is now ear- history of breast reconstruction flaps has ad- lier detection of breast cancer, and with advanced rapidly. vances in adjuvant therapy, there is also pro- Free tissue transfers for breast reconstruction longed survival. With this has come increasing were first described by Serafin et al. in 1978 emphasis on quality-of-life issues, including the using free groin flaps.4 Holmstrom,5 Robbins,6,7 psychological impact of the removal of a breast.2 and Hartrampf et al.,8,9 in the early 1980s, insti- gated the widespread use of abdominal tissue to From the Jack Brockhoff Plastic and Reconstructive Research reconstruct the breast, popularizing vertical and Unit, University of Melbourne. transverse rectus abdominis musculocutaneous Received for publication July 4, 2006; accepted September 25, (TRAM) flaps. These involved the pedicled or 2006. free transfer of the rectus abdominis muscle and Copyright ©2007 by the American Society of Plastic Surgeons overlying integument. In 1989, Koshima and DOI: 10.1097/01.prs.0000282030.77894.bb Soeda described the use of free abdominal wall

www.PRSJournal.com 1443 Plastic and Reconstructive Surgery • November 2007 flaps based on vessel perforators after they had emerged from the rectus sheath,10 and Allen and Treece went on to describe the deep inferior epigastric artery (DIEA) perforator flap, an abdominal wall flap that spares the rectus abdominis muscle.11 The need for muscle-sparing tissue transfers for breast reconstruction is based on the clinical observation of abdominal wall weakness and a predisposition to ventral abdominal wall hernias following pedicled or free TRAM flaps.12 The expectation of a muscle-sparing procedure with the DIEA perforator flap has seen it gain increasing popularity among surgeons and patients. However, the clinical scenario is not as benevo- lent, with the frequent necessity of dividing rectus abdominis fibers during dissection of the perforators.13,14 With the advent of perforator flaps for breast reconstruction, an escalation in the need for anatomical features of the perforating branches of the DIEA has occurred. Previous research has examined the course of the DIEA and the location of its perforating branches.15–18 Over the past 20 years, Fig. 1. Radiograph of the abdominal wall, demonstrating the no fewer than 11 anatomical studies on the course course of the DIEA (arrows) and the locations of its perforators and distribution of the DIEA have been published, (largedots).Theoval,justbelowthecenteroftheFigure,indicates with eight constituting dissection studies.12,19,20 The the umbilicus. Reprinted from Taylor, G. I. Angiosomes of the hu- supply of the rectus abdominis muscle and skin by man body. Anatomy and Cell Biology, Vol. MD. Parkville, Australia: large perforating vessels has been well described.21 The University of Melbourne, 1990. Boyd et al. pioneered this understanding, demonstrating the location of the perforating vessels and MATERIALS AND METHODS showing a significant periumbilical distribution The investigation was performed on 31 cadav- 20,22 (Fig. 1). eric hemiabdominal walls, consisting of 11 em- In addition to an inadequate number of per- balmed and 20 fresh hemiabdominal walls. The forators, a limiting factor to the use of perforator cadavers spanned a wide range of body habitus flaps is the dissection of the perforating types, and the cadaveric age ranged from 50 to 90 branches through the rectus abdominis muscle. years. No cadavers had undergone previous ab- Despite the previous studies of the DIEA, there dominal surgery. The study was completed at the has been a paucity of analysis of the actual intra- Jack Brockhoff Plastic and Reconstructive Surgery muscular course of the perforators of the DIEA, Research Unit in the Department of Anatomy and which has particular pertinence to their use for Cell Biology, at the University of Melbourne. All breast reconstruction. Despite the clinical obser- dissection was performed by a single operator. vations that there is a tortuous course of some perforators through the rectus abdominis mus- Dissection cle, this has been misrepresented often as a “di- The complete or hemiabdominal walls were 19,20,23 rect” course in previous work. This study harvested from their respective cadavers, and the focuses on this void in our knowledge, using DIEA was identified on the deep surface of each both dissection and angiographic injection tech- specimen. The peritoneum and posterior wall of niques to study the course of these perforators the rectus sheath were dissected carefully, and the through the rectus abdominis muscle. Comple- DIEA was traced to the point of penetration of the menting these was the use of cross-sections of the rectus abdominis muscle (Figs. 2 and 3). The anterior abdominal wall, a technique sparsely DIEA was dissected and each of its branches iden- used in previous studies.15,24 tified. Perforators larger than 1 mm in diameter

1444 Volume 120, Number 6 • Deep Inferior Epigastric Artery

Fig. 2. Deep surface of the abdominal wall (left) and with the peritoneum and rectus sheath removed, revealing the DIEA (arrows)(right). were followed by careful blunt dissection through weight/volume of commercial grade (96 percent the rectus abdominis muscle. Smaller perforators pure) lead oxide as an orange powder, and 10% were sacrificed. Figure 3 demonstrates several weight/volume gelatin.25 In each fresh whole ab- large perforators, showing their oblique, and of- dominal wall used, the two deep inferior epigastric ten tortuous, course through the rectus muscle. arteries were identified on the deep surface and cannulated. The mixture was slowly injected, and Radiographic Studies on extravasation through either the superior epi- An injection mixture was composed, which gastric artery or lateral branches, these outlets consisted of heated normal saline (to 50ºC), 10% were clamped and injection continued until increasing resistance was experienced. Each specimen was frozen (to –400ºC) for 48 hours and radiographed to identify the course of the DIEA and its branches. The abdominal wall specimens were then sectioned at 4-cm intervals using a rotating saw, in either the transverse, sagittal, or coronal plane, and the radiographs were repeated. Finally, each individual section was then rotated by 90 degrees, to a plane at right angles to the plane of sectioning, and cross-sectional radiographs were obtained (Figs. 4 and 5). The intramuscular course of the perforators was determined using both dissection and radiography, with intramuscular distances measured using the distances between entry and exit points of perforators from the rectus abdominis muscle. The umbilicus was used as a reference point. Both transverse and longitudinal distances traversed within the rectus abdominis muscle were thus calculated. Fig. 3. Deep surface of the abdominal wall, with the rectus ab- dominismuscleremoved,demonstratingthebranchesandlarge RESULTS perforators of the DIEA (DIEA, double-headed arrow; major per- The DIEA was identified in all specimens forating branch, solid arrow). and its course defined. Its overall course was

1445 Plastic and Reconstructive Surgery • November 2007

Fig. 4. Anterior abdominal wall specimen sectioned at 4-cm intervals after lead oxide injection (left), and a radiograph of the same specimen (right) (umbilicus, the oval, just below the center of the Figures; DIEA, arrows). similar to that described previously in the liter- point of penetration of the muscle was always ature. In all cases, the artery approached the below the umbilicus, at a mean distance of 3.4 rectus abdominis muscle from its lateral border cm (range, 5.9 to 0.9 cm below). and passed superiorly on its deep surface. There were a variable number of perforators Thereupon, the artery entered the muscle belly per hemiabdomen. Eighty-six percent of speci- as a single trunk (in all of our specimens). The mens had three or four large (Ͼ1 mm diameter) perforators, with 76 perforators identified in total. These major perforators showed a significantly periumbilical distribution, with all perforators penetrating the deep surface of the rectus abdominis within 5 cm of the umbilicus. The mean longitudinal distance from the umbilicus to the perforator was 1.8 cm (range, 0.1 to 4.9 cm), and the mean transverse distance from the umbilicus to the perforator was 2.1 cm (range, 0.2 to 4.9 cm). Figure 6 illustrates two large periumbilical perforators undertaking a tortuous course through the rectus abdominis muscle and clearly demonstrates the considerable transverse distance traversed by these two perforators. All of the perforators were found to demonstrate this tortuous course, with Table 1 demonstrating that all perforators traverse an indirect course through the rectus abdominis muscle. The mean intramuscular longitudinal dis- Fig. 5. Radiograph of sectioned anterior abdominal wall speci- tance traversed by perforators was 1.52 cm (range, men,witheachsectionrotated90degrees,enablingobservation 0.2 to 4.1 cm) (Fig. 7). Similarly, the mean intra- of the transverse course of the perforating vessels (umbilicus, the muscular transverse distance traversed was 1.32 oval, just below the center of the Figure; DIEA perforators, arrows). cm (range, 0.3 to 3.5 cm) (Fig. 8).

1446 Volume 120, Number 6 • Deep Inferior Epigastric Artery

Fig. 6. Radiographs of two rotated periumbilical sections of the anterior abdominal wall, mag- nified from panel above, with the perforators highlighted to demonstrate the significant transverse course through the rectus abdominis muscle, from their entry points into the rectus abdominis muscle to their points of exit from the muscle (below). Rectus abdominis muscle, light-colored ovals in panel below; course of periumbilical perforator, red; umbilicus, white oval with dot (above, center in each panel); superficial exit point of the perforator from the rectus abdominis muscle, double- headed arrows; DIEA and deep origin of the perforator into the rectus abdominis muscle, single- headed arrows.

DISCUSSION the perforators of the DIEA are lacking. Using Previous investigators have described the a combination of dissection and angiographic DIEA and its perforating branches. However, techniques, the intramuscular course of the per- detailed studies of the intramuscular course of forators of the DIEA has been elucidated in this study. There have been previous descriptions of the perforators of the DIEA, often depicting a Table 1. Intramuscular Distances Traversed by direct course through rectus abdominis Perforators in the Transverse and Longitudinal Planes muscle.19,20,23 Although there are studies sug- No. of Perforators gesting an oblique intramuscular course, these studies have not defined this course with Longitudinally Transversely measurements.21,26 The substantial transverse (76 ؍ n) (76 ؍ Distance (n and longitudinal expedition by the DIEA per- 0–0.1 mm 0 0 0.2–0.5 mm 11 10 forators through the muscle belly have been 0.6–1.0 mm 15 21 defined in this study. These measurements are 1.1–1.5 mm 18 23 crucial to optimizing the implementation of the 1.6–2.0 mm 12 11 2.1–2.5 mm 8 6 DIEA perforator flap for breast reconstruction. 2.6–3.0 mm 7 3 An understanding of the considerable trans- Ͼ 3.1 mm 5 2 verse distance traversed by the musculocutaneous

1447 Plastic and Reconstructive Surgery • November 2007

Fig. 7. Graph demonstrating the signiﬁcant longitudinal distance traversed by perforators during their course through the rectus abdominis muscle.

Fig. 8. Graph demonstrating the signiﬁcant transverse distance traversed by perforators during their course through the rectus abdominis muscle. perforators is imperative, as this necessitates not erative selection of patients for DIEA perforator only muscle splitting, but transection of muscle flaps. This may include preoperative investigation during the procedure. As rectus abdominis con- of the course of the perforators. Ultrasound has tributes to abdominal wall strength, transection of been used for this purpose in the past, but with rectus abdominis muscle fibers will predispose to increasing literature on the use of computed to- abdominal wall weakness and ventral abdominal mographic angiography as a reliable, noninvasive wall herniation.12 The findings of this study con- investigation for identifying features of these per- firm that there is always some lateral excursion of forators, selection of those patients whose perfo- the perforators, with the consequent likelihood of rators traverse a shorter intramuscular course may muscle transection. be possible.27,28 As a consequence of the usual need for an The current study has further clarified the vas- element of muscle transection with the use of a cular anatomy of the perforators of the DIEA, as DIEA perforator flap, the argued benefit of DIEA achieved in the literature, by giving measurement to perforator flaps over TRAM flaps is somewhat the intramuscular course of the perforators. With weakened. The increasing trend toward muscle- increasing interest in computed tomographic an- sparing operations may require improved preop- giography and other techniques for improved visu-

1448 Volume 120, Number 6 • Deep Inferior Epigastric Artery alization of the perforators, a greater understanding 11. Allen, R. J., and Treece, P. Deep inferior epigastric perforator of this anatomy may yet be sought, and individual flap for breast reconstruction. Ann. Plast. Surg. 32: 32, 1994. 12. Itoh, Y., and Arai, K. The deep inferior epigastric artery free patient anatomy may be evaluated preoperatively. skin flap: Anatomic study and clinical application. Plast. Re- constr. Surg. 91: 853, 1993. CONCLUSIONS 13. Nahabedian, M. Y., Tsangaris, T., and Momen, B. Breast The clinical experience that rectus abdominis reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: Is there a difference? Plast. Reconstr. muscle fibers are cut by necessity during DIEA Surg. 115: 436, 2005. perforator flap operations may be explained by 14. Bajaj, A. K., Chevray, P. M., and Chang, D. W. Comparison the significant transverse distance shown to be of donor site complications and functional outcomes in free traversed by all perforators. This supports clinical muscle-sparing TRAM flap and free DIEP flap breast recon- findings of abdominal wall morbidity following struction. Plast. Reconstr. Surg. 117: 737, 2006. 15. Taylor, G. I., Corlett, R. J., and Boyd, J. B. The versatile deep perforator flaps. An understanding of the intra- inferior epigastric (inferior rectus abdominis) flap. Br. J. muscular course of the perforators suggests that Plast. Surg. 37: 330, 1984. DIEA perforator flaps are not truly muscle-sparing 16. Taylor, G. I., Corlett, R. J., and Boyd, J. B. The extended deep when compared with TRAM flaps. The data pre- inferior epigastric flap: A clinical technique. Plast. Reconstr. sented may pave the way for improved preopera- Surg. 72: 751, 1983. 17. Heitmann, C., Felmerer, G., Durmus, C., Matejic, B., and tive selection of patients for DIEA perforator flaps Ingianni, G. Anatomical features of perforator blood vessels for breast reconstruction. in the deep inferior epigastric perforator flap. Br. J. Plast. Surg. 53: 205, 2000. G. Ian Taylor, M.D. 18. Ohjimi, H., Era, K., Fujita, T., Tanaka, T., and Yabuuchi, R. Department of Anatomy and Cell Biology Analyzing the vascular architecture of the free TRAM flap University of Melbourne, Room 3533 using intraoperative ex vivo angiography. Plast. Reconstr. Surg. Grattan Street 116: 106, 2005. Parkville, Victoria 3052, Australia 19. El-Mrakby, H. H., and Milner, R. H. The vascular anatomy of [email protected] the lower anterior abdominal wall: A microdissection study on the deep inferior epigastric vessels and the perforator DISCLOSURE branches. Plast. Reconstr. Surg. 109: 539, 2002. The authors declare that there is no source of finan- 20. Boyd, J. B., Taylor, G. I., and Corlett, R. J. The vascular cial or other support or any financial or professional territories of the superior epigastric and deep inferior epigastric systems. Plast. Reconstr. Surg. 73: 1, 1984. relationships that may pose a competing interest. 21. Stokes, R. B., Whetzel, T. P., Sommerhaug, E., and Saunders, C. J. Arterial vascular anatomy of the umbilicus. Plast. Recon- REFERENCES str. Surg. 102: 761, 1998. 1. Shons, A. R., and Mosiello, G. Postmastectomy breast recon- 22. Taylor, G. I. Angiosomes of the human body. Anatomy and Cell struction: Current techniques. Cancer Control 8: 419, 2001. Biology, Vol. MD. Parkville, Australia: The University of Mel- 2. Ramakrishnan, V. V. Microsurgical reconstruction of the bourne, 1990. breast: ‘The versatile lower abdomen’. Indian J. Plast. Surg. 23. Konerding, M. A., Gaumann, A., Shumsky, A., Schlenger, K., 37: 18, 2004. and Hockel, M. The vascular anatomy of the inner anterior 3. Nano, M. T., Gill, P. G., Kollias, J., Bochner, M. A., Carter, N., abdominal wall with special reference to the transverse and and Winefield, H. R. Qualitative assessment of breast recon- rectus abdominis musculoperitoneal (TRAMP) composite struction in a specialist breast unit. Aust. N. Z. J. Surg. 75: 445, flap for vaginal reconstruction. Plast. Reconstr. Surg. 99: 705, 2005. 1997. 4. Serafin, D., Geargiade, N. G., and Given, K. S. Transfer of free 24. Moon, H. K., and Taylor, G. I. The vascular anatomy of flaps to provide well vascularised, thick cover for breast re- rectus abdominis musculocutaneous flaps based on the constructions after radical mastectomy. Plast. Reconstr. Surg. deep superior epigastric system. Plast. Reconstr. Surg. 82: 62: 527, 1978. 815, 1988. 5. Holmstrom, H. The free abdominoplasty flap and its use in 25. Rees, M. J., and Taylor, G. I. A simplified lead oxide breast reconstruction. Scand. J. Plast. Reconstr. Surg. 13: 423, cadaver injection technique. Plast. Reconstr. Surg. 77: 141, 1979. 1986. 6. Robbins, T. H. Rectus abdominis myocutaneous flap for 26. Vandevoort, M., Vranckx, J. J., and Fabre, G. Perforator breast reconstruction. Aust. N. Z. J. Surg. 49: 527, 1979. topography of the deep inferior epigastric perforator flap in 7. Robbins, T. H. Post-mastectomy breast reconstruction using 100 cases of breast reconstruction. Plast. Reconstr. Surg. 109: a rectus abdominis musculocutaneous island flap. Br. J. Plast. 1912, 2002. Surg. 34: 286, 1981. 27. Alonso-Burgos, A., Garcia-Tutor, E., Bastarrika, G., Cano, D., 8. Hartampf, C. R., Jr., Scheflan, M., and Black, P. W. Breast Martinez-Cuesta, A., and Pina, L. J. Preoperative planning of reconstruction with a transverse abdominal island flap. Plast. deep inferior epigastric artery perforator flap reconstruction Reconstr. Surg. 69: 216, 1982. with multi-slice-CT angiography: Imaging findings and initial 9. Hartampf, C. R., Jr., and Benett, G. K. Autogenous tissue experience. J. Plast. Reconstr. Aesthet. Surg. 59: 585, 2006. reconstruction in the mastectomy patient: A critical review of 28. Masia, J., Clavero, J. A., Larranaga, J. R., Alomar, X., Pons, G., 300 patients. Ann. Surg. 205: 508, 1987. and Serret, P. Multidetector-row computed tomography in 10. Koshima, I., and Soeda, S. Inferior epigastric artery skin flaps the planning of abdominal perforator flaps. J. Plast. Reconstr. without rectus abdominis muscle. Br. J. Plast. Surg. 42: 645, 1989. Aesthet. Surg. 59: 594, 2006.

1449 BREAST

An Intraoperative Algorithm for Use of the SIEA Flap for Breast Reconstruction

Aldona J. Spiegel, M.D. Background: The deep inferior epigastric perforator (DIEP) flap has been Farah N. Khan, M.D. shown to be a reliable option for breast reconstruction. A further refinement Houston, Texas in the transfer of lower abdominal tissue for breast reconstruction is the superficial inferior epigastric artery (SIEA) flap. A retrospective study was conducted to assess the reliability and examine the outcomes of SIEA flaps for breast reconstruction while considering an intraoperative algorithm established in this study. Methods: Ninety-nine SIEA flap reconstructions were performed in 82 patients in a 3½-year period. Patients were divided into two groups (before and after algorithm implementation), and their medical records were evaluated with respect to demographic information, tumor type, tobacco use, ischemic time, flap weight, and complications. Potential risk factors for complications were also assessed. Results: Of the first 72 SIEA flaps, five were lost because of arterial thrombosis. All failed flaps had an SIEA diameter of less than 1.5 mm at the level of the lower abdominal incision. In February of 2004 (point T), the senior author (A.J.S.) implemented an intraoperative algorithm for flap selection that allowed use of the SIEA flap only when the SIEA diameter was 1.5 mm or greater than. In the remaining cases, a DIEP flap was used for breast reconstruction. After point T, 27 SIEA flap procedures were performed without any flap losses. Overall fat necrosis and partial flap loss rates were 1.0 and 5.1 percent, respectively. No abdominal bulges/hernias were observed. Only smoking at the time of surgery was associated with increased donor-site complications (p ϭ 0.016). Conclusion: The intraoperative algorithm helped decrease flap and abdominal complication rates for the SIEA flap. (Plast. Reconstr. Surg. 120: 1450, 2007.)

ew would deny that lower abdominal tissue considerably, from 1 to 82 percent.2–4 These continues to be the standard for autologous complications, which are usually more severe in Fbreast reconstruction. First popularized by patients undergoing bilateral reconstruction, in- Hartrampf and colleagues1 in 1982, it remains clude chronic discomfort, motor weakness, and unsurpassed in its quality and quantity. The a predisposition to hernia and/or bulge forma- added benefit to patients of having a vastly im- tion. Use of synthetic materials to repair the proved abdominal contour postoperatively and abdominal wall defect has not eliminated the an easily hidden bikini-line scar makes it the occurrence of such problems and, as a result, ideal donor site. Unfortunately, the incidence of attention has shifted from the use of pedicled abdominal wall complications associated with and free transverse rectus abdominis musculocu- sacrifice of the rectus abdominis muscle varies taneous (TRAM) flaps to muscle-sparing free flaps from the same donor region. From the Institute for Reconstructive Surgery, The Methodist The deep inferior epigastric perforator Hospital. (DIEP) flap, which was popularized by Allen and Received for publication December 21, 2005; accepted April Treece5 in 1994, has been shown to be a reliable 6, 2006. option for breast reconstruction. Although the Presented at the World Society for Reconstructive Microsur- DIEP flap offers decreased donor-site morbidity gery, in Buenos Aires, Argentina, October 25, 2005. because it does not require excision of the rectus Copyright ©2007 by the American Society of Plastic Surgeons abdominis muscle and fascia, the superficial in- DOI: 10.1097/01.prs.0000270282.92038.3f ferior epigastric artery (SIEA) flap is even more

1450 www.PRSJournal.com Volume 120, Number 6 • Algorithm for Breast Reconstruction advantageous because it requires neither the in- prereconstruction radiotherapy, and a flap weight cision nor the excision of these two structures. greater than 1000 g. Since its introduction in 1971 by Antia and Buch6 as a free-tissue transfer for facial recon- Intraoperative Algorithm struction, the SIEA flap has often been described In all cases, reconstruction with the SIEA for facial and limb reconstructions. This may be flap was attempted first. If the SIEA was not attributed to the favorable orientation of its present or was too small, reconstruction with the pedicle, with the vessels emerging from the bor- DIEP flap was performed. Later in our series (a der of the flap rather than from its deep surface. point in time that will be referred to as point T), In 1999, Arnez and colleagues7 reported their we implemented an algorithm that allowed us to experience with the SIEA flap for breast recon- determine when to use the SIEA flap (Fig. 1). The struction in a series of 20 patients. The SIEA flap algorithm is as follows: When performing a uni- was used in only five of the 20 cases, however, lateral breast reconstruction, we first preserve the because the protocol specified that the SIEA contralateral superficial inferior epigastric vein diameter had to be equal to or larger than 1.5 (SIEV) and then explore the contralateral SIEA. mm at the origin. More recently, Chevray8 de- Using a vessel sizer provided with the venous cou- scribed a series of 14 subjects in whom the SIEA pler, we measure the SIEA’s external diameter at flap was used for breast reconstruction. For it to the site of the lower abdominal incision. If its be used, several anatomical criteria, including an external diameter is larger than 1.5 mm and there SIEA with a palpable and visible pulsation and a is a visible and palpable pulse, we dissect it to the minimum diameter of 1.0 mm at the level of the origin and use the SIEA flap. If the external di- lower abdominal incision, had to be met. In this ameter is smaller than 1.5 mm or the pulse is weak, article, we present our experience with an intra- we explore the ipsilateral SIEA. If the ipsilateral operative algorithm for use of the SIEA free flap SIEA is adequate, we preserve it and use the ipsi- in 99 breast reconstructions. lateral SIEA flap. If, however, it is too small or displays a weak pulse at the level of the lower PATIENTS AND METHODS abdominal incision, we explore the contralateral lateral and medial row deep inferior epigastric Patient Population perforators. If these are unacceptable, we use the This study included 82 patients who under- ipsilateral DIEP flap. For this series, all arterial went breast reconstruction with the SIEA flap over anastomoses were performed between the SIEA a 3½-year period. During that time, 199 autolo- and the internal mammary artery. gous tissue breast reconstructions were performed in 145 patients. Flaps and patients were divided Statistical Analyses into two groups: before and after algorithm im- Demographic information, patient character- plementation. The medical records for all 82 pa- istics, and reconstruction-related variables are tients who underwent a total of 99 SIEA flap breast summarized as means Ϯ SD and medians for con- reconstructions were evaluated with respect to de- tinuous variables and as proportions for categor- mographic information, tumor type, tobacco use, ical variables based on the number of flaps. When ischemic time, flap weight, and complications. two flaps were used in the same patient, each flap Complications included flap-specific or donor-site was considered independently for all statistical adverse events, fat necrosis, venous congestion, tests. Overall flap complication was defined as partial flap loss, and total flap loss. Wound dehis- flaps with one or more complication(s). The in- cence was strictly defined as separation of the clo- cidence of overall and specific flap complications sure with evidence of epidermolysis. The diagnosis was calculated based on a total of 99 flaps. Overall of fat necrosis was based strictly on the results of donor-site complication was defined as patients physical examination findings persisting for more experiencing one or more donor-site complica- than 6 months postoperatively. No minimum per- tion(s). The incidence of overall and specific do- centage was defined for partial flap loss. Potential nor-site complications was calculated based on a risk factors for complications included age older total of 82 patients. Chi-square and Fisher’s exact than 60 years, a body mass index equal to or tests were used to determine whether flap and greater than 30 kg/m2, duration of ischemic time, donor-site complications differed when stratified current history of smoking, significant abdominal before and after implementation of the intraop- scarring from Pfannenstiel incisions, timing of re- erative algorithm. Univariate analyses were carried construction (immediate versus delayed), use of out to determine potential risk factors for flap and

1451 Plastic and Reconstructive Surgery • November 2007

Fig. 1. Intraoperative algorithm. SIEA, superﬁcial inferior epigastric artery; DIEP, deep inferior epigastric perforator. donor-site complications. Odds ratios and 95 per- model sparse data for specific complications. A cent confidence intervals were derived using a value of p Ͻ 0.05 was considered statistically sig- logistic regression model. Whenever appropriate, nificant. Statistical analyses were performed using an exact logistic regression model was used to SAS 9.1 (SAS Institute, Inc., Cary, N.C.).

1452 Volume 120, Number 6 • Algorithm for Breast Reconstruction

RESULTS prophylaxis, and 1.0 percent were performed after failed implants. Seventy-two SIEA flaps were com- Overall pleted before implementation of the intraopera- The overall patient descriptive statistics are tive algorithm, whereas 26 were performed after- listed in Table 1 and are based on the number of ward. The average patient age at the time of flaps (99 free SIEA flaps used in 82 patients). Of reconstruction was 49.6 years (range, 33 to 68 those 99, 77.8 percent were performed after can- years). Fifty-six reconstructions (57.2 percent) cer resection, 21.2 percent were performed for were performed immediately and 42 (42.8 per-

Table 1. Comparisons of Descriptive Statistics for SIEA Flap Breast Reconstructions Overall and before and after Algorithm Implementation Overall Before Algorithm After Algorithm (%) (27 ؍ n) (%) (72 ؍ n) (%) (99 ؍ Patient Characteristics (n No. of patients 82 60 22 Age, years Mean Ϯ SD 49.6 Ϯ 7.7 50.1 Ϯ 7.1 48.1 Ϯ 9.1 Range 33–68 33–68 33–67 Median 50 50 46.5 BMI, kg/m2 Mean Ϯ SD 27.5 Ϯ 4.7 27.2 Ϯ 4.2 28.6 Ϯ 6.0 Range 18.7–38 20.6–38 18.7–37 Median 26.6 26.6 27.3 Ischemic time, minutes* Mean Ϯ SD 95.7 Ϯ 23.8 101.1 Ϯ 23.3 81.5 Ϯ 19.2 Range 52–165 62–165 52–132 Median 92 100 80 Flap weight, g Mean Ϯ SD 655.7 Ϯ 294.0 649.7 Ϯ 260.9 672.3 Ϯ 379.3 Range 109–1416 161–1150 109–1416 Median 615.5 615 616 Follow-up, months Mean 28.4 Ϯ 9.8 31.8 Ϯ 8.1 16.9 Ϯ 10.3 Range 6–47 25–47 6–24 Median 29 33 19 Smoking at date of operation Yes 8 (8.1) 7 (9.7) 1 (3.7) No 91 (91.9) 65 (90.3) 26 (96.3) Prereconstruction irradiation Yes 22 (22.3) 16 (22.2) 6 (22.2) No 77 (77.7) 56 (77.8) 21 (77.8) Reason for mastectomy Cancer DCIS plus invasive ductal 1 (1.0) 0 (0.0) 1 (3.7) DCIS 27 (27.3) 22 (30.6) 5 (18.5) LCIS 4 (4.0) 4 (5.6) 0 (0.0) Inflammatory 1 (1.0) 0 (0.0) 1 (3.7) Invasive ductal 36 (36.4) 29 (40.3) 7 (25.9) Invasive lobular 3 (3.0) 2 (2.8) 1 (3.7) Unknown 5 (5.1) 4 (5.6) 1 (3.7) Prophylactic 21 (21.2) 11 (15.3) 10 (37.0) S/p failed implants 1 (1.0) 0 (0.0) 1 (3.7) Timing for breast reconstructions Immediate 56 (57.2) 38 (53.5) 18 (66.6) Delayed 42 (42.8) 33 (46.5) 9 (33.3) Flap technique Unilateral 51 (51.5) 39 (54.2) 12 (44.4) Bilateral 48 (48.5) 33 (45.8) 15 (55.5) Scars Appendectomy 3 (3.0) 3 (4.2) 0 (0.0) Cesarean section 24 (24.2) 17 (23.9) 7 (25.9) Cholecystectomy/laparotomy cholecystectomy 4 (4.0) 1 (1.4) 3 (11.1) Laparotomy/exploratory laparotomy 1 (1.0) 0 (0.0) 1 (3.7) Liposectomy 1 (1.0) 1 (1.4) 0 (0.0) No scars 61 (61.6) 48 (67.6) 13 (48.1) Others 4 (4.0) 1 (1.4) 3 (11.1) BMI, body mass index; DCIS, ductal carcinoma in situ; LCIS, lobular carcinoma in situ; S/p, status post. *Statistically significant reduction in ischemic time after implementation of algorithm was attributed to experience.

1453 Plastic and Reconstructive Surgery • November 2007 cent) were delayed. A total of 51 women under- observed after compared with before [n ϭ 6 (8.3 went unilateral SIEA breast reconstruction, whereas percent)] implementation of the intraoperative 31 underwent bilateral reconstruction. Of those 31, algorithm. None of these comparisons achieved 14 underwent reconstruction with both a DIEP and statistical significance because of the small sample an SIEA flap (data not shown). When flap-specific study numbers after point T. A comparison of the characteristics were compared between before and mean vessel size for thrombotic and nonthrom- after implementation of the intraoperative algo- botic vessels, however, revealed a statistically sig- rithm (Table 1), ischemic time was significantly re- nificant difference (1.4 mm versus 1.8 mm; p ϭ duced for the latter group (mean, 101.1 minutes 0.002). versus 81.5 minutes; p ϭ 0.0004). Donor-Site Complications Flap Complications Table 3 lists the overall and specific donor-site Table 2 lists the overall and specific flap com- complications before and after algorithm imple- plications before and after algorithm implemen- mentation. The specific donor-site complications tation. Flap complications assessed include fat ne- include abdominal wound dehiscence, abdominal crosis, partial flap loss, venous congestion, arterial hematoma, abdominal seroma, and bulge/hernia thrombosis, acute ischemia, total flap loss, breast formation. Before point T, the overall donor-site dehiscence, breast hematoma, breast seroma, and complication rate was 11.7 percent. After imple- breast infection. Before point T, the overall flap mentation of the algorithm, the overall donor-site complication rate was 25.0 percent compared with complication rate dropped to 0.0 percent. Again, 18.5 percent after point T. More importantly, no although the p value was not statistically significant total flap losses were observed after point T com- (p ϭ 0.187) because of small sample size, there is pared with five total flap losses (6.9 percent) be- a trend toward decreased donor-site complica- fore point T. Likewise, no arterial thrombosis was tions after algorithm implementation. This will be

Table 2. Flap Complications Overall and before and after Algorithm Implementation p, before Overall Before After versus after Flap Complications (%) Algorithm (%) Algorithm (%) Algorithm‡ Overall* 23 (23.2) 18 (25.0) 5 (18.5) 0.679§ Specific† Arterial thrombosis 6 (6.1) 6 (8.3) 0 (0) 0.332 Acute ischemia 1 (1.0) 0 (0) 1 (3.7) 0.250 Breast dehiscence 5 (5.1) 4 (5.6) 1 (3.7) 1.000 Breast hematoma 4 (4.0) 4 (5.6) 0 (0) 0.569 Breast infection 3 (3.0) 3 (4.2) 0 (0) 0.571 Breast seroma 0 (0) 0 (0) 0 (0) — Fat necrosis 1 (1.0) 0 (0) 1 (3.7) 0.250 Total flap loss 5 (5.1) 5 (6.9) 0 (0) 0.327 Partial flap loss 5 (5.1) 4 (5.6) 1 (3.7) 1.000 Venous congestion 2 (2.0) 1 (1.4) 1 (3.7) 0.440 *Overall flap complication was defined as presence of any listed flap-specific complications. †The incidence was based on number of flaps (72 flaps before algorithm and 27 flaps after algorithm). ‡Based on Fisher’s exact test. §Based on the chi-square test.

Table 3. Donor-Site Complications Overall and before and after Algorithm p, before Before After versus after Donor-Site Complications Overall (%) Algorithm (%) Algorithm (%) Algorithm‡ Overall* 7 (8.5) 7 (11.7) 0 (0) 0.187 Specific† Abdominal hematoma 0 (0) 0 (0) 0 (0) — Abdominal seroma 2 (2.4) 2 (3.3) 0 (0) 1.000 Abdominal wound dehiscence 5 (6.1) 5 (8.3) 0 (0) 0.329 Bulge/hernia 0 (0) 0 (0) 0 (0) — *Overall donor-site complication was defined as the presence of any listed donor-site specific complications. †The incidence was based on number of patients (60 patients before algorithm and 22 patients after algorithm implementation). ‡Based on Fisher’s exact test.

1454 Volume 120, Number 6 • Algorithm for Breast Reconstruction further explained in relation to flap design breast reconstruction performed at a single insti- changes that occurred before algorithm imple- tution. mentation. The major advantage of using the SIEA flap is that it virtually eliminates donor-site morbidity re- Risk Factor Analysis lated to the incision and/or excision of the rectus Risk factors were evaluated for their associa- abdominis muscle and fascia that is commonly tion with overall flap and overall donor-site com- seen with free transverse rectus abdominis muscu- plications. Based on univariate analyses, no risk locutaneous (TRAM) flaps and, to a lesser extent, factors demonstrated significant association with with the DIEP flap (Figs. 2 and 3). However, con- overall flap complications. Higher incidences of cerns have been raised regarding the adequacy of donor-site complications, however, were associ- the vessel size and pedicle length. Because these ated with patients who were current smokers at the two parameters can directly influence flap survival, time of surgery (odds ratio, 15.8; 95 percent con- it would be counterintuitive to use the SIEA flap if fidence interval, 1.62 to 164.40; p ϭ 0.016). The there is an increased risk of flap complications. imprecise odds ratio estimate for smoking was at- With our first 72 SIEA flaps, we based our flaps tributable to the small number of patients in our on the SIEA, provided that its diameter at the study population who reported being current origin was greater than or equal to 1.3 mm. Un- smokers at the time of surgery. fortunately, using this protocol, we had six cases of arterial thrombosis that required emergent reex- DISCUSSION ploration. Only one flap was salvaged. After re- Since implementing our algorithm, the SIEA viewing our data at point T, we noticed that all five flap has become our first choice for breast recon- flap failures had been based on superficial inferior struction. Although case series reporting the use epigastric arteries with a diameter of less than 1.5 of the SIEA flap for breast reconstruction have mm at the lower abdominal incision. Furthermore, been presented in the literature, large published at the time of reexploration, it was noted that the reports with strong statistical power are lacking. thrombus was always located at the turn in the To our knowledge, despite the fact that Rizzuto artery as it entered the flap. Unlike the DIEP flap, and Allen9 have mentioned performing over 200 the superficial inferior epigastric vessels enter the successful total breast reconstructions with the flap at its subcutaneous border instead of its infe- SIEA flap in a case report, this is the first published rior surface. To accommodate this, the vessels have report of a substantial number of SIEA flaps for to make an upward turn. We realized, therefore,

Fig. 2. (Left) Fifty-year-old woman approximately 3 years after right modiﬁed radical mastectomy. (Center) Three-year postoperative view after nipple-areola reconstruction. (Right) Intraoperative view of SIEA ﬂap. No violation of fascia has occurred.

1455 Plastic and Reconstructive Surgery • November 2007

Fig. 3. (Left) A 44-year-old woman diagnosed with left-sided breast cancer. Notice the bilateral grade II ptosis preoperatively. (Center) Two-yearpostoperativeviewaftercontralateralreductionandleftnipple-areolareconstruction.(Right)IntraoperativeviewofSIEA ﬂap. No violation of fascia has occurred. that even though the diameter of the SIEA at the and dissection. Often, an initially “adequate” SIEA origin may be more than adequate, what really or perforator will diminish in size and strength as mattered was its diameter as it entered the flap. If the dissection progresses. In addition, we recom- the diameter was smaller than 1.5 mm as the SIEA mend preserving the SIEV because it can serve as entered the flap, there was an increased chance of a lifeboat for venous drainage in cases of venous vascular compromise. This was further strength- congestion. Although we almost always use the two ened by the fact that a statistically significant dif- deep venae comitantes for our primary venous ference was found when the mean vessel sizes for anastomosis, the SIEV can be used for a secondary, thrombotic and nonthrombotic vessels were com- or even primary, anastomosis with the internal pared (1.4 mm versus 1.8 mm, respectively; p ϭ mammary vein. 0.002). Before implementing the above-mentioned al- Ideally, vascular imaging using duplex ultra- gorithm, our total flap loss rate was 6.9 percent. sonography preoperatively would allow us to de- After point T, however, this rate dropped to 0.0 termine whether or not the diameter of the SIEA percent. This rate compares favorably to those that is adequate. Unfortunately, we do not have access have been reported in the literature for free to such routine imaging at our institution. There- TRAM and DIEP flap breast reconstructions.10,11 fore, we instituted an intraoperative algorithm Interestingly enough, we found no association (Fig. 1) that allows us to determine when to use the between a flap weight greater than 1000 g and SIEA flap. Reconstruction with the SIEA flap was the development of overall flap complications. only attempted if the SIEA had a palpable and This parallels Allen’s experience with the DIEP visible arterial pulsation and a minimum external flap.11 diameter of 1.5 mm at the level of the lower ab- Although the superficial vessels are more lat- dominal incision. If these criteria were met, dis- eral than the lateral row of rectus abdominis per- section to the origin of the superficial inferior forators, we have been able to successfully harvest epigastric vessels from the femoral vessels was per- tissue across the midline. It is our observation that formed. If these criteria were not met, dissection as long as zone IV and any poorly perfused tissue for the deep inferior epigastric perforators was are excised after the completion of the anastomo- performed instead. It is of the utmost importance sis, we do not have to define the limit of the flap that the SIEA and/or perforators should display a at the midline or in terms of its weight. In 40 of our visible and palpable pulse at the level of the lower patients who underwent unilateral SIEA breast re- abdominal incision throughout the exploration construction, we recorded the total flap weight

1456 Volume 120, Number 6 • Algorithm for Breast Reconstruction

Table 4. Literature Review Hernia/ No. of Fat Partial Total Abdominal Flap Study Flaps Necrosis (%) Flap Loss (%) Flap Loss (%) Bulge (%) Free TRAM Kroll10 279 12.9 2.2 0.4 NR Free TRAM Nahabedian et al.12 113 7.1 NR 1.8 9.0 DIEP Nahabedian et al.12 110 6.4 NR 2.7 2.3 DIEP Blondeel13 100 6.0 7.0 2.0 2.0 DIEP Gill et al.11 758 12.9 2.5 0.5 0.6 SIEA Chevray8 14 14.3 0 7.1 0 SIEA This study (overall) 99 1.0 5.1 5.1 0 SIEA This study (before algorithm) 72 0 5.6 6.9 0 SIEA This study (after algorithm) 27 3.7 3.7 0 0 NR, not reported.

and the weight of the flap after excision of zone IV. wound dehiscence (8.3 percent) and two cases of We found that the average percentage of total flap abdominal seroma (3.3 percent). We believe the used was 66.5 percent. Furthermore, in 17 of those high incidence of abdominal wound dehiscence 40 patients, more than 70 percent of the total flap may be attributable to the fact that we changed our was used. Compared with complication rates that flap design midway through our series. Although have been reported with the free TRAM and DIEP the details of this will be presented in a subsequent flaps, our rates of 1.0 percent and 5.1 percent for article, we started with a high lower abdominal overall fat necrosis and partial flap loss are quite incision, approximately 1 to 1.5 cm above the pu- encouraging (Table 4).5,7,8,12,13 Therefore, we be- bic hairline. To facilitate dissection for the super- lieve that harvesting tissue across the midline is ficial vessels, we changed the design to a lower acceptable, provided that zone IV and any isch- abdominal incision before implementation of the emic tissue are carefully excised. algorithm. This caused the low abdominal incision No association was found between prerecon- to be at the level of the pubic hairline and the struction irradiation, obesity, or abdominal scar- upper abdominal incision to be approximately 3 ring caused by Pfannenstiel incisions and the de- cm below the umbilicus. With this design, we no- velopment of overall flap complication. Although ticed more cases of abdominal wound dehiscence, preoperative irradiation can induce scar forma- particularly in the central midline region. This tion, we have rarely observed it to make the in- prompted us to revert to the high lower abdominal ternal mammary vessels unacceptable for micro- incision at point T and, since then, we have not vascular anastomosis. It is our policy, however, to observed any major cases of abdominal wound delay reconstruction for at least 6 months in pa- dehiscence. tients who have undergone irradiation to allow for some of the soft-tissue changes to resolve. We be- We also carefully clip any major lymphatic ves- lieve that better cosmesis is obtained after allowing sels while dissecting the superficial vessels to their the initial inflammatory phase to pass. origin. We believe this has reduced our rate of Our overall donor-site complication rate for seroma formation at the donor site. the entire series was 8.5 percent. Perhaps most The disadvantages often cited for the SIEA importantly, no abdominal bulges or hernias were flap stem from the classic study of the anatomy of observed. A significant association was observed the SIEA in 100 cadaveric dissections by Taylor 14 between smoking at the time of reconstruction and Daniel. In 35 dissections, the SIEA was ab- and the development of abdominal complications sent. In 48 dissections, the SIEA arose as a com- (odds ratio, 15.8; 95 percent confidence interval, mon trunk with the superficial circumflex iliac 1.62 to 164.40; p ϭ 0.0032). Supporting Allen’s artery (SCIA), having an average external diam- suggestion,11 we now require all of our patients to eter of 1.4 mm. In the remaining 17 dissections, quit smoking for at least 2 months before surgery. the artery arose as an independent vessel with an It is interesting to note that after implemen- average diameter of 1.1 mm. More recent ana- tation of our algorithm, the overall donor-site tomical studies have shown more consistent re- complication rate dropped from 11.7 percent to sults, with Reardon et al.15 describing the SIEA in 0.0 percent. The 11.7 percent donor-site compli- 20 of 22 cadaveric dissections. The mean external cation rate included five cases of abdominal diameter was 1.9 mm at the origin from the fem-

1457 Plastic and Reconstructive Surgery • November 2007 oral artery, and the mean pedicle length from the and favorable donor-site complication rates cited origin to the inguinal ligament was 5.2 cm. Over above, we believe taking the extra time to explore 3 years, we performed 278 clinical dissections for for the SIEA is justified. the superficial vessels. The SIEA was absent or inconsequential in 118, or 42 percent of the total dissections. In the remaining 160, or 58 percent of CONCLUSIONS the total dissections, 87 SIEAs had an external The SIEA flap is an excellent choice for breast diameter greater than or equal to 1.5 mm at the reconstruction in selected patients. Having de- level of the lower abdominal incision. With our creased abdominal complication rates and flap algorithm in mind, this suggests that the SIEA is complication rates comparable to those of the adequate for use in approximately 31 percent of DIEP flap, the SIEA should be the flap of choice cases. Our series had a greater number of SIEA when attempting autologous abdominal tissue reconstruction. Perhaps most importantly, however, flaps because, before implementing the algo- our intraoperative algorithm allows physicians to rithm, we often used SIEAs with an external di- more confidently choose the most reliable flap for ameter of less than 1.5 mm. breast reconstruction. Although we did not measure the pedicle length in our dissections, we did not have a prob- Aldona J. Spiegel, M.D. lem anastomosing the superficial vessels to the The Center for Breast Restoration The Methodist Hospital internal mammary vessels. No vein grafts were 6560 Fannin, Suite 800 needed, suggesting sufficient length. Further- Houston, Texas 77030 more, provided that the SIEA is larger than or [email protected] equal to 1.5 mm, size mismatch is minimal because our average internal mammary artery diameter at the level of the third intercostal space was 2.14 ACKNOWLEDGMENTS mm. Of the 51 unilateral SIEA flaps used, 17 were The authors thank Heidi Weiss and Jessie Wu for statistical analysis and critical reading of the article. ipsilateral. We prefer to use the internal mamma- ries as the recipient vessels for both ipsilateral and contralateral flaps because they allow for more DISCLOSURE medial positioning of the flap. For both ipsilateral Neither of the authors has a financial interest in any and contralateral flaps, the triangular SIEA flap of the products, devices, or drugs mentioned in this needs to be rotated approximately 180 degrees to article. allow for the anastomosis. Once the anastomosis is complete, zone IV and any excess tissue are re- REFERENCES moved to allow for adequate shaping of the flap 1. Hartrampf, C. R., Sceflan, M., and Black, P. W. Breast re- before inset. construction with a transverse abdominal island flap. Plast. Use of the internal mammary vessels also al- Reconstr. Surg. 69: 216, 1982. lows us to keep the thoracodorsal vessels intact 2. Kroll, S., Schusterman, M., Reece, G., et al. Abdominal wall should the latissimus dorsi flap be needed in the strength, bulging, and hernia after TRAM flap breast reconstruction. Plast. Reconstr. Surg. 96: 616, 1995. future. If the sentinel lymph nodes are found to be 3. Edsander-Nord, A., Jurell, G., and Wickman, M. Donor-site positive after an immediate reconstruction, avoid- morbidity after pedicled or free TRAM flap surgery: A pro- ance of the thoracodorsal vessels allows the gen- spective and objective study. Plast. Reconstr. Surg. 102: 1508, eral surgeon to confidently perform an axillary 1998. 4. Feller, A. Free TRAM: Results and abdominal wall function. lymph node dissection. Clin. Plast. Surg. 21: 223, 1994. Critics will argue that because the SIEA flap 5. Allen, R. J., and Treece, P. Deep inferior epigastric perfo- can only be used in 30 percent of cases, we should rator flap for breast reconstruction. Ann. Plast. Surg. 8: 32, not include it in our algorithm. Because the pre- 1994. 6. Antia, N. H., and Buch, V. I. Transfer of an abdominal operative markings, and thus the lower and upper dermo-fat graft by direct anastomosis of blood vessels. Br. J. abdominal incisions, are the same for both the Plast. Surg. 24: 15, 1971. SIEA and DIEP flaps, we find it convenient to first 7. Arnez, Z. M., Khan, U., Pogorelec, D., and Planinsek, F. look for the superficial vessels. If the SIEA is in- Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br. J. Plast. Surg. adequate or missing, we simply continue our dis- 52: 351, 1999. section for the deep inferior epigastric perfora- 8. Chevray, P. M. Breast reconstruction with superficial in- tors. Given the comparable flap complication rates ferior epigastric artery flaps: A prospective comparison

1458 Volume 120, Number 6 • Algorithm for Breast Reconstruction

with TRAM and DIEP flaps. Plast. Reconstr. Surg. 114: 1077, 12. Nahabedian, M., Tsangaris, T., and Momen, B. Breast re- 2004. construction with the DIEP flap or the muscle-sparing (MS-2) 9. Rizzuto, R., and Allen, R. Reconstruction of a partial mas- free TRAM flap: Is there a difference? Plast. Reconstr. Surg. tectomy defect with the superficial inferior epigastric artery 115: 436, 2005. (SIEA) flap. J. Reconstr. Microsurg. 20: 441, 2004. 13. Blondeel, P. One hundred free DIEP flap breast reconstruc- 10. Kroll, S. Fat necrosis in free transverse rectus abdominis tions: A personal experience. Br. J. Plast. Surg. 52: 104, 1999. myocutaneous and deep inferior epigastric perforator flaps. 14. Taylor, G., and Daniel, R. The anatomy of several free flap Plast. Reconstr. Surg. 106: 576, 2000. donor sites. Plast. Reconstr. Surg. 56: 243, 1975. 11. Gill, P., Hunt, J., Guerra, A., et al. A 10-year retrospective 15. Reardon, C., Ceallaigh, S., and Sullivan, S. An anatomical review of 758 DIEP flaps for breast reconstruction. Plast. study of the superficial inferior epigastric vessels in humans. Reconstr. Surg. 113: 1153, 2004. Br. J. Plast. Surg. 57: 515, 2004.

1459 BREAST

Dermabond Skin Closures for Bilateral Reduction Mammaplasties: A Review of 255 Consecutive Cases

Gregory R. Scott, M.D. Background: 2-Octyl cyanoacrylate (Dermabond; Ethicon, Inc., Somerville, Cynthia L. Carson, P.A.-C. N.J.) has been available as a skin closure alternative or adjunct since 1997. The Gregory L. Borah, M.D. purpose of this study was to review a large series of 255 consecutive bilateral San Diego, Calif.; and reduction mammaplasty patients to evaluate the safety and efficacy of Derma- New Brunswick, N.J. bond for these procedures. Methods: A review was undertaken of 255 consecutive bilateral reduction mammaplasties performed by a single surgeon from 1999 to 2005 with Dermabond used for skin closure. This series of patients was compared with an earlier review by the same surgeon of 415 consecutive bilateral reduction mammaplasties using standard layered sutured skin closures. Results: Dermabond was associated with decreased operative times compared with the sutured closures (93 minutes compared with 118 minutes; 25 minutes or 20 percent less time). The rates for minor wound dehiscence (1.18 percent), major wound dehiscence (0.78), hypertrophic scar revisions (2.75 percent), and cellulitis (2.75 percent) were all lower in the Dermabond group, but these differences were not statistically significant. Conclusions: Dermabond is a safe and effective means of skin closure for bilateral reduction mammaplasties. Shortened operative times can lead to economic health cost savings. Patient discomfort is minimized and postoperative care is simplified. (Plast. Reconstr. Surg. 120: 1460, 2007.)

-Octyl cyanoacrylate (Dermabond; Ethicon, to evaluate the safety and efficacy of Dermabond Inc., Somerville, N.J.) has been available as for these procedures. 2a skin closure alternative or adjunct since 1997.1 Skin closures with Dermabond have been shown to be equivalent to sutured skin closures PATIENTS AND METHODS with regard to healing potential, wound A retrospective review was undertaken of 255 strength, and cosmesis.2,3 Dermabond has been consecutive patients undergoing primary bilateral reported as an adjunct to skin closure for bilat- reduction mammaplasty for relief of symptomatic eral reduction mammaplasty4; however, no large macromastia from 1999 to 2005. All operations series have been reported to date to substantiate were performed by a single primary plastic sur- the safety and efficacy of Dermabond for breast geon and an assistant surgeon. reductions. The purpose of this study was to Comparison was made with an earlier review by the same authors.5 In the earlier series, a review review a large series of 255 consecutive bilateral of 518 consecutive patients undergoing primary reduction mammaplasty patients (510 breasts) reduction mammaplasty for symptomatic macro- From the Departments of Plastic Surgery, Kaiser Permanente mastia from 1992 to 2001 was undertaken. Derma- San Diego Medical Center and Robert Wood Johnson Medical bond skin adhesive was used in all patients un- School, University of Medicine and Dentistry of New Jersey. dergoing breast reduction beginning in 1999. The Received for publication March 28, 2006; accepted August current review includes 103 patients who under- 25, 2006. went breast reductions from 1999 to 2001 with Presented at the 74th Annual Scientific Meeting of the Society Dermabond skin closures. A total of 255 patients of Plastic Surgeons, in Chicago, Illinois, September 24 from 1999 to 2005 had Dermabond skin closures. through 28, 2005. Their results were compared with the 415 consec- Copyright ©2007 by the American Society of Plastic Surgeons utive patients who had breast reductions with a DOI: 10.1097/01.prs.0000282032.05203.8b standard sutured skin closure from 1992 to 1998.

1460 www.PRSJournal.com Volume 120, Number 6 • Dermabond Skin Closures

The patients’ medical records were reviewed to obtain information including age, bra cup size (preoperative and postoperative), resection weight (grams per breast), and operative times. Postop- erative results, including nipple sensation, relief of symptoms, and satisfaction with results, were noted. Patients were asked postoperatively whether nipple sensation was present and whether there was any difference side to side. They were also asked about their overall satisfaction with the results from surgery. Complications including delayed wound healing, hypertrophic scar revisions, cellulitis, and wound dehiscence were noted and statistical significance was tested for by the chi-square Fisher’s exact test. Wound dehiscences were considered minor if the resulting wound edges could be reapproximated with Steri-Strips (3M Health Care, St. Paul, Minn.) or major if a sutured reclosure was necessary.

Patient Selection and Operative Technique The same guidelines were used to determine candidates for surgery as in our earlier review.5 Patients were evaluated and found to have symptomatic macromastia from breast excess of at least 400 g. Resections less than 400 g occurred if the patient had a 400-g excess on one side and breast asymmetry of at least one cup size on the opposite side. Candidates were nonsmokers (for at least 12 weeks) and encouraged to present to surgery with a body mass index of 30 or less. Mammographic screening when indicated was up to date at the time of surgery. As in the earlier series, a bilateral simultaneous resection was undertaken, with the primary surgeon determining the final resection. An inferior pedicle reduction approach with an inverted-T Wise pattern was used for all patients. At the completion of the resection, the wounds were irrigated with antibiotic containing saline, and hemostasis was achieved with electrocautery. The wound edges were approximated with interrupted, buried, intradermal sutures of 3-0 Monocryl (Ethi- Fig. 1. (Above) Key sutures. (Center) Completed dermal closure. con). Closure of the flaps included the placement (Below) Dermabond application. of eight key sutures, which allow for distribution of tension along the flap edges (Fig. 1, above). The first buried dermal suture is placed at the medial edge of the base of the pedicle. The second key point of the vertical limb, and the sixth suture is suture is placed at the apex of the nipple inset. The placed at the midpoint of the pedicle base where third suture is placed at the lateral edge of the base the vertical limb meets the inframammary fold of the pedicle. The fourth is placed at the infe- incision. Key sutures seven and eight are placed at rior nipple inset or the 6-o’clock position of the the 9-o’clock and 3-o’clock positions, respectively, nipple. The fifth key suture is placed at the mid- on the nipple inset.

1461 Plastic and Reconstructive Surgery • November 2007

With the key sutures in place, the remainder At the first postoperative visit (postoperative of the incisions are closed by dividing the differ- days 5 through 7), the surgical bra and dressings ence along the wound margins, with special at- are removed, the incisions are examined, and the tention to the medial and lateral endpoints to patients are instructed to resume showering and avoid the appearance of dog-ears at those points. bathing and to begin the application of a petro- Typically, this requires buried sutures at 0.5- to leum-based antibiotic ointment to the incisions. 1.0-cm intervals and a total of three 3-0 Monocryl Application of the ointment helps to cause disso- sutures (27-inch or 70-cm suture length; Ethicon) lution and removal of the glue remnants. Usually, for each breast. At the completion of the closure, the Dermabond remnants are completely re- the skin edges should be well apposed, with no moved at postoperative week 2 or 3. Patients are exposed dermis (Fig. 1, center). If any gaps remain instructed to continue to wear surgical bras or with exposed dermis and a buried suture cannot sports bras (preferably with frontal closures) 24 be placed to close it, a small absorbable suture hours per day, 7 days per week for the first 2 to 3 (such as fast-absorbing 5-0 gut) may be used on the weeks after surgery. outer surface of the skin. Dermabond skin adhesive is then applied to RESULTS seal the skin edges. The first layer is placed on the The average age of the patients was 41 years, incision quickly and evenly. After a few seconds, with a range of 15 to 73 years. The most common the second vial is used to place a second layer over bra cup size preoperatively was DD (52 percent) the incision (Fig. 1, below). High-viscosity Derma- and the most common postoperative bra cups size bond was used in addition to regular Dermabond, was C (60 percent). No free nipple grafts were with similar results in sealing the incisions. Several performed. These results are similar to those from minutes are required to allow the glue to dry be- the earlier review. fore the operative dressings are applied. Dressings The average resection per breast was 605 g, were made of Kerlix super sponges (Tyco Health- with a range of 174 to 1684 g. The average oper- care/Kendall, Pembroke, Bermuda) unfolded and ative time (incision to closure) was 93 minutes, molded into buns covered by ABD Pads (Tyco with a range of 50 to 130 minutes. This compares Healthcare/Kendall). A total of four vials of Derma- with a slightly longer overall operative time in the bond (each containing 0.5 ml) were used for each earlier series (118 minutes). patient. Occasionally, extra vials were required for The overall complication rate was 13.36 per- very long incisions. cent (Table 1). Delayed wound healing, usually in In the earlier series, the sutured skin closure the area of the inverted T, occurred in 15 patients was completed with a dermal closure of inter- (5.88 percent). These wounds healed uneventfully rupted buried 3-0 Monocryl followed by a second with local care. Hypertrophic scar revisions were layer of 4-0 Monocryl as a running, subcuticular performed in seven patients (2.75 percent). Cel- stitch used instead of Dermabond. One subcutic- lulitis resolving with oral antibiotic therapy oc- ular suture was used to close the inframammary curred in seven patients (2.75 percent). Minor fold incision and a second was used to close the wound dehiscence requiring nonsuture reclosure vertical limb and nipple inset. Dressings included (Steri-Strips) occurred in three patients (1.18 per- antibiotic ointment and 1-inch strips of Xeroform cent). Major wound dehiscence requiring a su- (Tyco Healthcare/Kendall). The same outer dressings were then applied. Table 1. Complications After application of the Dermabond and the 1992–1998* 1999–2005† dressings, a surgical bra was placed to secure the (%) (%) p‡ dressings. All procedures are performed as out- Delayed wound patient surgery. The patients were instructed to healing 21 (5.06) 15 (5.88) 0.65 leave the bra and dressings intact until the first Dehiscence postoperative visit (5 to 7 days after surgery). Minor 12 (2.89) 3 (1.18) 0.15 Major 8 (1.93) 2 (0.78) 0.33 Although the Dermabond closure is waterproof, Hypertrophic scar we preferred that the patients avoid the upper revisions 19 (4.58) 7 (2.75) 0.23 arm activity and motion as might be required in Cellulitis 17 (4.10) 7 (2.75) 0.36 bathing or showering to minimize the risks of Total 77 (18.46) 34 (13.36) *n ϭ 415 patients. postoperative bleeding and dehiscence of the †n ϭ 255 patients. healing incision. ‡Chi-square Fisher’s exact test.

1462 Volume 120, Number 6 • Dermabond Skin Closures tured reclosure occurred in two patients (0.78 Dermabond seal to “float off” the incision, allow percent). Two patients required liposuction for the accumulation of fluid underneath the glue, postoperative asymmetry, one patient required and thus prevent an adequate wound seal. There- surgical correction of medial symmastia, and fore, close attention to a properly sutured incision one patient developed unilateral necrosis of the is paramount to the successful use of Dermabond. lateral skin flap that healed secondarily. The use of Dermabond was associated with a Patients reported good to normal nipple sen- decrease in operative times (25 minutes or 20 sation in 86 percent of cases. Unilateral dimin- percent less time). This would appear to be asso- ished nipple sensation was reported in 14 percent ciated with the ease and speed of Dermabond of patients. No patients reported complete loss of application versus placement of the second-layer, nipple sensation. The majority of patients (98 per- subcuticular skin closure. This operative time sav- cent) reported relief of their preoperative symp- ings can have a significant health economic im- toms and satisfaction with their results. pact, considering the large number of breast re- In the earlier review, the rate of minor wound duction operations performed, and may also lead complications was 18.46 percent, and unilateral to shortened operative times when Dermabond is diminished nipple sensation occurred in 13 per- used for skin closure in other long-incision plastic cent of patients. The rates for minor dehiscence, surgical procedures (e.g., breast reconstructions, major dehiscence, hypertrophic scar revisions, panniculectomies, abdominoplasties). and cellulitis were all less in the Dermabond group Patient discomfort is minimized because no su- compared with the earlier series, but these differ- tures need be removed after surgery and no tapes or ences were not statistically significant (Table 1). other postoperative dressings are required beyond The rate for delayed wound healing was slightly gauze and a surgical bra. Patients are pleased to be higher in the Dermabond group, but this was not able to shower after their first postoperative visit (5 statistically significant. There were no allergic or to 7 days). In this large overall series of 670 consec- adverse reactions associated with Dermabond use utive patients (1340 breasts) undergoing primary (Table 2). reduction mammaplasty by a single primary plastic In this large series of patients undergoing bi- surgeon, the replacement of a sutured skin closure lateral reduction mammaplasty by the same sur- with Dermabond has led to shortened operative geon, replacing the subcuticular sutured skin clo- times and is associated with high patient compliance sure with the application of Dermabond appears and satisfaction and diminished postoperative dis- to give similar results regarding healing of the comfort. incisions and ultimate cosmesis based on both the patients’ comments and physician’s assessment. DISCUSSION The rates of wound of wound healing complica- Dermabond has been shown to be a safe and tions are similar in the “sutured” and Dermabond effective means of skin closure in a variety of clin- skin closures. ical settings. In an early report, Singer et al. dem- When dehiscence of the wound occurs, it is onstrated in a prospective, randomized, con- seen to be primarily a failure of the buried dermal trolled trial that skin closure in traumatic wounds suture (perhaps unraveling of the surgical knot or using Dermabond yielded results that were com- the surgical knot having been inadvertently cut parable to standard sutured closures with regard after being tied). Failure to place a sufficient num- to wound infection rates, dehiscence, and long- ber of sutures (at Ͼ1-cm intervals) may also be term cosmetic outcome.6 Perron et al. demon- causative. If Dermabond is applied to incisions strated that Dermabond could be used for repair that are weeping or bleeding, this may cause the of certain superficial lacerations in hockey players,

Table 2. Dermabond Skin Closures No. of Reference Patients/Incisions Incision Type Results Rajimwale et al., 20048 146/200 Pediatric urology High patient satisfaction Gennari et al., 20049 133 Breast surgery High patient satisfaction McKinley and Yen, 200510 19/21 Dacryocystorhinostomies Good results Hall and Bailes, 200511 200 Neurosurgical discectomies Safe for use Pachulski et al., 200512 460 Cardiac implants Good results Scott and Borah, 200513 94 Blepharoplasties High patient satisfaction

1463 Plastic and Reconstructive Surgery • November 2007 allowing the athletes to reenter competition with absorbable suture. The authors concluded that wound repairs that retained strength, durability, Dermabond was a safe and effective substitute for the and apposition for the duration of the game and superficial skin closure, with good cosmetic results for a period of 7 days after repair.7 and no increase in wound complications. Various recent reports have demonstrated the In an unpublished review, we reported on the effectiveness of Dermabond in skin closures in a use of Dermabond for skin closure in a consecutive wide array of clinical settings in the surgical sub- series of 94 blepharoplasty patients.13 After comple- specialties. Rajimwale et al. used Dermabond in a tion of a standard skin muscle resection for blepha- series of 146 patients with 200 incisions undergo- rochalasia, with or without eyelid ptosis repair, the ing a variety of extragenital open and laparoscopic skin edges were approximated with several sutures of pediatric urologic procedures.8 Dermabond served fast-absorbing gut suture followed by application of as the only topical dressing as well, allowing patients Dermabond to seal the skin edges. There were no to return to early bathing and normal activity. In a instances of Dermabond spillage into the eye, and all prospective, randomized, controlled trial, Derma- incisions healed well, with no dehiscences. We found bond skin closure was compared with standard su- patient comfort greatly enhanced because no skin tured skin closure in a series of patients undergoing tapes or bandages were required, patients were able breast surgery for breast cancer and benign breast to wash their faces immediately after surgery, and the lesions.9 In both groups, absorbable sutures were time and discomfort of suture removal were avoided. used to close the deeper subcutaneous tissues. The patients were then randomized for either a sutured CONCLUSIONS subcuticular skin closure or closure with Derma- The authors have found widespread indications bond. There was no infection, dehiscence, or he- and applicability for Dermabond in a wide variety of matoma in either group, and the cosmetic results plastic surgery skin closures for major and minor were similar. The skin closure with Dermabond was procedures. The use of Dermabond decreases op- significantly faster and led to a cost savings with re- erative times and enhances patient postoperative gard to differences in patient follow-up visits. comfort. Contraindications to the use of Derma- McKinley and Yen reported their results using bond include wounds with compromised skin integ- Dermabond to close 21 incisions in 19 patients rity along the incision edges with abrasions, epider- undergoing external dacrocystorhinostomy.10 They mal disruption, partial-thickness skin loss, burns, demonstrated the Dermabond closure to be equiv- and edematous wound edges that prevent approx- alent to sutured skin closures with respect to healing imation of the skin edges. With these few exceptions, and aesthetic appearance despite a late wound de- Dermabond has wide applicability in a large variety hiscence in one incision that was probably caused by of skin closures. infiltration of the Dermabond into the wound edges, preventing skin healing. Gregory R. Scott, M.D. Department of Plastic Surgery In a consecutive series of 200 patients under- Kaiser Permanente going various lumbar and cervical neurosurgical 3250 Fordham Street procedures including anterior cervical discectomy, San Diego, Calif. 92110 microlumbar discectomy, and lumbar laminec- [email protected] tomy, Hall and Bailes demonstrated the safety of Dermabond without an increased complication ACKNOWLEDGMENTS rate and with good cosmetic results.11 Contrain- The authors express their gratitude to the surgeons dications to Dermabond, according to the au- and staff of the Department of Plastic Surgery, Kaiser thors, included the presence of infection, cere- Permanente Medical Center, in San Diego, California, brospinal fluid leak, bleeding or oozing from the and also to Janis F. Yao for biostatistical analysis. incision, and incisions under tension requiring sutured approximation. In their series, there was DISCLOSURE one documented infection (0.5 percent). The authors have no financial disclosures to declare. Pachulski et al. reviewed 460 patients receiving implantable cardiac devices (pacemakers, cardio- REFERENCES verter defibrillators, and loop recorders), including 1. Quinn, J., Wells, G., Sutcliffe, T., et al. A randomized trial 125 patients in which Dermabond was used to re- comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. J.A.M.A. 277: 1527, 1997. place the superficial skin closure compared with the 2. Toriumi, D., O’Grady, K., Desai, D., et al. Use of octyl-2- 12 standard sutured three-layer closure. In both cyanoacrylate for skin closure in facial plastic surgery. Plast. groups, the deeper tissue layers were closed with Reconstr. Surg. 102: 2209, 1998.

1464 Volume 120, Number 6 • Dermabond Skin Closures

3. Greene, D., Koch, J., and Goode, R. Efficacy of octyl-2-cya- 9. Gennari, R., Rotmensz, N., Ballardini, B., et al. A prospective, noacrylate tissue glue in blepharoplasty. Arch. Facial Plast. randomized, controlled clinical trial of tissue adhesive Surg. 1: 292, 1999. (2-octylcyanoacrylate) versus standard wound closure in 4. Reiman, P. Tissue adhesive used for closing breast incisions. breast surgery. Surgery 136: 593, 2004. Cosmet. Surg. Times 4: 2, 2001. 10. McKinley, S., and Yen, M. Octyl-2-cyanoacrylate tissue adhe- 5. Scott, G., Carson, C., and Borah, G. Maximizing outcomes in sive in external dacryocystorhinostomy. Opthal. Plast. Recon- breast reduction surgery: A review of 518 consecutive pa- str. Surg. 21: 197, 2005. tients. Plast. Reconstr. Surg. 116: 1633, 2005. 11. Hall, L., and Bailes, J. Using Dermabond for wound closure 6. Singer, A., Hollander, J., Valentine, S., et al. Prospective, in lumbar and cervical neurosurgical procedures. Neurosur- randomized, controlled trial of tissue adhesive (2-octylcya- gery 56: 147, 2005. noacrylate) vs standard wound closure techniques for lacer- 12. Pachulski, R., Sabbour, H., Gupta, R., et al. Cardiac device ation repair. Acad. Emerg. Med. 5: 94, 1998. implant wound closure with 2-octylcyanoacrylate. J. Interv. 7. Perron, A., Garcia, J., Hays, P., et al. The efficacy of cyanoac- Cardiol. 18: 185, 2005. rylate-derived surgical adhesive for use in the repair of lacera- 13. Scott, G., and Borah, G. Dermabond skin closure for tions during competitive athletics. Am. J. Emerg. Med. 18: 61, 2000. blepharoplasty: A review of 94 consecutive patients. Pre- 8. Rajimwale, A., Golden, B., Oottomasathien, S., et al. Octyl- sented at the 38th Anniversary Meeting of the American 2-cyanoacrylate as a routine dressing after open pediatric Society of Plastic Surgeons, in New Orleans, La., April urologic procedures. J. Urol. 171: 407, 2004. 28–May 4, 2005.

Instructions for Authors: Key Guidelines Financial Disclosure and Products Page On the third page of the manuscript, all sources of funds supporting the work and a statement of financial interest, if any, must be included for each author, along with a list of all products, devices, drugs, etc., used in the manuscript. All manuscripts must have all of this information. Each author must disclose at the time of submission any commercial associations or financial relationships that might pose or create a conflict of interest with information presented in any submitted manuscript. Such associations include consultancies, stock ownership, or other equity interests, patent licensing arrangements, and payments for conducting or publicizing a study described in the manuscript. This information will be printed with the article.

1465 BREAST

The Versatility of the Superomedial Pedicle with Various Skin Reduction Patterns

Steven P. Davison, M.D., Background: The inferior pedicle technique remains one of the most com- D.D.S. monly used techniques in breast reduction surgery, despite lengthy operating Ali N. Mesbahi, M.D. times, poor nipple sensation, and bottoming-out over time. The superomedial Ivica Ducic, M.D., Ph.D. pedicle in reduction mammaplasty has previously been described using limited Marc Sarcia, M.D. incision patterns. This study evaluated the safety and reliability of the supero- Joseph Dayan, M.D. medial pedicle with various skin reduction patterns and compared the surgical Scott L. Spear, M.D. time with the inferior pedicle technique. Washington, D.C. Methods: A total of 279 superomedial breast reductions were reviewed over a 6-year period, representing the transition period from inferior pedicle to superomedial pedicle techniques of three attending surgeons. Among these reductions, 215 had complete records and were included in the data analysis. The remaining 64 records were evaluated for viability of the nipple-areola complex. Assessments included skin pattern markings, average size of reduction, average body mass index, and complications. Risk factors and patient comorbidities were also recorded. Results: There were no cases of nipple loss in the series. The overall complication rate was 18 percent; patients’ average body mass index was 29. The revision rate for contour or scar improvement was 4 percent. A statistically significant reduction in operating time of 41 minutes (p ϭ 0.0001) was seen in comparison with the inferior pedicle reduction. Conclusions: The superomedial dermoglandular pedicle is a safe and reliable technique for reduction mammaplasty. Its versatility allows for reproducible results in a broad range of patients with various skin excision patterns. Use of the superomedial pedicle provides consistent results with respect to breast contour, nipple viability, and lasting superomedial fullness, and saves operating time compared with the inferior pedicle technique. (Plast. Reconstr. Surg. 120: 1466, 2007.)

he American Society of Plastic Surgeons from Hall-Findlay’s medially based pedicle de- reports a 25 percent increase in reduction scribed in 1999.5 Tmammaplasty over the past 4 years. Over There are two components to breast reduction: 105,000 breast reductions were performed in the pedicle and the skin excision. Although re- 2004.1,2 Rohrich has previously reported that the lated, they are independent of each other.6–8 The inferior pedicle and Wise pattern techniques Wise pattern skin excision has been described with were the most popular based on a survey of a variety of pedicles and, similarly, a short scar skin board-certified plastic surgeons.3 We believe the excision has been described with various pedicles most common technique for breast reduction including those used by Lejour, Hall-Findlay, Las- surgery remains the inferior pedicle.4 However, sus, and Hammond.7–11 at our institution, the preferred method became The superomedial pedicle is potentially versa- the superomedial pedicle technique modified tile and could be used with many skin reduction patterns. Hall-Findlay has argued its value for From the Department of Plastic Surgery, Georgetown Uni- vertical scar reductions.5 In larger breasts with a versity Hospital. stretched skin envelope, the pedicle could work Received for publication March 23, 2006; accepted August well with a Wise pattern skin excision. 30, 2006. In breast reduction, a technique that provides a Copyright ©2007 by the American Society of Plastic Surgeons safe and predictable result with nipple preserva- DOI: 10.1097/01.prs.0000282033.58509.76 tion is paramount. However, the end result is

1466 www.PRSJournal.com Volume 120, Number 6 • Superomedial Pedicle Technique judged on volume, scar pattern, shape, symmetry, pop excision, or a circumvertical with short trans- and nipple position. Other techniques do not al- verse inframammary scar.1 The second technique ways address these issues. For instance, Lejour’s combines the pedicle with a Wise pattern skin technique was known for its versatility but was crit- excision16 or Wise pattern with a free nipple graft. icized for its lack of predictability.12 Likewise, the Superomedial Pedicle with Limited Incisions inferior pedicle has been associated with a boxy The standard breast landmarks are drawn with shape and bottoming-out over time.5,13 This series the patient in the standing or upright-seated po- of 279 superomedial pedicle reductions with vari- sition. The sternal notch, chest midline, breast ous skin pattern excisions addresses versatility, meridians, and inframammary folds are marked. safety, and predictability in breast reduction. The anticipated nipple positions are marked 0 to 2 cm above the inframammary folds. The superior PATIENTS AND METHODS margin of the new areolar position is drawn 2 cm This is a retrospective review of 279 reduction above this. The breast is moved medially and then mammaplasties completed over a 6-year period laterally, and each point that crosses the line rep- from 1999 to 2005. This group was accumulated resenting the breast meridian is marked on either during a transition period of three surgeons from side of each breast. The vertical extent of resection other techniques to the superomedial pedicle is marked by a horizontal line located 4 cm above technique. Among the patient records, only 215 the inframammary fold. A circular aperture is had complete records and were included in the drawn connecting the superior margin of the data analysis. The only variable for which the re- planned areola to the inferior margin of the ex- maining 64 were evaluated was the postoperative isting areolar complex. The superomedial pedicle viability of the nipple-areola complex. We exam- is marked within this aperture. ined the patients for pedicle type and skin excision For the limited incision technique, the cir- pattern. The superomedial pedicle group was sub- cumareolar skin excision is never greater than a divided into those with circumvertical, circumver- 3:1 ratio. The lateral pillars of the vertical reduc- tical with short transverse scar, and Wise pattern tion are marked relative to the meridian by pulling skin excisions. In addition, free nipple reductions the breast medial and lateral. The vertical lines of were evaluated to see how many were grafted to a excision are connected by a horizontal line drawn superomedial glandular base. The weight of the 4 cm superior to the fold. When excising peri- specimens was measured. Patient comorbidities areolar skin, a 5-mm fringe of dermis is deepithelialized to hold a purse-string blocking stitch as such as obesity, diabetes mellitus, coronary artery 6 disease, breast cancer, and smoking were noted. described by Hammond. Vertical cuts are made The average body mass index of the patients from toward the lower pole, with excision of excess skin each skin excision pattern was recorded. Compli- and breast tissue (Fig. 1, above). From the inferior cations were classified as major if a return to the pole, greater volume is removed by flaring the operating room was required. Minor complica- dissection both medially and with direct excision tions included seroma/hematoma, cellulitis, su- from the lateral flap. Thickness of the lateral flap perficial skin necrosis, and loss of nipple sensa- is preserved so there is no compromise to the skin tion. The surgical scar revision rate was recorded. viability. An arc of tissue is excised en bloc above A random consecutive cohort of 25 inferior pedi- the pedicle to provide space to rotate the pedicle. cle reductions with Wise pattern excisions was Excess breast and skin can be excised in medial matched with a consecutive cohort of superome- and lateral wedges, creating a short transverse scar dial pedicle reductions with Wise pattern excisions if needed. The short scar should be concealed in to compare operating room time for the same the inframammary fold. The circumvertical and surgeon. The operative times were gathered from circumvertical with short transverse scar tech- documented start and stop times from the anes- niques are used mostly in moderate reductions of thesia records. Finally, to address Goldwyn’s re- less than 1000 g. quest for authors to show a range of results,14 a Wise Pattern Excision and Free series of consecutive patients with 1-year follow-up Nipple Transfers photographs is presented. Reductions larger than 1000 g with excess skin are performed using the superomedial pedicle but with an abbreviated Wise pattern excision. The Surgical Techniques preoperative markings are drawn with the patient The first technique combines the superome- in the standing position. Breast meridians are de- dial pedicle with either a circumvertical, or lolli- termined using the suprasternal notch and acro-

1467 Plastic and Reconstructive Surgery • November 2007 mion to measure the midline of each breast. A vertical line through the nipple-areola complex (unless significantly displaced) is drawn. The inframammary fold is marked. Nipple placement is then marked along the breast meridians at the level of the fold height. The nipple height on larger reductions is in the range of 22 to 26 cm from the suprasternal notch. The length of skin from the areola to the inframammary fold is measured at 5 to 8 cm. If the breast is large, a longer vertical limb of 7 to 8 cm avoids pulling the abdominal skin and final scar superiorly onto the breast. The superomedial pedicle is then marked 6 to 8 cm wide (Fig. 1, below). The majority of the reduction comes from the inferolateral portion of the breast, and care is Fig. 2. Excision of an arc of tissue above the areola to create taken to avoid parenchymal excision from be- space for the new position of the nipple-areola complex. neath the superomedial flap. A wedge of tissue is excised as an arc above the areola to provide space to rotate the pedicle and is removed en bloc with the main specimen (Fig. 2). The superomedial pedicle is flared at the chest wall to maximize the intercostal perforators. The pedicle is then fixed by the skin envelope, not sutures. A setup suture is placed at the T junction of the skin flaps with the inframammary fold. This suture is placed in the classic manner at the meridian of the breast. How- ever, if it is moved 1 to 2 cm medially, greater coning of the breast is achieved. Free nipple transfers are accomplished using the same Wise pattern excision. The nipple is transferred in the standard fashion onto a modified superomedial pedicle that maintains the normal width but does not extend in length to the original nipple-areola complex. Enough length is maintained to rotate the pedicle toward the new location of the nipple-areola complex. Free nipple grafts are placed directly on the deepithelialized pedicle.

RESULTS A total of 279 superomedial breast reductions were reviewed. Two hundred fifteen records were used for complete analysis and the remaining 64 were evaluated only for nipple compromise. The distribution of skin excision patterns was 30 circumvertical reductions, 43 circumvertical with short transverse scar, 133 Wise pattern excisions Fig. 1. (Above) Circumvertical with short transverse scar tech- with a pedicled nipple-areola complex, and nine nique. After the areola size is chosen, the skin of the pedicle and free nipple grafts using the Wise pattern. Circum- a 5-mm dermal fringe is deepithelialized in preparation for a vertical reductions averaged 688 g per breast and block stitch. Vertical cuts are made for excision of excess breast circumvertical reductions with short transverse and skin from the inferior pole. (Below) Width of the superome- scars averaged 1137 g of removed tissue. Volumes dial pedicle before excision of breast parenchyma. using the Wise pattern and free nipple graft tech-

1468 Volume 120, Number 6 • Superomedial Pedicle Technique

Table 1. Superomedial Pedicle Reductions with Varying Skin Excisions Circumvertical with Free Variable Circumvertical Short Transverse Scar Wise Nipple Graft No. of reductions 30 43 133 9 Average breast weight, g 688 1137 1183.5 1929 Average BMI 22.9 24 33.2 37.5 BMI, body mass index. niques were greater, with a mean of 1183.5 and neck or back pain in the larger breast reduc- 1929 g, respectively. An analysis of variance statis- tions, and a single procedure with no need for tical test was performed to evaluate the differences postoperative revision. There was no case of par- between the average reduction weights of the four tial or complete nipple loss (Table 1). In Figures groups. A value of p Ͻ 0.0001 was calculated, in- 3 through 8, six consecutive patients are shown dicating a statistically significant difference. The at 1-year follow-up. patients who received circumvertical reductions Among the revisions, nine patients (4 percent) had an average body mass index of 22.9, whereas were not satisfied with the postoperative breast those that underwent the circumvertical reduc- contour or scar. The complications were classified tion with a short transverse scar had an average as major and minor. Major complications were body mass index of 24. Patients who underwent those necessitating a return to the operating room Wise pattern excisions and those that received free (Table 2). Ten patients required a return to the nipple transfers had average body mass index’s of operating room (4.6 percent). Three patients (1.4 33.2 and 37.5, respectively. percent) required immediate return to the oper- Despite an average patient body mass index ating room for evacuation of hematomas. Another of 29, a success rate of 96 percent was achieved. three patients (1.4 percent) were revised for con- Success was defined as a satisfied patient with tour improvement and four patients (1.8 percent) respect to aesthetic outcome, improvement in required revision of the surgical scar. The remain-

Fig. 3. (Left) Preoperative and (right) 1-year postoperative views.

1469 Plastic and Reconstructive Surgery • November 2007

Fig. 4. (Left) Preoperative and (right) 1-year postoperative views.

Fig. 5. (Left) Preoperative and (right) 1-year postoperative views.

1470 Volume 120, Number 6 • Superomedial Pedicle Technique

Fig. 6. (Left) Preoperative and (right) 1-year postoperative views.

Fig. 7. (Left) Preoperative and (right) 1-year postoperative views.

1471 Plastic and Reconstructive Surgery • November 2007

Fig. 8. (Left) Preoperative and (right) 1-year postoperative views. ing minor complications with each excision pat- performed in the office setting, making the total tern were recorded (Table 3). The most common scar revision rate 2.7 percent. Hypesthesia of the minor complications were seromas, hematomas, nipple-areola complex was a complaint in two pa- and delayed wound healing. Cellulitis of the op- tients but resolved in both within 6 weeks. Two erative site developed in five patients. Two patients patients experienced superficial necrosis of the (0.91 percent) had minor surgical scar revision surgical closure sites that healed without further

Table 2. Major Complications Requiring Return to the Operating Room Circumvertical with Free Nipple Complication Circumvertical Short Transverse Scar (%) Wise (%) with Wise Hematoma (1.4%) 0 0 3 (2.2) 0 Contour revision (1.4%) 0 1 (2.3) 2 (1.5) 0 Scar revision (1.8%) 0 0 4 (3.0) 0 Total (4.6%) 0 1 9 0

Table 3. Minor Complications Associated with Varying Skin Patterns (13.4 percent) Circumvertical with Free Nipple Complication Circumvertical (%) Short Transverse Scar (%) Wise (%) with Wise (%) Seroma 1 (3.3) 0 5 (3.7) 0 Hematoma 0 1 (2.3) 5 (3.7) 0 Delayed wound healing 4 (13) 0 1 (0.75) 1 (0.75) Cellulitis 0 1 (2.3) 2 (1.5) 2 (1.5) Subjective nipple hypesthesia 0 1 (2.3) 1 (0.75) NA Superficial necrosis 0 0 2 (1.5) 0 Scar revision 0 0 2 (1.5) 0 Nipple loss 0 0 0 0 Total 5 3 18 3 NA, not applicable.

1472 Volume 120, Number 6 • Superomedial Pedicle Technique intervention. One patient with sickle cell trait had Safety skin loss in the lateral flap that was salvaged with Strauch et al. presented their series of 1500 hyperbaric oxygen. The nipple, however, re- reductions using the superolateral pedicle. They mained viable. had six total losses of the nipple-areola complex A t test was performed to evaluate the oper- (0.2 percent) and reported a significant decrease ating time for cohorts of 25 consecutive supero- or total absence of nipple sensibility in 4 percent medial and inferior pedicle reductions combined of the patients. This study did not address body with Wise pattern excisions by the same surgeon mass index or patient comorbidities.23 In our se- assisted by a senior plastic surgical resident. The ries, despite comorbidities in 12 percent of pa- superomedial pedicle was found to be a statisti- tients and smoking in 13 percent, the overall com- cally significant 41 minutes faster (p ϭ 0.0001) plication rate was limited to 18 percent. None of than the comparison group of inferior pedicle the complications included nipple loss. Among reductions. our complications, 74 percent of the patients had a body mass index greater than 30, 29 percent were active smokers, and 10 percent had diabetes. DISCUSSION This complication rate of 18 percent is lower than The idea of a dermoglandular pedicle was in- the literature for breast reductions in heavier pa- troduced when Strombeck first used a pedicle of tients. Wagner and Alfonso reported an overall dermis and subcutaneous tissue to transpose the complication rate of 38 percent for patients with nipple-areola complex superiorly with consistent a mean body mass index of 30, with seroma being safety.16 In 1973, Weiner et al. described a single the most common complication in 30 percent.24 superior dermal pedicle.17 Orlando and Guthrie Similarly, Brown et al. showed an overall compli- followed in 1975 with a description of the supero- cation rate of 33 percent in patients with a body medial dermoglandular pedicle.18 This technique mass index of more than 30.25 Both of these studies was further popularized by Hauben, who de- were conducted on patients who had undergone scribed the associated safety and speed of this par- inferior pedicle reductions and free nipple grafts. ticular design.19,20 Nevertheless, the McKissock and inferior pedicle techniques had been the pre- Neurovascular Supply dominant methods used for reduction mammaplasty at our institution.21 In 1999, however, Hall- The blood supply is as reliable as the inferior or central pedicle, as it originates from the inter- Findlay described her technique using a medial 26 pedicle in conjunction with a vertical reduction nal mammary perforators. In larger reductions, pattern.5 As she discussed, the reliability of the feathering of the pedicle can extend the perforators from the lateral thoracic artery and associated medial pedicle, its ease of insetting in larger breast 22 reductions, and faster operating times prompted lateral intercostal and thoracoacromial vessels. us to explore that technique. Flaring away from the pedicle also allows for the Others have written about the applications of acquisition of the lateral rami of the fourth the superomedial pedicle. Finger and colleagues intercostal nerve. Additional sensory contribution may be made by the third and fifth inter- suggested the applicability of the technique in 27–29 reductions as large as 4100 g, with a mean pedicle costal nerves. The pedicle rotates easily into 22 place and does not require folding. This is in length of 11.6 cm. In contrast, use of the medial 11 pedicle by Abramson et al. excluded patients with contrast to the superior pedicle of Lejour, which may require folding that could compro- a pedicle length of greater than 16 cm. Their 30 additional exclusion criteria were short pedicle mise the pedicle. Objectively, the medial or length (Ͻ6 cm) and a lack of superior and medial superomedial techniques compare favorably in postoperative breast sensitivity compared with fullness because of concern over vascularity of the 31 breast parenchyma.13 Interestingly, these exclu- the inferior pedicle. Our review found only two sion criteria would match our profile of a candi- cases (0.91 percent) of subjective complaints of date for a superomedial reduction. Furthermore, hypesthesia. As some of the patients may not we find no anatomical basis for patient exclusion have been questioned about nipple sensibility, using this technique. If nipple-areola complex vi- this deficit in sensation is likely underreported. ability is a concern because of large breast size and excessive pedicle length, a free nipple graft can be Pedicle Length safely combined with this pedicle for a reliable The superomedial pedicle has a superior aesthetic outcome. blood supply because of its shorter length when

1473 Plastic and Reconstructive Surgery • November 2007 compared with an inferiorly based pedicle in an dial pedicle reductions matched with inferior equivalently sized breast. Despite very large reduc- pedicle reductions translated into a 41-minute re- tions, Finger and associates showed that the mean duction in operating time for the same surgeon. length of the pedicle was 11.6 cm, and Hall-Findlay The skin excision pattern is not dictated by the used the superomedial glandular technique ex- amount of breast tissue to be removed. In our tensively in a wide range of mammaplasties.9,22 series, similar amounts of breast parenchyma were With an inferior pedicle technique, the distance excised for the circumvertical, circumvertical with from the nipple to the inframammary fold could short transverse scar, and Wise pattern patient be closer to 16 to 19 cm in length for a similar sized groups. This underscores the principle that it is reduction and potentially necessitate a free nipple the amount of excess skin that influences the pat- graft. The arc of rotation is favorable and the tern of skin excision and not the size of the breast pedicle needs to be rotated no more than 110 reduction. Using the superomedial technique, the degrees. It also does not need to be sewn in place progressive skin excision from circumvertical to a to the chest. It maintains its position in the soft- short transverse scar or Wise pattern allows the tissue pocket created by excision of tissue superior surgeon to achieve a more ideal breast in one to the pedicle itself and by its attachment to the operation. As such, one may reduce the reopera- chest wall superiorly and medially. This avoids ad- tion rate compared with other vertical techniques ditional steps to attach the pedicle superiorly, as is that have revision rates as high as 11 percent.32 In done with the short scar periareolar inferior pedi- our series, only nine of 215 (4.2 percent) patients cle reduction mammoplasty technique. The com- required revision for either scar or contour im- plexity increases when the pedicle is short with provement. As these cases were all performed at a medially located areolas and the arc of rotation is university hospital, such a low revision rate illus- limited by the dermal attachment. This may re- trates another feature of this technique—being quire incising some of the inferomedial dermal easy to teach. pedicle to facilitate rotation (Fig. 9). However, as the pedicle is attached directly to the chest and has excellent internal mammary artery perforators, Breast Shape this can be performed safely. The superomedial pedicle inherently provides a substantial amount of superomedial fullness by preserving the upper-inner quadrant of the breast. Deepithelialization and Skin Excision Although this was not measured objectively, we The superomedial pedicle requires less deepi- believe it accentuates this area and resists the glan- thelializing compared with the inferior pedicle dular bottoming-out phenomenon associated with for the same size reduction. This significantly the inferior pedicle. The inferior pedicle tech- decreases the operating time consumed by deepi- nique attempts to raise the inferior breast tissue thelialization. A cohort of consecutive superome- superiorly while basing it inferiorly, thus involving two inherently opposing vectors. Results of a study by Hsia and Thomson comparing breast shape preferences between plastic surgeons, lay people, and patients seeking breast augmentation showed that the latter two groups preferred a convex breast shape or fuller superior pole.33 In patients seeking breast reduction, we find similar preference to superior fullness and also elimination of inferolateral excess. The superomedial pedicle base location does not interfere with skin gathering like inferior base reduction techniques when the skin flaps are sewn over the deepithelialized dermal attachments. The primary disadvantage when the pedicle is short is that achieving the arc of rotation requires a dermal incision. When combined with the Wise Fig. 9. Dermal incision at the inferomedial aspect of the pedicle pattern skin excision, the bulk of the pedicle is to facilitate rotation. The blood supply to the nipple-areola com- central, not inferior, thereby reducing boxiness. plex is not jeopardized. In larger breasts, this advantage is used to maxi-

1474 Volume 120, Number 6 • Superomedial Pedicle Technique mize the aesthetic result of free nipple transfer. REFERENCES Forming a pedicle without a nipple creates an 1. Spear, S. L., Davison, S. P., and Ducic, I. Superomedial pedi- ideal mound that gives the reduction the desired cle reduction with short scar: New trends in reduction and shape without the limiting concern of nipple-are- mastopexy. Semin. Plast. Surg. 18: 203, 2004. ola complex viability.34,35 2. American Society of Plastic Surgeons. Available at: http:// www.plasticsurgery.org. Accessed August 1, 2005. 3. Rohrich, R. J., Gosman, A. A., Brown, S. A., Tonadapu, P., and Foster, B. Current preferences for breast reduction tech- Limitations niques: A survey of board certified plastic surgeons. Plast. Some significant advantages of using the su- Reconstr. Surg. 114: 1724, 2004. peromedial pedicle in reduction mammaplasty 4. Spear, S. L. Personal communications at symposia, 2005. have been presented. However, additional find- 5. Hall-Findlay, E. J. A simplified vertical reduction mammaplasty: Shortening the learning curve. Plast. Reconstr. Surg. ings could have validated some important points. 104: 748, 1999. Future studies objectively evaluating superome- 6. Hammond, D. C. Short scar periareolar-inferior pedicle re- dial fullness, nipple sensibility, long-term breast duction (SPAIR) mammaplasty. Oper. Tech. Plast. Reconstr. shape, and descent compared with the inferior Surg. 6: 106, 1999. pedicle will provide strong arguments for the sub- 7. Hammond, D. C. Short scar periareolar-inferior pedicle reduc- jective points presented in this article. In addition, tion (SPAIR) mammaplasty. Plast. Reconstr. Surg. 103: 890, 1999. 8. Hall-Findlay, E. J. Super pedicle for breast surgery: An op- a subjective rating scale for patient satisfaction or eration for all reasons (Discussion). Plast. Reconstr. Surg. 115: one for independent plastic surgeons to evaluate 1278, 2005. our long-term results could support or refute what 9. Hall-Findlay, E. J. Vertical breast reduction: New trends in we believe is a gratifying procedure for both the reduction and mastopexy. Semin. Plast. Surg. 18: 211, 2004. patient and surgeon. 10. Lassus, C. A 30-year experience with vertical mammaplasty. Plast. Reconstr. Surg. 97: 373, 1996. 11. Lejour, M. Vertical mammaplasty and liposuction of the breast. Plast. Reconstr. Surg. 94: 100, 1994. CONCLUSIONS 12. Spear, S. L., and Little, J. W. Reduction mammoplasty and The key advantages of a superomedial pedicle mastopexy. In S. J. Aston, R. W. Beasley, and C. H. Thorne with various skin reduction patterns are as follows: (Eds.), Grabb and Smith’s Plastic Surgery, 5th Ed. Philadelphia: Lippincott-Raven, 1997. Pp. 725–752. 1. Safety: A low complication rate and a 100 13. Abramson, D. L., Pap, S., Shifteh, S., and Glasberg, S. B. percent rate of nipple preservation were Improving long-term breast shape with the medial pedicle achieved in this series. wise pattern reduction. Plast. Reconstr. Surg. 115: 1937, 2. Speed: A 41-minute reduction in operating 2005. time was found compared with the inferior 14. Goldwyn, R. Wanted: Real clinical results. Plast. Reconstr. Surg. 114: 1000, 2004. pedicle reduction. 15. Wise, R. J. A preliminary report on a method of planning the 3. Adaptability: This technique allows the sur- mammaplasty. Plast. Reconstr. Surg. 17: 367, 1956. geon to marry one pedicle with various skin 16. Strombeck, J. O. Report of a new technique based on the two patterns and reduction volumes. pedicle procedure. Br. J. Plast. Surg. 13: 79, 1960. 4. Reproducibility and predictability: These 17. Weiner, D. L., Aiache, A. I., Silver, L., and Tittiranonda, T. are features that make the technique easy to A single dermal pedicle for nipple transposition in subcutaneous mastectomy, reduction mammaplasty, or mas- teach and execute. topexy. Plast. Reconstr. Surg. 51: 115, 1973. 5. Aesthetic shape: Superior pole fullness is 18. Orlando, J. C., and Guthrie, R. H., Jr. The superomedial enhanced, with less bottoming-out and boxi- dermal pedicle for nipple transposition. Br. J. Plast. Surg. 28: ness over time. 42, 1975. 19. Hauben, D. J. Experience and refinements with the superomedial dermal pedicle for nipple-areola transposition in reduction mammaplasty. Aesthetic Plast. Surg. 8: 189, Steven P. Davison, M.D., D.D.S. 1984. Department of Plastic Surgery 20. Hauben, D. J. Superomedial pedicle technique of reduction Georgetown University Hospital mammaplasty (Discussion). Plast. Reconstr. Surg. 83: 479, 3800 Reservoir Road, NW 1989. PHC Building, 1st Floor 21. McKissock, P. K. Reduction mammoplasty with a vertical Washington, D.C. 20007 dermal flap. Plast. Reconstr. Surg. 49: 245, 1972. [email protected] 22. Finger, R. E., Vasquez, B., Drew, G. S., and Given, K. S. Superomedial pedicle technique of reduction mammaplasty. Plast. Reconstr. Surg. 83: 471, 1989. DISCLOSURES 23. Strauch, B., Elkowitz, M., Baum, T., and Herman, C. Supero- None of the authors has a financial interest in any of lateral pedicle for breast surgery: An operation for all rea- the products, devices, or drugs mentioned in this article. sons. Plast. Reconstr. Surg. 115: 1269, 2005.

1475 Plastic and Reconstructive Surgery • November 2007

24. Wagner, D. S., and Alfonso, D. R. The influence of obesity and W. C. Wood (Eds.), Surgery of the Breast: Principles and Art. and volume of resection on success in reduction mamma- Philadelphia: Lippincott-Raven, 1998. Pp. 717–733. plasty: An outcomes study. Plast. Reconstr. Surg. 116: 1034, 31. Mofid, M. M., Dellon, A. L., Elias, J. J., and Nahabedian, 2005. M. Y. Quantitation of breast sensibility following reduction 25. Brown, A. P., Hill, C., and Khan, K. Outcome of reduction mammaplasty: A comparison of inferior and medial pedi- mammaplasty: A patient’s perspective. Br. J. Plast. Surg. 53: cle techniques. Plast. Reconstr. Surg. 109: 2283, 2002. 584, 2000. 32. Cruz-Korchin, N., and Korchin, L. Vertical versus wise pat- 26. Shin, K. S., Chung, S., Lee, H. K., and Lew, J. D. Reduction tern breast reduction: Patient satisfaction, revision rates, and mammaplasty by central pedicle flap with short submammary complications. Plast. Reconstr. Surg. 112: 1573, 2003. scar. Aesthetic Plast. Surg. 20: 69, 1996. 33. Hsia, H., and Thomson, J. G. Differences in breast 27. Courtiss, H. E., and Goldwyn, R. M. Breast sensation be- shape preferences between plastic surgeons and patients fore and after plastic surgery. Plast. Reconstr. Surg. 58: 1, seeking breast augmentation. Plast. Reconstr. Surg. 112: 1976. 312, 2003. 28. Craig, R. D. P., and Sykes, P. A. Nipple sensitivity following 34. Gradinger, G. P. Breast reduction with the free nipple graft. reduction mammaplasty. Br. J. Plast. Surg. 23: 165, 1970. In S. L. Spear, J. W. Wood, M. E. Lippman, and W. C. Wood 29. Farina, M. A., Newby, B. G., and Alani, H. M. Innervation (Eds.), Surgery of the Breast: Principles and Art. Philadelphia: of the nipple-areola complex. Plast. Reconstr. Surg. 66: 497, Lippincott-Raven, 1998. Pp. 807–822. 1980. 35. Casas, L. A., and Byun, M. Y. Maximizing breast projection 30. Lassus, C. Vertical scar breast reduction and mastopexy with- after free nipple graft reduction mammaplasty. Plast. Recon- out undermining. In S. L. Spear, J. W. Wood, M. E. Lippman, str. Surg. 107: 961, 2001.

Instructions for Authors: Key Guidelines Manuscript Length/Number of Figures To enhance quality and readability and to be more competitve with other leading scientific journals, all manuscripts must now conform to the new word-count standards for article length and limited number of figure pieces: • Original Articles and Special Topics/Comprehensive Reviews are limited to 3000 words and 20 figure pieces. • Case Reports, Ideas & Innovations, and Follow-Up Clinics are limited to 1000 words and 4 figure pieces. • Letters and Viewpoints are limited to 500 words, 2 figure pieces, and 5 references.

1476 BREAST

Immediate Postoperative Complications in DIEP versus Free/Muscle-Sparing TRAM Flaps

Constance M. Chen, M.D., Background: The deep inferior epigastric perforator (DIEP) flap is a major M.P.H. advance in breast reconstruction, but many surgeons are reluctant to use it Eric G. Halvorson, M.D. because of concerns about a higher flap loss rate when compared with free/ Joseph J. Disa, M.D. muscle-sparing transverse rectus abdominis myocutaneous (TRAM) flaps. Pre- Colleen McCarthy, M.D., vious studies, however, have not statistically analyzed the relationship of patient M.P.H. characteristics to outcome. This study evaluates the authors’ institutional ex- Qun-Ying Hu, M.D. perience with immediate postoperative complications following DIEP and free/ Andrea L. Pusic, M.D., muscle-sparing TRAM flaps. M.H.S. Methods: Results of 200 consecutive free/muscle-sparing TRAM and DIEP flaps Peter G. Cordeiro, M.D. performed by two surgeons at a single institution between 2003 and 2005 were Babak J. Mehrara, M.D. reviewed using a prospectively maintained database. The incidence of flap New York, N.Y. complications was compared. Patient demographics, procedure type, diagnosis, adjuvant treatment, and complications were recorded. Outcome variables included total and partial flap loss, infection, seroma, hematoma, wound-healing problems, fat necrosis, and mastectomy flap necrosis. Results: One hundred forty-three patients were treated with 159 free/muscle- sparing TRAM flaps and 41 DIEP flaps. The demographics of the two groups were statistically similar. No statistically significant differences were noted in total or partial flap loss. Conclusions: In the authors’ series, the use of the DIEP flap did not result in more postoperative flap-related complications when compared with the free/ muscle-sparing TRAM flap. Furthermore, no patient characteristics were statistically associated with a more successful result. The authors conclude that in patients whose anatomy reveals perforators of adequate size, the DIEP flap is a safe and reliable procedure for breast reconstruction. (Plast. Reconstr. Surg. 120: 1477, 2007.)

he deep inferior epigastric perforator advantage of potentially restoring cutaneous sen- (DIEP) flap is a major advance in autolo- sation to the breast mound.5–8 Patients treated Tgous tissue breast reconstruction.1–5 By pre- with DIEP breast reconstructions, however, have serving the rectus abdominis muscle and fascia, significantly less postoperative pain and a the DIEP flap has all the advantages of the free shorter hospital stay than TRAM flap patients.9 transverse rectus abdominis myocutaneous Finally, early and late donor-site morbidity may (TRAM) flap yet minimizes the disadvantages. be diminished with DIEP flaps.10–13 Both the TRAM and DIEP flaps have a direct Many surgeons are reluctant to make the tran- blood supply, natural shape, soft consistency, sition to DIEP flap reconstructions because of and long-lasting aesthetic result. By connecting concerns about a higher flap loss rate when com- the sensory branch of the tenth or eleventh in- pared with free/muscle-sparing TRAM flaps. tercostal nerve to the anterior ramus of the lat- The published rates of partial and total flap loss eral branch of the fourth intercostal nerve, both for DIEP flaps range from 2.5 to 8.7 percent and 3,5,14–20 the free TRAM and DIEP flaps also have the 0.5 to 5.0 percent, respectively. The reported rates of partial and total flap loss for From the Plastic and Reconstructive Service, Department of free or muscle-sparing TRAM flaps range from Surgery, Memorial Sloan-Kettering Cancer Center. 2.2 to 7 percent and 0.3 to 3.5 percent, Received for publication June 26, 2006; accepted December respectively.17–19,21,22 In practice, DIEP flap recon- 5, 2006. struction involves a more technically challenging Copyright ©2007 by the American Society of Plastic Surgeons dissection and a learning curve associated with DOI: 10.1097/01.prs.0000288014.76151.f7 perforator selection. Eliminating the muscular

www.PRSJournal.com 1477 Plastic and Reconstructive Surgery • November 2007 component of the TRAM flap reduces the num- detailed chart review and a review of data from our ber of perforators supplying the skin and soft prospectively maintained free flap database were tissue. The DIEP flap typically relies on only one performed for each patient. Risk factors analyzed to four perforating vessels, which would seem to included radiation, prior node dissection, timing make the blood supply to the DIEP flap less than of reconstruction, recipient vessel usage, body that of the free/muscle-sparing TRAM flap.23 mass index, smoking, diabetes mellitus, abdomi- With a presumably decreased blood supply, nal scarring, and cardiovascular disease. Informa- one would expect increased complications, such tion was compiled on the incidence of flap as partial or complete flap failure, venous con- complications following DIEP and free/muscle- gestion, and fat necrosis.18 Indeed, one series of sparing TRAM flaps, including reexplorations, to- 310 breasts reconstructed by a single surgeon did tal and partial flap loss, infection, seroma/hema- report a higher incidence of partial flap loss and toma, minor wound-healing problems, donor-site fat necrosis in DIEP flaps than in free/muscle- sequelae, and mastectomy flap necrosis, using our sparing TRAM flaps, particularly in the early prospectively maintained clinical database. The cases.17 Few studies have directly compared the characteristics of both the free/muscle-sparing rates of complications after DIEP and free or TRAM and DIEP patient populations were com- muscle-sparing TRAM flaps. In 2000, Blondeel et pared to identify any relevant differences between al. reported on the incidence of venous conges- the two groups. An unpaired t test was used to tion and total flap loss in 511 reconstructions.23 determine whether or not there were any differ- In that study, however, the vast majority of DIEP ences between two means, and the Fisher’s exact flaps were performed at one institution (Gent, test was used to determine whether there were Belgium), and all free/muscle-sparing TRAM nonrandom associations between two categorical flaps were performed in the other (Houston, variables. In all statistical analyses, a value of p Ͻ Texas), making direct comparison of flap loss 0.05 was considered significant. This study was rates difficult. In addition, the rate of partial flap approved by the Memorial Sloan-Kettering Can- loss, the incidence of fat necrosis, and wound- cer Center Institutional Review Board. healing complications were not reported.23 Thus, reports in the literature have been in- RESULTS conclusive. In addition, previous studies have not statistically analyzed and compared the rela- Demographics tionship of patient characteristics to outcome. From 2003 to 2005 at Memorial Sloan-Kettering The primary objective of this study was to exam- Cancer Center, 143 patients underwent 200 con- ine immediate postoperative flap complications secutive autologous tissue free flap breast recon- of the DIEP flap when compared with free or structions with either a free/muscle-sparing muscle-sparing TRAM flaps for breast reconstruc- TRAM flap or a DIEP flap. There were 114 patients tion when performed by the same surgeons. In who underwent 159 free/muscle-sparing TRAM addition, we sought to analyze the characteristics flap surgery and 29 patients who underwent 41 of the two patient populations to determine statis- DIEP flap operations. The mean age was 48.6 years tical similarities and differences. Finally, we evalu- [free/muscle-sparing TRAM flap, 48 years (range, ated the relationship of flap complications to 24 to 67 years); DIEP flap, 51 years (range, 35 to known patient risk factors such as smoking, obe- 65 years)]. The mean body mass index was 27.1 sity, diabetes mellitus, prior abdominal surgery, [free/muscle-sparing TRAM flap, 26.9 (range, and radiation therapy. By examining the incidence 18.2 to 42.4); DIEP flap, 28 (range, 20.5 to 36.9)]. of immediate postoperative flap complications, we Among the DIEP flaps, 18 (43.9 percent) were hope to address the safety of the DIEP flap in bilateral; among the free/muscle-sparing TRAM comparison with the free/muscle-sparing TRAM flaps, 60 (37.7 percent) were bilateral. The fol- flap as a practical option for autologous tissue lowing risk factors were analyzed: radiation (free/ breast reconstruction. muscle-sparing TRAM flap, 27 percent; DIEP flap, 22 percent), prior node dissection (free/muscle- PATIENTS AND METHODS sparing TRAM flap, 59.1 percent; DIEP flap, 61 The authors conducted a retrospective review percent), timing of reconstruction (free/muscle- of 200 consecutive autologous tissue free flaps per- sparing TRAM flap, 62.9 percent immediate; DIEP formed between 2003 and 2005 at Memorial flap, 65.9 percent immediate), recipient vessel Sloan-Kettering Cancer Center for breast recon- (free/muscle-sparing TRAM flap, 67.3 percent struction by two surgeons (J.J.D. and B.J.M.). A thoracodorsal; DIEP flap, 9.8 percent thoracodor-

1478 Volume 120, Number 6 • Complications in DIEP and TRAM Flaps

Table 1. Patient Characteristics Free/Muscle-Sparing DIEP p (%) (41 ؍ n) (%) (159 ؍ Patient Characteristics TRAM (n Age, years 0.07* Mean 48 51 Range 24–67 35–65 Body mass index 0.2* Mean 26.9 28 Range 18.2–42.4 20.5–36.9 Bilateral reconstructions 60 (37.7) 18 (43.9) 0.48† Radiation 43 (27) 9 (22) 0.56† Prior node dissection 94 (59.1) 25 (61) 0.86† Immediate reconstruction 100 (62.9) 27 (65.9) 0.48† Thoracodorsal recipient 107 (67.3) 4 (9.8) Ͻ0.05†‡ Tobacco use 19 (11.9) 3 (7.3) 0.57† Diabetes mellitus 4 (2.5) 1 (2.4) 1† Cardiovascular disease 25 (15.7) 8 (19.5) 0.64† Previous abdominal surgery 80 (50.3) 12 (29.3) Ͻ0.05†‡ Systemic disease 22 (13.8) 7 (17.1) 0.61† *Unpaired t-test. †Two-tailed Fisher’s exact test. ‡Statistically significant. sal), smoking (free/muscle-sparing TRAM flap, flap loss in zero (0 percent), infection in one (3.5 11.9 percent; DIEP flap, 7.3 percent), diabetes percent), seroma/hematoma in zero (0 percent), mellitus (free/muscle-sparing TRAM flap, 2.5 per- systemic in zero (0 percent), minor wound-heal- cent; DIEP flap, 2.4 percent), abdominal scarring ing problem in one (3.5 percent), and mastectomy (free/muscle-sparing TRAM flap, 50.3 percent; flap necrosis in two (7 percent). No statistically DIEP flap, 29.3 percent), and cardiovascular dis- significant differences were noted for any com- ease (free/muscle-sparing TRAM flap, 13.8 per- plications, including total or partial flap loss cent; DIEP flap, 17.1 percent). (Table 2). Using an unpaired t test, no statistically significant differences were seen in mean age or body mass index. Fisher’s exact test revealed no statis- DISCUSSION tically significant differences between the two Autologous tissue breast reconstruction is the groups with regard to number of bilateral recon- preferred method of breast reconstruction for structions, radiation, prior lymph node dissection, many women. Until recently, the standard of care timing of surgery, smoking history, diabetes mel- for autologous tissue reconstruction was the pedi- litus, or cardiovascular disease. Thoracodorsal cled or free/muscle-sparing TRAM flap. In 1989, anastomoses were more prevalent in the free/ however, Koshima and Soeda described a method muscle-sparing TRAM flap group, reflecting a bias of harvesting lower abdominal skin and fat without in this center’s early clinical practice. In addition, sacrificing the rectus abdominis muscle, which re- significantly fewer patients undergoing DIEP flap lied on dissecting one or more perforators origi- reconstruction had previous abdominal surgery, nating from the deep inferior epigastric vessels which can influence the ability to identify perforating vessels of adequate size when elevating the Table 2. Complications abdominal flap (Table 1). TRAM Flaps DIEP Flaps *p (%) (41 ؍ n) (%) (159 ؍ Complication (n Complications Total flap loss 1 (0.6) 0 1 Complications for free/muscle-sparing TRAM Partial flap loss 2 (1.3) 0 1 flaps were as follows: total flap loss in one (0.9 Infection 6 (3.8) 1 (2.4) 1 Seroma 12 (7.5) 2 (4.9) 0.74 percent), partial flap loss in one (0.9 percent), Hematoma 11 (6.9) 1 (2.4) 0.47 infection in six (5.3 percent), seromas/hemato- Minor wound-healing mas in 10 (8.8 percent), systemic in two (1.8 per- problems 5 (4.4) 1 (3.5) 1 Fat necrosis 20 (12.8) 5 (12.2) 1 cent), minor wound-healing problems in five (4.4 Mastectomy flap percent), and mastectomy flap necrosis in six (5.3 necrosis 24 (15.1) 6 (14.6) 1 percent). Complications for DIEP flaps were as Systemic 2 (1.3) 0 1 follows: total flap loss in zero (0 percent), partial *Two-tailed Fisher’s exact test.

1479 Plastic and Reconstructive Surgery • November 2007 and traversing the muscle.24 Since that time, nu- supports our findings, as it also found no increase merous surgeons have advocated the use of the in fat necrosis or other complications in this pa- DIEP flap over muscle-sparing or free/muscle- tient population.14 In part, the success of the DIEP sparing TRAM flaps.1–5,10,25 flap in overweight patients may have been because Perhaps the most compelling reason to make zone IV was always resected in unilateral DIEP the transition to the DIEP flap is the potential for flaps, and only zones I and III were used in bilat- lower abdominal wall morbidity. Given the choice, eral DIEP flaps.14 a patient may intuitively prefer the preservation of In our series, one significant difference be- her rectus abdominis muscle. In part, this patient tween the DIEP flap and free/muscle-sparing preference is supported by data. Although mul- TRAM flap patients was that fewer DIEP flap pa- tiple studies have not been able to definitively tients had a history of previous abdominal surgery. demonstrate a reduced incidence of donor-site Scarring can make it more difficult to identify morbidity with regard to hernia, bulge, or func- perforators, and our data likely reflect this sur- tional outcome,10–13 pain and hospital stay have geon bias. Some surgeons have argued, however, been shown to be lower among DIEP flap pa- that a medial abdominal scar may actually facili- tients than among free/muscle-sparing TRAM tate the dissection of the medial perforators.31 Fur- flap patients.9,26–28 Thus, the use of perforator thermore, a midline scar can help preserve the flaps for breast reconstruction has gained cau- option of using the contralateral side as a free/ tious acceptance. muscle-sparing TRAM flap if problems arise dur- A recent article from M. D. Anderson Cancer ing flap dissection.31 It is possible that this differ- Center compares donor-site morbidity in 48 DIEP ence was responsible for the trend toward higher flaps and 155 muscle-sparing TRAM flaps.29 The wound-healing complications that was noted in the authors noted no difference in donor-site mor- free/muscle-sparing TRAM flap groups as com- bidity, and recommend the DIEP flap when one or pared with the DIEP flap patients. more perforators arise from the same intermus- Our main selection criterion for the DIEP flap cular septum, and a muscle-sparing TRAM flap was the ability to identify at least one perforator in when two or more arise from different intermus- each flap that was of sufficient size to maintain cular septi. Although there was no statistically sig- adequate perfusion to the skin paddle. Specifi- nificant difference between the two groups in cally, the perforating vessels needed to have a pal- rates of emergency reoperation, partial flap loss, pable pulse and a vein that was at least 1.5 mm in or fat necrosis, there was a trend (p ϭ 0.06) toward diameter. One technique to assess flap viability was higher total flap loss in the DIEP flap group, which to selectively occlude perforators with microvas- was not observed in our study. cular clamps. Temporary occlusion helped to de- The greatest barrier to using the DIEP flap for lineate regions of the flap that would or would not breast reconstruction is a lack of confidence in be perfused if the occluded perforators were sac- providing an adequate blood supply for a large rificed. Although without objective data, this was amount of flap tissue using a single perforator with a potentially valuable technique that aided in per- vessels 1 mm in diameter or smaller.30 In making forator selection. In general, if no dominant per- the transition to the DIEP flap, proper patient forators were identified or if more than four iden- selection is crucial to maximize chances of suc- tical perforators were present, a muscle-sparing cess. The ideal patient is a young, nonsmoking TRAM flap was performed. woman; thin or of normal habitus; without diabe- Other selection criteria, such as prior irradi- tes mellitus or cardiovascular disease (including ation, prior node dissection, timing of reconstruc- hypertension).31 In our series, when looking at tion, recipient vessel, body mass index/obesity, most patient characteristics, there were no statis- smoking history, diabetes mellitus, abdominal tically significant differences between the free/ scarring, and cardiovascular disease, were consid- muscle-sparing TRAM and the DIEP flap patients. ered before surgery but were not the basis for If anything, there was a trend toward older, determining whether a patient was to undergo heavier women with a higher prevalence of car- DIEP or a free/muscle-sparing TRAM flap breast diovascular disease among the DIEP flap patients. reconstruction. Instead, all patients signed a Despite the less favorable patient characteristics of surgical consent to undergo either a DIEP or the DIEP flap patient, however, there was no sig- free/muscle-sparing TRAM flap procedure, nificant difference in flap complication rates. In- with the understanding that a free DIEP flap terestingly, one study examining the use of the would be performed if adequate perforators DIEP flap among overweight and obese patients could be identified.

1480 Volume 120, Number 6 • Complications in DIEP and TRAM Flaps

CONCLUSIONS 9. Kroll, S. S., Sharma, S., Koutz, C., et al. Postoperative morphine requirements of free TRAM and DIEP flaps. Plast. In our experience, the DIEP flap has been a Reconstr. Surg. 107: 338, 2001. valuable reconstructive option for breast cancer 10. Blondeel, N., Vanderstraeten, G. G., Monstrey, S. J., et al. The patients. In comparing two statistically similar pa- donor site morbidity of free DIEP flaps and free TRAM flaps tient populations, we found that the use of the for breast reconstruction. Br. J. Plast. Surg. 50: 322, 1997. DIEP flap did not result in more postoperative 11. Bottero, L., Lefaucheur, J. P., Fadhul, S., Raulo, Y., Collins, E. D., and Lantieri, L. Electromyographic assessment of rec- flap-related complications when compared with tus abdominis muscle function after deep inferior epigastric the free/muscle-sparing TRAM flap. This was true perforator flap surgery. Plast. Reconstr. Surg. 113: 156, 2004. even though the DIEP flap patients exhibited a 12. Futter, C. M., Webster, M. H., Hagen, S., and Mitchell, S. L. trend toward less favorable patient characteristics A retrospective comparison of abdominal muscle strength with regard to age, body mass index, and cardio- following breast reconstruction with a free TRAM or DIEP flap. Br. J. Plast. Surg. 53: 578, 2000. vascular health status. Both DIEP and free/mus- 13. Futter, C. M., Weiler-Mithoff, E., Hagen, S., et al. Do pre- cle-sparing TRAM flap patients underwent a sim- operative abdominal exercises prevent post-operative donor ilar selection process. The main differentiating site complications for women undergoing DIEP flap breast criterion for the DIEP flap was the ability to iden- reconstruction? A two-centre, prospective randomised con- tify at least one perforator in each flap that was of trolled trial. Br. J. Plast. Surg. 56: 674, 2003. 14. Garvey, P. B., Buchel, E. W., Pockaj, B. A., Gray, R. J., and sufficient size to maintain adequate perfusion to Samson, T. D. The deep inferior epigastric perforator flap for the skin paddle. Thus, in the patient whose anat- breast reconstruction in overweight and obese patients. Plast. omy reveals perforators of adequate size, we con- Reconstr. Surg. 115: 447, 2005. clude that the DIEP flap is a safe and reliable 15. Hamdi, M., Weiler-Mithoff, E. M., and Webster, M. H. Deep procedure for breast reconstruction. inferior epigastric perforator flap in breast reconstruction: Experience with the first 50 flaps. Plast. Reconstr. Surg. 103: 86, Babak J. Mehrara, M.D. 1999. Plastic and Reconstructive Service 16. Keller, A. The deep inferior epigastric perforator free flap for Department of Surgery breast reconstruction. Ann. Plast. Surg. 46: 474, 2001. Memorial Sloan-Kettering Cancer Center 17. Kroll, S. S. Fat necrosis in free transverse rectus abdominis 1275 York Avenue myocutaneous and deep inferior epigastric perforator flaps. New York, N.Y. 10021 Plast. Reconstr. Surg. 106: 576, 2000. [email protected] 18. Nahabedian, M. Y., Tsangaris, T., and Momen, B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: Is there a difference? Plast. Reconstr. DISCLOSURES Surg. 115: 436, 2005. 19. Nahabedian, M. Y., Momen, B., Galdino, G., and Manson, P. None of the authors has any interest or commercial N. Breast reconstruction with the free TRAM or DIEP flap: association with information submitted in article. Patient selection, choice of flap, and outcome. Plast. Reconstr. Surg. 110: 466, 2002. 20. Scheer, A. S., Novak, C. B., Neligan, P. C., and Lipa, J. E. REFERENCES Complications associated with breast reconstruction using a 1. Allen, R. J. DIEP versus TRAM for breast reconstruction. perforator flap compared with a free TRAM flap. Ann. Plast. Plast. Reconstr. Surg. 111: 2478, 2003. Surg. 56: 355, 2006. 2. Allen, R. J., and Heitmann, C. Perforator flaps: The history 21. Schusterman, M. A., Kroll, S. S., Miller, M. J., et al. The free of evolution. Handchir. Mikrochir. Plast. Chir. 34: 216, 2002. transverse rectus abdominis musculocutaneous flap for 3. Gill, P. S., Hunt, J. P., Guerra, A. B., et al. A 10-year retro- breast reconstruction: One center’s experience with 211 con- spective review of 758 DIEP flaps for breast reconstruction. secutive cases. Ann. Plast. Surg. 32: 234, 1994. Plast. Reconstr. Surg. 113: 1153, 2004. 22. Mehrara, B. J., Santoro, T. D., Arcilla, E., Watson, J. P., Shaw, 4. Guerra, A. B., Metzinger, S. E., Bidros, R. S., et al. Bilateral W. W., and Da Lio, A. L. Complications after microvascular breast reconstruction with the deep inferior epigastric per- breast reconstruction: Experience with 1195 flaps. Plast. Re- forator (DIEP) flap: An experience with 280 flaps. Ann. Plast. constr. Surg. 118: 1100, 2006. Surg. 52: 246, 2004. 23. Blondeel, P. N., Arnstein, M., Verstraete, K., et al. Venous 5. Blondeel, P. N. One hundred free DIEP flap breast recon- congestion and blood flow in free transverse rectus abdo- structions: A personal experience. Br. J. Plast. Surg. 52: 104, minis myocutaneous and deep inferior epigastric perforator 1999. flaps. Plast. Reconstr. Surg. 106: 1295, 2000. 6. Blondeel, P. N., Demuynck, M., Mete, D., et al. Sensory nerve 24. Koshima, I., and Soeda, S. Inferior epigastric artery skin flaps repair in perforator flaps for autologous breast reconstruc- without rectus abdominis muscle. Br. J. Plast. Surg. 42: 645, tion: Sensational or senseless? Br. J. Plast. Surg. 52: 37, 1999. 1989. 7. Yap, L. H., Whiten, S. C., Forster, A., and Stevenson, J. H. The 25. Allen, R. J. Comparison of the costs of DIEP and TRAM flaps. anatomical and neurophysiological basis of the sensate free Plast. Reconstr. Surg. 108: 2165, 2001. TRAM and DIEP flaps. Br. J. Plast. Surg. 55: 35, 2002. 26. Kroll, S. S., Reece, G. P., Miller, M. J., et al. Comparison of 8. Temple, C. L., Tse, R., Bettger-Hahn, M., MacDermid, J., cost for DIEP and free TRAM flap breast reconstructions. Gan, B. S., and Ross, D. C. Sensibility following innervated Plast. Reconstr. Surg. 107: 1413, 2001. free TRAM flap for breast reconstruction. Plast. Reconstr. 27. Thoma, A., Veltri, K., Khuthaila, D., Rockwell, G., and Duku, Surg. 117: 2119, 2006. E. Comparison of the deep inferior epigastric perforator flap

1481 Plastic and Reconstructive Surgery • November 2007

and free transverse rectus abdominis myocutaneous flap in muscle-sparing TRAM flap and free DIEP flap breast recon- postmastectomy reconstruction: A cost-effectiveness analysis. struction. Plast. Reconstr. Surg. 117: 737, 2006. Plast. Reconstr. Surg. 113: 1650, 2004. 30. Vesely, J., Stupka, I., Drazan, L., Holusa, P., Licata, P., and 28. Kaplan, J. L., and Allen, R. J. Cost-based comparison between Corradini, B. DIEP flap breast reconstruction: New experi- perforator flaps and TRAM flaps for breast reconstruction. ence. Acta Chir. Plast. 43: 3, 2001. Plast. Reconstr. Surg. 105: 943, 2000. 31. Garcia-Tutor, E., and Murillo, J. The ideal patient for the first 29. Bajaj, A. K., Chevray, P. M., and Chang, D. W. Comparison breast reconstruction using a DIEP flap. Plast. Reconstr. Surg. of donor-site complications and functional outcomes in free 111: 947, 2003.

1482 IDEAS AND INNOVATIONS

Correction of Inverted Nipples by Strong Suspension with Areola-Based Dermal Flaps

Jin Sik Burm, M.D., Ph.D. Yang Woo Kim, M.D., Ph.D. Seoul, Korea

he goal of inverted nipple correction is and below). The short diagonal of each quadrangle both aesthetically satisfactory projection of lies on the circle line of the nipple neck and mea- Tthe nipple and functional preservation of sures 7 to 8 mm in moderate cases and 4 to 5 mm the lactiferous ducts. To achieve this outcome, in severe cases. The tip of the areolar part is kept many surgeons1–7 have used areolar dermal flap within the areolar margin, and the tip of the nipple techniques that add bulk or struts underneath part is kept within the dome margin of the nipple. the nipple and tighten the nipple neck. How- After applying local anesthesia, the quadran- ever, the base of these flaps is placed at the gles are deepithelialized. Full-thickness skin inci- nipple neck, which cannot provide a rigid, im- sions are made on two sides of the nipple part and mobile fulcrum. If the nipple neck is not recon- on one side of the areolar part. Diamond-shaped structed tightly, these flaps can be pulled down dermal flaps are raised with a pedicle on one side simultaneously with the nipple because of scar- of the areolar part. A subcutaneous tunnel is made ring or retraction forces. Consequently, these under the nipple by repeated vertical splitting and techniques have a risk of nipple inversion or stretching maneuvers with fine dissecting scissors, flattening recurrence, especially in severely in- crossing over the lactiferous ducts to the opposite verted nipples (Fig. 1, above), indicating the side. The periductal fibrous tissues and lactiferous need for a stronger supporting system. ducts are released until the nipple is able to re- If the bases of the dermal flaps are placed on main everted without traction but without cutting the areola and thereby supported by the com- all the ducts. A 5-0 nylon suture is placed onto the pact subcutaneous tissue and the mammary tip of the dermal flap. The tip of the flap is gland, these flaps may strongly resist scarring turned down and pulled out through the tunnel and retraction forces and may support the nip- to the opposite side and sutured at the areolar ple more effectively (Fig. 1, below). In this article, dermis of the base of the opposite flap. This we present a strong nipple suspension technique results in the nipple being supported by two or using areola-based dermal flaps for correcting four areola-based dermal flaps with each of the moderately and severely inverted nipples. two rigid areolar fulcrums. The donor sites are closed in two layers, and the traction suture is PATIENTS AND METHODS removed from the nipple, with no application of nipple traction splinting. A donut-type pad The nipple is pulled out by gentle traction with dressing is applied for 2 to 3 months postoper- a hook or stay suture after injecting a small atively to avoid nipple compression. amount of lidocaine into the nipple apex. The dome margin and neck of the nipple are marked as two concentric circles. In moderately inverted RESULTS nipples, two diamond-shaped quadrangles are We performed the above procedure on 28 nip- marked at the 3- and 9-o’clock positions (Fig. 2, ples in 17 patients, 19 with moderately inverted nip- above and second row), whereas four quadrangles ples and nine with severely inverted nipples. There are marked at the 3-, 6-, 9-, and 12-o’clock posi- were two cases of acquired unilateral inverted nipple tions in severely inverted nipples (Fig. 2, third row caused by severe fibrosis after periductal mastitis. The patients were 21 to 39 years of age. From the Department of Plastic and Reconstructive Surgery, There were no surgical complications such as School of Medicine, Ewha Womans University. traction pain, infection, hematoma, permanent Received for publication December 16, 2006; accepted Feb- numbness, or skin necrosis. Follow-up examinations ruary 9, 2007. were performed at 3 to 8 months (average, 6.3 Copyright ©2007 by the American Society of Plastic Surgeons months) and revealed no evidence of recurring in- DOI: 10.1097/01.prs.0000282028.29647.ad version or nipple tilting. Most cases (27 nipples),

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Fig. 1. Differences in long-term support of the corrected inverted nipple between techniques using nipple-based areolar dermal flaps (above) and areola-based nipple dermal flaps (below). (Above) Areolar dermal flaps can be pulled down by postoperative retraction forces, which can result in recurrence of inversion. (Below) Nipple dermal flaps support the nipple effectively because they are strongly attached to the areola. This results in minimal relapse and no recurrence of inversion.

Fig.2. Schematicdiagramsofnipplesuspensionwithtwoareola-baseddermalflapsforcorrecting a moderately inverted nipple (A) and with four dermal flaps for correcting a severely inverted nipple (B). (Top two rows, left and center) Design and deepithelialization of two or four diamond-shaped areas. (Top two rows, right) Elevation of nipple dermal flaps based on the areola, followed by sufficient release of lactiferous ducts and formation of subcutaneous tunnels under the nipple. (Bottom two rows, left and center) The flap tip is sutured to the areolar dermis of the opposite flap and interposed. (Bottom two rows, right) Closure of donor site.

1484 Volume 120, Number 6 • Correction of Inverted Nipples

Fig. 3. (Left) Bilateral moderately inverted nipples. (Right) Six months after nipple suspension with two areola-based dermal ﬂaps. even one of severe inversion after mastitis, exhibited DISCUSSION excellent aesthetic projection (Figs. 3 and 4). Un- The primary aesthetic goal of corrective sur- satisfactory aesthetic projection occurred in one case gery for the inverted nipple is sufficient nipple of moderate inversion caused by early bra wearing projection. The most common surgical technique without nipple protection. involves sufficiently releasing the lactiferous ducts

Fig.4. (Above,left)Bilateralseverelyinvertednipple.(Above,right)Sixmonthsafternipplesuspensionwithfourareola-baseddermal ﬂaps. (Below, left) Very severely inverted nipple caused by periductal mastitis in another patient. (Below, right) Three months after surgery.

1485 Plastic and Reconstructive Surgery • November 2007 under the nipple, adequately supporting the nip- amond-shaped dermal flaps are raised with an ple by adding bulk or struts beneath the nipple, areolar pedicle, and these tips are turned down and tightening the nipple neck.1–7 through the formed tunnels and sutured at the Many surgeons3–7 cut the lactiferous ducts in se- opposite areolar dermis. There was no evidence of verely inverted nipples to sufficiently release the recurring inversion or complications. Moreover, ducts. The nipple is innervated from the lateral cu- most of the cases exhibited excellent postopera- taneous branches of the fourth intercostal nerve,8 tive aesthetic projection of the nipple, even in very which is present along the major duct system.9 severely inverted nipples. This technique involv- Therefore, the lactiferous ducts should be preserved ing a strong suspension system with areolar ful- to maximize nipple sensation (sexual pleasure) and crums allows all types of inverted nipples to be to facilitate breastfeeding. We also never cut the corrected while preserving the lactiferous ducts. ducts, even in cases of severely inverted nipples. Jin Sik Burm, M.D., Ph.D. Our nipple suspension technique using areola- Department of Plastic and Reconstructive Surgery based dermal flaps is analogous to a suspension Ewha Womans University School of Medicine bridge or hammock. To ensure a suspension bridge 911-1 Mok-Dong will not collapse, its suspending ropes must be tightly Yangcheon-Gu, Seoul 158-710, Korea attached on strong and immobile pillars to over- [email protected] come traction forces. The bases of our dermal flaps are arranged vertically from the nipple neck to the DISCLOSURE areolar margin and thus are attached to the areola Neither of the authors has received any financial as a strong pillar (Fig. 1, below). In addition, two or support or benefits pertaining to the study. four layers of dermal bands support the corrected nipple in a criss-cross pattern. Thus, this technique REFERENCES uses a suspension system that is stronger than the 1. Lee, H. -B., Roh, T. -S., Chung, Y. -K., et al. Correction traditional nipple-based dermal flap techniques. of inverted nipple using strut reinforcement with deepi- Our technique can be applied in all types of thelialized triangular flaps. Plast. Reconstr. Surg. 102: 1253, inverted nipples. The type of flap is easily chosen 2000. 2. Kim, J. T., Lim, Y. S., and Oh, J. G. Correction of inverted based on the degree of nipple inversion, and the nipples with twisting and locking principles. Plast. Reconstr. designs are simple. A wide operative field from Surg. 118: 1526, 2006. the nipple to the areola facilitates easy, conve- 3. Teimourian, B., and Adham, M. N. Simple technique for nient, and accurate surgical procedures. No spe- correction of inverted nipple. Plast. Reconstr. Surg. 65: 504, cial dressing or postoperative traction suture is 1980. 4. Yanai, A., Okabe, K., and Tanaka, H. Correction of the in- required because of the strong suspension sys- verted nipple. Aesthetic Plast. Surg. 10: 51, 1986. tem, which improves postoperative patient com- 5. Han, S., and Hong, Y. G. The inverted nipple: Its grading fort. Extreme tightening of the nipple neck is and surgical correction. Plast. Reconstr. Surg. 104: 389, 1999. not required, which reduces complications. Fur- 6. Kim, D. Y., Jeong, E. C., Eo, S. R., et al. Correction of inverted thermore, our technique can be used to reduce nipple: An alternative method using two triangular areolar dermal flaps. Ann. Plast. Surg. 51: 636, 2003. the size of the nipple by reducing the nipple 7. Lee, K. Y., and Cho, B. C. Surgical correction of inverted trunk with flap elevation, which provides excel- nipples using the modified Namba or Teimourian technique. lent nipple contour and projection. Plast. Reconstr. Surg. 113: 328, 2004. 8. Schlenz, I., Kuzbari, R., Gruber, H., et al. The sensitivity of the CONCLUSIONS nipple-areola complex: An anatomic study. Plast. Reconstr. Surg. 105: 905, 2000. We have developed a nipple suspension tech- 9. Montagna, W., and McPherson, E. E. Some neglected as- nique using areola-based dermal flaps for correct- pects of the anatomy of human breasts. J. Invest. Dermatol. ing moderately and severely inverted nipples. Di- 63: 10, 1974.

1486 EXPERIMENTAL

Norian Craniofacial Repair System: Compatibility with Resorbable and Nonresorbable Plating Materials

David G. Genecov, M.D. Background: Choice of bone replacement materials is important when recon- Michael Kremer, M.D. structing large craniofacial defects. Hydroxyapatite cements are often used for Rajiv Agarwal, M.D. such reconstructions. Recent advances in the development of these cements Kenneth E. Salyer, M.D. have produced locally applied, in situ hardening materials excellent for use in C. Raul Barcelo, M.D. craniofacial defects. To date, there has been a paucity of data comparing the use Harold M. Aberman, of calcium phosphate cements in combination with titanium or resorbable D.V.M., M.S.E. plating systems and their combined biocompatibility. An experimental dog Lynne A. Opperman, Ph.D. model was used to compare these systems. ϫ Dallas, Texas; and West Chester, Pa. Methods: Two 4 4-cm calvarial defects were created in each of 18 mongrel dogs, and defects were reconstructed with calcium phosphate cement with either titanium or resorbable mesh sheets to evaluate their interaction. Spec- imens were harvested and evaluated histologically for the development of new bone formation at 3, 6, and 12 months. Results: At 3 months, no differences were noted in the amount of bone formed between titanium and resorbable plating. By 6 months, the resorbable mesh sheet showed delayed bone formation compared with the titanium mesh. At 12 months, bone formation over the resorbable mesh accelerated to be no different from the titanium mesh. Importantly, new bone formation was seen within the monocalcium phosphate cement Norian Craniofacial Repair System on a reliable basis, regardless of mesh plate used. Conclusions: There are no long-term adverse effects with the use of Norian cement with either titanium or resorbable mesh. However, further studies need to be conducted to determine why there is an arrested healing phase between 3 and 6 months with the Norian cement and resorbable plating materials. (Plast. Reconstr. Surg. 120: 1487, 2007.)

here is still great difficulty associated with mities. The preferred method for the repair of finding sufficient material with which to close bone defects is still autograft.3–7 Free vascularized Tlarge bone defects.1,2 Having a choice of a grafts are routinely used, with satisfactory results.8 variety of well-tested bone repair materials is of vital However, allograft is still required for larger importance when reconstructing structural cranio- defects.9–26 Currently, several different methods facial defects associated with congenital malforma- and a variety of materials are used to fill large tions, oncologic surgery, and posttraumatic defor- defects. These include the use of preformed grafts from porcine or bovine tissues,27 hydroxyapatite,28,29 From the International Craniofacial Institute, Cleft Lip and and coral.30,31 Calcium phosphate cements are Palate Treatment Center, Medical City; Synthes, Inc.; and the second generation of hydroxyapatite bone Texas A&M University System Health Science Center, Bay- substitutes. In the United States, at least four lor College of Dentistry. Received for publication January 17, 2006; accepted February U.S. Food and Drug Administration–approved 8, 2006. calcium phosphate cements have been devel- Presented in part at the Tenth International Congress of the oped for clinical use. More recently, chemically International Society of Craniofacial Surgery, in Monterrey, stable, monocalcium phosphate bone cement, California, September 21 through 24, 2003. Norian Craniofacial Repair System (Synthes Copyright ©2007 by the American Society of Plastic Surgeons Maxillofacial, West Chester, Pa.), has been used DOI: 10.1097/01.prs.0000282034.07517.cc for surgical repair of bone defects.32–35

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When encountering large calvarial defects, physicians have noted that repair material must be supported by a framework of titanium or resorbable plates and screws as a scaffolding to keep the material from fracturing because of continued brain pulsations.36 Chemical compatibility of the repair material with resorbable mesh and screws is being studied, and initial observations indicate that resorbable polylactic acid mesh may work better than polylactic acid membranes in supporting bioactive ␤-tricalcium phosphate.37 It has yet to be determined whether polylactic acid mesh is more efficient than titanium mesh in stabilizing calcium phosphate cements. This study was aimed at evaluating the interactions between the acidic chemical Fig. 1. Intraoperative photograph showing the size of the dual breakdown products from polylactic acid– calvarial defects on either side of the sagittal suture. The defect derived fixation materials and the Norian on the left has a titanium mesh plate ﬁxed in place, and on the Craniofacial Repair System. The biocompatibil- right, there is a resorbable mesh plate. The Norian Craniofacial ity and effectiveness of this combination of ma- Repair System cement appears as a white paste packed on top of terials will be compared with the Norian cement the mesh plates. stabilized with titanium mesh in an experimental canine model.

MATERIALS AND METHODS Animals and Surgical Procedures Eighteen adult male mongrel dogs with an average weight of 29 kg (range, 23 to 34 kg) were used in this study. All animal care procedures and aseptic operations were performed in accordance with the requirements of the Institutional Animal Care and Use Committee at Medical City, which follow the guidelines for animal care stipulated by the National Institutes of Health. All animals received gentamicin preoperatively and postoperatively, 4 mg/kg subcutaneously twice daily, starting on the day of surgery and continuing until Fig. 2. Diagram showing the calvarial defects with metal and 10 days postoperatively. Anesthesia was induced resorbable plates surrounded by host bone. The positions of the with propofol, 4 to 8 mg/kg intravenously, and cuts to create four equal-sized blocks are shown as dashed lines. animals were then intubated and anesthesia main- Solidlinesshowthepositionofthesixcutsusedtocreatethethick tained with isoflurane and oxygen. This was fol- undecalciﬁed sections for histomorphometry. lowed by administration of a one-time dose of glycopyrrolate (0.02 mg/kg) and the creation of bilateral 4 ϫ 4-cm (16 cm2) craniectomies using all edges of the defect. Once the trays were fixated, aseptic technique (Figs. 1 and 2). Control defects 8 ml of Norian cement for each defect was pre- were repaired with titanium 2.0-mm mesh sheets pared according to the directions for use. Enough and screws (Synthes Maxillofacial). The experi- of the material was placed within each defect to fill mental side was repaired with resorbable 2.0-mm the craniectomy flush with the periosteal surface, mesh sheets and screws (Synthes Maxillofacial). and the calcium phosphate cement was allowed to The mesh plates were prepared such that they set (Fig. 1). Once the Norian cement set (approx- fitted the defect exactly and the edges of the mesh imately 10 minutes after application), the wounds were parallel to the edges of the craniectomies, were closed. Buprenorphine (0.005 mg/kg sub- and a perpendicular flap was created to allow for cutaneously twice daily) was given for pain imme- screw placement. The mesh sheets were secured to diately postoperatively and then twice the follow-

1488 Volume 120, Number 6 • Norian Craniofacial Repair System ing day. The animals were transferred to the acute straight edges, butted up against blue-stained soft care facility at Medical City, where they were al- tissue. The specimens were measured under a lowed to recover for 7 days, and then they were 20-␮m gridded graticule in a 10ϫ magnification transferred to a long-term laboratory animal hous- eyepiece (Edmund Industrial Optics, Barrington, ing facility until they were euthanized for evalua- N.J.). New bone growth was evaluated and the tion. The animals were divided into three groups thickness measured at the junction of the calcium of six dogs each. The first group was euthanized at phosphate cement, plating material, and native 3 months, the second at 6 months, and the third bone (Fig. 3). Scores for new bone growth were at 12 months after surgery. All animals were eu- given for both the dural and the periosteal sides thanized by administration of 10 ml of 390 mg/ml of the calvarial specimens. For these evaluations, of sodium pentobarbital intravenously (120 mg/kg) three separate reviewers scored the specimens. according to American Veterinary Medical Asso- 38 ciation guidelines. Statistical Analysis Results were tabulated and expressed in mil- Ϯ Tissue Collection and Data Analysis limeters as the mean SD. Statistical analysis was After gross examination of the surgical site performed on all groups with intergroup compar- and removal of the overlying scalp, the defects isons using a one-way analysis of variance with Tukey-Kramer post hoc test for significance at were photographed. Inflammatory changes in all ␣ groups were subjectively reported. The calvariae each time point. An level of 0.05 or less was were then removed en bloc from the dogs and considered significant. Analysis of variance as- placed in 10% buffered formalin. After a week of sumes that the sample population is normally dis- fixation, each calvaria was cut in half in a sagittal tributed, has equal variance, and is mutually in- plane, and each half was then cut into four equal- dependent. As the defects were discrete from each sized blocks (Fig. 2). Each block was embedded in other with no potential for or evidence of cross- methylmethacrylate, with the surface showing the over effects, the treatment given to each defect was greatest bone/mesh sheet contact area presented mutually independent. Inflammatory changes in all groups were analyzed using chi-square evalua- for sectioning. Six thick sections were cut from ␣ each specimen with an IsoMet low-speed saw tion, and an level of 0.05 or less was considered (Buehler, Ltd., Lake Bluff, Ill.). Each thick section significant. was then ground down and the ground sections stained with methylene blue to reveal soft tissues, RESULTS and with van Gieson picrofuchsin to reveal min- All 18 animals survived their respective time- eralized tissue. Under the microscope, titanium lines. In the 3-month group, one animal devel- mesh appeared black, whereas the resorbable oped an open fistula on the experimental side, mesh appeared as unstained blank areas with and one other animal developed cellulitis over the

Fig. 3. Diagrams showing the measurement of maximum bone thickness on the periosteal and dural surfaces of the defects. The plate is shown as a thick black line, with new bone outlined in gray. Arrows show the position of the measurements.

1489 Plastic and Reconstructive Surgery • November 2007 incision site that was treated with oral antibiotics. calvariae from the remaining 15 animals, five in The animal with the draining fistula was noted to each group, were examined histologically. This have complete separation between the Norian ce- represented a total of 30 specimens, 15 with tita- ment and the resorbable mesh at necropsy. Two nium and 15 with resorbable mesh. animals in the 6-month group also developed localized skin infections over the incision site and were treated with oral antibiotics until necropsy. 3-Month Animals One animal in the 12-month group was treated for Gross analysis of the craniectomies at 3 a chronic surgical site infection. Overall, this rep- months after surgery showed integration of the resented a 22.5 percent infection rate. newly formed bone to the edges of the defect (Fig. During processing of the specimens after nec- 4). The periosteal surface showed no gross differ- ropsy, the calvaria from one animal in each group ences in the Norian cement overlying either the did not appear on gross examination to have titanium or resorbable mesh sheet. In those spec- enough reliable bone to be graded. The calvariae imens where the dura mater was still intact after were from the 3-month animal with the fistula and resection, good association of the dura with the one animal each in the 6-month group and the overlying materials was observed in all groups. On 12-month group with infection. These three ani- gross manipulation, the resorbable mesh was non- mals were removed from histologic analysis. The malleable in all cases.

Fig. 4. Defects at tissue harvest at 3 months. (Above, left) Periosteal view in situ, with the position of the defects indicated by arrows.(Above, right) Defect repaired with titanium mesh, with periosteum reﬂected to show Norian cement within the mesh grid. (Below, left) Endocranial view of calvaria showing close attachment of dura mater to the Norian cement and mesh in both defects. Arrows indicate the border of each defect. (Below, right) Defect repaired with resorbable mesh, showing Norian cement within the intact mesh grid.

1490 Volume 120, Number 6 • Norian Craniofacial Repair System

Table 1. Analysis of Bone Measurements Time Plate Dural Measurement (mm ؎ SD) p Periosteal measurement (mm ؎ SD) p 3 months Titanium 0.47 Ϯ 0.63 NS 0.18 Ϯ 0.2 NS Resorbable 0.44 Ϯ 0.74 0.17 Ϯ 0.13 6 months Titanium 1.57 Ϯ 0.92 Ͻ0.001 0.35 Ϯ 0.35 NS Resorbable 0.30 Ϯ 0.39 0.15 Ϯ 0.08 12 months Titanium 0.88 Ϯ 0.23 NS 0.22 Ϯ 0.22 NS Resorbable 1.07 Ϯ 0.4 0.46 Ϯ 0.28 NS, not significant.

The histomorphometric measurements of the group and no different from the measurements thickness of the bone along the dural surface were for the resorbable mesh group (0.17 Ϯ 0.13 mm). 0.47 Ϯ 0.63 mm for the craniectomies fixed with the titanium mesh and 0.44 Ϯ 0.74 mm for the craniectomies fixed with the resorbable mesh (Ta- 6-Month Animals ble 1). This difference was not significant. Mea- Gross analysis of the craniectomies at 6 months surements of bone thickness on the periosteal sur- after surgery showed integration of the newly face were 0.18 Ϯ 0.2 mm for the titanium mesh formed bone to the edges of the defect (Fig. 5). The

Fig. 5. Defects at tissue harvest at 6 months. (Left) Intracranial view, showing close association of the dura mater withthedefects.Atearinthedurainthedefectontheleftwascreatedduringremovalofthecalvaria.(Above,right) Defect repaired with titanium mesh, with periosteum reﬂected. Note the large amount of intact Norian cement within the mesh. (Below, right) Defect repaired with resorbable mesh. Note the Norian cement broken into pieces and the transparent appearance of the resorbable mesh.

1491 Plastic and Reconstructive Surgery • November 2007

Norian cement was present in both the titanium DISCUSSION and resorbable mesh–repaired defects. However, When repairing large calvarial defects, two ma- the Norian cement in the resorbable mesh group jor issues must be addressed when looking for was less intact than that seen at 3 months, and the repair materials. First, materials need to be chosen mesh had a more transparent appearance. In the that will result in sufficient bone formation to specimens where the dura mater was intact after cover the defect. Second, although not less im- resection, good association of the dura with the portant, it is necessary to choose materials based overlying materials was observed in all groups. on how soon they have to be load bearing (or at This is also similar to the findings for the 3-month least resistant to deformation). When very large group. However, on gross manipulation, the defects need filling, bone void fillers are re- resorbable mesh was becoming malleable in all quired, and several calcium phosphate cements cases. have been used. These materials are biocompat- The histomorphometric measurements of ible and osteoconductive.34,39 However, these ma- bone thickness at the dural surface were 1.57 Ϯ terials were prone to fracturing and required a 0.92 mm for the titanium mesh group and 0.3 Ϯ supporting framework to stabilize the material in 0.35 mm for the resorbable mesh group (Table 1). the defect.36 The advantage of using titanium This difference was significant (p Ͻ 0.001). The mesh for support is that they provide immediate bone thickness at the periosteal surface was 0.35 Ϯ and permanent stability, are osteoconductive, and 0.35 mm for the titanium mesh group and 0.15 Ϯ become osseointegrated into the new bone. One 0.08 mm for the resorbable mesh group, a differ- problem is that the mesh will not alter shape, ence that was not significant. which is a disadvantage in situations where bone remodeling will occur, as in growing skulls of young children. This requires surgical removal of 12-Month Animals the titanium mesh. More recently, several resorb- Gross analysis of the craniectomies at 12 able polylactic acid plating materials have become months revealed good integration of the newly available. These meshes have the advantage of providing good scaffolding and early stiffness and formed bone with the host bone in both the tita- do not need to be removed. However, there are nium and resorbable mesh groups. The appear- indications that breakdown of these resorbable ance of the Norian cement and mesh appeared materials may be inhibitory to bone formation, similar to that described for the 6-month group and they may not provide long-term stability to the (not shown). On gross manipulation, the resorb- healing defect.36,40–45 able mesh appeared more malleable than it did at The present study compared the amount of 6 months. Good contact between new bone and bone formation occurring when resorbable or ti- titanium, and new bone and Norian cement was tanium mesh was used to stabilize monocalcium noted in the titanium mesh group (Fig. 6). How- phosphate bone cement (Norian Craniofacial Re- ever, in the resorbable mesh group, new bone did pair System). Bone healing was compared by his- not make contact with the resorbable mesh, and tomorphometric analysis, and mesh stability was was only found in direct contact with the Norian compared qualitatively by gross manipulation at 3, cement. In the titanium-plated group, soft tissues 6, and 12 months. New bone formation at the with good cellularity resembling periosteum were dural and periosteal surfaces was noted in all noted surrounding the titanium mesh (Fig. 6, left). groups at all time points. Although new bone was However, in the resorbable mesh groups, the soft- noted throughout the defect, most new bone was tissue matrix surrounding the mesh was disrupted being appositionally deposited against the im- and acellular (Fig. 6, right). No localized inflam- planted materials, with some invasion of the cal- matory reaction around the resorbable mesh was cium phosphate by bone. Bone formation at 3 noted in any of the groups. The bone thickness at months was significantly greater at the dura than the dural surface was 0.88 Ϯ 0.23 mm for the at the periosteum in the titanium-plated group, titanium mesh group and 1.07 Ϯ 0.4 mm for the but not the resorbable plating group. New bone resorbable mesh group (Table 1). The bone thick- formation in the titanium plated group peaked at ness at the periosteal surface was 0.22 Ϯ 0.22 mm 6 months and remained unchanged thereafter. for the titanium mesh group and 0.46 Ϯ 0.28 mm Bone formation in the resorbable plating group for the resorbable mesh group. Neither of these was significantly delayed compared with the tita- differences was significant. nium-plated group at 6 months but showed similar

1492 Volume 120, Number 6 • Norian Craniofacial Repair System

Fig. 6. Histologic sections through undecalciﬁed bone of specimens harvested at 12 months. (Above, left) Low-power image of a titanium-repaired defect showing thick bone on the dural surface and the thin rim of bone completely encircling the titanium (arrows). (Above, right) Low-power image of a resorbable mesh–repaired defect showing a thin rim of bone on the surface of the Norian cement, with a complete absence of bone along the resorbable mesh surface (asterisk). (Below, left) High-power image of above, left, showing the presence of an intact periosteum on the bone surface abutting the titanium plate (arrowheads). (Below, right) High-power image of above, right, showing the disorganized and acellular matrix on the surface of the bone abutting the resorbable plate (arrowheads). b, bone; c, Norian Craniofacial Repair System; r, resorbable mesh; t, titanium mesh. Bar ϭ 400 ␮m.

levels of bone formation compared with the ti- defects at 1 year. This difference was likely at- tanium group at 12 months. This is similar to the tributable to (1) the difference in animal model finding of McGinnis et al.46 and Nasser et al.,47 used, as the Eppley and Sadove study used a who showed delayed bone formation in de- rabbit model; and (2) the type of resorbable fects fixed with resorbable versus nonresorbable polymer used in plating, because Eppley and meshes. The delayed bone formation noted in Sadove used fast-resorbing LactoSorb (Biomet the resorbable mesh group was likely attribut- Microfixation, Jacksonville, Fla.). able to the increased mobility induced by the Interestingly, although good bone formation breakdown of the resorbable mesh, also result- could be seen against the Norian cement and ing in resorption of the cement. These results surrounding the titanium mesh, little to no bone concur with those of Eppley and Sadove,42 who formation was noted in the proximity of the showed healing of the bone against defects fixed mesh. This appeared to be attributable to a lo- with either titanium or resorbable meshes. How- calized disruption of the soft tissues in contact ever, unlike the Eppley and Sadove findings, the with the resorbable mesh, with an absence of resorbable mesh was still present in the cranial cellularity in the soft tissues. Although this re-

1493 Plastic and Reconstructive Surgery • November 2007 action appeared to be a necrotic reaction, no be appropriate for good long-term outcomes evidence of inflammatory cells was noted in the where early stability is not an issue. areas of disrupted tissue. All inflammation re- David G. Genecov, M.D. ported was noted at the site of wound closure. International Craniofacial Institute The high percentage of infection was likely at- Cleft Lip and Palate Treatment Center tributable to stress on the wound closure caused 7777 Forest Lane, Suite C717 by the massive size of the defect created by two Dallas, Texas 75230 osteotomies, one on either side of the sagittal [email protected] suture. It is important to note here that although there appeared to be some inhibition of ACKNOWLEDGMENT bone formation surrounding the resorbable This study was supported by grants from AO/ASIF mesh, this inhibition was not associated with and Synthes Maxillofacial. infection and did not extend to the Norian cement. Because the infection did not extend into DISCLOSURE the defect, no further culture or examination of None of the authors has a financial interest in any the infected tissue was carried out. Good bone of the products, devices, or drugs mentioned in this formation was seen surrounding and within the article. Norian cement in both the titanium and resorbable mesh–plated groups. REFERENCES The resorbable mesh showed increased mal- 1. Salgado, A. J., Coutinho, O. P., and Reis, R. L. Bone tissue leability at 6 months, compared with the 3-month engineering: State of the art and future trends. Macromol. group and compared with the titanium-plated Biosci. 4: 743, 2004. 2. Logeart-Avramoglou, D., Anagnostu, F., Bizios, R., and Pe- groups. However, the malleability was not marked tite, H. Engineering bone: Challenges and obstacles. J. Cell. and would be in agreement with the observa- Mol. Med. 9: 72, 2005. tions of Wiltfang et al.,48 who concluded that the 3. Redondo, L. M., Verrier Hernandez, A., Garcia Cantera, mechanical properties were sufficient for creat- J. M., et al. Repair of experimental mandibular defects in rats ing stability within craniofacial surgical defects. with autogenous, demineralized, frozen and fresh bone. Br. J. Oral Maxillofac. Surg. 35: 166, 1997. One rationale for placing the plating system 4. Kawcak, C. E., Trotter, G. W., Powers, B. E., et al. Comparison under the bone cement is that the mesh proof bone healing by demineralized bone matrix and autoge- vides a barrier against the dural pulsations, nous cancellous bone in horses. Vet. Surg. 29: 218, 2000. which may be responsible for breaking up the 5. Rabie, A. B., Chay, S. H., and Wong, A. M. Healing of au- bone cement within the defects. Similar to the togenous intramembranous bone in the presence and ab- 49 50 sence of homologous demineralized intramembranous findings of Losee et al. and Pang et al., this bone. Am. J. Orthodont. Dentofac. Orthop. 117: 288, 2000. study found that placing the mesh under the 6. Zhu, Z., Stevens, M. R., and Wu, H. Use of autogenous cranial cement resulted in good bone formation at the bone grafts for orbital floor reconstruction. Zhonghua Zheng dural surface, against the cement squeezed through Xing Wai Ke Za Zhi 17: 294, 2001. the mesh gaps. The question remains whether sim- 7. Chen, T. M., and Wang, H. J. Cranioplasty using allogeneic perforated demineralized bone matrix with autogenous ilar or greater bone formation could be induced if bone paste. Ann. Plast. Surg. 49: 272, 2002. the plating systems were placed over the top of the 8. Ihara, K., Doi, K., Yamamoto, M., et al. Free vascularized cement. fibular grafts for large bone defects in the extremities after tumor excision. J. Reconstr. Microsurg. 14: 371, 1998. CONCLUSIONS 9. Reynolds, M. A., and Bowers, G. M. Fate of demineralized freeze-dried bone allografts in human intrabony defects. On the basis of the results of this study, the use J. Periodontol. 67: 150, 1996. of the Norian Craniofacial Repair System and ti- 10. Brown, D. M., Chung, S. H., Lantieri, L. A., et al. Osteo- tanium mesh together appears to be appropriate chondral allografts with an intramedullary muscle flap in for both short- and long-term stability and bone rabbits. Clin. Orthop. Rel. Res. 334: 282, 1997. formation. Bone formation associated with Norian 11. Harris, R. J. A clinical evaluation of guided tissue regeneration with a bioabsorbable matrix membrane combined with cement in the resorbable plating groups appears an allograft bone graft: A series of case reports. J. Periodontol. similar to that in the titanium plating groups at 12 68: 598, 1997. months but was delayed compared with this group 12. Buser, D., Hoffmann, B., Bernard, J. P., et al. Evaluation of at 6 months. This finding, along with the increased filling materials in membrane–protected bone defects: A malleability of the resorbable mesh at 6 months comparative histomorphometric study in the mandible of miniature pigs. Clin. Oral Implants Res. 9: 137, 1998. would suggest that this combination not be used 13. Babbush, C. A. The use of a new allograft material for osseous where early stability and accelerated bone forma- reconstruction associated with dental implants. Implant Dent. tion are desired. However, this combination may 7: 205, 1998.

1494 Volume 120, Number 6 • Norian Craniofacial Repair System

14. Harris, R. J. A clinical evaluation of an allograft combined 32. Goodman, S. B., Bauer, T. W., Carer, D., et al. Norian SRS with a bioabsorbable membrane versus an alloplast/allograft cement augmentation in hip fracture treatment: Laboratory composite graft combined with a bioabsorbable membrane: and initial clinical results. Clin. Orthop. 348: 2, 1998. 100 consecutively treated cases. J. Periodontol. 69: 536, 1998. 33. Mahr, M. A., Bartley, G. B., Bite, U., et al. Norian craniofacial 15. Laurell, L., Gottlow, J., Zybutz, M., et al. Treatment of in- repair system bone cement for the repair of craniofacial trabony defects by different surgical procedures: A literature skeletal defects. Ophthal. Plast. Reconstr. Surg. 16: 93, 2000. review. J. Periodontol. 69: 303, 1998. 34. Karmacharya, J., Losee, J. E., Gannon, F. H., et al. Repair of 16. Yukna, R. A., Callan, D. P., Krauser, J. T., et al. Multi-center the pediatric craniofacial skeleton with a calcium phosphate clinical evaluation of combination anorganic bovine-derived bone mineral substitute (Norian CRS): Analysis of biocom- hydroxyapatite matrix (ABM)/cell binding peptide (P-15) as patibility, osteoconductivity, and remodeling capacity. Plast. a bone replacement graft material in human periodontal Surg. Forum 23: 30, 2000. osseous defects: 6-month results. J. Periodontol. 69: 655, 1998. 35. Sanchez-Sotelo, J., Munuera, L., and Madero, R. Treatment 17. Boyan, B. D., Lohmann, C. H., Somers, A., et al. Potential of porous poly-D,L-lactide-co-glycolide particles as a carrier for of fractures of the distal radius with a remodellable bone recombinant human bone morphogenetic protein-2 during cement: A prospective, randomized study using Norian SRS. osteoinduction in vivo. J. Biomed. Mater. Res. 46: 51, 1997. J. Bone Joint Surg. (Br.) 82: 856, 2000. 18. Hall, E. E., Meffert, R. M., Hermann, J. S., et al. Comparison 36. Ahn, D. Y., Sims, C. D., Randolph, M. A., et al. Craniofacial of bioactive glass to demineralized freeze-dried bone allo- skeletal fixation using biodegradable plates and cyanoacry- graft in the treatment of intrabony defects around implants late glue. Plast. Reconstr. Surg. 99: 508, 1997. in the canine mandible. J. Periodontol. 70: 526, 1999. 37. Kikuchi, M., Koyama, Y., Takakuda, K., et al. In vitro change 19. Sailer, R., Gabl, M., Lutz, M., et al. Integration of porous in mechanical strength of beta-tricalcium phosphate/copo- hydroxyapatite ceramic prosthesis at the distal radius in el- lymerized poly-L-lactide composites and their application for derly patients: Radiological examination. Unfallchirurg 102: guided bone regeneration. J. Biomed. Mater. Res. 62: 265, 531, 1999. 2002. 20. Fowler, E. B., Breault, L. G., and Rebitski, G. Ridge preser- 38. American Veterinary Medical Association Panel on Eutha- vation utilizing an acellular dermal allograft and deminer- nasia. 2000 report. J. Am. Vet. Med. Assoc. 218: 6696, 2001. alized freeze-dried bone allograft: Part I. A report of 2 cases. 39. Frankenburg, E. P., Goldstein, S. A., Arbor, A., et al. Biome- J. Periodontol. 71: 1353, 2000. chanical and histological evaluation of a calcium phosphate 21. Goldberg, V. M. Selection of bone grafts for revision total hip cement. J. Bone Joint Surg. (Am.) 80: 1112, 1998. arthroplasty. Clin. Orthop. Rel. Res. 381: 68, 2000. 40. Habal, M. B., and Reddi, A. H. Bone Grafts and Bone Substitutes. 22. Kohles, S. S., Vernino, A. R., Clagett, J. A., et al. A morpho- Philadelphia: Saunders, 1992. metric evaluation of allograft matrix combinations in the 41. Habal, M. B. Triad of system applications for absorbable rigid treatment of osseous defects in a baboon model. Calcif. Tissue fixation of the craniofacial skeleton. J. Craniofac. Surg. 7: 94, Int. 67: 156, 2000. 1996. 23. Lamb, J. W., III, Greenwell, H., Drisko, C., et al. A comparison of porous and non-porous teflon membranes plus demin- 42. Eppley, B. L., and Sadove, A. M. A comparison of resorbable eralized freeze-dried bone allograft in the treatment of class and metallic fixation in healing of calvarial bone grafts. Plast. II buccal/lingual furcation defects: A clinical reentry study. Reconstr. Surg. 96: 316, 1995. J. Periodontol. 72: 1580, 2001. 43. Eppley, B. L., Sadover, A. M., and Havlik, R. J. Resorbable 24. Rosen, P. S., and Reynolds, M. A. A retrospective case series plate fixation in pediatric craniofacial surgery. Plast. Reconstr. comparing the use of demineralized freeze-dried bone allo- Surg. 100: 1, 1997. graft and freeze-dried bone allograft combined with enamel 44. Pietrzak, W. S., Sarver, D. R., and Verstynen, M. L. Bioab- matrix derivative for the treatment of advanced osseous le- sorbable polymer science for the practicing surgeon. sions. J. Periodontol. 73: 942, 2002. J. Craniofac. Surg. 8: 87, 1997. 25. Tsai, C. H., Chou, M. Y., Jonas, M., et al. A composite graft 45. Tharanon, W., Sinn, D. P., Hobar, P. C., et al. Surgical out- material containing bone particles and collagen in osteoin- comes using bioresorbable plating systems in pediatric duction in mouse. J. Biomed. Mater. Res. 63: 65, 2002. craniofacial surgery. J. Craniofac. Surg. 9: 441, 1998. 26. Cheung, S., Westerheide, K., and Ziran, B. Efficacy of con- 46. McGinnis, M., Larsen, P., Miloro, M., et al. Comparison of tained metaphyseal and periarticular defects treated with two resorbable and nonresorbable guided bone regeneration different demineralized bone matrix allografts. Int. Orthop. materials: A preliminary study. Int. J. Oral Maxillofac. Implants 27: 56, 2003. 13: 30, 1998. 27. Moore, D. C., Pedrozo, H. A., Crisco, J. J., III, et al. Preformed 47. Nasser, N. J., Friedman, A., Friedman, M., et al. Guided bone grafts of porcine small intestine submucosal (SIS) for bridg- regeneration in the treatment of segmental diaphyseal de- ing segmental bone defects. J. Biomed. Mater. Res. A 69: 259, fects: A comparison between resorbable and non-resorbable 2004. membranes. Injury 36: 1460, 2005. 28. Burstein, F. D., Cohen, S. R., Hudgins, R., et al. The use of 48. Wiltfang, J., Merten, H. A., Becker, H. J., et al. The resorbable porous granular hydroxyapatite in secondary orbitocranial reconstruction. Plast. Reconstr. Surg. 100: 869, 1997. miniplate system Lactosorb in a growing cranio-osteoplasty 29. Burstein, F. D., Cohen, S. R., Hudgins, R., et al. The use of animal model. J. Craniomaxillofac. Surg. 27: 207, 1999. hydroxyapatite cement in secondary craniofacial reconstruc- 49. Losee, J. E., Karmacharya, J., Gannon, F. H., et al. Recon- tion. Plast. Reconstr. Surg. 104: 270, 1999. struction of the immature craniofacial skeleton with a car- 30. Pool, R. Coral chemistry leads to human bone repair. Science bonated calcium phosphate bone cement: Interaction with 267: 1772, 1995. bioresorbable mesh. J. Craniofac. Surg. 14: 117, 2003. 31. Fadilah, A., Zuki, A. B., Logman, M. Y., et al. Gross, radiology 50. Pang, D., Tse, H. H., Zwienenberg-Lee, M., et al. The com- and ultrasonographic evaluation of coral post-implantation bined use of hydroxyapatite and bioresorbable plates to re- in sheep femur. Med. J. Malaysia 59: 178, 2004. pair cranial defects in children. J. Neurosurg. 102: 36, 2005.

1495 EXPERIMENTAL

Experimental Animal Model Proving the Benefit of Primary Defatting of Full-Thickness Random-Pattern Skin Flaps by Suppressing “Perfusion Steal”

Arie Chetboun, M.D. Background: The value of primary flap defatting remains unclear. This exper- Alain Charles Masquelet, imental animal study provides a novel theory on the problem of primary de- M.D. fatting, “steal of perfusion” to the skin by fat. This theory is based on the fact Bobigny, France that the fat brings blood supply to the proximal flap portion but blood is sequestered in the fat of the distal flap portion, to the disadvantage of skin perfusion. Methods: Fifteen full-thickness random-pattern skin flaps, with a 3:1 length- to-width ratio, elevated on the necks of pigs and then left in situ on a plastic sheet interposed between the flap and the deep vascularization from the muscle, were compared with 15 identical contralateral flaps, defatted in the distal half. Results: In the 15 nondefatted flaps, necrosis of the distal half of the flap was observed. Among the 15 defatted flaps, no necrosis was observed in four defatted flaps, partial necrosis was seen in five defatted flaps, concentric necrosis in three defatted flaps, partial necrosis in two defatted flaps, and necrosis in one defatted flap. Necrosis in defatted flaps was significantly less than that in nondefatted flaps (25.6 Ϯ 21.8 percent of flap surface versus 50 Ϯ 2.7 percent; p Ͻ 0.001). Conclusions: There is a benefit to primary defatting. Perfusion steal exists for pedicular and peripheral vascularization. Primary partial defatting of a random- pattern flap is beneficial for distal perfusion, which is attributed to suppression of perfusion steal. Complete defatting is detrimental to flap survival. The fat is indispensable for perfusion of the proximal flap portion and is paradoxically detrimental for the distal region. (Plast. Reconstr. Surg. 120: 1496, 2007.)

rimary defatting of a cutaneous random- of blood is sequestered that is detrimental to pattern skin flap or its equivalent has been cutaneous vascularization. Pthe object of numerous discussions.1–11 Pri- The scope of this work is to prove that primary mary defatting is always contraindicated because defatting is beneficial for flap survival, perfusion it is considered detrimental to flap survival5,6,9,12; steal exists in the distal portion, and primary defat- therefore, secondary defatting is preferred if ting works by suppressing the perfusion steal. To necessary.13–16 Our concept on the problem is this end, we performed an experimental animal the contrary. We think that primary defatting of study, evaluating the behavior of full-thickness de- the distal portion of a full-thickness random- fatted and nondefatted random-pattern flaps. pattern skin flap is not only possible without risk Before exposing the theory of perfusion steal, but beneficial for flap survival. We base this notion it is important to understand how a random- on what we call steal of perfusion to the skin from pattern flap is vascularized. The subcutaneous the fat. In the distal portion of the fat, a quantity network of the fat layer at the base of the flap is essential for the vascularization.4 Inside the sub- From the Orthopedics and Reconstructive Surgery Depart- cutaneous vascular network of the fat layer, there ment, Avicenne Hospital. exists a gradient of blood flow progressively de- Received for publication January 23, 2006; accepted March creasing, from proximal to distal (Fig. 1). 21, 2006. The subdermal network is supplied by the fol- Copyright ©2007 by the American Society of Plastic Surgeons lowing4–6: the subcutaneous network of the fat DOI: 10.1097/01.prs.0000282039.99450.9d layer at every portion (thus, it follows the same

1496 www.PRSJournal.com Volume 120, Number 6 • Value of Primary Flap Defatting

Fig. 1. Random-pattern ﬂap vascularization. decreasing gradient); and the subdermal net- of 30 flaps in total were raised in six male pigs work itself, from the proximal to the distal por- weighing 60 kg (two flap pairs in three animals and tion, as a result of the rich and plexiform anas- three flap pairs in the other three). The flaps were tomoses of this network. raised in the porcine neck region, which resembles human anatomy the best: 15 defatted flaps THEORY OF PERFUSION STEAL and 15 nondefatted flaps were compared. The fat is a living and voluminous tissue inside The flaps were raised transversely, with the of which resides the rich vascular network of the pedicle on the lateral side and the free edge on the subcutaneous fatty tissue. There exists a blood sequestration inside the fat, before the blood is distributed to the skin (the part of the flap used for coverage). The fat behaves like a vascular parasite for the skin. It is this sequestration of blood that produces the perfusion steal. The blood initially sequestered inside the fat will be distributed to the subdermal network after the primary defatting. The improvement in the distal perfusion of the subdermal network is responsible for the survival of the distal flap portion and thus for increasing the viable flap surface. Schematically, if two units of blood are provided at the base of the flap, one will be distributed to the skin and the other will be sequestered in the fat (Fig. 2). With primary de- Fig. 2. Nondefatted ﬂap: perfusion steal. fatting, the two blood units will be distributed to the skin (Fig. 3).

MATERIALS AND METHODS The survival of defatted versus nondefatted random-pattern flaps was examined in an in vivo animal model. In a preliminary stage, we under- took an anatomical study in two pigs to investigate a region of skin sufficiently rich in fat, which resembles the human cutaneous anatomy. The porcine neck has sufficient subcutaneous fat, directly under the skin, without the interposing platysma musculature. This fat is more dense and compact than in the human; however, the fat is divided into layers, similar to the situation in humans. A series Fig. 3. Defatted ﬂap: no perfusion steal.

1497 Plastic and Reconstructive Surgery • November 2007

Fig. 4. Arrangement of flaps on pig neck: face-to-face comparison of defatted flaps (DF) and nondefatted flaps (NDF).

Fig. 6. Defatting of the distal half of the ﬂap.

Fig.5. Completedefattingofthefattylayercomparedwithnon- defatted ﬂaps.

medial side. The dimensions were as follows: 12 ϫ 4 cm (length ϫ width), with a ratio of 3:1. Every defatted flap was compared with a symmetric nondefatted flap on the other side of the midline, to limit the variations of the cutaneous vascularization from one territory to the other (Fig. 4). The Fig. 7. Deep revascularization was suppressed by a plastic sheet flaps were evaluated and observed for viability placed and ﬁxed at the site of ﬂap elevation. daily for a period of 21 days. The area of necrosis was evaluated at the last follow-up. Photographs of all the flaps were taken. Flap defatting was realized by raising all of the the muscular bed. For this purpose, a plastic sheet fat with sharp dissection from the muscular bed. was placed and fixed below the site of flap elevation. The defatting was performed with a blade, and 1 This was done for both defatted and nondefatted to 2 mm of fat was left under the skin (Fig. 5). The skin flaps. The interposition of the plastic sheet was defatting involved the distal half of the flap length inspired by the theory of graft flap by Colson.10–12 (Fig. 6). To prove perfusion steal, one must rely on The plastic sheet covered the site of elevation, the pedicular vascularization alone, and one should whereas the dermis and epidermis of the edges on thus suppress deep revascularization, which is from which the flap was sutured back were left uncov-

1498 Volume 120, Number 6 • Value of Primary Flap Defatting

crosis over the total flap area. For flaps with a rectangular surface of necrosis, the area of necrosis was calculated by dividing the length of necrosis by the total flap length. For flaps with an irregular necrosis area, the necrosis surface was calculated using ImageJ software (version 1.34s; National Institutes of Health, Bethesda, Md.). Statistical analysis was performed using the t test (XLSTAT; Addinsoft, Brooklyn, N.Y.). RESULTS Nondefatted Flaps The results for the 15 nondefatted flaps were homogeneous; necrosis of the distal half of the flap was observed (Fig. 8 and Table 1).

Defatted Flaps The results were heterogeneous (Table 1) and categorized into the following patterns: (1) no necrosis in four (Fig. 9); (2) necrosis of one-fourth to one-fifth of the distal flap length in five (Fig. 10); (3) a concentric distal necrosis with a viable Fig. 8. Nondefatted ﬂaps: necrosis in the distal half of the ﬂap. border in three (Fig. 11); (4) necrosis in the half distal flap portion, identical to the one observed ered. This prevented deep revascularization only in nondefatted flaps in two; and (5) a large area (Fig. 7). Wounds were closed without tension in all of necrosis in one, involving 75 percent of the flap cases (both defatted flaps and nondefatted flaps). length. This flap was infected and the wound was In a second part of the study, the behavior of with dehiscence. Defatted flaps had a significantly four nondefatted flaps and four defatted flaps was smaller area of necrosis compared with nondefat- compared. Two flap pairs were raised in a similar ted flaps (25.6 Ϯ 21.8 percent of flap surface versus fashion in two animals. However, the defatting 50 Ϯ 2.7 percent; p Ͻ 0.001). involved the total flap length, with an otherwise identical technique. Complications The necrosis observed in the flaps was cal- For the nondefatted flaps, two infections with culated and expressed as the percentage of ne- pus under the flap were observed. For two other

Table 1. Description of Flaps Raised in Each Animal* Animal Flap Pair DF Flap Description DF Necrosis (%) NDF Necrosis (%) 1 1 Partial necrosis (smaller than in NDF) 25 49 2 Concentric necrosis with viable border 32 50 2 3 No necrosis 0 51 4 No necrosis 0 48 3 5 Partial necrosis (similar to NDF) 47 45 6 No necrosis 0 55 7 Concentric necrosis with viable border 35 52 4 8 Partial necrosis (smaller than in NDF) 29 50 9 Partial necrosis (smaller than in NDF) 22 54 10 Necrosis larger than in NDF 76 50 5 11 Partial necrosis (smaller than in NDF) 18 49 12 Partial necrosis (smaller than in NDF) 25 46 6 13 No necrosis 0 52 14 Partial necrosis (similar to NDF) 53 48 15 Concentric necrosis with viable border 34 51 Mean Ϯ SD 26.4 Ϯ 21.8† 50 Ϯ 7.3† NDF, nondefatted flaps; DF, defatted flaps. *NDF necrosis description: distal half of the flap. †The difference between defatted flaps and nondefatted flaps was significant, with p Ͻ 0.001. Results of survival with qualitative description and percentage of total flap area with necrosis.

1499 Plastic and Reconstructive Surgery • November 2007

Fig. 9. No necrosis in defatted flaps (DF)(below, right and above, Fig. 11. Defatted flaps: concentric necrosis with viable border. left). Necrosis involving the half distal portion of the nondefatted flaps (NDF)(below, left and above, right).

Fig. 12. Defatted ﬂaps: defatting involved the total ﬂap length. Necrosis of the entire length was observed.

defatting was observed. All the animals survived immediately postoperatively and for the longer follow-up.

Second Part: Complete Defatting Necrosis of the nondefatted flaps was similar Fig. 10. Defatted ﬂaps: necrosis of one-fourth of the distal ﬂap and involved the half distal portion. Necrosis of length. the nondefatted flaps was complete, involving the entire length of the four defatted flaps (Fig. 12). nondefatted flaps, the presence of traumatic skin DISCUSSION lesions was noted on their surface, caused by an The value of primary defatting of random- intense animal agitation following surgery. Among pattern flaps is conflicting. Alkureishi et al. in these four cases, there were two wounds with dehis- 20039 concluded that primary defatting is detri- cence and a scar smaller than 2 cm. mental to the survival of the flap. They performed For the defatted flaps, one infection with pus progressive defatting of anterolateral thigh flaps was observed. For two other flaps, traumatic le- in cadavers and analyzed the vascularization with sions were present. Among these three cases, two radiologic vessel opacification after each sequence wounds with dehiscence and scar along the area of of defatting. They observed that the vascular net-

1500 Volume 120, Number 6 • Value of Primary Flap Defatting work diminished progressively with every layer de- We did not find any articles mentioning the fatted, until all of the vascular opacifications dis- concept of “steal perfusion” to the skin by the appeared. To explain this observation, we think fat. Our experimental study confirms some clin- that the subdermal microvasculature of the distal ical and anatomical results encountered in the flap portion cannot be evaluated radiographically. literature. The vessels of the subdermal network are too small Primary defatting does not compromise vital- a caliber to be injected and/or the resolution of ity of the flap. A limitation of this study is that on the radiologic equipment is too weak to visualize each animal, more than one flap pair was raised. such microscopic structures. However, all animals were similar in terms of Several other authors, however, have per- growth and health status. formed primary flap defatting with no detrimental Our findings indicated that, first, primary de- effects on flap survival. The subdermal network fatting was beneficial for the distal flap vascular- alone has the capacity to provide vascularization ization. A superior survival of the distal flap por- for the skin, even in the absence of fat, as dem- tion was observed in defatted flaps compared with onstrated in an anatomical study by Zbrodowski in nondefatted flaps. In four cases, there was no ne- 1995.4 Primary defatting involved the groin flap,11 crosis, and necrosis was smaller in another five. the inferior rectus abdominis flap,8 and the inter- Necrosis of the distal flap portion was observed in costal and occipitocervical flaps, called the super- all nondefatted flap cases (Table 1). Statistical thin flap.10 A better distal perfusion was noted in analysis also supported the notion that defatted the last flap. The largest series is that by Kimura et flap survival was superior (25.6 Ϯ 21.8 percent of al. in 2001,7 with 31 anterolateral thigh flaps, de- flap surface versus 50 Ϯ 2.7 percent; p Ͻ 0.001). fatted primarily for reconstruction of the neck, Second, the flap is vascularized from its prox- axilla, forearm, hand, and foot. Among these 31 imal basis to the distal free border by the inter- flaps, the authors observed two distal necroses of mediate subdermal network (the revasculariza- ischemic origin, one necrosis of venous origin, tion from the depth was suppressed by the and five superficial epidermal necroses in the dis- interposition of the plastic sheet). The improve- tal flap portions. The authors noted that in addi- ment in the distal flap part perfusion, observed tion to the cosmetic benefit, resensibilization of previously, provides a better cutaneous blood re- the flap was superior and range of motion of the distribution, which is no longer dispersed and se- involved joints was larger. questered inside the fat (Figs. 2 and 3). We there- In 1992, Itoh and Arai17 created thin, “prefab- fore concluded that the perfusion steal exists, and ricated” skin flaps, with the goal of establishing its suppression is what constitutes primary defat- flap vascularization by the subdermal network ting beneficial for survival of the distal flap part. alone, with the interposition of a silicone sheet Third, in three defatted flaps, a concentric between the skin and the fat 15 days before total necrosis with a viable peripheral border was ob- flap elevation. Our study confirms these results, served. The localization of the necrosis suggests a because no aggravation of the vitality of defatted phenomenon of revascularization, because the pe- flaps compared with nondefatted flaps was ob- ripheral border demarcated a center of necrosis served, except for one case, where the flap was (Fig. 11) and the revascularization from the depth totally dehiscent and infected. was suppressed by the plastic sheet. This was not In 1966, Colson1–3 was the first to discuss the observed for any of the nondefatted flaps, in which beneficial effect of primary defatting; however, he the blood supplied by the periphery was no longer never published his work in English. It was based dispersed in the fat by the vertical intermediary on the theory of the graft flap, according to which vascular connections between the subdermal and the beneficial effect is caused by an improved re- the subcutaneous network.4–6 For the defatted vascularization from the depth, once the flap is flaps, the perfusion supplied by the periphery was defatted. The author performed a series of 35 flaps distributed exclusively in the skin and was thus larger than 10 cm, defatted primarily for recon- sufficient for its survival, at least at its periphery. struction of the hand. He observed the presence The perfusion steal applied also for the phenom- of three partial necroses, treated with thin skin enon of peripheral revascularization, which we grafts. In our study, we interposed a sheet of plastic believe is beneficial for flap survival. between the flap and the muscle to neutralize the Fourth, the second part of the study allowed us phenomenon of graft flap and also to rely solely on to conclude that complete primary defatting is the vascularization coming from the base of the detrimental to flap survival. We defatted four flaps flap to prove the perfusion steal. totally from proximal to distal and observed a full-

1501 Plastic and Reconstructive Surgery • November 2007 length necrosis in all (Fig. 12). The defatting of DEPUY Society for their support in realizing this study; both the proximal and distal flap portions sup- and Ioannis Pappou for help. pressed all vascular supply to the flap. Fifth, one defatted flap had a necrosis surface larger than nondefatted flaps and two other de- DISCLOSURE fatted flaps had a necrosis surface equal to non- None of the authors has a financial interest in any defatted flaps. Among these three defatted flaps, of the products, devices, or drugs mentioned in this one was infected, two others had traumatic skin article. lesions, and two partial dehiscences with scar were noted. For the same complications of nondefatted REFERENCES flaps, we observed neither increase in the necrosis 1. Colson, P., and Janvier, H. Primary and total defatting of surface nor increase in the ischemic zone, and the autoplasty flaps from a distance. Ann. Chir. Plast. 11: 11, 1966. dehiscent wounds with scar were of smaller di- 2. Colson, P., Houot, R., Gangolphe, M., et al. Use of thinned mensions. Without reliable evidence, we think flaps (flap-grafts) in reparative hand surgery. Ann. Chir. Plast. 12: 298, 1967. that defatted flaps are more fragile and more sen- 3. Colson, P. The dermo-epidermal flap: Its biological be- sitive to trauma and infection. havior. The flap-graft. Its use in hand surgery. Chirurgie 96: Except for the advantages of primary defatting 639, 1970. (cosmetic advantages and absence of a second 4. Zbrodowski, A., Gumener, R., Gajisin, S., Montandon, D., operation), this experimental work provides the and Bednarkiewicz, M. Blood supply of subcutaneous tissue in the leg and its clinical application. Clin. Anat. 8: 202, 1995. reconstructive surgeon with a supplemental ele- 5. Pearl, R. M., and Johnson, D. The vascular supply to the skin: ment of reflection and numerous clinical perspec- An anatomical and physiological reappraisal. Part I. Ann. tives [e.g., the enhancement of the donor site of Plast. Surg. 11: 99, 1983. the defatted flap compared with the same nonde- 6. Pearl, R. M., and Johnson, D. The vascular supply to the skin: fatted flap (the increased perfusion permits spread An anatomical and physiological reappraisal. Part II. Ann. Plast. Surg. 11: 196, 1983. to the potential territory); and early pedicle division 7. Kimura, N., Satoh, K., Hasumi, T., and Otsuka, T. Clinical of the flap, on the basis of a better peripheral re- application of the free thin anterolateral thigh flap in 31 vascularization and thus faster incorporation into consecutive patients. Plast. Reconstr. Surg. 108: 1197, 2001. the recipient site]. These clinical applications in re- 8. Akizuki, T., Harii, K., and Yamada, A. Extremely thinned constructive surgery would be the objects of further inferior rectus abdominis free flap. Plast. Reconstr. Surg. 91: 936, 1993. study. 9. Alkureishi, L. W., Shaw-Dunn, J., and Ross, G. L. Effects of thinning the anterolateral thigh flap on the blood supply to CONCLUSIONS the skin. Br. J. Plast. Surg. 56: 401, 2003. This study allowed us to conclude that perfu- 10. Hyakusoku, H., and Gao, J. H. The “super-thin” flap. Br. J. sion steal exists for the vascularization coming Plast. Surg. 47: 457, 1994. from the base of the flap and the peripheral re- 11. Hyakusoku, H., Pennington, D. G., and Gao, J. H. Microvas- cular augmentation of the super-thin occipito-cervico-dorsal vascularization. Primary partial defatting of a ran- flap. Br. J. Plast. Surg. 47: 465, 1994. dom pattern flap is beneficial for the distal per- 12. Murakami, R., Fujii, T., Itoh, T., et al. Versatility of the thin fusion, which is attributed to suppression of groin flap. Microsurgery 17: 41, 1996. perfusion steal. Complete defatting is detrimental 13. Arner, M., and Moller, K. Morbidity of the pedicled groin to flap survival. The fat is indispensable for per- flap: A retrospective study of 44 cases. Scand. J. Plast. Reconstr. Surg. Hand Surg. 28:143, 1994. fusion of the proximal flap portion and is para- 14. Chen, H. C., Tang, Y. B., Mardini, S., and Tsai, B. W. Re- doxically detrimental to the distal region. construction of the hand and upper limb with free flaps based on musculocutaneous perforators. Microsurgery 24: Arie Chetboun, M.D. 270, 2004. Orthopedics and Reconstructive Surgery Department 15. Cooper, T. M., Lewis, N., and Baldwin, M. A. Free groin flap Avicenne Hospital revisited. Plast. Reconstr. Surg. 103: 918, 1999. 125, rue de Stalingrad 16. Safak, T., Akyurek, M., Yuksel, E., Kayikcioglu, A., and Kecik, 93009 Bobigny, France A. Head and neck reconstruction with the latissimus dorsi [email protected] musculocutaneous pedicled flap: Functional preservation of the muscle by staged transfer. Ann. Plast. Surg. 41: 156, 1998. ACKNOWLEDGMENTS 17. Itoh, Y., and Arai, K. The deep inferior epigastric artery free The authors thank “L’Ecole de Chirurgie de Paris” skin flap: Anatomic study and clinical application. Plast. Re- for permitting and enabling conduct of this study; the constr. Surg. 91: 853, 1993.

1502 EXPERIMENTAL rhBMP-4 Gene Therapy in a Juvenile Canine Alveolar Defect Model

Joyce C. Chen, M.D. Background: Autologous bone grafts have the disadvantages of donor-site pain Shelley R. Winn, Ph.D. and morbidity, finite supply, increased costs, and prolonged hospitalizations. Xi Gong, M.D. Using a juvenile canine model, the authors hypothesized that recombinant Wayne H. Ozaki, M.D. human (rh) bone morphogenetic protein (BMP)-4 gene therapy–treated alve- Portland, Ore.; and Simi Valley, Calif. olar defects would promote bone healing and canine tooth eruption equal to their autografted counterparts. Methods: Sixty-five maxillary alveolar defects were created in juvenile foxhound dogs with a mean age of 80.8 days. Nineteen defects were treated with DNA plasmid encoding rhBMP-4, 16 defects were autografted, 15 defects contained scaffold only, and 15 defects were left unrepaired. At 4 and 12 weeks after surgery, bone density and tooth eruption were measured, respectively. Data were subjected to one-way analysis of variance testing with statistical significance established at p Ͻ 0.05. Results: At 4 weeks, the bone densities in the rhBMP-4, autografted, scaffold- only, and defect-only groups were 31.2 Ϯ 6.5, 30.5 Ϯ 8.1, 18.4 Ϯ 3.8, and 15.2 Ϯ 4.0 percent, respectively. A significant effect (p Ͻ 0.05) was observed between the rhBMP-4 gene therapy–treated and autografted groups compared with the scaffold-only and defect-only groups. At 12 weeks, the rates of tooth eruption measured in the rhBMP-4, autografted, scaffold-only, and defect-only groups were 67.4 Ϯ 15.8, 58.3 Ϯ 18.8, 52.7 Ϯ 16.2, and 45.0 Ϯ 13.3 percent, respectively. A significant effect (p Ͻ 0.05) was observed between the rhBMP-4 gene therapy– treated and defect-only groups. Conclusions: In the present studies, rhBMP-4 gene therapy was equivalent to autografting and superior to the scaffold-only and unrepaired defect in bone regeneration and tooth eruption. With decreased morbidity and cost, rhBMP-4 gene therapy may ultimately become an alternative to autografting to repair bony defects. (Plast. Reconstr. Surg. 120: 1503, 2007.)

ony defects resulting from congenital de- restore enduring bony contour at a predictable fects, dental diseases, orthopedic trauma, success rate of 80 percent.4 Despite a laudatory Breconstructive operations, and tumor re- record, autografting has recognized liabilities, section contribute to a worldwide health care including a finite supply of donor tissue, in- burden.1,2 Conventional therapies of autograft- creased donor-site morbidity, protracted hospi- ing and allografting have exhibited limitations talizations (which can be especially traumatic in that may be addressed with the development of the pediatric population), and increased costs. alternative treatment strategies.1–3 For congeni- Also, autograft failure could require regrafting. tal defects, maxillary alveolar clefts are most fre- In general, avoiding donor-site morbidity would quently autografted with either cranial or iliac greatly reduce postoperative pain. crest bone grafts, and the grafting procedures To minimize the morbidity of autografting, specific members within a family of proteins called From the Department of Surgery, Division of Plastic and bone morphogenetic proteins (BMPs) have been Reconstructive Surgery, School of Medicine, and the Depart- used to enhance bone regeneration. Bone mor- ment of Restorative Dentistry, Division of Biomaterials and phogenetic proteins are essential components in Biomechanics, School of Dentistry, Oregon Health and Sci- 5 ence University, and the Westlake Surgical Center. bone regeneration, and 16 bone morphogenetic Received for publication October 2, 2005; accepted July 12, proteins have been cloned and expressed through 2006. recombinant DNA technology.6 Several of the bone Copyright ©2007 by the American Society of Plastic Surgeons morphogenetic proteins (e.g., BMP-2, BMP-4, DOI: 10.1097/01.prs.0000282029.99225.b5 BMP-6, BMP-7, and BMP-9), are present in the en-

www.PRSJournal.com 1503 Plastic and Reconstructive Surgery • November 2007 dogenous osseous wound-healing continuum, act with bone morphogenetic proteins delivered by as proliferation factors for stem cells, induce dif- an appropriate carrier.6 ferentiation of osteoblasts, and are likely chemo- tactic for osteoblasts.7 Furthermore, an increasing MATERIALS AND METHODS number of multispecies animal studies (from rat to Immature foxhound dogs were purchased nonhuman primate) have validated the efficacy when the permanent central incisors were start- and safety of recombinant human bone morpho- ing to erupt (3 or 4 months of age). All animals genetic proteins.1,2,8 A gene-based and/or tissue- were radiographed to determine the timing of engineered bone morphogenetic protein formula- canine eruption. When the canine root is half tion could be a suitable alternative to bone grafting formed, the tooth is near its time for eruption. in repairing bony defects while also reducing many Traditional and standard laboratory techniques of its clinical limitations. were used for all components of our work. All Because of the potential safety challenges pre- preoperative, intraoperative, and postoperative sented with certain viral vectors, our laboratory care complied with strict university policy, which has chosen to pursue the nonviral strategy of complies with the standard National Institutes DNA plasmid encoding recombinant human of Health protocol for care and handling of (rh) BMP-4. A plasmid is a stable, extrachromo- experimental animals. Animals were divided somal fragment of DNA, which can be taken up into four experimental groups for a study du- and expressed in the local reactive host cell. A ration of 4 and 12 weeks after surgery. DNA plasmid has a stable, flexible chemistry that is compatible with polymer-based drug delivery Scaffold Fabrication systems. Systemic toxicity from the DNA turn- The poly(D,L-lactide) polymer (100 kDa; 0.4 over is rare and should not be a concern.9 Qui- iv; Alkermes, Inc., Wilmington, Ohio) was fabri- escent, nonhealing tissue is impacted minimally 13 10 cated into sheets as previously reported. Disks by plasmid gene transfer. Plasmid DNA is eco- 2 cm in diameter were prepared from the poly(D, nomical compared with molecular rhBMP and 1,10 L-lactide) sheets, packaged eight to 10 disks per relatively simple to manufacture. Finally, container, and sterilized with hydrogen peroxide BMP-4 should instigate a local, osteogenerative plasma gas (58%) in a Sterrad 100 Sterilizer (Ad- effect at the site of a bony defect. vanced Sterilization Products, Johnson & Johnson, In a previous study, equivalency of the BMP-2 a division of Ethicon, Inc., Somerville, N.J.) as protein to autografting was observed in an adult previously described.13 The devices were allowed canine alveolar defect model at 4 months after to de-gas for 4 days before implantation. surgery.11 Although successful, this study had several limitations, including the high dose of 200 ␮g of rhBMP-2 that was used. In addition, tooth rhBMP-4 Plasmid DNA eruption was not addressed because an adult Recombinant polymerase chain reaction canine model was evaluated. More recently, our methodology was used to generate a rhBMP-4 fu- laboratory has used a stable, circular plasmid sion gene. Thereafter, a 545-bp IgSP-hBMP-4 fu- DNA encoding rhBMP-4 in a delivery system that sion polymerase chain reaction product and the demonstrated a statistically significant increase cloning vector pCEF1a promoter were digested in bone formation at 4 and 8 weeks in the plas- with NheI and NotI restriction enzymes and sub- mid and carrier group, as compared with the sequently purified from 1% agarose gels using the empty defect, the plasmid alone, or the carrier SpinPrep Gel DNA Kit (Novagen, Inc., Madison, alone.12 Using these previous studies, we hypoth- Wis.). The resulting plasmid was purified as previously reported, and purified plasmid was run on esized that in a juvenile canine model, rhBMP-4 14 gene therapy–treated alveolar defects would pro- a 1% agarose gel size (10.7 kb) to ensure quality. mote bone healing and canine tooth eruption equal to their autografted counterparts. A po- Preparation of Experimental Compositions rous, resorbable poly(D,L-lactide) delivery sys- Three hours before surgery, the sterilized tem was used to localize and protect the plasmid poly(D,L-lactide) polymer disks were prewetted with DNA. This carrier was not only used to transport 70% isopropyl alcohol for 15 minutes and twice the DNA plasmid but also functioned as a soft- purged for 10 minutes with filter-sterilized distilled tissue barrier similarly reported for large seg- deionized water to decrease surface hydrophobicity. mental defects in the 2- to 2.5-cm length range The poly(D,L-lactide) disks were washed in phos-

1504 Volume 120, Number 6 • rhBMP-4 Gene Therapy phate-buffered saline (pH 7.4) for 30 minutes before infiltration with the rhBMP-4 plasmid DNA. Regarding rhBMP-4 plasmid DNA, 50-␮lwas infiltrated into a 2.0-cm poly(D,L-lactide) scaffold disk consisting of 25.0 ␮l of a type 1 collagen sol/gel (Cell Prime; Cohesion, Inc., Palo Alto, Calif.; 2.5 mg/ml in calcium and magnesium–free phosphate-buffered saline) and 25 ␮lof2␮g/␮l rhBMP-4 plasmid DNA (50 ␮g total) in the plasmid buffer. The implants were placed on a Petri dish in a humidified 37°C incubator for 90 minutes before implantation to allow gelation of the matrix. The devices then were transported asep- tically to the surgical site for implantation.

Creation of the Alveolar Defect Dogs were given nothing by mouth for 12 hours before surgery. Acepromazine (0.05 mg/lb subcutaneously) was given as the preoperative sed- ative. Other preoperative analgesics included ketoprofen 1 mg/lb intravenously and 1 mg/lb oral carprofen. Amoxicillin (10 mg/lb) was given orally or subcutaneously for antibacterial prophylaxis, and an intravenous line was established in the cephalic Fig. 1. Schematic of the intact native alveolar ridge (above), the vein to deliver crystalloid fluids (saline, lactated 2.0-cm alveolar cleft (center), and the 2.0-cm poly(D,L-lactide) Ringer’s solution, 25% dextrose, and 0.45% sodium scaffold with BMP-4 DNA placed in the alveolar cleft (below). chloride at 10 mg/kg per hour) during the procedure. After induction of anesthesia, each dog was intubated and maintained at surgical anesthesia by intact native alveolar ridge, the 2.0-cm alveolar means of an endotracheal tube with 1.5 to 3% isoflu- defect created, and the 2.0-cm alveolar defect rane and a nonrebreathing system with 2 to 3 liters filled with BMP-4 DNA embedded in the poly(D,L- per minute of oxygen. Monitoring throughout sur- lactide) scaffold. gery was accomplished with end-tidal carbon dioxide, pulse oximetry, and preoperative and postoperative temperatures. Autografting The palatal and mucobuccal fold mucosae cir- The excess bone removed from the alveolar cumscribing and contiguous to the right maxillary ridge was used as the autograft material. The bone canine to the left maxillary canine were infiltrated was morselized to a pate and kept moist with 0.9% with 3.6 ml of 2% lidocaine hydrochloride with physiologic saline in a gauze sponge until needed. 1:100,000 epinephrine. Full-thickness palatal and After creation of the alveolar cleft in the selected mucobuccal fold flaps were raised to visualize max- sides, autografting was achieved by filling in the illary incisors, the palatine process of the maxilla, defect with the morselized bone graft. The mucosa and the alveolar crestal bone. Two of the three was then closed in layers with 3-0 Dexon suture. maxillary incisors, and the deciduous canine on each side of the midline, were extracted with dental forceps. A high-speed rotary Hall drill with a Postoperative Care 703 dental burr and copious sterile physiologic Postoperatively, the dogs were given amoxi- saline irrigation were used to prepare a 2.0-cm- cillin, 10 mg/lb orally or subcutaneously twice wide bony defect extending cephalad from the daily for 7 days. An analgesic (buprenorphine palatine fissures to the floor of the nose. The HCL, 0.1 to 0.2 mg/kg, subcutaneously every 12 wound was then closed in layers with 3-0 Dexon hours for three days) was administered postop- suture (Ethicon, Inc.) after either no treatment, eratively as needed. Also, the ketoprofen and scaffold only, autografting, or scaffold with BMP-4 carprofen combination as above was given daily DNA placed in the wound. Figure 1 depicts the postoperatively for 5 days. Each dog was moni-

1505 Plastic and Reconstructive Surgery • November 2007 tored closely postoperatively to ensure quality Evaluation of Tooth Eruption of life. The permanent canines were evaluated for their extent of eruption. The canine teeth were classified as fully erupted (the tooth crown was lying on the Necropsy occlusal plane), partially erupted (the tooth crown At 4 and 12 weeks postoperatively, each dog was exposed but above the occlusal plane), or une- was killed in an acceptable, humane fashion with rupted (no crown was visualized through the mu- intravenous pentobarbital (200 mg/kg) following cosa). Partially erupted canines were further evalu- initial induction with ketamine (20 mg/kg, intra- ated for the number of millimeters the crown was muscularly). Intraoral clinical photographs of the above the occlusal plane. Percentage eruption was cleft were taken. A skin incision was prepared determined by comparing the amount of tooth around the recipient beds, the soft tissue was re- erupted to the total crown length. flected carefully to the underlying bone, and another set of clinical photographs was taken. Using Statistical Analysis a dental burr and handpiece, the recipient beds with surrounding bone were recovered from the Tooth eruption was measured as a percentage maxillary complex and placed immediately into of the length of tooth erupted to the total crown 70% ethanol. Tissues were prepared for radiom- length. Bone density was measured as a percent- orphometric and histomorphometric analyses. age of bone in a standardized area adjacent to the canine tooth. Data were subjected to one-way analysis of variance testing and post hoc analyses (Fish- Radiography and Radiomorphometry er’s least significant difference), with statistical sig- Ͻ Radiographic images of the bilateral maxilla/ nificance established at p 0.05. clefts of each animal were obtained before the second operation and after the animals were RESULTS killed. All radiographs were scanned and digitally The procedures were well tolerated by all test stored at high resolution. The digitized images subjects. Each dog was monitored closely postop- were thresholded so that each voxel assumed a eratively for signs of pain or discomfort. No ad- bone or nonbone value. A computerized radio- verse complications were observed in any of the density analysis was performed to quantitatively animals. At 4 weeks after surgery, both the scaf- determine new bone formation in each specimen. fold-only and defect-only groups demonstrated a wide spectrum of bone regeneration from limited bone regeneration to islands of bone regenera- Histology and Histomorphometry tion, to bony edges juxtaposed to one another. After radiography, all bone specimens were Both the rhBMP-4 and autograft-treated groups analyzed using histology and histomorphometry. showed a significant increase in bone regenera- All samples were histologically processed by stan- tion when compared with the defect-only group dard thick-section techniques. Specimens were (Figs. 2 and 3). No tooth eruption was seen at the surface polished and stained with Goldner’s 4-week time point in any of the four groups. Per- trichrome stain. Sections were analyzed qualitatively centage bone densities in the rhBMP-4, au- for a description of cellular events and bone graft tografted, scaffold-only, and defect-only groups healing. were 31.2 Ϯ 6.5, 30.5 Ϯ 8.1, 18.4 Ϯ 3.8, and 15.2 Ϯ Histomorphometry was performed on thick 4.0, respectively. The rhBMP-4 and autograft sections to quantitatively evaluate features of new groups were equivalent. A significant effect (p Ͻ bone formation. The trabecular thickness, sepa- 0.05) was observed for the rhBMP-4 gene therapy– ration, and number were calculated using a series treated group when compared with both the scaf- of image-processing algorithms, bone volume frac- fold-only and defect-only groups and also the au- tion, and the bone-to–surface volume ratio. tografted group compared with the scaffold-only and defect-only groups (Fig. 3). New bone could be differentiated from grafted bone. There was a Evaluation of Bone Density low-grade host reaction to implant material, with Using computer software histomorphometric no evidence of any granulomatous infiltrate. Us- analysis, a 1-cm standardized area adjacent to the ing polarized light, evidence of implant material canine tooth was measured in relation to the total [poly(D,L-lactide) polymer] was seen as repeated area measured for the percentage bone density. patterns of short, parallel lines. However, the col-

1506 Volume 120, Number 6 • rhBMP-4 Gene Therapy

Fig. 2. Histology of created alveolar defect at 4 weeks of defect only (left), autograft (center), and BMP-4–treated defects (right). At 4 weeks after surgery, both the rhBMP-4 and autograft-treated groups showed a signiﬁcant increase in bone regeneration when comparedwiththedefect-onlygroup.Thescaffold-onlygroupwasomittedbecauseitwasdeterminedtobeequivalenttothedefect only group. B, bone; T, tooth; D, defect.

tween new and grafted bone could not be appre- ciated. Osteoblastic activity indicative of bone remodeling was seen in all four treatment groups. All four groups exhibited tooth eruption at 12 weeks. The percentage tooth eruption means in the rhBMP-4, autografted, scaffold-only, and defect-only groups were 67.4 Ϯ 15.8, 58.3 Ϯ 18.8, 52.7 Ϯ 16.2, and 45.0 Ϯ 13.3, respectively. A significant effect (p Ͻ 0.05) was seen between the rhBMP-4 gene therapy–treated and defect-only groups (Fig. 4). Minimal host reaction to the implant was seen at this time, with no cellular infiltrate or granulomatous reaction. By 12 weeks, no evidence of the delivery system material was observed under polarized light. Fig. 3. Percentage bone density at the 4-week interval. At 4 weeks,thepercentagebonedensityintherhBMP-4,autografted, scaffold-only, and defect-only groups was 31.2 Ϯ 6.5, 30.5 Ϯ 8.1, DISCUSSION 18.4 Ϯ 3.8, and 15.2 Ϯ 4.0, respectively. The rhBMP-4 gene thera- In this juvenile canine alveolar defect model, py–treated and autografted groups were equivalent. A signiﬁ- rhBMP-4 gene therapy was equivalent to autograft- cant effect (p Ͻ 0.05) was observed between the rhBMP-4 gene ing, and both were superior to the scaffold-only therapy–treated group compared with the scaffold-only (a, p ϭ group and the unrepaired defect in initial bone 0.0019) and defect-only group (b, p ϭ 0.0002). In addition, a sig- regeneration at the 4-week interval. In addition, niﬁcant effect was observed between the autografted group the rhBMP-4 gene therapy group was equivalent to compared with the scaffold-only (c, p ϭ 0.0012) and defect-only autografting and superior to the unrepaired de- groups (d, p ϭ 0.0001). fect in promoting tooth eruption. However, the 2.0-cm defects that were created did not result in a critical-sized defect, with bone regeneration oc- lagen infiltrate material likely resorbed within the curring even in the unrepaired defects. Because durations of the present studies. the animals were of a younger age, and therefore By 12 weeks after surgery, the canine essen- smaller, the 2.0-cm defect size was chosen to ex- tially filled the entire area where the defect had hibit defect sizes proportionally the same to those been created. Histologically, the difference be- previously reported for an adult.11

1507 Plastic and Reconstructive Surgery • November 2007

present new plasmid to the environment as the material biodegrades.16 The present studies were designed to provide a localized delivery of the bone morphogenetic protein by using regional gene therapy, which is the uptake and expression of the DNA plasmid by resident cells. Various treatment strategies have been developed using both ex vivo and in vivo gene therapy and viral and nonviral techniques.17 In addition, combined treatments with barrier membranes and local delivery of rhBMP-2 may be another useful tool in reconstructive surgery.18 The in vivo technique delivers the vector directly to the target site, whereas the ex vivo approach harvests cells from the patient and then reim- Fig. 4. Percentage tooth eruption at 12 weeks. By 12 weeks, all plants the cells back after they have been trans- three groups exhibited canine tooth eruption at this time. The duced in vitro. The direct in vivo approach imparts percentage tooth eruption measured in the rhBMP-4, au- advantages such as the safety of fewer manipula- tografted, scaffold-only, and defect-only groups was 67.4 Ϯ 15.8, tions and reduced cost. However, disadvantages 58.3 Ϯ 18.8, 52.7 Ϯ 16.2, and 45.0 Ϯ 13.3, respectively. A signiﬁ- include the nonselectivity of cells transfected and cant effect (*p Ͻ 0.05) was observed between the rhBMP-4 gene the potential for low transfection rates in vivo. The therapy–treated and defect-only groups. advantage of the ex vivo technique is that there is an increased transfection efficiency with selection of a specific delivery system, whereas the main Several strategies will be investigated to im- disadvantage is the increased complexity and costs prove and sustain the delivery and expression of of a multistep process.17 A successful combination the BMP plasmid. Preliminary in vitro studies have approach of bone marrow cells expanded in vitro demonstrated increased uptake and expression of combined with rhBMP-2 for bone regeneration in DNA plasmid in the presence of various polymer- a nonhuman primate mandible was recently DNA complexes coupled with polylactic acid described.19 scaffolds.14 In situ expression is dependent on lo- To transport, localize, protect, and deliver cal cells within the wound environment incorpo- the DNA plasmid, an appropriate delivery sys- rating the plasmid during proliferation in the tem must be used. With a 25-year history of healing process. Fibroblasts in the granulation tis- clinical efficacy and safety, the poly(␣-hydroxy sue have been shown to be the primary target cells, acid) poly(D,L-lactide) was used in the present because they are the most prevalent and efficient studies.20 This carrier not only transports the at absorbing and expressing DNA plasmids. Ex- DNA plasmid but also functions as a soft-tissue perimentally, fibroblasts have been labeled as the barrier until new bone formation occurs. The cells that express the plasmid in the granulation ideal carrier will theoretically allow large bony tissue.15 Using labeling reporter genes (DNA plas- defects to be completely healed, provided the mid markers), a cell that has taken-up the plasmid wound is in its healing phase and can take up the will become microscopically visible. The efficiency DNA plasmid. of DNA plasmid uptake is highly variable. Reports Using a juvenile canine model, rhBMP-4 gene have indicated efficiencies in the range of 5 to 50 therapy was used to treat alveolar defects, which percent, with a gene-activated matrix, similar to begins to address tooth eruption while also deliv- the delivery system used in the present studies, ering a reduced protein dose by using plasmid exhibiting local expression in the 30 to 50 percent DNA encoding rhBMP-4. The present studies have range.10,15 The uptake efficiency depends on the indicated the feasibility of rhBMP-4 gene therapy delivery system, the type of plasmid, and the wound for providing a therapeutic modality with which to environment.1,10,15 Although extracellular plasmid fill alveolar defects. There are still many steps to be has a relatively short half-life (several hours), once taken for this tissue engineering technology to taken up by the surrounding cells, plasmids will become clinically viable. When successful, rh- continue to function for several weeks. A sus- BMP-4 gene therapy may provide an alternative tained delivery system will protect the plasmid to the traditional clinical use of autografts to fill from the surrounding environment and also bony defects.

1508 Volume 120, Number 6 • rhBMP-4 Gene Therapy

CONCLUSIONS 6. Barnes, G. L., Kostenuik, P. J., Gerstenfield, L. C., and In this juvenile canine alveolar defect model, Einhorn, T. A. Growth factor regulation of fracture repair. J. Bone Miner. Res. 14: 1805, 1999. rhBMP-4 gene therapy was equivalent to autograft- 7. Cheng, H., Jiang, W., Phillips, F. M., et al. Osteogenic activity ing and superior to the unrepaired defect in bone of the fourteen types of human bone morphogenetic pro- regeneration and tooth eruption. With decreased teins (BMPs). J. Bone Joint Surg. (Am.) 85: 1544, 2003. morbidity and cost, rhBMP-4 gene therapy may 8. Reddi, A. H. Initiation of fracture repair by bone morpho- ultimately become an alternative to the traditional genetic proteins. Clin. Orthop. 355: 66, 1998. 9. Lew, D., Parker, S. E., Latimer, T., et al. Cancer gene therapy clinical use of autografts to fill bony defects. using plasmid DNA: Pharmacokinetic study of DNA follow- Shelley R. Winn, Ph.D. ing injection in mice. Hum. Gene Ther. 6: 533, 1995. Division of Plastic and Reconstructive Surgery 10. Bonadio, J., Smiley, E., Patil, P., and Goldstein, S. Localized, Oregon Health and Science University, L352A direct plasmid gene therapy in vivo: Prolonged therapy re- 3181 S. W. Sam Jackson Park Road sults in reproducible tissue regeneration. Nat. Med. 5: 753, Portland, Ore. 97239 1999. [email protected] 11. Mayer, M. H., Hollinger, J. O., Ron, E., and Wozney, J. Repair of alveolar clefts in dogs with recombinant bone morpho- ACKNOWLEDGMENT genetic protein and poly (alpha-hydroxy acid). Plast. Reconstr. This study was funded in part by a grant from the Surg. 98: 247, 1996. 12. Winn, S. R., Winn, S. R., Xi, G., Hung, C. C., Sasaki, A., and Northwest Health Foundation, Portland, Oregon. Hu, Y. Gene therapy to heal critical-sized rat cranial defect. J. Am. Coll. Surg. 195: S45, 2002. DISCLOSURES 13. Hu, Y., Grainger, D., Winn, S. R., and Hollinger, J. O. Fab- None of the authors received payments or other ben- rication of poly(alpha-hydroxy acid) foam scaffolds using efits or a commitment or agreement to provide such ben- multiple solvent systems. J. Biomed. Mater. Res. 59: 563, 2002. efits from a commercial entity. No commercial entity paid 14. Winn, S. R., Chen, J. C., Gong, X., Bartholomew, S. V., or directed, or agreed to pay or direct, any benefits to any Shreenivas, S., and Ozaki, W. O. Non viral-mediated gene therapy approaches for bone repair. Orthod. Craniofac. Res. 8: research fund, foundation, educational institution, or 183, 2005. other charitable or nonprofit organization with which the 15. Bonadio, J., Goldstein, S. A., and Levy, R. J. Gene therapy for authors are affiliated or associated. tissue repair and regeneration. Adv. Drug Deliv. Rev. 33: 53, 1998. REFERENCES 16. Hollinger, J. O., and Schmitz, J. P. Macrophysiologic roles of 1. Winn, S. R., Hu, Y., Sfeir, C., and Hollinger, J. O. Gene a delivery system for vulnerary factors needed for bone re- therapy approaches for modulating bone regeneration. Adv. generation. Ann. N. Y. Acad. Sci. 831: 427, 1997. Drug Deliv. Rev. 42: 121, 2000. 17. Balzer, A. W., and Lieberman, J. R. Regional gene therapy to 2. Franceschi, R. T. Biological approaches to bone regenera- enhance bone repair. Gene Ther. 11: 344, 2004. tion by gene therapy. J. Dent. Res. 84: 1093, 2005. 18. Zellin, G., and Linde, A. Bone neogenesis in domes made of 3. Enneking, W. F., and Mindell, E. R. Observations on massive expanded polytetrafluoroethylene: Efficacy of rhBMP-2 to retrieved human allografts. J. Bone Joint Surg. (Am.) 73: 1123, enhance the amount of achievable bone in rats. Plast. Re- 1991. constr. Surg. 103: 1229, 1999. 4. Kortebein, M. J., Nelson, C. L., and Sadove, A. M. Retro- 19. Seto, I., Marukawa, E., and Asahina, I. Mandibular recon- spective analysis of 135 secondary alveolar cleft grafts using struction using a combination graft of rhBMP-2 with bone iliac or calvarial bone. J. Oral Maxillofac. Surg. 49: 4933, 1991. marrow cells expanded in vitro. Plast. Reconstr. Surg. 117: 902, 5. Urist, M. Bone morphogenetic protein, bone regeneration, 2006. heterotopic ossification and the bone-bone marrow consor- 20. Hollinger, J. O., and Leong, K. Poly(alpha-hydroxy acids): tium. In W. A. Peck (Ed.), Bone and Mineral Research. Am- Carriers for bone morphogenetic proteins. Biomaterials 17: sterdam: Elsevier Science Publishers, 1989. Pp. 57–112. 187, 1996.

1509 EXPERIMENTAL

Influences of Preservation at Various Temperatures on Liposuction Aspirates

Daisuke Matsumoto, M.D. Background: Aspirated fat is not only a filler material but also an abundant Tomokuni Shigeura, M.S. source of adipose-derived stem cells. The aim of this study was to assess degen- Katsujiro Sato, M.D. eration of aspirated fat during preservation and optimize the preservation Keita Inoue, M.D. method for lipoaspirates. Hirotaka Suga, M.D. Methods: Aspirated fat was preserved at room temperature for 1, 2, 4, and 24 Harunosuke Kato, M.D. hours (n ϭ 10 each); at 4°C for 1, 2, and 3 days (n ϭ 14 each); or at –80°C for Noriyuki Aoi, M.D. 1 month (n ϭ 3). Morphologic changes were assessed with scanning electron Syoko Murase, Ph.D. microscopy. Adipose-derived stem cell yield was measured after 1 week of cul- Koichi Gonda, M.D. ture. For aspirated fat preserved at room temperature, damaged adipocytes were Kotaro Yoshimura, M.D. assessed by measuring the oil volume ratio after centrifugation (n ϭ 6) and ϭ Tokyo and Kanagawa, Japan glycerol-3-phosphate-dehydrogenase activity in washing solution (n 4). Cell surface marker expression was examined by flow cytometry (n ϭ 3). Results: Although the scanning electron microscopic assay indicated no remarkable anatomical changes based on preservation methods, oil volume significantly increased in fat preserved at room temperature for 4 hours. Adipose- derived stem cell yield was significantly reduced by preservation at room temperature for 24 hours and by preservation at 4°C for 2 or 3 days. Flow cytometric analysis suggested that the biological properties of adipose-derived stem cells did not significantly change at 4°C up to 3 days. The cells were isolated from cryopreserved fat, but the yield was much less than that from fresh aspirated fat. Conclusions: Aspirated fat should be transplanted as quickly as possible if it is preserved at room temperature. For adipose-derived stem cell isolation, aspirated fat can be stored or transported overnight if it is preserved at 4°C without adipose-derived stem cell yield loss or changes in biological properties. (Plast. Reconstr. Surg. 120: 1510, 2007.)

lthough fat tissue has been used as a filler after harvesting is recommended. Thus, it is of material for more than 100 years,1,2 there great interest to investigate how adipose tissue Aare several problems to be resolved, in- viability after aspiration changes over time de- cluding unpredictability and fat necrosis result- pending on preservation methods. Clinically, as- ing in infection and calcification.2,3 Autologous pirated fat tissue is usually preserved at room fat transfer, however, is almost the only method temperature in a suction bottle, but how aspi- of soft-tissue augmentation that can be per- rated fat in the suction bottle changes during the formed without detectable scarring on either a postoperative hours is unknown. donor or a recipient site and without complica- It was recently revealed that adipose tissue is a tions associated with foreign materials. Because remarkable source of multipotent stem cells,4,5 fat tissue is more easily damaged by ischemia which can differentiate into adipogenic, chon- compared with other tissues such as skin and drogenic, osteogenic, myogenic, neurogenic, en- bone, transferring fat tissue as quickly as possible dothelial, and other lineages.6 Adipose-derived stem cells have already been used in some clini- From the Department of Plastic Surgery, University of Tokyo 7 School of Medicine, and the Division of Research and De- cal trials, including treatments for bone defects ; velopment, Biomaster, Inc. rectovaginal fistula8; and soft-tissue augmenta- Received for publication August 15, 2006; accepted January tion, including breast enhancement, breast re- 4, 2007. construction, and facial rejuvenation.9 Adipose- Copyright ©2007 by the American Society of Plastic Surgeons derived stem cells may be clinically used or DOI: 10.1097/01.prs.0000288015.70922.e4 banked also for other therapeutic purposes in

1510 www.PRSJournal.com Volume 120, Number 6 • Preservation of Liposuction Aspirates the near future. In practice, there is some time Flow Cytometric Analysis lag between liposuction and cell isolation; it Adherent adipose-derived stem cells were ex- takes a few to several hours for liposuction sur- amined for surface marker expression using flow gery, depending on the volume and sites to suc- cytometry after 1 week of culture (n ϭ 3). The tion, and a few hours to even a day or two for following monoclonal antibodies were used: transportation from an operating room to a cell- CD29-PE; CD31-PE; CD34-PE; CD45-PE; CD90- processing unit. To maximize the potential of PE; CD133-PE; CD144-PE; HLA-A, B, and C-PE; adipose aspirates as a stem cell source, it is very Tie-2-PE (BD Biosciences, San Diego, Calif.); important to optimize protocols for their preser- CD105-PE (Serotec, Oxford, United Kingdom); vation. and Flk-1-PE (Techne, Princeton, N.J.). Cells were Thus, aspirated fat is now valuable as an autol- incubated with the directly conjugated monoclo- ogous filler material and as an abundant stem nal antibodies in phosphate-buffered saline con- cell source. We sought to comprehensively eval- taining 0.5% bovine serum albumin for 30 min- uate the influences of preservation at different utes at 4°C, washed with phosphate-buffered temperatures on the viability of aspirated fat and saline containing 0.2% bovine serum albumin, adipose-derived stem cells. and diluted in phosphate-buffered saline containing 0.1% bovine serum albumin. Flow cytometric PATIENTS AND METHODS analyses were performed using an LSR2 (Becton Dickinson, San Jose, Calif.). Human Tissue Sampling and Preservation We obtained liposuction aspirates from 21 healthy female donors undergoing liposuction of Quantitative Analysis of Damaged Adipocytes in the abdomen or thighs after informed consent Aspirated Fat using an institutional review board–approved pro- To assess damaged adipocytes in aspirated fat, tocol. The adipose portion of the liposuction as- we measured the ratios of oil and fat volumes after ϭ pirates was preserved at room temperature for 1, centrifugation (n 6), and an extracellular ac- 2, 4, or 24 hours (n ϭ 10); at 4°C for 0, 1, 2, and tivity of an enzyme, glycerol-3-phosphate-dehydro- 3 days (n ϭ 14); or at –80°C for 1 month (n ϭ 3) genase, with a GPDH Activity Measurement Kit ϭ and subjected to assays as described below. Ex- (Cell Garage, Tokyo, Japan) (n 4). The enzyme cised fat obtained from a cosmetic surgery patient is normally strictly intracellular, and the enzyme was also used for comparison. activity in a washing solution is proportional to the amount of adipocyte destruction. For measurement of the oil ratio, the fatty Cell Processing and Culture portion of liposuction aspirates was divided into Stromal vascular fractions were isolated from 20 tubes (15-ml conical tubes) and preserved at the fatty portion of liposuction aspirates as previ- room temperature. After preservation for 1, 2, 4, ously described.10 Briefly, the aspirated fat was or 24 hours, five of the tubes were centrifuged washed with phosphate-buffered saline and di- at 2330 g for 5 minutes to separate the oil, fat, gested on a shaker at 37°C in phosphate-buffered and fluid into distinct layers from top to bottom saline containing 0.075% collagenase for 30 min- (Fig. 1). The oil ratio was calculated as follows: utes. Mature adipocytes and connective tissues oil ratio ϭ (oil volume)/[(oil volume) ϩ (fat were separated from pellets by centrifugation (800 g volume)]. Data were collected from lipoaspirates for 10 minutes). The cell pellets were resus- obtained from six patients. pended, filtered with a 100-␮m mesh (Millipore, For extracellular glycerol-3-phosphate-dehy- Bedford, Mass.), plated (30,000 cells/cm2) onto drogenase assessment, after1gofaspirated fat gelatin-coated dishes, and cultured at 37°C in an lobules was washed in a tube with 4 ml of phos- atmosphere of 5% carbon dioxide in humid air. phate-buffered saline, 1 ml of the phosphate-buff- The culture medium was M-199 containing 10% ered saline solution was transferred to another fetal bovine serum, 100 IU of penicillin, 100 tube and centrifuged at 15,000 g for 5 minutes. mg/ml streptomycin, 5 ␮g/ml heparin, and 2 After the supernatant was appropriately (two to 20 ng/ml acidic fibroblast growth factor. Medium times) diluted with the enzyme extracting reagent, was replaced every third day. After 7 days, ad- 100 ␮l of each diluted sample was transferred onto herent cells were trypsinized and counted with a 96-well plate. The enzyme reaction was then a cell counter (NucleoCounter; ChemoMetec, started by the addition of 200 ␮l of substrate re- Allerod, Denmark). agent containing dihydroxyacetone phosphate

1511 Plastic and Reconstructive Surgery • November 2007

dylate buffer for 1 week at room temperature and then fixed in 1% osmium tetroxide. After dehy- dration, samples were dried with a supercritical point carbon dioxide dryer (HCP-2; Hitachi, To- kyo, Japan), sputter-coated with platinum/palla- dium, and examined with a scanning electron microscope (S3500N; Hitachi).

Statistical Analysis Results were expressed as mean Ϯ SE. Paired or unpaired t tests were performed to evaluate differences between groups, and no correction was made for multiple comparisons.

RESULTS

Morphology of Adipocytes in Aspirated Fat Aspirated fat was preserved at 4°C and fixed for scanning electron microscopic study at different time points. Adipocytes from aspirated fat al- Fig. 1. Analysis of adipocyte damage in lipoaspirates by centrif- most retained their round shape and showed no ugation. After centrifugation, aspirated fat tissue was separated significant morphologic differences compared intodistinctlayersfromtoptobottom:theoil,fat,andﬂuidlayers. with those of excised fat (Fig. 2, above, left). No Adipocyte damage by preservation was quantiﬁed by calculat- remarkable change in adipocyte morphology was ing the oil ratio in the volume as follows: oil ratio ϭ (oil volume)/ found in aspirated fat tissues on days 0, 1, and 3 [(oil volume) ϩ (fat volume)]. (Fig. 2, above, second from left, second from right, and right). Aspirated fat was preserved for 1, 2, 4, or 24 and nicotinamide adenine dinucleotide (NADH). hours at room temperature and evaluated by scan- The assay measures the reduction of NADH to ϩ ning electron microscopy also (Fig. 2, below). No NAD in the presence of glycerol-3-phosphate- remarkable difference in adipocyte morphology dehydrogenase. The absorbance at 340 nm was was identified. recorded every 30 seconds for 10 minutes by using a spectrometer (DTX880; Beckman Coulter, Ful- lerton, Calif.) to produce an extinction curve for Degeneration of Adipocytes with Preservation calculating the maximum decrease, indicating the Time glycerol-3-phosphate-dehydrogenase activity. Because we clinically observe a gradual increase of oil volume in lipoaspirates, the oil ratio Procedure for Cryopreserving and Thawing (oil volume/[oil volume ϩ fat volume]) was used Aspirated Fat as one of indices of degeneration of adipocytes in Fresh adipose tissue was mixed with an equal aspirated fat. The oil ratio increased over time amount of freezing medium (Cell Banker BLC-1; during preservation at room temperature (Fig. 3, ZENOAQ, Fukushima, Japan) and cooled to above, left). Oil ratios at 4 and 24 hours were sig- –80°C in a programmable freezing system (TNP- nificantly greater than those at 1 hour, and the oil 87S; Nihon Freezer, Tokyo, Japan) at a freezing ratio per-hour increase slowed remarkably after 4 rate of 1°C every 15 minutes. After 1 month, cryo- hours (Fig. 3, above, right). Glycerol-3-phosphate- preserved adipose tissue was thawed by placement dehydrogenase activity in a washing solution of of the cryotube into a water bath at 37°C. preserved fat increased slightly up to 4 hours and increased markedly after 24 hours of preservation Scanning Electron Microscopic Study (Fig. 3, below, left). Unlike the results with the oil After preservation at room temperature or ratio, glycerol-3-phosphate-dehydrogenase activity 4°C, aspirated fat was fixed with 2% paraformal- increase per hour did not change up to 4 hours dehyde and 2.5% glutaraldehyde in 0.2 M caco- but significantly increased after that time point.

1512 Volume 120, Number 6 • Preservation of Liposuction Aspirates

Fig.2. Comparisonwithscanningelectronmicroscopyofhumanaspiratedfattissuesafterpreservationat4°Corroomtemperature. (Above,left)Excisedadiposetissuewasfixedimmediatelyaftertheoperation.Aspiratedfattissuespreservedat4°Cwerefixedonday 0(above,secondfromleft),day1(above,secondfromright),orday3(above,right),whereasthosepreservedatroomtemperaturewere fixed at 1 hour (below, left), 2 hours (below, second from left), 4 hours (below, second from right), or 24 hours (below, right) after the operation. Each sample was treated for evaluation with scanning electron microscopy, and representative photographs are shown. No significant morphologic changes over time were found by scanning electron microscopy in aspirated fat, even in samples stored at 4°C for 3 days or at room temperature for 24 hours. Scale bar ϭ 250 ␮m.

Adipose-Derived Stem Cell Yield from ervation time at a cool temperature, surface Aspirated Fat Preserved at Room or Cool marker analysis was performed on adipose-derived Temperature stem cells isolated from aspirated fat tissues pre- When preserved at room temperature, adi- served for 0, 1, 2, and 3 days at 4°C (Table 1). pose-derived stem cell yield was maintained up to 4 hours and decreased remarkably at 24 hours Adipose-Derived Stem Cell Yield from Cryopre- (Fig. 4). In contrast, after preservation at 4°C, served Aspirated Fat almost the same number of adipose-derived stem We also evaluated the possibility of isolating cells were isolated from aspirated adipose tissue adipose-derived stem cells from aspirated fat cryo- on days 0 and 1 (Fig. 5). The number of isolated preserved for 30 days (n ϭ 3). Adipose-derived adipose-derived stem cells was extensively de- stem cells were harvested from the cryopreserved creased in some cases on day 2 and in all cases on aspirated fat, but the adipose-derived stem cell day 3. Statistical significance was seen between Ͻ yield was significantly less than that obtained from days 0 and 3 (p 0.001) and between days 1 and fresh aspirated fat (Fig. 6). 3(p Ͻ 0.001). Surface Marker Expression of Adipose-Derived DISCUSSION Stem Cells Isolated from Aspirated Fat The scanning electron microscopic assay Preserved at a Cool Temperature showed that no significant morphologic change in To examine changes in the biological prop- adipocytes was found among aspirated fat tissues erties of adipose-derived stem cells based on pres- preserved either at 4°C for up to 3 days or at

1513 Plastic and Reconstructive Surgery • November 2007

Fig. 3. Assessment of damaged adipocytes after preservation at room temperature. Damaged adipocytes were evaluated by measurement of the oil ratio after centrifugation (above) or glycerol-3-phosphate-dehydrogenase activity of preserved fat in washing solution (below). Statistical analysis was performed using paired t tests between groups. Values are mean Ϯ SE; *p Ͻ 0.05. (Above, left) Oil ratios in aspirated fat preserved at room temperature for 1, 2, 4, or 24 hours are shown. The oil volume ratio gradually increased with storage time, likely because of the breakdown of adipocytes. (Above, right) The oil ratio per-hour increase slowed remarkably with storage time. (Below, left) Glycerol-3-phosphate-dehydrogenase activity of preserved fat in washing solution for 1, 2, 4, or 24 hours was measured for assessment of damaged adipocytes. Glycerol-3-phosphate-dehydrogenase activity had slightly increased up to 4 hours and was markedly increased at 24 hours. (Below, right) Glycerol-3-phosphate-dehydrogenase activity increase per hour did not change signiﬁcantly up to 4 hours, but did increase after 4 hours. room temperature for up to 24 hours. However, 400 g increased the oil portion in lipoaspirates but quantitative analysis of damaged adipocytes by that further centrifugation did not significantly measuring the oil ratio and glycerol-3-phosphate- damage adipocytes or increase oil volume.12 In dehydrogenase activity revealed that preserved addition, our histologic examinations of centri- adipocytes were partly degenerated and ruptured fuged aspirated fat with light and scanning elec- over preservation time when stored at room tem- tron microscopy showed that adipocytes appeared perature. Thus, preservation at room temperature to be intact even after centrifugation at 4300 g.12 resulted in damage to some adipocytes that may Therefore, we considered that the increased oil have been located superficially; however, the re- volume after centrifugation (for 5 minutes at 2330 maining adipocytes retained almost-intact mor- g) in the present study was attributable to adipo- phology. cyte damage from preservation at room temper- In this study, damaged adipocytes were eval- ature. The measurement of glycerol-3-phosphate- uated by measurement of the oil ratio after cen- dehydrogenase activity produced results that were trifugation and glycerol-3-phosphate-dehydroge- similar to those of the oil ratio up to 4 hours but nase activities in washing solution of preserved fat. that differed somewhat at 24 hours; glycerol-3- Boschert et al.11 reported that centrifugation at phosphate-dehydrogenase activity had increased greater than 100 g caused adipose cell destruction; remarkably after 24 hours of preservation. This however, we recently found that centrifugation at difference might be attributable to incomplete

1514 Volume 120, Number 6 • Preservation of Liposuction Aspirates

Table 1. Surface Marker Expression of Adipose- Derived Stem Cells Isolated from Aspirated Fat Tissues Preserved at 4ºC* Day 0 Day 1 Day 2 Day 3 CD29 98.7 Ϯ 0.8 98.4 Ϯ 0.8 99.4 Ϯ 0.1 97.3 Ϯ 1.8 CD31 1.7 Ϯ 0.3 2.0 Ϯ 0.4 1.4 Ϯ 0.8 0.7 Ϯ 0.1 CD34 48.1 Ϯ 6.5 46.3 Ϯ 5.5 35.8 Ϯ 5.2 31.2 Ϯ 3.4 CD45 1.0 Ϯ 0.3 1.2 Ϯ 0.4 0.7 Ϯ 0.2 1.1 Ϯ 0.6 CD90 99.2 Ϯ 0.5 98.1 Ϯ 0.9 99.2 Ϯ 0.1 97.1 Ϯ 2.1 CD105 97.8 Ϯ 1.3 97.0 Ϯ 2.2 97.8 Ϯ 0.8 96.2 Ϯ 2.1 CD133 3.1 Ϯ 1.5 2.2 Ϯ 1.6 0.9 Ϯ 0.6 1.0 Ϯ 0.4 CD144 0.5 Ϯ 0.2 0.5 Ϯ 0.1 0.2 Ϯ 0.1 0.2 Ϯ 0.1 HLA-ABC 98.3 Ϯ 0.8 97.4 Ϯ 1.6 96.5 Ϯ 1.6 93.6 Ϯ 3.0 Flk-1 56.1 Ϯ 17.2 54.4 Ϯ 26.5 81.7 Ϯ 4.4 71.0 Ϯ 5.5 Fig. 4. Adipose-derived stem cell yield after preservation at Tie-2 2.2 Ϯ 17.2 2.3 Ϯ 0.9 1.7 Ϯ 0.6 1.8 Ϯ 0.4 room temperature. We preserved aspirated adipose tissues at *Adipose-derived stem cells isolated from aspirated fat preserved at room temperature for 1, 2, 4, or 24 hours and processed them for 4ºC for 0, 1, 2, and 3 days and flow cytometric analyses were per- isolationofadipose-derivedstemcells,whichwerethencultured formed on adipose-derived stem cells after culture for 1 week. Few differences in expression profile of principal surface markers were for 1 week. Ratios of adipose-derived stem cell yield to control observed among groups, suggesting that biological properties of (1-hour preservation) were calculated; data were obtained from adipose-derived stem cells do not change by preservation at 4ºC for Ϯ three patients, and statistical analysis was performed using up to 3 days. Vales are mean SE. pairedttestsbetween1-hourandothergroups.Adipose-derived stem cell yield seemed to be maintained for up to 4 hours of preservation and decreased remarkably when preserved for 24 hours at room temperature. Values are mean Ϯ SE; *p Ͻ 0.05.

Fig. 6. Adipose-derived stem cell yields from cryopreserved lipoaspirates. Fresh aspirated adipose tissue was mixed with an equal amount of freezing medium, cooled to –80°C in a programmable freezing system, and stored at –80°C for 1 month. Fig.5. Adipose-derivedstemcellyieldsafterpreservationat4°C. The cryopreserved adipose tissue was thawed and processed Wepreservedaspiratedfattissuesat4°Cfor0,1,2,and3daysand to isolate adipose-derived stem cells, which were then cul- processed them for isolation of adipose-derived stem cells, tured for 1 week. The ratio of adipose-derived stem cell yield which were then cultured for 1 week. Ratios of adipose-derived to control (fresh lipoaspirates) was calculated. Data were ob- stemcellyieldtocontrol(day0,nopreservation)werecalculated; tained from three patients, and statistical analysis was per- data were obtained from 14 patients (data for day 2 came from formed using paired t tests between groups. Adipose-derived four of the 14 patients), and statistical analysis was performed stem cells were isolated from cryopreserved aspirated fat using unpaired t tests between day 0 and other groups. A statis- (6.7 Ϯ 4.7 ϫ 104 cells/ml after 1 week of culture), but the yield tical difference in adipose-derived stem cell yield was not found was much less than that of the fresh fat. Values are mean Ϯ SE; between days 0 and 1, whereas adipose-derived stem cell yield *p Ͻ 0.05. decreased signiﬁcantly on days 2 and 3. Values are mean Ϯ SE; *p Ͻ 0.05. indicated that preservation at room temperature for 4 hours significantly damaged adipocytes in release of leaked intracellular oil from damaged aspirated fat; thus, lipotransfer should be per- adipocytes; the oil might be trapped in the sur- formed as quickly as possible after aspiration, es- rounding matrices, proving difficult to measure pecially when a large volume of aspirated fat is to using the oil ratio assay. Thus, the present result be transplanted.

1515 Plastic and Reconstructive Surgery • November 2007

Since the reports showing that adipose tissue is comparable to our result (6.7 Ϯ 4.7 ϫ 104 contains multipotent stem cells,4,5 aspirated adi- cells/ml after 1 week of culture), because adipose- pose tissue has been regarded as not only a filler derived stem cells proliferate 10 to 100 times in a material but also as an abundant source of stem week, depending on culture conditions. However, cells. Adipose-derived stem cells reside in adipose the reported adipose-derived stem cell yield from tissue as progenitors of adipocytes, but it has fresh adipose (4.1 Ϯ 1.4 ϫ 105 cells/ml after 2 been suggested that adipose-derived stem cells weeks of culture17) was much less than that in this can differentiate into vascular endothelial study (7.9 Ϯ 1.5 ϫ 105 cells/ml after 1 week of cells,13,14 can release angiogenetic factors under culture). It is unknown why the reported adipose- hypoxic conditions,15 and can contribute to a derived stem cell yield from fresh adipose differs higher graft take of transplanted fat.14,16 In the between the two studies, but it may be the result current study, adipose-derived stem cell yield was of different methods of cell isolation. maintained up to 4 hours at room temperature, and an adipose-derived stem cell yield similar to CONCLUSIONS that of fresh aspirated fat was obtained from that We have demonstrated how the adipose-de- preserved at 4°C for 24 hours. This finding indi- rived stem cell yield from aspirated fat changes cates that a 1-day delay in isolation of adipose- depending on preservation conditions and time derived stem cells from aspirated fat can be ap- periods. Preservation for 4 hours at room temper- propriate when the tissue is stored in a ature significantly damaged adipocytes but did not refrigerator. Therefore, overnight cooling trans- significantly alter adipose-derived stem cell yield. portation of aspirated fat to a specialized cell-pro- Adipose-derived stem cell yield significantly de- cessing center for isolation and banking of adi- creased with preservation for 24 hours at room pose-derived stem cells can be regarded as temperature but not with preservation at 4°C. practical, although adipose-derived stem cell yield Thus, aspirated fat can be transported to a cell- after 2 or 3 days would be uncertain, even with processing center for cell isolation on the day after preservation at 4°C. harvesting and for subsequent banking if it is kept Isolated adipose-derived stem cells can be fro- at 4°C. Adipose-derived stem cell yield from cryo- zen, thawed, and cultured again as well as almost preserved aspirated fat was minimal, and a further any other cell type. However, whether aspirated fat optimization of methodology of freezing and pres- tissue can be frozen as an effective filler material ervation is needed for practical use of cryopreser- or a source of adipose-derived stem cells has not vation of aspirated fat intended as an adipose- yet been established. In this study, we tried to derived stem cell source. isolate adipose-derived stem cells from aspirated fat cryopreserved for 30 days and from fresh as- Kotaro Yoshimura, M.D. Department of Plastic Surgery pirated fat. The adipose-derived stem cell yield University of Tokyo School of Medicine from cryopreserved fat was much lower than that 7-3-1, Hongo, Bunkyo-Ku of fresh aspirated fat. We tried several kinds of Tokyo 113-8655, Japan freezing conditions (rapid or slow freezing) and [email protected] other freezing media (Dulbecco’s Modified Eagle Medium or M-199 containing 10% dimethyl sul- ACKNOWLEDGMENTS foxide with 1% methylcellulose or 1% trehalose or This study was supported by Japanese Ministry of 1 to 20% gelatin, or their mixture), but the adi- Education, Culture, Sports, Science, and Technology pose-derived stem cell yield was not improved grant-in-aid B2-16390507. The authors thank Dr. Sa- (data not shown). Although there were a number toru Fukuda for assistance in the histologic assay with of red blood cells contaminating cell fractions iso- scanning electron microscopy. lated from fresh aspirated fat, almost no red blood cells contaminated those from cryopreserved as- DISCLOSURE pirated fat. Our result with adipose-derived stem None of the authors has any commercial associations cell yield from cryopreserved fat contradicts a re- or financial interests that might pose or create a conflict cent report17 showing that the adipose-derived of interest with information presented in this article. stem cell yield from cryopreserved lipoaspirates REFERENCES was approximately 90 percent of that from fresh lipoaspirates. The reported adipose-derived stem 1. Neuber, K. Fettgewebstransplantation. Verh. Dtsch. Ges. Chir. Ϯ 1: 66, 1893. cell yield from cryopreserved adipose is 3.7 2. Shiffman, M. A., and Mirrafati, S. Fat transfer techniques: 1.4 ϫ 105 cells/ml after 2 weeks of culture,17 which The effect of harvest and transfer methods on adipocyte

1516 Volume 120, Number 6 • Preservation of Liposuction Aspirates

viability and review of the literature. Dermatol. Surg. 27: 819, the fatty and fluid portions of liposuction aspirates. J. Cell. 2001. Physiol. 208: 64, 2006. 3. Ersek, R. A., Chang, P., and Salisbury, M. A. Lipo layering of 11. Boschert, M. T., Beckert, B. W., Puckett, C. L., et al. Analysis autologous fat: An improved technique with promising re- of lipocyte viability after liposuction. Plast. Reconstr. Surg. 109: sults. Plast. Reconstr. Surg. 101: 820, 1998. 761, 2002. 4. Zuk, P. A., Zhu, M., Mizuno, H., et al. Multilineage cells from 12. Kurita, M., Matsumoto, D., Shigeura, T., et al. Influences of human adipose tissue: Implications for cell-based therapies. centrifugation on cells and tissues in liposuction aspirates: Tissue Eng. 7: 211, 2001. Optimized centrifugation for lipotransfer and cell isolation. 5. Zuk, P. A., Zhu, M., Ashjian, P., et al. Human adipose tissue Plast. Reconstr. Surg. (in press). is a source of multipotent stem cells. Mol. Biol. Cell 13: 4279, 13. Miranville, A., Heeschen, C., Sengenes, C., et al. Improve- 2002. ment of postnatal neovascularization by human adipose tis- 6. Tholpady, S. S., Llull, R., Ogle, R. C., et al. Adipose tissue: sue-derived stem cells. Circulation 110: 349, 2004. Stem cells and beyond. Clin. Plast. Surg. 33: 55, 2006. 14. Matsumoto, D., Sato, K., Gonda, K., et al. Cell-assisted lipo- 7. Lendeckel, S., Jodicke, A., Christophis, P., et al. Autologous transfer (CAL): Supportive use of human adipose-derived stem cells (adipose) and fibrin glue used to treat widespread cells for soft tissue augmentation with lipoinjection. Tissue traumatic calvarial defects: Case report. J. Craniomaxillofac. Surg. 32: 370, 2004. Eng. 12: 3375, 2006. 8. Garcia-Olmo, D., Garcia-Arranz, M., Herreros, D., et al. A 15. Rehman, J., Traktuev, D., Li, J., et al. Secretion of angiogenic phase I clinical trial of the treatment of Crohn’s fistula by and antiapoptotic factors by human adipose stromal cells. adipose mesenchymal stem cell transplantation. Dis. Colon Circulation 109: 1292, 2004. Rectum 48: 1416, 2005. 16. Masuda, T., Furue, M., and Matsuda, T. Novel strategy for 9. Yoshimura, K., Sato, K., Aoi, N., et al. Cell-assisted lipotrans- soft tissue augmentation based on transplantation of frag- fer (CAL) for cosmetic breast augmentation: Supportive use mented omentum and preadipocytes. Tissue Eng. 10: 1672, of adipose derived stem/stromal cells [epub September 1, 2002. 2007.] Aesthetic Plast. Surg. DOI:10.1007/s00266-007-9019-4. 17. Pu, L. L., Cui, X., Fink, B. F., et al. Adipose aspirates as a 10. Yoshimura, K., Shigeura, T., Matsumoto, D., et al. Charac- source for human processed lipoaspirate cells after optimal terization of freshly isolated and cultured cells derived from cryopreservation. Plast. Reconstr. Surg. 117: 1845, 2006.

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1517 RECONSTRUCTIVE

Impact of the SMAS on Frey’s Syndrome after Parotid Surgery: A Prospective, Long-Term Study

Andrea Wille-Bischofberger, Background: Clinical observations indicate that creation of the superficial mus- M.D. culoaponeurotic system (SMAS) flap during parotid surgery decreases postopera- Gunesh P. Rajan, M.D. tive gustatory sweating (Frey’s syndrome) and improves cosmesis after surgery. Thomas E. Linder, M.D. Methods: On the basis of their previous study with 23 patients where no SMAS flap Stephan Schmid, M.D. was used, the authors performed a prospective, long-term study of 6½ years in 25 Zu¨rich and Luzern, Switzerland; and patients, using the SMAS flap, and compared these results with the postoperative Fremantle, Australia results of their initial study. Twenty-two patients of the SMAS flap group were available for reassessment of gustatory sweating and symptoms. The Minor starch test was used to document the extent and intensity of postoperative sweating. Satisfaction with postoperative cosmetic results was assessed through a semiquantitative questionnaire as used in the previous study. Results: The incidence of symptomatic Frey’s syndrome was significantly higher in the no–SMAS flap group after 23 months (43 percent versus 0 percent; p ϭ 0.003). The surface extent of Frey’s syndrome after 23 months was significantly reduced in the SMAS flap group (p ϭ 0.006). At final follow-up, the incidence and extent of symptomatic Frey’s syndrome showed no significant differences between the two groups (41 percent versus 56 percent; p ϭ 0.42). The rate of satisfactory cosmetic results was significantly higher in the SMAS flap group (96 percent versus 35 percent; p Ͻ 0.05). Conclusions: Creation of the SMAS flap in parotid surgery for benign lesions delays the onset and reduces the intensity and extent, but does not prevent the occurrence, of Frey’s syndrome. It reliably improves the cosmetic results by reducing the retromandibular depression after parotid surgery. (Plast. Reconstr. Surg. 120: 1519, 2007.)

rey’s syndrome is a common complication for the postoperative gustatory sweating, or in parotid surgery. The classic signs are Frey’s syndrome.2 Fsweating, rubor, and a sensation of heat Reports on the incidence of symptomatic Frey’s in the preauricular region during food intake. syndrome after parotid surgery vary between 43 It was initially described by the neurologist and 53 percent; the Minor starch-iodine test, how- Lucie Frey.1,2 The pathophysiologic basis was ever, is 100 percent positive in most of these stud- elucidated by Andre´ Thomas, who demon- ies. Several techniques and materials have been strated the aberrant nerve regeneration after described to reduce the incidence of Frey’s syn- surgery, trauma, or infection, resulting in the drome: some involve the sternocleidomastoid parasympathetic innervation of the preauricu- transposition or the interposition of fascia lata or lar eccrine sweat glands that are responsible adipose tissue; others use materials such as lyoph- ilized dura or mesh materials such as Ethisorb From the Department of Otorhinolaryngology, Head and (Ethicon, Inc., Somerville, N.J.) or polytetrafluoro- Neck Surgery, University Hospital Zu¨rich; Otolaryngology, ethylene (Gore-Tex; W. L. Gore and Associates, Head and Neck Surgery Unit, Ear Sciences Center, Lions Ear Flagstaff, Ariz.).3–7 In this prospective study, the and Hearing Institute, University of Western Australia; and superficial musculoaponeurotic system (SMAS) Department of Otorhinolaryngology, Head and Neck Sur- flap, its long-term effects on Frey’s syndrome, and gery, Kantonsspital Luzern. the cosmetic impact of the flap were investigated Received for publication February 7, 2006; revised June 23, and compared with the previously published study 2006. where no SMAS flap was used. The previous study Copyright ©2007 by the American Society of Plastic Surgeons investigated 23 patients; 43 percent of these pa- DOI: 10.1097/01.prs.0000282036.04717.1d tients became symptomatic within 9 months of

www.PRSJournal.com 1519 Plastic and Reconstructive Surgery • November 2007 follow-up, and almost all the patients displayed a positive Minor starch test after 23 months of follow-up (96 percent). The number of symptomatic patients among the available 18 long-term follow-up patients remained stable after 23 and 108 months postoperatively, and eight of 23 patients were satisfied with the postoperative cosmetic appearance.8 PATIENTS AND METHODS Between 1996 and 1998, 25 patients undergoing parotid surgery for benign parotid tumors were included. All revision cases and patients with fine needle aspiration–proven malignan- cies and tumors involving the parotid capsula Fig. 1. Intraoperative SMAS ﬂap preparation. were excluded. Capsular involvement was excluded through preoperative magnetic resonance imaging scans. The patient demographics and histologies of The exact area of the starch discoloration was the lesions are listed in Table 1. measured using a standardized grid system and documented. Surgical Technique All study patients underwent superficial pa- Cosmetic Appearance rotidectomy by means of an S-shaped, preauricu- Postoperative cosmetic results were assessed by lar incision. The SMAS plane was dissected off the the patients with the help of a semiquantitative glandular capsula and preserved as a flap in con- questionnaire, also used in the previous no–SMAS tinuity with the platysma, deep to the skin-subcu- flap study, focusing on symmetric appearance and taneous layer. After tumor excision, the SMAS flap change of cosmesis during follow-up. Satisfaction was reapproximated and sutured to the tragal was graded as follows: 1 ϭ not satisfactory, 2 ϭ plane (Fig. 1). satisfactory, and 3 ϭ highly satisfied.

Minor Starch-Iodine Test Statistical Analysis The surface extent of Frey’s syndrome was as- The results are given as percentages and sessed using the starch test described by Viktor means, with the ranges in parentheses, and were Minor.9 The affected preauricular region is coated statistically compared with the postoperative re- with iodine and Lugol’s solution, and then the test sults of our previously published study in which no is performed while the patient is chewing an ap- SMAS flap was used. The incidences of Frey’s syn- ple. Any blue discoloration of the white starch is drome were compared using the chi-square test graded for intensity as mild, moderate, or intense. and Fisher’s exact test, and the extent of involvement was compared using the Mann-Whitney test. Values of p Ͻ 0.05 were regarded as statistically Table 1. Patient Demographics and Histologic significant. (25 ؍ Patterns from 1996 through 2004 (n Characteristic Value RESULTS Sex Frey’s Syndrome Female 7 Male 18 The incidence of symptomatic Frey’s syn- Age, years drome at the 23-month follow-up was significantly Median 47 lower in the SMAS flap group (0 percent versus 43 Range 27–85 ϭ Follow-up, months percent; p 0.003) (Table 2). The extent and Mean 78 intensity of surface involvement after 23 months Range 60–100 were significantly smaller in the SMAS flap group Histologic diagnosis 2 2 ϭ Pleomorphic adenoma 19 (76) (12.5 cm versus 18.4 cm ; p 0.006) (Table 2). Warthin tumor 3 (12) On short- and long-term review, the number of Various (lymphangioma, basaloid adenoma, 3 (12) patients showing a positive starch test was lower in chronic recurrent parotitis) the SMAS flap group but did not reach signifi-

1520 Volume 120, Number 6 • SMAS and Frey’s Syndrome

Table 2. Comparison of the SMAS Flap Group and the No–SMAS Flap Group after a Mean Follow-Up of 23 and 78 Months, Respectively No–SMAS Flap Group SMAS Flap Group No–SMAS Flap Group SMAS Flap Group after 23 Months after 23 Months after 108 Months after 78 Months of Follow-Up of Follow-Up of Follow-Up of Follow-Up (%) (22 ؍ n) (%) (18 ؍ n) (%) (25 ؍ n) (%) (23 ؍ n) Symptomatic Frey’s syndrome 10/23 (43) 0% 10/18 (56) 9/22 (41) Positive minor starch-iodine test 22/23 (96) 19/25 (76) 18/18 (100) 19/22 (86) Iodine-positive surface area, cm2 Mean 18.4 12.5 22.3 21 Range 1–45 6–29 5–31 4–32 cance. After 108 months of follow-up in the no– perienced localized depigmentation that was SMAS flap group and 78 months of follow-up in treated conservatively. the SMAS group, the two groups did not display any significant differences with regard to the incidence, symptoms, or extent of Frey’s syndrome Follow-Up (41 percent versus 56 percent; p ϭ 0.42) (Table 2). The first follow-up was performed after 23 months (range, 12 to 43 months). The late timing of the first follow-up was intentional to allow enough Cosmesis time for aberrant nerve regeneration and ingrowth. Cosmetic results remained stable during the Of the initial 25 patients in the SMAS flap group, 22 follow-up. Twenty-four patients in the SMAS flap were available for long-term follow-up. Of the 23 group were highly satisfied with regard to the patients in the no–SMAS flap group, 18 were avail- scar, retromandibular depression, and facial able for follow-up. The long-term follow-up was per- symmetry. Compared with the eight patients in formed after a mean of 78 months (range, 60 to 100 the no–SMAS flap group, this was statistically months) and 108 months (range, 96 to 124 months). significant (p Ͻ 0.05) (Fig. 2). One patient ex- One patient who was subjectively highly impaired by

Fig.2. Postoperativecosmesisafter6months;comparisonofthecontralateralsidewith the side that was operated on.

1521 Plastic and Reconstructive Surgery • November 2007 the gustatory sweating received local botulinum compared with our study population as, on the toxin type A therapy. one hand, Bonanno and Casson’s series consists of subtotal and total parotidectomies requiring ex- DISCUSSION tensive dissection of the prestyloid space with sub- The aim of this prospective study was to report sequent impact on aberrant nerve regeneration, the long-term effects of the SMAS flap on the onset and on the other hand, objective starch testing was and intensity of Frey’s syndrome and on subjective not performed in these studies to detect asymp- satisfaction with the cosmesis after parotid surgery tomatic Frey’s syndrome. Several authors, such as for benign lesions. The results of the current study Cesteleyn et al., report similar outcomes using a were compared with the outcomes of an analo- combination of interposition flaps; however, their gous study conducted by the senior authors in 8 technique does not allow appropriate comparison which no SMAS flap was used. with our results, where only the SMAS flap was Various explanations for the development of used as an interposition flap.16 Frey’s syndrome exist in literature. It is widely The hypothesis of how the SMAS flap and accepted that, after transsection, the parasympa- other interposition flaps and materials delay the thetic secretory fibers regenerate. They thereby follow the sympathetic nerve sheaths of the de- onset of Frey’s syndrome is that the additional nervated sweat glands of the facial skin.9 Subse- dissection of the subcutaneous layer and the sub- quently, these sweat glands are activated during SMAS layer with the interposed flap or material mastication through cholinergic neurotransmis- leads to denser and thicker scar formation that sion. Thus, the rationale for the various described hinders and slows down nerve regeneration and techniques and materials is to prevent or amelio- ingrowth. This is supported by observations in rate Frey’s syndrome by means of mechanically studies where no interposition flaps or materials obstructing aberrant nerve ingrowth.10,11 The were used.17,18 long-term outcomes of these studies, as assessed by Interestingly, most authors agree that cos- the Minor starch-iodine test, demonstrate Frey’s metic results are persistently improved and highly syndrome in nearly all of the cases, of which be- satisfactory through the face-lift effect that occurs tween 30 and 55 percent are symptomatic.12 with the use of the SMAS flap, through which the Comparison of the current results with our postoperative preauricular, retromandibular de- previous no–SMAS flap study shows that the short- pression can be reduced markedly, as demon- term occurrence, extent, and intensity of symp- strated. This explains the significant difference in tomatic Frey’s syndrome are significantly lower in patient satisfaction between this study and our the SMAS flap group; the long-term outcomes, previous study.4,8,13–15 however, show no difference between the SMAS Because the SMAS extends into the super- flap group and the no–SMAS flap group. This ficial capsular layers of the parotid gland, ma- means that the SMAS flap is capable of delaying lignant abnormalities are a contraindication for the onset of symptomatic Frey’s syndrome. In ad- the use of the SMAS flap, as oncologic radical dition, it reduces the intensity and extent of the resection requires total periparotid SMAS re- gustatory sweating in the short term. These posi- moval. However, resection of benign lesions ex- tive effects, however, do not persist in the long tending to the parotid capsule frequently leaves term. Similar findings were reported by Taylor SMAS portions back, which then can be used for and Yoo,13,14 who reported a 45 percent incidence cosmetic reconstruction. of Frey syndrome, with 65 percent showing positive starch tests after a follow-up of 3 to 5 years. In cases where symptomatic Frey’s syndrome However, no short-term follow-up was performed impairs the patient’s quality of life, repeated as in our study, explaining their similar long-term local intradermal botulinum toxin instillations results. Several studies demonstrate much higher offer a simple method that has proven to be 19 success rates with the SMAS flap. Frequently, these effective in controlling gustatory sweating. We studies do not have a long-term follow-up period; currently use botulinum toxin treatment in one thus, it is not surprising that the incidences of study patient with impairing Frey’s syndrome, symptomatic Frey’s syndrome do correspond with and it provides inhibition of gustatory sweating our short-term results.3,5,15 Other authors such as for 6 to 8 months, after which the botulinum Bonanno and Casson report complete elimination toxin treatment is repeated. The remainder of of Frey syndrome by using the SMAS flap, based on the patients are managed satisfactorily with top- 5 to 22 years of follow-up. These results cannot be ical dermatologic preparations.

1522 Volume 120, Number 6 • SMAS and Frey’s Syndrome

CONCLUSIONS 7. Dulguerov, P., Quinodoz, D., Cosendai, G., Piletta, P., Marchal, F., and Lehmann, W. Prevention of Frey syndrome during The SMAS flap delays the onset and reduces parotidectomy. Arch. Otolaryngol. Head Neck Surg. 125: 833, 1999. the intensity and extent of symptomatic Frey’s syn- 8. Linder, T. E., Huber, A., and Schmid, S. Frey’s syndrome drome and consistently improves postoperative after parotidectomy: A retrospective and prospective analy- cosmetic results after parotid surgery. We there- sis. Laryngoscope 107: 1496, 1997. fore recommend the use of the SMAS flap for 9. Minor, V. Ein neues Verfahren zu der klinischen Untersu- chung der Schweissabsonderung. Dtsch. Z. Nervenheilkunde surgery of benign parotid lesions. 101: 302, 1928. Andrea Wille-Bischofberger, M.D. 10. Bischofberger, A., Linder, T., Melik, N., and Schmid, S. In- Kapfsteig 44 dications and effects of the SMAS in parotid surgery (in CH-8032 Zurich German). Schweiz. Med. Wochenschr. Suppl. 125: 112S, 2000. CH-8091 Zurich, Switzerland 11. Laage-Hellman, J. E. Gustatory sweating and flushing: Ae- [email protected] tiological implications of response of separate sweat glands to various stimult. Acta Otolaryngol. 49: 363, 1958. 12. Laage-Hellman, J. E. Gustatory sweating and flushing: Ae- tiological implications of latent period and mode of devel- DISCLOSURES opment after parotidectomy. Acta Otolaryngol. 49: 306, 1958. None of the authors has associated financial or com- 13. Roark, D. T., Sessions, R. B., and Alford, B. R. Frey’s syndrome: mercial interests; the study was entirely self-funded. Stan- A technical remedy. Ann. Otol. Rhinol. Laryngol. 84: 734, 1975. dard operation instruments, routine analgesics, and 14. Taylor, S. M., Yoo, J., Matthews, T. W., Lampe, H. B., and Trites, J. R. Frey’s syndrome and parotidectomy flaps: A standardized starch preparations were used during the retrospective cohort study. Otolaryngol. Head Neck Surg. 122: study. 201, 2000. 15. Taylor, S. M., and Yoo, J. Prospective cohort study comparing subcutaneous and sub-superficial musculoaponeurotic sys- REFERENCES tem flaps in superficial parotidectomy. J. Otolaryngol. 32: 71, 1. Dulguerov, P., Marchal, F., and Gysin, C. Frey syndrome before 2003. Frey: The correct history. Laryngoscope 109: 1471, 1999. 16. Cesteleyn, L., Helman, J., King, S., and Van de Vyvere, G. 2. Thomas, A. Le double re´flexe vaso-dilateur et sudoral de la Temporoparietal fascia flaps and superficial musculoapo- face conse´cutif aux blessures de la loge parotidienne. Rev. neurotic system plication in parotid surgery reduces Frey’s Neurol. (Paris) 1: 447, 1927. syndrome. J. Oral Maxillofac. Surg. 60: 1284, 2002. 3. Moltrecht, M., and Michel, O. The woman behind Frey’s 17. Yu, L. T., and Hamilton, R. Frey’s syndrome: Prevention syndrome: The tragic life of Lucja Frey. Laryngoscope 114: with conservative parotidectomy and superficial muscu- 2205, 2004. loaponeurotic system preservation. Ann. Plast. Surg. 29: 4. Bonanno, P. C., and Casson, P. R. Frey’s syndrome: A pre- 217, 1992. ventable phenomenon. Plast. Reconstr. Surg. 89: 452, 1992. 18. Rappaport, I., and Allison, G. R. Superficial musculoapo- 5. Bonanno, P. C., Palaia, D., Rosenberg, M., and Casson, P. neurotic system amelioration of parotidectomy defects. Ann. Prophylaxis against Frey’s syndrome in parotid surgery. Ann. Plast. Surg. 14: 315, 1985. Plast. Surg. 44: 498, 2000. 19. Ferraro, G., Altieri, A., Grella, E., and D’Andrea, F. Botuli- 6. Casler, J. D., and Conley, J. Sternocleidomastoid muscle transfer num toxin: 28 patients affected by Frey’s syndrome treated and superficial musculoaponeurotic system plication in the pre- with intradermal injections. Plast. Reconstr. Surg. 115: vention of Frey’s syndrome. Laryngoscope 101: 95, 1991. 344, 2005.

1523 RECONSTRUCTIVE

Reconstruction of Postburn Neck Contractures Using Free Thin Thoracodorsal Artery Perforator Flaps with Cervicoplasty

Goo-Hyun Mun, M.D. Background: Severe postburn neck contractures are devastating functional and Byeng-June Jeon, M.D. cosmetic deformities. The ideal material for coverage of defects created by neck So-Young Lim, M.D. contracture release is thin, supple, large, well-vascularized, healthy tissue. The Won-Sok Hyon, M.D. thoracodorsal artery perforator flap, a workhorse flap for reconstruction, allows Sa-Ik Bang, M.D. a large dimension and free thickness control with low donor-site morbidity. The Kap-Sung Oh, M.D. value of a free thin thoracodorsal artery perforator flap for anterior neck burn Seoul, Korea deformities has not been evaluated in a substantial series. Methods: Four men and eight women underwent neck reconstruction from December of 2002 to August of 2004. Mean patient age was 34.3 years (range, 21 to 47 years). Thorough burn scar contracture releases were performed and cervicoplasty was added for optimal neck appearance. Uniformly thin thoracodorsal artery perforator flaps were made. Both lateral ends of these flaps were designed with a fishtail shape for sufficient release and to minimize linear scar band formation in the most lateral region of the neck. Results: Elevated flaps as large as 24 ϫ 12 cm and with a mean thickness 5.3 mm were used. All flaps survived without significant complications. Range of neck motion increased, and the cervicomandibular angle was sharpened in all patients. A highly natural neck contour was universally obtained without a secondary debulking procedure. Conclusions: The free thin thoracodorsal artery perforator flap with cervicoplasty provides good functional and aesthetic results in terms of neck contour and cervicomental angle, with a reduced necessity for secondary procedures and low donor-site morbidity. This method is highly valuable for reconstruction of severe postburn neck contractures. (Plast. Reconstr. Surg. 120: 1524, 2007.)

arious methods have been suggested for good neck contour without significant donor- releasing postburn neck contractures. When site morbidity.1–4 Va contracture is limited to a small area, The ideal material for coverage of defects cre- Z-plasties and/or local skin flaps successfully ated by neck contracture release would be a thin, resolve these problems. However, when the supple, large, well-vascularized healthy tissue. contractures involve a wide area, it is difficult Given the increasing preference for the perforator to reconstruct the anterior neck using conven- flap in a wide spectrum of reconstruction cases, tional methods, such as skin grafting and/or resurfacing after scar contracture release has be- local flaps, because skin grafting often results come another indication for use of a perforator in postoperative recontracture, and the flap. Thus, several perforator flap donors have amount of uninvolved skin available for use as been selected for the reconstruction of burn scar a local flap is insufficient. Free flaps have sev- contractures in various regions of the body, includ- eral advantages, as they provide sufficient tis- ing the neck.5–12 sue with excellent function, and provide a Of the perforator flaps selected, the thoracodorsal artery perforator flap can provide generous skin From the Department of Plastic Surgery, Samsung Medical territory dimensions without causing significant Center, Sungkyunkwan University School of Medicine. donor-site morbidity and can be sufficiently Received for publication November 14, 2005; accepted Jan- thinned to match the depth of the defect created uary 12, 2006. by full neck contracture release. To the best of our Copyright ©2007 by the American Society of Plastic Surgeons knowledge, there has been no report demonstrat- DOI: 10.1097/01.prs.0000282040.39007.1d ing the value of the thoracodorsal artery perforator

1524 www.PRSJournal.com Volume 120, Number 6 • Thoracodorsal Artery Perforator Flap flap in the burn neck deformity. In this article, we beneath the inferior mandibular border in the present 12 cases of severe burn neck deformities lateral region. Platysmaplasty, which included full- reconstructed using a thoracodorsal artery perfo- width horizontal incision of the platysma, lateral rator flap with cervicoplasty and their outcomes. suspension of the platysma to the sternocleidomastoid muscle, and a midline plication with sub- PATIENTS AND METHODS cutaneous and subplatysmal lipectomy, was then From December of 2002 to August of 2004, 12 carried out. Dissection of recipient vessels (e.g., patients were treated using a thoracodorsal artery superior thyroid artery, facial artery, external jug- perforator flap with cervicoplasty. The patient ular vein, facial vein, or a branch of internal jug- group was composed of four men and eight ular vein) followed. women, with a mean age of 34.3 years (range, 21 For flap elevation, patients were placed in to 47 years). The patients had sustained flame the lateral decubitus position with the ipsilateral burns (11 cases) or a scald (one case) at least 2 arm free. Marks were placed on anatomical land- years before these presentations. marks, such as the lowest tip of the scapula, the All patients had been treated previously with posterior axillary fold, and the expected lateral skin grafts at other hospitals, but because of in- border of the latissimus dorsi muscle. A Hadeco complete contracture release and/or recurrence, ES-1000SPM flowmeter (Hadeco Inc., Kawasaki, considerable contracture remained when they Japan) with an 8-MHz probe was used intraop- presented at our institution. The patients com- eratively to detect the thoracodorsal artery per- plained of significant tightness, limitations of mo- forator. A region centered approximately 1.5 to tion in the anterior cervical region, and an un- 3 cm from the lateral free border of the latissi- natural appearance. Preoperatively, cervical range mus dorsi muscle and 8 to 12 cm from the origin of motion was measured in the six primary direc- of the posterior axillary fold was mapped out tions: flexion, extension, right and left rotation, using an audible Doppler flowmeter. To in- and right and left lateral flexion. In addition, the crease the specificity of the test, perforating cervicomandibular angle was recorded. vessels and more deeply located vessels were Patients’ back regions were free of burn inju- differentiated not only in terms of point local- ries, but two patients had skin graft donor-site ization characteristics of perforator sound but also using the authors’ perforator compression marks. Disregarding these marks, a thoracodorsal 13 artery perforator flap was selected for reconstruc- test. tion in all cases. Using the template of the neck wound made after release, a thoracodorsal artery perforator flap was designed on the back, with fishtail-shaped Surgical Technique lateral ends. An exploratory incision along the With the patient placed supine with neck and lateral margin of the design was made, and dis- shoulder hyperextension, and after infiltration of section above the dorsal thoracic fascia was per- vasoconstrictive agents (epinephrine 1:200,000) formed. Once the perforator was visualized and over the submental area, horizontal contracted judged to be adequate, adjustment of the final skin scar excision, several centimeters wide, was per- paddle design was made according to the exact formed at a level just beneath the hyoid bone. perforator location, if required. Both lateral ends of releasing skin incisions were After placing a full incision around the flap dart shaped for release of the lateral cervical con- margin, a retrograde perforator dissection was ini- tracture sufficiently and to prevent the develop- tiated. Gentle retraction of the muscle fiber in ment of postoperative linear scar contracture. opposite directions perpendicular to the course of Thorough release was achieved by incising scar the pedicle, maintenance of a bloodless field, and tissues in subcutaneous, platysmal, and subplatys- preceding dissection of intramuscular nerve mal layers according to the depth of scarring. If branches away from the pedicle are prerequisites the neck inferior to the releasing incision had for safe separation of the perforator from muscle. unsightly skin, further excision of the lower mar- After pedicle division, flaps were thinned to a gin was performed for aesthetic reasons. Generous thickness of 4 to 6 mm by removing subcutaneous subcutaneous undermining of both superior and fat on a side table. A cone-shaped small area of fat inferior wound edges was added for further re- several centimeters in diameter remained around lease. Finally, the fully stretched superior margin the perforator. This thinned flap was transferred of the defect usually resided at a level just above to the neck, and microvascular anastomoses be- the cervicomental angle in the center, and just tween donor and recipient vessels were performed

1525 Plastic and Reconstructive Surgery • November 2007

Table 1. Patient Demographics Flap Sex/ Flap Thickness Recipient Recipient Patient Age (yr) Size (cm) (mm) Artery Vein Donor Closure Complication Follow-Up 1 F/42 20 ϫ 7 6 Facial a. EJV Primary closure Tip necrosis (1.5 ϫ 1cm) 2yr10mo 2 M/26 24 ϫ 12 6 Facial a. Facial v. Skin graft Tip necrosis (1.5 ϫ 1cm) 2yr6mo 3 F/44 18 ϫ 9 5 Facial a. Facial v. Primary closure 2 yr 4 F/53 24 ϫ 12 5 STA Facial v. Primary closure 2 yr 5 F/42 22 ϫ 8 5 STA Branch of IJV Primary closure 2 yr 6 F/24 17 ϫ 8 6 STA Branch of IJV Primary closure 1 yr 6 mo 7 F/22 16 ϫ 12 4 STA Branch of IJV Primary closure 1 yr 4 mo 8 F/18 13 ϫ 6 6 Facial a. Facial v. Primary closure 1 yr 9 F/31 18 ϫ 9 5 Facial a. Facial v. Primary closure 1 yr 10 M/37 24 ϫ 9 5 Facial a. Facial v. Primary closure 8 mo 11 M/26 11 ϫ 7 5 Facial a. Facial v. Primary closure 9 mo 12 M/28 22 ϫ 8 5 Facial a. Facial v. Primary closure 6 mo F, female; M, male; a., artery; v., vein; STA, superior thyroid artery; EJV, external jugular vein; IJV, internal jugular vein. with 9-0 nylon. During insetting of the flap, both ment, respectively. The average hospital stay was 9 superior margins of the neck wound and the up- days. The postoperative course was uneventful for per border of the thoracodorsal artery perforator all patients. flap were anchored to the inferior mandibular During the follow-up period (mean, 18.9 border with strong sutures to prevent descent of months; range, 6 months to 2 years 10 months), the flap by gravity and chest burn scar. Primary five patients underwent complementary proce- closure of the donor wound was achieved up to a dures on the cervical region. Two patients with an flap width of 12 cm, but a skin graft was required extensive burn scar over the entire neck and chest in 1 patient. underwent half–Z-plasty on lateral scar bands remaining below the flap on an outpatient basis. In another patient with lateral cervical contracture, RESULTS the flap margin placed at the neck midline showed Patient clinical data are summarized in Table hypertrophic change, with a linear scar band that 1. Ten flaps were raised safely based on a single required scar revision with Z-plasty. One patient perforator. In two patients in whom large flaps underwent a tissue expansion procedure for fur- were required, a second perforator adjacent to the ther reduction of a scar remaining on the lower first was included. All perforators were true mus- neck and adjacent chest region for cosmesis. How- culocutaneous perforators with a thoracodorsal ever, debulking of the transferred flap was not vessel source. The mean location of the first per- needed in any patient. forator actually dissected in this series was 10 cm The average cervicomental angle was im- inferior to the posterior axillary fold and 3 cm proved by 48 degrees (preoperatively, 149 de- posterior to the lateral border of the latissimus grees; postoperatively, 101 degrees) (Table 2). dorsi muscle. The mean thickness of the flap mea- Thus, after surgery, the cervicomental angle in all sured in the center before defatting was 1.8 cm, 12 patients fell into the normal range (range, and the harvested pedicle length was 11 cm. The 106 to 120 degrees) and a natural neck contour final thicknesses and sizes of transferred flaps was obtained. Functional improvements were ranged from 4 to 6 mm (mean, 5.3 mm) and from evaluated minimally at 4 months after surgery, 11 ϫ 7cmto24ϫ 12 cm, respectively. Combined and a mean increase in extension of 19 degrees procedures performed simultaneously were ad- (preoperatively, 38 degrees; postoperatively, 57 vancement genioplasty (one case) and cheek scar degrees) was obtained (Table 2). No neck con- band release (one case). Donor defects were tracture recurrences occurred in this series. closed primarily in 11 patients and skin grafting was required in one. The average operation time CASE REPORTS was 8 hours. All flaps survived without significant complications. No explorations were necessary. Case 1 Two triangular tips of fishtail flaps in different A 26-year-old man sustained flame burns to his face and neck patients showed necrosis of a small area of less when he was 8 years old. Although contracture release and ϫ split-thickness skin grafting had been performed when he was than 1 1.5 cm, and these healed successfully 12 years old, severe neck contracture remained. On growing up, secondarily and by direct closure after debride- he had a hypoplastic mandible with an anterior open bite

1526 Volume 120, Number 6 • Thoracodorsal Artery Perforator Flap

Table 2. Results Rotation Lateral Flexion (degrees) (degrees) CMA Extension Flexion (degrees) (degrees) (degrees) Right Left Right Left

Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Mean 149 114 38 57 48.5 53 63 70.25 58 73.25 34.25 37.75 36.25 38.75 Range 120–180 106–120 26–45 34–70 18–62 18–80 60–68 64–78 48–68 66–82 28–40 28–45 27–40 26–45 CMA, cervicomental angle; Pre, preoperatively; Post, postoperatively.

Fig. 2. View of the thoracodorsal artery perforator ﬂap (24 ϫ 12 cm) in place on the neck.

and the patient was able to extend his neck to 45 degrees (Fig. 3). Further treatment will be undertaken in this patient to correct a residual lower lip contracture after the completion of orthodontic treatment for the correction of a labial inclination ϫ of the lower incisors, which plays a significant role in the ever- Fig. 1. (Above) A thoracodorsal artery perforator flap (24 12 sion of his lower lip. cm) was designed with fishtail-shaped lateral ends. (Below) The flap was thinned on a side table and transferred to the neck. Case 2 A 24-year-old woman sustained flame burns to her face and neck, with 18 percent total body surface area involvement, when she was 4 years old. She underwent a skin-grafting procedure 6 caused by tight anterior neck soft tissue. After releasing the years after injury, with a poor result. After meticulous contrac- contracture, cervicoplasty was performed by full-width platysma ture release, platysma transaction and lateral plication along transaction, lateral suspension, and subplatysmal fat sculptur- with sculpturing of subcutaneous and subplatysmal fat were ing. A free thin thoracodorsal artery perforator flap measuring performed. A recessed chin developed because of a tight skin ϫ 24 12 cm, with fishtail-shaped lateral ends, supplied by a envelope over the mandible during the growth period, and thus single perforator was harvested from his right back (Fig. 1, advancement genioplasty was added to improve her facial pro- above). The thickness of the flap transferred was 5.0 mm on file. A single perforator-based thoracodorsal artery perforator average after defatting (Fig. 1, below, and Fig. 2). The right facial flap (17 ϫ 8 cm) was elevated, and its thickness was reduced to artery and vein were selected as recipient vessels, and end-to- 6 mm by defatting on a side table. The superior thyroid artery end microsurgical anastomoses using 9-0 nylon were per- and a branch of the internal jugular vein were used as recipient formed. The transferred flap survived in its entirety without vessels. Her postoperative course was uneventful. At the sequelae, and an 18 ϫ 5-cm split-thickness skin graft was needed 7-month follow-up, the patient had achieved a natural neck for donor wound coverage. Six months after the operation, the contour and cervicomandibular angle improvement from 180 cervicomental angle improved from 174 degrees to 106 degrees degrees to 120 degrees (Fig. 4).

1527 Plastic and Reconstructive Surgery • November 2007

Fig. 3. Case 1. (Left) Preoperative views. (Right) Six-month postoperative views.

Case 3 been followed for 2 years without contracture recurrence, and Two years before this presentation, a 44-year-old woman an aesthetically pleasing result has been achieved (Fig. 5, above, patient suffered from second- to third-degree flame burns, with right). 55 percent total body surface area involvement. Early excision and skin grafting had been followed by multiple sessions of skin DISCUSSION grafting to treat recontracture. Nevertheless, significant ante- The goal of neck contracture reconstruction is rior cervical contracture remained and patient was unhappy with the result (Fig. 5, above, left). A 5-mm-thick thoracodorsal to thoroughly release the contracture, to obtain a artery perforator flap measuring 18 ϫ 9 cm was transferred to natural appearance, and to prevent secondary con- the neck wound following release (Fig. 5, below). The patient has tracture. To obtain a natural neck appearance, a

1528 Volume 120, Number 6 • Thoracodorsal Artery Perforator Flap

Fig. 4. Case 2. (Left) Preoperative views. (Right) Seven-month postoperative views. number of factors must be considered. Thickness and thinning by subcutaneous fat atrophy, a two- matching of the flap to the remaining neck region stage procedure and expander-associated patient is essential for achieving an aesthetically satisfactory morbidity are drawbacks of pretransfer expansion.4,15 result. The primary shortcomings of conventional Ellenbogen and Karlin16 suggested that a distinct free flaps (i.e., latissimus dorsi myocutaneous,14 inferior mandibular border, subhyoid depression, scapular-parascapular,2,3 and groin1 flaps) are their a visible thyroid cartilage bulge, a visible anterior bulkiness and the unavoidability of a secondary de- border of sternomastoid muscle, and a cervico- fatting procedure. Although preexpansion of con- mental angle of between 105 and 120 degrees are ventional donor flaps provides sufficient dimensions visual criteria of the youthful neck. However, no

1529 Plastic and Reconstructive Surgery • November 2007

Fig. 5. Case 3. (Below) A 5-mm-thick ﬂap is ready to be transferred. (Above, left) Preoperative view. (Above, right) Lateral view 2 years postoperatively.

surgical method of burn neck reconstruction can posal level. However, although large subdermal fully satisfy these goals. Only tissue with much vascular network flaps have been reported to give thinness and pliability has the potential to reflect excellent results for burn neck reconstruction, the borders, bulges, and depressions created by un- frequent need for microvascular augmentation derlying bone, cartilage, and muscle in the cervi- and a relatively restricted flap design are potential cal region. Flaps thinned by expansion still cannot weak points. Nevertheless, the authors believe that delicately reflect underlying structures because of subdermal vascular network flaps are suitable the thick periprosthetic capsule located in the un- when a very large flap is required for extensive dersurface of the mobilized flap. neck burn contracture. We assert that a skin flap with a thin layer of Perforator flaps have the inherent advantage fat not only without deep fascia and fat but also that enough fat can be removed safely, leaving only without much of the superficial fascial layer is well a small amount of fat to preserve the subdermal suited for this situation. Subdermal vascular net- plexus.5,19 Although previous reports using thinned work flaps,17,18 a recently classified flap entity, can perforator flaps harvested from the lower ex- allow sufficient thinning to the subdermal adi- tremity have achieved acceptable neck burn re-

1530 Volume 120, Number 6 • Thoracodorsal Artery Perforator Flap construction results,5–7 these donor sites have muscle is maintained.28 Furthermore, the donor- some disadvantages (e.g., unmatched skin color site scar is located in a relatively hidden area. and hairiness, limited donor skin dimension, Thus, this flap has been steadily increasing in the necessity for donor-site skin grafting, and popularity in a variety of reconstruction cases in less concealed donor-site scars). the lower extremity (including the foot), upper In addition to correct thickness control, color extremity (including hand), breast, axilla, head, and texture matching is also an important con- and neck regions. sideration for achieving an aesthetically pleasing With regard to flap design, we used a dart- neck. Flaps transferred from the lower extremity shaped incision for lateral contracture release, are known to become darker than adjacent cer- and flap lateral ends were designed with a fishtail vicofacial skin in Asians. In contrast, flaps har- pattern to fit the defects created. Although three vested from the trunk area provide a good color patients required secondary Z-plasties on lateral match with facial skin.20,21 Flaps elevated from the scar bands, when compared with other reports,1,2 deltopectoral area provide the best color match- we were able to reduce the possibility of marginal ing; however, this area is more frequently involved scar contracture formation by supplying more tis- in primary burn injuries, and donor-site morbidity sue and choosing a zigzag scar formation in the is more problematic than with flaps in the trunk most lateral aspect. However, an acute tip angle area. The upper lateral thoracic region, where the and excessive defatting of the triangular flap must thoracodorsal artery perforator flap is usually de- be avoided because of the increased chance of signed, also offers an alternative donor site for venous congestion, which the authors experi- large full-thickness skin grafts for facial burn re- enced in two cases. construction, with relatively acceptable color and 22 In our opinion, the thoracodorsal artery perfo- texture matching. Other perforator flaps from rator flap with cervicoplasty is a good alternative to the same donor territory (i.e., the dorsal thoracic 23 other approaches to severe postburn neck recon- fascia), such as dorsal scapular artery perforator struction. The advantages of the authors’ method and dorsal and lateral intercostal perforator are as follows: (1) flaps can be thinned radically, flaps,18,24 are equally suitable for cervical recon- which obviates a secondary defatting procedure; (2) struction because of their common flap charac- larger flaps with long pedicles can be harvested; (3) teristics. for flap widths of up to 12 cm, donor sites are closed The en bloc neck unit reconstruction principle proposed by Angrigiani2 undoubtedly in- primarily; (4) donor-site scars are relatively well hid- curs aesthetically superior results; however, we den and no functional deficit resulted; (5) a natural are concerned about associated donor-site mor- neck contour including a sharp cervicomental angle bidity with respect to thoracodorsal artery per- can be achieved; (6) the postoperative tendency to forator flap use. Although a skin graft was ac- form disfiguring lateral scar bands is reduced; and tually performed on the donor wound when unit (7) lateral thoracic skin provides acceptable color resurfacing was required for a patient with a and texture matching. severe contracture, we favored direct closure of The use of a free thoracodorsal artery perfo- the donor wound by limiting the flap width to 12 rator flap has several disadvantages, including pa- cm. Several methods for overcoming the limi- tient repositioning during the operation, the need tations of perforator flap width, thus allowing for careful planning and perforator mapping, and direct closure of a thigh donor site, have been difficult perforator dissection with a steep learn- proposed, including split three-dimensional ing curve. In particular, the surgeon should be harvesting,25 double flap transfer,26 and perfo- fully aware of perforator topographic variations. rator-based tissue expansion.27 However, in ad- Moreover, because of the limited dimensions of dition to the above-mentioned drawbacks of the flap that can be reliably perfused by a perfo- thigh donor and the expansion procedure, the rator, en bloc resurfacing is usually impossible. addition of another scar on the center of the This would cause an inferior aesthetic result and neck is a shortcoming of flap splitting or double an imperfect functional outcome, particularly flap techniques. when this flap is in direct contact with other skin The thoracodorsal artery perforator flap is an grafts or a contracted burn scar. However, pre- appealing flap because it offers distinct advan- transfer expansion, perforator location centraliza- tages, including a long donor vessel, a homoge- tion, and the inclusion of a double perforator neous flap thickness, and a large size. In addition, within a flap would help in the harvesting of a the function of the underlying latissimus dorsi larger flap.

1531 Plastic and Reconstructive Surgery • November 2007

CONCLUSIONS 10. Yildirim, S., Avci, G., Akan, M., Misirlioglu, A., and Akoz, T. Anterolateral thigh flap in the treatment of postburn flexion This series demonstrates the value of the contractures of the knee. Plast. Reconstr. Surg. 111: 1630, 2003. free thin thoracodorsal artery perforator flap for 11. Kimura, N., Satoh, K., and Hosaka, Y. Tensor fascia latae providing thin, supple, large amounts of tissue perforator flap. Clin. Plast. Surg. 30: 439, 2003. that well suit neck wounds created by burn scar 12. Hallock, G. G. A history of the development of muscle per- release. Twelve flaps were successfully harvested forator flaps and their specific use in burn reconstruction. J. Burn Care Rehabil. 25: 366, 2004. for reconstruction of the anterior neck, with 13. Mun, G. H., and Jeon, B. J. An efficient method to increase minimal donor-site morbidity. By complete con- specificity of acoustic Doppler sonography for planning a tracture release with cervicoplasty, and by using perforator flap: Perforator compression test. Plast. Reconstr. a unique flap design and by radical flap defat- Surg. 118: 296, 2006. ting, optimal functional and aesthetic results 14. Wilson, I. F., Lokeh, A., Schubert, W., and Benjamin, C. I. Latissimus dorsi myocutaneous flap reconstruction of neck were achieved. The described method is of con- and axillary burn contractures. Plast. Reconstr. Surg. 105: 27, siderable value for the reconstruction of severe 2000. postburn neck contractures. 15. Takushima, A., Harii, K., and Asato, H. Expanded latissimus dorsi free flap for the treatment of extensive post-burn neck Goo-Hyun Mun, M.D. contracture. J. Reconstr. Microsurg. 18: 373, 2002. Department of Plastic Surgery 16. Ellenbogen, R., and Karlin, J. V. Visual criteria for success in Samsung Medical Center restoring the youthful neck. Plast. Reconstr. Surg. 66: 6, 1980. Sungkyunkwan University School of Medicine 17. Hyakusoku, H., Gao, J. H., Pennington, D. G., Aoki, R., Ilwon-dong 50 Murakami, M., and Ogawa, R. The microvascular augmented Gangnam-ku subdermal vascular network (ma-SVN) flap: Its variations and Seoul, Korea 135-710 recent development in using intercostals perforators. Br. J. [email protected] Plast. Surg. 55: 402, 2002. 18. Ogawa, R., Hyakusoku, H., Iwakiri, I., and Akaishi, S. Severe DISCLOSURE neck scar contracture reconstructed with a ninth dorsal in- The authors of this article have no financial interests tercostals perforator augmented “super-thin flap”. Ann. Plast. Surg. 52: 216, 2004. to disclose. 19. Mun, G. Resurfacing with thoracodorsal artery perforator flap of variable thickness (Abstract). Presented at the World REFERENCES Society for Reconstructive Surgery, Second Congress, Hei- 1. Ohkubo, E., Kobayashi, S., Sekiguchi, J., and Ohmori, K. delberg, Germany, June 11–14, 2003. P. 62. Restoration of the anterior neck surface in the burned pa- 20. Yamamoto, Y., Minakawa, H., Sugihara, T., et al. Facial re- tient by free groin flap. Plast. Reconstr. Surg. 84: 276, 1990. construction with free tissue transfer. Plast. Reconstr. Surg. 94: 2. Angrigiani, C. Aesthetic microsurgical reconstruction of an- 483, 1994. terior neck burn deformities. Plast. Reconstr. Surg. 93: 507, 21. Yamamoto, Y. Colorimetric evaluation of skin color in the 1994. Japanese. Plast. Reconstr. Surg. 96: 139, 1995. 3. Tseng, W. S., Cheng, M. H., Tung, T. C., Wei, F. C., and Chen, 22. Celikoz, B., Deveci, M., Duman, H., and Nisanci, M. Recon- H. C. Microsurgical combined scapular/parascapular flap struction of facial defects and burn scars using large size for reconstruction of severe neck contracture: Case report freehand full-thickness skin graft from lateral thoracic re- and literature review. J. Trauma 47: 1142, 1999. gion. Burns 27: 174, 2001. 4. Ninkovic, M., Moser-Rumer, A., Ninkovic, M., et al. Anterior 23. Angrigiani, C., Grilli, D., Karanas, Y. L., Longaker, M. T., and neck reconstruction with pre-expanded free groin and scap- Sharma, S. The dorsal scapular island flap: An alternative for ular flaps. Plast. Reconstr. Surg. 113: 61, 2004. head, neck, and chest reconstruction. Plast. Reconstr. Surg. 5. Kimura, N. A microdissected thin tensor fasciae latae per- 111: 67, 2003. forator flap. Plast. Reconstr. Surg. 109: 69, 2002. 24. Hamdi, M., Van Landuyt, K., Monstrey, S., and Blondeel, P. 6. Tsai, F. C., Yang, J. Y., Chuang, S. S., Chang, S. Y., and Huang, Pedicled perforator flaps in breast reconstruction: A new W. C. Combined method of free lateral leg perforator flap concept. Br. J. Plast. Surg. 57: 531, 2004. with cervicoplasty for reconstruction of anterior cervical scar 25. Tsai, F., Yang, J., Mardini, S., Chuang, S., and Wei, F. Free contracture: A new flap. J. Reconstr. Microsurg. 18: 185, 2002. split-cutaneous perforator flaps procured using a three-di- 7. Yang, J. Y., Tsai, F. C., Chana, J. S., Chuang, S. S., Chang, S. Y., mensional harvest technique for the reconstruction of post- and Huang, W. C. Use of free thin anterolateral thigh flaps burn contracture defects. Plast. Reconstr. Surg. 113: 185, 2004. combined with cervicoplasty for reconstruction of postburn 26. Lin, J., Tsai, F., Yang, J., and Chuang, S. Double free flaps for anterior cervical contractures. Plast. Reconstr. Surg. 110: 39, reconstruction of postburn anterior cervical contractures: 2002. Use of perforator flaps from the lateral circumflex femoral 8. Kim, D. Y., Jeong, E. C., Kim, K. S., Lee, S. Y., and Cho, B. system. Burns 29: 622, 2003. H. Thinning of the thoracodorsal perforator-based cutane- 27. Tsai, F. A new method: Perforator-based tissue expansion for ous flap for axillary burn scar contracture. Plast. Reconstr. a preexpanded free cutaneous perforator flap. Burns 29: 845, Surg. 109: 1372, 2002. 2003. 9. Er, E., and Ucar, C. Reconstruction of axillary contractures with 28. Kim, J. T. Latissimus dorsi perforator flap. Clin. Plast. Surg. thoracodorsal perforator island flap. Burns 31: 726, 2005. 30: 403, 2003.

1532 RECONSTRUCTIVE

A Face Lift Approach for Sentinel Node Biopsy in Head and Neck Melanoma Patients

Mark L. Venturi, M.D. Background: Management of head and neck melanoma has changed dramat- Steven P. Davison, D.D.S., ically with the use of sentinel node biopsy for staging. Nodal dissection may now M.D. be delayed or deferred based on the results of the sentinel node biopsy. The Washington, D.C. authors suggest using a face lift incision to access the nodal basins for sentinel node biopsy in head and neck melanoma. Methods: A face lift incision was used successfully for sentinel node biopsy in 21 patients. The diagnosis of melanoma, histologic subtype, and depth of penetration were established by biopsy with permanent sections. All patients underwent lymphoscintigraphy on the morning of their surgery. If the scan showed multiple nodes at various levels of the neck or parotid, the patient was selected for a face lift incision for biopsy. Results: The study comprised 14 men and seven women between the ages of 26 and 82 years (mean age, 55 years). The sites of melanoma included the temple in six patients, cheek in five, neck in four, and ear and scalp in two patients each. The average Clark’s level and Breslow depth were 3.67 and 1.76 mm, respectively. The average number of basins involved was 2.14; the average number of nodes was 3.33, with an average of 1.56 nodes per basin. Follow-up ranged from 2 to 53 months (average, 26 months). Only two patients had sentinel nodes that were positive for metastatic melanoma. One complication, a transient paresis of the right marginal mandibular nerve, was observed. Conclusions: Using a face lift incision for sentinel node biopsy in head and neck melanoma is a safe, reliable technique. It provides excellent access to multiple nodal basins, well-concealed incisions, wide exposure for delayed therapeutic nodal dissection, and local and regional flap options for reconstructing the excision site. (Plast. Reconstr. Surg. 120: 1533, 2007.)

he management of cutaneous head and with melanoma and 7900 died as a result of the neck melanoma is a challenge. The combi- disease.1 Tnation of resecting wide margins in aesthet- The use of sentinel node biopsy represents ically sensitive areas and complex reconstruction the most significant advancement in the man- creates a unique situation that is often best ad- agement of melanoma. After the histologic dressed with plastic surgery principles. In the diagnosis of cutaneous melanoma, pathologic United States, the incidence of cutaneous mela- staging of the primary tumor determines the noma is increasing at a dramatic rate of 5 per- prognosis and options regarding further sur- cent per year. To place this problem in perspec- gery or adjuvant therapy. Nodal involvement tive, comparing the years 1950 and 2000, the has emerged as the most important predictor incidence of cutaneous melanoma has increased of recurrence and survival. Currently, sentinel 619 percent and the annual mortality from mel- lymph node biopsy is favored over elective anoma has increased 165 percent. In 2004, ap- lymph node dissection for staging. The use of proximately 55,000 Americans were diagnosed this technique has decreased the higher incidence of postoperative complications associ- From the Department of Plastic Surgery, Georgetown Uni- ated with elective node dissections.2 versity Medical Center. Approximately 15 to 20 percent of cutaneous Received for publication October 24, 2005; accepted February melanomas occur in the head and neck.3 These 15, 2006. melanomas offer a particular challenge because Copyright ©2007 by the American Society of Plastic Surgeons the lymphatic drainage patterns of the head and DOI: 10.1097/01.prs.0000282042.60672.c5 neck are multiple and extremely variable.4,5 This

www.PRSJournal.com 1533 Plastic and Reconstructive Surgery • November 2007 situation is further complicated by the fact that and 2 hours after injection to map the location of vital structures including cranial nerves run the nodal basins involved. Sentinel nodes are de- throughout the lymphatic basins. Preoperative fined as any nodes that receive afferent lymphatic lymphoscintigraphy is essential in head and neck drainage from the primary site. The skin overlying melanoma to map out the specific drainage pat- the involved nodal basin or basins is then marked tern and identify all of the nodal basins involved with indelible ink for intraoperative identification. before performing a sentinel node biopsy.2 Isosulfan Blue Dye PATIENTS AND MATERIALS Immediately after the induction of general an- One hundred twenty-eight patients with mel- esthesia or conscious sedation, 0.5 to 1.0 cc of anoma were evaluated by the Department of Plas- isosulfan blue dye (Lymphazurin; Zenith Paren- tic Surgery at Georgetown University Medical Cen- terals, Rosemont, Ill., or Hirsh Industries, Rich- ter between July of 2000 and February of 2005. Of mond, Va.) was injected intradermally around the these patients, 43 were diagnosed with head and primary melanoma site. The patient was then pre- neck melanoma. The diagnosis of melanoma, his- pared and draped for surgery, allowing the nec- tologic subtype, and depth of penetration were essary 15 to 20 minutes for the injected blue dye already established by biopsy with permanent sec- to travel through the afferent lymph vessels and tions. Patient selection was based on the results of stain the first draining lymph nodes. The sentinel preoperative lymphoscintigraphy. All patients un- node biopsy was performed before the excision of derwent lymphoscintigraphy on the morning of the primary melanoma site to avoid an excessive their surgery. If the lymphoscintigraphic scan accumulation of blue dye in the lymphatic basin showed multiple nodes at various levels of the neck that might make the identification of the sentinel or parotid nodal involvement, the patient was node more difficult. This technique differs from deemed to be a candidate for a face lift incision for that of other surgeons who prefer to remove the sentinel node biopsy (Fig. 1). primary tumor first to decrease background radiation caused by the primary tumor injection site. Lymphoscintigraphy On the morning of surgery, technetium-99m, Face Lift Incision which has a half-life of approximately 6 hours, was The patient is marked with their head turned injected around the primary melanoma site at four approximately 60 degrees to the opposite side to to six circumferential locations for a total volume expose the pretragal area. A pretragal face lift of 0.05 to 0.1 ml. Anteroposterior and lateral ra- incision is marked along the ear from the top of diographs were obtained at 1 minute, 10 minutes, the helix around the lobule and up the postauricular crease. An incision is made along the markings and an anterior flap is raised with the plane of dissection deep to the superficial musculoaponeurotic system (SMAS) and superficial to the parotid fascia. This plane of dissection is deeper than the subcutaneous face lift plane but necessary to access the parotid and supraomohyoid nodes and provides a better vascularized plane for subsequent flap closure. If the parotid is involved, the plane is extended medially until the position of the in- traparotid node is identified by the gamma probe. Once the position is confirmed, the parotid fascia is incised horizontally parallel to the path of the facial nerve. Parallel blunt dissection is then used to expose the blue node, which is then excised (Fig. 2). When supraomohyoid nodes are involved, the original face lift incision is continued around the Fig. 1. Lymphoscintigraphy demonstrates drainage to multiple lobule and up the postauricular crease and down nodal basins at various levels of the right neck. the posterior hairline. The dissection is extended

1534 Volume 120, Number 6 • Head and Neck Melanoma

Fig. 2. (Above) A pretragal face lift incision is marked along the ear from the superior aspect of the helix, around the lobule, and up the postauricular crease. (Below) Blunt dissection parallel to thedirectionofthefacialnerveisperformedtoexposeandexcise the blue-stained sentinel node.

inferiorly in the same plane as previously described. The platysma is reflected anteriorly and the sternocleidomastoid is reflected posteriorly to expose the lymphatic basins of the supraomohyoid nodes. If nodal involvement extends beyond the supraomohyoid nodes into levels IV and V, the same incision can be extended down as far as the clav- Fig. 3. (Above) Lymphoscintigraphy demonstrates drainage to icle. This incision can be incorporated into a cer- multiple nodal basins including levels IV and V. (Center) The patient vicofacial flap used for closure of the primary mel- is marked for excision of melanoma following sentinel node biopsy. anoma site. An additional 1- to 2-cm horizontal Isosulfan blue is injected at the melanoma site and the markings incision may be required to expose the inferior extend inferiorly to allow for exposure of level IV and V nodal basins. level IV nodes and level V nodes. In this situation, (Below) The extension of the face lift incision down the posterior the horizontal incision is positioned to function hairline allows for adequate surgical access to nodal basins at levels as a “back-cut” for the cervicofacial flap. The IV and V. This incision is easily incorporated into a cervicofacial ﬂap cervicofacial flap is raised deep to the platysma used for closure of the primary melanoma site. and the SMAS, maximizing the vascular perforators (Fig. 3).

1535 Plastic and Reconstructive Surgery • November 2007

Table 1. Patient and Melanoma Characteristics Age Clark’s Breslow No. of No. of Follow-Up Patient (yr) Sex Location Level (mm) Type Basins Nodes (mo) 1 70 F Right cheek 4 1.3 SS 3 7 21 2 57 F Right ear 4 0.94 SS 2 2 12 3 31 M Left temple 4 1.4 SS 2 2 25 4 47 F Right medial canthus 2 0.31 SS 4 3 26 5 57 M Left cheek 4 1.9 SS 2 2 37 6 44 M Right temple 4 1.0 SS 2 3 43 7 34 F Left cheek 4 2.2 N 2 2 31 8 41 M Right ear 4 3.0 N 2 6 50 9 38 F Right neck 2 0.6 SS 2 8 31 10 82 M Posterior neck 2 3.0 SS 1 2 53 11 40 M Posterior neck 3 0.9 SS 2 2 52 12 69 M Scalp 4 3.5 N 2 2 24 13 62 M Right neck 4 1.1 SS 1 1 26 14 76 M Scalp 4 1.6 SS 4 5 47 15 56 M Right forehead 4 1.1 SS 2 5 10 16 26 F Right temple 5 2.5 N 2 4 44 17 65 M Left cheek 4 2.0 N 2 2 7 18 56 M Left temple 4 3.0 N 1 1 3 19 64 M Left temple 4 1.5 SS 3 4 4 20 79 F Right cheek 3 0.42 SS 2 3 2 21 55 M Right temple 4 3.6 SS 2 4 3 Mean 55 3.67 1.76 2.14 3.33 26 M, male; F, female; SS, superficial spreading; N, nodular.

Intraoperative Identification of Sentinel Nodes were identified (superficial spreading and nodu- After the required skin flaps were raised, all lar), with the average Clark’s level being 3.67 and basins identified by preoperative lymphoscintig- the average Breslow depth being 1.76 mm. The raphy were explored using the handheld gamma average number of basins involved was 2.14, and probe (C-Track; Care Wise Medical Products, the average number of nodes was 3.33, with an Morgan Hill, Calif.). All blue nodes identified average of 1.56 nodes per basin. Only two of the were measured for radioactivity and removed as 21 patients had sentinel nodes that were positive sentinel nodes. Ex vivo sentinel node to residual for metastatic melanoma. Both patients had pos- nodal basin radioactivity percentages were calculated. Additional “hot” nodes were removed until the percentage of the residual basin to the hottest ex vivo sentinel node was less than or equal to 10 percent.6 If a node was found to be positive for metastatic melanoma then, at the time of the lymphatic dissection, the investing fascia of the nodal basin was removed. This technique was performed to adhere to sound oncologic principles. The face lift incision is not located immediately over the area of the nodal biopsy; therefore, it does not need to be incorporated in the excision and nodal dissection.

RESULTS Patient and melanoma characteristics are listed in Table 1. The study comprised 14 men and seven women between the ages of 26 and 82 years (mean, 55 years). The most common site of melanoma was the temple region (six patients), followed by the cheek (five patients), neck (four patients), and ear (two patients), and scalp (two Fig. 4. A full-thickness skin graft will often result in a suboptimal patients). Only two histologic types of melanoma color match when used for head and neck reconstruction.

1536 Volume 120, Number 6 • Head and Neck Melanoma

Fig. 5. (Above) Preoperative photographs of a 31-year-old man with a superﬁcial spreading melanoma located on his left temple. Biopsy revealed a Breslow depth of 1.4 mm. (Below) Lymphoscintigraphy demonstrates drainage to the parotid nodes and level II nodal basin. itive nodes that were located in the superficial lobe DISCUSSION of the parotid gland. They subsequently under- The reliability and utility of sentinel node biopsy went superficial parotidectomy with supraomohy- in head and neck melanoma patients have been well oid neck dissections. Fortunately, their metastatic established.7 However, the approach to the lym- disease was limited to the sentinel nodes. The phatic basins in sentinel node biopsy is of strategic follow-up ranged from 2 to 53 months, with an importance because the melanoma defect is often average of 26 months. large and in close proximity to the sentinel node. There was only one complication in the series. Traditionally, sentinel node biopsy in head and neck One patient sustained a transient paresis to the melanoma has been performed in one of two ways. right marginal mandibular nerve. She was treated The first consists of multiple small incisions over the conservatively with observation and her symptoms lymphatic basins of the neck, and the latter requires resolved in 2 months. a long extended neck incision across levels II

1537 Plastic and Reconstructive Surgery • November 2007

Fig. 6. A face lift incision is used to access both the parotid nodes and the level II nodes. After sentinel node biopsy, the melanoma site is excised with 2-cm margins and the defect is recon- structedwithacombinationofacervicofacialﬂapandascalpﬂap.Notethatapretragalincision was used in this particular case.

through IV. Either option is adequate for accessing sentinel node. It this situation, the approach to the the lymphatic basins; however, when the multiple sentinel node biopsy is not complicated. More incision approach is applied, these incisions cannot often, multiple lymphatic basins are involved at be reused should a therapeutic node dissection be various levels of the neck and require careful plan- required in the event of positive sentinel nodes. In addition, the multiple incision approach and the extended neck incision both compromise local and regional flap reconstruction, often necessitating a skin graft for reconstruction of the melanoma defect. This results in a suboptimal skin color match (Fig. 4). Ideally, facial and temporal defects are best reconstructed with like tissue from the supraclavicular region. Melanoma defects can be quite large, given the 1- to 2-cm margins often required, resulting in a defect of 2 to 6 cm in diameter. These defects can usually be reconstructed either entirely with a cervicofacial rotation flap or as a component of both a cervicofacial rotation flap and a forehead rotation flap or a scalp flap (Figs. 5 through 7). Using a face lift incision for accessing the parotid gland in melanoma surgery is not a new concept.8 However, this approach not only is useful to access the parotid gland but is also the most strategic way to approach the multiple lymphatic basins of the neck. Head and neck melanoma Fig. 7. Postoperative results at 6 months show an aesthetic re- lymphoscintigraphy rarely shows a single isolated construction facilitated by strategic sentinel node access.

1538 Volume 120, Number 6 • Head and Neck Melanoma ning to remove all of the sentinel nodes without approach is reliable and can be performed with a compromising the reconstructive options for the high degree of safety. melanoma excision site. Steven Paul Davison, D.D.S., M.D. The face lift approach has four main advan- Department of Plastic Surgery tages over the multiple incision and extended 1 PHC Building neck incision approaches. First, it provides excel- 3800 Reservoir Road, NW lent access to the multiple lymphatic basins. Pa- Washington, D.C. 20007 rotid nodes and levels II through IV and postau- [email protected] ricular nodes can easily be accessed by means of DISCLOSURE this approach directly or with a small postauricular The authors have no financial interest, commercial extension of the incision. Second, the final line of association, or conflicts of interest in any of the products, closure is located in an aesthetically favored place. materials, or techniques mentioned in this article. Third, if a sentinel node is found to be positive for metastatic disease, the same incision can be used REFERENCES for either parotidectomy or elective nodal dissec- 1. Tsao, H., Atkins, M. B., and Sober A. J. Management of cutaneous melanoma. N. Engl. J. Med. 351: 998, 2004. tion. Lastly, and most significantly, the face lift 2. Wells, K.E., Rapaport, D.P., Cruse, C. W., et al. Sentinel lymph incision does not violate the local tissues of the node biopsy in melanoma of the head and neck. Plast. Reconstr. neck, preserving the cervicofacial flap for recon- Surg. 100: 591, 1997. struction. 3. Stadelmann, W. K., McMasters, K., Digenis, A. G., et al. Cu- taneous melanoma of the head and neck: Advances in evaluation and treatment. Plast. Reconstr. Surg. 105: 2105, 2000. 4. Wells, K. E., Cruse, C. W., Daniels, S., et al. The use of lym- CONCLUSIONS phoscintigraphy in melanoma of the head and neck. Plast. Lymphoscintigraphy for sentinel node biop- Reconstr. Surg. 93: 757, 1994. sies in head and neck melanoma frequently dem- 5. Uren, R. F., Howman-Giles, R., and Thompson, J. F. Patterns onstrates involvement of multiple lymphatic ba- of lymphatic drainage from the skin in patients with melanoma. J. Nucl. Med. 44: 570, 2003. sins at various levels of the neck. In this situation, 6. Wagner, J. D., Corbett, L., Park, H. M., et al. Sentinel lymph the authors suggest using a face lift incision to node biopsy for melanoma: Experience with 234 consecutive access the nodal basins for sentinel node biopsy. procedures. Plast. Reconstr. Surg. 105: 1956, 2000. This technique provides excellent access to the 7. Davison, S. P., Clifton, M. S., Hauffman, L., et al. Sentinel node nodal basins, conceals the incisions in an aestheti- biopsy for the detection of head and neck melanoma: A review. Ann. Plast. Surg. 47: 206, 2001. cally favorable location, can provide wide exposure 8. Ollila, D. W., Foshag, L. J., Essner, R., et al. Parotid region should a therapeutic nodal dissection be required, lymphatic mapping and sentinel lymphadenectomy for cuta- and preserves flap options for reconstruction. The neous melanoma. Ann. Surg. Oncol. 6: 150, 1999.

American Society of Plastic Surgeons Mission Statement The mission of the American Society of Plastic Surgeons௡ is to support its members in their efforts to provide the highest quality patient care and maintain professional and ethical standards through education, research, and advocacy of socioeconomic and other professional activities.

1539 RECONSTRUCTIVE

Anatomical and Technical Aspects of Harvesting the Auricle as a Neurovascular Facial Subunit Transplant in Humans

Betul Gozel Ulusal, M.D. Background: Auricular transplants from cadaveric sources may be a viable al- Ali Engin Ulusal, M.D. ternative for difficult auricular reconstruction once immunologic problems are Jeng-Yee Lin, M.D. largely solved. The authors report on the neurovascular anatomy and technical Bien-Keem Tan, F.R.C.S.(Ed.) details of harvesting the auricle as a single facial subunit. Chin-Ho Wong, M.R.C.S.(Ed.) Methods: Nine auricles were studied in latex-injected (n ϭ 5) and fresh ca- Colin Song, F.R.C.S.(Ed.) daveric heads (n ϭ 4). In latex-injected heads, dissection in the neck and Fu-Chan Wei, M.D. auricular region and microdissection within the substance of the auricle were Taipei, Taiwan; and Singapore performed under loupe magnification. The arterial network was exposed and measurements were taken, including the size, length, and diameters of vessels. The number of branches supplying the entire auricle was noted. Methylene blue dye was injected into fresh cadaveric heads through the posterior auricular (n ϭ 2) or superficial temporal arteries (n ϭ 2) to assess the territory supplied by each arterial system. Results: Dye injected into the superficial temporal artery stained the upper two-thirds of the anterior and posterior auricular regions; all anterior cartilaginous eminences, except the antitragus, were homogenously stained. Dye injected into the posterior auricular artery stained the lobule, posterior auricular skin, and the depressed anterior auricular regions, including the cavum conchae, scapha, and triangular fossa. Neither the superficial temporal nor the posterior auricular arteries could adequately nourish the entire auricle as single pedicles. The auriculotemporal and great auricular nerves can be included in the transplant for sensation. The temporoparietal scalp can also be reliably included to meet reconstructive requirements. Conclusions: The auricle can be reliably elevated as a transplant when nourished by both the superficial temporal and posterior auricular arterial systems. The external jugular vein and external carotid artery can therefore be used as the vascular pedicle for auricular transplantation. (Plast. Reconstr. Surg. 120: 1540, 2007.)

he auricle is a specialized and complex fa- fibrocartilage, with characteristic eminences and cial subunit that is difficult to reconstruct depressions, which is lined with thin skin and Twhen severely deformed, such as by burn, connected to its surrounding parts and external trauma, or tumor ablation, or for congenital auditory meatus by ligaments, muscles, and fi- reasons. It is composed of a thin plate of yellow brous tissues. The most common current reconstructive alternative is the autogenous rib carti- From the Department of Plastic Surgery, Chang Gung Me- laginous framework.1 If the quality of skin in the morial Hospital, Chang Gung Medical College, Chang periauricular area is poor, however, or if there is Gung University, and the Department of Plastic Surgery, a shortage of autogenous cartilage because of Singapore General Hospital. previously failed operations, the reconstruction Received for publication March 27, 2006; accepted July 18, 1–3 2006. becomes even more difficult. Auricular trans- Presented at the 18th Annual Meeting of American Society plantation from cadaveric sources might be a for Reconstructive Microsurgery, January 14 through 17, valuable alternative for such patients. Recently, 2006, in Tucson, Arizona. following the first successful composite Copyright ©2007 by the American Society of Plastic Surgeons facial/scalp4 and auricle5 allotransplantations in DOI: 10.1097/01.prs.0000287992.28125.ce animal models, the first successful clinical case of

1540 www.PRSJournal.com Volume 120, Number 6 • Auricle Transplantation in Humans human auricular allotransplantation along with ously, immediately superficial to the galea. The the cephalocervical flap was reported by Jiang et parietal branch of the superficial temporal ar- al.6 Successful composite tissue allotransplanta- tery, the superficial temporal vein, and the au- tion requires competent microsurgical free tis- riculotemporal nerve were identified and in- sue transfer techniques, thorough knowledge of cluded in the transplant. These structures were the relevant anatomy, and stringent control of ligated cephalad unless a portion of scalp was immunologic allograft rejection.7–9 required. Dissection then continued anteriorly in The anatomy of the auricle as related to vari- a caudal direction; the frontal, middle temporal, ous flap elevations has been extensively zygomaticoorbital, and transverse facial branches studied.10–12 This anatomical study is the first to of the superficial temporal vessels were divided. explore the feasibility of harvesting the auricle Care was taken to include the neurovascular pedi- alone as a single neurovascular facial subunit cle and small anterior auricular branches along flap. the anterior portion of the auricle emanating from the superficial temporal artery and superfi- MATERIALS AND METHODS cial temporal vein. Immediately behind the neck A total of nine auricles, five latex-injected and of the mandible, at the level of the tragus, the four fresh cadaveric, were studied. For the latex superficial temporal artery and superficial tempo- injection study, the internal carotid artery was in- ral vein penetrated deep into the substance of the jected with 10% buffered formalin (to induce la- parotid gland. Because the inclusion of the pa- tex coagulation), followed by pigmented latex. rotid gland may not be desirable in auricular trans- The heads were then kept at 4°C in refrigerators plantation, the branches of the superficial tempo- for at least 24 hours. In latex-injected heads, dis- ral artery and superficial temporal vein to the section in the neck and auricular region and mi- parotid gland and masseter muscle were divided crodissection within the substance of the auricle and the gland was dissected away. Individual dis- were performed under loupe magnification. The sections of the superficial temporal artery and su- arterial network supplying the entire auricle was perficial temporal vein continued in different tis- exposed. Measurements were taken, including the sue planes. The superficial temporal vein united size, length, and diameters of vessels (with a Ver- with the internal maxillary vein to drain into the nier caliper). The number of vascular branches posterior facial vein within the parotid gland. The was also recorded. Injection studies with methyl- posterior facial vein ran inferiorly and divided into ene blue were performed in fresh cadaveric heads its anterior and posterior branches between the using either the posterior auricular artery (n ϭ 2) ramus of the mandible and the sternocleidomas- or the superficial temporal artery (n ϭ 2) to assess toid muscle. The anterior branch was ligated and the vascular territory supplied by each arterial sys- the posterior branch preserved as it was joined by tem in isolation. the posterior auricular vein to become the external jugular vein. The external jugular vein was Relevant Anatomy therefore the principal draining vessel of the auricular transplant. The posterior auricular vein The main arteries supplying the auricle are the was dissected toward the auricle. The posterior superficial temporal artery and the posterior au- auricular branch of the great auricular nerve was ricular artery, which arise from the external ca- found accompanying the posterior auricular vein rotid artery. Another branch from the occipital immediately beneath the auricular lobule. This artery provides a minor contribution to the auric- 10–13 nerve was divided and included in the transplant. ular circulation. Draining veins accompany For the arterial pedicle, the superficial tem- the corresponding arteries. Sensory innervation is poral artery was dissected toward the auricle. The provided by the great auricular and lesser occipital internal maxillary artery, a terminal branch of the nerves from the cervical plexus, the auriculotem- external carotid artery, was identified and divided poral branch of the mandibular nerve, and the 13 at the level of the mandibular neck. The posterior auricular branch of the vagus nerve. auricular artery was identified, beneath the digastric and stylohyoid muscles and opposite the apex Technique of Harvesting an Auricular of the styloid process, originating from the exter- Transplant nal carotid artery and dividing into auricular and A circular incision was placed to include a occipital branches between the auricular cartilage 1-cm skin island surrounding the auricle. Antero- and the mastoid process. The occipital branch was superiorly, the dissection continued subcutane- ligated and the auricular branch included in the

1541 Plastic and Reconstructive Surgery • November 2007

Fig. 1. The superficial temporal artery and its auricular branches Fig. 2. The vascular pedicle of the auricular flap formed from the (arrowheads). The largest branch, which crosses the helix, is uni- superficial temporal artery and the posterior auricular artery. a to formly located superior to the tragus (upper arrowhead). Note b, Posterior auricular artery length; c to d, superficial temporal that the superficial temporal artery does not give direct artery length, from the exit of the internal maxillary artery to the branches to the lobule. a, Facial region; b, temporal region; c, first auricular branch. tragal region. of the superficial temporal artery arose immedi- transplant. The auricular branch of the posterior ately below the level of the tragus (Fig. 1). At this auricular artery arose between the external audi- point, the artery became superficial as it exited tory meatus and the auriculocephalic sulcus, giv- from the substance of the parotid gland. The su- ing off several branches to the lobule and poste- perficial temporal artery did not provide direct rior auricle. Attention was paid to protect these branches to the auricular lobule (Fig. 1). A lower branches, and the cartilaginous base of the audi- branch supplying the lobule could not be identi- tory meatus was divided. The auricle was then fied in any of the specimens (Fig. 1). separated from its surrounding soft tissues, but its The mean length of the superficial temporal two pedicles, the superficial temporal and poste- artery, from its first auricular branch to the exit rior auricular vessels, were not yet divided. Dis- point of the internal maxillary artery, was 3.0 cm section of the external carotid artery and external (range, 2.5 to 3.5 cm) (Fig. 2), and its mean ex- jugular vein were continued until the required ternal diameter was 3.25 mm (range, 3.0 to 4.0 length of pedicle was harvested. mm). The external carotid artery, from the exit point of the internal maxillary artery to the carotid RESULTS bifurcation, was 5.75 cm long (range, 5.0 to 6.0 cm), and its mean diameter was 6.0 mm (range, Latex Injection Studies 5.0 to 6.0 mm). Superficial Temporal Artery Posterior Auricular Artery The superficial temporal artery provided a The auricular branch of the posterior auricu- mean of three (range, two to four) branches to the lar artery ascended behind the ear in the auricu- auricle along its anterior margin; the largest was locephalic sulcus and gave off two to three sizable uniformly located superior to the tragus (Fig. 1) branches to the lower, middle, and upper poste- and crossed the ascending helix to join the net- rior auricle (Fig. 3). The auricular lobule was pre- work in the triangular fossa and scapha. The blood dominantly supplied by a network of branches supply to the triangular fossa and scapha was from the posterior auricular artery (Fig. 3). Some therefore mainly from the superficial temporal branches curved around the cartilaginous margin, artery network. The first anterior auricular branch whereas others perforated it to supply the anterior

1542 Volume 120, Number 6 • Auricle Transplantation in Humans

mean length of the posterior auricular artery, from its first branch supplying the inferior pole of the auricle to its exit from the external carotid artery, was 3.5 cm (range, 2.5 to 4.5 cm), and its mean external diameter was 2.25 mm (range, 2.0 to 3.0 mm) (Fig. 2).

Dye Injection Studies Neither the superficial temporal artery nor the posterior auricular artery alone provided homog- enous dye staining to the entire auricle (Fig. 4). Injection into the posterior auricular artery stained the posterior auricular skin and anterior auricular depressions, including the cavum conchae, scapha, and triangular fossa (Fig. 4, left and center); approximately 8 ϫ 5 cm of the adjacent temporal scalp was also stained. Injection of this artery failed to stain the tragus (Fig. 4, left and center). Injection of the superficial temporal artery Fig. 3. The posterior auricular artery and its branches to the stained the upper two-thirds of the posterior and lower, middle, and upper posterior auricle (arrowheads). Note anterior auricle (Fig. 4, center and right), including that the lobule of the auricle is predominantly supplied by a net- all the anterior cartilaginous eminences except work formed by branches from the posterior auricular artery. the antitragus. The temporoparietal scalp region was also stained. The cavum conchae and the lobule were not stained following superficial tempo- surface of the auricle. The cymba, cavum conchae, ral artery dye injection (Fig. 4, center and right). scapha, and helix were supplied by branches from the posterior auricular artery. It formed anasto- DISCUSSION moses with the parietal and anterior auricular Facial subunits, which include the auricles, branches of the superficial temporal artery. The forehead, eyelids, nose, cheek, upper and lower

Fig. 4. Staining pattern of the auricle following methylene blue dye injection. (Left) Staining after injection into the posterior auricular artery. (Center) Schematic drawing of branches arising from the superﬁcial temporal artery and the posterior auricular artery that cause characteristic staining patterns. (Right) Stain- ing after injection into the superﬁcial temporal artery.

1543 Plastic and Reconstructive Surgery • November 2007 lips, chin, submentum, and neck, define adjacent topographic areas with characteristic skin qualities, outlines, and shapes.14,15 The subunit approach to facial reconstruction is a useful principle to follow for concealing scars, maintaining skin qualities, and restoring morphologic and landmark symmetry.15 Although microvascular surgery allows the replacement of large defects, the reconstruction of facial units that have specialized functions and three-dimensional configurations, composed of support, lining, and cover, remains a great challenge. The face is an integral part of an individual’s identity and psychological outlook. Regarding the effects of facial disfigurement on individuals, MacGregor remarked that an “unsightly scar or conspicuous defect may be as severe a social and economic handicap as complete physical incapacity.”16 The effects of facial disfigurement should not be underestimated. The ability to reconstruct facial subunits with Fig. 5. Anterior view of the auricular ﬂap based on the posterior specialized form and function from cadaveric auricular artery and superﬁcial temporal artery. sources could revolutionize the field of reconstructive surgery. This option presents an im- mense availability of neurovascular composite tis- poral artery provides a greater contribution to the sue blocks that could closely match the features, anterior and posterior aspects of the upper two- such as dimensions, texture, hairiness, and thick- thirds of the auricle and that the posterior auric- ness, of any given facial defect. A near-normal ular artery provides a greater contribution to the facial appearance could be achieved in a single posterior skin and lower third of the auricle. We also stage, with subsequent reestablishment of motor noted an absence of blood supply from the super- and/or sensory functions. Importantly, donor-site ficial temporal artery to the auricular lobule, which morbidity would be nonexistent. The require- contradicts the findings of earlier studies.10,13 Like- ment for nonspecific, toxic, lifelong immunosup- wise, Pinar et al. recently showed that a lower pression to maintain a non–life-saving allotrans- superficial temporal artery branch to the lobule plant, however, remains a major concern, and was absent in 10 of 15 specimens.12 debates regarding the clinical application of such Because anastomoses exist between the two allotransplants continue. Only if adequate immu- arterial systems, the auricle could potentially be nosuppression or donor-specific immunotoler- well vascularized by one arterial system if the other ance can be achieved with more acceptable risk was ligated intraoperatively.17,18 If the entire auri- profiles can composite tissue allotransplantations, cle is to be harvested as a flap, however, these such as that of the auricular subunit as described interconnections are divided or damaged, neces- in this article, become a widespread clinical prac- sitating the inclusion of both arteries to provide a tice. In addition to the immunologic concerns, the reliable circulation. Our dye injection studies re- technical aspects of a transplant should always be vealed that neither the superficial temporal artery elucidated before clinical attempts. In this study, nor the posterior auricular artery alone was ade- we explored the feasibility of elevating the auricle quate to homogenously stain the entire auricle, as a neurovascular facial subunit transplant (Fig. making inclusion of the external carotid artery 5) and established the technical details. necessary. The arterial anatomy of the auricle has previously been studied as related to various flap har- CONCLUSIONS vests from different parts of the auricle. It was The allotransplantation of facial subunits at believed that the anterior auricular surface was the present time appears only applicable to those supplied by the superficial temporal artery and the patients who are already on potent immunosup- posterior surface by the posterior auricular pression for other reasons, such as to maintain a artery.10 This study found that the superficial tem- previous vital organ allotransplant. These proce-

1544 Volume 120, Number 6 • Auricle Transplantation in Humans dures represent a new frontier in reconstructive donor-specific tolerance and maintenance of chimerism. surgery that could become a clinically widespread J. Immunol. 172: 1463, 2004. practice if safe transplantation tolerance strategies 8. Mapara, M. Y., Pelot, M., Zhao, G., Swenson, K., Pearson, D., and Sykes, M. Induction of stable long-term mixed hemato- or less toxic immunosuppressants are developed. poietic chimerism following nonmyeloablative conditioning Fu-Chan Wei, M.D. with T cell-depleting antibodies, cyclophosphamide, and thy- Department of Plastic and Reconstructive Surgery mic irradiation leads to donor-specific in vitro and in vivo Chang Gung Memorial Hospital tolerance. Biol. Blood Marrow Transplant. 7: 646, 2001. Chang Gung Medical College 9. Neipp, M., Gammie, J. S., Exner, B. G., et al. A partial con- Chang Gung University ditioning approach to achieve mixed chimerism in the rat: 199, Tung Hwa North Road Depletion of host natural killer cells significantly reduces the Taipei 105, Taiwan amount of total body irradiation required for engraftment. [email protected] Transplantation 68: 369, 1999. 10. Park, C., and Roh, T. S. Anatomy and embryology of the DISCLOSURE external ear and their clinical correlation. Clin. Plast. Surg. None of the authors has a financial interest in any 29: 155, 2002. of the products, devices, or drugs mentioned in this 11. Siegert, R., Weerda, H., and Remmert, S. Embryology and article. surgical anatomy of the auricle. Facial Plast. Surg. 10: 232, 1994. 12. Pinar, Y., Ikiz, Z. A., and Bilge, O. Arterial anatomy of the REFERENCES auricle: Its importance for reconstructive surgery. Surg. Ra- 1. Brent, B. Microtia repair with rib cartilage grafts: A review of diol. Anat. 25: 175, 2003. personal experience with 1000 cases. Clin. Plast. Surg. 29: 257, 13. Davis, J. E. Anatomy of the ear. In R. B. Stark (Ed.), Plastic 2002. Surgery of the Head and Neck. New York: Churchill Livingstone, 2. Nagata, S. Total auricular reconstruction with a three-di- 1987. Pp. 445–462. mensional costal cartilage framework. Ann. Chir. Plast. Esthet. 14. Menick, F. Facial reconstruction with local and distant tissue: 40: 371, 1995. The interface of aesthetic and reconstructive surgery. Plast. 3. Elsahy, N. I. Ear replantation. Clin. Plast. Surg. 29: 221, 2002. Reconstr. Surg. 102: 1424, 1998. 4. Ulusal, B. G., Ulusal, A. E., Ozmen, S., Zins, J. E., and Si- 15. Menick, F. Artistry in facial surgery: Aesthetic perceptions emionow, M. Z. A new composite facial and scalp transplantation model in rats. Plast. Reconstr. Surg. 112: 1302, 2003. and the subunit principle. Clin. Plast. Surg. 14: 723, 1987. 5. Ulusal, A. E., Ulusal, B. G., Hung, L. M., and Wei, F. C. 16. MacGregor, F. C. Some psycho-social problems associated Establishing composite auricle allotransplantation model in with facial deformities. Am. Soc. Rev. 16: 629, 1951. rats: Introduction to transplantation of facial subunits. Plast. 17. Park, C., Lew, D. H., and Yoo, W. M. An analysis of 123 Reconstr. Surg. 116: 811, 2005. temporoparietal fascial flaps: Anatomic and clinical consid- 6. Jiang, H. Q., Wang, Y., Hu, X. B., Li, Y. S., and Li, J. S. eration in total auricular reconstruction. Plast. Reconstr. Surg. Composite tissue allograft transplantation of cephalocervical 104: 1295, 1999. skin flap and two ears. Plast. Reconstr. Surg. 115: 31e, 2005. 18. Converse, J. M., McCarthy, J. G., Brauer, R. O., and Ballantyne, 7. Xu, H., Chilton, P. M., Huang, Y., Schanie, C. L., and Ildstad, D. L. Reconstructive Plastic Surgery, 2nd Ed. Philadelphia: Saun- S. T. Production of donor T cells is critical for induction of ders, 1999. Pp. 217–232.

PRS Mission Statement The goal of Plastic and Reconstructive Surgery௡ is to inform readers about significant developments in all areas related to reconstructive and cosmetic surgery. Significant papers on any aspect of plastic surgery—original clinical or laboratory research, operative procedures, comprehensive reviews, cosmetic surgery—as well as selected ideas and innovations, letters, case reports, and announcements of educational courses, meetings, and symposia are invited for publication.

1545 IDEAS AND INNOVATIONS

Measuring Sensibility of the Trigeminal Nerve

A. Lee Dellon, M.D. Eugenia Andonian, M.D. Ramon A. DeJesus, M.D. Tucson, Ariz.; and Baltimore, Md.

he form and function of the face have al- distance discrimination been considered ways been a central focus for plastic sur- before,18,19 but the Pressure-Specified Sensory geons. As approaches to facial rejuvenation Device also has been reported for evaluation of T 20–22 23 and craniomaxillofacial surgery become increas- lip and cheek sensibility. Because these lat- ingly sophisticated, measurement techniques ter clinical studies have not included normative have become more crucial. Appropriately, it is data, the present study was undertaken to pro- being recognized that the trigeminal nerve, re- vide this requisite information. sponsible for facial sensibility, plays an essential role in evaluating outcomes and complications PATIENTS AND METHODS in craniomaxillofacial surgery. Investigations so The population tested to obtain normative far have considered the sensory changes associ- data for the trigeminal nerve included 27 women ated with orofacial pain,1 facial trauma,2 facial and 15 men, with an age range of 14 to 69 years. palsy,3 cleft lip repair,4 flap reconstruction of the Exclusion criteria were history of facial injury; his- face,5,6 complications of intracranial surgery,7 tory of facial pain; history of facial surgery; history headache,8,9 and complications of Le Fort and of headaches; history of central nervous system mandibular osteotomies.10–14 Normative data us- problems, including stroke, seizure, or loss of coning traditional neurologic techniques for the tri- sciousness; and history of taking any narcotic or geminal nerve have been reported,2,15,16 such as neuropathic pain medication within the previous the Semmes-Weinstein nylon monofilaments, 2 weeks. Subjects were recruited from employees, two-point discrimination, and vibration thresh- friends, relatives, and coworkers. Total time for olds. enrollment and neurosensory testing was 2 hours. Traditional techniques for evaluating sensibil- Evaluation of trigeminal sensibility was per- ity have important limitations. The Semmes- formed with the Pressure-Specified Sensory De- Weinstein nylon monofilaments, for example, vice (Sensory Management Services, LLC, Balti- do not make a true measurement, but rather more, Md.). This device is a computer-linked, give an estimate of the one-point static pressure hand-held instrument that uses a force-transducer threshold that in reality lies between two of the attached to two independently mounted metal filaments. Vibration uses a waveform stimulus prongs. Each prong has a rounded end. As the that travels across the skin for a considerable prong or prongs are pressed against the skin sur- distance, and therefore is not valid for defining face to be tested with slowly increasing force by the the threshold for a given nerve to a restricted examiner (E.A.), the subject is asked to answer a region of skin. Two-point discrimination records question related to what sensation is perceived. only the distance component of the cutaneous The subject is asked to discriminate either one- pressure threshold, whereas the true cutaneous point static or one-point moving touch stimulus pressure threshold requires the pressure at on the skin surface, or two-point static or two-point which the two points can be distinguished also to moving touch on the skin surface. The subject be specified.17 Not only has application of the responds by pressing a hand-held button, the mes- concept of applying measurement of force to sage from which signals the computer to stop acquiring the increasing pressure stimulus data input. From the Divisions of Plastic Surgery and Neurosurgery of The force measured divided by the hemispherical Johns Hopkins University and University of Arizona, and the surface area of the prong is recorded as the pressure Dellon Institute for Peripheral Nerve Surgery. at which the individual stimulus was perceived. Five Received for publication October 16, 2006; accepted Novem- such perceptions are recorded. The highest and low- ber 30, 2006. est are discarded by the computer, which averages Copyright ©2007 by the American Society of Plastic Surgeons the remaining three and reports the result as the DOI: 10.1097/01.prs.0000282097.75302.2a cutaneous pressure threshold for either one-point

1546 www.PRSJournal.com Volume 120, Number 6 • Sensibility of the Trigeminal Nerve static, one-point moving, two-point static, or two- RESULTS point moving touch stimulus. The unit of measure- Table 1 lists the age-related normative data for ment for these pressure thresholds is grams per mil- the eight sites tested. The cutaneous pressure limeter squared. The distance at which one from two thresholds for static and moving two-point dis- points can be distinguished is varied throughout the crimination were significantly higher (less sensi- test to determine the smallest distance at which the tive) for the group 45 years or older in the regions discrimination can be determined. The unit of mea- of the medial and lateral forehead, zygoma, na- surement for this distance is millimeters. The cuta- solabial fold, and mentum (p Ͻ 0.001) but not neous pressure two-point threshold for a given piece significantly different for the upper lip (white) or of skin is defined by both the pressure and distance for the upper or lower vermilion. There was no measurement. Normative data for the Pressure- significant difference in sensibility for any site re- Specified Sensory Device have been reported al- lated to age for either one-point static or one-point ready for the upper extremity (index and little finger moving touch stimulus (Fig. 2). pulp, dorsal ulnar and radial hand, and thenar Comparison of cutaneous pressure thresholds eminence)24,25 and for the lower extremity (deep between sites demonstrated the vermilion to be and superficial peroneal nerves, hallux pulp, and significantly more sensitive (lower thresholds) medial calcaneal surface of the heel).26 than the zygoma, cheek, mentum, or medial or lateral forehead (p Ͻ 0.001) and the zygoma and Statistical analysis compared the normally dis- the cheek regions each to be significantly more tributed data for each test site for differences related sensitive (lower thresholds) than the forehead re- to the two age brackets younger than 45 years and 45 gions (p Ͻ 0.001). The medial forehead region years or older, as this cutoff has been demonstrated 24,26 was significantly more sensitive (lower thresholds) previously to have physiologic significance. Sta- than the lateral forehead (p Ͻ 0.001). There was tistical description of the data demonstrated them to no significant difference between the cheek and be normally distributed, and therefore a parametric the zygoma or between the upper and lower ver- test, the t test, was used to compare differences in milion. mean sensibility between facial regions related to different branches of the trigeminal nerve, V1 (forehead), V2 (midface), and V3 (mandible) (Fig. 1). DISCUSSION It is perhaps not surprising that the most prominent part of the face, the nose, has received the most study in terms of sensibility. In the blind burrowing animal, the mole, its nasal sensory organ, described first by Eimer, has the analogues of the quickly and slowly adapting nerve fibers and receptors of the human fingertips.27 In the bill of the duck, required for “seeing” underwater in the silt to select appropriate food items from small stones, Boecke, from Utrecht, Holland, demonstrated the same types of sensory end-organs.27 Thirty years ago, in a comparative study of mammals, Montagna and colleagues observed that the hair follicles (vibrissae) around the nose, lips, and mouth were the most innervated parts of the body, except for the hairless face of humans.28 It would appear to be the appropriate time, now, to document the sensibility of hairless human facial skin. Fig. 1. Neurosensory testing of the trigeminal nerve being per- Documenting sensibility has been a continu- formed with the Pressure-Speciﬁed Sensory Device. The patient ing struggle. The perception of pain, a small (di- reclines comfortably. The examiner applies the rounded metal ameter) nerve fiber function, remains without a prongs of the sensory testing device to the skin surface being physiologic instrument with which to measure its tested(zygoma),andslowlyincreasesthepressureofapplication threshold, and so a psychological instrument, the of either one or two prongs, as either a static or a moving touch. visual analogue scale, or the Likert scale, has been When the nonpainful stimulus is perceived, the patient pushes a validated for that purpose.29,30 For the perception button, communicating to the computer to stop acquiring data. of touch, a large (diameter) nerve fiber function,

1547 Plastic and Reconstructive Surgery • November 2007

Table 1. Mean Normative Facial Sensibility Data 1PS (g/mm) 2PS (g/mm) 2PS (mm) 1PM (g/mm) 2PM (g/mm) 2PM (mm) Lateral forehead Ͻ45 yr 0.88 31.11 10.6 0.58 10.16 8.2 Ն45 yr 1.16 39.42 14.9 0.71 11.78 12.5 Medial forehead Ͻ45 yr 0.88 22.94 8.4 0.56 5.27 6.4 Ն45 yr 0.95 33.38 11.2 0.88 8.23 9.1 Zygoma Ͻ45 yr 0.71 23.10 6.5 0.54 5.47 4.7 Ն45 yr 0.78 20.58 9.4 0.58 5.20 7.4 Nasolabial fold Ͻ45 yr 0.76 13.39 5.1 0.54 3.45 3.8 Ն45 yr 0.80 13.53 7.6 0.55 3.72 5.9 Upper lip (white) Ͻ45 yr 0.77 11.08 4.5 0.51 2.66 3.4 Ն45 yr 0.82 13.07 6.0 0.57 4.68 4.4 Upper vermilion Ͻ45 yr 0.77 3.98 3.1 0.49 1.10 2.8 Ն45 yr 0.73 3.80 3.8 0.52 1.15 3.0 Lower vermilion Ͻ45 yr 0.69 3.57 3.0 0.47 1.13 2.8 Ն45 yr 0.78 3.27 3.6 0.54 1.31 3.0 Mentum Ͻ45 yr 0.82 16.88 5.0 0.52 2.52 3.70 Ն45 yr 0.64 17.18 7.1 0.62 4.28 5.30 1PS, one-point static; 2PS, two-point static; 1PM, one-point moving; 2PM, two-point moving.

ameter myelinated fingers unambiguously. By measuring both the force and the distance at which one from two either static or moving points can be distinguished, the Pressure-Specified Sen- sory Device has been proven to be the instrument most appropriate for recording the human cutaneous pressure threshold.31 In this report, normative data for the facial skin innervated by the trigeminal nerve are reported. For the lips, especially the vermilion, the level of two-point discrimination, on the order of 3 mm, is the same as these thresholds in the fingers for people younger than 45 years. This implies that the innervation density of nerve fibers and recep- Fig.2. Close-upofapplicationofthePressure-SpeciﬁedSensory tors in the vermilion and the fingertips is the same. Device to the mentum. The lips, however, do not have either Meissner, Pacinian, or Merkel cell receptors. Rather, they have a mucocutaneous end organ, which appears there are two subgroups physiologically: slowly to be a form of the Meissner corpuscle adapted for and quickly adapting fibers. Vibratory threshold epithelium in transition from glabrous to mucous testing can measure the threshold for the quickly membrane.27 The results of the present study dem- adapting subgroup but, as the stimulus is a wave onstrate that most regions of the face, with the form, the stimulus spreads for a considerable dis- exception of the lip regions, have a significant tance, depending on its intensity, to adjacent skin increase in the cutaneous pressure threshold for surfaces, stimulating overlapping nerve territories static and moving two-point discrimination (are (i.e., both the radial and median nerves for the less sensitive) after the age of 45 years. This has not index finger pulp). In contrast, the cutaneous been demonstrated previously. pressure threshold can uniquely define a small Comparison of the data in this study with those area of skin surface. Static and moving touch stim- previously published using Semmes-Weinstein ny- uli can measure, respectively, both the slowly and lon monofilaments, vibration, and traditional quickly adapting subpopulations of the large-di- two-point discrimination2,15,16 qualitatively simi-

1548 Volume 120, Number 6 • Sensibility of the Trigeminal Nerve lar judgment that the vermilion is the most sen- 4. Posnick, J. C., Al-Qattan, M. M., Pron, G. E., and Grossman, sitive area and the forehead the least sensitive. J. A. Facial sensibility in adolescents born with cleft lip after For some regions of the face, there is a quali- undergoing repair in infancy. Plast. Reconstr. Surg. 93: 682, 1994. tative difference, for example, the study by Ke- 5. Schliephake, H., Schmelzeisen, R., and Neukam, F. W. Long- 2 sarwani et al. demonstrates the cheek and the term results of blood flow and cutaneous sensibility of flaps chin to be of equal sensitivity, whereas the study used for the reconstruction of facial soft tissue. J. Oral Max- by Posnick et al.15 and the present study (Table illofac. Surg. 52: 1247, 1994. 1) demonstrate the chin to be more sensitive 6. Boyd, B., Mulholland, S., Gullane, P., et al. Reinnervated than the cheek. In quantitative terms, the pre- lateral antebrachial cutaneous neurosome flaps in oral re- vious studies that used the Semmes-Weinstein construction: Are we making sense? Plast. Reconstr. Surg. 93: 1350, 1994. nylon monofilaments to characterize the value 7. Bergenheim, A. T., Shamsgovara, P., and Ridderheim, P. A. for one-point static touch are reported as the Microvascular decompression for trigeminal neuralgia: No marking on the nylon monofilament, represent- relation between sensory disturbance and outcome. Ster- ing a logarithmic value of force (not even the eotact. Funct. Neurosurg. 68: 200, 1997. force in milligrams) and therefore cannot be 8. Sandrini, G., Alfonsi, E., Ruiz, L. O., et al. Impairment of compared directly to the actual measurement of corneal pain perception in cluster headache. Pain 47: 299, the one-point static pressure reported in this 1991. 9. Guyuron, B., Kriegler, J. S., Davis, J., and Amini, S. B. Com- present study. In quantitative terms, the previ- prehensive surgical treatment of migraine headaches. Plast. ous studies that reported moving and static two- Reconstr. Surg. 115: 1, 2005. point discrimination values (two-point moving 10. Lawrence, J. E., and Poole, M. D. Mid-facial sensation fol- and two-point static) did so just in the distance lowing craniofacial surgery. Br. J. Plast. Surg. 45: 519, 1992. between the prongs (in millimeters), but with- 11. Posnick, J. C., Al-Qattan, M. M., and Pron, G. Facial sensibility out stratifying for age. The values for two-point in adolescents with and without clefts one year after under- moving and two-point static discrimination given in going Le Fort I osteotomy. Plast. Reconstr. Surg. 94: 431, 1994. 12. Rosenbert, A., and Sailer, H. F. A prospective study on previous studies correspond to those reported in the changes in the sensibility of the oral mucosa and the mucosa present study for the age group older than 45 years. of the upper lip after Le Fort I osteotomy. J. Craniomaxillofac. The increasing threshold with increasing age iden- Surg. 22: 286, 1994. tified in the present study confirms similar findings 13. Posnick, J. C., Al-Qattan, M. M., and Stepnern, N. M. Alter- for the upper and lower extremities24,26 and is most ation in facial sensibility in adolescents following sagittal split likely related to the previously documented decrease and chin osteotomies of the mandible. Plast. Reconstr. Surg. in sensory receptor density that occurs with age and 97: 920, 1996. 27 14. Jovic, N., Cvetinovic, M., Stosic, S., Mirkovic, Z., and Mile- which has been reviewed. These results seem es- usnic, B. Bimaxillary osteotomies in correction of dentofacial pecially timely as plastic surgeons contemplate their deformities. Vojnosanit. Pregl. 54: 53, 1997. involvement with diseases as common as the head- 15. Posnick, J. C., Zimbler, A. G., and Grossman, J. A. Normal ache and as rare as transplanting (and reinnervat- cutaneous sensibility of the face. Plast. Reconstr. Surg. 86: 429, ing) the human face.32 1990. 16. Costas, P. D., Heatley, G., and Seckel, B. R. Normal sensation A. Lee Dellon, M.D. of the human face and neck. Plast. Reconstr. Surg. 93: 1141, 3333 N. Calvert Street, Suite 370 1994. Baltimore, Md. 21218 17. Aszmann, O. C., and Dellon, A. L. Relationship of cutaneous [email protected] pressure threshold and innervation density. J. Reconstr. Mi- crosurg. 14: 417, 1998. 18. Vriens, J. P. M, and van der Glan, H. W. Relationship of facial DISCLOSURE two-point discrimination to applied force under clinical test A. Lee Dellon, M.D., has a proprietary interest in the conditions. Plast. Reconstr. Surg. 109: 943, 2002. Pressure-Specified Sensory Device. 19. Dellon, A. L. The relationship of facial two-point discrimination to applied force under clinical test conditions (Dis- REFERENCES cussion). Plast. Reconstr. Surg. 109: 953, 2002. 20. Grime, P. D. A pilot study to determine the potential 1. Hampf, G., Ekholm, A., and Salo, T. Sensibility threshold, mental health, and endocrine markers in patients with application of the pressure specified sensory device in the chronic orofacial pain. Int. J. Psychosom. 36: 37, 1989. maxillofacial region. Br. J. Oral Maxillofac. Surg. 34: 500, 2. Kesarwani, A., Antonyshyn, O., Mackinnon, S. E., Gruss, J. S., 1996. Novak, J. C., and Kelly, L. Facial sensibility testing in the 21. Evans, R. R. D., Crawley, W. A., and Dellon, A. L. Inferior normal and posttraumatic population. Ann. Plast. Surg. 22: alveolar nerve reconstruction without IMF. Ann. Plast. Surg. 416, 1989. 33: 221, 1994. 3. Novak, C. B., Ross, B., Mackinnon, S. E., and Nedzelski, J. M. 22. Mucci, S., and Dellon, A. L. Restoration of lower lip sensa- Facial sensibility in patients with unilateral facial nerve pation: Neurotization of the mental nerve with the supracla- resis. Otolaryngol. Head Neck Surg. 109: 506, 1993. vicular nerve. J. Reconstr. Microsurg. 13: 151, 1997.

1549 Plastic and Reconstructive Surgery • November 2007

23. Fogacco, W., Ferreira, M. C., and Dellon, A. L. Neurosensory 28. Montagna, W., Roman, N. A., and Macpherson, E. Compar- testing after zygoma fractures with the PSSD. Plast. Reconstr. ative study of the innervation of the facial disc of selected Surg. 113: 1943, 2004. mammals. J. Invest. Dermatol. 65: 458, 1975. 24. Dellon, A. L., and Keller, K. M. Computer-assisted quanti- 29. Revill, S. I., Robinson, J. O., Rosen, M., and Hogg, M. I. J. The tative sensory testing in carpal and cubital tunnel syndromes. reliability of a linear analogue for evaluating pain. Anesthesia Ann. Plast. Surg. 38: 493, 1997. 31: 1191, 1976. 25. Rosenberg, D., Conolley, J., and Dellon, A. L. Thenar emi- 30. Price, D. D., McGrath, P. A., Rafii, A., and Buckingham, B. nence quantitative sensory testing in diagnosis of proximal The validation of visual analogue scales as ratio scale mea- median nerve compression. J. Hand Ther. 14: 258, 2001. sures for chronic and experimental pain. Pain 17: 45, 1983. 26. Tassler, P. L., and Dellon, A. L. Pressure perception in the 31. Dellon, A. L. Somatosensory Testing and Rehabilitation. Be- normal lower extremity and in tarsal tunnel syndrome. Mus- thesda, Md.: American Occupational Therapy Association, cle Nerve 19: 285, 1996. 1997. 27. Dellon, A. L. Evaluation of Sensibility and Re-Education of Sen- 32. Siemionow, M., and Agaoglu, G. Allotransplantation of the sation in the Hand. Baltimore: Williams & Wilkins, 1981. face: How close are we? Clin. Plast. Surg. 32: 401, 2005.

Online CME Collections This partial list of titles in the developing archive of CME article collections is available online at www. PRSJournal.com. These articles are suitable to use as study guides for board certification and/or recertification, to help readers refamiliarize themselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old can be taken for CME credit. Reconstructive Head and Neck The Role of Open Rhinoplasty in the Management of Nasal Dermoid Cysts—Rod J. Rohrich et al. The Evolution of the Hughes Tarsoconjunctival Flap for Lower Eyelid Reconstruction—Rod J. Rohrich and Ross I. S. Zbar Subunit Principles in Midface Fractures: The Importance of Sagittal Buttresses, Soft-Tissue Reductions, and Sequencing Treatment of Segmental Fractures—Paul Manson et al. Microsurgical Replantation of the Amputated Nose—Dennis C. Hammond et al. Advances in Head and Neck Reconstruction—Geoffrey C. Gurtner and Gregory R. D. Evans Auricular Reconstruction: Indications for Autogenous and Prosthetic Techniques—Charles H. Thorne et al. Reconstruction of the Cheek—Frederick J. Menick Management of the Recurrent, Benign Tumor of the Parotid Gland—David L. Larson The Superiorly Based Nasolabial Flap for Simultaneous Alar and Cheek Reconstruction—Rod J. Rohrich and Matthew H. Conrad Pharmacologic Optimization of Microsurgery in the New Millennium—Matthew H. Conrad and William P. Adams, Jr. Understanding the Nasal Airway: Principles and Practice—Brian K. Howard and Rod J. Rohrich Auricular Reconstruction for Microtia: Part I. Anatomy, Embryology, and Clinical Evaluation—Elisabeth K. Beahm and Robert L. Walton Auricular Reconstruction for Microtia: Part II. Surgical Techniques—Robert L. Walton and Elisabeth K. Beahm Rhinophyma: Review and Update—Rod J. Rohrich et al. Velopharyngeal Incompetence: A Guide for Clinical Evaluation—Donnell F. Johns et al. Basal Cell Carcinoma: An Overview of Tumor Biology and Treatment—David T. Netscher and Melvin Spira Nasal Reconstruction: Forehead Flap—Frederick J. Menick Reconstruction of Acquired Scalp Defects: An Algorithmic Approach—Jason E. Leedy Further Clarification of the Nomenclature for Compound Flaps—Geoffrey G. Hallock Current Options in Head and Neck Reconstruction—Keith A. Hurvitz et al.

1550 RECONSTRUCTIVE

The Superior and Inferior Gluteal Artery Perforator Flaps

Reza Ahmadzadeh, B.Sc. Background: Perforator flaps have allowed reconstruction of soft-tissue defects Leonard Bergeron, M.D., throughout the body. The superior and inferior gluteal artery perforator flaps C.M., M.Sc. have been used clinically, yet the published anatomical studies describing the Maolin Tang, M.D. blood supply to the gluteal skin are inadequate. This study comprehensively Steven F. Morris, M.D., M.Sc. evaluated the anatomical basis of these flaps to present anatomical landmarks Halifax, Nova Scotia, Canada to facilitate flap dissection. Methods: In six fresh cadavers, the integument of the gluteal region was dissected. Cutaneous perforators of the superior and inferior gluteal arteries were identified. Their course, size, location, and type (septocutaneous versus musculocutaneous) were recorded based on dissection, angiography, and photography. The surface areas of cutaneous territories and perforator zones were measured and calculated. Results: The average number of superior and inferior cutaneous perforators greater than or equal to 0.5 mm in the gluteal region was 5 Ϯ 2 and 8 Ϯ 4, respectively, with all of the superior and 99 percent of the inferior gluteal artery perforators being musculocutaneous. Their average perforator internal diameter was 0.6 Ϯ 0.1 mm. The average superior and inferior gluteal artery cutaneous vascular territory was 69 Ϯ 56 cm2 and 177 Ϯ 38 cm2, respectively. The superior gluteal perforators were found adjacent to the medial two-thirds of a line drawn from the posterior superior iliac spine to the greater trochanter. The inferior gluteal artery perforators were concentrated along a line in the middle third of the gluteal region above the gluteal crease. Conclusion: The reliable size and consistency of the superior and inferior gluteal artery perforators allow the use of pedicled and free superior and inferior gluteal artery perforator flaps in a variety of clinical situations. (Plast. Reconstr. Surg. 120: 1551, 2007.)

ne of the main goals in reconstructive procedures. However, the sacrifice of muscle in the surgery of soft-tissue defects is to replace region and the potentially difficult dissection have O“like with like.” During the evolution of limited their acceptance. The superior gluteal ar- flap design and transfer over the past 50 years, tery perforator (SGAP) and inferior gluteal artery surgeons have gradually improved the results of perforator (IGAP) flaps have been well described reconstructive surgical procedures by selecting clinically and are reliable flap procedures. A more the best flap for a specific reconstructive chal- detailed description of the vascular anatomy will lenge. Perforator flaps have become well accepted aid surgeons in the customized design of perfora- 2 and are useful alternatives to historical reconstruc- tor flaps in this region. 3 tive techniques.1 The musculocutaneous superior Fujino et al. first used the gluteal region as a and inferior gluteal artery flaps have been previ- donor site in 1975. Since then, gluteal flaps based ously described and may have a role in certain on the superior gluteal artery have advanced, as shown in the works of Blondeel4 and Allen and 5 From the Departments of Anatomy and Neurobiology and Tucker. The inferior gluteal artery free flap was 6 Surgery, Dalhousie University. first reported by Le-Quang in 1979 and later was Received for publication December 13, 2005; accepted June used as a perforator flap by Higgins et al.7 in 2002. 7, 2006. Potential donor sites for breast reconstruction Presented at the 51st Annual Meeting of the Research Council are few. In the thin patient, the buttocks region of Plastic Surgery, in Dana Beach, California, May 20, 2006. offers a substantial amount of soft tissue that can Copyright ©2007 by the American Society of Plastic Surgeons be microsurgically transferred. Clinical works DOI: 10.1097/01.prs.0000282098.61498.ee have documented the use of the superior gluteal

www.PRSJournal.com 1551 Plastic and Reconstructive Surgery • November 2007 artery and the inferior gluteal artery musculocutaneous flaps. More recently, enthusiasm for perforator flaps has led to many reports of SGAP and IGAP perforator flaps.4,7–9 Although the SGAP flap has been extensively used, the IGAP flap has been used less widely. There is a lack of detailed anatomical information regarding the location and properties of gluteal artery perforators, which has slowed the adoption of perforator flaps in the area. The goal of this study was to objectively and comprehensively document the surgical anatomy of the superior and inferior gluteal artery perforator flaps with regard to vessel diameter, length, and cutaneous territory. MATERIALS AND METHODS Whole-body lead oxide and gelatin arterial injection studies were carried out in six fresh human Fig. 1. Medial view of the left pelvic region of a human cadaver cadavers (12 specimens) using the technique de- injected with lead oxide and gelatin. The superior and inferior scribed by Tang et al.10 For the purpose of this gluteal arties are terminal branches of the internal iliac artery. 1, study, the gluteal area is defined superiorly by the external iliac artery; 2, internal iliac artery; 3, lateral sacral artery; iliac crest, inferiorly by the inferior gluteal fold, 4, umbilical artery; 5, obturator nerve; 6, obturator artery; 7, su- laterally by the trochanter, and medially by the periorglutealartery;8,inferiorglutealartery;9,internalpudendal midline. These landmarks were identified and the artery; S1 through S4, anterior rami of sacral spinal nerves. integument was dissected. Cutaneous perforators were labeled with radiopaque markers. Radio- graphs, photographs, and dissection notes were (Fig. 1). They both exit the pelvis through the used to document the dissection at each stage. By greater sciatic foramen. The superior gluteal ar- means of angiography, photography, and dissec- tery passes superior to the piriformis muscle. It tion notes, the exact course and source artery of then gives off a deep branch that runs laterally in individual perforators were described. between the gluteus medius muscle and the iliac The length, diameter, type (musculocutane- bone. The superior gluteal artery enters the glu- ous or septocutaneous), and source artery of each teus maximus muscle to supply its upper portion perforator were identified. Vessel measurements and to send perforators to the overlying skin. The were obtained directly on the original angiogram. inferior gluteal artery travels inferior to the piri- The radiographs were assembled using Adobe formis muscle. It is accompanied by the internal Photoshop CS (Adobe Systems, Inc., San Jose, pudendal vessels, the pudendal nerve, the poste- Calif.), and the cutaneous territories of specific rior femoral cutaneous nerve (posterior cutane- perforators were determined. The cutaneous vas- ous nerve of the thigh), and the sciatic nerve. The cular territory of a specific perforating cutaneous inferior gluteal artery supplies the lower half of the blood vessel was defined as the region supplied by gluteus maximus and also provides perforators to a specific vessel between adjacent territories sep- the overlying gluteal skin. The descending branch arated by choke anastomotic vessels. Scion Image of the inferior gluteal artery, when present, ac- Beta 4.02 (Scion Corporation, Frederick, Md.) was companies the posterior femoral cutaneous nerve. used to measure cutaneous vascular territories and average perforator zones (the cutaneous ter- Local Vascular Anatomy ritory of a single cutaneous perforator). Average Both the superior and inferior gluteal arteries perforator zones were determined by dividing the are major contributors to the blood supply of the area of each vascular territory by the number of its skin in the gluteal region (Fig. 2). Other source cutaneous perforators. arteries such as the lumbar artery, deep circumflex iliac artery, lateral sacral arteries, obturator artery, RESULTS internal pudendal artery, femoral artery, pro- Regional Vascular Anatomy funda femoris artery, and medial and lateral cir- The superior and inferior gluteal arteries are cumflex femoral arteries also contribute to the both terminal branches of the internal iliac artery blood supply of the gluteal region (Fig. 2). How-

1552 Volume 120, Number 6 • Gluteal Artery Perforator Flaps

Table 1. Properties of the Superior and Inferior Gluteal Arteries Superior Gluteal Inferior Gluteal Artery Artery Regional blood Internal iliac Internal iliac supply artery artery No. of cutaneous perforators 5 Ϯ 28Ϯ 4 Average perforator size, mm 0.6 Ϯ 1 0.6 Ϯ 1 Cutaneous vascular territory, cm2 69 Ϯ 56 177 Ϯ 38 Perforator zone, cm2 21 Ϯ 824Ϯ 13

teal arteries, respectively. The average cutaneous vascular territory for the superior gluteal artery and the inferior gluteal artery in the gluteal region was found to be 69 Ϯ 56 cm2 and 177 Ϯ 38 cm2, respectively. Each perforator of the superior gluteal artery supplies an area (perforator zone) of 21 Ϯ 8cm2, and each perforator of the inferior Fig. 2. Angiogram of the integument of the left side of the ca- gluteal artery supplies 24 Ϯ 13 cm2 (Table 1). The daver from the L3 level to the midthigh region, dissected after superior gluteal artery perforators were generally medialincision.Theglutealregionisoutlinedinred.Notethatthe more vertical and the inferior gluteal artery per- superior and inferior gluteal artery vascular territories occupy forators were generally more horizontal or most of the gluteal region. G, greater trochanter; P, posterior su- oblique as they passed through the muscle. Most perior iliac spine; LA, lumbar artery; DCIA, deep circumﬂex iliac of the superior gluteal artery perforators were lo- artery; LSA, lateral sacral arteries; SGA, superior gluteal artery; IGA, cated adjacent to the medial two-thirds of a line inferior gluteal artery; IPA, internal pudendal artery; LCFA, lateral drawn from the posterior superior iliac spine to circumﬂex femoral artery; PFA, profunda femoris artery. the greater trochanter. The inferior gluteal artery perforators were mostly located in the horizontal middle third of the gluteal region parallel to the gluteal crease. Inferior gluteal artery perforators ever, the frequency of their contribution, their were also found at approximately 5 cm superior to cutaneous territory, and the number of their per- the lateral third of the gluteal crease (Fig. 3). forators in the region is minor when compared with the major contribution of superior and inferior gluteal arteries. Landmarks for SGAP Dissection On average, we found 5 Ϯ 2 cutaneous per- Based on our study, the following landmarks forators arising from the superior gluteal artery could be used to locate the SGAP and IGAP per- and 8 Ϯ 4 cutaneous perforators arising from the forators and design a viable skin paddle (Figs. 4 inferior gluteal artery. All of the superior gluteal and 5). To locate SGAP perforators, a line is drawn artery perforators and 99 percent of the inferior from the posterior superior iliac spine to the gluteal artery perforators were musculocutane- greater trochanter. Perforators are usually found ous. All of the inferior gluteal musculocutaneous adjacent to the medial two-thirds of the drawn perforators and 50 percent of the superior gluteal line. A skin paddle is positioned over the most musculocutaneous perforators passed through suitable perforator. In general, the more lateral the gluteus maximus muscle, and the remaining the perforator, the longer the pedicle. 50 percent of the superior gluteal musculocutaneous perforators passed through the gluteus me- Landmarks for IGAP Dissection dius muscle. The average diameter of the perfo- A line is drawn from the greater trochanter to rators arising from the superior and inferior the middle of the distance between the posterior gluteal artery was similar at 0.6 Ϯ 0.1 mm. superior iliac spine and the medial border of the The average pedicle length from the deep fas- gluteal crease (Figs. 4 and 5). Perforators are lo- cia was 23 Ϯ 11 mm and 21 Ϯ 11 mm for perfo- cated on the marked areas. A skin paddle is po- rators arising from the superior and inferior glu- sitioned over a desirable (size and position-wise)

1553 Plastic and Reconstructive Surgery • November 2007

100 years, including the impressive works of Manchot11 and Salmon.12 As surgery evolves, the need for specific anatomical information contin- ually changes. Thus, with the recent enthusiasm for perforator flaps, precise anatomical studies are required to carefully document cutaneous perforators suitable for flap harvest. In this study, we have described the cutaneous territories supplying the gluteal region. We specifically looked at the superior and inferior gluteal arteries and provided landmarks to perforators arising from these arteries.

SGAP The SGAP flap5 is the most used gluteal artery perforator flap. Fujino et al.3 reported in 1975 and Fig. 3. Angiogram of the integument of the left gluteal region. 197613 the use of the gluteal region for breast The superior and inferior gluteal artery vascular territories are reconstruction. In 1988, Kroll and Rosenfield14 outlined in blue and red, respectively. The yellow line indicates the documented the first use of local skin flaps based glutealcrease.Superiorglutealarteryperforatorsareusuallylocated on unspecified perforators in the gluteal area. Ko- along the superior two-thirds of a line drawn from the posterior su- shima et al.15 showed that a flap in this area can be perior iliac spine (P) to the greater trochanter (G). The inferior gluteal nourished even by one perforator. SGAP flaps artery perforators are usually located in the middle third of the glu- have been used since for sacral pressure sores,8 teal region above the gluteal crease, and also at approximately 5 cm breast reconstruction,4,5,9 breast augmentation,16 superior to the lateral third of the gluteal crease. and closure of lumbosacral myelomeningoceles.17 Musculocutaneous flaps3,13,18 and perforators flaps4,5,8,9,16,17,19–22 based on the superior gluteal artery have been described. Nevertheless, clinical studies of this region4,5,7–9,14,16,17,19–23 far outnumber the few anatomical studies15 documenting its cutaneous blood supply. In their clinical/anatomical study, Koshima et al.15 described the perforators in the gluteal region of five fresh cadavers after injecting barium into the internal iliac arteries using the arterial embalming method. They found 20 to 25 perforators in each gluteal region but did not specify the number of perforators based on each source arteries. They reported that the main cutaneous vessels of the gluteal region arise from the superior and inferior gluteal artery, which is consistent with our findings, and explained that the perforators of the superior gluteal artery are located mostly in the superolateral gluteal region. Fig. 4. Landmarks to locate inferior (a) or superior (b) gluteal ar- No previous anatomical study exists regarding the tery perforators. Cross marks (x) are at the posterior superior iliac size of the cutaneous vascular territory and per- spine and the greater trochanter. forator zones of the superior gluteal artery. Pre- vious clinical reports have documented5 flap sizes as large as 12 ϫ 32 cm2, although donor sites larger perforator and dissection proceeds as for a stan- than 10 cm in diameter after harvesting flaps tend dard perforator flap. to be more difficult to close primarily. Our anatomical findings for the superior glu- DISCUSSION teal artery perforators support clinical reports in The study of the blood supply of the skin of terms of perforator and skin paddle location. The the human body has been carried out for over ability to identify and trace back individual per-

1554 Volume 120, Number 6 • Gluteal Artery Perforator Flaps

Fig. 5. Superior gluteal artery perforator ﬂap (left) and inferior gluteal artery perforator ﬂap (right) raised on respective perforators. forators of the gluteal region with angiography has and they described its relationship to the posterior allowed better demonstration of the relationship femoral cutaneous nerve. They mentioned that of the SGAP with regards to other cutaneous vas- when this branch was absent, the cutaneous cular territories (Fig. 2). The total gluteal perfo- branch came from either the lateral or medial rator count (Table 1) is lower than that found by circumflex or profunda femoris artery. We found Koshima. This might be explained by more pre- the descending branch of the inferior gluteal ar- cise characterization of perforators with the lead tery to be present in 33 percent of cases. This oxide technique10 or by anatomical variation. illustrates the variability of this branch and should probably mandate the imaging of this branch before designing a flap on this pedicle. IGAP The inferior gluteal artery is the other domi- SGAP versus IGAP nant blood supply to the gluteal region. Surpris- ingly, very little clinical and anatomical infor- Table 1 demonstrates similar characteristics mation is available. Le-Quang6 was the first to between the SGAPs and IGAPs. Of interest is the describe the use of an inferior gluteal musculo- larger cutaneous territory of the inferior gluteal cutaneous free flap in 1979. Pedicled IGAP flaps artery. This might be of clinical significance when have been used for ischial pressure sores,7 a bulky flap needs to be raised in the gluteal region, such as for breast reconstruction. However, and free IGAP flaps have been used for breast 9 reconstruction.9 Despite these IGAP reports, no Guerra et al. used the IGAP flap in six cases for comprehensive description of the number of per- breast reconstruction but found that the exposure forators and their characteristics exists. In their of the sciatic nerve could cause prolonged post- study, Koshima et al.15 reported that the perfora- operative dysesthesia when compared with the tors of the inferior gluteal artery are located in the SGAP flap. inferomedial and inferolateral areas of the gluteal The SGAP flap has been previously described region. Our findings provide detailed anatomical in the reconstruction of trochanteric and sacral information concerning the characteristics (Table defects. Its short pedicle has prevented its use in the repair of ischial defects. This shortcoming 1) and location of IGAPs (Fig. 2) that are relevant 7 to perforator flap design in this region. prompted Higgins et al. to use an inferior gluteal The descending branch of the inferior gluteal artery perforator flap to cover an ischial pressure artery has been used clinically to perfuse flaps.24–26 sore. Its anatomy has been variably reported in the literature. Hurwitz et al.25 and Paletta et al.26 found CONCLUSIONS this branch to be consistently present. However, Both the inferior and superior gluteal arteries Cormack and Lamberty27 found that it was present supply cutaneous vascular territories that can be in 25 percent of specimens and Rubin et al.28 did harvested as valuable flaps. This study compre- not find this branch to be consistent. Windhofer hensively describes the anatomy of the SGAPs and et al.29 documented the presence of the descend- IGAPs. Clinical studies will confirm the dynamic ing inferior gluteal artery branch to be 90 percent, cutaneous vascular territory of these arteries that

1555 Plastic and Reconstructive Surgery • November 2007 will predictably be larger than our observations, 11. Manchot, C. Die Hautarterien des Menschlichen Korpers. Leipzig: because of the role of physiologic anastomoses. Vogel, 1889. The inferior gluteal artery has a more generous 12. Salmon, M. Arteries of the Skin. Paris: Masson, 1936. 13. Fujino, T., Harashina, T., and Enomoto, K. Primary breast cutaneous territory compared with the superior reconstruction after a standard radical mastectomy by a free gluteal artery. Dissection of the IGAP flap tends to flap transfer: Case report. Plast. Reconstr. Surg. 58: 371, 1976. be easier; however, proximity to the sciatic and 14. Kroll, S. S., and Rosenfield, L. Perforator-based flaps for low femoral cutaneous nerves may result in painful posterior midline defects. Plast. Reconstr. Surg. 81: 561, 1988. paresthesias postoperatively. Both of these flaps 15. Koshima, I., Moriguchi, T., Soeda, S., et al. The gluteal per- are useful options for breast reconstruction and forator-based flap for repair of sacral pressure sores. Plast. Reconstr. Surg. 91: 678, 1993. for local reconstruction in the sacral, hip, and 16. Allen, R. J., and Heitland, A. S. Autogenous augmentation perineal areas. mammaplasty with microsurgical tissue transfer. Plast. Recon- str. Surg. 112: 91, 2003. Steven F. Morris, M.D., M.Sc. 17. Duffy, F. J., Jr., Weprin, B. E., and Swift, D. M. A new approach Division of Plastic Surgery, Room 4443 1796 Summer Street to closure of large lumbosacral myelomeningoceles: The Halifax, Nova Scotia B3H 3A7, Canada superior gluteal artery perforator flap. Plast. Reconstr. Surg. [email protected] 114: 1864, 2004. 18. Shaw, W. W. Breast reconstruction by superior gluteal mi- DISCLOSURE crovascular free flaps without silicone implants. Plast. Recon- str. Surg. 72: 490, 1983. The authors have no financial interest in the prod- 19. Guerra, A. B., Soueid, N., Metzinger, S. E., et al. Simulta- ucts, devices, or drugs mentioned in this article. neous bilateral breast reconstruction with superior gluteal artery perforator (SGAP) flaps. Ann. Plast. Surg. 53: 305, REFERENCES 2004. 1. Blondeel, P. N., Morris, S. F., Hallock, G. G., and Neligan, P. 20. DellaCroce, F. J., and Sullivan, S. K. Application and refine- C. Perforator Flaps: Anatomy, Technique & Clinical Applications. ment of the superior gluteal artery perforator free flap for St. Louis: Quality Medical, 2005. bilateral simultaneous breast reconstruction. Plast. Reconstr. 2. Geddes, C. R., Morris, S. F., and Neligan, P. C. Perforator Surg. 116: 97, 2005. flaps: Evolution, classification, and applications. Ann. Plast. 21. Leow, M., Lim, J., and Lim, T. C. The superior gluteal artery Surg. 50: 90, 2003. perforator flap for the closure of sacral sores. Singapore Med. J. 3. Fujino, T., Harasina, T., and Aoyagi, F. Reconstruction for 45: 37, 2004. aplasia of the breast and pectoral region by microvascular 22. Hamdi, M., Blondeel, P., Van Landuyt, K., et al. Bilateral transfer of a free flap from the buttock. Plast. Reconstr. Surg. autogenous breast reconstruction using perforator free flaps: 56: 178, 1975. A single center’s experience. Plast. Reconstr. Surg. 114: 83, 4. Blondeel, P. N. The sensate free superior gluteal artery per- 2004. forator (S-GAP) flap: A valuable alternative in autologous 23. Gurunluoglu, R., Spanio, S., Rainer, C., et al. Skin expansion breast reconstruction. Br. J. Plast. Surg. 52: 185, 1999. before breast reconstruction with the superior gluteal artery 5. Allen, R. J., and Tucker, C., Jr. Superior gluteal artery per- perforator flap improves aesthetic outcome. Ann. Plast. Surg. forator free flap for breast reconstruction. Plast. Reconstr. 50: 475, 2003. Surg. 95: 1207, 1995. 24. Hurwitz, D. J. Closure of a large defect of the pelvic cavity by 6. Le-Quang, C. Two new flaps proceedings from aesthetic sur- an extended compound myocutaneous flap based on the gery: The lateral mammary flap and the inferior gluteal flap. inferior gluteal artery. Br. J. Plast. Surg. 33: 256, 1980. In Transactions of the 7th International Congress of Plastic and 25. Hurwitz, D. J., Swartz, W. M., and Mathes, S. J. The gluteal Reconstructive Surgery, Rio de Janeiro, Brazil, May of 1979. 7. Higgins, J. P., Orlando, G. S., and Blondeel, P. N. Ischial thigh flap: A reliable, sensate flap for the closure of buttock pressure sore reconstruction using an inferior gluteal artery and perineal wounds. Plast. Reconstr. Surg. 68: 521, 1981. perforator (IGAP) flap. Br. J. Plast. Surg. 55: 83, 2002. 26. Paletta, C., Bartell, T., and Shehadi, S. Applications of the 8. Verpaele, A. M., Blondeel, P. N., Van Landuyt, K., et al. The posterior thigh flap. Ann. Plast. Surg. 30: 41, 1993. superior gluteal artery perforator flap: An additional tool in 27. Cormack, G. C., and Lamberty, B. G. The blood supply of the treatment of sacral pressure sores. Br. J. Plast. Surg. 52: thigh skin. Plast. Reconstr. Surg. 75: 342, 1985. 385, 1999. 28. Rubin, J. A., Whetzel, T. P., and Stevenson, T. R. The pos- 9. Guerra, A. B., Metzinger, S. E., Bidros, R. S., et al. Breast terior thigh fasciocutaneous flap: Vascular anatomy and clin- reconstruction with gluteal artery perforator (GAP) flaps: A ical application. Plast. Reconstr. Surg. 95: 1228, 1995. critical analysis of 142 cases. Ann. Plast. Surg. 52: 118, 2004. 29. Windhofer, C., Brenner, E., Moriggl, B., et al. Relationship 10. Tang, M., Geddes, C. R., Yang, D., et al. Modified lead oxide- between the descending branch of the inferior gluteal artery gelatin injection technique for vascular studies. J. Clin. Anat. and the posterior femoral cutaneous nerve applicable to flap 1: 73, 2002. surgery. Surg. Radiol. Anat. 24: 253, 2002.

1556 SPECIAL TOPIC

Resumption of Sexual Activity after Plastic Surgery: Current Practice and Recommendations

Marlene Rankin, Ph.D. Background: Information on sexual counseling and practice guidelines after Gregory Borah, M.D. plastic surgery is quite limited and poorly documented as part of clinical care Sonia Alvarez, M.D. after surgery. The aim of this study was to assess board-certified plastic surgeons’ New Brunswick, N.J. current practices and to make clinical recommendations for resumption of sexual activity in the postoperative period. Methods: A descriptive mailed survey of randomly chosen American Society of Plastic Surgeons’ members was designed to evaluate plastic surgeons’ methods of screening for sexual concerns, the frequency of postoperative discussions with patients, and clinical recommendations for safe sexual positions. Results: There were 281 respondents, for a response rate of 40 percent. A minority of plastic surgeons (32.9 percent) felt it was the surgeon’s role to provide postoperative sexual counseling regarding restrictions and guidelines; the majority of plastic surgeons (63 percent) felt that their nurse should provide this service. Patients never (46.6 percent) or rarely (23.8 percent) asked about sexual activity restrictions after surgery. Some surgeons (27.8 percent) proactively discussed postoperative sexual activity, but 57.3 percent said they rarely or never gave specific advice. There were gender differences; male plastic surgeons discussed specific sexual techniques and positions significantly more frequently than female plastic surgeons (p ϭ 0.001), and patients ask male plastic surgeons significantly more frequently about sexual activity restrictions than they do female plastic surgeons (p ϭ 0.001). Conclusions: Many plastic surgeons gave little or no advice to patients regarding resumption of sexual activity after surgery, and the majority of patients do not initiate the discussion. Most surgeons expect their nursing staff to provide sexual counseling. (Plast. Reconstr. Surg. 120: 1557, 2007.)

exuality is an important dimension of perceived negative body image.1–4 There is a small sonality that is manifested in the person’s but growing body of evidence that suggests that appearance, beliefs, behaviors, and rela- changes in body image after plastic surgery may S 1,2,5 tionships with others. It is a normal part of life have a direct impact on sexuality. Body image for most adult individuals. Attributes of sexuality and self-concept have a profound effect on one’s include body image and personal expressions of desire for sexual intimacy.6 Stofman et al. re- sexual health. It is well documented in the plas- ported that women who undergo common elec- tic surgery literature that patients undergo elective cosmetic procedures such as breast, abdo- tive plastic surgery to improve their physical ap- men, and thigh operations report improved pearance or physical attractiveness, with one of body image, with higher degrees of sexual 7 the postsurgical outcomes being an improved satisfaction. emotional satisfaction with the underlying per- An integrative literature review was conducted searching MEDLINE, CINAHL, and PsycINFO From the College of Nursing, Rutgers University, and the databases for relevant studies. The literature cri- Division of Plastic Surgery, Robert Wood Johnson Medical tique identified that most articles were theoreti- School, University of Medicine and Dentistry of New Jersey. cal discussions, case studies, or research in the Received for publication April 7, 2006; accepted July 30, orthopedic, urology, or hysterectomy surgery lit- 2006. erature, or breast cancer outcome studies using Copyright ©2007 by the American Society of Plastic Surgeons samples of convenience.8,9 The review revealed DOI: 10.1097/01.prs.0000282087.22997.86 gaps in published research in the plastic surgery

www.PRSJournal.com 1557 Plastic and Reconstructive Surgery • November 2007 literature about guidelines regarding sexual characteristics were reported as descriptive statis- function after surgery, and implications for spe- tics using frequencies. Nominal data (e.g., fre- cific recommendations were absent. quencies of discussions, gender differences) were The purpose of this study was to report the analyzed using chi-square statistics. Tests of signif- results of a survey of a large group of experi- icance were two-tailed and p values were reported. enced plastic surgeons regarding their opinions A reliability analysis was computed on the re- on appropriate guidelines for safe return to sex- turned questionnaires. The ␣ coefficient for the ual activity after plastic surgery. Patients do not total Plastic Surgery Questionnaire scale for inter- generally volunteer information about their sex- nal consistency was r ϭ 0.85. The ␣ coefficient for ual concerns; it is incumbent on health profes- part III of the data set, which contained the psy- sionals to counsel about sexual function. In ad- chosexual functioning and counseling scale, was dition, we document surgeons’ preferences computed at r ϭ 0.78. The analysis of the part III concerning which member of the health care data set and qualitative comments sought to an- team should primarily deal with patients’ sexual swer the specific research questions that were for- concerns and issues. mulated to determine plastic surgeons’ presurgical screening for sexual history, recommendations MATERIALS AND METHODS for safe sexual positions, and general level of pa- This study was part of a larger descriptive, cor- tient concerns about sexual restrictions and guide- relational survey that assessed psychological com- lines after surgery. plications and patient concerns reported by plas- The qualitative data analysis consisted of sort- tic surgeons. A three-part survey instrument, the ing data into categories representing different Plastic Surgery Questionnaire, was developed and ideas or themes. Each idea was given a preliminary mailed to 702 randomly selected American Board label. Plastic surgeons’ comments were tran- of Plastic Surgery–certified plastic surgeons. A scribed and reviewed for accuracy and classified master sampling frame was compiled from the into preliminary categories. Comments were re- American Society of Plastic Surgeons Executive analyzed for validity by the primary research team, Office that included all board-certified members. and transcription classifications were refined and A cover letter explaining the purpose of the study resorted using emerging themes. The descriptive and requesting participation accompanied the category themes related to sexuality guidelines survey booklet. The study design and survey in- and activity described by plastic surgeons were struments were approved by Rutgers University coded and indexed into three final categories. and the Robert Wood Johnson Medical School’s Identified categories were placed on a matrix, or institutional review boards. visual display of the data, and the final across- The anonymous, confidential responses were respondent analysis was performed.11 directed to the nonsurgical investigator in post- age-paid business reply envelopes and pooled to RESULTS maintain the confidentiality of respondents. No The sample consisted of 281 board-certified plas- personally identifiable codes or reminder mail- tic surgeons, for a total response rate of 40 percent, ings were used. On receipt, the returned ques- 281 respondents of 702 mailed questionnaires. This tionnaires underwent data examination to ensure survey represented a well-distributed cross-section of that directions were followed and questionnaires surgeons that included 253 male plastic surgeons were consistent, accurate, and complete. Ques- and 28 female plastic surgeons. The number of years tionnaires that were not complete were not in- respondents practiced surgery ranged from 0 to cluded in the final data analysis. Based on the 281 greater than or equal to 31 years, with female plastic board-certified plastic surgeons who returned ac- surgeons practicing a mean of 10.17 years and male curate questionnaires, this study has a plus or mi- plastic surgeons practicing a mean of 13.8 years. The nus 5 percent margin of error at a 95 percent level types of practice structure identified by respondents of confidence.10 The survey instrument consisted were primarily solo (58.4 percent) or partnerships of three sections or subscales that were pilot tested (20.6 percent). There were similar percentages on on five plastic surgeons who helped determine gender and types of practice structures when the content and face validity. respondents were compared with the entire mem- The questionnaires took approximately 15 bership of the American Society of Plastic Surgeons minutes to complete. Statistical analyses were per- (Table 1). formed using SPSS Version 11 (SPSS, Inc., Chi- Plastic surgeons were asked how long pa- cago, Ill.). Demographic data and plastic surgeon tients should refrain from sexual activity in the

1558 Volume 120, Number 6 • Sexual Activity after Surgery

Table 1. Demographic Characteristics of Plastic percent) reported that the nurse should perform it, and 14 surgeons (5 percent) reported (281 ؍ Surgeons (n ASPS that someone from psychiatry should perform Variable Frequency % (%)* the postoperative sexual activity counseling. In- Sex terestingly, in a parallel survey of 312 plastic Male 253 90 91 surgical nurses conducted by the investigators, Female 28 10 9 106 nurses (34 percent) reported that it was the Years in practice 0–5 years 64 22.8 13 plastic surgeon and 78 nurses (25 percent) re- 6–10 years 68 24.2 21 ported that psychiatrists should be responsible 11–20 years 80 28.5 31 for patient sexuality counseling and concerns. 21–30 years 56 19.9 35† Ն31 years 13 4.6 Only 128 nurses (41 percent) reported that it Type of practice structure was the responsibility of the nurse.12 Statistical Solo 164 58.4 61 analysis of these two data sets showed a signifi- Partnership 58 20.6 17 Multispecialty 15 5.3 5 cant difference between plastic surgeons’ and Academic 43 15.7 14 plastic surgical nurses’ reports on which team Military 1 member should be responsible for sexual activ- Medical school appointment ϭ or affiliation ity counseling with patients (chi-square 47.96; No 136 48.4 NA p ϭ 0.001) (Table 2). Other 5 1.8 NA ASPS, American Society of Plastic Surgeons; NA, not available. *American Society of Plastic Surgeons. Personal communication, June 8, 2005, and June 19, 2006. Gender Perspective †Reported as 21 to Ն31 years combined. Even though only 10 percent of the sample were female plastic surgeons, data were analyzed from the female and male plastic surgeons’ re- postoperative period. More than half (58 per- sponses to determine whether there is a gender cent), or 165 plastic surgeons, reported that it difference. There was a significant difference depends on the type of surgical procedure, 78 (chi-square ϭ 31.6, p ϭ 0.001) between male surgeons (27.8 percent) reported 2 weeks, 34 and female respondents when asked whether surgeons (12.1 percent) reported 3 weeks, and they discussed specific sexual techniques or rec- four surgeons (1.4 percent) reported 4 weeks or ommended positions with their patients. Sixty- more. When asked how frequently patients ask four percent of female plastic surgeons reported about sexual activity restrictions in the postop- never, 21 percent reported rarely, 11 percent erative period, 131 plastic surgeons (46.6 per- reported sometimes, and only 4 percent recent) reported that patients never ask, 67 plastic ported always discussing sexual techniques or surgeons (23.8 percent) reported that patients recommending positions to their patients. Four rarely ask, five plastic surgeons (1.8 percent) percent (12 male plastic surgeons) reported reported that patients ask some of the time, and never discussing sexual techniques or recom- 78 plastic surgeons (27.8 percent) reported that mending positions to their patients, 49 percent patients always ask. When asked whether plastic (125 respondents) reported rarely, 46 percent surgeons discuss specific sexual techniques or (115 surgeons) reported sometimes, and less positions with patients in the postoperative pe- than 1 percent always discussed sexual tech- riod, 30 plastic surgeons (10.7 percent) re- niques or recommended positions. ported that they never discuss sexual techniques or positions, 131 plastic surgeons (46.6 percent) reported rarely, 118 plastic surgeons (42.3 per- Table 2. Surgeons’ and Nurses’ Reports of Team cent) reported some of the time, and only two Members Responsible for Postoperative Sexual plastic surgeons (0.4 percent) reported that Counseling they always discuss sexual techniques or posi- Responsible Team Members tions. Physician/ Psychiatrist The respondents were asked which team Surgeon (%) Nurse (%) (%) member should be responsible for counseling Plastic surgeons the patients on postoperative sexual activities. A (n ϭ 281) 90 (32) 177 (63) 14 (5) minority of 90 plastic surgeons (32 percent) Plastic surgical reported that the surgeon should perform post- nurses (n ϭ 312) 106 (34) 128 (41) 78 (25) operative sexual counseling, 177 surgeons (63 ␹2 ϭ 47.96; p ϭ 0.001.

1559 Plastic and Reconstructive Surgery • November 2007

When asked about how frequently patients Table 3. Plastic Surgeons Comments: Postoperative ask about sexual activity restrictions in the post- Sexual Activity and Patient Guidelines operative period, there was a significant differ- Patient comfort determines postoperative sexual activity ence between male and female plastic surgeon Let pain be the guide. respondents (chi-square ϭ 59.1, p ϭ 0.001). Fe- Sexual activity has no effect on postoperative results. There is no need to refrain from sex with any surgical male surgeons reported that 28 percent of their procedure ever. patients never ask, 54 percent reported that pa- Patients can determine this by themselves. tients rarely ask, 14 percent reported that pa- Whenever patients feel they are ready and comfortable. It is the patient’s discretion. tients sometimes ask, and 4 percent reported When they feel like it. that patients always ask about sexual activity re- I never ask them to refrain. strictions. Forty-eight percent of male plastic Do not raise the blood pressure; no hematomas. Sex should not last longer than half an hour. surgeons reported that patients never ask, 21 Just modify—easy does it! percent of males reported that patients rarely No specific time; whenever comfort permits. ask, 1 percent reported that patients sometimes Never discuss sexual postoperative concerns with the patients ask, and 30 percent of male surgeons reported I will not discuss sex with patients. that patients always ask about sexual activity re- I never discuss sex with patients.* strictions in the postoperative period. It is sick to discuss sexual activity or suggest sexual Three major category themes were identi- position. These questions make me suspicious of the fied during the qualitative data analysis and plas- questionnaire. tic surgeons’ comments were summarized. It is not appropriate to discuss sexual activity with These categories were as follows: patient com- patients after surgery.† fort determines postoperative sexual activity; I do not have the time to counsel patients with regard to sexual concerns in the postoperative period. plastic surgeons discuss sexual postoperative It is not my business. I refuse to discuss sexual concerns concerns with the patient; and recommended with patients. guidelines for sexual activity during the postop- Recommended guidelines for sexual activity during the postoperative period erative period (Table 3). Varies, depends on procedures Never refrain from sex activity with any surgical procedure DISCUSSION Very briefly or not at all 2 weeks Research about sexuality activity and con- 4 weeks or more cerns in plastic surgery is limited. The results of Should not significantly raise blood pressure for 2 weeks this study show that more than half of plastic No restrictions for 2 weeks unless vaginal, penile, or surgeons surveyed rarely or never discuss sexual perineal construction is performed *With 29 respondents, more than 10 percent of sample made this activity or guidelines with their patients after statement. surgery. For those who do discuss sexual activity †Sixteen plastic surgeons, or 5 percent of the sample, made this with their patients, the majority reported that it statement. depends on the surgical procedure. This study documented a relative lack of communication between patients and plastic surgeons, with al- tion. This is an area that deserves further inves- most three-quarters of patients never or rarely tigation. asking for information about sexual activity Sexuality is a sensitive topic for most pa- guidelines in the postoperative period. Inappro- tients. There may be a traditional reticence on priate sexual activity may put the patient at risk. the part of the surgeon because of time con- Like any vigorous exercise, inappropriate sexual straints, attitudes, or beliefs. The results of this activity after surgery may theoretically increase study showed that plastic surgeons are reluctant complications such as hematomas, dehiscence, to initiate discussions with patients about their muscular strains, infection, and seromas that sexual functioning after surgery. Nevertheless, if result in delayed wound healing. Data on the the plastic surgeons are comfortable with sexual actual occurrence of any such complications are issues, they will convey this to the patients, who anecdotal at best and not reported in the liter- will feel more comfortable discussing these is- ature. Patients may be reluctant to share infor- sues. Patients usually experience pain after any mation about their sexual activities negatively surgical procedure, so it is important to discuss impacting surgical results, especially if their phy- how pain will temporarily impact their sexual sicians seem uncomfortable with discussion of functioning and to suggest adaptive responses limits on sex as part of the presurgical educa- during the recovery period. The surgeon will be

1560 Volume 120, Number 6 • Sexual Activity after Surgery

Table 4. Sexual Counseling Recommendations after In a survey of 1059 women by Mavis and Plastic Surgery colleagues,15 physician gender was one of the ● Establish privacy and ensure confidentiality. least important characteristics, regardless of ● Take the initiative; recognize link between sexuality and specialty. Excellent skills gave all physicians an body image. edge in patients’ choice decisions, a finding con- ● Use language that is simple and direct. ● Discuss the specific effect of altered sexual dysfunction trary to widely held beliefs about gender oppor- during the postoperative period: duration, body part tunities in some specialties. These cited studies involvement, pressure, multiple procedures, and did not specifically address the plastic surgery recommended positions/techniques. specialty; additional research may be warranted ● Discuss the effect of postoperative pain medication/ in this area. management on sexual function, such as erections and fatigue. The paramount role that nurses play in the ● Provide handouts that give factual information and plastic surgery practice for sexual counseling address myths about pain, positions, and possible was well documented by this study. The majority misinformation, and allow for questions. of plastic surgeons indicated that nurses were ● Keep your attitude nonjudgmental, caring, and respectful. the team member primarily responsible for pro- ● Partner issues vary; include partners if possible. viding information to the patient about sexual ● Address special patient populations, age groups, and guidelines and postoperative sexual activity. Al- types of operations that would most benefit from sexual though the question was not asked directly, the counseling. inference is that nurses in turn are also being delegated the responsibility of providing suggestions for sexual positions and techniques or better equipped to deal with patients and their sex- interventions that alleviate patients’ concerns ual concerns by combining self-understanding, a during the postoperative period. Nurses are of- firm knowledge base, and expert use of surgical ten called to intervene in the sexual concerns of methodology combined with identified sexual patients when providing patient care, yet nurses activity guidelines and a nonjudgmental attitude may assume that someone else is providing in- (Table 4). formation on sexuality and perceive it is not The significant gender differences in this their job or responsibility. This discrepancy sug- study need to be interpreted with caution. There gests that patients’ needs for information are was a large difference in the number of female not being addressed by the health care team. and male respondents to this survey (28 women Clarification of responsibility among team mem- versus 253 men) even though they were com- bers is critical. Nurses need to develop skills and parable to the American Society of Plastic Sur- competence in this area through continuing ed- geons’ membership. Interestingly, male sur- ucation so that they are adequately prepared to geons discussed sexual positions and techniques provide specific instructions and address more frequently than did female surgeons, and concerns.16 male surgeons’ patients asked about resumption There are both strengths and limitations in of sexual activity more frequently than the fe- using the survey methodology as a form of re- male plastic surgeons’ patients. This finding is porting. The strengths of the study are its scope, contrary to widely held beliefs about physician size, and broad range. This survey represents 40 gender sensitivity. According to feminist medi- percent of all randomly selected subjects who cal literature, the influx of women into the med- are members of the American Society of Plastic ical profession would incorporate more “femi- Surgeons in the United States and reports across nine” values of caring, listening to patients, a broad, nongeographic population. Limita- empathy, and patient centeredness, in contrast tions of our study include an incomplete re- to the more “masculine” values of curing, dic- sponse rate and potential limitations of respon- tating to patients, and care provider centered- dent recall. Busy surgeons may not review ness. In a recent large study of 3985 surveys, patient charts, or their recollections regarding Wolosin and Gesell13 found no support for these time spent counseling patients may not be ac- generalizations and no statistical effects for phy- curate. The data findings in this study are sub- sician gender on patient care or satisfaction. ject to nonsampling error. Sources of nonsam- Johnson and colleagues14 reported that the ma- pling error include nonbias response, which jority of women did not select their obstetrician- arises when individuals who do respond to a gynecologist on the basis of gender and consid- survey differ significantly from those who do ered other physician attributes more desirable. not. Another limitation relates to the fact that

1561 Plastic and Reconstructive Surgery • November 2007 the survey was anonymous and, as such, the va- sexuality outcomes of the procedures they perform lidity of the data cannot be independently ver- and proactively manage their patients’ outcomes in ified. However, given the relatively sensitive na- the postoperative period. Specific clinical practice ture of the study, ensuring each respondent’s recommendations include a minimum of 2 weeks’ anonymity was important. Another limitation is abstinence for breast, face, and abdominal opera- that mailed surveys are subject to systematic bias tions; and specific counseling regarding techniques resulting from respondent self-selection. Re- that should include the woman on top or standing sponse is strongly influences by the respon- with rear entry, which allows for the most comfort, dent’s interest in the subject matter of the sur- alleviation of pressure, and reduction of surgical risk. vey. A probability sampling methodology using If the operation was a secondary revision or related random selection was used to control for these to previous complications, the surgeon needs to give limitations. detailed instructions related to timing and specific Unfortunately, we did not include all of the techniques for safe return to sexual activity. questions in our survey that we should have. The Marlene Rankin, Ph.D. following additional questions could have been Rutgers University included: What specific recommendations/tech- College of Medicine niques do you have for resumption of sexual ac- 180 University Avenue tivity after specific types of surgical procedures, Newark, N.J. 07102 such as abdominoplasties, breast reductions, hand [email protected] trauma, or face lifts? What specific age groups would benefit most from presurgical sexual coun- ACKNOWLEDGMENT seling? What proportion of your practice is elderly The authors express their gratitude to the staff of the or children? Department of Plastic Surgery, Robert Wood Johnson Plastic surgeons need to recognize the im- Medical School, New Brunswick, New Jersey. portance of postsurgical sexual matters to their patients. Postoperative sexual function and ac- DISCLOSURE tivity is important to patients, but there is a None of the authors has a financial interest in any of breakdown of communication. More than half the products, devices, or drugs mentioned in this article. of plastic surgeons in this study do not give advice on postsurgical sexual activity, but when REFERENCES they do, resumption of full activity in 2 to 3 1. Cerovac, S., Ali, F. S., Blizard, R., Lloyd, G., and Butler, weeks is the consensus. Plastic surgeons should P. E. M. Psychosexual function in women who have undergone reduction mammaplasty. Plast. Reconstr. Surg. 116: identify which team member is responsible for 1306, 2005. the sexuality counseling within their practice 2. van Soest, T., Kvalem, I. L., Skolleborg, K. C., and Roald, and provide resource material to patients for a H. E. Psychosocial factors predicting the motivation to safe return to sexual activity. A presurgical cli- undergo cosmetic surgery. Plast. Reconstr. Surg. 117: 51, mate that openly addresses specific patient lim- 2006. 3. Rankin, M., Borah, G. L., Perry, A. W., and Wey, P. D. Quality itations and concerns regarding postoperative of life outcomes after cosmetic surgery. Plast. Reconstr. Surg. sexual activity should be fostered. 102: 2139, 1998. 4. Sarwer, D. B., and Crerand, C. E. Body image and cosmetic CONCLUSIONS medical treatments. Body Image 1: 99, 2004. Many plastic surgeons gave little or no advice 5. Pelusi, J. Sexuality and body image. Am. J. Nurs. 106: 32, 2006. to patients regarding resumption of sexual ac- 6. Grunert, B. K., Devine, C. A., Matloub, H. S., Sanger, J. R., tivity, and the majority of patients do not initiate and Yousif, N. J. Sexual dysfunction following traumatic hand the discussion. There were significant gender injury. Ann. Plast. Surg. 21: 46, 1988. differences between female and male plastic sur- 7. Stofman, G. M., Neavin, T. S., Ramineni, P. M., and Alford, geons. Barriers identified by our study include A. Better sex from the knife? An intimate look at the effects of cosmetic surgery on sexual practices. Aesthetic Surg. J. 26: the following: too little time, perception that it 12, 2006. is someone else’s job, personal attitudes and 8. Dahm, D. L., Jacofsky, D., and Lewallen, D. G. Surgeons beliefs about sexuality, and lack of recom- rarely discuss sexual activity with patients after THA. Clin. mended practice guidelines. Orthop. Relat. Res. 428: 237, 2004. Surgeons expect nurses to play the primary 9. Frumovitz, M., Sun, C. C., Schover, L. R., et al. Quality of life and sexual functioning in cervical cancer survivors. J. Clin. role in sexual counseling. The implications of Oncol. 23: 7428, 2005. these findings are that plastic surgeons and their 10. Cohen, J. Statistical Power Analysis for the Behavioral Sciences. staffs need to be educated more thoroughly about New York: Academic Press, 1977.

1562 Volume 120, Number 6 • Sexual Activity after Surgery

11. Denzin, N. K., and Lincoln, Y. S. (Eds.). Sage Handbook of or male obstetrician-gynecologists? A study of patient Qualitative Research, 3rd Ed. Thousand Oaks, California: Sage gender preference. J. Am. Osteopath. Assoc. 105: 369, Publications, 2005. 2005. 12. Rankin, M., and Borah, G. National plastic surgical nursing 15. Mavis, B., Vasilenko, P., Marshall, J., and Jeffs, M. C. Female survey. Plast. Surg. Nurs. 26: 178, 2006. patients’ preferences related to interpersonal communica- 13. Wolosin, R. J., and Gesell, S. B. Physician gender and primary tions, clinical competence, and gender when selecting a care patient satisfaction: No evidence of “feminization.” physician. Acad. Med. 80: 1159, 2005. Qual. Manag. Health Care 15: 96, 2006. 16. Lamp, J. K., Alteneder, R. R., and Lee, C. Nurses’ knowledge, 14. Johnson, A. M., Schnatz, P. F., Kelsey, A. M., and Ohan- attitudes, and skills related to sexuality. J. Nurs. Scholarsh. 32: nessian, C. M. Do women prefer care from female 391, 2000.

Online CME Collections This partial list of titles in the developing archive of CME article collections is available online at www. PRSJournal.com. These articles are suitable to use as study guides for board certification, to help readers refamiliarize themselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old can be taken for CME credit. Reconstructive Trunk Donor-Site Morbidity Comparison between Endoscopically Assisted and Traditional Harvest of Free Latis- simus Dorsi Muscle Flap—Chih-Hung Lin et al. Reconstruction of a Severe Chest and Abdominal Wall Electrical Burn Injury in a Pediatric Patient—Craig MacKinnon et al. The Separation of Anatomic Components Technique for the Reconstruction of Massive Midline Abdominal Wall Defects: Anatomy, Surgical Technique, Applications, and Limitations Revisited—Kenneth C. Shestak et al. Endoscopically Assisted “Components Separation” for Closure of Abdominal Wall Defects—James B. Lowe et al. An Algorithm for Abdominal Wall Reconstruction—Rod J. Rohrich et al. The Surgical Treatment of Brachial Plexus Injuries in Adults—Julia K. Terzis and Vasileios K. Kostopoulos Pharmacologic Optimization of Microsurgery in the New Millennium—Matthew H. Conrad and William P. Adams, Jr. Risks Associated with “Components Separation” for Closure of Complex Abdominal Wall Defects—James B. Lowe, III et al. The Surgical Treatment of Obstetric Brachial Plexus Palsy—Saleh M. Shenaq et al. Tissue Engineering: Progress and Challenges—Mark A. F. Knight and Gregory R. D. Evans Fire in the Operating Room: Principles and Prevention—Stephen P. Daane and Bryant A. Toth Gender Identity Disorder: General Overview and Surgical Treatment for Vaginoplasty in Male-to-Female Transsexuals—Gennaro Selvaggi et al. Further Clarification of the Nomenclature for Compound Flaps—Geoffrey G. Hallock Burn Injuries Inflicted on Children or the Elderly: A Framework for Clinical and Forensic Assessment—Adam R. Greenbaum et al. Management of Posterior Trunk Defects—David Mathes et al.

1563 IDEAS AND INNOVATIONS

Treatment of Giant Omphalocele with Intraabdominal Tissue Expansion

Marissa J. Tenenbaum, M.D. Robert P. Foglia, M.D. Devra B. Becker, M.D. Alex A. Kane, M.D. St. Louis, Mo.

iant omphaloceles challenge the surgeon. mal ventilator support and maintained adequate urine output. These abdominal wall defects range in Volumetric computed tomographic analysis revealed that the severity from minor umbilical hernias to volume of her expander exceeded the volume of her extra- G peritoneal viscera by a margin of 20 to 25 percent (Fig. 2). She complete defects of the abdominal wall. Giant then underwent successful reduction of her extraperitoneal omphaloceles have a fascial defect greater than 6 viscera. The resultant 9 ϫ 8-cm fascial defect was treated with cm and an extraperitoneal liver. Silastic sheeting and intermittent suture plication. She was then Small defects may be closed primarily or with returned to the operating room for removal of the tissue expander and closure of the abdominal wall. The patient was an absorbable mesh patch. However, giant rapidly weaned from the ventilator, started on enteral feedings, omphaloceles require gradual reduction of the and discharged to home. At 1-year follow-up, she continues to extraperitoneal viscera using preformed silos.1–5 do well (Fig. 1, right). In patients with severe abdominovisceral dispro- Case 2 portion, the silo may tear free of the fascia under A girl with severe cardiopulmonary defects and diaphrag- the stress of the reduction. Alternatives such as matic hernia was born with a giant omphalocele. The diaphrag- delayed repair and staged repair are suboptimal, matic hernia was repaired in infancy, but the giant omphalocele as the patient may develop skin ulceration or was allowed to granulate and epithelialize, leaving a massive ventral hernia (Fig. 3). The patient had frequent skin ulcer- damage to intraperitoneal organs. ations and required daily supportive dressings. At 4 years of age, The fundamental problem that requires correc- she presented to St. Louis Children’s Hospital with a giant tion in giant omphaloceles is the abdominovisceral omphalocele that measured 30 cm in circumference at the base and projected 10 cm from the surrounding skin (Fig. 4, left). disproportion. We propose a method of intraperi- ϫ toneal tissue expansion with volumetric computed This patient underwent placement of 10 12-cm rectangular tissue expander (PMT Corp.) in her lower abdominal cavity that tomographic analysis for operative planning. Two was initially filled with 80 ml of saline. The expander was filled cases treated in this manner are presented. at 25 to 30 ml/day to a maximum of 900 ml over 5 weeks at home. Follow-up volumetric computed tomographic scan re- CASE REPORTS vealed that the volume of her expander exceeded the volume of her extraabdominal viscera by a margin of 20 to 25 percent Case 1 (Fig. 4, right). She underwent removal of the tissue expander, A full-term girl weighing 2.9 kg was born with a giant ompha- reduction of the extraperitoneal viscera, and closure of her locele. The omphalocele contained liver and large and small fascia with a 4 ϫ 12-cm sheet of AlloDerm (LifeCell Corp., bowel, and the fascial defect was approximately 8 cm in diam- Branchburg, N.J.). The skin was closed primarily under no eter. At birth, initial treatment with a Silastic silo failed sec- tension. She was extubated on postoperative day 1, started to ondary to liver hemorrhage that required evacuation and silo feed on postoperative day 6, and discharged to home on day 14. removal (Fig. 1, left). At this point, the plastic surgery service was At 1-year follow-up, she is doing well, with healing of her consulted and the decision was made to place an intraperito- wounds, no hernias, and good weight gain (Fig. 3, right). neal tissue expander to increase the intraperitoneal volume. A 6 ϫ 8-cm rectangular tissue expander (PMT Corp., Chanhas- DISCUSSION sen, Minn.) was placed in her pelvis and filled with 70 ml of Repair of giant omphaloceles remains contro- saline. Tissue expansion proceeded at 10 to 20 ml/day to a total of 300 ml. Throughout expansion, the patient required mini- versial. There have been several reports in the literature of novel techniques aimed at visceral From the Divisions of Plastic and Reconstructive Surgery and reduction and abdominal wall closure and Pediatric Surgery, St. Louis Children’s Hospital, Washing- reconstruction.2,4–31 A single case report of intra- ton University School of Medicine. abdominal tissue expansion to increase the peri- Received for publication February 3, 2006; accepted August toneal domain9 inspired use of this technique in 25, 2006. our patients. In theory, tissue expansion in a new- Copyright ©2007 by the American Society of Plastic Surgeons born risks abdominal compartment syndrome, re- DOI: 10.1097/01.prs.0000282091.40103.6b spiratory compromise, vital structure erosion, in-

1564 www.PRSJournal.com Volume 120, Number 6 • Treatment of Giant Omphalocele

Fig. 1. (Left) View after ﬁxation of the Silastic silo to the fascial edges. The majority of the omphalocele contents appear to be liver. (Right) Postoperative view shows well-healed scars, no residual hernia, and successful reduction of abdominal contents into the abdominal cavity.

fection, and further extrusion of the abdominal laparotomy but often requires more extended pe- contents from the peritoneal cavity. Each infant riods of expansion. Also, in neonates, it is difficult needs an individualized rate of expansion, with to successfully place the expander in the thin mus- close observation and monitoring of peak airway cular layers of the abdominal wall. Intraperitoneal pressure, end-tidal carbon dioxide, urine out- tissue expansion addresses the primary defect of put, and visual inspection of the silo-fascia inter- abdominovisceral disproportion directly. This ca- face. In older children with untreated omphalo- pacity of the abdominal wall to respond to the cele, expansion may be able to be performed on stress of intraabdominal tissue expansion is dem- an outpatient basis. onstrated by pregnancy. In fact, pregnancy has Our method contrasts with strategies aimed to been used as a form of tissue expansion to close a expand components of the abdominal wall.6,7 Plac- large ventral hernia. Pneumoperitoneum32 has ing the expander within the abdominal wall avoids also been used less successfully.

Fig. 2. Computed tomographic scans of the patient’s abdomen before (left) and after (right) the expander had been ﬁlled to a total of300mlofsterilesaline.Thethree-dimensionalviewshowstheexpanderinthepelviswiththeportexitingtheleftlowerquadrant. Note the contents of the omphalocele and the approximate volume as compared with the 300-ml volume of the expander.

1565 Plastic and Reconstructive Surgery • November 2007

Fig. 3. (Left) A 4-year-old patient with a giant omphalocele that was not repaired. Note the enormous dispro- portionbetweenthevolumeoftheherniatedvisceraandtheabdominalcavityandtheulceratedskinoverlying the hernia. (Right) Postoperative view shows well-healed scars, no residual hernia, and successful reduction of abdominal contents into the abdominal cavity.

Fig. 4. Computed tomographic scans of the patient’s abdomen before and after the expander had been ﬁlled to 900 ml. The three-dimensional views illustrate the volume expansion obtained by the expander in relation to the volume of the extraperitoneal contents.

In these cases, the extraperitoneal visceral vol- CONCLUSIONS ume was derived from the preoperative computed We report the use of intraabdominal tissue ex- tomographic scan by the Analyze program (Bio- pansion in conjunction with volumetric imaging medical Imaging Resource, Mayo Clinic, Roches- analysis to treat two cases of giant omphaloceles that ter, Minn.). An appropriate expander size was cho- were refractory to treatment by other methods. Our sen to accommodate this estimated volume. Once technique directly addresses the primary problem of the volume of the expander exceeded the calcu- abdominovisceral disproportion. The objectives lated volume by a margin of 20 to 25 percent, we with regard to safety, integrity of repair, and ana- proceeded with removal of the expander and re- tomical reconstruction were satisfactorily met. The duction of the viscera. technique may be applicable to other causes of large

1566 Volume 120, Number 6 • Treatment of Giant Omphalocele abdominal wall defects, and we believe it merits fur- 14. Nissan, S. Pneumoperitoneum as aid for second stage repair ther consideration in these difficult cases. of omphalocele. Arch. Surg. 91: 839, 1965. 15. Othersen, H. B., Jr., and Hargest, T. S. A pneumatic reduc- Alex A. Kane, M.D. tion device for gastroschisis and omphalocele. Surg. Gynecol. Division of Plastic Surgery Obstet. 144: 243, 1977. 660 South Euclid Avenue 16. Othersen, H. B., Jr., and Smith, C. D. Pneumatic reduction Campus Box 8238 bag for treatment of gastroschisis and omphalocele: A 10- St. Louis, Mo. 62110 year experience. Ann. Surg. 203: 512, 1986. [email protected] 17. Ladd, A. P., Rescorla, F. J., and Eppley, B. L. Novel use of acellular dermal matrix in the formation of a bioprosthetic silo for giant omphalocele coverage. J. Pediatr. Surg. 39: 1291, DISCLOSURE 2004. None of the authors has any financial interest in the 18. Aoyama, K. A new operation for repair of large ventral her- tissue expander used in the patients mentioned in this nias following giant omphalocele and gastroschisis. J. Pediatr. Surg. 14: 172, 1979. article. 19. Pereira, R. M., Tatsuo, E. S., Simoes e Silva, A. C., et al. New method of surgical delayed closure of giant omphaloceles: REFERENCES Lazaro da Silva’s technique. J. Pediatr. Surg. 39: 1111, 2004. 1. Schwartz, M. Z., Tyson, K. R., Milliorn, K., et al. Staged 20. Schuster, S. R. A new method for the staged repair of large reduction using a Silastic sac is the treatment of choice for omphaloceles. Surg. Gynecol. Obstet. 125: 837, 1967. large congenital abdominal wall defects. J. Pediatr. Surg. 18: 21. Schaeffer, C. S., Levin, L. S., and King, L. R. A new approach 713, 1983. to the closure of cloacal exstrophy. World J. Urol. 14: 384, 2. Vanamo, K. Silo reduction of giant omphalocele and gas- 1996. troschisis utilizing continuous controlled pressure. Pediatr. 22. Stone, H. H. Immediate permanent fascial prosthesis for Surg. Int. 16: 536, 2000. gastroschisis and massive omphalocele. Surg. Gynecol. Obstet. 3. Nuchtern, J. G., Baxter, R., and Hatch, E. I., Jr. Nonoperative 153: 221, 1981. initial management versus Silon chimney for treatment of 23. Kaneko, K. T., and Suda, M. Four-triangular-skin-flap ap- giant omphalocele. J. Pediatr. Surg. 30: 771, 1995. proach to umbilical diseases and laparoscopic umbilical port. 4. Barlow, B., Cooper, A., Gandhi, R., et al. External silo re- J. Pediatr. Surg. 39: 1404, 2004. duction of the unruptured giant omphalocele. J. Pediatr. 24. DeLuca, F. G., Gilchrist, B. F., Paquette, E., et al. External Surg. 22: 75, 1987. compression as initial management of giant omphaloceles. 5. Rubin, S. Z., and Ein, S. H. Experience with 55 Silon pouches. J. Pediatr. Surg. 31: 965, 1996. J. Pediatr. Surg. 11: 803, 1976. 25. Sander, S., Elicevik, M., and Unal, M. Elastic bandaging 6. De Ugarte, D. A., Asch, M. J., Hedrick, M. H., et al. The use facilitates primary closure of large ventral hernias due to of tissue expanders in the closure of a giant omphalocele. giant omphaloceles. Pediatr. Surg. Int. 17: 664, 2001. J. Pediatr. Surg. 39: 613, 2004. 26. Zama, M., Gallo, S., Santecchia, L., et al. Early reconstruction 7. Paletta, C. E., Huang, D. B., Dehghan, K., et al. The use of of the abdominal wall in giant omphalocele. Br. J. Plast. Surg. tissue expanders in staged abdominal wall reconstruction. 57: 749, 2004. Ann. Plast. Surg. 42: 259, 1999. 27. Dickey, J. W., Jr. Delayed repair of large omphalocele. J. Fla. 8. Moazam, F., Rodgers, B. M., and Talbert, J. L. Use of Teflon Med. Assoc. 53: 285, 1966. mesh for repair of abdominal wall defects in neonates. J. Pe- 28. Delarue, A., Camboulives, J., Bollini, G., et al. Delayed cure diatr. Surg. 14: 347, 1979. of an omphalocele requiring abdominosternoplasty, right 9. Bax, N. M., van der Zee, D. C., Pull ter Gunne, A. J., et al. hepatectomy and partial splenectomy. Eur. J. Pediatr. Surg. 10: Treatment of giant omphalocele by enlargement of the ab- 58, 2000. dominal cavity with a tissue expander. J. Pediatr. Surg. 28: 29. Zaccara, A., Zama, M., Trucchi, A., et al. Bipedicled skin flaps 1181, 1993. for reconstruction of the abdominal wall in newborn ompha- 10. Seashore, J. H., MacNaughton, R. J., and Talbert, J. L. Treat- locele. J. Pediatr. Surg. 38: 613, 2003. ment of gastroschisis and omphalocele with biological dress- 30. Patkowski, D., Czernik, J., and Baglaj, S. M. Active enlarge- ings. J. Pediatr. Surg. 10: 9, 1975. ment of the abdominal cavity: A new method for earlier 11. Shermeta, D. W. Simplified treatment of large congenital closure of giant omphalocele and gastroschisis. Eur. J. Pediatr. ventral wall defects. Am. J. Surg. 133: 78, 1977. Surg. 15: 22, 2005. 12. Harjai, M. M., Bhargava, P., Sharma, A., et al. Repair of a 31. Bawazir, O. A., Wong, A., and Sigalet, D. L. Absorbable mesh giant omphalocele by a modified technique. Pediatr. Surg. Int. and skin flaps or grafts in the management of ruptured giant 16: 519, 2000. omphalocele. J. Pediatr. Surg. 38: 725, 2003. 13. Canty, T. G., and Collins, D. L. Primary fascial closure in 32. Braye, F. M., Breton, P., and Caillot, J. L. Preoperative pneu- infants with gastroschisis and omphalocele: A superior ap- moperitoneum used for tissue expansion before abdominal proach. J. Pediatr. Surg. 18: 707, 1983. wall reconstruction. Ann. Plast. Surg. 50: 649, 2003.

1567 RECONSTRUCTIVE

Outcome of Simultaneous and Staged Microvascular Free Tissue Transfer Connected to Arteriovenous Loops in Areas Lacking Recipient Vessels

Peter M. Vogt, M.D., Ph.D. Background: Arteriovenous loops are an indispensable tool in free flap surgery Hans Ulrich Steinau, M.D., when appropriate recipient vessels are missing. In this study, the authors ana- Ph.D. lyzed whether the outcome differs when flaps were transferred simultaneously Marcus Spies, M.D., Ph.D. or subsequently after construction of arteriovenous loops. Susanne Kall, M.D. Methods: Twenty-seven patients requiring free tissue transfer received arterio- Andreas Steiert, M.D. venous loops by pedicled or free vein grafts because of inadequate local recipient Pejman Boorboor, M.D. vessels. In head and neck reconstruction, pedicled brachiocephalic or free Bernd Vaske, Ph.D. saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled Andreas Jokuszies, M.D. major saphenous vein grafts were used in the pelvic area whereas, in lower leg Hannover and Bochum, Germany and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n ϭ 10) or 4 to 17 days later (n ϭ 17). Results: Thrombosis required revision in staged transfer (n ϭ 3 patients) or in simultaneous flap transfer (n ϭ 2). No free flap was lost. Fisher’s exact test did not indicate a significant difference between a simultaneous or staged flap transfer. Conclusions: Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer. (Plast. Reconstr. Surg. 120: 1568, 2007.)

xperience of the surgeon remains the most ditional factors concern the type of anastomosis important factor for the successful outcome (end-to-end or end-to-side),1 selection of the re- Eof free tissue transfer. Only broad technical cipients vessels (especially the venous outflow),2,3 skills and anticipation of pitfalls guarantee opti- quality of the wound, and the use of interposi- mal performance of the procedure, including tional vein grafts.4 Even more importantly, do- microsurgical techniques and the selection and nor vessels of appropriate size and adequate handling of recipients vessels. blood flow have to be within the reach of the free Other factors responsible for flap loss and un- flap pedicle. favorable results have been related to the age of In some instances, extrinsic factors such as the patient, the type of flap used, previous sur- trauma, irradiation, infection, and previous or- gical procedures, and location of the defect. Ad- thopedic or vascular procedures may result in damage of local vessels, therefore rendering From the Departments of Plastic, Hand, and Reconstructive them unsuitable for successful anastomosis and Surgery and Biostatistics, Medizinische Hochschule Han- adequate blood flow. Microsurgical free tissue nover, and Universita¨tsklinik fu¨r Plastische Chirurgie und transfer thus becomes a particular challenge Schwerbrandverletzte, BG-Kliniken Bergmannsheil. when reconstruction is required in irradiated Received for publication April 1, 2006; accepted July 11, areas,5 in mangled extremities, or in lower ex- 2006. tremities with vascular compromise.6 Also, ex- Copyright ©2007 by the American Society of Plastic Surgeons tended soft-tissue defects of the sacroperineal DOI: 10.1097/01.prs.0000282102.19951.6f region after pelvic exenteration for rectal cancer

1568 www.PRSJournal.com Volume 120, Number 6 • Microvascular Free Tissue Transfer may be frequent situations in which no appro- pedicled pectoralis major flap and iliac crest bone priate vascular supply is present.7 graft. One option with which to overcome the problem of the lack of vessels at the recipient site has always been the use of long interpositional vein Construction of Loops grafts.8 In addition, other authors have demon- Because of lacking or occluded local recipient strated the usefulness of arteriovenous loops as vessels, an arteriovenous loop was constructed by an alternative in which a constant high blood pedicled or free vein grafts, allowing for place- flow is established by shunting the arterial and ment of the most distant portion of the loop into venous portion and thereby achieving high-flow the position of the desired microanastomosis. Ar- perfusion of the newly created loop. The free teriovenous loops were constructed in the head flap transfer may then be performed either as a and neck region either from pedicled brachioce- simultaneous procedure or at a second stage phalic veins of the ipsilateral arm anastomosed after perfusion has been ensured for an appro- end-to-side to the axillary artery (four-in-one la- 9 priate time interval. tissimus flap for maxillary reconstruction, n ϭ 1), Although both strategies have been previously or from free saphenous vein grafts connected end- described as safe, it has not been evaluated so far to-end to the superior thyroid artery and external which approach provides greater success rates. jugular vein (latissimus flaps to scalp, n ϭ 4) or to We have therefore analyzed patients receiving the axillary vessels (jejunal graft for esophagus free flap transfer after simultaneous or staged reconstruction, n ϭ 1). On the trunk, pedicled construction of arteriovenous loops for compli- (Fig. 1) major saphenous vein grafts were anasto- cations and outcome of procedures performed mosed to the common femoral or external iliac by the first two authors (P.M.V., H.U.S.). artery in an end-to-side fashion (groin and sa- crum, n ϭ 9) or as free saphenous or brachioce- PATIENTS AND METHODS phalic vein loops in the lower leg and foot connected end-to-side to the posterior tibial artery Between January of 1994 and December of and end-to-end to concomitant veins (n ϭ 13). 2004, 27 patients receiving free tissue transfer had to have additional prefabrication of an arteriovenous loop to provide sufficient recipient vessels Timing of Flap Transfer for microvascular anastomosis. Microvascular tissue transfer was performed either after 4 to 17 days (mean, 9.9 Ϯ 5.2 days) or Types of Flaps Transferred simultaneous with creation of the loop (Table 1). Of the 27 patients, 23 patients received free In all cases, the loop was divided at the most distant latissimus dorsi myocutaneous flaps, one com- part to perform an end-to-end anastomosis be- bined rectus–tensor fasciae latae myofasciocuta- tween the arterial and venous parts; 8-0 inter- neous flap (mutton chop flap), one combined rupted sutures were used in all cases. In all patients osteomyofasciocutaneous flap based on the scap- undergoing staged flap transfer, the timing was ular and parascapular system (four-in-one flap), scheduled ahead and not based on complications one radial forearm flap, and one free jejunal graft such as intraoperative thrombosis during con- for complex defects. The indication for the mut- struction of the arteriovenous loop. ton chop flap was a large sacral defect after pelvic exenteration resulting from resection of a metas- tasizing squamous cell carcinoma of the anus de- Pharmacologic Regimen veloping in condylomata acuminata (Buschke- During surgery, all patients received a bolus Loewenstein tumor). The design of the flap injection of 1000 U of heparin immediately be- enabled total skin coverage of an area measuring fore declamping of the arterial anastomosis in 30 ϫ 40 cm and local brachytherapy of the tumor addition to local irrigation of the vessels with hep- bed.10 The chimeric four-in-one flap was used to arinized saline (100 IU/ml). Then, 15,000 IU of reconstruct a 12-cm mandibular and soft-tissue heparin per 24 hours was started as a continuous defect in a patient transferred to our department infusion until 7 days after flap transfer (simulta- after mandibular and soft-tissue resection, radical neous or staged). After microsurgical anastomosis, neck dissection, radiochemotherapy with an 85-Gy an overly intense vascular spasm was treated with total dose of irradiation, and previous failure of a local papaverine.

1569 Plastic and Reconstructive Surgery • November 2007

Fig. 1. Huge sacral defect with presacral tumor recurrence after pelvic exenteration (R1 resection) of a rectum adenocarcinoma. Irradiation with 80 Gy had destroyed superior and inferior vessels for microvascular anastomosis (above, left). Therefore, a 75-cm greater saphenous vein graft reaching from the dorsum of the foot and left attached to the superficial femoral vein is anastomosed to the superficial femoral artery and transferred to the sacral area for later free latissimus transfer (above, right, and center, left). Seven days later, a free latissimus myocutaneous flap (center, right) is transplanted with anastomosis of the flap pedicle to the arterial and venous limb in an end-to-end fashion (center, right, and below, left). The flap was perfused well and healed primarily in conjunction with brachytherapy catheters (below, right).

1570 Volume 120, Number 6 • Microvascular Free Tissue Transfer

Table 1. Free Flaps Transferred in Conjunction with an Arteriovenous Loop* Secondary Revisions Immediate Revisions Tissue Transfer of Loop† Tissue Transfer of Loop† Latissimus dorsi flap 23 14 2 9 2 Mutton chop flap 1 1 Four-in-one flap 1 1 1 Radial forearm flap 1 1 Free jejunal graft 1 1 Total 27 17 3 10 2 *Loop construction and subsequent or immediate flap transfer was performed with comparable rates of complications. The number of revisions of loops in the two groups did not differ significantly from each other (Fisher’s exact test). †Not significant.

Tissue Protection and Monitoring of In the staged transfer, microvascular trans- Arteriovenous Loops plantation was performed after 4 to 17 days (mean, All arteriovenous loops were covered with 9.9 Ϯ 5.2 days). None of the patients with arte- local or regional skin and were not fixed to riovenous loops and secondary flap transfer de- surrounding structures. In cases of staged pro- veloped compromised flow such as the steal phe- cedures, arteriovenous loops were monitored nomenon in the dependant extremity or increased regularly and patency was controlled using a hand- cardiac preloading. held ultrasound flow Doppler probe (Kranzbu¨- All 27 patients underwent successful free flap hler, Solingen, Germany). Arterial and venous transfer. No free flap was lost. Analysis of results by portions of the loops were marked on the overly- Fisher’s exact test did not indicate a significant ing skin with nylon stitches. The decision of difference between the simultaneous flap transfer whether to use a staged flap transfer was based on group (two thrombosed loops of 10 patients) and the length of the loop: immediate transfer was staged flap transfer (three loop complications of accomplished to vein segments of less than 20 cm 17 patients). and staged approaches were chosen in longer vein Long-term results showed stable healing. Also, grafts. Differences between groups were analyzed flaps tolerated additional procedures such as for significance by the Fisher’s exact test at the brachytherapy (Fig. 1) or segmental bone trans- Department of Biostatistics, Hannover Medical port in the lower extremity (Figs. 2 through 5). School (B.V.). CASE REPORTS Case 1 RESULTS A 6-year-old patient had undergone pelvic exenteration after In five patients, thrombosis required revision presacral recurrence after resection and radiochemotherapy of of the loops in either the staged transfer (n ϭ 3 an adenocarcinoma of the rectum (Fig. 1). He had received patients) or in the venous portion of the anasto- irradiation, with a total of 80 Gy. A huge sacral defect and cavity mosis in simultaneous flap transfer after flap trans- resulted because of a lack of healing as a consequence of ex- ϭ cessive radiation doses and residual tumor after R1 resection. fer (n 2). In the simultaneous approach, one An indication for free latissimus dorsi coverage was given. How- venous thrombosis had to be revised intraopera- ever, radiotherapy had destroyed the superior and inferior ves- tively (n ϭ 1) and 2 days after flap transfer. Two sels for microvascular anastomosis. Therefore, a 75-cm greater of the three patients undergoing the staged flap saphenous vein graft reaching from the dorsum of the foot and transfer developed thrombosis of the loops, re- left attached to the superficial femoral vein was anastomosed to the superficial femoral artery and transferred to the sacral area quiring revision and construction of a new loop for later free latissimus transfer. The postoperative course was before flap transfer. uneventful, with a well-perfused arteriovenous loop. Seven days In one of these cases, a pedicled cephalic vein later, a free latissimus myocutaneous flap was transplanted suc- loop connected to the axillary artery thrombosed cessfully with anastomosis of the flap pedicle to the arterial and because of excessive external fibrosis in the irra- venous limb in end-to-end fashion. The flap was well-perfused and healed primarily in conjunction with brachytherapy cath- diated tissue bed of the neck and supraclavicular eters that were implanted to facilitate postoperative brachy- region into which the graft was placed. A new therapy. arteriovenous loop was constructed from a fresh Case 2 major saphenous vein and placed in a long curve A 27-year-old patient had sustained a Gustilo type IIIC frac- into the healthy soft tissue of the upper thorax. ture of the distal third of his lower leg (Figs. 2 through 5). All After this, the course was uneventful. three arteries in the lower leg had been destroyed by the injury.

1571 Plastic and Reconstructive Surgery • November 2007

Blood flow in the leg was reestablished by reconstruction of the posterior tibial artery with a free saphenous graft from the opposite leg. After soft-tissue and bony debridement, unreamed nailing and segmental bone shortening was performed. Despite limb shortening, a defect of such size remained that required free flap coverage. To avoid microanastomosis in the area of vessel destruction, an arteriovenous loop was constructed from a free brachiocephalic vein of the ipsilateral arm. The vein graft was anastomosed in end-to-side fashion to the popliteal artery on the arterial side and in end-to-side fashion to the popliteal vein. After 7 days, a latissimus free flap was performed successfully by anastomosing the flap to the divided loop, providing arterial and venous supply. The residual portion of the defect was covered by a pedicled medial gastrocnemius muscle flap. Immediately after wound healing, a proximal tibia osteotomy was performed and bone distraction performed (G. Moel- lenhoff, M.D., Department of Orthopedics and Trauma, Berg- mannsheil University Hospital, Bochum). The free latissimus flap and the interpositioned vein grafts tolerated the leg lengthening procedure of 12 cm uneventfully. Fifteen months after the injury, the patient was fully rehabilitated.

DISCUSSION Free microvascular tissue transfer has become one of the most potent techniques in reconstructive plastic surgery. Although being requested more frequently for clinical applications, free flap tissue reconstruction is being challenged by increasingly complex defects and impaired vascular situations in the defect areas.11–13 In specific regions such as the lower leg and the irradiated neck or pelvic area, appropriate vessels for vascular supply of the flap may not even be present for proper vascular supply of the free flap.14–16 Nevertheless, the safety and reliability of free tissue transfer must not be compromised because, for many patients, the procedure is the last possible surgical option. For several years, vein grafts have been used successfully to bridge the distance between appropriate donor vessels and the flap.16–20 To avoid longer periods of vein graft occlusion in compromised areas, the concept of arteriovenous loops has been developed. By this approach, the dis- eased autogenous vascular bed is bypassed and the Fig. 2. Latissimus dorsi transfer to arteriovenous loop con- arteriovenous shunt provides the opportunity to structed from free brachiocephalic vein graft in a crushed lower verify vein graft patency on a continuous basis leg after Gustilo type IIIC fracture of the distal third. All three ar- before performing free tissue transfer.9,21–24 teries in the lower leg had been destroyed by the injury. The pos- In the literature, the question of whether free terior tibial artery was reconstructed initially by a free saphenous flaps should be transferred during the same op- graft from the opposite leg. After debridement, unreamed nail- eration or at a secondary time point after “matu- ing, and segmental bone shortening, an arteriovenous loop was ration” of the loops has not been answered. Ob- constructed from free brachiocephalic vein of the ipsilateral arm (above). The vein graft was anastomosed end-to-side to the popliteal artery on the arterial side and in end-to-side fashion to the viding arterial and venous supply (center). The residual portion of popliteal vein. After 7 days, a latissimus free flap was performed thedefectwascoveredbyapedicledmedialgastrocnemiusmus- successfully by anastomosing the flap to the divided loop pro- cle flap (below).

1572 Volume 120, Number 6 • Microvascular Free Tissue Transfer

Fig.3. Immediatelyafterwoundhealing,aproximaltibiaosteot- Fig. 5. The patient was fully rehabilitated. omy and bone distraction were performed (G. Moellenhoff, M.D., Department of Orthopedics and Trauma, Bergmannsheil Univer- sity Hospital Bochum). The free latissimus ﬂap and the interpo- However, the question remains of whether the sitioned vein grafts tolerated the leg lengthening procedure of timing of flap transfer may be of importance for 12 cm uneventfully. the outcome and which approach is safer. As is known from early studies, free tissue transfer between 1 week and 3 months after injury viously, the decision of whether to perform a places the microvascular transfer at increased risk, simultaneous or subsequent flap transfer depends mainly because of vascular problems at the recip- on the surgeon’s choice, his or her experience ient site.25 In those days, arteriovenous loops were with either approach, and the local conditions. not mentioned as part of the regimen, and ad-

Fig. 4. Results after completion of segmental transport on unilateral distraction ﬁxator.

1573 Plastic and Reconstructive Surgery • November 2007 vanced techniques of temporary wound closure vasoconstrictor. Endothelin-1 was identified as such as vacuum closure26 were not used. one of the major determinants of vascular failure Because free tissue transfer is frequently re- in coronary bypass surgery.28 This may explain the quired during this time period, the question also involvement of vein grafts in complications after arises of whether this critical period may have an free flap surgery as mentioned previously.29 impact on the outcome of flaps anastomosed to In an international survey involving 23 micro- vein loops. We have therefore statistically analyzed vascular centers, a total of 493 free flaps were our own population of subsequent cases at two analyzed. The overall incidence of flap failure was major centers of reconstructive surgery to estimate 4.1 percent. Flap failure was correlated to an ir- the risk of vascular complications in simultaneous radiated recipient site and the use of a skin-grafted and sequential flap transfer after arteriovenous muscle flap. The incidence of a venous thrombosis loop construction. In all patients, the local con- was significantly higher when the flap was trans- dition of vessels adjacent to the defect prohibited ferred to a chronic wound and when vein grafts microanastomoses to local vessels because of ra- were used. Also, intraoperative thrombosis was ob- diation damage or direct injury by the trauma as served more frequently in myocutaneous flaps or a primary cause. As a result of this statistical anal- when vein grafts were needed. These data show ysis, no differences between simultaneous and that vein grafts are significantly involved in vascu- staged flap transfer were found. lar complications after free flap surgery.4 They do A variety of reasons may explain this finding. not necessarily imply a risk factor themselves but First, all loops were anastomosed to major vessels rather indicate the intraoperative need for further such as the axillary, femoral, or popliteal artery reconstructive surgery to the local vessels. and veins. This provided a maximum of flow, as it Spasm of interpositioned vein grafts is one is provided by the arteries in this location. important factor and is controlled and most safely Also, meticulous monitoring of microvascular assessed in the staged approach using an arterio- perfusion was performed in both approaches, and venous fistula, as no valuable free flap is depen- early intervention was performed (revision rate of dent on ill-perfused recipient vessels. Our clinical 18 percent in 27 patients) when necessary to en- impression was that the venous side of long loops sure appropriate loop perfusion. Also, the same in the stage procedure after a week’s time had anticoagulation regimen was applied. more outflow capacity because of a constant lu- Second, in our own algorithm, vein loops have men and forced high-pressure flow. been used for simultaneous transfer only in the A very attractive aspect is provided by the fact head and neck area and did not exceed a length that, in the secondary tissue transfer, the flap of 20 cm. In the pelvic and lower extremity region, can be connected to well-perfused vessels by loops longer than 20 cm were covered by regional means of a quick and straightforward end-to-end skin and monitored between 4 and 17 days until anastomosis. Risk factors of flap survival such as the microvascular tissue transfer was performed. hypothermia resulting from the long operation By this approach, careful monitoring and early time, prolonged clamping and vascular stasis,30 intervention were possible to enable proper blood and hypotension leading to impaired flow in the flow at any time before free flap transfer. flap can thus be avoided. Particular attention should be directed to proper positioning of the arteriovenous loop. Be- CONCLUSIONS sides undue pressure, an acute angle has to be We confirmed that constructing an arterio- avoided at the extremity of its course. As can be venous loop is a safe method of enabling micro- observed when the loop has not been positioned surgery in difficult local situations and expands yet is that the high-flow perfusion gives a circular the possibilities of reconstructive plastic surgery. shape to the loop (Fig. 1, above, right, and below, Based on the results of the small sample size of 27 left). We found it practical to allow for enough patients, it appears that neither the simultaneous space at the extremity of the loop or even place it nor the staged transfer exerts a higher risk for away from its final position to cover it by a safe complications leading to flap loss. Especially in the soft-tissue envelope in the staged procedure. setting of staged flap transfer, continuous moni- As is known from previous studies, the risk of toring of the arteriovenous loop enables the sur- vascular spasm in the lower leg is one of the most geon to identify the problem of thrombosis as critical problems for free flap transfer.27 Also, vein early as possible. A staged transfer might be an grafts have been reported to express more endo- option in all situations in which flow may be im- thelin-1, which is known to be the most potent paired, such as in the lower extremity or when

1574 Volume 120, Number 6 • Microvascular Free Tissue Transfer spasms reside in the vein graft and the length of 13. Gooden, M. A., Gentile, A. T., Mills, J. L., et al. Free tissue vein graft segments exceeds 20 cm. transfer to extend the limits of limb salvage for lower extremity tissue loss. Am. J. Surg. 174: 644, 1997. Peter M. Vogt, M.D., Ph.D. 14. Lepantalo, M., and Tukiainen, E. Combined vascular recon- Department of Plastic, Hand, struction and microvascular muscle flap transfer for salvage and Reconstructive Surgery of ischaemic legs with major tissue loss and wound compli- Medizinische Hochschule Hannover cations. Eur. J. Vasc. Endovasc. Surg. 12: 65, 1996. Carl-Neubergstr. 1 15. Park, S., Han, S. H., and Lee, T. J. Algorithm for recipient 30625 Hannover, Germany vessel selection in free tissue transfer to the lower extremity. [email protected] Plast. Reconstr. Surg. 103: 1937, 1999. 16. Acland, R. D. Refinements in lower extremity free flap surgery. Clin. Plast. Surg. 17: 733, 1990. DISCLOSURE 17. Earle, A. S., Feng, L. J., and Jordan, R. B. Long saphenous None of the authors has any commercial associations vein grafts as an aid to microsurgical reconstruction of the that might pose or create a conflict of interest with in- trunk. J. Reconstr. Microsurg. 6: 165, 1990. 18. Germann, G., and Steinau, H. U. The clinical reliability of formation on products presented in this article. vein grafts in free-flap transfer. J. Reconstr. Microsurg. 12: 11, 1996. REFERENCES 19. Kim, K. A., and Chandrasekhar, B. S. Cephalic vein in salvage 1. Godina, M., Arnez, Z. M., and Lister, G. D. Preferential use microsurgical reconstruction in the head and neck. Br. J. of the posterior approach to blood vessels of the lower leg in Plast. Surg. 51: 2, 1998. microvascular surgery. Plast. Reconstr. Surg. 88: 287, 1991. 20. Masquelet, A. C., Valenti, P., Destable, M. D., Moreau, C., 2. Muramatsu, K., Shigetomi, M., Ihara, K., Kawai, S., and Doi, Lamour, A., and Dubert, T. Free-flap coverage technique K. Vascular complication in free tissue transfer to the leg. with double vascular bypass in the lower limb (in German). Microsurgery 21: 362, 2001. Chirurgie 117: 181, 1991. 3. Tsao, C. K., Chen, H. C., Chuang, C. C., Chen, H. T., Mardini, 21. Atiyeh, B. S., Sfeir, R. E., Hussein, M. M., and Husami, T. S., and Coskunfirat, K. Adequate venous drainage: The most Preliminary arteriovenous fistula for free-flap reconstruction critical factor for a successful free jejunal transfer. Ann. Plast. in the diabetic foot. Plast. Reconstr. Surg. 95: 1062, 1995. Surg. 53: 229, 2004. 22. Hell, B., Heissler, E., Menneking, H., and Bier, J. Venous 4. Khouri, R. K., Cooley, B. C., Kunselman, A. R., et al. A graft as temporary arteriovenous shunt in free tissue transfer. prospective study of microvascular free-flap surgery and out- Int. J. Oral Maxillofac. Surg. 23: 344, 1994. come. Plast. Reconstr. Surg. 102: 711, 1998. 23. Silveira, L. F., and Patricio, J. A. Arteriovenous fistula with a 5. Disa, J. J., Pusic, A. L., Hidalgo, D. H., and Cordeiro, P. G. saphenous long loop. Microsurgery 14: 444, 1993. Simplifying microvascular head and neck reconstruction: A 24. Topalan, M., Bilgin-Karabulut, A., and Ermis, I. “Extracor- rational approach to donor site selection. Ann. Plast. Surg. 47: poreal loop” (blind loop): An alternative microsurgical tech- 385, 2001. nique for prelaminated flap transfer. J. Reconstr. Microsurg. 18: 6. Wells, M. D., Bowen, C. V., Manktelow, R. T., Graham, J., and 155, 2002. Boyd, J. B. Lower extremity free flaps: A review. Can. J. Surg. 25. Godina, M. Early microsurgical reconstruction of complex 39: 233, 1996. trauma of the extremities. Plast. Reconstr. Surg. 78: 285, 1986. 7. Fudem, G. M., and Marble, K. R. Latissimus dorsi free flap for 26. Steiert, A. E., Partenheimer, A., Schreiber, T., et al. The sacral wound closure: The world’s longest vein grafts for free V.A.C. system (vacuum assisted closure) as bridging between tissue transfer. Microsurgery 17: 449, 1996. primary osteosynthesis in conjunction with soft tissue recon- 8. Salibian, A. H., Tesoro, V. R., and Wood, D. L. Staged transfer struction of open fractures type 2 and type 3 (in German). of a free microvascular latissimus dorsi myocutaneous flap Zentralbl. Chir. 129(Suppl. 1): S98, 2004. using saphenous vein grafts. Plast. Reconstr. Surg. 71: 543, 27. Sato, O., Miyata, T., Deguchi, J., Sugawara, Y., Kimura, H., 1983. and Tada, Y. Completion arteriography in paramalleolar 9. Freedman, A. M., and Meland, N. B. Arteriovenous shunts in bypasses: Effect of configurational changes, with special ref- free vascularized tissue transfer for extremity reconstruction. erence to spasm, on long-term outcome. Int. Angiol. 15: 219, Ann. Plast. Surg. 23: 123, 1989. 1996. 10. Vogt, P. M., Kall, S., Lahoda, L. U., Spies, M., and Muehl- 28. Davenport, A. P., and Maguire, J. J. The endothelin system berger, T. The free “mutton chop” flap: A fascio-musculo- in human saphenous vein graft disease. Curr. Opin. Pharma- cutaneous flap for the reconstruction of the entire sacral and col. 1: 176, 2001. perineal area. Plast. Reconstr. Surg. 114: 1220, 2004. 29. Dashwood, M., Anand, R., Loesch, A., and Souza, D. Sur- 11. Gurlek, A., Miller, M. J., Amin, A. A., et al. Reconstruction of gical trauma and vein graft failure: Further evidence for complex radiation-induced injuries using free-tissue trans- a role of ET-1 in graft occlusion. J. Cardiovasc. Pharmacol. fer. J. Reconstr. Microsurg. 14: 337, 1998. 44: S16, 2004. 12. Hidalgo, D. A., Disa, J. J., Cordeiro, P. G., and Hu, Q. Y. A 30. Thomson, J. G., Kim, J. H., Syed, S. A., Reid, M. A., Madsen, review of 716 consecutive free flaps for oncologic surgical J., and Restifo, R. J. The effect of prolonged clamping and defects: Refinement in donor-site selection and technique. vascular stasis on the patency of arterial and venous microa- Plast. Reconstr. Surg. 102: 722, 1998. nastomoses. Ann. Plast. Surg. 40: 436, 1998.

1575 RECONSTRUCTIVE

Use of the Soleus Musculocutaneous Perforator for Skin Paddle Salvage of the Fibula Osteoseptocutaneous Flap: Anatomical Study and Clinical Confirmation

Chin-Ho Wong, M.R.C.S. Background: The skin paddle of the fibula osteoseptocutaneous flap is reliably Bien-Keem Tan, F.R.C.S. vascularized by septocutaneous perforators from the peroneal artery. However, Fu-Chan Wei, M.D. in 5 to 10 percent of lower limbs, these perforators are absent. This anatomical Colin Song, F.R.C.S. study evaluated use of the soleus musculocutaneous perforator for skin paddle Singapore and Taipei, Taiwan salvage in such situations. Methods: Latex injection studies were performed on 20 cadaveric lower limbs. The presence, prevalence, and location of the musculocutaneous perforators in the distal leg were documented. The perforators were traced proximally to determine their origins. Results: Of the 20 cadaveric limbs, one or more musculocutaneous perforators of at least 0.5 mm in diameter were noted in 18 specimens (90 percent). They were located within 6 cm of the junction of the middle and lower thirds of the fibula. The soleus musculocutaneous perforators originated in the peroneal artery in 10 specimens (50 percent), the posterior tibial artery in seven (35 percent), and the tibioperoneal trunk in one (5 percent). This information was successfully used to salvage the skin paddle in two of our clinical cases. Conclusions: Use of the soleus musculocutaneous perforator depends on its origin. When it arises from the peroneal artery, a single set of anastomoses is all that is necessary for flap revascularization, with the skin paddle serving as a monitor for the bone flap. When it originates from the posterior tibial artery or tibioperoneal trunk, a second set of anastomoses is needed and the skin paddle cannot monitor the bone flap. The authors propose that one or two soleus musculocutaneous perforators be preserved during harvest until existence of the septocutaneous perforator is confirmed. (Plast. Reconstr. Surg. 120: 1576, 2007.)

he fibula osteoseptocutaneous flap with a distal leg at the junction of the middle and distal distal skin island is a well-established design thirds of the fibula is reliably supplied by the perfor oromandibular reconstruction. Wei et al. oneal septocutaneous vessels passing within the T 1 demonstrated that a skin island centered over the posterior crural septum. Later, Jones et al. confirmed unequivocally that a skin flap can be reli- From the Department of Plastic, Reconstructive, and Aes- ably harvested with the fibula based purely on the thetic Surgery, Singapore General Hospital, and the Depart- septocutaneous perforator, without the need to ment of Plastic and Reconstructive Surgery, Chang Gung incorporate portions of the soleus or flexor hallu- Memorial Hospital. cis longus muscles.2,3 Received for publication March 28, 2006; accepted June 23, Occasionally, however, such septocutaneous 2006. Presented at the Inaugural Congress of the World Society of perforators are absent. In the senior author’s Reconstructive Microsurgery, in Taipei, Taiwan, October 29 (F.-C.W.) personal experience of over 1100 fib- through November 3, 2001; 10th Congress of the European ula osteocutaneous flaps, 3 percent (n ϭ 30) had Society of Plastic, Reconstructive, and Aesthetic Surgery no septocutaneous perforator. Faced with such a 2005, in Vienna, Austria, August 30 through September 3, situation, the surgeon may choose one of the 2005; and Ninth International Course on Perforator Flaps, following surgical options. First, rely on the sep- in Barcelona, Spain, October 5 through October 8, 2005. tum’s intrinsic circulation to vascularize the skin Copyright ©2007 by the American Society of Plastic Surgeons flap.1 This is unreliable and may result in partial DOI: 10.1097/01.prs.0000282076.31445.b4 or complete flap loss.4 Second, abandon the skin

1576 www.PRSJournal.com Volume 120, Number 6 • Fibula Osteoseptocutaneous Flaps flap and substitute it with a second flap from cutaneous perforator was located within 2 cm of another site. This option is safe but adds to the the junction of the middle and distal thirds of the duration and morbidity of surgery. Third, sal- fibula, with the farthest being within 6 cm from vage the skin island by preserving the soleus this reference point (Fig. 1). The diameter of the musculocutaneous perforators to the flap. Such musculocutaneous perforators ranged from 0.8 to perforators are traced by intramuscular dissec- 1.5 mm (mean, 1.1 mm) at the deep fascia level. tion to their origins and the skin paddle raised as When traced to its origin at the major vessels, its a perforator-type flap.1,4–6 The purpose of our diameter ranged from 1.2 to 2.2 mm (mean, 1.6 anatomical study is to elucidate the anatomy of mm). The pedicle length of the musculocutane- the soleus musculocutaneous perforators in the ous perforators ranged from 4 to 25 cm (mean, distal leg. This information will be valuable to 12.5 cm). In the 20 lower limbs dissected, the the surgeon attempting to salvage a fibula flap septocutaneous perforator was absent in one spec- skin paddle. imen (5 percent). The musculocutaneous perforators supplying MATERIALS AND METHODS the fibula flap’s distal skin paddle were noted to originate from three sites (Table 1). In 10 speci- Anatomical Study and Specimen Preparation mens (50 percent), they arose from the peroneal Injection studies were carried out in 20 cadav- artery. In seven specimens (35 percent), the vessel eric lower limbs (10 cadavers). The femoral artery originated from the posterior tibial artery, and in was cannulated and injected with 10% buffered one specimen (5 percent), it arose from the tib- formalin followed by pigmented latex to delineate ioperoneal trunk. The musculocutaneous perfo- the arterial system of the leg. The limbs were then rator was absent in two specimens (10 percent). allowed to cure overnight by refrigerating at 4°C. We classified the vascular pattern of the soleus The latex coagulated in the presence of the for- musculocutaneous perforators into two types malin; thus, the arterial tree was preserved for based on their origin; namely, convergent and further study. Each specimen was dissected to ob- divergent (Fig. 2). A convergent system is defined tain the following information: (1) the prevalence as one in which the perforator arises from the of the soleus musculocutaneous perforator in the peroneal artery and thus the fibula osteocutane- distal leg, (2) its position in relation to the junc- ous flap can be raised as a single composite unit tion of the middle and lower thirds of the fibula comprising bone and skin subunits (50 percent). where septal perforators reside, and (3) the origin A divergent system is one in which the perforator of the soleus musculocutaneous perforator. originates from an artery other than the peroneal In each specimen, a skin paddle measuring artery. These can be either the posterior tibial ϫ 20 8 cm was elevated and centered over the artery (35 percent) or tibioperoneal trunk (5 per- junction of the middle and distal thirds of the cent). A divergent system would mean that the fibula. Using a posterior approach, the skin flap skin and the bone portions would have to be raised was elevated subfascially toward the posterior cru- as separate flaps. ral septum. All soleus perforators greater than 0.5 mm in diameter in the vicinity were preserved. The septocutaneous vessels in the posterior crural Surgical Technique septum were also identified. Their relative loca- Based on our anatomical findings, we propose tions and diameters were documented. Intramus- a slight modification of the technique of harvest- cular dissections of the soleus perforators were ing the fibula osteoseptocutaneous flap, which is then performed to trace these vessels to the artery to preserve one or two soleus musculocutaneous of origin. The pedicle length and perforator di- perforators until the septocutaneous perforator is ameter at the artery of origin were documented. clearly seen. In the standard fashion, the axis of All dissections were recorded by photography. the skin flap is centered over the posterior border of the fibula, at the junction of the middle and RESULTS lower thirds of the bone.1,7 Preoperative Doppler Eighteen lower limb specimens (90 percent) assessment is used to mark the location of the skin were found to have at least one large musculocu- perforators. The skin flap is incised along its pos- taneous perforator coming through the soleus terior margin and deepened down to muscle. It is muscle to supply a skin paddle over the lateral elevated in the subfascial plane toward the poste- aspect of the distal leg. Our findings are summa- rior crural septum. When approaching the poste- rized in Table 1. Most of the dominant musculo- rior crural septum from posteriorly, one or more

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Table 1. Summary of Cadaveric Dissection Findings Diameter of Soleus Diameter of Soleus Length of the Distance from Source of Soleus MC Perforator MC Perforators at MC Perforators at MC Junction of Middle SC Soleus MC the Deep Fascia the Origin of Perforator and Lower Thirds Posterior Tibioperoneal Cadaver Perforator Perforator Level (mm) Perforator (mm) (cm) of the Fibula (cm) Peroneal Tibia Trunk 1 ϩϩ 1.0 1.2 11 ϩ3 ϩ 2 ϩϩ 1.2 1.2 15 ϩ5 ϩ 3 ϩϪ 4 ϩϩ 1.0 1.4 12 ϩ4.5 ϩ 5 ϩϩ 1.2 1.2 20 Ϫ1 ϩ 6 ϩϩ 1.2 1.4 15 Ϫ6.5 ϩ Surgery Reconstructive and Plastic 7 ϩϩ 0.8 1.4 25 Ϫ6 ϩ 8 ϩϪ 9 ϩϩ 1.5 2.2 12 ϩ2 ϩ 10 ϩϩ 1.2 2.0 8 Ϫ1 ϩ 11 ϩϩ 0.8 1.5 4 ϩ2 ϩ 12 ϩϩ 0.8 1.5 8 ϩ2 ϩ 13 ϩϩ 1.2 2.2 12 ϩ5 ϩ 14 ϩϩ 1.2 2.0 12 Ϫ1 ϩ 15 ϩϩ 1.2 1.6 5 ϩ5.5 ϩ 16 ϩϩ 1.0 1.2 14.5 Ϫ1.5 ϩ 17 ϩϩ 0.8 1.6 12 ϩ4 ϩ 18 ϩϩ 1.0 1.6 16 ϩ1 ϩ 19 Ϫϩ 1.2 1.2 14 ϩ1 ϩ 20 ϩϩ 1.2 1.8 12 Ϫ2 ϩ Mean 1.1 1.6 12.5 Prevalence 50% 35% 5% SC, septocutaneous; MC, musculocutaneous. • oebr2007 November Volume 120, Number 6 • Fibula Osteoseptocutaneous Flaps

Fig. 1. The distances of the largest soleus musculocutaneous perforators from the junction of the middle and distal thirds of the fibula (arrow) noted in 18 cadaveric specimens (numerical scale on the right, in centimeters). soleus musculocutaneous perforators may come in the way of the dissection, and it is at this stage that the technique is modified to preserve these perforators until the septal perforator is clearly seen. If present, the musculocutaneous perfora- Fig. 2. Schematic representations of the origin of the soleus tors are ligated and flap elevation proceeds as musculocutaneous perforator that can be used for skin paddle usual; if absent, the course of the musculocutane- salvage (viewed from the posterior aspect of the lower limb). A ous perforator is dissected out for skin paddle convergent system can be raised as a composite flap (above, left), salvage. In such situations, the surgeon should be whereas divergent systems (above, right and below, left) have to cognizant of the variability of the musculocutane- beraisedasseparateflaps.(Above,left)Aconvergentsystemwith ous perforator’s origin and be prepared for a sec- a musculocutaneous perforator originating from the peroneal ond set of microvascular anastomoses. As a rou- artery. (Above, right) A divergent system with a musculocutane- tine, one should raise only one border first, check ous perforator originating from the posterior tibial artery. (Below, for perforators, and then, if necessary, recenter left) A divergent system with a musculocutaneous perforator the skin paddle based on the location of the new originating from the tibioperoneal trunk. (Below, right) No mus- musculocutaneous perforator location. Occasion- culocutaneous perforator. ally, no soleus perforator is seen in the distal leg. In such situations, the incision is extended up the leg to look for more proximal perforators. Once planned skin island. A similar approach can be identified, the skin paddle is relocated accord- adopted to deal with cases with absent septocuta- ingly. neous perforators when an initial anterior incision Some surgeons prefer to approach the poste- has been made. In such cases, a parallel posterior rior crural septum from the anterior aspect of the skin incision would have to be made to locate

1579 Plastic and Reconstructive Surgery • November 2007

Fig. 3. (Above, left) Skin markings for the fibula osteocutaneous flap with a distally sited skin island. Preop- erativeDopplerassessmentdetectedtwogood-qualitysoundingskinperforators.(Right)Noseptocutaneous perforator was seen in the posterior crural septum intraoperatively. Instead, a significantly sized musculocutaneous perforator was noted. This was traced intramuscularly for a distance of 12 cm up to its origin at the tibioperoneal trunk (white arrow, soleus musculocutaneous perforator; yellow arrow, peroneal artery). (Below, left) A skin paddle was raised as a perforator flap and revascularized as a second free flap. soleus musculocutaneous perforators, as these are fibula was used. Preoperative Doppler assessment identified two located posterior to the posterior crural septum. vessels supplying the skin paddle (Fig. 3, above, left), but during flap harvest, no peroneal septocutaneous perforator was seen. Having confirmed the presence and location of Instead a musculocutaneous perforator arising from the soleus these perforators, the skin is then islanded and muscle was noted. This was traced intramuscularly for a distance intramuscular dissection proceeds in the usual of 12 cm up to its origin at the tibioperoneal trunk (Fig. 3, right). fashion. Because the soleus perforator did not originate from the peroneal artery, the skin paddle was raised as a perforator flap and CASE REPORTS revascularized as a second free flap (Fig. 3, below, left). Both flaps healed well and she was able to commence radiotherapy post- Our practice of preserving the soleus muscu- operatively. She was well at 3-year follow-up (Fig. 4). locutaneous perforator was useful in two clinical cases. This technique was used successfully to salvage the skin paddle for intraoral lining. Case 2 A 60-year-old man underwent right hemimandibulectomy for squamous cell carcinoma. Reconstruction with a fibula Case 1 osteoseptocutaneous flap was planned and preoperative A 61-year-old woman underwent resection of a retromolar Doppler assessment noted the presence of skin perforators trigone squamous cell carcinoma that included excision of the over the planned skin paddle. Intraoperatively, no septocu- left hemimandible and ipsilateral neck nodes. To reconstruct taneous perforator was seen in the posterior crural septum. the defect, the ipsilateral fibula with a 12 ϫ 5-cm skin paddle Instead, a 1.2-mm-diameter musculocutaneous perforator centered over the junction of the middle and lower thirds of the was noted coming through the soleus muscle. Intramuscular

1580 Volume 120, Number 6 • Fibula Osteoseptocutaneous Flaps

Fig. 4. The patient at 3-year follow-up, with complete survival of both the bone and skin ﬂap.

dissection was performed and the perforator and its venae comitantes were found to originate from the peroneal vessels (Fig. 5). Because it was a convergent system, the skin was kept Fig. 6. This convergent system was raised and transferred as attached to the bone and the entire flap was raised as a a single composite ﬂap with one set of microvascular anasto- composite (Fig. 6). Only one set of microvascular anastomoses was required. Postoperative recovery was uneventful, moses. with complete survival of the skin paddle.

Fig. 5. Intraoperatively, no septocutaneous perforator was seen in the posterior crural septum. Intramuscular dissection of a soleus musculocutaneous perforator was performed and it was found to originate from the peroneal artery (white arrows, peroneal artery; yellow arrow, soleus musculocutaneous perforator joining the peroneal artery).

1581 Plastic and Reconstructive Surgery • November 2007

DISCUSSION bone flap. In a divergent system, using the soleus Recent attention has focused on the anatom- musculocutaneous perforator to salvage the skin ical variations of the fibula osteoseptocutaneous paddle would necessitate a second set of micro- flap.2–6 This anatomical study concentrates on the vascular anastomoses, and the skin flap cannot anatomy of the soleus musculocutaneous perfo- function as a monitor because it is independent of rator and its clinical application for vasculariza- the fibula flap. When a divergent vascular pattern tion of the distal lateral leg skin paddle. The sep- is encountered, the skin paddle may be separated tocutaneous perforator in the distal lower limb from the fibula by incising the posterior crural may be absent in 5 to 10 percent of cases.2,3,8 In septum. By so doing, ischemic time is minimized these instances, most authors would recommend for one of the flaps, because they have indepen- intramuscular dissection to elucidate the course of dent vascular supplies and one flap can remain the soleus musculocutaneous perforator supply- attached while the other is being revascularized at ing the skin flap.4–6 the recipient site. More importantly, separating The origin of the musculocutaneous perfora- the flaps affords more freedom in inset of the skin tor, although not well described, is nonetheless paddle and the selection of optimal location at important because it affects the course of surgery. which to perform the microvascular anastomosis The findings of our study were that this was con- without being restricted by the fibula. In cases vergent or divergent from the source artery of the where there is a lack of donor vessels in the head fibula flap (i.e., the peroneal artery) in 50 and 40 and neck region, the distal end of the peroneal percent of cases, respectively (Fig. 7). A conver- vessel can also serve as the recipient vessel in a gent system is favorable because both the skin piggyback manner as previously described.7 When paddle and the fibula are vascularized by the same the skin paddle is harvested as a perforator flap, source artery and vein, obviating the need for a care should be taken not to damage the poste- second set of microvascular anastomoses. Further- rior tibial artery or tibioperoneal trunk to avoid more, the skin island serves as a monitor for the foot ischemia. From a technical standpoint, the diameter of the pedicle is expected to be smaller (mean diameter, 1.6 mm), its length more variable (range, 4 to 25 cm), and the vessels (particularly the vein) more flimsy. These technical challenges, however, can be overcome by using perforator flap techniques.9 It was previously assumed that the soleus musculocutaneous vessels in the distal lateral leg originated solely from the peroneal artery. Thus, some authors have advocated including a 1-cm cuff of the soleus and flexor hallucis longus muscles to ensure skin viability.8,10,11 Despite doing so, the incidence of skin flap loss has remained considerable, with an incidence approaching 10 percent.8,12–15 This is not surprising, as incorporating a cuff of muscle, however generous, would not preserve the vascularity of the skin component if it were supplied by a different source artery.4,8,16 With the advent of the perforator flap era,17–24 such a practice is increasingly consid- Fig. 7. It was previously assumed that the musculocutaneous ered imprecise, as perforator dissection expertise is vessel in the distal lateral leg originated from the peroneal artery. available to make skin paddle salvage safe and To preserve these musculocutaneous perforators, inclusion of a reliable.9,25 1-cm cuff of both the deep and superﬁcial posterior musculature, Several authors have reported success using an including the soleus and ﬂexor hallucis longus muscles, has been approach similar to ours for skin paddle salvage in recommended by some authors to capture the musculocutaneous the absence of significantly sized septocutaneous perforators supplying the skin component. This is effective only for perforators. Weber and Pederson6 successfully sal- a convergent perforator (blue arrow). However, in patients with a vaged two cases where the perforator did not stem divergent perforator (red arrow), taking a cuff of muscle, no matter from the peroneal artery. Yakoo et al.5 reported an howgenerous,willinvariablycuttheperforator,asitoriginatesfrom unusual fibula flap in which the musculocutane- a different artery. ous perforator when traced intramuscularly was

1582 Volume 120, Number 6 • Fibula Osteoseptocutaneous Flaps found to have an arterial origin from the posterior harvested by using musculocutaneous perforators tibial artery and a venous origin from the peroneal supplying the skin through the soleus muscle. vein. This osteocutaneous flap was successfully re- However, the origins of these vessels are more vascularized with two arterial anastomoses and a sin- variable and may necessitate the raising of two gle venous anastomosis. These clinical experiences separate free flaps to accomplish the reconstruc- illustrate the usefulness of raising the distal lateral tion. leg skin as a perforator flap in salvage situations. Bien-Keem Tan, F.R.C.S. The spectrum and prevalence of variant tri- Department of Plastic, Reconstructive, and Aesthetic furcation arterial anatomy have been well docu- Surgery mented by radiologic studies.26,27 Of relevance to Singapore General Hospital the harvest of the fibula flap are the various de- Outram Road grees of hypoplasia or aplasia of the anterior tibial Singapore 169608 and posterior tibial arterial systems. In such arte- [email protected] rial anomalies, the peronea arteria magna takes over the blood supply of the foot.28 Rarely, in a ACKNOWLEDGMENTS variant known as peroneal arterial magna, the pe- The authors thank Robert Ng for specimen prepa- roneal artery exists as the sole supply to the foot. ration. The lower limb specimens were obtained with Because the peroneal artery is procured with the permission of Arthur Chern, M.D., Director, Health Ser- fibula, the foot would be at risk in such situations. vices Development Division, Ministry of Health, Singapore. If detected preoperatively (by conventional, computed tomographic, or magnetic resonance an- DISCLOSURE giography), the presence of such anomalies would The authors did not receive any funding for this be a relative contraindication to the fibula flap work and declare no conflict of interest in this present harvest. The contralateral leg or a different donor work. site should be chosen. Therefore, increasingly, preoperative angiographic evaluation has been REFERENCES recommended for fibula flap harvest. However, 1. Wei, F. C., Chen, H. C., Chuang, C. C., and Noordhoof, M. S. Fibula osteoseptocutaneous flap: Anatomic study and clin- Lutz et al. have shown that routine preoperative ical application. Plast. Reconstr. Surg. 78: 191, 1986. angiography of the donor leg is not justified, as 2. Jones, N. F., Monstrey, S., and Gambier, B. A. Reliability of intraoperative evaluation by direct visualization of the fibula osteocutaneous flap for mandibular reconstruc- the anterior and posterior tibial arteries would be tion: Anatomical and surgical confirmation. Plast. Reconstr. a sufficient safeguard. They prospectively evalu- Surg. 97: 707, 1996. 3. Soutar, D. S. Reliability of the fibular osteocutaneous flap for ated the use of preoperative angiography on 120 mandibular reconstruction: Anatomic and surgical confir- 29 lower limbs. Of these, 119 fibula flaps were sub- mation (Discussion). Plast. Reconstr. Surg. 97: 717, 1996. sequently harvested without any adverse sequelae 4. Winters, H. A. H., and de Jongh, G. J. Reliability of the to the leg. They recommended preoperative an- proximal skin paddle of the osteocutaneous free fibula flap: giography only for patients with nonpalpable foot A prospective clinical study. Plast. Reconstr. Surg. 103: 846, 29 1999. pulses or previous trauma to the leg. Newer mo- 5. Yokoo, S., Komori, T., Furudoi, S., Umeda, M., Nomura, T., dalities such as multidetector row computed to- and Tahara, S. Rare variants of the intrasoleus musculocu- mographic angiography capable of delineating taneous perforator: Clinical consideration in raising a free skin perforators are increasingly available.30 When peroneal osteocutaneous flap. J. Reconstr. Microsurg. 17: 225, using this technique for preoperative evaluation, 2001. 6. Weber, R. A., and Pederson, W. C. Skin paddle salvage in the potentially useful information that could be de- fibula osteocutaneous free flap with secondary skin paddle rived includes the arterial anatomy of the lower vascular anastomosis. J. Reconstr. Microsurg. 11: 239, 1995. limb, distal leg skin perforators, and their origins. 7. Wei, F. C., Seah, C. S., Tsai, Y., et al. Fibula osteocutaneous This may improve donor-site selection and pre- flap for reconstruction of composite mandibular defects. operative planning. Plast. Reconstr. Surg. 93: 294, 1994. 8. Schusterman, M. A., Reece, G. P., Miller, M. J., and Harris, S. The osteocutaneous free fibula flap: Is the skin paddle CONCLUSIONS reliable? Plast. Reconstr. Surg. 90: 787, 1992. The skin component of the fibula osteosepto- 9. Wei, F. C., and Mardini, S. Free-style free flaps. Plast. Reconstr. cutaneous flap is often reliably supplied by septo- Surg. 114: 910, 2004. cutaneous perforators running within the poste- 10. Chen, Z. W., and Yan, W. The study of the clinical application of the osteocutaneous flap of the fibula. Microsurgery 4: 11, 1983. rior crural septum from the peroneal artery. 11. Van Twisk, R., Pavlov, P. W., and Sonneveld, J. Reconstruc- Occasionally, these perforators may be absent. In tion of bone and soft tissue defects with free fibula transfer. such situations, the skin paddle can still be reliably Ann. Plast. Surg. 21: 555, 1988.

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12. Hidalgo, D. A. Free fibula flap: A new method of mandible 22. Allen, R. J., and Tucker, C. Superior gluteal artery perforator reconstruction. Plast. Reconstr. Surg. 84: 71, 1989. free flap for breast reconstruction. Plast. Reconstr. Surg. 95: 13. Hidalgo, D. A. The osteocutaneous free fibula flap: Is the skin 1207, 1995. paddle reliable? (Discussion). Plast. Reconstr. Surg. 90: 797, 23. Angrigiani, C. A., Grilli, D., and Siebert, J. Latissimus dorsi 1992. musculocutaneous flap without muscle. Plast. Reconstr. Surg. 14. Flemming, A. F. S., Brough, M. D., Evans, N. D., et al. Man- 96: 1608, 1995. dibular reconstruction using vascularized fibula. Br. J. Plast. 24. Blondeel, P. N., Van Landuyt, K. H., Monstrey, S. J., et al. The Surg. 43: 403, 1990. Gent consensus on perforator flap terminology: Preliminary 15. Urken, M. L. The osteocutaneous free fibula flap: Is the skin definitions. Plast. Reconstr. Surg. 112: 1378, 2003. paddle reliable? (Discussion). Plast. Reconstr. Surg. 90: 794, 25. Celik, N., Wei, F. C., Lin, C. H., et al. Technique and strategy 1992. in anterolateral thigh perforator flap surgery, based on an 16. Hidalgo, D. A. The osteocutaneous free fibula flap: Is the skin analysis of 15 complete and partial failures in 439 cases. Plast. paddle reliable? (Discussion). Plast. Reconstr. Surg. 90: 797, Reconstr. Surg. 109: 2211, 2002. 1992. 26. Kim, D. S., Orron, D. E., and Skillman, J. J. Surgical signif- 17. Koshima, I., Saisho, H., Kawada, S., Hamanaka, T., Umeda, icance of the popliteal artery variants: A unified angiographic N., and Moriguchi, T. Flow-through thin latissimus dorsi classification. Ann. Surg. 210: 776, 1989. perforator flap for repair of soft-tissue defect in the legs. Plast. Reconstr. Surg. 103: 1483, 1999. 27. Mauro, M. A., Jacques, P. F., and Moore, M. The popliteal 18. Kroll, S. K., and Rosenfield, L. R. Perforator-based flaps for artery and its branches: Embryological basis of normal low posterior midline defects. Plast. Reconstr. Surg. 81: 561, and variant anatomy. A.J.R. Am. J. Roentgenol. 150: 335, 1988. 1988. 19. Koshima, I., Moriguchi, T., Soeda, S., Tanaka, H., and 28. Senior, H. D. The development of the arteries of the human Umeda, N. Free thin paraumbilical perforator-based flaps. lower extremity. Am. J. Anat. 25: 55, 1919. Ann. Plast. Surg. 29: 12, 1992. 29. Lutz, B. S., Wei, F. C., Ng, S., et al. Routine donor leg 20. Koshima, I., Moriguchi, T., Soeda, S., Kawada, S., Ohta, S., angiography before vascularized free fibula transplantation and Ikeda, A. The gluteal perforator-based flap for repair of is not necessary: A prospective study in 120 clinical cases. sacral pressure score. Plast. Reconstr. Surg. 91: 678, 1993. Plast. Reconstr. Surg. 103: 121, 1999. 21. Allen, R. J., and Treece, P. Deep inferior epigastric per- 30. Chow, L. C., Napoli, A., Klein, M., et al. Vascular mapping of forator flap for breast reconstruction. Ann. Plast. Surg. 32: the leg with multi-detector row CT angiography prior to 32, 1994. free-flap transplantation. Radiology 354: 353, 2005.

1584 HAND/PERIPHERAL NERVE

Evaluation of Elbow Flexion as a Predictor of Outcome in Obstetrical Brachial Plexus Palsy

David M. Fisher, M.D. Background: The purpose of this study was to answer two questions. First, are Gregory H. Borschel, M.D. there obstetrical brachial plexus palsy patients with no elbow flexion at 3 months Christine G. Curtis, P.T., who go on to recover useful upper extremity function without surgical inter- M.Sc. vention? Second, are there patients with evidence of elbow flexion at 3 months Howard M. Clarke, M.D., who do benefit from brachial plexus reconstruction? Ph.D. Methods: The authors retrospectively reviewed a sample drawn from 253 con- Toronto, Ontario, Canada secutive patients at The Hospital for Sick Children obstetrical brachial plexus database from 1993 to 1996. Inclusion criteria were examination at age 3 months and either complete spontaneous recovery or repeated examination after age 3 years. Two hundred nine patients satisfied the inclusion criteria. Patients were distributed into four groups: group A, no elbow flexion at age 3 months (operative management); group B, elbow flexion present at 3 months (operative management); group C, no elbow flexion at age 3 months (nonoperative management); and group D, elbow flexion present at 3 months (nonoperative management). Results: Groups A, B, and C showed significant intragroup improvements in both elbow flexion (p Ͻ 0.0001) and total limb motion scores (the sum of 15 individual joint motions) (p Ͻ 0.0001) with time. No differences were noted among groups A, B, and C for either elbow flexion or total limb motion scores at final follow-up. Conclusions: Early elbow flexion alone is not a sufficient criterion to recommend a nonoperative approach. In addition, spontaneous recovery of useful upper extremity function has been observed in a carefully selected subset of patients without elbow flexion at 3 months. (Plast. Reconstr. Surg. 120: 1585, 2007.)

he absence of spontaneous recovery of the flexion at age 3 months improve significantly biceps by 3 months of age is the most com- without surgery. Also, we have found that other Tmonly used indication for reconstruction patients develop poor upper extremity function of obstetrical brachial plexus palsy.1 However, we despite having evidence of elbow flexion at age 3 have found that some patients with absent elbow months. We have previously described our present From the Division of Plastic Surgery and Division of Phys- guidelines for management of obstetrical bra- iotherapy, Department of Rehabilitation Services, The Hos- chial plexus palsy.2,3 Fifteen distinct upper ex- pital for Sick Children, and Department of Surgery, Uni- tremity joint motions are graded (from 0 to 7) versity of Toronto. using the Active Movement Scale (Table 1), a Received for publication February 14, 2006; accepted No- validated instrument.4,5 The sum of grades yields vember 30, 2006. a total limb motion score (maximum, 105). Pa- Presented at the American Society for Peripheral Nerve meeting, in San Diego, California, January 14, 2001; Canadian tients are evaluated regularly during the first Society of Plastic Surgeons meeting, in Jasper, Alberta, Can- year. At the 3-month evaluation, Active Move- ada, June 7, 2001; Eighth Congress of the International ment Scale scores are converted using a standard Federation of Societies for Surgery of the Hand, in Istanbul, formula to obtain a test score ranging from 0 to Turkey, June 13, 2001; and 13th International Congress of 10.2 A test score of less than 3.5 of 10 is an the International Confederation for Plastic, Reconstructive, indication for surgery at that age. In addition, and Aesthetic Surgery, in Sydney, Australia, August 12, patients with documented Horner’s syndrome 2003. or clinical evidence of T1 avulsion are offered Copyright ©2007 by the American Society of Plastic Surgeons surgery at 3 months of age. A final decision for DOI: 10.1097/01.prs.0000282104.56008.cb surgery, based on physical examination findings

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Table 1. The Active Movement Scale* Table 2. Groupings of Patients in the Study* Observation Muscle Grade Operative Nonoperative Gravity eliminated Elbow flexion No contraction 0 ϭ0 or 1 (AMS) at Group A Group C Contraction; no motion 1 Age 3 months n ϭ 29 n ϭ 6 Motion Յ1/2 range 2 Ͼ Elbow flexion Motion 1/2 range 3 Ͼ Full range 4 1 (AMS) at Group B Group D Against gravity Age 3 months n ϭ 16 n ϭ 158 Motion Յ1/2 range 5 Ͼ AMS, Active Movement Scale. Motion 1/2 range 6 *Group A, no elbow flexion at age 3 months (operative manage- Full range 7 ment); group B, elbow flexion present at age 3 months (operative *Reprinted from Curtis, C. G., and Clarke, H. M. An approach to management); group C, no elbow flexion at age 3 months (nonop- obstetrical brachial plexus injuries. Hand Clin. 11: 563, 1995, with erative management); and group D, elbow flexion present at age 3 permission from Elsevier. months (nonoperative management). and degree of recovery, is made at age 9 months. Intragroup (3-month and-3 year) and inter- At that age, we recommend surgery for patients group (3-month and 3-year) comparisons of elbow who may have passed the 3-month test but for flexion (Active Movement Scale) and total limb whom sufficient further improvement has not motion scores were performed using analysis of been observed by 9 months of age, as measured variance (SAS Institute, Inc., Cary, N.C.) for a by the “cookie test.”2,3 In the cookie test, the two-factor (group and time) design with a re- child is given a cookie, and if he or she can bring peated measure on one factor (time). Statistical it to the mouth without flexing the neck more significance was defined as p Ͻ 0.05. A power than 45 degrees, and with the arm held at the analysis was performed to determine whether side, then he or she passes. We do not rely on there was adequate statistical power to detect clin- only one piece of data at one time to make a ically significant differences in elbow flexion and final decision regarding surgery. Surgical inter- total limb motion scores, comparing groups A ver- vention involves surgical exploration, resection sus C and A versus B, with a significance level (␣) of the lesion, nerve grafting, and nerve transfers. set to 0.05. The clinically significant difference The purpose of this study was to answer two selected was a one-point difference in elbow flex- questions: first, are there patients who, despite ion scores (and a 15-point difference in total limb demonstrating good early (3-month) elbow flex- motion score, or a one-point difference for each ion, would benefit from brachial plexus recon- motion tested). As a statistical cross-check, we per- struction? Second, are there patients with no formed Wilcoxon rank sum intragroup testing (3- elbow flexion at 3 months who go on to recover month and 3-year) for elbow flexion and total limb useful upper extremity function without surgical motion scores. As an additional cross-check, we intervention? performed Kruskal-Wallis intergroup testing among groups A, B, and C at 3 months and at 3 years for elbow flexion and total limb motion PATIENTS AND METHODS scores. Group D was compared with groups A, B, After obtaining approval from our research and C for both elbow flexion and total limb mo- ethics board, we retrospectively reviewed the data tion scores at 3 months. from 253 consecutive patients seen at The Hospi- tal for Sick Children obstetrical brachial plexus clinic from 1993 to 1996. Inclusion criteria were RESULTS examination at 3 months of age and either com- Two hundred nine patients met the inclusion plete spontaneous recovery or repeated examina- criteria and were distributed among the four study tion after age 3 years of age. Among these 253 groups as follows: group A, n ϭ 29; group B, n ϭ children, 209 met the inclusion criteria. Patients 16; group C, n ϭ 6; and group D, n ϭ 158. Groups were distributed into four groups (Table 2): group A, B, and C each showed significant increases in A, no elbow flexion at age 3 months (operative both elbow flexion (p Ͻ 0.0001) (Fig. 1 and Table management); group B, elbow flexion present at 3) and total limb motion scores (p Ͻ 0.0001) (Fig. 3 months (operative management); group C, no 2 and Table 4) from the initial evaluation at age elbow flexion at age 3 months (nonoperative man- 3 months to the final evaluation after 3 years of agement); and group D, elbow flexion present at age. No statistically significant differences were 3 months (nonoperative management). noted at the time of final clinical evaluation

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Fig. 1. Three-month and 3-year elbow flexion. Elbow flexion Active Movement Scale scores at 3 months were compared with elbow flexion scores at 3 years or more for groups A (operative, no elbow flexion; red), B (operative, elbow flexion; blue), C (nonoperative, no elbow flexion; green), and D (nonoperative, elbow flexion; gray). Groups A, B, and C experienced a statistically significant increase in elbow function by the end of the study period, with no statistically significant differences between groups by the end of the study period. Elbow flexion scores in group D were statistically significantly increased at 3 months compared with groups A, B, and C. Error bars represent 1 SD. among groups A, B, and C in either elbow flexion ing the study period. For group A, the following or total limb motion scores. Twenty-five of 29 chil- procedures were performed: latissimus dorsi mus- dren (86 percent) in group A had elbow flexion cle transfer with or without subscapularis release scores of 6 or 7 (maximum, 7) at 3 years; 16 of 16 (n ϭ 3); teres major transfer (n ϭ 1); and sub- children (100 percent) in group B, and six of six scapularis and/or pectoralis major release (n ϭ children (100 percent) in group C. There was a 6). For group B, the following procedures were statistically significant difference in the 3-month performed: subscapularis and pectoralis major re- elbow flexion and total limb motion scores (Figs.1 lease (n ϭ 1); release of trigger digits (n ϭ 1); and and 2 and Tables 3 and 4) between group D and glenoid osteotomy with latissimus dorsi muscle groups A, B, and C as tested by one-way analysis of transfer (n ϭ 1). No children from groups C or D variance. underwent secondary procedures. Nine children in group A and three children Assuming that a clinically significant differ- in group B underwent secondary procedures dur- ence corresponded to a one-point difference in

Table 3. Intragroup Comparison of Elbow Flexion (Active Movement Scale) Performed Using Analysis of Variance for a Two-Factor (Group and Time) Design with a Repeated Measure on One Factor (Time)* p (intergroup comparison at p (intragroup p (intergroup p (intergroup 3 mo against p (intragroup comparison by comparison at comparison at 3-Month group D by 3-Year comparison by Wilcoxon rank 3yrby 3yrby Group Score Kruskal-Wallis) Score ANOVA) sum test) ANOVA) Kruskal-Wallis) A(n ϭ 29) 0.14 Ϯ 0.35 Ͻ0.001 6.14 Ϯ 1.22 Ͻ0.0001 Ͻ0.0001 B(n ϭ 16) 2.75 Ϯ 1.18 Ͻ0.001 6.69 Ϯ 0.48 Ͻ0.0001 Ͻ0.0001 0.11 0.13 C(n ϭ 6) 0.33 Ϯ 0.52 Ͻ0.001 6.83 Ϯ 0.41 Ͻ0.0001 0.031 } D(n ϭ 158) 5.37 Ϯ 1.98 N/A N/A N/A N/A N/A N/A ANOVA, analysis of variance; N/A, not applicable. *As a cross-check, intragroup comparisons were made with Wilcoxon rank sum testing. Intragroup comparison demonstrated that groups A, B, and C significantly increased in elbow flexion between 3 months and 3 years. Intergroup comparisons among groups A, B, and C (with a cross-check using the Kruskal-Wallis test) demonstrated no statistically significant differences in elbow flexion between groups at 3 years. Kruskal-Wallis testing comparing group D at 3 months to each of groups A, B, and C was statistically significant (p Ͻ 0.001 against groups A, B, and C).

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Fig. 2. Three-month and 3-year total limb motion scores. Total limb motion scores at 3 months were compared with total limb motion scores at 3 years or more for groups A (operative, no elbow flexion; red), B (operative, elbow flexion; blue), C (nonoperative, no elbow flexion; green), and D (nonoperative, elbow flexion; gray). Groups A, B, and C experienced a statistically significant increase in total limb motion by the end of the study period, with no statistically significant differences between groups by the end of the study period. Total limb motion scores in group D were statistically significantly increased at 3 months compared with groups A, B, and C. Error bars represent 1 SD. individual measured motions, two-tailed power have been treated similarly in other centers, and analysis demonstrated that comparing elbow flex- those in either group B or group C, which would ion scores between groups A and C after 3 years at have been treated differently elsewhere. a significance level (␣) of 0.05 had a statistical power of 0.50. The power comparing groups A DISCUSSION and B was 0.85. Comparison of total limb motion Gilbert and Tassin’s criteria for the manage- scores after 3 years between groups A and C had ment of obstetrical brachial plexus palsy1 are prob- a power of 0.60 and the power comparing groups ably the most widely practiced worldwide, al- A and B was 0.85. A power analysis comparing though others have been published.2–8 According group B to group C was not performed, because to their criteria, if biceps function is absent at 3 we were interested in detecting differences in out- months of age, primary surgical brachial plexus come between the group A patients, who would reconstruction is recommended; if biceps func-

Table 4. Intragroup Comparison of Total Limb Motion Score (Active Movement Scale) Performed Using ANOVA for a Two-Factor (Group and Time) Design with a Repeated Measure on One Factor (Time)* p (intergroup comparison at p (intergroup 3 mo against p (intragroup p (intergroup comparison at group D by p (intragroup comparison by comparison at 3yrby 3-Month Kruskal-Wallis 3-Year comparison by Wilcoxon rank 3yrby Kruskal-Wallis Group Score testing) Score ANOVA) sum testing) ANOVA) testing) A(n ϭ 29) 55.59 Ϯ 17.70 Ͻ0.001 84.93 Ϯ 15.18 Ͻ0.0001 Ͻ0.0001 B(n ϭ 16) 67.44 Ϯ 18.08 Ͻ0.001 91.75 Ϯ 15.51 Ͻ0.0001 Ͻ0.0001 0.10 0.06 C(n ϭ 6) 63.17 Ϯ 16.30 Ͻ0.01 97.17 Ϯ 4.07 Ͻ0.0001 0.031 } D(n ϭ 158) 91.22 Ϯ 13.68 N/A N/A N/A N/A N/A N/A ANOVA, analysis of variance; N/A, not applicable. *As a cross-check, intragroup comparisons were made with Wilcoxon rank sum testing. Intragroup comparison demonstrated that groups A, B, and C significantly increased in elbow flexion between 3 months and 3 years. Intergroup comparisons among groups A, B, and C (with a cross-check using the Kruskal-Wallis test) demonstrated no statistically significant differences in total limb motion between groups at 3 years. Kruskal-Wallis testing comparing group D at 3 months to each of groups A, B, and C was statistically significant (p Ͻ 0.001 against groups A and B; p Ͻ 0.01 against group C).

1588 Volume 120, Number 6 • Brachial Plexus Palsy tion is present, patients are managed without pri- but otherwise having poor upper extremity func- mary nerve surgery.1 Thus, according to Gilbert tion and a low test score. and Tassin, there are two groups of patients to Another limitation to our analysis is that group consider: those with biceps function and those C contained only six patients, leaving open the without. Others have proposed similar strategies, possibility of a nonnormal distribution. However, and some would wait longer than 3 months to the p values for intragroup comparison were very determine whether a nonflail arm merits opera- low, lending support to our findings, and we used tive exploration.6,8–10 Our current selection crite- nonparametric methods for analysis, controlling ria are summarized above. A complete discussion for a potentially nonnormal score distribution. would necessarily be a complete article of itself Group C represents a small subset of the group of and the reader is referred to previous articles that patients who have no demonstrable elbow flexion describe the patient selection process at length.2,3 at 3 months of age but who pass the test score, do For patients without elbow flexion at age 3 not have Horner’s sign, and do not have evidence months, we believe that although most would ben- of T1 avulsion. In this subset of six patients, elbow efit from surgery, a small but distinct subgroup flexion developed rapidly over the ensuing 6 (group C) would not. Likewise, in those in whom months and they passed the cookie test at 9 elbow flexion is present at age 3 months, although months of age, avoiding surgery. This pattern of most would not benefit from surgery, there is recovery is not commonly seen but argues for the again a distinct subgroup (group B) that would need to follow each patient’s progress carefully improve with operative management. By our cri- over time. teria, there are four potential treatment groups The addition of secondary procedures may instead of the two originally proposed by Gilbert have affected the 3-year scores in some patients. and Tassin (Table 2). We feel that the current However, the overwhelming majority of patients in indications may lead to undertreatment of some groups A and B did not receive secondary proce- patients who present with elbow flexion at 3 dures. No children in groups C or D underwent months. A patient could have elbow flexion secondary surgery. Those patients with elbow flex- present at 3 months, but if wrist and hand exten- ion present at age 3 months who underwent pri- sion were not present, for example, then we may mary nerve reconstruction (group B) had a low recommend surgery depending on the test score. rate of secondary surgery (18 percent). It is pos- Conversely, current indications could lead to over- treatment in some patients who present without sible that the rate of secondary surgery in group B elbow flexion at 3 months. If elbow flexion is ab- would have been higher had these children not sent at 3 months but the extremity has otherwise undergone neuroma excision and grafting. Con- good function, we may recommend nonoperative versely, no children in group C underwent sec- management based on the test score and the ondary procedures. If these children had been cookie test. We have been able to evaluate the incorrectly assigned to nonoperative manage- outcomes of patients within the nonstandard ment, one would expect that some of them would treatment groups (groups B and C). Other centers have required secondary procedures. have reported use and validation of the test score Group D was compared with groups A, B, and as well.4,7,11–13 C at age 3 months for elbow flexion and total limb One potential weakness of using the Active motion scores and demonstrated significantly bet- Movement Scale to produce a test score is that it ter movement at that age. Because these patients does not differentiate between use of the biceps or demonstrated rapid spontaneous recovery, most the brachioradialis for elbow flexion. However, by were discharged from the clinic before age 3 years, focusing on multiple actions rather than on iso- and therefore complete 3-year data for group D lated muscles, using the test score accommodates were not available. Although it would be expected the variability in presentations inherent in obstet- that their Active Movement Scale scores would rical brachial plexus injuries. This variability in remain high (7 of 7) at 3 years of age, it would not presentation arises in part because the brachial have been appropriate to bring back patients who plexus is a naturally complex anatomical system, had demonstrated complete spontaneous recov- and also because the nature of the lesion is dif- ery at an early age for late follow-up for the pur- ferent in each case. For example, a possible sce- poses of this study. The importance of group D is nario could arise in which the elbow flexors re- that these patients can be differentiated easily main innervated but other groups are severely from patients in groups A, B, or C, and their prog- impaired, leading to the ability to flex the elbow nosis for spontaneous recovery is excellent.

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CONCLUSIONS Louis Children’s Hospital, during a portion of the prep- Power analysis demonstrated reasonable sta- aration of this article. tistical power to detect a clinically significant dif- DISCLOSURE ference in elbow flexion and total limb motion The authors have no financial interest in the ma- scores between groups A versus C and A versus B terial presented in this article. had there been one at 3 years. We believe that the reason there were no statistically significant dif- REFERENCES ferences in outcome is because we have assigned 1. Gilbert, A., and Tassin, J. L. Re´paration chirurgicale du these patients to the course of treatment that max- plexus brachial dans la paralysie obste´tricale. Chirurgie 110: 70, 1984. imized functional recovery. We have maximized 2. Clarke, H. M., and Curtis, C. G. An approach to obstetrical 3-year function by operating on patients who brachial plexus injuries. Hand Clin. 11: 563, 1995. would most benefit from operative management 3. Marcus, J. R., and Clarke, H. M. Management of obstetrical and avoiding surgery in those who would not. We brachial plexus palsy: Evaluation, prognosis, and primary are not advocating a conservative approach; in- surgical treatment. Clin. Plast. Surg. 30: 289, 2003. 4. Bae, D. S., Waters, P. M., and Zurakowski, D. Reliability of three stead, we operated on 45 patients in the series and classification systems measuring active motion in brachial denied surgery to six highly selected cases. Ad- plexus birth palsy. J. Bone Joint Surg. (Am.) 85: 1733, 2003. dressing anatomical lesions in those specific pa- 5. Curtis, C., Stephens, D., Clarke, H. M., and Andrews, D. The tients whose test scores are low results in mean- active movement scale: An evaluative tool for infants with ingful recovery. Groups A, B, and C showed obstetrical brachial plexus palsy. J. Hand Surg. (Am.) 27: 470, 2002. significant improvements in elbow flexion and to- 6. Waters, P. M. Comparison of the natural history, the outcome tal limb function. In group A, 86 percent (25 of 29 of microsurgical repair, and the outcome of operative re- children) scored either 6 or 7 at 3 years for elbow construction in brachial plexus birth palsy. J. Bone Joint Surg. flexion; in groups B and C, all children (100 per- (Am.) 81: 649, 1999. cent) scored either 6 or 7 in elbow flexion. Be- 7. Al-Qattan, M. M. The outcome of Erb’s palsy when the decision to operate is made at 4 months of age. Plast. Reconstr. cause patients in groups B and C ultimately fared Surg. 106: 1461, 2000. no worse than those in group A, we conclude that 8. Chuang, D. C., Mardini, S., and Ma, H.-S. Surgical strategy for we have correctly assigned their treatment modal- infant obstetrical brachial plexus palsy: Experiences at ities and, at worst, we have done no harm by basing Chang Gung Memorial Hospital. Plast. Reconstr. Surg. 116: our recommendations for or against surgery on 132, 2005. 9. Nehme, A., Kany, J., Sales-De-Gauzy, J., Charlet, J. P., Dautel, the test score and cookie test rather than elbow G., and Cahuzac, J. P. Obstetrical brachial plexus palsy: Pre- flexion alone. diction of outcome in upper root injuries. J. Hand Surg. (Br.) 27: 9, 2002. Howard M. Clarke, M.D., Ph.D. 10. Xu, J., Cheng, X., and Gu, Y. Different methods and results Division of Plastic Surgery in the treatment of obstetrical brachial plexus palsy. J. Re- The Hospital for Sick Children constr. Microsurg. 16: 417, 2000. 555 University Avenue, Suite 1524 11. Al-Qattan, M. M. The first multi-disciplinary obstetrical bra- Toronto, Ontario M5G 1X8, Canada chial plexus clinic in Saudi Arabia. J. Hand Surg. (Br.) 21: 124, [email protected] 1996. 12. Aydın, A., Mersa, B., Erer, M., O¨ zkan, T., and O¨ zkan, S. Dog˘umsal brakiyal pleksus yaralanmalarında sinir cerrahisi- ACKNOWLEDGMENTS nin erken sonuc¸ları: Early results of nerve surgery in obstet- Gregory H. Borschel, M.D., is grateful for financial rical brachial plexus palsy. Acta Orthop. Traumatol. Turc. 38: 170, 2004. support from the Division of Plastic and Reconstructive 13. Yılmaz, K., C¸ alıs¸kan, M., O¨ ge, E., Aydınlı, N., Tunacı, M., and Surgery, Washington University School of Medicine, and O¨ zmen, M. Clinical assessment, MRI, and EMG in congenital the Division of Plastic and Reconstructive Surgery, St. brachial plexus palsy. Pediatr. Neurol. 21: 705, 1999.

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Intravenous Regional Anesthesia Administered by the Operating Plastic Surgeon: Is It Safe and Efficient? Experience of a Medical Center

Joseph S. Bou-Merhi, M.D. Background: Intravenous regional anesthesia (Bier’s block) is an effective Alain R. Gagnon, M.D. method of providing anesthesia for extremity surgery. This technique is most Jean-Yves St. Laurent, M.D. suitable for short-duration, less than 60-minute surgical procedures in distal Marc Bissonnette, M.D. extremities. Earlier studies recommended that intravenous regional anesthesia Andre A. Chollet, M.D. be performed by anesthesiologists who are familiar with the technique and fully Montreal, Quebec, Canada trained to treat its complications. This study was conducted to demonstrate that intravenous regional anesthesia administered by the operating plastic surgeon is safe, efficient, and simple to perform. Methods: A 5-year retrospective chart review (January of 2000 to December of 2004) was undertaken. The study included patients who underwent surgical procedures and were administered intravenous regional anesthesia by the surgeon. Results: Four hundred forty-eight patients were included in the study, and 479 operations of 483 scheduled were completed under intravenous regional anesthesia performed by the operating surgeon. Intravenous regional anesthesia was efficient in 478 of 479 of the cases (99.8 percent). Tourniquet-related technical problems were noted in five of 483 cases (1 percent), resulting in cancellation of four operations, with no reported consequent anesthetic toxicity. Minor complications were reported in six of 479 of the cases (1.2. percent). No major complications occurred. Conclusions: Despite earlier worries about the safety of intravenous regional anesthesia if not administered by anesthesiologists, the authors found that intravenous regional anesthesia represents a safe and efficient technique of anesthesia for extremity surgery when performed carefully and appropriately by the operating surgeon. The authors suggest that plastic surgeons familiarize themselves with this technique, which is simple to perform. This could probably result in lower overall costs and greater autonomy for the surgeon. (Plast. Reconstr. Surg. 120: 1591, 2007.)

ntravenous regional anesthesia is a wide- thetic solution following exsanguination and iso- spread and well-established technique of pro- lation of the extremity. This technique was first Ividing anesthesia for extremity surgery, espe- described in 1908 by August Bier, a German cially in the surgical ambulatory setting. It surgeon, with the use of procaine, and was sub- consists of intravenous injection of local anes- sequently referred to as Bier’s block.1 The technique has become increasingly popular since From the Division of Plastic and Reconstructive Surgery, Holmes reintroduced the technique in 1963,2 us- Maisonneuve–Rosemont Hospital, a University of Mont- ing lidocaine as an anesthetic agent, which became real–affiliated medical center. the most commonly used local anesthetic agent for Received for publication June 30, 2006; accepted November intravenous regional anesthesia.3 It is quick and 28, 2006. Presented at the 59th Annual Meeting of the Canadian simple to administer, provides rapid onset of anes- Society of Plastic Surgeons, in Nanaimo, British Columbia, thesia, and is safe and effective when performed June 8 through 11, 2005, and Plastic Surgery 2005, the carefully. Its published success rates range from 94 American Society of Plastic Surgeons Annual Meeting, in to 100 percent.4,5 The technique is most suitable Chicago, Illinois, September 24 through 28, 2005. for short-duration (Ͻ60 minutes) surgical proce- Copyright ©2007 by the American Society of Plastic Surgeons dures in distal extremities (forearm, hand, ankle, DOI: 10.1097/01.prs.0000282105.02623.38 and foot).6 The main disadvantages of this tech-

www.PRSJournal.com 1591 Plastic and Reconstructive Surgery • November 2007 nique are related to its requirement for a tourni- block was also assessed as noted in the operative quet, which include tourniquet cuff pain and the nursing notes. All cases were analyzed for any po- risk of local anesthetic toxicity caused by accidental tential complication. Any sign of lidocaine sys- or premature tourniquet cuff deflation. Another temic toxicity was also noted. A regional block was drawback of this technique is the limited posttour- established in all patients by following carefully niquet deflation analgesia resulting from washout the standard recommended technique for admin- of the local anesthetic solution. Although the tech- istering intravenous regional anesthesia on the nique is generally safe,5 complications related to upper extremity,3,5,6,9 hereafter described: intravenous regional anesthesia can occur in the clinical setting3 and are usually related to local • Intravenous regional anesthesia should be per- anesthetic toxicity. Minor complications occurring formed in an area with immediate access to during intravenous regional anesthesia in- resuscitative drugs, equipment, and expertise. clude dysphoria, facial tingling, dizziness, • Proper preoperative patient evaluation is carried light-headedness, metallic taste, tinnitus,3,4 and out with emphasis on relevant history, focused incomplete anesthetic block. Seizure, cardiac ar- physical examination, and laboratory tests while rest, and death are rare but reported as well with making sure that the patient has no contraindi- this technique.3,7,8 Previous studies recom- cation to intravenous regional anesthesia. mended that intravenous regional anesthesia be • Current standard monitoring is used (electro- performed following a recognized protocol by cardiography, noninvasive blood pressure, and anesthesiologists who are familiar with the tech- pulse oximetry). Continuous monitoring of nique and fully trained to manage its potential pulse, blood pressure, electrocardiogram, and complications.3,9 We therefore conducted this oxygen saturation throughout the surgical pro- study to evaluate the safety and efficiency of cedure is recommended. intravenous regional anesthesia administered by • All operating room equipment including the the operating plastic surgeon during surgery in- pneumatic tourniquet must be in proper work- volving mainly the upper extremity, in an ambu- ing condition. latory surgical setting. • The surgeon performing the block must obtain and maintain his or her credentials and certification in Basic or Advanced Cardiac Life PATIENTS AND METHODS Support. A 5-year retrospective chart review was un- • The nursing operating room personnel should dertaken at Maisonneuve Rosemont Hospital, a be appropriately licensed and should have the University of Montreal–affiliated medical cen- necessary expertise. Such personnel must have ter. The study included all patients who under- clearly specified responsibilities and should went surgical procedures between January of maintain basic cardiopulmonary resuscitation 2000 and December of 2004 and were adminis- training. The nursing support staff includes tered intravenous regional anesthesia by the op- one scrub nurse, one circulating nurse, and erating surgeon. The surgeon first performed the one trained nurse whose only responsibility is intravenous regional block and then went on to to continuously monitor the patient’s vital carry out the surgical procedure. A trained oper- signs and to operate and monitor the pneu- ating room nurse was always present to operate matic tourniquet cuff. and supervise the tourniquet and to monitor the • An intravenous catheter is inserted in the ex- patient’s vital signs, with no other assigned re- tremity not being operated on for emergency sponsibilities. Three surgeons participated in the intravenous access. A second intravenous cath- study. All the operations and Bier’s blocks were eter is inserted in a distal vein on the dorsum performed in a fully equipped operating room in of the hand of the extremity being operated on a hospital setting with immediate availability of for local anesthetic injection and is taped se- anesthesia backup. In our institution, a trained curely. An antecubital vein should not be used anesthesiologist is always available in case of emer- for injection because this increases the risk of gency or should problems arise. The information local anesthetic leakage under the cuff and obtained from the medical charts included the age because the local anesthetic injection site of the patient, sex, American Society of Anesthe- should be as close as possible to the area being siologists physical status, site and duration of sur- operated on for faster onset of action. A small- gery, tourniquet time, and type of surgical proce- gauge intravenous catheter should be used to dure performed. The efficiency of the intravenous prevent oozing after catheter removal.

1592 Volume 120, Number 6 • Intravenous Regional Anesthesia

• A double cuff pneumatic tourniquet is applied 20 minutes has elapsed since the injection of on the arm being operated on and the extrem- lidocaine, to allow binding of local anesthetic ity is exsanguinated with the use of an Esmarch to tissues.3,5 Pulse rate, blood pressure, electro- bandage. cardiography, oxygen saturation, and level of • The pneumatic tourniquet is then inflated to a consciousness should be closely monitored for pressure of 250 or 100 mmHg greater than the approximately 5 minutes after tourniquet de- systolic blood pressure. The distal cuff should flation. The patient is informed of possible be inflated first to aid in exsanguination of the transient adverse effects of lidocaine following tissue under the cuff, followed by the proximal tourniquet cuff deflation, such as lightheaded- cuff. Before injecting, always check for infla- ness, metallic taste, and tinnitus. tion of the tourniquet cuff by palpation. Both • The maximal duration of tourniquet inflation cuffs should be left inflated during injection of should not exceed 120 minutes at the same the local anesthetic to minimize leakage. The tourniquet site, to avoid ischemic injury to distal tourniquet cuff is deflated after the in- muscles.15 However, in practice, the tourniquet jection of local anesthetic to allow anesthesia is rarely tolerated for a period longer than 60 to develop under the cuff. The pneumatic minutes. tourniquet should never be left unattended • The patient is then transferred to the recovery during the surgical procedure. room, where a registered nurse is assigned to • The Esmarch bandage is removed and the ab- monitor the patient’s vital signs during the sence of radial pulse is confirmed. recovery period before discharging him or her • Intravenous regional anesthesia was estab- to the outpatient ward. lished in all patients using 40 ml of a solution • Parenteral or oral opioid analgesics, if not con- containing preservative-free lidocaine 0.5% traindicated, are started immediately postoper- (200 mg). The maximal recommended dose of atively to counteract the limited post–tourni- lidocaine for intravenous regional anesthesia is quet deflation analgesia. 3 mg/kg.4,10,11 Leakage under the tourniquet cuff is minimized by the use of a distal site of Statistical Analysis injection (dorsal veins of the hand) and by Data were compiled on an Excel file (Mi- slowly injecting the medication over a mini- crosoft Corp., Redmond, Wash.) and converted to mum period of 90 seconds.12–14 After injection, an SPSS version 11.0 software data set (SPSS, Inc., the catheter is withdrawn. The onset of anes- Chicago, Ill.). Descriptive statistics included thesia in the region distal to the tourniquet means and standard deviations and counts and occurs within 5 to 10 minutes. percentages. Results are reported either as means • Once the surgeon’s attention is directed to the with standard deviations or as percentages when operative procedure, a trained registered appropriate. nurse is assigned to effectively monitor and operate the pneumatic tourniquet. • During surgery, tourniquet pain can be de- RESULTS creased by inflation of the distal tourniquet A total of 448 patients were included in the cuff followed by deflation of the proximal one. study. The age of the patients ranged between 12 Tourniquet pressure will then be applied over and 85 years (mean, 44 years). Patients were all an anesthetized area. Adjunctive parenteral American Society of Anesthesiologists status I or medications can also be given to supplement II. All operations were performed by three board- the regional block. Benzodiazepines (e.g., mi- certified plastic surgeons on an outpatient basis. dazolam) are useful to produce sedation and In total, 483 procedures were scheduled, of which to raise the threshold of central nervous system 479 were completed on 448 patients, because four side effects of local anesthetic agents. Narcotics operations were canceled as a result of a tourni- (e.g., fentanyl) can help decrease tourniquet quet-related technical problem; 33 patients (7.4 pain.3 Supplemental infiltration of local anes- percent) underwent more than one procedure thetic into the operative site may be needed under intravenous regional anesthesia adminis- occasionally in case of incomplete intravenous tered by the operating surgeon at different times. block. Table 1 lists patient demographics and surgical • At the end of the surgical procedure, the tour- data. Total operative time varied from 10 to 180 niquet cuff may be deflated in one step if a minutes (mean, 54 minutes), with tourniquet time recommended minimal period of inflation of varying from 14 to 122 minutes (mean, 51 min-

1593 Plastic and Reconstructive Surgery • November 2007

Table 1. Patient Demographics and Surgical Data* Table 4. Classiﬁcation of Minor Complications Total no. of patients 448 Complications No. of Cases (%) Age, years Tinnitus 2 (0.4) Range 12–85 Metallic taste 1 (0.2) Mean Ϯ SD 44.4 Ϯ 15.0 Dizziness 1 (0.2) Male, % 54.8 Chest pain 1 (0.2) Total no. of procedures performed 479 Bradycardia (asymptomatic) 1 (0.2) Duration of surgery, minutes Total 6 (1.2) Range 10–180 Mean Ϯ SD 54.4 Ϯ 24.2 Tourniquet time, minutes Range 14–122 erate the pneumatic tourniquet without signifi- Mean Ϯ SD 51.1 Ϯ 20.7 cant discomfort. Furthermore, no cases were converted to general anesthesia or other type of regional anesthesia. The intervention of an anes- Table 2. Operative Site thesiologist was never required. Anatomical Region No. of Procedures (%) Upper extremity Hand 279 (58.2) DISCUSSION Wrist 132 (27.6) A great number of upper extremity operations Forearm 11 (2.3) Elbow 55 (11.5) are performed on an ambulatory basis under in- Total 477 (99.6) travenous regional anesthesia or brachial plexus Lower extremity blockade. The advantages of regional over general Toes 1 (0.2) Foot 1 (0.2) anesthesia are numerous and have been clearly Total 2 (0.4) established.16–18 These include avoidance of airway instrumentation, decreased postoperative intensity of care, decreased recovery times and hospital Table 3. Type of Surgical Procedures Performed stay, decreased costs, and intraoperative commu- Type of Surgical Procedure No. (%) nication with the patient. Intravenous regional anesthesia is an effective Tendon surgery 93 (19.4) Dupuytren’s surgery 79 (16.5) anesthetic technique for short-duration surgery at Other soft-tissue surgery 133 (27.8) or distal to the elbow region, making it an ideal Bone surgery 156 (32.5) technique for many upper extremity procedures Microsurgery 18 (3.8) Total 479 performed on an ambulatory basis. The main advantages of this technique include simplicity, reliability, safety, rapid onset of action, rapid recovery, and provision of a bloodless surgical utes). Most of the cases (99.6 percent) were per- field. It appears that surgical anesthesia in informed on the upper extremity as summarized in travenous regional anesthesia is the result of Table 2. Intravenous regional anesthesia was used several mechanisms.19 The initial effect seems to for a variety of suitable procedures (Table 3). The be a block of peripheral nerve endings by the local intravenous block was efficient in 478 of the 479 anesthetic. This is quickly followed by a block of cases (99.8 percent). Only one case of incomplete nerve branches at a more proximal site through intravenous block was reported, requiring a sup- infiltration of epineural vessels. The importance plemental infiltration of local anesthetic into the of other contributing factors such as ischemia and operative site. Tourniquet-related technical prob- nerve compression is unclear. lems were noticed in five of 483 scheduled cases (1 As to the selection of drugs for intravenous percent), resulting in the cancellation of four of regional anesthesia, no drug has been demon- these five cases. There was no reported conse- strated to be superior to lidocaine, although var- quent local anesthetic toxicity. Minor complica- ious local anesthetic agents may be used to induce tions of intravenous regional anesthesia per- intravenous regional anesthesia. Lidocaine re- formed by the operating surgeon were reported in mains the most commonly used local anesthetic six of 479 cases (1.2 percent) (Table 4). These agent for surgical procedures in North America3 minor complications occurred mostly at the end because of its perceived safety and its well-known of the procedure, immediately after tourniquet profile of activity and side effects. Prilocaine, pre- deflation. No major cardiac or neurologic com- viously considered the safest local anesthetic for plication occurred. All patients were able to tol- intravenous regional anesthesia,20 is no longer

1594 Volume 120, Number 6 • Intravenous Regional Anesthesia available in North America in a form suitable for • A cone-shaped short arm may cause an uneven intravenous regional anesthesia. The drug was tourniquet to contact during inflation, thereby withdrawn because of concern about methemo- increasing local anesthetic leakage under the globinemia, although significant methemoglobin- tourniquet. emia does not occur with the doses used for in- • Uncontrolled high blood pressure. travenous regional anesthesia.4,20 Complications occurring during intravenous The use of bupivacaine for intravenous re- 9 gional anesthesia is contraindicated as a result of regional anesthesia include the following : several deaths associated with its use, with at least • Local anesthetic toxicity: Tourniquet failure or seven deaths reported in the United Kingdom its premature release can cause acute, severe from 1979 to 1983.7 Details for all of the cases are toxicity with neurologic and cardiovascular col- not known, but there were common factors in five lapse. Minor neurologic symptoms such as diz- of the deaths: the patients were healthy, automatic ziness, light-headedness, metallic taste, or tin- tourniquets were used, the block was performed nitus can occur on release of the tourniquet at with bupivacaine, and the surgical procedure was the end of the procedure. carried out without a second person to supervise • Nerve injury: Generally transient and related the use of the tourniquet. In three cases, the to pressure and/or ischemia. equipment was examined and found to be satis- • Inadequate anesthesia: Adjunctive systemic an- factory but the cuff had been deflated at an inap- algesia, supplemental local anesthetic infiltra- propriate time.7 After this, Heath recommended tion, or conversion to general anesthesia may that intravenous regional anesthesia be per- be required. formed using a drug other than bupivacaine by an anesthesiologist trained in intravenous regional Although simple to perform, a number of is- anesthesia and possessing resuscitative skills, who sues should be addressed with this technique: the would supervise the use of the tourniquet during risk of systemic toxicity is usually associated with the operation.7 Ropivacaine has been compared leakage of local anesthetic into the systemic cir- with lidocaine in volunteers; it provided compa- culation. Local anesthetic toxicity may be caused rable intravenous regional anesthesia but more by leakage past the tourniquet following injec- prolonged residual anesthesia and analgesia after tion resulting from either tourniquet failure or tourniquet release, and side effects were less.21,22 build-up of excessively high venous pressure dis- In an attempt to improve the quality of the tal to the tourniquet.13 To prevent this compli- block, reduce tourniquet pain, and prolong du- cation, meticulous attention to details is essen- ration of postoperative analgesia following tour- tial in testing the double-cuffed tourniquet, niquet deflation, various adjuvants including opi- performing a proper extremity exsanguination, oids (e.g., fentanyl, meperidine, and morphine), and during the administration of the local an- nonsteroidal antiinflammatory drugs (e.g., ke- esthetic (i.e., slow injection limited to the max- torolac), clonidine, and muscle relaxants (e.g., imum recommended dose, averaging 3 mg/kg atracurium) have been added to the local anes- at a distal intravenous site). General recommen- thetic solution with varying degrees of success.23–30 dations for the safe administration of intravenous Contraindications specific to intravenous regional regional anesthesia have already been discussed in anesthesia include the following9: the previous sections. The complications encountered in our study • Uncooperative patient: This applies to psychi- were mild, occurred immediately after tourniquet atric and pediatric patients because all local deflation at the end of the procedure, and re- anesthetic procedures require cooperation. solved without any sequelae. Our incidence of mi- • Sickle cell disease: Red cells are prone to sick- nor local anesthetic toxic effects was low, probably ling in the hypoxemic environment of the iso- because most of the patients received routinely lated extremity. small doses of intravenous benzodiazepines and • Raynaud’s phenomenon, because vasospasm narcotics perioperatively for a better tourniquet can be precipitated. tolerance and to ensure comfort during the pro- • Known hypersensitivity to the local anesthetic cedure. This study has some limitations. It is a solution. retrospective review and no control group of pa- • Peripheral vascular disease. tients who underwent intravenous regional anes- • Obesity: A large tourniquet and high inflation thesia by anesthesiologists was present during the pressures may be required. same time period at our institution. The incidence

1595 Plastic and Reconstructive Surgery • November 2007 of adverse events in this study was no higher than current guidelines to avoid anesthesia-related that reported in the literature of intravenous re- complications. Therefore, we suggest that plastic gional anesthesia performed by anesthesiologists. and hand surgeons familiarize themselves with In a retrospective review of 20 years’ experience this technique, which is simple, safe, and efficient. with intravenous regional anesthesia, Brown et al.5 This could probably result in substantial savings in reported an incidence rate of adverse events of 1.6 time and costs, with greater autonomy for the percent following intravenous regional anesthesia surgeon, greater control over the schedule, and performed by anesthesiologists in a series of 1906 increased efficiency. patients that consisted of minor events such as Joseph S. Bou-Merhi, M.D. temporary dizziness, tinnitus, or mild bradycardia. Division of Plastic and Reconstructive Surgery There was no mortality or major morbidity. Dun- Department of Surgery bar and Mazze4 reported an incidence rate of 2.1 University of Montreal percent of mild central nervous system toxicity, Pavillon Roger-Gaudry including dizziness, blurred vision, facial numb- 2900 Boulevard Edouard-Montpetit Montreal, Quebec H3T 1J4, Canada ness, and difficulty speaking in a series of 779 [email protected] patients, 778 of whom had received lidocaine. CONCLUSIONS DISCLOSURE As outpatient surgery continues to grow, there None of the authors has a financial interest in any is increasing interest in the use of regional tech- of the products, devices, or drugs mentioned in this niques to provide anesthesia for surgical proce- article. dures on the upper extremity. Despite earlier worries about the safety of intravenous regional REFERENCES anesthesia if not administered by anesthesiolo- 1. Bier, A. Uber einen neuen Weg Lokalanasthesie und den gists, we feel that intravenous regional anesthesia Gliedmaszen ze erzuegen. Arch. Klin. Chir. 86: 1007, 1908. represents a safe, well-tolerated, and cost-effective 2. Holmes, C. Intravenous regional anaesthesia: A useful method of anesthesia for upper extremity surgery method of producing analgesia of the limbs. Lancet 1: 245, when performed appropriately by the operating 1963. surgeon. However, we stress that the technique 3. Henderson, C. L., Warriner, C. B., McEwen, J. A., and Mer- rick, P. M. A North American survey of intravenous regional should follow carefully the current recognized anesthesia. Anesth. Analg 85: 858, 1997. protocol that has been presented. The technique 4. Dunbar, R. W., and Mazze, R. I. Intravenous regional anes- does require training but no extensive experience thesia: Experience with 779 cases. Anesth. Analg. 46: 806, or anesthesiologist’s expertise. Any local anes- 1967. thetic technique is potentially hazardous. Prereq- 5. Brown, E. M., and McGriff, J. T. Intravenous regional anaesthesia (Bier block): Review of 20 years’ experience. Can. uisites to performing this technique include the J. Anaesth. 36: 307, 1989. following: 6. Rawal, N. Intravenous regional anesthesia techniques. Reg. Anesth. Pain Med. 4: 51, 2000. • The surgeon must be familiar with the local 7. Heath, M. L. Deaths after intravenous regional anaesthesia. anesthetic agent used, its safe dosage, and its B.M.J. (Clin. Res. Ed.) 285: 913, 1982. side effects. The nursing support staff and the 8. Auroy, Y., Narchi, P., Messiah, A., Litt, L., Rouvier, B., and Samii, K. Serious complications related to regional anesthe- surgeon must obtain and maintain their cre- sia: Results of a prospective survey in France. Anesthesiology 87: dentials and certification in Advanced Cardiac 479, 1997. Life Support. They must be able to recognize 9. Marchant, A. E., and McConachie, I. Intravenous regional local anesthetic side effects at an early stage and anaesthesia. Curr. Anaesth. Crit. Care 14: 32, 2003. manage all potential complications. 10. Plourde, G., Barry, P. P., and Tardif, L. Decreasing the toxic • potential of intravenous regional anaesthesia. Can. J. Anaesth. Emergency equipment should also be on hand, 36: 498, 1989. and the full range of resuscitation equipment 11. Mazze, R., and Dunbar, R. Plasma lidocaine concentrations and drugs should be immediately accessible. after caudal, lumbar, epidural, axillary block, and intrave- • Proper patient selection (American Society of nous regional anesthesia. Anesthesiology 27: 574, 1966. Anesthesiologists status I or II) and adequate 12. El-Hassan, K., Hutton, P., and Black, A. Venous pressure and arm volume changes during simulated Bier’s block. 39: 229, and continuous patient monitoring through- 1984. out the procedure by a well-trained registered 13. Grice, S., Morell, R., and Balestrieri, F. Intravenous regional nurse is mandatory. anesthesia: Evaluation and prevention of leakage under the tourniquet. Anesthesiology 65: 316, 1986. The patient’s safety must remain our first pri- 14. Duggan, J., McKeown, D., and Scott, D. Venous pressures in ority. Our responsibility as surgeons is to follow intravenous regional anaesthesia. Reg. Anesth. 9: 70, 1984.

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15. Sapega, A., Heppenstall, R., and Chance, B. Optimizing tour- 23. Steinberg, R., Reuben, S., and Gardner, G. The dose-re- niquet application and release times in extremity surgery: A sponse relationship of ketorolac as a component of intrave- biochemical and ultrastructural study. J. Bone Joint Surg. (Am.) nous regional anesthesia with lidocaine. Anesth. Analg. 86: 67: 303, 1985. 791, 1998. 16. Brown, A., Weiss, R., and Greenberg, C. Interscalene block 24. Arthur, J., Heavner, J., and Mian, T. Fentanyl and lido- for shoulder arthroscopy: Comparison with general anesthe- caine versus lidocaine for Bier block. Reg. Anesth. 17: 223, sia. Arthroscopy 9: 295, 1993. 1992. 17. D’Alessio, J., Rosenblum, M., and Shea, K. A retrospective com- 25. Gupta, A., Bjornsson, A., and Sjoberg, F. Lack of peripheral parison of interscalene block and general anesthesia for am- analgesic effect of low dose morphine during intravenous bulatory surgery shoulder arthroscopy. Reg. Anesth. 20: 62, 1995. regional anesthesia. Reg. Anesth. 18: 250, 1993. 18. Pavlin, D., Rapp, S., and Polissar, N. Factors affecting dis- 26. Elhakim, M., and Sadek, R. Addition of atracurium to lidocaine for intravenous regional anaesthesia. Acta Anaesthesiol. charge time in adult outpatients. Anesth. Analg. 87: 816, 1998. Scand. 38: 542, 1994. 19. Rosenberg, P., and Heavner, J. Multiple and complementary 27. Reuben, S., Steinberg, R., and Lurie, S. A dose-response study mechanisms produce analgesia during intravenous regional of intravenous regional anesthesia with meperidine. Anesth. anesthesia. Anesthesiology 62: 840, 1985. Analg. 88: 831, 1999. 20. Bader, A., Concepcion, M., Hurley, R. J., and Arthur, G. R. 28. Reuben, S., Steinberg, R., and Klatt, J. Intravenous regional Comparison of lidocaine and prilocaine for intravenous re- anesthesia using lidocaine and clonidine. Anesthesiology 91: gional anesthesia. Anesthesiology 69: 409, 1988. 654, 1999. 21. Atanassoff, P., and Hartmannsgruber, M. Is ropivacaine 0.2% 29. Gentili, M., Bernard, J. M., and Bonnet, F. Adding clonidine an alternative to lidocaine 0.5% for intravenous regional to lidocaine for intravenous regional anesthesia prevents anesthesia. Br. J. Anaesth. 80: A377, 1998. tourniquet pain. Anesth. Analg. 88: 1327, 1999. 22. Chan, V., Welsbrod, M., and Kaezee, S. Comparison of Ropi- 30. Gorgias, N., Maidatsi, P., and Kyriakidis, A. Clonidine versus vacaine and lidocaine for intravenous regional anesthesia in ketamine to prevent tourniquet pain during intravenous re- volunteers: A preliminary study on anesthetic efficacy and gional anesthesia with lidocaine. Reg. Anesth. Pain Med. 26: blood level. Anesthesiology 90: 1602, 1999. 512, 2001.

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1597 IDEAS AND INNOVATIONS

Hand Evaluation following Ulnar Forearm Perforator Flap Harvest: A Prospective Study

Eduardo D. Rodriguez, M.D., D.D.S. Suhail K. Mithani, M.D. Rachel Bluebond-Langner, M.D. Paul N. Manson, M.D. Baltimore, Md.

he radial forearm flap, described by Song in and neck defects performed by a single surgeon 1981, has been used for reconstruction (E.D.R.). Tthroughout the body.1 The thin and supple skin paddle, variety of donor tissues, long vascular Operative Technique pedicle, and minimal donor-site morbidity make it All patients had negative preoperative and in- particularly attractive for application in the head traoperative Allen’s tests. Flaps were dissected in and neck. However, the radial forearm is hirsute the suprafascial plane, leaving the forearm fascia and the donor site requires a skin graft that is less intact. The ulnar artery, nerve, and venae comi- easily concealed when the hand is in repose. The tantes were identified and the artery and its venae ulnar forearm flap, first described by Lovie et al. in comitantes ligated and divided distally. Retro- 19842 and subsequently reported by several grade dissection of the pedicle was performed to authors,3–8 shares identical qualities but tends to be achieve sufficient length. The proximal extent of less hirsute, and the donor site is easier to conceal. artery was then ligated. The flap was inset, and the These reports focus on the anatomy, technique, pedicle was tunneled to either the superficial tem- flap characteristics, and outcomes. This study was poral vessels or facial artery. Donor sites were designed to evaluate, empirically, hand function closed primarily or covered with full-thickness skin and perfusion after ulnar flap harvest. grafts from the groin (Fig. 1). Despite the advantages of the ulnar flap, the radial flap continues to be more popular, per- Postoperative Studies haps because the ulnar flap is technically more Ten patients agreed to undergo postoperative challenging and many are concerned about vascular, motor, and sensory testing for the pur- hand ischemia. Although the ulnar artery is spe- pose of this institutional review board–approved cifically dominant at the level of the elbow, it is study. The vascular evaluation consisted of high- rarely dominant at the level of the forearm and resolution color flow duplex ultrasound of bilat- 9,10 therefore a practical reconstructive option. eral forearms and hands and photoplethysmogra- We set out to evaluate the functional, sensory, phy of the distal digits of both hands.11 Grip and vascular parameters of the hand following strength in both hands was measured with the ulnar forearm perforator flap harvest for head Jamar dynamometer (Sammons Preston, Boling- and neck reconstructive defects. brook, Ill.). Two-point discrimination thresholds PATIENTS AND METHODS in the median and ulnar distributions were eval- Fifteen patients over an 18-month period un- uated on the distal phalanx of the first and derwent ulnar free flap reconstruction for head fourth digits of both hands using the DiskCrimi- nator (Lafayette Instrument Company, Lafayette, 12 From the Division of Plastic, Reconstructive, and Maxillo- Ind.). facial Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, and Johns Hop- RESULTS kins School of Medicine. The defects were the result of trauma (nine of Received for publication December 7, 2006; accepted Febru- 15), oncologic resection (five of 15), or infection ary 5, 2007. (one). With the exception of one patient, flaps Copyright ©2007 by the American Society of Plastic Surgeons were taken from the nondominant hand. The ma- DOI: 10.1097/01.prs.0000282077.59961.86 jority of patients were female (11 of 15), with an

1598 www.PRSJournal.com Volume 120, Number 6 • Hand Evaluation after Flap Harvest

Fig. 1. Ulnar artery free flap. (Above, left) Markings outlining planned location and pedicle for ulnar artery–based perforator flap. (Above, right) Ulnar free flap dissected in the suprafascial plane. The black arrow indicates the perforator. The white arrow indicates the ulnar nerve. Note the proximity to the pedicle. (Below, left) Healed donor site after closure with full-thickness skin graft. (Below, right) View of hand as seen in repose after ulnar artery free flap. Note the concealment of the donor site from this view. average age of 43 years (range, 16 to 73 years). Thirteen of 15 of forearm defects (87 percent) There were no flap failures or skin graft loss at the were covered with a full-thickness skin graft, and donor site. Mean follow-up time was 12 months the remaining were closed primarily (Table 1). (range, 5 to 18 months). Average flap size was 80 ϫ By 2 months, all patients indicated that they 51 mm (range, 50 to 110 mm ϫ 20 to 90 mm). felt no pain at the donor site or distally. All patients

Table 1. Patient Summary Patient Cause Sex Age (yr) Defect Location Donor Side Flap Size (cm) Recipient Vessel 1 Trauma F 48 Right inferior eyelid Left 5 ϫ 3 STA/STV 2 Trauma M 24 Right inferior eyelid Left 5 ϫ 4 STA/STV 3 Trauma M 59 Left inferior eyelid Left 7 ϫ 4 STA/STV 4 Trauma F 28 Upper lip Left 7 ϫ 2 FA/FV 5 Cancer F 58 Right nasal ala Left 6 ϫ 2.5 STA/STV 6 Cancer F 63 Lower lip Right 7 ϫ 5 STA/EJV 7 Cancer M 73 Forehead Left 10 ϫ 7 STA/STV 8 Trauma F 16 Nose Right 10 ϫ 9 FA/FV 9 Cancer F 28 Forehead Left 11 ϫ 9 STA/STV 10 Cancer F 46 Forehead Left 11 ϫ 6 STA/STV 11 Trauma F 23 Left temporal Left 7 ϫ 7 STA/STV 12 Trauma F 44 Right forehead Left 7 ϫ 5 STA/STV 13 Trauma F 46 Right inferior eyelid Left 7 ϫ 3.5 STA/STV 14 Trauma M 43 Upper lip Left 10 ϫ 2 FA/FV 15 Infection F 47 Right cheek, right commissure Left 14 ϫ 5.5 FA/FV F, female; M, male; STA, superficial temporal artery; STV, superficial temporal vein; FA, facial artery; FV, facial vein; EJV, external jugular vein.

1599 Plastic and Reconstructive Surgery • November 2007

Table 2. Comparison of Arterial Peak Systolic hand flexors following skin grafting, and is an im- Velocities portant consideration for avoiding compromise of Radial Ulnar the hand. Widespread use of the ulnar flap is limited in Peak Velocity Peak Velocity part because of concern about vascular compro- Location/Side (cm/sec) SD (cm/sec) SD mise of the hand. We have shown that although Proximal Donor 63.6 18.3 peak systolic flow velocities in the proximal ra- Nondonor 54.1 19.0 57.7 17.2 dial artery increase on average 17.5 percent after Distal ulnar harvest, digital perfusion determined by Donor 66.3 23.0 Nondonor 44.2 18.6 50.8 15.5 photoplethysmography was not compromised. This increase in velocity is consistent with previous studies that have shown a 17.8 percent increase in ulnar artery peak systolic velocity after radial har- denied cold intolerance or symptoms of hand vest for coronary artery bypass grafting.17 claudication. All patients had two-point discrimination less than 6 mm in both hands. No difference was seen between donor and nondonor CONCLUSIONS hands. Grip strength was equal in the donor and nondonor hands (ratio, 1.0; range, 0.8 to 1.3). At The ulnar forearm perforator flap is a safe and 2 months, there was an increase in velocity reliable option for head and neck reconstruction through the radial artery of the donor arm but no and does not result in functional, motor, sensory, change in digital perfusion as measured by pho- or vascular embarrassment to the hand. This flap toplethysmography (Table 2). The mean ratio of carries a unique combination of advantages that brachial artery to digital pressure was 1.00 Ϯ 0.08 make it suitable for reconstruction in a variety of (range, 0.88 to 1.1) on the donor side; on the scenarios. It offers the benefits of limited hair, nondonor side, it was 1.03 Ϯ 0.07 (range, 0.91 to elasticity, and a donor site that is easier to conceal. 1.13). All digits of both hands were tested by We strongly advocate consideration of use of this photoplethysmography. Waveforms of occlu- flap for head and neck reconstruction. sion and distal flow were found to be equivalent Eduardo D. Rodriguez, M.D., D.D.S. for all digits. The superficial palmar arch was Division of Plastic, Reconstructive, complete by color duplex ultrasound in all pa- and Maxillofacial Surgery tients tested. R Adams Cowley Shock Trauma Center 22 South Greene Street Baltimore, Md. 21201 DISCUSSION [email protected] This study demonstrates that the ulnar artery perforator flap is a safe option for head and neck reconstruction. The radial and ulnar flaps have util- DISCLOSURE ity in reconstruction of a variety of defects that are None of the authors has a financial interest in any of similar in nature. Our findings demonstrate that the the products, devices, or drugs mentioned in this article. function of the ulnar artery flap donor site is comparable to, or compares favorably with, the radial REFERENCES artery flap donor site. Previous studies of sensation following radial artery forearm flap harvest demon- 1. Song, R., Gao, Y., Song, Y., et al. The forearm flap. Clin. Plast. strated a 13 to 54 percent incidence of neurologic Surg. 9: 21, 1982. 13–16 2. Lovie, M. J., Duncan, G. M., and Glasson, D. W. The ulnar morbidity (paresthesia/cold intolerance). We artery forearm free flap. Br. J. Plast. Surg. 37: 486, 1984. found no evidence of sensory embarrassment, clau- 3. Arnstein, P. M., and Lewis, J. S. Free ulnar artery forearm flap: dication, or cold intolerance. Our studies demon- A modification. Br. J. Plast. Surg. 55: 356, 2002. strate preservation of grip strength distal to the do- 4. Devansh. Superficial ulnar artery flap. Plast. Reconstr. Surg. 97: nor site similar to radial forearm flaps.14,15 Grip 420, 1996. strength is preserved despite close association of the 5. Gabr, E. M., Kobayashi, M. R., Salibian, A. H., et al. Role of ulnar forearm free flap in oromandibular reconstruction. ulnar nerve to the vascular pedicle of the flap, un- Microsurgery 24: 285, 2004. derscoring the reliability of flap harvest without mo- 6. Glasson, D. W., Lovie, M. J., and Duncan, G. M. The ulnar tor sequelae. Suprafascial dissection of the flap min- forearm free flap in penile reconstruction. Aust. N. Z. J. Surg. imizes adhesion of the tendon bellies of the extrinsic 56: 477, 1986.

1600 Volume 120, Number 6 • Hand Evaluation after Flap Harvest

7. Koshima, I., Iino, T., Fukuda, H., et al. The free ulnar fore- 13. Grinsell, D., and Theile, D. Radial nerve morbidity in radial arm flap. Ann. Plast. Surg. 18: 24, 1987. artery free flaps: Harvest of cephalic vein versus venae co- 8. Wax, M. K., Rosenthal, E. L., Winslow, C. P., et al. The ulnar mitantes. Aust. N. Z. J. Surg. 75: 542, 2005. fasciocutaneous free flap in head and neck reconstruction. 14. Lutz, B. S., Wei, F. C., Chang, S. C., et al. Donor site morbidity Laryngoscope 112: 2155, 2002. after suprafascial elevation of the radial forearm flap: A pro- 9. Haerle, M., Hafner, H. M., Dietz, K., et al. Vascular dom- spective study in 95 consecutive cases. Plast. Reconstr. Surg. inance in the forearm. Plast. Reconstr. Surg. 111: 1891, 103: 132, 1999. 2003. 15. Richardson, D., Fisher, S. E., Vaughan, E. D., et al. Radial 10. Little, J. M., Zylstra, P. L., West, J., et al. Circulatory patterns forearm flap donor-site complications and morbidity: A pro- in the normal hand. Br. J. Surg. 60: 652, 1973. spective study. Plast. Reconstr. Surg. 99: 109, 1997. 11. Pannier, B. M., Avolio, A. P., Hoeks, A., et al. Methods and 16. Schoeller, T., Otto, A., Wechselberger, G., et al. Radial fore- devices for measuring arterial compliance in humans. arm flap donor-site complications and morbidity. Plast. Re- Am. J. Hypertens. 15: 743, 2002. constr. Surg. 101: 874, 1998. 12. Dellon, A. L., Mackinnon, S. E., and Crosby, P. M. Reliability 17. Brodman, R. F., Hirsh, L. E., and Frame, R. Effect of radial of two-point discrimination measurements. J. Hand Surg. artery harvest on collateral forearm blood flow and digital (Am.) 12: 693, 1987. perfusion. J. Thorac. Cardiovasc. Surg. 123: 512, 2002.

1601 PEDIATRIC/CRANIOFACIAL

Primary Grafting with Autologous Cranial Particulate Bone Prevents Osseous Defects following Fronto-Orbital Advancement

Arin K. Greene, M.D., Background: Approximately 20 percent of patients require cranioplasty for M.M.Sc. defects after fronto-orbital advancement. The authors hypothesized that corti- John B. Mulliken, M.D. cocancellous cranial particulate bone placed over exposed dura at the time of Mark R. Proctor, M.D. fronto-orbital advancement would decrease the frequency of incomplete ossi- Gary F. Rogers, M.D., J.D., fication. M.B.A. Methods: The authors retrospectively analyzed consecutive children who un- Boston, Mass. derwent fronto-orbital advancement for craniosynostosis between 1988 and 2006. In group I, cranial gaps resulting from frontal advancement were left open and allowed to heal spontaneously. In group II, corticocancellous particulate bone was used to fill the calvarial defects. Bone was harvested from the endocortex of the frontal segments or parietal calvaria using a hand-driven brace and bit. Outcome variables were persistent osseous defects and need for corrective cranioplasty. Results: The study included 213 children. There were 50 patients in group I: mean age at fronto-orbital advancement was 7.0 months (range, 2 to 15 months); 12 patients (24 percent) had residual defects and 10 (20 percent) required cranioplasty. Group II contained 163 patients: mean age at fronto- orbital advancement was 14.1 months (range, 6 to 72 months); nine children (5.5 percent) had a cranial defect and five (3.1 percent) required cranioplasty. Infants in group II were less likely to have bony defects (p ϭ 0.0005) or require cranioplasty (p ϭ 0.0002) compared with children in group I, despite being older at the time of fronto-orbital advancement (p ϭ 0.001). Conclusion: Corticocancellous cranial particulate bone grafting during fronto-orbital advancement reduces the prevalence of osseous defects and the need for secondary cranioplasty, independent of patient age. (Plast. Reconstr. Surg. 120: 1603, 2007.)

ronto-orbital advancement is the standard openings is problematic because it subjects the procedure for expanding the anterior cra- child to a second procedure, and the reconstruc- Fnial fossa and contouring the upper face in tive options are limited in the pediatric popula- infants with coronal or metopic synostosis. The tion. Autogenous bone graft is the standard operation leaves a calvarial gap behind the ad- treatment for secondary calvarial reconstruction; vanced segments and reossification can be in- however, split calvarial bone graft cannot be har- complete, especially when the procedure is per- vested until the child is at least 4 years of age, formed in older infants. Residual bony defects when a diploic space has formed.4 In addition, have been reported to occur in 12 to 23 percent the quantity of rib and iliac bone available in of patients after fronto-orbital advancement, and young children is limited and there is donor-site the frequency of reparative cranioplasty is as morbidity. Synthetic alloplasts (e.g., methyl high as 18 percent.1–3 Correction of these cranial methacrylate, porous polyethylene), widely used in adult cranioplasty, are not advocated in the From the Craniofacial Center and Department of Plastic Sur- pediatric cranium because they do not osseointe- gery, Children’s Hospital Boston, Harvard Medical School. grate and may inhibit cranial growth. Deminer- Received for publication January 15, 2007; accepted March alized bone matrix has shown promise,5–14 but its 25, 2007. use is limited by the relatively high cost. Alloplastic Copyright ©2007 by the American Society of Plastic Surgeons bone substitutes, such as hydroxyapatite cement DOI: 10.1097/01.prs.0000282106.75808.af and osteoconductive ceramics, have been studied

www.PRSJournal.com 1603 Plastic and Reconstructive Surgery • November 2007 in growing animals15–20 and have been used vancement for craniosynostosis between 1988 and successfully to reconstruct the craniofacial skeleton 2006. Group I consisted of patients who did not in children.21–26 Nevertheless, these materials are have particulate bone graft placed over exposed associated with higher infection and failure rates dura at the time of fronto-orbital advancement. compared with autologous bone.8,10,21–23,26 Further- Group II patients had autologous cranial partic- more, they are expensive and their long-term sta- ulate bone graft placed in all bony gaps at the time bility and capacity to osseointegrate are of fronto-orbital advancement. Patient records unknown.11,15–17,19–22,27–29 were reviewed for age at the time of fronto-orbital To minimize residual cranial defects, some advancement, type of sutural fusion, syndromic authors have recommended performing fronto- diagnosis, and length of follow-up evaluation. Out- orbital advancement at an earlier age, when os- come variables were the presence of a persistent teogenesis is more predictable.3 Unfortunately, bony defect, the need for cranioplasty to fill these this is not an option for an infant who presents areas, and complications. Patients were examined late or has comorbidity that precludes an early for defects by palpation at a minimum of 6 months procedure. In addition, several investigators postoperatively. have documented an inverse relationship between revision rate and age at fronto-orbital advancement (i.e., the earlier the advancement, Harvesting Particulate Bone Graft the more likely a secondary procedure is The technique for harvesting corticocancellous necessary).2,30–32 Calvarial distraction-osteogene- particulate bone has been previously described37 sis has been proposed as a method for reducing (Fig. 1). The graft is taken from the ectocortical the frequency of bony defects from cranial ex- surface of the parietal bones or the endocortical pansion. However, this technique does not al- surface of the frontal elements using a hand-driven low shaping of fronto-orbital segments and re- Hudson brace and D’Errico craniotomy bit (Cod- quires an additional operation to remove the man & Shurtleff, Inc., Raynham, Mass.). When the device.33–36 parietal donor site is used, the head is stabilized and In 1990, the senior author (J.B.M.) began fill- the bit is placed firmly against the exposed cranium ing the cranial gaps during fronto-orbital ad- posterior to the coronal gap. As the bit engages the vancement with corticocancellous particulate cortex, the axis of the Hudson brace is rotated in a bone taken from the parietal calvaria. The ma- gradually larger angular motion (i.e., yaw) to allow jority of infants with craniosynostosis had this widening, with minimal deepening, of the partial- form of primary bone grafting, especially those thickness cortical defect. If the inner cortex is pen- who were older and therefore less likely to expe- etrated, the blunt bit does not injure the dura and rience spontaneous ossification of bony defects. the defect readily reossifies. The procedure for har- In 2002, we began using large full-thickness vesting graft from the endocortical surface of the grafts from the parietal areas to fill the inferior removed frontal bones is similar. Each frontal seg- coronal gap to prevent temporal hollowing fol- ment is placed on a towel, endocortical side up, and lowing fronto-orbital advancement.37 The har- secured with two large needle drivers. If the surface vest of these structural inlay grafts produced is irregular or hard, an egg-burr can be used to make large resultant donor defects (40 to 60 cm2) that a small starting defect before introducing the bit and required additional particulate bone graft. brace. Therefore, we began harvesting the particulate The particulate bone graft is placed in a cup bone graft from the endocortical surface of the and mixed with blood to prevent desiccation and frontal elements rather than from the parietal to preserve living osteocytes. After the advance- cranium. The purpose of this study was to comment is complete and the frontal grafts are stabi- pare the prevalence of calvarial defects and re- lized by resorbable plates, areas of exposed dura parative cranioplasty in patients who underwent that are not level with the surrounding bone (i.e., fronto-orbital advancement with and without pri- inferolateral coronal gap) are inlaid with full- mary particulate bone graft coverage of exposed thickness cortical grafts taken from the parasag- dura. ittal region to avoid a contour depression or temporal hollow.37 Because particulate bone graft PATIENTS AND METHODS provides no short-term structural support, graft Study Groups should only be applied in areas where the dura is We reviewed the records of consecutive pa- against the endocortex of the surrounding bone. tients who underwent primary fronto-orbital ad- A 4- to 5-mm-thick layer of particulate bone is

1604 Volume 120, Number 6 • Fronto-Orbital Advancement

Fig. 1. (Above, left) Endocortical harvest of corticocancellous particulate bone graft from detached frontal bones.(Below,left)Corticocancellousparticulatebonegraftforplacementoverexposeddura.(Right)Partial- thickness donor-site defects on the endocortical surface of frontal bones. spread over all exposed dura until the graft is level grafting and in those who did not, adjusting for with the surrounding cranial surface (Fig. 2). The the effect of age at fronto-orbital advancement particulate bone graft is secured with a layer of and covariates. The SAS v9.0 software package fibrin glue (Tisseel; Baxter, Deerfield, Ill.) to pre- (SAS Institute, Inc., Cary, N.C.) was used for all vent displacement when the forehead flap is re- analyses. Differences were considered significant draped. for values of p Ͻ 0.05.

Statistical Analysis RESULTS Results are presented as means and range, The study included 213 children (Table 1). from lowest to highest value. A possible association Group I consisted of 50 patients who had fronto- between the application of cranial particulate orbital advancement without bone graft at a mean bone graft and persistent osseous defects or need age of 7.0 months (range, 2 to 15 months). Types for cranioplasty was determined using Fisher’s ex- of synostosis included bilateral coronal (n ϭ 25), act test. The age at fronto-orbital advancement unilateral coronal (n ϭ 13), metopic (n ϭ 9), and between children who did not undergo grafting multiple suture (n ϭ 3); 48 percent of patients and those who did was compared with two-sided t were syndromic. Mean follow-up was 11.8 years tests. Logistic regression was used to evaluate the (range, 3 to 22 years). There was one infection (2.0 risk of cranioplasty in patients who underwent percent). Twelve of 50 infants (24 percent) had

1605 Plastic and Reconstructive Surgery • November 2007

Fig. 2. Primary grafting of exposed dura during fronto-orbital advancement in an 18-month-old with bilateral coronal synostosis and elevated intracranial pressure. (Left) Exposed dura resulting from forehead advancement, cranial expansion, and harvest of full-thickness parietal bone for the inferolateral coronal gap to prevent temporal hollowing. (Right) Dura covered with autologous cranial corticocancellous particulate bone harvested from the endocortical side of detached frontal bones.

Table 1. Effect of Autologous Cranial Particulate Bone Graft on the Prevention of Osseous Defects (range, 0.5 to 16 years). There were two infections following Primary Fronto-Orbital Advancement (1.2 percent). Nine infants (5.5 percent) had a persistent cranial defect, and five of these patients Without With (3.1 percent) required cranioplasty. Age at fronto- Particulate Particulate Bone Bone orbital advancement, syndromic diagnosis, type of Graft (%) Graft (%) p sutural fusion, and length of follow-up were not No. of patients 50 163 predictors of a residual calvarial opening or need Age at advancement, for cranioplasty (p ϭ 0.61 to 1.0). months 0.0001 Whereas infants in group II were significantly Mean 7.0 14.1 older than those in group I (p ϭ 0001), they were Range 2–15 6–72 ϭ Residual osseous 12 (24.0) 9 (5.5) 0.0005 much less likely to have persistent bone defects (p defects 0.0005) and undergo reparative cranioplasty (p ϭ Cranioplasty 10 (20.0) 5 (3.1) 0.0003 0.0002) (Fig. 4). Patients in whom the coronal gap was allowed to heal spontaneously were 7.9 times more likely to require reparative cranioplasty than patients grafted with corticocancel- persistent osseous defects, and 10 (20.0 percent) lous particulate bone at the time of fronto-or- of these defects were sufficiently large to require bital advancement (p ϭ 0.0003). cranioplasty (Fig. 3). Age at fronto-orbital advancement, syndromic diagnosis, type of sutural fusion, and length of follow-up were not predic- DISCUSSION tors of a residual cranial defect or need for cra- Failure of complete bony healing of the coro- nioplasty (p ϭ 0.25 to 1.0). nal gap is a well-recognized problem after fronto- Group II consisted of 163 children who had orbital advancement in infancy. Although it is fronto-orbital advancement with primary particu- commonly asserted that complete reossification late bone grafting at an average age of 14.1 months occurs in children younger than 18 months of (range, 6 to 72 months). The distribution of su- age,38 the literature does not support this suppo- tural fusion was unilateral coronal (n ϭ 64), bi- sition. Prevot et al. found residual cranial defects lateral coronal (n ϭ 48), metopic (n ϭ 36), and in 12.4 percent of children after fronto-orbital multiple suture (n ϭ 15); 27 percent of patients advancement, independent of whether the pa- were syndromic. Mean follow-up was 4.6 years tient had the procedure before or after 1 year of

1606 Volume 120, Number 6 • Fronto-Orbital Advancement

Fig. 3. A 9-year-old with Apert syndrome underwent fronto-orbital advancement at age 7 months. The coronal gap was left open and failed to ossify completely. The defects were closed with split rib grafts at age 10 years. Because of signiﬁcant rib graft resorption, she required two subsequent cranioplasties. age.1 Consequently, they recommended covering rate of anesthetic complications. An infant anes- all areas of exposed dura, even in infants. Never- thetized at younger than 1 month is at greater risk theless, they noted that “this approach is not pos- than those 2 to 12 months of age.39 Infants sible in forehead advancements after brachyceph- younger than 1 year of age are three-to-eight times aly.” Similarly, Wagner et al. reported an 18.2 more likely to suffer an anesthetic-related compli- percent cranioplasty rate for residual osseous de- cation than older children.40–42 Second, the fects after fronto-orbital advancement.2 Paige and thicker cranium in an older infant facilitates rigid colleagues documented the long-term prevalence fixation that, we believe, is important for main- of a calvarial defect following fronto-orbital ad- taining the contour and position of the advanced vancement to be 23.3 percent; the likelihood of forehead and bandeau. Third, we agree with other incomplete cranial healing was higher in older authors that the possibility of readvancement is patients.3 Regression analysis predicted that when reduced when the operation is delayed until the the operation was performed after 9 months of child is closer to 1 year of age.2,30–32 Given the rapid age, the probability of spontaneous healing of the cranial growth during the first year, waiting until coronal gap was less than 50 percent. On the basis the deformity is more fully expressed is superior to of these observations, the authors recommended early correction and the risk of recurrent frontal that fronto-orbital advancement should be under- recession. For these reasons, we schedule fronto- taken before 9 months of age. In our study, the orbital advancement at approximately 9 months of frequency of osseous defects (24 percent) and age. At this age, there is adequate cranial thickness secondary cranioplasty (20 percent) after fronto- and low anesthetic morbidity, and the osteogenic orbital advancement without particulate bone potential of the dura remains high. grafting was similar to these reports. Nevertheless, Our study showed that autologous bone grafting we failed to confirm a correlation between the age was the only variable that predicted complete cal- at fronto-orbital advancement and the prevalence varial healing. Patients who did not have corticocan- of osseous defects or need for reparative cranio- cellous particulate bone placed over exposed dura plasty. during fronto-orbital advancement were 7.9 times Some authors have suggested that fronto-or- more likely to require a secondary cranioplasty for bital advancement undertaken earlier in infancy an osseous defect compared with grafted patients. might reduce the frequency of residual osseous This superior outcome is even more striking con- defects. However, there are many situations in sidering that the average age in the group that was which this is not possible, such as late presenta- grafted was nearly twice that of the cohort that did tion, or delay attributable to comorbid conditions. not undergo grafting. Thus, primary corticocancel- Early fronto-orbital advancement also has several lous particulate bone grafting over exposed dura disadvantages. First, younger infants have a higher does not appear to rely on age-dependent bony

1607 Plastic and Reconstructive Surgery • November 2007

Fig. 4. A 15-year-old with Muenke syndrome underwent late fronto-orbital advancement at age 7 years. Particulate bone graft, taken from the endocortex of the frontal bones and parietal calvaria, was placed in the coronal gap at the time of the procedure. (Above) Three-dimensional computed tomographic scans show complete osseous healing. (Below) Axial computed tomographic cuts document bony thickness and a diploic space in the grafted site (boxes). Parietal donor sites have remodeled without irregular contour. healing from dura or pericranium43–46 (i.e., it is who were between 3 and 27 years of age, to close equally effective in older patients). This may be defects as large as 12 cm in diameter.49 Bakamjian related to rapid revascularization of corticocan- and Leonard modified this technique by adding cellous bone graft as compared with split cal- oxycellulose over the bone graft to prevent it from varial bone.47,48 In our experience, particulate dislodging when the scalp flap was redraped.50 bone graft is firm by 3 weeks and solid by 6 Their patient had a 9-cm defect that was clinically weeks. The newly formed bone becomes as thick healed at 8 weeks and had complete radiographic as the adjacent calvaria and forms a diploic ossification at 12 weeks. Corticocancellous bone space. In addition, the parietal donor sites from the iliac crest also has been described to (when used) remodel without a contour irreg- repair calvarial defects.51 O’Broin et al. demon- ularity (Fig. 4). strated that bone graft collected using a high- The use of autogenous corticocancellous cal- speed drill is not viable and cranial healing is varial graft to cover exposed dura was first de- unpredictable when it is used.52 In contrast, har- scribed by Shehadi.49 In a canine model, he dem- vesting particulate bone using a hand-driven, onstrated that calvarial gaps filled with “bone dust” low-speed bit and brace avoids thermal necrosis completely ossified in 83 percent of animals versus and maintains osteocyte viability, thus preserv- 8 percent of defects that were not grafted. He ing the osteogenic, osteoinductive, and osteo- subsequently used this method in three patients, conductive potential.

1608 Volume 120, Number 6 • Fronto-Orbital Advancement

Calvarial corticocancellous particulate bone CONCLUSIONS graft offers many advantages over other sources of Cranial particulate bone graft inlay of the autogenous bone for prevention of cranial defects coronal gap during fronto-orbital advancement after fronto-orbital advancement. The most obvious markedly reduces the risk of residual osseous de- benefit is that there is no additional donor-site mor- fects and the need for reparative cranioplasty. We bidity. Autogenous particulate graft can be harvested have expanded our use of cranial particulate bone from the cranium of infants and young children in graft for secondary cranioplasty in both children whom a diploic space has not yet formed. Even when and adults, particularly when structural graft is not the cranial bone is sufficiently thick to split, obtain- required. ing bone-mush is safer and easier than taking split cranial graft. Because the D’Errico bit has a broad Gary F. Rogers, M.D., J.D., M.B.A. Department of Plastic Surgery tip, it will not injure the dura even when a full- Children’s Hospital Boston thickness parietal defect is created. In contrast, re- 300 Longwood Avenue moving a full-thickness cranial bone graft has been Boston, Mass 02115 associated with dural tear, bleeding, cerebrospinal [email protected] fluid leak, and meningitis.53,54 Harvesting the endocortical surface of the ACKNOWLEDGMENT frontal bones offers several additional advantages The authors thank Peter Forbes, M.A., Clinical Re- over the parietal donor site. First, the endocortical search Program, Children’s Hospital Boston, for statis- site provides sufficient graft to fill any residual tical expertise. defect, regardless of the extent of frontal advancement. None of the last 62 patients have required DISCLOSURE a cranioplasty using our current technique, likely None of the authors received any financial support because of the increased thickness of particulate or benefits from any source that is related to the scientific bone graft inlay. Second, endocortical shaving work reported in this article. thins the frontal bones, which facilitates remodeling, contouring, and revascularization. Before REFERENCES using this technique, we scored the endocortex to 1. Prevot, M., Renier, D., and Marchac, D. Lack of ossification relax the internal hoop stresses and make the fron- after cranioplasty for craniosynostosis: A review of relevant tal elements more pliable. After endocortical har- factors in 592 consecutive patients. J. Craniofac. Surg. 4: 247, vest, the frontal bone is easily molded and holds 1993. its new form. Third, the detached frontal seg- 2. Wagner, J. D., Cohen, S. R., Maher, H., Dauser, R. C., and Newman, H. M. Critical analysis of results of craniofacial ments do not bleed and thus a large amount of surgery for nonsyndromic bicoronal synostosis. J. Craniofac. bone graft can be harvested without the addi- Surg. 6: 32, 1995. tional blood loss that occurs when harvesting 3. Paige, K. T., Vega, S. J., Kelly, C. P., et al. Age-dependent from the ectocranial parietal donor site. Fourth, closure of bony defects after frontal orbital advancement. advancing the thinned frontal elements gives Plast. Reconstr. Surg. 118: 977, 2006. 4. Koenig, W. J., Donovan, J. M., and Pensler, J. M. Cranial bone slightly more expansion of the intracranial vol- grafting in children. Plast. Reconstr. Surg. 95: 1, 1995. ume. There were no adverse effects related to 5. Mulliken, J. B., and Glowacki, J. Induced osteogenesis for thinning the bones, such as increased infection repair and construction in the craniofacial region. Plast. or frontal resorption. Reconstr. Surg. 65: 553, 1980. Reliance on palpation to detect osseous de- 6. Glowacki, J., Altobelli, D., and Mulliken, J. B. Fate of min- eralized and demineralized osseous implants in craniofacial fects could be considered a possible limitation of defects. Calcif. Tissue Int. 33: 71, 1981. this study. Nevertheless, investigators have used 7. Glowacki, J., Kaban, L. B., Murray, J. E., Folkman, J., and this method to assess calvarial healing rather than Mulliken, J. B. Application of the biological principle of computed tomography, to minimize unnecessary induced osteogenesis for craniofacial defects. Lancet 1: 959, radiation and general anesthesia.1–3 In our expe- 1981. 8. Salyer, K. E., Gendler, E., Menendez, J. L., Simon, T. R., Kelly, rience, large bony gaps are easy to discern clini- K. M., and Bardach, J. Demineralized perforated bone im- cally. A fibrous defect can be depressed with pres- plants in craniofacial surgery. J. Craniofac. Surg. 3: 55, 1992. sure, and dural pulsations can be seen with the 9. Moss, S. D., Joganic, E., Manswaring, K. H., and Beals, S. P. child’s head in dependent position. Although Transplanted demineralized bone graft in cranial recon- computed tomography is more accurate than pal- structive surgery. Pediatr. Neurosurg. 23: 199, 1995. 10. Salyer, K. E., Gendler, E., and Squier, C. A. Long-term out- pation for identifying a very small cranial defect, come of extensive skull reconstruction using demineralized such an osseous gap would not require cranio- perforated bone in Siamese twins joined at the skull vertex. plasty and thus is not clinically significant. Plast. Reconstr. Surg. 99: 1721, 1997.

1609 Plastic and Reconstructive Surgery • November 2007

11. Clokie, C. M., Moghadam, H., Jackson, M. T., and Sandor, 29. Cho, Y. R., and Gosain, A. K. Biomaterials in craniofacial G. K. Closure of critical sized defects with allogenic and reconstruction. Clin. Plast. Surg. 31: 377, 2004. alloplastic bone substitutes. J. Craniofac. Surg. 13: 111, 2002. 30. Whitaker, L. A., Bartlett, S. P., Schut, L., and Bruce, D. 12. Mardas, N., Kostopoulos, L., and Karring, T. Bone and suture Craniosynostosis: An analysis of the timing, treatment, and regeneration in calvarial defects by e-PTFE-membranes and complications in 164 consecutive patients. Plast. Reconstr. demineralized bone matrix and the impact on calvarial Surg. 80: 195, 1987. growth: An experimental study in the rat. J. Craniofac. Surg. 31. Wall, S. A., Goldin, J. H., and Hockley, A. D. Fronto-orbital 13: 453, 2002. re-operation in craniosynostosis. Br. J. Plast. Surg. 47: 180, 13. Chen, T. M., and Wang, H. J. Cranioplasty using allogeneic 1994. perforated demineralized bone matrix with autogenous 32. Paige, K. T., Cohen, S. R., Simms, C., Burstein, F. D., Hud- bone paste. Ann. Plast. Surg. 49: 272, 2002. gins, R., and Boydston, W. Predicting the risk of reoperation 14. Haddad, A. J., Peel, S. A., Clokie, C. M., and Sandor, G. K. in metopic synostosis: A quantitative CT scan analysis. Ann. Closure of rabbit critical-sized defects using protective com- Plast. Surg. 51: 167, 2003. posite allogenic and alloplastic bone substitutes. J. Craniofac. 33. Akuzuki, T., Komuro, Y., and Ohmori, K. Distraction osteo- Surg. 17: 926, 2006. genesis for craniosynostosis. Neurosurg. Focus 9: e1, 2000. 15. Lykins, C. L., Friedman, C. D., Costantino, P. D., and Horio- 34. Cho, B. C., Hwang, S. K., and Uhm, K. I. Distraction osteo- qiu, R. Hydroxyapatite cement in craniofacial skeletal re- genesis of the cranial vault for the treatment of craniofacial construction and its effect on developing craniofacial skel- synostosis. J. Craniofac. Surg. 15: 135, 2004. eton. Arch. Otolaryngol. Head Neck Surg. 124: 153, 1998. 35. Satoh, K., Mitsukawa, N., Hayashi, R., and Hosaka, Y. Hybrid 16. Kirschner, R. E., Karmacharya, J., Ong, G., et al. Repair of distraction osteogenesis unilateral frontal distraction and immature craniofacial skeleton with a calcium phosphate supraorbital reshaping in correction of unilateral coronal cement: Quantitative assessment of craniofacial growth. Ann. synostosis. J. Craniofac. Surg. 15: 953, 2004. Plast. Surg. 49: 33, 2002. 36. Yano, H., Tanaka, K., Sueyoshi, O., Takahashi, K., Hirata, R., 17. Lossee, J. E., Karmacharya, J., Gannon, F. H., et al. Recon- and Hirano, A. Cranial vault distraction: Its illusionary effect struction of the immature craniofacial skeleton with a car- and limitations. Plast. Reconstr. Surg. 117: 193, 2006. bonated calcium phosphate bone cement: Interaction with 37. Oh, A. K., Greene, A. K., Mulliken, J. B., and Rogers, G. F. bioresorbable mesh. J. Craniofac. Surg. 14: 117, 2003. Prevention of temporal depression that follows fronto-orbital 18. Eppley, B. L. Hydroxyapatite cranioplasty: 1. Experimental advancement for craniosynostosis. J. Craniofac. Surg. 17: 980, results from a new quick-setting material. J. Craniofac. Surg. 2006. 14: 85, 2003. 38. Wolfe, S. A., Rivas-Torres, M. T., and Ozerdem, O. Acquired 19. Elshahat, A., Shermak, M. A., Inoue, N., Chao, E. Y., and facial bone deformities. In S. J. Mathes and V. R. Hentz Manson, P. The use of Novabone and Norian in cranioplasty: (Eds.), Plastic Surgery. Philadelphia: Elsevier, 2006. Pp. 564– A comparative study. J. Craniofac. Surg. 15: 483, 2004. 565. 20. Smartt, J. M., Karmacharya, J., Gannon, F. H., et al. Repair 39. Cohen, M. M., Cameron, C. B., and Duncan, P. G. Pediatric of the immature and mature craniofacial skeleton with a anesthesia morbidity and mortality in the perioperative pe- carbonated calcium phosphate cement: Assessment of bio- riod. Anesth. Analg. 70: 160, 1990. compatibility, osteoconductivity, and remodeling capacity. 40. Tiret, L., Nivoche, Y., Hatton, F., Desmonts, J. M., and Plast. Reconstr. Surg. 115: 1642, 2005. Vourch, G. Complications related to anesthesia in infants 21. Baker, S. B., Weinzweig, J., Kirschner, R. E., and Bartlett, S. P. Applications of a new carbonated calcium phosphate and children. Br. J. Anaesth. 61: 263, 1988. bone cement: Early experience in pediatric and adult cranio- 41. Tay, C. L. M., Tan, G. M., and Ng, S. B. A. Critical incidents facial reconstruction. Plast. Reconstr. Surg. 109: 1789, 2002. in paediatric anaesthesia: An audit of 1000 anaesthetics in 22. Eppley, B. L., Hollier, L., and Stal, S. Hydroxyapatite cra- Singapore. Paediatr. Anaesth. 11: 711, 2001. nioplasty: 2. Clinical experience with a new quick-setting 42. Murat, I., Constant, I., and Maudhuy, H. Perioperative an- material. J. Craniofac. Surg. 14: 209, 2003. aesthetic morbidity in children: Database of 24165 anaes- 23. Magee, W. P., Ajkay, N., Freda, N., and Rosenblum, R. S. Use thetics over a 30-month period. Paediatr. Anaesth. 14: 158, of fast-setting hydroxyapatite cement for secondary cranio- 2004. facial contouring. Plast. Reconstr. Surg. 114: 289, 2004. 43. Greenwald, J. A., Mehrara, B. J., Spector, J. A., et al. Biomo- 24. David, L., Argenta, L., and Fisher, D. Hydroxyapatite cement lecular mechanisms of calvarial bone induction: Immature in pediatric craniofacial reconstructions. J. Craniofac. Surg. versus mature dura mater. Plast. Reconstr. Surg. 105: 1382, 16: 129, 2005. 2000. 25. Gomez, E., Martin, M., Arias, J., and Carceller, F. Clinical 44. Greenwald, J. A., Mehrara, B. J., Spector, J. A., et al. Immature applications of Norian SRS (calcium phosphate cement) in versus mature dura mater: II. Differential expression of genes craniofacial reconstructions in children: Our experience at important to calvarial reossification. Plast. Reconstr. Surg. 106: La Paz since 2001. J. Oral Maxillofac. Surg. 63: 8, 2005. 630, 2000. 26. Burstein, F. D., Williams, K. J., Hudgins, R., et al. Hydroxy- 45. Cowan, C. M., Quarto, N., Warren, S. M., Salim, A., and apatite cement in craniofacial reconstruction: Experience in Longaker, M. T. Age-related changes in the biomolecular 150 patients. Plast. Reconstr. Surg. 118: 484, 2006. mechanisms of calvarial osteoblast biology affect fibroblast 27. Ducic, Y. Titanium mesh and hydroxyapatite cement cranio- growth factor-2 signaling and osteogenesis. J. Biol. Chem. 278: plasty: A report of 20 cases. J. Oral Maxillofac. Surg. 60: 272, 32005, 2003. 2002. 46. Gosain, A. K., Santoro, T. D., Song, L. S., Capel, C. C., 28. Durham, S. R., McComb, J. G., and Levy, M. L. Correction Sudhaker, P. V., and Matloub, H. S. Osteogenesis in calvarial of large (Ͼ25 cm) cranial defects with “reinforced” hydroxy- defects: Contribution of the dura, the pericranium, and the apatite cement: Technique and complications. Neurosurgery surrounding bone in adult versus infant animals. Plast. Re- 52: 842, 2003. constr. Surg. 112: 515, 2003.

1610 Volume 120, Number 6 • Fronto-Orbital Advancement

47. Stringa, G. Studies of the vascularisation of bone grafts. J. coated mesh and autogenous bone paste. Plast. Reconstr. Surg. Bone Joint Surg. (Br.) 39: 395, 1957. 61: 394, 1978. 48. Deleu, J., and Trueta, J. Vascularisation of bone grafts in the 52. O’Broin, E. S., Morrin, M., Breathnach, E., Allcutt, D., and anterior chamber of the eye. J. Bone Joint Surg. (Br.) 48: 319, Earley, M. J. Titanium mesh and bone dust calvarial patch 1965. during cranioplasty. Cleft Palate Craniofac. J. 34: 354, 1997. 49. Shehadi, S. I. Skull reconstruction with bone dust. J. Bone Joint 53. Kline, R. M., and Wolfe, S. A. Complications associated with Surg. (Br.) 23: 227, 1970. the harvesting of cranial bone grafts. Plast. Reconstr. Surg. 95: 50. Bakamjian, V. Y., and Leonard, A. G. Bone dust cranioplasty. 5, 1995. Plast. Reconstr. Surg. 60: 784, 1977. 54. Yaremchuk, M. J. Acquired cranial bone deformities. In 51. Habal, M. B., Leake, D. L., Maniscalco, J. E., and Kim, J. S. J. Mathes and V. R. Hentz (Eds.), Plastic Surgery. Phil- Repair of major cranio-orbital defects with an elastomer- adelphia: Elsevier, 2006. Pp. 547–556.

Instructions for Authors: Update Registering Clinical Trials Beginning in July of 2007, PRS will require all articles reporting results of clinical trials to be registered in a public trials registry that is in conformity with the International Committee of Medical Journal Editors (ICMJE). All clinical trials, regardless of when they were completed, and secondary analyses of original clinical trials must be registered before submission of a manuscript based on the trial. Phase I trials designed to study pharmacokinetics or major toxicity are exempt. Manuscripts reporting on clinical trials (as defined above) should indicate that the trial is registered and include the registry information on a separate page, immediately following the authors’ financial disclosure information. Required registry information includes trial registry name, registration identification number, and the URL for the registry. Trials should be registered in one of the following trial registries: ● http://www.clinicaltrials.gov/ (Clinical Trials) ● http://actr.org.au (Australian Clinical Trials Registry) ● http://isrctn.org (ISRCTN Register) ● http://www.trialregister.nl/trialreg/index.asp (Netherlands Trial Register) ● http://www.umin.ac.jp/ctr (UMIN Clinical Trials Registry) More information on registering clinical trials can be found in the following article: Rohrich, R. J., and Longaker, M. T. Registering clinical trials in Plastic and Reconstructive Surgery. Plast. Reconstr. Surg. 119: 1097, 2007.

1611 PEDIATRIC/CRANIOFACIAL

Evaluation of Cleft Lip Bony Depression of Piriform Margin and Nasal Deformity with Cone Beam Computed Tomography: “Retruded-like” Appearance and Anteroposterior Position of the Alar Base

Junpei Miyamoto, M.D. Background: As the nasal platform, the piriform margin is considered the most Tomohisa Nagasao, M.D. important nasal structure. An insufficient bony structure has been suggested to Tatsuo Nakajima, M.D. be the major factor in secondary nasal deformities such as the “depressed alar Hisao Ogata, M.D. base.” It is unclear, however, how the piriform margin is depressed or how bony Tokyo, Japan depression influences nasal shape. Methods: Using cone beam computed tomography, the anteroposterior positions of the cleft-side piriform margin and alar base were compared with those of the noncleft side in 52 postoperative unilateral cleft lip patients with no alveolar bone graft. Patients were divided based on cleft type into either the unilateral cleft lip, alveolus, and palate group or the unilateral cleft lip and alveolus group. Results: In all cases, the cleft-side piriform margin was depressed. The anteroposterior position of the alar base was related to the piriform depression in both groups. However, in contrast with bony depression, the cleft-side alar base was located more anteriorly than the non–cleft-side alar base in 35 of 52 patients. Conclusions: The authors’ study suggests that bony depression does not necessarily lead to postoperative alar depression. The postoperative cleft lip alar position can be maintained independently of the collapsed lesser segment of the maxilla. In addition, in many cleft lip newborns the cleft alar crease is hypoplastic, and the paranasal triangle is easily elevated by operative manipulation because of the muscular dysfunction. This shallowness leads to a “retruded” appearance. For improvement, preservation of the paranasal triangle and alar crease plasty are important. (Plast. Reconstr. Surg. 120: 1612, 2007.)

orrection of the cleft lip nasal deformity is tant structure in its role as the nasal platform.1 challenging because of its complexity. Sur- Lateral deviation of the major and lesser seg- Cgical correction of the cleft lip nasal defor- ments of the maxilla is the major cause of new- mity includes repositioning the cleft lower lat- born cleft lip nasal deformity. Particularly in uni- eral cartilage upward, achieving symmetrical lateral complete cleft lip, alveolus, and palate, projection of both alar domes, elongating the displacement of each segment is great because columella when necessary, and repositioning the of disruption of skin and bony structures. The cleft alar base superomedially. cleft-side piriform margin is severely depressed, The maxillary structure plays an important the alar base is significantly displaced inferopos- role in the cleft lip nasal deformity, and the terolaterally with the lesser segment,2 and dis- piriform margin is considered the most impor- placement of the alar base and columellar base leads to nostril rim drooping.3 Even in micro- From the Department of Plastic and Reconstructive Surgery, form cleft lip without apparent cleft alveolus and School of Medicine, Keio University. palate, it has been suggested that there is some Received for publication November 13, 2005; accepted Feb- degree of hypoplasia of the cleft-side maxilla, ruary 16, 2006. which leads to the nasal deformity.4 Copyright ©2007 by the American Society of Plastic Surgeons Secondary nasal deformity, such as redroop- DOI: 10.1097/01.prs.0000267421.69284.c7 ing of the lower lateral cartilage, septal devia-

1612 www.PRSJournal.com Volume 120, Number 6 • Piriform Margin and Nasal Deformity tion, and displacement of the alar base, is con- so in unilateral cleft lip, the discrepancy be- sidered to be caused by many factors, such as tween the lesser segment and the major seg- contracture of the orbicularis oris muscle and ment cannot be assessed well. We used cone molding of the maxilla, and bony structure in- beam computed tomography, which can easily sufficiency has been suggested to be the major evaluate the discrepancies in maxillary seg- factor responsible for secondary nasal deformity. ments and soft-tissue position at the same Some surgeons have applied presurgical orth- time. The purpose of the present study was to odontics and the lip adhesion technique for analyze the anteroposterior positions of the alignment of the nasal platform before primary alar base, focusing on the bony depression of nasal repair.5 the cleft-side piriform margin. We also evalu- In primary lip correction, appropriate reposi- ated the relationship between alar position tioning of the alar base is important, because the and the “retruded” appearance. alar correction is easiest in primary correction with or without nasal correction. However, a PATIENTS AND METHODS postoperative “retruded” appearance of the ala (Fig. 1) is one of the most difficult deformities to Cone Beam Computed Tomography improve. Some surgeons have suggested that res- Although various imaging modalities have toration of the piriform aperture deformity is been used in the maxillofacial fields in the past important for support of the “depressed alar few decades, their results have never been sat- base,”6,7 while others have suggested that aug- isfactory for plastic surgeons. Conventional mentation of the alar base improves the whole cephalography provides limited information, es- nasal appearance.1 Bone grafts,8 cartilage grafts,9 pecially for evaluating the asymmetrical face and and Surgicel10 have been applied to improve soft tissue. Conventional and three-dimensional nasal symmetry. computed tomography methods involve large It is unclear, however, how the piriform mar- and expensive systems that are designed primar- gin is depressed on the cleft side, how the bony ily for full-body scanning. In addition, conven- depression influences the nasal shape and tional computed tomography has two critical causes alar depression, or how the alveolar issues: the low vertical resolution and the high bone graft supports the alar base. To date, radiation dose. cephalometric evaluation of cleft lip maxillary Cone beam computed tomography is a new growth has been widely performed. However, technique that uses a conical x-ray beam and a cephalography is a two-dimensional modality, two-dimensional detector, instead of the fan-

Fig. 1. Postoperative “retruded” appearance of the ala is the most common deformity and is difﬁcult to improve. This 31-year-old woman has had several rhinoplasties, but the left alar base is hypoplastic and “retruded.”

1613 Plastic and Reconstructive Surgery • November 2007 shaped beam and one-dimensional detector used Table 1. Patient Data in conventional computed tomography. Due to Cleft Type the use of a conical beam and two-dimensional UCLAP 29 detector, cone beam computed tomography can UCLA 23 generate a scan of the entire head with a single Right side 23 rotation. In comparison, obtaining a complete im- Left side 29 Age, years age with conventional scanners requires the tak- Average 6.6 ing of multiple slices. Thus, the cone beam Range 3–12 method has several advantages compared with Cheiloplasty, 0–3 months Millard’s procedure with triangular flap 23 conventional scanning, such as a shorter scan without primary rhinoplasty time, better vertical resolution, and a lower expo- Straight method with triangular flap 28 sure dose.11 with primary rhinoplasty Beginning in 2004, postoperative cleft lip pa- Tennison-Randall method without 1 primary rhinoplasty tients were evaluated by cone beam computed Palatoplasty, 1–1.5 years tomography (CB MercuRay dentomaxillofacial Furlow method 22 cone beam x-ray system; Hitachi Medical Corpo- Push-back method 3 3M flap method 3 ration, Tokyo, Japan), mainly in preoperative eval- Two-stage repair 1 uation for alveolar bone grafting and secondary Secondary rhinoplasty 9 rhinoplasty. Measurements were taken using the Total no. of primary or secondary rhinoplasties 37 cone beam computed tomography software (CB- UCLAP, Unilateral cleft lip, alveolus, and palate; UCLA, unilateral works version 2.01; Hitachi Medical). Display and cleft lip and alveolus. measurement of osseous tissues and the skin surface were achieved by adjusting the computed to- noplasty. In 24 cases, nine patients had already mographic thresholds. undergone first nasal correction in our unit before radiographic examination. That is, 37 of the 52 patients had undergone primary or sec- Patients ondary rhinoplasty. The study group was divided We reviewed the radiographic records of 52 based on cleft type into the unilateral cleft lip, consecutive cases of unilateral cleft lip without alveolus, and palate group or the unilateral cleft alveolar bone graft between June of 2004 and lip and alveolus group. December of 2005. Only patients with cone beam In our unit, the alar base was positioned with computed tomography of sufficient quality to al- minimal supraperiosteal dissection under the piri- low clear assessment of the maxillary bone and alar form margin and suspension of the orbicularis oris base were included in the study. We did not find muscle to the anterior nasal spine or septal cartilage any cases of severe deviation of the alar base, for near the anterior nasal spine. Primary and secondary which the alar examination was inappropriate. Pa- rhinoplasty procedures were performed with the re- tient data are listed in Table 1. There were 23 male verse U method without manipulation of the alar and 29 female patients. The study population in- base. Gingivoperiosteoplasty was not performed in cluded 29 cases of unilateral cleft lip, alveolus, and any patient. palate, including five incomplete cases. There were 23 cases of unilateral cleft lip and alveolus, including 13 incomplete cases. The patients’ av- Measurement erage age was 6.6 years (range, 3 to 12 years). The Reference points were the posteriormost study population included five patients for whom point on the lateral piriform margins, the later- primary correction was performed in other units. almost point in the alar crease, the sella, and the Because their operative particulars were known in nasion. All measurements were taken by one ob- detail, however, we did not exclude these five pa- server (J.M.); direct measurements of linear dis- tients from the study. tance were made using the cone beam computed Of the 52 patients in the present study, 28 tomography caliper. treated with the Straight method12 had nasal Using a volume-rendered, three-dimensional correction in primary cheiloplasty. Twenty- display with bony set, the image was first rotated three of the remaining 24 patients were treated into the lateral view with the Frankfort horizontal with Millard’s procedure without primary rhi- plane. The true lateral view was confirmed with noplasty, and one patient was treated with the the mandibular plane after confirmation that Tennison-Randall method without primary rhi- there were no differences in bilateral mandibular

1614 Volume 120, Number 6 • Piriform Margin and Nasal Deformity

Fig. 2. (Left) Ventrodorsal distances between the posterolateralmost points of the non–cleft-side and cleft-side piriform margins were measured for evaluation of cleft-side bony depression. (Right) Using the axial two-dimensional display, the ventrodorsal distances of the lateralmost points in the alar crease in the non–cleft-side and cleft-side were measured for assessment of the anteroposterior position of the cleft-side alar base. growth. Ventrodorsal distances between the later- position of the alar base (p ϭ 0.165) between the almost points of the non–cleft-side and cleft-side unilateral cleft lip, alveolus, and palate group and piriform margins (Fig. 2, left) were measured for the unilateral cleft lip and alveolus group. Piri- evaluation of the cleft-side bony depression. Using form depression was related to the anteroposte- the axial two-dimensional display, the ventrodor- rior position of the alar base in both the unilateral sal distances of the non–cleft-side and cleft-side cleft lip, alveolus, and palate (p ϭ 0.013) and lateralmost points in the alar crease were mea- unilateral cleft lip and alveolus (p ϭ 0.031) groups sured (Fig. 2, right) for assessment of the antero- (Fig. 3). However, the cleft-side alar base was lo- posterior position of the cleft-side alar base. The cated more anteriorly than the non–cleft-side alar true transverse line was confirmed with the man- base in 35 of the 52 patients (67.3 percent). This dibular plane for alar measurement to be consis- tendency was observed with both the Millard pro- tent with the bony examination. Using the sagittal cedure and the Straight method. two-dimensional display, the sella-nasion distance was measured as a correction for age. The former CASE REPORT transverse line was confirmed to not deviate from A 4-year-old boy with left complete cleft lip, alveolus, and the perpendicular line of the sella-nasion. palate had undergone the Millard procedure without primary rhinoplasty at 3 months and veloplasty in a two-stage procedure at 1 year 6 months in another unit. In contrast with the Analysis “retruded” appearance of the nose and depression of the piri- As all data demonstrated standard distribu- form margin by 1.9 mm, computed tomography images showed that the cleft-side alar base was 2.3 mm anterior to the non–cleft tions in both groups, we used the Student t test side alar base (Fig. 4). for comparison of the data between the two groups. All data were divided by sella-nasion to DISCUSSION correct for age. A p value of less than 0.05 in- The piriform margin is considered an impor- dicated statistical significance. All calculations tant structure in its role as the cleft lip nasal plat- were performed using SPSS version 11 for Win- form, and changes in its position influence nasal dows (SPSS Inc., Chicago, Ill.). shape.13,14 However, there have been few previous reports regarding skeletal analysis of cleft lip pa- RESULTS tients. Zemann et al. analyzed primary cleft lip, In all cases, the cleft-side piriform margin was alveolus, and palate in 3-month-old patients using depressed. There were no statistically significant computed tomography, a three-dimensional skull differences in piriform depression (p ϭ 0.740) or model, and a laser technique.15In their study, the

1615 Plastic and Reconstructive Surgery • November 2007

Fig. 3. (Above) The piriform depression was related to the anteroposterior position of the alar base in the unilateral cleft lip, alveolus, and palate (UCLAP) group (pϭ0.013). However, in 21 of 29 patients, the cleft-side alar base was located more anteriorly than the non– cleft-side alar base. (Below) The piriform depression was related to the anteroposterior position of the alar base in the unilateral cleft lip andalveolus(UCLA)group(pϭ0.031).However,in14of23patients, Fig. 4. A 4-year-old boy with left complete cleft lip, alveolus, and the cleft-side alar base was located more anteriorly than the non– palate. In contrast to the “retruded” appearance of the nose and cleft-side alar base. S-N, sella-nasion. depression of the piriform margin by 1.9 mm, computed tomography images showed that the cleft-side alar base was 2.3 mm anterior to the non–cleft-side alar base. piriform margin was depressed on the cleft side in 52 percent of cases, and the piriform margin protruded compared with the noncleft side in cated more posteriorly than the non–cleft-side 19 percent of cases. Fisher et al. also analyzed alar base in all cases (mean, 3.6 mm; range, 1 to 3-month-old infants with complete cleft lip and 5.5 mm), and the cleft-side piriform margin was palate using three-dimensional computed located more posteriorly than the non–cleft- tomography.2 The cleft-side alar base was lo- side piriform margin in all cases (mean, 2.1 mm;

1616 Volume 120, Number 6 • Piriform Margin and Nasal Deformity range, 0.5 to 4 mm). However, these authors Straight method, suggesting that bony depres- studied primary cases, and there have been no sion did not necessarily lead to postoperative reports of postoperative cases. We studied ven- alar depression. trodorsal discrepancies in the piriform margins We agree that in newborn infants with cleft lip, of the lesser and major segments in postopera- the alar base is depressed, as reported by Fisher et tive cases and the relationship between bony al., and the cleft lip alar position changes depend- structures and alar position. ing on the surgical techniques used. However, we In all of our postoperative cases, the cleft- consider that the postoperative cleft lip alar posi- side piriform margin was located more posteri- tion can be kept independent of the collapsed orly than the non–cleft-side margin, similar to lesser segment of the maxilla. Figure 5 shows the the observations of primary cases reported by relationship of the alar base, orbicularis oris mus- Fisher et al.2 In addition, there were no statis- cle, and alveolar arch in a more upright slice cor- tically significant differences in piriform depres- responding to the direction of suspension of the sion between the unilateral cleft lip and alveolus orbicularis oris. In the postoperative period, the and unilateral cleft lip, alveolus, and palate position of the alar base seems to be maintained groups. The position of the alar base was pos- by tension around tissue, such as the orbicularis terior in relation to the piriform depression in oris, the major segment of maxilla, and the upper both groups. However, in 35 of 52 patients (67.3 nasal pyramid, rather than bony tissue on the back percent), the cleft-side alar base was located of the alar base. In primary cleft correction, the more anteriorly than the non–cleft-side alar orbicularis oris is suspended to the anterior nasal base in contrast to the bony depression. This spine, and the alar base is repositioned medially, tendency was observed in patients treated with superiorly, and anteriorly. If the alar base is in- both the Millard procedure and with the sufficiently released from the maxilla or the or-

Fig. 5. The relationship of the alar base, orbicularis oris muscle, and alveolar arch in a more upright slice. In the postoperative period, the position of the alar base seemed to be maintained by the tension of the surrounding tissue,suchastheorbicularisorismuscle,themajorsegmentofthemaxilla,andtheuppernasalpyramid,rather than the bony tissue on the back of the alar base. In primary cleft correction, the orbicularis oris is suspended to the anterior nasal spine, and the alar base is repositioned medially, superiorly, and anteriorly. If the alar base isreleasedinsufﬁcientlyfromthemaxillaortheorbicularisorismuscleisreconstructedinappropriately,thealar base is deviated laterally and may actually be retruded. Conversely, if sutures of the orbicularis oris muscle are too tight, the alar base is positioned forward and distorted. Then, if cleft reconstruction is performed appropriately, the cleft lip alar base shows a tendency toward anterior deviation due to the shallow alar crease and elevated paranasal triangle.

1617 Plastic and Reconstructive Surgery • November 2007 bicularis oris is reconstructed inappropriately, the tion because of the muscular dysfunction. This alar base will deviate laterally and may actually be shallowness leads to a “retruded” appearance. For retruded. In contrast, if excessively tight sutures of improvement of nasal appearance, the deep alar the orbicularis oris are added, the alar base is crease and the hollows in the upper lip beneath positioned forward and distorted. If appropriate the alar base are required (Fig. 7). reconstruction is performed, because the orbicu- Shallowness of the alar crease is more prom- laris oris does not drop into the cleft hole, the alar inent in bilateral cases. The alar base may be base does not drop into the bony depression. Our deteriorated by protrusion of the premaxilla in appropriate reconstruction involves tension-free some measures. However, in bilateral cleft lip alar base repositioning with minimal dissection there is bone-free space on the back of the alar and level-to-level reconstruction of the orbicularis base as in unilateral cases, and the alar base is oris muscle with suspension to the anterior nasal not depressed. The boundary of the alar base is spine. vague due to the shallow alar crease, and bilat- In addition, if cleft reconstruction is per- eral elevation of the paranasal triangle makes a formed appropriately, the cleft lip alar base broad and low nose remarkable. Hollows are shows a tendency toward anterior deviation due required in the upper lip beneath the alar base, to the shallow alar crease and elevated paranasal and deep stitches that tack the superficial sub- triangle (Fig. 6). In noncleft patients and on the cutaneous tissue improve the appearance. This non–cleft-side of cleft lip patients, the alar is similar to unilateral cases. crease is a deep sulcus and the paranasal triangle In some of our cases, the cleft-side alar base is a depressed area with compression of muscles, was truly posterior to the non–cleft-side alar base. such as the nasalis muscle and the levator 16,17 However, the slight difference in anteroposterior group. This depth leads to a three-dimen- position itself would not markedly influence the sional image in the human face. As the paranasal nasal appearance. In addition, if the orbicularis triangle makes contact with a bony structure oris muscle is reconstructed appropriately, severe with thin soft tissue in normal cases and reflects collapse of the alar base is rare. The problem is the changes in the bony structure directly, the that the alar boundary is vague. In cases of true maxillary hypoplasia is associated with a deep paranasal triangle. For example, in older males, alar depression, augmentation under the alar base posterior remodeling at the piriform results in is not recommended, because the shallow alar a loss of support for the alar base and leads to crease is deteriorated and the paranasal triangle is the retruded appearance.13 elevated. This should be managed with muscular In many newborn infants with cleft lip, the manipulation. cleft alar crease is hypoplastic and the paranasal Of course, we consider alveolar bone graft- triangle is easily elevated by operative manipula- ing to be necessary, and in our unit, alveolar bone grafting is performed routinely, which provides a number of advantages, including stability of the maxillary arch and postoperative orthodontic manipulation of abnormal dentition to the correct position. However, alveolar bone grafting should not be applied only for alar augmentation, and care should be taken to avoid excessive augmentation under the alar base. Preservation of the paranasal triangle and alar crease plasty are important for improvement of the “retruded” appearance.

CONCLUSIONS Our study result suggests that bony depression does not necessarily lead to postoperative alar depression. The postoperative cleft lip alar Fig. 6. In noncleft patients and on the non–cleft-side of cleft lip position can be maintained independently of patients, the alar crease is a deep sulcus and the paranasal trian- the collapsed lesser segment of the maxilla. In gle is a deep structure. addition, in many cleft lip newborns the cleft

1618 Volume 120, Number 6 • Piriform Margin and Nasal Deformity

Fig. 7. (Above, left and right) A 6-year-old girl with right incomplete cleft lip and alveolus had been treated with the Straight method. The alar base seemed to be depressed. (Center, left) The lower lateral cartilage was suspended with a reverse U incision, deep stitches under the alar base were tacked to septal cartilage, and alar crease plasty was performed after dissection beneath the alar base.(Center,right,andbelow)Six-monthpostoperativeviews.Alardeﬁnitionwasimprovedandthe “retruded” appearance had disappeared. alar crease is hypoplastic, and the paranasal tri- Excessive bone grafting and augmentation un- angle is easily elevated by operative manipula- der the alar base lead to a more shallow alar tion because of the muscular dysfunction. This crease and elevation of the paranasal triangle. shallowness leads to a “retruded” appearance. For improvement of the “retruded” appearance,

1619 Plastic and Reconstructive Surgery • July 2007 preservation of the paranasal triangle and alar 7. Ortiz Monasterio, F., and Ruas, E. J. Cleft lip rhinoplasty: The crease plasty are important. role of bone and cartilage grafts. Clin. Plast. Surg. 16: 177, 1989. 8. Albert, T. W. Oral and maxillofacial surgery: Considerations Junpei Miyamoto, M.D. in cleft nasal deformities. Facial Plast. Surg. 16: 79, 2000. Department of Plastic and Reconstructive Surgery 9. Kokkinos, P. P., Ledoux, W. R., Kinnebrew, M. C., et al. Iliac Keio University School of Medicine apophyseal cartilage augmentation of the deficient piriform 35 Shinanomachi, Shinjuku-ku rim and maxilla in alveolar cleft grafting. Am. J. Orthod. Dento- Tokyo 160-8582, Japan fac. Orthop. 112: 145, 1997. [email protected] 10. Chen, P. K., Yeow, V. K., Noordhoff, M. S., et al. Augmen- tation of the nasal floor with Surgicel in primary lip repair: DISCLOSURE A prospective study showing no efficacy. Ann. Plast. Surg. 42: None of the authors has a financial interest in any 149, 1999. of the products, devices, or drugs mentioned in this 11. Maki, K., Inou, N., and Takanishi, A. Computer-assisted sim- ulations in orthodontic diagnosis and the application of a article. new cone beam X-ray computed tomography. Orthod. Cranio- fac. Res. 6: 95, 2003. REFERENCES 12. Nakajima, T., and Yoshimura, Y. Early repair of unilateral 1. van der Wal, K. G., van der Meulen, B. D., van der Biezen, cleft lip employing a small triangular flap method and pri- J. J., et al. Bone grafting the piriform aperture deformity in mary nasal correction. Br. J. Plast. Surg. 46: 616, 1993. isolated cleft lip patients: Indication, technique, and results. 13. Pessa, J. E., Desvigne, L. D., and Zadoo, V. P. The effect of J. Oral Maxillofac. Surg. 55: 1089, 1997. skeletal remodeling on the nasal profile: Considerations for 2. Fisher, D. M., Lo, L. J., Chen, Y. R., et al. Three-dimensional rhinoplasty in the older patient. Aesthetic Plast. Surg. 23: 239, computed tomographic analysis of the primary nasal defor- 1999. mity in 3-month-old infants with complete unilateral cleft lip 14. Mommaerts, M. Y., Lippens, F., Abeloos, J. V., et al. Nasal and palate. Plast. Reconstr. Surg. 103: 1826, 1999. profile changes after maxillary impaction and advancement 3. Fisher, D. M., and Mann, R. J. A model for the cleft lip nasal surgery. J. Oral Maxillofac. Surg. 58: 470, 2000. deformity. Plast. Reconstr. Surg. 101: 1448, 1998. 15. Zemann, W., Santler, H., and Karcher, H. Analysis of midface 4. Cosman, B., and Crikelair, G. F. The minimal cleft lip. Plast. asymmetry in patients with cleft lip, alveolus and palate at the Reconstr. Surg. 37: 334, 1966. age of 3 months using 3D-COSMOS measuring system. 5. Millard, D. R., and Morovic, C. G. Primary unilateral cleft J. Craniomaxillofac. Surg. 30: 148, 2002. nose correction: A 10-year follow-up. Plast. Reconstr. Surg. 102: 16. Tajima, S. The importance of the musculus nasalis and the 1331, 1998. use of the cleft margin flap in the repair of complete uni- 6. Cho, B. C., and Baik, B. S. Correction of cleft lip nasal lateral cleft lip. J. Maxillofac. Surg. 11: 64, 1983. deformity in Orientals using refined reverse-U incision and 17. Meneghini, F. Clinical Facial Analysis, 1st Ed. Berlin: Springer- V-Y plasty. Br. J. Plast. Surg. 54: 588, 2001. Verlag, 2005. P. 127.

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1620 PEDIATRIC/CRANIOFACIAL

Midterm Follow-Up of Midface Distraction for Syndromic Craniosynostosis: A Clinical and Cephalometric Study

Pradip R. Shetye, M.D.S., Background: The authors studied the effect of midface distraction on maxillary M.Orth.R.C.S. skeletal position and clinical appearance in patients with Crouzon, Pfeiffer, and Sean Boutros, M.D. Apert syndromes, and examined the stability of these changes at 1 year after Barry H. Grayson, D.D.S. distraction. Joseph G. McCarthy, M.D. Methods: Fifteen consecutive patients (six male and nine female; average age, New York, N.Y. 5.9 years) underwent Le Fort III osteotomy with midface advancement using a rigid external distraction device. Six patients had Crouzon, five had Pfeiffer, and four had Apert syndrome. Midface advancement was initiated at the level of the occlusal splint and at the zygomatic/maxillary anchor screws. The device was activated 11 mm on average, at a rate of 1 mm per day. Twenty anatomical landmarks were identified and digitized at three time intervals, and displacement of each landmark was compared with its pretreatment position. Results: By the time of device removal, point A had advanced sagittally along the x axis 15.85 mm and moved downward 1.06 mm along the y axis; the orbitale was moved sagittally along the x axis 12.72 mm and downward 1.99 mm along the y axis. Maximum mean advancement (17.16 mm) was observed at the upper incisal edge. Maxillary and mandibular skeletal discrepancy was significantly decreased, with the ANB angle changing from Ϫ5.87 to ϩ13.17 degrees. At 1 year after distraction, point A had advanced an additional 0.81 mm, and the orbitale and upper incisal edge had moved posteriorly 0.07 mm and 1.34 mm, respectively. Conclusion: Significant midface advancement can be achieved and maintained with rigid external distraction of the Le Fort III osteotomy segment (up to 24 mm), with excellent stability of the advanced midfacial skeleton. (Plast. Re- constr. Surg. 120: 1621, 2007.)

istraction osteogenesis has become an im- hypoplasia is characterized by nasomaxillary and portant clinical tool in craniofacial sur- zygomatic hypoplasia, upper dental arch retru- Dgery since its first application to lengthen sion, and anterior crossbite. There may be asso- the human mandible.1 Distraction techniques ciated exorbitism. The condition was tradition- have been applied extensively to all components ally treated by Le Fort III osteotomy with of the craniofacial skeleton, including the max- midface advancement, bone grafting, and rigid illa, zygoma, and cranial vault. Long-term fol- fixation. This resulted in an improvement in low-up of mandibular distraction has demon- obstructive sleep apnea, a decrease in corneal strated stability as well continued favorable exposure, and improvements in dental relations growth of the distracted mandible.2 and dysmorphic facies. There were, however, Severe brachycephaly with midface hypoplasia significant drawbacks to the Le Fort III osteot- is a common finding in patients with Apert, omy with immediate advancement, including Crouzon, and Pfeiffer syndromes. The midface soft-tissue resistance to skeletal advancement, prolonged operative time, bleeding, the need From the Institute of Reconstructive Plastic Surgery, New for a bone graft, infection, and an extended York University Medical Center. hospital stay. Received for publication October 18, 2005; accepted March Distraction techniques have been applied to 17, 2006. the midfacial skeleton with favorable results. The Copyright ©2007 by the American Society of Plastic Surgeons purpose of this study was to evaluate the effect of DOI: 10.1097/01.prs.0000267422.37907.6f Le Fort III distraction on patients with Crouzon,

www.PRSJournal.com 1621 Plastic and Reconstructive Surgery • November 2007

Pfeiffer, and Apert syndromes and to record sta- tial distraction at either the right (one patient) or bility and/or change over a period of 1 year after left (three patients) side to correct clinically ap- removal of the distraction device. parent preoperative differences in malar projection during the distraction activation process. Activation of the device was concluded after suf- PATIENTS AND METHODS ficient maxillary advancement was achieved, as This retrospective chart review was approved judged by clinical (orbitozygomatic contour) and by New York University’s Institutional Review dental evaluations and assessment of the lateral Board. Only patients who were treated from No- cephalometric findings. One of the objective criteria vember of 2000 to May of 2005 with Le Fort III to end midface advancement during distraction was maxillary distraction utilizing a rigid external de- to bring the infraorbital rim just behind the plane of vice and who had adequate cephalometric and the cornea and to avoid enophthalmos. At the end clinical follow-up were included in the study. of distraction, “especially” in the growing patient, at There were six male and nine female patients. least 3 to 4 mm of positive overjet should be present. The diagnoses were as follows: Pfeiffer syndrome, The device was left in position for an average con- six patients; Crouzon syndrome, five patients; and solidation period of 54 days. The rigid external dis- Apert syndrome, four patients. The mean patient traction devices and intraoral splints were removed age was 5.9 years at the time of osteotomy and in the operating room. distraction (range, 4.3 to 11.9 years). All patients underwent a classic subcranial Le Clinical Data Fort III osteotomy as described by Tessier.3 After osteotomy and mobilization of the Le Fort III seg- All relevant clinical data regarding the preop- ment, absorbable sutures at the lateral orbital wall erative, operative, immediate postoperative, acti- were used to return the mobilized segment to its vation, and consolidation periods were obtained native position relative to the cranium. An acrylic from medical and dental chart reviews. Attention and wire splint with outrigger hooks was secured to was paid to complications observed in the perioperative and activation periods, the multidimen- the maxillary teeth with dental cement. Distraction sional distraction of the Le Fort segment, and any fixation posts (intraosseous screws) were secured to clinical symptoms. the zygoma (11 patients) or the nasomaxillary but- The lateral cephalograms used in this study tress (four patients). The rigid external distraction were obtained by using a fixed subject-to-radio- device (KLS-Martin) was secured to the cranium graph distance of 5 feet. The head was oriented with pins. Double 26-gauge stainless steel wires were with the Frankfort horizontal plane parallel to connected from the distraction posts and oral splint the floor, with the teeth in centric occlusion and to the distraction units on the cross-arms of the ver- the lips relaxed. The cephalometric radiograph tical bar of the device. machine was calibrated for 10 percent magnifi- After a mean latency period of 5 days, the cation and the magnification was not corrected device was activated at a rate of 0.5 mm twice a day in the measurements. for a total average of 11 mm of activation (range, The lateral cephalograms were obtained at 4 to 20 mm), as recorded on the device. The three time intervals: T1, before distraction; T2, at anteroposterior and vertical positions of the max- the end of consolidation (or device removal); and illa were controlled by differentially activating the T3, 1 year after distraction. The pretreatment superior and inferior wire attachments to the de- cephalogram was obtained not more than 2 vice, along with changing the position of the hor- months before surgery, and the postdistraction izontal distraction bar on the central vertical com- film was obtained within 1 month after device ponent. Nine of the 15 patients had differential removal, except in two patients for whom the postdistraction such that they were activated only at operative film was obtained at 3 months. The the distraction posts (and not the oral splint) dur- mean postdistraction follow-up period was 1 year, ing the last portion of the activation phase. This except in one patient whose follow-up cephalo- was based on clinical assessment of the orbitozy- gram was taken at 2 years after distraction. gomatic position and overjet. In these patients, the The lateral cephalograms were traced man- vector was adjusted in a downward direction to ually. Soft-tissue and hard-tissue landmarks were discontinue alveolar-dental advancement while identified as listed in Table 1 and shown in continuing distraction of the orbitozygomatic Figure 1. All cephalometric landmarks were complex. In addition, four patients had differen- identified independently by two orthodontists.

1622 Volume 120, Number 6 • Syndromic Craniosynostosis

Table 1. Skeletal Landmarks Identiﬁed on Each Lateral Cephalogram 1 A Point A The most posterior point on the curve of the maxilla between the anterior nasal spine and the supradentale 2 ANS Anterior nasal spine The tip of the median, sharp bony process of the maxilla at the lower margin of the anterior nasal opening 3 B Point B The point most posterior to a line from the infradentale to the pogonion on the anterior surface of the symphyseal outline of the mandible 4 BA Basion The most inferior posterior point on the anterior margin of the foramen magnum 5 Co Condylion The most posterior superior point on the curvature of the average of the right and left outlines of the condylar heads 6 Gn Gnathion The most anterior inferior point on the contour of the bony chin symphysis 7 Go Gonion The midpoint of the angle of the mandible 8 ID Infradentale The anterior superior point on the mandible at its labial contact with the mandibular central incisors 9 LIE Lower incisor The incisal tip of the mandibular central incisor incisal edge 10 Me Menton The most inferior point on the symphyseal outline 11 N Nasion The junction of the frontonasal suture at the most posterior point on the curve at the bridge of the nose 12 OR Orbitale The lowest point on the average of the right and left borders of the bony orbit 13 PG Pogonion The most anterior point on the contour of the bony chin, as determined by a tangent through the nasion 14 PNS Posterior nasal The most posterior point at the sagittal plane on the spine bony hard palate 15 Po Porion The midpoint of the line connecting the superior point of the radiopacity of the each anatomic porion 16 PTM Pterygomaxillary The most inferior point on the average of the right fissure and left outlines of the pterygomaxillary fissure 17 S Sella turcica The center of the pituitary fossa of sphenoid bone 18 SD Supradentale The most anterior inferior point on the maxilla at its labial contact with the maxillary central incisor 19 SE Ethmoid The intersection of the sphenoidal plane with the registration point averaged greater sphenoid wing 20 UIE Upper incisor The incisal tip of the maxillary central incisor incisal edge

Discrepancies in landmark identification be- cephalograms, and three-dimensional com- tween examiners were discussed and changes puted tomography scans were also used to sup- were agreed on. Predistraction, postdistraction, plement the identification of cephalometric and 1-year follow-up cephalometric tracings landmarks. were superimposed at the sella and best fit to the Predistraction and postdistraction film tracings anterior contours of the middle cranial fossae, were superimposed utilizing Dolphin imaging soft- the contours of the cribriform plate and fron- ware. Both tracings were positioned along the x and toethmoidal crests, the cerebral surfaces of the y axes, with the sella registered at 0, 0 in this coor- orbital roofs, and the cortical layers of the fron- dinate system. The x axis was oriented parallel to the tal bone (Figs. 2 and 3). Since there were sur- anterior cranial base. Displacement for each of these gical alterations and changes in the position of landmarks was measured along the x and y coordi- the anatomical landmark nasion in the T2 and nates (Fig. 3). The postdistraction and 1-year fol- T3 films, the nasion was transferred from the low-up tracings were similarly superimposed in the x pretreatment film to the posttreatment and and y coordinate system to measure the change in 1-year follow-up films. All tracings with their skeletal position during the 1-year postdistraction superimposition registrations were scanned us- time period (Figs. 4 and 5). ing the ScanMaker 9800XL at 300 dpi resolu- Traditional cephalometric measurements for tion. Panoramic radiographs, posteroanterior the three time points were also taken, as shown in

1623 Plastic and Reconstructive Surgery • November 2007

Fig. 1. Lateral cephalometric tracing shows 11 of the 50 land- Fig. 2. The predistraction (T1, black) and end of consolidation marks that were measured. S, sella; N, nasion; BA, basion; PNS, (T2, green) lateral cephalogram tracings of a single patient super- posterior nasal spine; OR, orbitale; ANS, anterior nasal spine; A, imposed on the sella and oriented along the anatomy of the an- point A; LIE, lower incisal edge; UIE, upper incisal edge; B, point B; terior cranial base and constructed nasion. The midface shows PG, pogonion. differential advancement at the orbitale, anterior nasal spine, and upper incisor edge. Table 2. All data were analyzed statistically for mean and standard deviation. Six of the 15 patients had obstructive sleep apnea, as documented by clinical and historic di- RESULTS agnoses. The apnea resolved in five of the six patients after midface distraction, with no evi- Clinical Results dence of recurrence at 1-year follow-up. The one There were no major complications in this patient with residual obstructive sleep apnea also group of patients. There were, however, 12 minor had obstruction of the posterior chord; fiberoptic incidents in eight patients. The most common was endoscopy showed satisfactory pharyngeal air localized infection at a pin site, as noted in five space. In addition, three patients had recurrent patients. Of these patients, four had halo pin-site upper respiratory infections, all of which im- infections. One patient had cellulitis at the zygo- proved after midface distraction. matic post, and one patient had both halo and All patients had improvement in facial convexity local pin-site infections. All were treated success- and appearance. There was marked reduction of fully with oral antibiotics and local pin-site care, globe exposure (exorbitism) and improvement in with complications resolving without surgical in- lid position. Zygomatic prominence was especially tervention or device removal. improved in all patients (Figs. 6 through 10). Two patients had trauma in the home setting that resulted in dislodgement of the rigid external distraction device. In one patient, the halo frame Cephalometric Results was dislodged and reapplied in the operating We measured the mean differences in orbit- room; this patient also later developed a cepha- ale, anterior nasal spine, point A, upper incisal lohematoma. In another patient, the oral splint edge, lower incisal edge, point B, pogonion, and was dislodged and reapplied in a dental chair. posterior nasal spine on the x and y axes between Other incidents noted were gingivitis (n ϭ 1), time points T1 and T2 and between T2 and T3 poor oral intake (n ϭ 1), retained wire (n ϭ 1), (Table 3). Linear displacement between the two and abscess at a zygomatic plate (n ϭ 1). time points was also calculated.

1624 Volume 120, Number 6 • Syndromic Craniosynostosis

Fig. 3. The predistraction (T1, black) and end of consolidation Fig. 4. Serial lateral cephalometric superimposition of a patient (T2, green) lateral cephalogram tracings of a single patient super- before distraction (T1, black), at the end of consolidation (T2, imposed on the sella and oriented along the anatomy of the an- green),andat1-yearfollow-up(T3,red).Notetheadvancementof terior cranial base using a constructed nasion. The superimposi- the Le Fort III segment at the end of the consolidation period and tiontracingT2(green)waspositionedalongthexandyaxes,with the stability of the advancement at 1-year follow-up. the sella registered at 0, 0. Displacement for each of the landmarks identiﬁed was measured along the x and y coordinates. The displacement measured for point A on the x and y coordi- came forward by 0.69 mm and moved inferiorly by natesisshown,aswellasthelineardisplacementbetweentheT1 3.17 mm; point B came forward by 1.03 mm and and T2 tracings. moved downward by 2.65 mm. Several cephalometric angular changes were measured (Table 2). The SNA angle changed from a predistraction (T1) mean of 69.47 degrees T1 to T2 Measurement to 89.29 degrees at the time of device removal The mean advancement for the orbital point (T2), a change of 19.81 degrees following distrac- was 12.72 mm on the x axis, and inferior move- tion. The ANB angle changed from Ϫ5.87 degrees ment was 1.99 mm as measured along the y axis to ϩ13.17 degrees. The angle between the palatal (Table 3). The effective displacement measured plane and the SN changed from 10.75 degrees to for the orbital point between T1 and T2 was 13.1 4.33 degrees in a counterclockwise direction. An- mm. The anterior nasal spine and point A were gular change in mandibular position was minimal. advanced by 14.84 and 15.85 mm, respectively, along the x axis and displaced inferiorly by 0.27 and 1.06 mm, respectively, along the y axis. T2 to T3 Measurements Whereas the effective displacement for the ante- The lateral cephalogram at 1-year follow-up rior nasal spine was 15.36 mm and that for point (T3) was compared with the postdistraction (T2) A was 16.26, maximum advancement was observed film, and changes in the position of the previously at the incisal level (17.6 mm on the x axis and defined landmarks were noted (Table 3). The in- Ϫ2.22 mm along the y axis, for a total of 17.72 mm ferior orbital rim (orbitale) showed posterior of displacement). At the same time, the posterior movement of 0.07 mm and downward movement nasal spine point advanced 13.58 mm along the x of 0.94 mm. The anterior nasal spine advanced axis and displaced inferiorly 4.93 mm on the y axis, 0.85 mm and moved downward 1.64 mm, whereas with total displacement of 14.82 mm. the posterior nasal spine appeared to be posteri- Change in the position of the mandible during orly and inferiorly repositioned by 1.75 and 1.22 this interval was only minimal. The pogonion mm, respectively. Point A advanced 0.81 mm and

1625 Plastic and Reconstructive Surgery • November 2007

Fig. 5. Serial lateral cephalograms taken (above, left) before treatment, (above, right) at the initiation of distraction, (below, left) at the end of activation, and (below, right) at the end of the consolidation phase. Note the positions of the distraction posts (intraosseous screws) and the intraoral acrylic splint to which the distraction force is applied.

Table 2. Traditional Cephalometric Measurements at the Three Time Points* Difference from Difference from T1 T2 T3 T2 to T1 T3 to T2 SNA, degrees 69.47 Ϯ 4.36 89.29 Ϯ 6.50 89.67 Ϯ 6.35 19.81 Ϯ 7.14 0.39 Ϯ 2.51 SNB, degrees 75.35 Ϯ 5.30 76.11 Ϯ 4.77 77.48 Ϯ 5.28 0.75 Ϯ 3.25 1.37 Ϯ 1.72 ANB, degrees Ϫ5.87 Ϯ 5.26 13.17 Ϯ 5.40 12.21 Ϯ 4.70 19.05 Ϯ 4.95 Ϫ0.96 Ϯ 2.42 PP-SN, degrees 10.75 Ϯ 7.43 4.33 Ϯ 7.29 4.74 Ϯ 6.70 Ϫ6.41 Ϯ 5.45 0.41 Ϯ 3.30 PP, palatal plane; SN, sella-nasion. *Data are expressed as mean Ϯ SD. moved downward 0.97 mm, whereas the upper illa did. The lower incisors advanced by 3.29 mm incisal edge moved posteriorly by 1.34 mm and and moved inferiorly 1.61 mm; point B advanced downward 2.95 mm. by 1.73 mm and moved downward 3.12 mm; and During a 1-year follow-up period, the mandi- the pogonion advanced by 3.07 mm and moved ble showed more change in position than the max- inferiorly 2.52 mm.

1626 Volume 120, Number 6 • Syndromic Craniosynostosis

Fig. 6. Female patient with Apert syndrome before treatment at age 5.6 years.

Fig. 7. Note the position of the rigid external distraction device and ﬁxation of the midface to the device with skeletal screws and intraoral splint anchorage.

During the 1-year follow-up period (from T2 effects on both functional issues, such as respira- to T3), the SNA angle increased from 89.29 de- tion, sleep, globe exposure, occlusion, and grees to 89.67 degrees, a 0.39-degree increase dur- speech, and appearance issues, such as midfacial ing the two time points, whereas the SNB angle contour, nasal projection, and eyelid position. To- increased from 76.11 degrees to 77.48 degrees, a gether, the abnormalities can significantly affect difference of 1.37 degrees. During the same pe- both psychosocial and physical development. Lon- riod, the ANB angle decreased from 13.17 degrees gitudinal cephalometric studies have demon- to 12.21 degrees (a net decrease of 0.96 degrees). strated that in patients with syndromic craniosyn- The palatal plane was relatively stable, with 0.41 ostosis, midfacial growth in a forward direction is degrees of change in a clockwise direction. severely diminished, while there is change in the vertical (downward) growth of the maxilla.4,5 DISCUSSION Le Fort III osteotomy and advancement were Midface retrusion is one of the classic findings first described by Gillies and Harrison6 and later of Apert, Crouzon, and Pfeiffer syndromes. This popularized by Tessier.3 This procedure signifi- craniofacial abnormality has significant negative cantly improved quality of life for many patients

1627 Plastic and Reconstructive Surgery • November 2007

Fig.8. Thepatientaftertreatment.Notethecorrectionofthemidfacehypoplasia,reductioninexorbitism,andoverallimprovement in facial appearance. with syndromic midface hypoplasia by improving method of midface advancement in patients with many of the above-outlined abnormalities. More- midface retrusion. The procedure obviates the over, for these patients with limited potential for need for bone graft harvest and a fixation system, midfacial growth, it did not preclude further facial and it reduces blood transfusion and infection growth, and the surgically advanced patients grew rates. There is less intraoperative dissection and in the postoperative period in a manner similar to less separation of the bone/soft-tissue interface. that of nontreated patients in both the vertical and Currently, midface distraction can be achieved by horizontal planes.7 A cephalometric study of clas- using either an external halo device or paired sic early Le Fort III advancement osteotomy in internal (buried) devices. Both systems have ad- growing patients showed no deleterious effect on vantages and disadvantages. The ideal system midface growth.7 However, it was not without awaits further technological development. drawbacks. The lengthy surgical procedure ini- This study examined 15 patients with cranio- tially required intermaxillary fixation and had facial synostosis who underwent Le Fort III mid- high complication rates, including infection and face advancement using the rigid external distrac- blood loss requiring transfusion. Also, wide expo- tion device. At a mean age of 5.9 years, all patients sure was necessary to bone graft the advancement were in their growing phase. Through this expe- defects. Although the procedure was improved rience, we have made several observations, with with the introduction of rigid internal fixation, its corresponding recommendations to improve the shortcomings remained significant. results in this emerging field. Distraction osteogenesis was first applied to the long bones of the human skeleton. The procedure gradually lengthened the bones and soft Intraoperative Observations tissues and provided stable results for the difficult It has been observed during completion of the problems of lower extremity orthopedic injuries. Le Fort III osteotomy that the zygomatic-maxillary The technique was first applied to the human junction (suture) is fragile in this group of imma- craniofacial skeleton by McCarthy et al.1 and was ture patients. This connection can be easily dis- used to lengthen the mandible in patients with rupted intraoperatively. If this occurs, distraction congenital mandibular deficiency. This concept at the affected zygomatic post will not be reliable. was then applied, after preliminary canine If disruption is observed intraoperatively, the zy- studies,8 to other areas of the craniofacial skele- goma should be fixed to the maxilla at the zygo- ton, including the midface at the Le Fort I9,10 and matic maxillary suture with one small plate. This III levels.11,12 Distraction is now an alternative is important, as the distraction force applied to the

1628 Volume 120, Number 6 • Syndromic Craniosynostosis

Fig.9. MalepatientwithCrouzonsyndromebeforetreatmentatage9years(above)andafterdistraction(below).Notethecorrection of the midface hypoplasia, reduction in exorbitism, and improvement in facial contour after distraction.

dislocated zygoma will not be transmitted to the greater degree than at the anterior nasal spine, remainder of the Le Fort III segment, thereby thereby causing a counterclockwise rotation of the accentuating the dislocation with the end result of mobilized Le Fort III segment and further open- a malpositioned zygoma.13 ing of the bite. This finding, plus the future down- Complete mobilization of the Le Fort III seg- ward growth of the midfacial skeleton, may result ment was initially performed in the study popu- in an increased posterior facial height that will lation. Attempts were made to return the segment need correction at the definitive orthognathic to its original location with absorbable suture sus- procedure, when craniofacial skeletal growth is pension. Despite this effort, initial postoperative completed. The initial displacement also contrib- cephalograms showed displacement of the Le Fort uted to the additional advancement of the mid- III segment before device activation. This is the- face than that recorded on the rigid external dis- oretically disadvantageous, as the bone osteotomy traction device following activation. Although sites are not accurately aligned. In experimental the device was activated 11 mm, the initial dis- animal models, nonalignment of the distraction placement of the midface following Le Fort III segments has resulted in fibrous union.8 While this osteotomy and some advancement during the did not seem to have a deleterious effect on sta- first day of activation contributed to the total bility and bony union, it did result in downward 15.58 mm of point A advancement measured on displacement of the posterior nasal spine to a the cephalogram.

1629 Plastic and Reconstructive Surgery • November 2007

Fig. 10. The patient at 1-year follow-up. Photographs demonstrate stability of the midface correction and subsequent growth.

Table 3. Mean Differences in Cephalometric Measurements on the x and y Axes between T1 and T2 and T2 and T3* T1 to T2 (mm) T2 to T3 (mm) Displacement from Displacement from x Axis y Axis T1 to T2 (mm) x Axis y Axis T2 to T3 (mm) OR 12.72 Ϯ 5.11 Ϫ1.99 Ϯ 2.61 13.1 Ϯ 5.11 Ϫ0.07 Ϯ 3.05 Ϫ0.94 Ϯ 2.21 3.4 Ϯ 1.68 ANS 14.84 Ϯ 5.10 0.27 Ϯ 4.63 15.3 Ϯ 5.51 0.85 Ϯ 2.20 Ϫ1.64 Ϯ 2.13 2.5 Ϯ 1.89 A 15.85 Ϯ 4.80 Ϫ1.06 Ϯ 3.83 16.2 Ϯ 4.97 0.81 Ϯ 2.24 Ϫ0.95 Ϯ 1.91 2.7 Ϯ 1.45 UIE 17.16 Ϯ 4.60 Ϫ2.22 Ϯ 4.00 17.7 Ϯ 4.56 Ϫ1.34 Ϯ 3.40 Ϫ2.95 Ϯ 3.27 4.5 Ϯ 2.50 PNS 13.58 Ϯ 4.79 Ϫ4.93 Ϯ 2.38 14.8 Ϯ 4.15 Ϫ1.75 Ϯ 2.78 Ϫ1.22 Ϯ 2.93 3.73 Ϯ 2.50 LIE 1.69 Ϯ 4.57 Ϫ2.89 Ϯ 5.53 6.85 Ϯ 3.29 3.29 Ϯ 2.12 Ϫ1.61 Ϯ 4.15 5.25 Ϯ 2.51 B 1.03 Ϯ 4.42 Ϫ2.65 Ϯ 4.48 6.19 Ϯ 2.67 1.73 Ϯ 3.25 Ϫ3.12 Ϯ 5.57 6.17 Ϯ 3.79 PG 0.69 Ϯ 6.23 Ϫ3.17 Ϯ 5.40 7.75 Ϯ 3.38 3.07 Ϯ 3.43 Ϫ2.52 Ϯ 4.93 6.63 Ϯ 3.12 OR, orbitale; ANS, anterior nasal spine; A, point A; UIE, upper incisal edge; PNS, posterior nasal spine; LIE, lower incisal edge; B, point B; PG, pogonion. *Data are expressed as mean Ϯ SD. Linear displacement between the two time points was also calculated.

Activation and Consolidation mean advancement at the inferior orbital rim (or- Initially in the series, a downward distraction bitale) was 12.72 mm, and at upper incisal edge it vector was used in an effort to close the anterior was 17.16 mm. These measurements indicate dif- open bite in patients with significant occlusal abnor- ferential advancement at the orbital level and oc- malities. This manipulation process, however, runs clusal levels. The differential advancement was the risk of increasing the vertical dimension of the possible by varying the activation of the halo de- orbit and midfacial segment. It also resulted in in- vice during the distraction process. Control of the creased orbital volume, such that clinically apparent distraction vectors was achieved by varying the enophthalmos was seen earlier than otherwise an- direction and magnitude of pull in the wires that ticipated, most likely limiting the advancement at connected the zygomatic and intraoral anchorage the orbital level. The malocclusion, however, should points on the mobilized Le Fort III segment to the be accepted, because the patient is still growing and vertical shaft of the halo device. Clinical exami- the malocclusion can be corrected either by orth- nation and cephalometric data were reviewed at odontic therapy or by a definitive orthognathic pro- each of the follow-up visits to guide the differential cedure at an older age. activation. Together, all patients had some degree The reported patients had significantly of differential activation, with only one patient greater amounts of advancement with distraction having complete activation at one level of skeletal than is possible to obtain with conventional ad- attachment only. The two points of attachment vancement osteotomies. Point A was advanced an offer the important advantage of precise vector average of 16.2 mm (range, 8.8 to 24 mm). The control of the midfacial segment. We found that

1630 Volume 120, Number 6 • Syndromic Craniosynostosis a lesser amount of distraction is usually required resistance of the distraction segment, it will at the occlusal level compared with that at the translate forward with little, if any, rotation. In- orbital level to give the patient an aesthetically stead, multiple points of fixation are used to pleasing convex orbitozygomatic profile without control the segment by placing several force producing enophthalmos.8,14 vectors around the center of resistance. Havlik The amount of horizontal midface correction et al. described a “cat’s cradle” midface fixation at the orbital level, especially in young, growing technique to control the rotation of the midface by children, has been an area of discussion.11,15 Some circumferential suspension of the midface skeleton authors use Baumrind’s longitudinal data [porion using wires placed through the soft palate.17 to orbitale distance (females, 70.5 Ϯ 4.5 mm; During the consolidation period, three pa- males, 74.5 Ϯ 5.0 mm)] to determine the postop- tients did have difficulty with halo pin sites. erative position of the orbit. However, although These cases were mild in nature and were seen these patients have limited growth potential, there toward the end of the consolidation period. In remains some anterior growth at the orbital level. one patient, the oral splint was dislodged at Although the patients should be overcorrected, approximately 1 month of consolidation, during correction to adult norms gives a distorted facial rough play, and was immediately replaced. Over- appearance. Extreme overcorrection can be diffi- all, the halo was well tolerated by the patients. cult for both the children and their parents. With Though recent articles have reported decreas- this, they see the facial appearance change during ing the time of consolidation (until further data the distraction process from abnormal to normal are reported), the prolonged consolidation pe- to abnormal once again. From the psychological riod is recommended. As demonstrated in this perspective, it is recommended not to distract to report, it is associated with minimal relapse of the final adult maxillary position, as recom- the distracted Le Fort segment. Moreover, a re- mended by others.16 Instead, the midface should cent serial three-dimensional computed tomogra- be advanced as much as possible, especially at the phy study documented bony deposition at the var- orbitozygomatic components, while avoiding a sig- ious osteotomy sites following midface distraction.18 nificantly abnormal appearance. Although it may be possible that minimal relapse An important consideration during midface could be obtained with a shorter consolidation pe- advancement is control of the vertical height. In riod, this supposition is, at best, only conjectural at our study, the vertical position of the anterior this time. nasal spine was maintained at 0.27 mm and the posterior nasal spine descended by about 4.93 Midterm Results and Stability mm. While some of this was due to initial down- One-year follow-up cephalometric tracing su- ward descent at the time of the osteotomy, addi- perimpositions showed that point A (anterior tional posterior descent was observed with distrac- maxilla) moved forward 0.81 mm. The orbital tion of the Le Fort segment. These two factors point and the upper incisal edge moved back by contributed to the counterclockwise rotation of 0.07 mm and 1.34 mm, respectively. The SNA the midface segments; that is, the palatal plane angle increased by a mean 0.39 degrees and the rotated by 6.41 degrees. As noted in previous long- SNB angle by a mean 1.37 degrees. There was term studies of patients with craniosynostosis, mean reduction of the ANB angle by 0.96 degrees there is more growth in the vertical direction, from the originally gained 19.05 degrees after ad- while horizontal growth is greatly diminished.5 vancement. The 1-year follow-up measurements Thus, any additional increase in the vertical height suggest stability of midface advancement with ev- of the midface during distraction will further add idence of minimal anterior growth. The retropo- to this unfavorable growth trend. sitioning of the maxillary incisal edges may be ex- An improper point of application of distrac- plained by the significantly changed lip and tongue tion force on the midface may also contribute to posture and increased lip pressure on the maxillary the observed rotation effect with distraction. If incisors following midface advancement. The alter- the vector or line of force of activation passes ation in the position of the orbitale (Ϫ0.07 mm) may very close to the occlusal plane, one would ex- represent stability rather then measurable negative pect the maxilla to rotate in a counterclockwise change. The reduction of the ANB angle (0.96 de- direction. Likewise, if the line of force of acti- grees) was due to different growth rates observed vation passes at a higher level, the maxilla will between the maxilla and the mandible. Mandibular rotate in a clockwise direction. If the force vec- growth is less affected in these patients and thus is tor should pass directly through the center of relatively greater than maxillary growth.

1631 Plastic and Reconstructive Surgery • November 2007

During the 1-year follow-up period, there was 3. Tessier, P. Total facial osteotomy: Crouzon’s syndrome, Ap- downward movement of the upper incisor (Ϫ2.95 ert’s syndrome. Oxycephaly, scaphocephaly, turricephaly. mm), anterior nasal spine (Ϫ1.64 mm), and or- Ann. Chir. Plast. 12: 273, 1967. Ϫ 4. Kreiborg, S. Crouzon syndrome: A clinical and roentgen- bitale ( 0.94 mm). These findings also suggest cephalometric study. Scand. J. Plast. Reconstr. Surg. Suppl. 18: that the vertical position of the midface is not only 1, 1981. stable but also capable of additional growth in a 5. Coccaro, P. J., McCarthy, J. G., Epstein, F. J., Wood-Smith, D., downward direction. The palatal plane–to–SN an- and Converse, J. M. Early and late surgery in craniofacial dysostosis: A longitudinal cephalometric study. Am. J. Orthod. gle changed by 0.41 degrees in a clockwise direc- 77: 421, 1980. tion, suggesting a minimal but positive change due 6. Gillies, H., and Harrison, S. H. Operative correction by os- to growth. The downward displacement of the teotomy of recessed malar maxillary compound in a case of upper incisors may indicate vertical growth in the oxycephaly. Br. J. Plast. Surg. 3: 123, 1950. alveolar process. Therefore, it is important to 7. McCarthy, J. G., Grayson, B., Bookstein, F., Vickery, C., and Zide, B. Le Fort III advancement osteotomy in the growing maintain the vertical height of the midface during child. Plast. Reconstr. Surg. 74: 343, 1984. the Le Fort III distraction. Any effort to increase 8. Staffenberg, D. A., Wood, R. J., McCarthy, J. G., Grayson, this dimension surgically will only augment the B. H., and Glasberg, S. B. Midface distraction advancement inherent vertical growth capacity of this area. in the canine without osteotomies. Ann. Plast. Surg. 34: 512, Overall, this study concluded that significant 1995. 9. Molina, F., Monasterio, F. O., Aguilar, M. D., and Barrera, J. midface advancement can be achieved and main- Maxillary distraction: Aesthetic and functional benefits in tained with Le Fort III distraction (up to 24 mm). cleft lip-palate and prognathic patients during mixed den- This was accompanied by an improvement in pa- tition. Plast. Reconstr. Surg. 101: 951, 1998. tients’ clinical function (airway, protection of the 10. Polley, J. W., and Figueroa, A. A. Rigid external distraction: globe, speech, and sleep) and aesthetic appear- Its application in cleft maxillary deformities. Plast. Reconstr. Surg. 102: 1360, 1998. ance. These results were stable at 1 year, and there 11. Chin, M., and Toth, B. A. Le Fort III advancement with was supplementary cephalometric evidence of gradual distraction using internal devices. Plast. Reconstr. continued growth in the midface following Le Fort Surg. 100: 819, 1997. III distraction. We will continue to follow these 12. Cohen, S. R. Craniofacial distraction with a modular internal patients according to the protocol. distraction system: Evolution of design and surgical techniques. Plast. Reconstr. Surg. 103: 1592, 1999. Joseph G. McCarthy, M.D. 13. Gosain, A. K., Santoro, T. D., Havlik, R. J., Cohen, S. R., and Institute of Reconstructive Plastic Surgery, TH-169 Holmes, R. E. Midface distraction following Le Fort III and New York University Medical Center monobloc osteotomies: Problems and solutions. Plast. Recon- 530 First Avenue, 8V str. Surg. 109: 1797, 2002. New York, N.Y. 10016 14. Mitsukawa, N., Satoh, K., Hayashi, T., Uemura, T., and Ho- [email protected] saka, Y. Salvaged Le Fort II halo distraction for an unfavorable outcome of midfacial distraction using an internal device in syndromic craniosynostosis. Plast. Reconstr. Surg. 113: DISCLOSURE 1219, 2004. None of the authors has a financial interest in any of 15. Cedars, M. G., Linck, D. L., Chin, M., and Toth, B. A. Ad- vancement of the midface using distraction techniques. Plast. the products, devices, or drugs mentioned in this article. Reconstr. Surg. 103: 429, 1999. 16. Fearon, J. A. The Le Fort III osteotomy: To distract or not to REFERENCES distract? Plast. Reconstr. Surg. 107: 1091, 2001. 1. McCarthy, J. G., Schreiber, J., Karp, N., Thorne, C. H., and 17. Havlik, R. J., Seelinger, M. J., Fashemo, D. V., and Hathaway, Grayson, B. H. Lengthening the human mandible by gradual R. “Cat’s cradle” midfacial fixation in distraction osteogen- distraction. Plast. Reconstr. Surg. 89: 1, 1992. esis after Le Fort III osteotomy. J. Craniofac. Surg., 15: 946, 2. Shetye, P. R., Grayson, B. H., Mackool, R. J., and McCarthy, 2004. J. G. Long-term stability and growth following unilateral man- 18. Jensen, J. N., McCarthy, J. G., Grayson, B. H., Nussbaun, A.O., dibular distraction in growing children with craniofacial mi- and Eski, M. Bone deposition/generation with LeFort III crosomia. Plast. Reconstr. Surg. (in press). (midface) distraction. Plast. Reconstr. Surg. (in press).

1632 PEDIATRIC/CRANIOFACIAL

The Septospinal Ligament in Cleft Lip Nose Deformity: Study in Adult Unilateral Clefts

Rajiv Agarwal, M.Ch., D.N.B. Background: Septal deviation and alar cartilage deformities constitute an im- (Plast. Surg.) portant component of both the aesthetic deformity and airway compromise in Ramesh Chandra, F.R.C.S. unilateral cleft lip nose deformity. The purpose of this study was to examine the Lucknow, India retrocolumellar preseptal area in this deformity for evaluation of deforming forces in the adult population. Methods: Fifty-five patients aged 13 years or older presenting with unilateral cleft nasal deformity were included. The caudal border of the septum was accessed using an incision along the ipsilateral membranous septum. Perio- peratively, the curved caudal septal edge was exposed and explored down to its attachment with the hypertrophied anterior nasal spine. The overlying tethering tissues were excised and submitted for histopathologic examination. The curved septal cartilage was straightened and the misplaced anterior nasal spine was excised. The remaining cleft nasal deformity was corrected depending on the specific presenting pathologic abnormality. Results: A well-defined, tough, fibrous band was detected extending from the deviated curved surface of the septal cartilage to the anterior nasal spine that was filling up the retrocolumellar area. Histopathologic examination revealed fibrous tissue in all cases studied, consistent with diagnosis of a ligament. Postoperatively, the nasal tip complex cosmetic result was considered to be good or very good in 89.7 percent, satisfactory in 8.1 percent, and poor in 2.0 percent of patients. Conclusions: A well-defined ligament has been documented and demonstrated in adult patients with unilateral cleft lip nose deformity. The authors recommend that this septospinal ligament, previously unreported, should be excised in toto to achieve straightening of the septum, columellar centralization, and nasal sill symmetry in unilateral cleft lip nose deformity. (Plast. Reconstr. Surg. 120: 1633, 2007.)

econstruction of the disfigured nose asso- innovative techniques and long-term results ciated with unilateral cleft lip is a challeng- for the correction of cleft nasal deformity.3–7 Ring problem that often defies satisfactory Septal curvature and associated soft-tissue de- correction. The nasal deformity is three-dimen- viations are important components of the cleft sional, complicated, and frequently associated with lip nasal deformity. The septum is responsible varying grades of tissue hypoplasia, which makes for producing both a functional nasal obstruction corrective efforts frustrating.1,2 Innumerable re- and aesthetic deformity associated with deviation ports in the literature have described a plethora of of the columella and nasal tip. Description of septal deformities and specific treatment approaches From the Postgraduate Department of Plastic and Recon- for correcting the nasal septal cartilage in unilat- structive Surgery, King George’s Medical University. eral cleft lip nose repair procedures have previ- Received for publication March 2, 2005; accepted August ously received scant attention in the literature.8–11 15, 2006. The present report is focused on studying the de- Presented at the Ninth International Congress on Cleft Palate forming forces operating in the septocolumellar and Related Craniofacial Anomalies, in Goteborg, Sweden, June 25 through 29, 2001, and the 39th National Confer- area in patients with unilateral cleft lip deformity. ence of the Association of Plastic Surgeons of India, in ANATOMY OF THE DEFORMITY Jaipur, India, November 23 through 27, 2004. Clinical Observations Copyright ©2007 by the American Society of Plastic Surgeons In unilateral cleft lip nose deformity, there is DOI: 10.1097/01.prs.0000288013.97239.fd a persistent septal-columellar deformity of varying

www.PRSJournal.com 1633 Plastic and Reconstructive Surgery • November 2007

Fig. 1. Diagram of the nasal septum showing its borders (1, cau- Fig.2. A19-year-oldfemalepatientwithleft-sidesecondaryuni- dal; 2, cephalic; 3, dorsal; and 4, ventral). lateral cleft lip nose deformity, where no septal surgery was performed at the time of primary cheiloplasty, showing signiﬁcant severity in addition to other deformities of the septal deformity. nasal bony and cartilaginous framework. The base of the columella is pulled to the noncleft side, and the tip deviates toward the cleft side. The septal section, mobilization, and centralization proce- deformity consists of differential deviation of the dures. The vomerine ridge may also be angulated entire septum toward the cleft and noncleft sides. in severe cases. A cord-like, tough, resilient struc- The body of the septum deviates to the cleft side ture was found spanning and filling the entire vestibule, producing varying grades of cleft-side retrocolumellar space extending from the caudal nasal obstruction, and the caudal border is devi- edge of the septum to the anterior nasal spine ated toward the noncleft side. The various borders (Fig. 3). This tethering structure creates a “guy of the septum are illustrated in Figure 1, and the rope” effect, firmly fixing the septum against the septal deformity is especially noteworthy in involv- maxilla and anterior nasal spine in a deformed ing the caudal and ventral border. The anterior position. nasal spine is hypertrophied and is tilted toward The anterior nasal spine was found to be es- the noncleft side from the midline, where it may pecially hypertrophied and even bifid in older age be palpable through the sill. The cleft-side inferior groups, with length ranging from 3 to 9 mm. The nasal turbinate is hypertrophied, contributing to spine is also deviated axially toward the noncleft nasal obstruction in tandem with the deviated sep- side and clinically presents as a palpable projec- tum, especially in cases with absent nasal floor. tion in the noncleft nose sill (Fig. 4). Columellar deviation, septal deformity, and hypertrophied anterior nasal spine are major stig- Computed Tomographic Observations mata of adult unilateral cleft lip nose deformity Computed tomography performed in selected (Fig. 2). adult cases with gross deformity revealed appre- ciable deviation of the free caudal border of the septal cartilage. The anterior nasal spine was also Perioperative Observations deviated and hypertrophied toward the noncleft Intraoperatively, the preoperative clinical side. Three-dimensional reconstruction of serial findings can be confirmed. In addition, the ventral thin (1.25 mm) sections revealed additional de- border of the septum that rests in the vomerine formities such as asymmetry of cleft-side pyriform groove becomes progressively dislocated from the aperture, deviation of perpendicular plate of eth- groove on the crest of the maxilla in tandem with moid, and vomer also toward the cleft side (Fig. 5). increasing septal deformity and continued growth in the nasoseptal region. It is noteworthy that this Histologic Observations border becomes invariably thickened and skewed, Histologic examination of hematoxylin and as is evident on its exploration during septal dis- eosin–stained paraffin sections of the excised

1634 Volume 120, Number 6 • Septospinal Ligament in Cleft Lip Nose

Fig. 3. (Left) Intraoperative view of a 21-year-old male patient with primary unilateral right-sided cleft lip nose deformity. The septospinal ligament hooked by an elevator is seen coursing from the curved deﬂected caudal border and surface of the nasal septum toward the anterior nasal spine. (Right) Diagram of the same patient showing the spatial orientation of the septospinal ligament, which has been hooked by an elevator. cord-like tissue revealed fibrous tissue interlaced PATIENTS AND METHODS with scanty amounts of fatty tissue and blood ves- Fifty-five patients aged 13 years and older sels. The sections also revealed bony trabeculae in (range, 13 to 45 years) presenting with severe un- continuity with the fibrous tissue, suggesting his- corrected or inadequately corrected unilateral tology consistent with that of ligament (Fig. 6). cleft nasal deformity were included in the study However, no muscle tissue was demonstrable in starting in January of 1998. This included 16 pri- Masson trichrome–stained sections. mary and 39 secondary patients with cleft lip nose deformity, of which 38 were female and 17 were male patients (Table 1). All of the patients presented with both aesthetic deformity and varying grades of airway obstruction. All patients were studied preoperatively, and the presenting anatomical deformity was noted clinically, intraoperatively, radiologically, and histologically. For each patient, three-dimensional nose models were made preoperatively and postoperatively, after a minimum of 8 months. All measurements were obtained on these dental stone models with the help of calipers and tapes. The various parameters measured were nose height, nose length, nostril height, nostril width, nostril perimeter, length of columella, and nose width on cleft and noncleft sides.

Operative Technique Cheiloplasty was performed using a modified Fig.4. Intraoperativeviewofa22-year-oldadultpatientwithleft lower triangular flap method under general en- unilateral cleft lip nose deformity showing a signiﬁcantly hyper- dotracheal anesthesia.12 The nasal cartilaginous trophied anterior nasal spine (near the suction nozzle) seen tilted framework was accessed using the intracartilagi- and presenting into the sill of the right (noncleft) side. nous incision, which was extended medially over

1635 Plastic and Reconstructive Surgery • November 2007

Fig. 6. Paraffin section showing fibrous tissue interlaced with blood vessels. A part of the section shows bony trabeculae (original magnification; hematoxylin and eosin, ϫ 100).

Table 1. Age and Sex Distribution of Patients with Unilateral Cleft Lip Nose Deformity Age Range

13–20 21–30 31–40 >40 Years Years Years Years Male patients 3 8 4 2 Female patients 19 13 3 3 Fig. 5. Three-dimensional computed tomographic reconstruction of the nose and paranasal structures in a 19-year-old female patient with right-sided secondary unilateral cleft lip nose defor- anterior nasal spine was dissected and osteoto- mity, where no septal surgery was performed at the time of pri- mized flush with the maxilla, and the leading edge mary cheiloplasty. (Above) Frontal view; (below) basal view. of the nasal septum was then fixed to the midline maxillary periosteum. The remaining alar cartilage framework was reconstructed and sculptured, the membranous nasal septum to expose the area depending on the specific tissue requirements of of the caudal border of the septum. Mucoperi- the deficient areas. chondrial flaps were elevated on both sides to expose the nasal septum. Adequate exposure of this area, especially around the anterior nasal Statistical Analysis spine and nostril floor, was performed to evaluate Data were analyzed using SPSS software (SPSS, and assess these areas for deforming forces and for Inc., Chicago, Ill.). The one-sided paired t test was performing septal repositioning and correction. used to compare the preoperative and postoper- The curved caudal septal edge was dissected and ative nasal deformities. explored down to its attachment to the vomer behind the anterior nasal spine. The intervening RESULTS tethering tissues between the septal cartilage and A total of 55 patients aged 13 to 45 years pre- the nasal spine were defined by careful dissection senting with varying severity of unilateral cleft lip and were then excised completely to free the sep- nose deformity were evaluated and treated (Table tum, and the tissue was submitted for histopatho- 1). All of the patients had the characteristic sep- logic examination. The curved portion of the septocolumellar deformity, with abnormality of the tal cartilage presenting beyond the midline into anterior nasal spine along with the presence of the noncleft vestibule was excised. The misplaced deforming ligament as previously described. Cor-

1636 Volume 120, Number 6 • Septospinal Ligament in Cleft Lip Nose

Fig. 7. Preoperative and 3-year postoperative photographs of a 14-year-old girl who had right-sided primary unilateral cleft lip nose deformity following primary septorhinocheiloplasty. rection of the septal curvature and excision of the three were submitted to cosmetic and functional ligament were performed in all cases, along with evaluation (three patients refused cosmetic eval- necessary work on other components of the nasal uation by the independent observer). In addition, deformity (Fig. 7). The triad of displaced caudal three patients did not come for follow-up. The part of the septum, septospinal ligament, and hy- nasal tip complex cosmetic result was considered pertrophied anterior nasal spine has been consis- to be good or very good in 89.7 percent, satisfac- tently observed by us for the first time in all of the tory in 8.1 percent, and poor in 2.0 percent of the cases in our series. patients in the independent observer category. Statistical analysis of the results revealed an Furthermore, the shape of nose was considered to increase in postoperative measurements on nostril be good or very good in 93.7 percent, satisfactory height (cleft side) and columella height, whereas in 4.0 percent, and poor in 2.0 percent. The sym- there was a decrease in postoperative measure- metry of the nose was considered to be good or ments on nostril width (cleft side), nostril perim- very good in 91.8 percent, satisfactory in 6.1 per- eter (cleft side), and nose width. One-sided paired cent, and poor in 2.0 percent. Airway obstruction t tests were performed on the results obtained (Table 2). All of the results are highly significant, was improved and considered to be good or very with the smallest p value being 0.0055. Therefore, good in 91.8 percent, satisfactory in 6.1 percent, there is strong evidence that surgery improved and poor in 2.0 percent of the cases (Table 3). The nasal deformities to a great extent. longest follow-up period has been 7 years, showing stable results. Complications were negligible in the present series. One patient had a poor result Results and Level of Satisfaction that was found to be attributable to significant The overall cosmetic and functional results uncorrected malalignment of the alveolar arches were evaluated at a minimum of 8 months (range, preoperatively, contributing to tilting of the nasal 8 to 12 months) after surgery. All patients except tripod following rhinoplasty.

Table 2. Comparison of Preoperative and Postoperative Nasal Deformities 95% Confidence Nasal Deformities t Statistic p Interval Nose length 2.64 0.0055 0.04 to 0.32 Nostril height (cleft side) 10.27 Ͻ0.0001 (2.64 to 3.92) Columella height 3.84 (0.16 to 0.52) Nostril width (cleft side) –11.24 Ͻ0.0001 –4.64 to –3.24 Nostril perimeter (cleft side) –8.6 Ͻ0.0001 –2.71 to –1.69 Nose width –24.15 Ͻ0.0001 –4.53 to –3.83

1637 Plastic and Reconstructive Surgery • November 2007

Table 3. Cosmetic and Functional Results of Surgery Patient (%) Surgeon (%) Independent Observer* (%) Nasal tip complex Very good 35 (71.4) 30 (61.2) 28 (57.1) Good 12 (24.4) 16 (32.6) 16 (32.6) Satisfactory 1 (2.0) 3 (6.1) 4 (8.1) Poor 1 (2.0) 0 1 (2.0) Shape of nose Very good 31 (63.2) 28 (57.1) 34 (69.3) Good 14 (28.5) 16 (32.6) 12 (24.4) Satisfactory 3 (6.1) 4 (8.1) 2 (4.0) Poor 1 (2.0) 1 (2.0) 1 (2.0) Symmetry of nose Very good 34 (69.3) 29 (59.1) 32 (65.3) Good 12 (24.4) 14 (28.5) 13 (26.5) Satisfactory 3 (6.1) 6 (12.2) 3 (6.1) Poor 0 0 1 (2.0) Airway obstruction Very good 40 (81.6) 37 (75.5) 35 (71.4) Good 8 (16.3) 10 (20.4) 10 (20.4) Satisfactory 0 1 (2.0) 3 (6.1) Poor 1 (2.0) 1 (2.0) 1 (2.0) *Three patients refused the cosmetic evaluation by the independent observer. Three patients did not return for follow-up.

DISCUSSION A specific review of literature pertaining to Cleft lip deformity is always accompanied by description of such a structure in adult unilateral deformity of the nose. Numerous techniques have cleft lip nose deformity led to interesting findings. been described for correction of nasal deformity First and foremost, this structure has not been for achieving reasonable nasal shape3–11; neverthe- reported or described in patients ranging from less, secondary nasal correction is still warranted infancy to adult age groups. It was Latham,17–19 an in many cases because further growth of the nose embryologist who conducted histologic studies in often leads to deterioration of symmetry. Apart unilateral cleft human embryos and demonstrated from alar cartilage sculpturing procedures, atten- a structure coursing from the anterior border of tion to the nasal septum is of paramount impor- the nasal septum to the anterior nasal spine and tance for improving the architectural support and median suture of the premaxillary region, who aesthetic appearance of the nose (especially the termed it the septopremaxillary ligament. It is tip area) in addition to providing undisturbed noteworthy that Latham’s findings have been re- breathing function. This aspect of cleft lip rhino- ported in fetuses and embryos, where the tissues plasty has been left rather untouched, with scant in the retrocolumellar area have had limited time description of septal deformity and its pathogen- to manifest the deformity. esis and correction in the majority of reports.13–15 In contrast, in the current study, we have ob- In contrast to these reports, the current study served unique findings in adult unilateral clefts that in adult unilateral cleft patients demonstrates a are different from those reported by Latham,17–19 in unique cord-like structure fanning from the de- which the preseptal retrocolumellar area has had flected caudal border of the septum to the anterior full influence and manifestations of the various nasal spine that is itself misplaced and hypertro- deforming forces over the years of development of phied. This structure histologically is composed of this deformity. We have consistently observed that predominantly fibrous tissue. A ligament, by def- the spatial arrangement and attachment of the inition, is a band of tissue that connects two bones septospinal ligament is also different from the pre- or cartilages. Thus, this structure in consonance viously described septopremaxillary ligament. The with the dictionary description and histologic attachment of the septospinal ligament is not lim- appearance has been termed a ligament. Fur- ited to the leading edge of the caudal border of the thermore, as this structure connects the septal septum but is present all over the entire curved cartilage with the nasal spine, we have termed it caudal surface of the septum. In fact, the site the “septospinal ligament” or “Rajiv-Ramesh liga- where the nasal septum buckles behind the ante- ment.” Tomographically, our findings of septal de- rior nasal spine and grows toward the noncleft viation corroborate with those of Fisher et al.16 in vestibule provides a significant attachment to the these patients. septospinal ligament (Fig. 8). Moreover, the rel-

1638 Volume 120, Number 6 • Septospinal Ligament in Cleft Lip Nose

It would not be out of context to review Asian published literature on this subject, as the age of presentation and surgery is often delayed in these cases. The deformity is florid and the patients often have had either no or inadequate primary rhinoplasty. Ahuja21,22 published results of secondary and primary cleft lip rhinoplasty in adult patients and described a broad range and spectrum of operative techniques to address the different components of the deformity; however, the role of septal correction and the influence of regional deforming forces in these and other reports23,24 needs greater emphasis. The role of the septum in cleft nose deformity has been addressed and emphasized by Chinese re- Fig.8. Diagramincoronalviewoftheorientationofthedeviated searchers, who have reported comprehensive cor- nasal septum and hypertrophied anterior nasal spine in an adult rection of nasal deformity by replacement of dis- left unilateral cleft lip nose deformity. placed tissue, excision, and correction of the deviated septum and the deformity of the lower nose. Short of describing the septospinal ligament, this report represents a focused study aimed at septal ative thickness of the ventral edge of the nasal correction and its importance in unilateral cleft lip septum and its skewing along the vomerine border nasal deformity.25 Interestingly, monographs on has also not been previously or currently de- cleft lip nose deformity, including the classic Mill- scribed. The anterior nasal spine also manifests a ard’s cleft craft26 and recent atlases,27 make no men- florid deformity, with a shift toward the noncleft tion of this ligament because the septospinal liga- side, skewing in axial axis toward the noncleft side ment is never exposed and displayed in Millard’s along with marked hypertrophy. These physical find- rotation advancement type of technique or its vari- ings have not been described earlier in the literature, ants while performing cheiloplasty. The septospinal in either in utero or ex utero studies. ligament discussed in this report has been observed It is interesting to note that although Latham by us consistently over a period of 8 years since 1998 picked up delicate “connexions” in the septopre- in our cases with cleft nasal deformity. This ligament maxillary area in fetal specimens, Siegel et al.,20 has somehow escaped attention of surgeons repair- reporting many years later after Latham’s pub- ing clefts over the last decades of surgery for cleft lip lished work, could not demonstrate the septopre- nose correction. maxillary ligament in 29 cleft fetuses that they We believe that this ligament is rudimentary to studied by light microscopic analysis. These find- start with, but subsequently with facial growth over ings apparently contradict previously reported fe- the years, it is subjected to the interplay of forces tal studies. In our opinion, such studies should from differential growth and pull of neighboring always be viewed in light of the force vectors op- structures in the labioseptocolumellar area, lead- erating in the septocolumellar labial region in ing to ultimate development of this structure. The fully grown subjects. Observations conducted on predominant vector is the advancing caudal septal in utero and perineonatal abortal specimens por- edge in unilateral clefts secondary to unrestricted tray only an inadequately developed structure in growth of the septovomerine unit, which puts this the soft in utero milieu whose clinical relevance in ligament in duress, leading to its unyielding in- later life cannot be predicted by such studies. Sec- fluence on the septal deformity. Concomitantly, ond, bone has not formed in utero, and with ab- the same forces also cause hypertrophy of the an- sence of the anterior nasal spine, any studies on terior nasal spine. the description of ligament or the septal deformity The present series dealt with two categories of are inadequate. Third, the majority of these stud- patients with unilateral cleft lip nose deformity. The ies have elucidated findings based on cross-sec- deforming forces and triad remain the same in both tional light microscopic histologic studies. It is the- primary and secondary rhinoplasty categories; thus, oretically very difficult in the absence of gross there is no difference in the surgical technique in dissectional study to recreate and describe a three- these categories. The cosmetic and functional anal- dimensional structural deformity on cross-sections. ysis of results was performed after a minimal dura-

1639 Plastic and Reconstructive Surgery • November 2007 tion of 8 months after rhinoplasty so that edema and 7. Cronin, T. D., and Denkler, K. A. Correction of the unilateral tissue reaction settles down. The majority of the re- cleft lip nose. Plast. Reconstr. Surg. 82: 419, 1988. 8. Takato, T., Yonehara, Y., and Susami, T. Early correction of sults were considered to be either very good or good the nose in unilateral cleft lip patients using an open method: in 79.4 percent and satisfactory in 14.7 percent as A 10-year review. J. Oral Maxillofac. Surg. 53: 28, 1995. evaluated by the independent observer. 9. McComb, H. Primary correction of unilateral cleft lip nasal Septospinal ligament excision, centraliza- deformity: A 10-year review. Plast. Reconstr. Surg. 75: 791, 1985. tion of the septum, and nasal sill augmentation 10. Mulliken, J. B., and Martinez-Perez, D. The principle of 28 rotation advancement for repair of unilateral complete cleft procedures should form a fundamental basic set lip and nasal deformity: Technical variations and analysis of of procedures for correction of unilateral cleft lip results. Plast. Reconstr. Surg. 104: 1247, 1999. nose deformity. The triad of caudal septal devia- 11. Millard, D. R., Jr. Primary unilateral cleft nose correction: A tion, septospinal ligament, and hypertrophied an- 10-year follow up. Plast. Reconstr. Surg. 102: 1331, 1998. terior nasal spine has been a characteristic and 12. Chandra, R. A new geometrical design for cleft lip repair. In Transactions of the IX International Conference of Plastic and consistent finding observed by us in patients with Reconstructive Surgery, New Delhi, India, March 1–6, 1987. unilateral cleft lip nose deformity. 13. Stenstrom, S. J., and Oberg, T. The nasal deformity in unilateral cleft lip. Plast. Reconstr. Surg. 28: 295, 1961. CONCLUSIONS 14. Hogan, V. M., and Converse, J. M. Secondary deformities of unilateral cleft lip and nose. In W. C. Grabb, S. Rosenstein, The anatomy, histology, and pathophysiology and K. Bzoch (Eds.), Cleft Lip and Palate. Boston: Little, of a previously unreported finding of a septospinal Brown, 1971. ligament as a part of a deforming triad in adult 15. Fara, M. The musculature of cleft lip and palate. In J. G. unilateral cleft lip nose deformity has been de- Converse and J. G. McCarthy (Eds.), Reconstructive Plastic scribed. This structure needs to be excised to Surgery. Philadelphia: Saunders, 1977. 16. Fisher, D. M., Lo, L. J., Chen, Y. R., and Noordhoff, M. S. achieve aesthetic results in cleft lip rhinoplasty. Three-dimensional computed tomographic analysis of the pri- Rajiv Agarwal, M.Ch., D.N.B.(Plast. Surg.) mary nasal deformity in 3-month-old infants with complete unilateral cleft lip and palate. Plast. Reconstr. Surg. 103: 1826, A-15 Nirala Nagar 1999. Lucknow 226020, India 17. Latham, R. A. The septopremaxillary ligament and maxillary [email protected] development. J. Anat. 104: 584, 1969. 18. Latham, R. A. The pathogenesis of the skeletal deformity ACKNOWLEDGMENTS associated with unilateral cleft lip and palate. Cleft Palate J. 6: The authors gratefully acknowledge and appreciate 404, 1969. the help of Drs. Padam K. Agarwal and Tulika Chandra 19. Latham, R. A. Maxillary development and growth: The septo- in interpretation of histology and G. G Agarwal for premaxillary ligament. J. Anat. 107: 471, 1970. 20. Siegel, M. I., Mooney, M. P., Kimes, K. R., and Gest, T. R. statistical work. Traction, prenatal development, and the labioseptopremax- illary region. Plast. Reconstr. Surg. 76: 25, 1985. DISCLOSURES 21. Ahuja, R. B. Radical correction of secondary nasal deformity No financial or commercial interests exist in the current in unilateral cleft lip patients presenting late. Plast. Reconstr. Surg. 108: 1127, 2001. study with any company. The study was self-funded. 22. Ahuja, R. B. Primary definitive nasal correction in patients presenting for late unilateral cleft lip repair. Plast. Reconstr. REFERENCES Surg. 110: 17, 2002. 1. Davis, P. K. B. Cleft lip nose tip deformity: A tutorial disser- 23. Kumar, P. A. V. A comprehensive repair of unilateral cleft lip tation. Br. J. Plast. Surg. 36: 200, 1983. in adults. Br. J. Plast. Surg. 40: 478, 1987. 2. Bardach, J., and Salyer, K. E. Surgical Techniques in Cleft Lip 24. Boo-Chai, K. Primary repair of the unilateral cleft lip nose in the and Palate. Chicago, Ill.: Year Book Medical, 1987. oriental: A 20-year follow-up. Plast. Reconstr. Surg. 80: 185, 1987. 3. Reichert, H., and Gubisch, W. Various techniques of sec- 25. Zheng, Y., Chen, Z., and Chen, M. Correction of nasal septal ondary nose correction in unilateral cleft-lip procedure. Ann. deformities of the unilateral cleft lip. Zhonghua Zheng Xing Plast. Surg. 26: 18, 1991. Shao Shang Wai Ke Za Zhi 14: 249, 1998. 4. Salyer, K. E., Genecov, E. R., and Genecov, D. G. Unilateral 26. Millard, D. R. The unilateral deformity. In Cleft Craft: The cleft lip-nose repair: A 33-year experience. J. Craniofac. Surg. Evolution of Its Surgery. Boston: Little, Brown, 1976. 14: 549, 2003. 27. Salyer & Bardach’s Atlas of Craniofacial & Cleft Surgery: Vol. I. Cleft 5. Salyer, K. E. Primary correction of the unilateral cleft lip Lip and Palate Surgery. Philadelphia: Lippincott-Raven, 1999. nose: 15-year experience. Plast. Reconstr. Surg. 77: 558, 1986. 28. Agarwal, R., Bhatnagar, S. K., Pandey, S. D., Singh, A. K., and 6. Anderl, H. Simultaneous repair of lip and nose in the uni- Chandra, R. Nasal sill augmentation in adult incomplete cleft lateral cleft (a long term report). In I. T. Jackson and B. C. lip nose deformity using superiorly based turn over orbicu- Sommerlad (Eds.), Recent Advances in Plastic Surgery, Vol. 3. laris oris muscle flap: An anatomic approach. Plast. Reconstr. New York: Churchill Livingstone, 1985. Surg. 102: 1350, 1998.

1640 PEDIATRIC/CRANIOFACIAL

A Virtual Reality Atlas of Craniofacial Anatomy

Darren M. Smith, M.D. Background: Head and neck anatomy is complex and represents an educational Aaron Oliker, M.S. challenge to the student. Conventional two-dimensional illustrations inherently Christina R. Carter, D.M.D. fall short in conveying intricate anatomical relationships that exist in three Miro Kirov, M.F.A. dimensions. A gratis three-dimensional virtual reality atlas of craniofacial anat- Joseph G. McCarthy, M.D. omy is presented in an effort to address the paucity of readily accessible and Court B. Cutting, M.D. customizable three-dimensional educational material available to the student of Pittsburgh, Pa.; and New York, N.Y. head and neck anatomy. Methods: Three-dimensional model construction was performed in Alias Maya 4.5 and 6.0. A basic three-dimensional skull model was altered to include surgical landmarks and proportions. Some of the soft tissues were adapted from previous work, whereas others were constructed de novo. Texturing was completed with Adobe Photoshop 7.0 and Maya. The Internet application was designed in Viewpoint Enliven 1.0. Results: A three-dimensional computer model of craniofacial anatomy (bone and soft tissue) was completed. The model is compatible with many software packages and can be accessed by means of the Internet or downloaded to a personal computer. As the three-dimensional meshes are publicly available, they can be extensively manipulated by the user, even at the polygonal level. Conclusions: Three-dimensional computer graphics has yet to be fully exploited for head and neck anatomy education. In this context, the authors present a publicly available computer model of craniofacial anatomy. This model may also find applications beyond clinical medicine. The model can be accessed gratis at the Plastic and Reconstructive Surgery Web site or obtained as a three-dimensional mesh, also gratis, by contacting the authors. (Plast. Reconstr. Surg. 120: 1641, 2007.)

ead and neck anatomy is infamously com- the tortuous relationships of head and neck plex: the region is noted to contain many structures, many anatomical relationships re- Hintricate structures compressed into a main obscure despite intricate dissection. The small amount of space. There are two classic second method of anatomical study is the two- methods of learning this anatomy. First, there is dimensional diagram. These aids are in wide- dissection. Fresh cadaveric study is often difficult spread use because of their accessibility and abil- to arrange, but offers superb access to lifelike ity to selectively display anatomical structures to head and neck morphology. Dissection of pre- clarify relationships. Diagrams are inherently served cadavers is one step removed from fresh limited by their two-dimensionality as they at- dissection. Preserved material is easier to work tempt to illustrate three-dimensional structures. with on a practical level, but remains expensive In this article, we present a three-dimensional and offers a dissection experience of a quality computer model of craniofacial anatomy in an inferior to that of fresh dissection. Because of effort to combine the best elements of the above

From the Division of Plastic Surgery, University of Pitts- burgh, and Institute of Reconstructive Plastic Surgery and Advanced Educational Systems, New York University Med- ical Center. Supplemental digital content is available for Received for publication February 5, 2006; accepted April this article. Direct URL citations appear in the 20, 2006. printed text; simply type the URL address into Presented at the 51st Annual Meeting of the Plastic Surgery any web browser to access this content. Click- Research Council, in Dana Point, California, May 17 able links to the material are provided in the through 20, 2006. HTML text and PDF of this article on the Copyright ©2007 by the American Society of Plastic Surgeons Journal’s Web site (www.PRSJournal.com). DOI: 10.1097/01.prs.0000282452.22620.25

www.PRSJournal.com 1641 Plastic and Reconstructive Surgery • November 2007 modes of anatomical study. Our model is widely tures was performed by using Maya’s deformation available (gratis on the Internet or by contacting tools to ensure that each structure was accurately the authors), offers clear views of anatomical struc- represented and that the individual structures, when tures, and through user-defined structure visibility, taken together, offered an accurate and informative elucidates critical anatomical relationships (see synthesis of craniofacial anatomy. The Internet ap- Video, Supplemental Digital Content 1, which plication was designed in Viewpoint Enliven Version demonstrates a (three-dimensional) computer 1.0 (Viewpoint Corp., New York, N.Y.). model of craniofacial anatomy, http://links.lww. com/A95). Although three-dimensional computer RESULTS graphics is not by any means a substitute for fresh dissection, we submit that our model may prove A virtual reality model of adult craniofacial useful as a method complementary to classic anatomy was created. This model includes the modes of anatomical study and education. craniofacial skeleton and the facial musculature, nerves, blood vessels, medial canthal apparatus, MATERIALS AND METHODS and elements of the lacrimal system. Key surgical All three-dimensional model construction and landmarks such as the lingula, ante-lingula, in- editing were completed by using Alias Maya ver- fraorbital foramen, and anterior and posterior sions 4.5 and 6.0 (Autodesk, Inc., San Rafael, ethmoidal foramina were integrated into the skel- Calif.). Texture mapping was completed by using etal model. As virtual reality models, these struc- Adobe Photoshop version 7.0 (Adobe Systems, tures exist in three-dimensional space such that Inc., San Jose, Calif.) and Maya. the user has control over how they are viewed; they Skeletal anatomy was based on a computer can be represented in any orientation, at any model completed by Nachbar et al.1,2 This group’s zoom, and at any opacity ranging from completely skull model was not sufficiently detailed for our transparent to completely opaque. In addition to purposes. Through literature review and discus- viewing the models in three-dimensional space, sion with the senior authors, the basic skull model the user may render two-dimensional images of was altered in Maya to satisfy the requirements of the models (Figs. 1 through 4). a detailed atlas of craniofacial anatomy.3–7 Modi- With a broad user base in mind, our priorities fications included changes in skeletal topography in constructing this model were accuracy and ver- to increase detail, improve correlation with known satility. All structures are labeled and can be landmarks and relationships between those landmarks, and fit the soft-tissue structures to be over- laid (discussed below). Nachbar et al. have autho- rized the free distribution of this highly modified skull for educational purposes. Soft-tissue models of muscles, nerves, blood vessels, and other significant structures were constructed in Maya after literature review and discussion with the senior authors.3,4,7,10–12 The muscle models, along with some of the neurovascular models, were derived from our previous work.8,9 These models were imported into Maya and altered by using the program’s various deformation tools to fit the skull model. The National Library of Medicine’s Visible Human Project was used as a reference in creating some of these models, and the models remain freely distributable, as no Vis- ible Human Project data are included with the models. After all of the models were present in the same Fig.1. Inthisrendering,anoverviewofthethree-dimensional Maya file, they were texture-mapped with a combi- model is shown. The right zygoma and right halves of the max- nation of digital photographs (Internet public do- illa and mandible have been made invisible to expose more of main and thus freely distributable13 or captured by the neurovasculature. Arteries are red, veins are blue, and the authors) enhanced in Photoshop and materials nerves are yellow. The lacrimal apparatus is pink. Musculature designed in Maya. A final integration of the struc- is not shown.

1642 Volume 120, Number 6 • Virtual Reality Craniofacial Anatomy

Fig. 2. Frontal perspective. Facial muscles are shown on the left Fig. 4. Perspective medial to the mandible. Structures labeled side of the model but have been removed from the right. For for reference include the mandibular nerve (V3) and accessory orientation, certain structures are labeled: M, medial canthal ten- meningeal artery (AM) as they pass through foramen ovale, the don; F, facial arteries; and V3, third branch of the ﬁfth cranial middle meningeal artery (MM) as it passes through foramen spi- nerve. nosum, the internal carotid artery (IC) as it passes through the carotid canal, the maxillary artery (M), and the inferior alveolar artery and nerve (IA) as they pass behind the lingula (L) and into the mandibular foramen.

end-user’s computer. The resulting models contain relatively few data points for their high level of anatomical detail, ensuring widespread usabil- ity. The model of normal adult craniofacial anatomy can be viewed at the Plastic and Reconstructive Surgery Web site and can be obtained as a three- dimensional mesh by contacting the authors.

DISCUSSION In third and fourth century BC Greece, Herophilus and Eristratus conducted the first scientific human dissections and thus pioneered the exploration of human anatomy. The next great anatomist was Vesalius, working in the six- 14. Fig. 3. The occipital, parietal, and temporal bones have been teenth century. Modern dissections and two- removed; the viewer is posterior to the remaining skeletal seg- dimensional representations of anatomy have ments, looking in an anterior direction (T, trigeminal ganglia; P, their roots in these pioneering efforts. Eventu- pterygoidplates;I,internalcarotids).Immediatelysuperiortothe ally, computer technology was applied to the asterisk are the ascending pharyngeal arteries, and immediately study of anatomy: the release of the National inferior to the asterisk are the ascending palatine arteries. Library of Medicine’s digitized cadavers in the mid 1990s, the Visible Human Project, catalyzed a burgeoning of computer-derived two- and three-dimensional anatomy resources.15 Such viewed individually or with any other components resources range from Peitgen’s collection of of the model. two-dimensional histologic images to the com- In constructing the models, we were cognizant plex Web-based three-dimensional model gen- of the need to compromise between anatomical eration systems of Evesque et al. and Golland detail and the processing capacity of the average et al.5,16,17

1643 Plastic and Reconstructive Surgery • November 2007

Common problems with these digital re- of uses for such a model in the movie and com- sources included a lack of clearly detailed ana- puter game sector. The model could also serve as tomical relationships, limited user interfaces, cost, a reference to engineers, such as in previous work and an inability to support user-interactivity on a on the development of realistic heads for crash- polygonal level (such that models can be viewed test dummies.28 but not altered). Moreover, a three-dimensional The model is available gratis, in contrast to anatomy resource devoted expressly to craniofa- commercial anatomy education applications that cial anatomy with close attention paid to surgical charge for access to a viewer-embedded propri- landmarks has yet to be developed. The aim of this etary model. This is to say that commercially avail- project was thus to exploit three-dimensional com- able anatomy models incur associated costs and puter imaging in the context of a broad array of many can be viewed only with the seller’s software. anatomical applications while attempting to ad- Such a system often leads to limited user interac- dress the above-mentioned problems with existing tivity and prohibits user modification of the model digital anatomy systems. to hinder unauthorized end-user reproduction or Applications of a detailed three-dimensional development. We do not place any barriers be- model of craniofacial anatomy are myriad. The tween the user and the model: the actual polyg- model can be used for anatomical study by med- onal mesh files are being released, and thus our ical students, residents, or any health care profes- anatomical models are compatible with widely sional desiring a view of anatomy from a different available software packages (Fig. 6). perspective. Difficult dissections are simple to sim- This compatibility allows the user to choose his ulate (Fig. 5). There is precedent for the incor- or her favorite three-dimensional modeling pack- poration of three-dimensional graphics in surgical age for interacting with the models both as intact education and planning both within and outside plastic surgery.8,9,18–26 The craniofacial model may also find use (perhaps as a normal reference) in legal and forensic applications; three-dimensional graphics has already been used in this field, for instance, in identifying unknown victims and analyzing the stigmata of traumatic injuries.27,28 Ar- cheologists may find the model useful as a normal reference in their efforts to reconstruct historical figures from their remains.29 There is no shortage

Fig. 6. Schematic illustrating the direct access users have to the model. When the user (left) attempts to manipulate a three-dimensional model in a commercial software package, he or she usually encounters a barrier (black box). The box represents the commercial software into which the commercially available anatomy models are embedded. The user’s command (gray arrow) is translated into a new command (checkered arrow) before Fig. 5. In this anterolateral perspective, a nontraditional dissec- the user’s interaction with the model is performed. This system, tion is illustrated in which the orbicularis oculi (OO) has been dis- in an effort to protect commercial models from unauthorized sectedfromthemedialcanthaltendon(M)andthelacrimalsac(L) modiﬁcation or reproduction, results in an unwieldy user inter- is exposed. Also indicated are the supratrochlear artery (STA), the face. As depicted on the right, in our system the user is free to supraorbital artery (SOA), and the infraorbital nerve (V2) as it exits interact directly with the model, allowing for a more intuitive in- the infraorbital foramen. terface and unlimited possibilities for model modiﬁcation.

1644 Volume 120, Number 6 • Virtual Reality Craniofacial Anatomy anatomical structures and as polygonal constructs. REFERENCES The high degree of interactivity allows for com- 1. Nachbar, M. S., Bogart, B., Chao, W.-C., Garcia, J., O’Sullivan, pletely customizable user experiences, such that D., and Kirov, M. Virtual Skull Model. New York: Academic the models can not only be manipulated as com- Computing NYU School of Medicine, 2000. plete structures but also subdivided to suit the 2. Qualter, J., Triola, M. M., Weiner, M. J., Hopkins, M. A., Kirov, M., and Nachbar, M. The virtual surgery patient: De- user’s needs. For example, one may wish to con- velopment of a digital, three-dimensional model of human ceal a portion of the maxilla while leaving the rest anatomy designed for surgical education. In Proceedings of the of the bone intact. Other ways to exploit this poly- 17th IEEE Symposium on Computer-Based Medical Systems, Be- gon-based interaction might include the simula- thesda, Maryland, June 24–25, 2004. tion of osteotomies and bone fragment move- 3. Zide, B. M., and McCarthy, J. G. The medial canthus revisited: An anatomical basis for canthopexy. Ann. Plast. Surg. 11: 1, ment. Aside from using the models as they are, one 1983. may incorporate them into educational materials 4. Zide, B. M., and Jelks, G. W. Surgical Anatomy of the Orbit. New of one’s own. For example, a user might create York: Raven Press, 1985. computer animations based on these models. The 5. Peitgen, H. The Complete Visible Human: The Complete High- models are also compatible with emerging tech- Resolution Male and Female Datasets from the Visible Human Project. New York: Springer-Verlag, 1998. nologies, such as the deformer-based simulator 6. Karakas, P., Bozkir, M. G., and Oguz, O. Morphometric mea- 22 being developed by Cutting et al. surements from various reference points in the orbit of male Essentially, the applications of this craniofacial Caucasians. Surg. Radiol. Anat. 24: 358, 2003. model are limited only by the software package the 7. Pernkopf, E., and Platzer, W. Pernkopf Anatomy: Atlas of To- user selects and the needs of the user. Those users pographic and Applied Human Anatomy. Baltimore: Urban & Schwarzenberg, 1989. inexperienced in three-dimensional graphics can 8. Smith, D. M., Aston, S. J., Cutting, C. B., Oliker, A., and begin by simply tumbling the models in three- Weinzweig, J. Designing a virtual reality model for aes- dimensional space, and experts might find it use- thetic surgery. Plast. Reconstr. Surg. 116: 893, 2005. ful for simulating complex surgical procedures. 9. Smith, D. M., Aston, S. J., Cutting, C. B., and Oliker, A. Our goal is to ensure not only that the model Applications of virtual reality in aesthetic surgery. Plast. Re- is available to anyone who may wish to use it but constr. Surg. 116: 898, 2005. 10. McCarthy, J. G., Lorenc, Z. P., Cutting, C., and Rachesky, M. also that it is easy for users to improve this model The median forehead flap revisited: The blood supply. Plast. over time. Users are encouraged to submit revi- Reconstr. Surg. 76: 866, 1985. sions of the model to the authors for inclusion in 11. Siebert, J. W., Angrigiani, C., McCarthy, J. G., and Longaker, future versions. M. T. Blood supply of the Le Fort I maxillary segment: An anatomic study. Plast. Reconstr. Surg. 100: 843, 1997. 12. Baker, D. C., and Conley, J. Avoiding facial nerve injuries in CONCLUSIONS rhytidectomy: Anatomical variations and pitfalls. Plast. Re- A three-dimensional computer model of constr. Surg. 64: 781, 1979. 13. 3dcafe.com (Web site). Available at: www.3dcafe.com. craniofacial anatomy is presented. Its uses in med- 14. Wiltse, L. L., and Pait, T. G. Herophilus of Alexandria (325– ical education and other areas of intellectual in- 255 B.C.): The father of anatomy. Spine 23: 1904, 1998. quiry are discussed. The model can be accessed 15. National Library of Medicine. The Visible Human Project. Be- gratis by means of the Plastic and Reconstructive thesda, Md.: National Library of Medicine, 1994. Surgery Web site ͓see Video, Supplemental Digital 16. Evesque, F., Gerlach, S., and Hersch, R. D. Building 3D anatomical scenes on the Web. J. Visual. Comput. Animat. 13: Content 1, which demonstrates a (three-dimen- 43, 2002. sional) computer model of craniofacial anatomy, 17. Golland, P., Kikinis, R., and Halle, M. AnatomyBrowser: A http://links.lww.com/A95 ͔ or obtained (also gratis) novel approach to visualization and integration of medical as a three-dimensional mesh by contacting the information. Comput. Aided Surg. 4: 129, 1999. authors. The models may then be used in users’ 18. Friedl, R., Preisack, M. B., Klas, W., et al. Virtual reality and 3D visualizations in heart surgery education. Heart Surg. own endeavors. Individuals who use and amend Forum 5: E17, 2002. the meshes are encouraged to submit their up- 19. Verma, D., Wills, D., and Verma, M. Virtual reality simulator dates to the authors for inclusion in future releases for vitreoretinal surgery. Eye 17: 71, 2003. of the model. 20. Cutting, C., LaRossa, D., Sommerlad, B., et al. Virtual Surgery CD Set: Volume I: Unilateral Cleft. Volume II: Bilateral Cleft. Vol- Court B. Cutting, M.D. ume III: Cleft Palate. New York: The Smile Train, 2001. 333 East 34th Street, Suite 1K 21. Cutting, C., Oliker, A., Haring, J., Dayan, J., and Smith, D. New York, N.Y. 10016 Use of three-dimensional computer graphic animation to [email protected] illustrate cleft lip and palate surgery. Comput. Aided Surg. 7: 326, 2002. 22. Cutting, C., Oliker, A., Khorramabadi, D., and Haddad, B. A DISCLOSURE deformer-based surgical simulator program for cleft lip and The authors have no financial interests to disclose. palate surgery. Comput. Aided Surg. (Submitted).

1645 Plastic and Reconstructive Surgery • November 2007

23. Cutting, C., Grayson, B., McCarthy, J. G., et al. A virtual reality 27. De Greef, S., and Willems, G. Three-dimensional cranio- system for bone fragment positioning in multisegment craniofacial reconstruction in forensic identification: Latest facial surgical procedures. Plast. Reconstr. Surg. 102: 2436, 1998. progress and new tendencies in the 21st century. J. Forensic 24. Marsh, J. L., and Vannier, M. W. Surface imaging from com- Sci. 50: 12, 2005. puterized tomographic scans. Surgery 94: 159, 1983. 28. Thali, M. J., Braun, M., Buck, U., et al. VIRTOPSY—Scientific 25. Marsh, J. L., Vannier, M. W., and Stevens, W. G. Surface re- documentation, reconstruction and animation in forensic: constructions from computerized tomographic scans for eval- Individual and real 3D data based geo-metric approach in- uation of malignant skull destruction. Am. J. Surg. 148: 530, 1984. cluding optical body/object surface and radiological CT/ 26. Dayan, J. H., Smith, D., Oliker, A., Haring, J., and Cutting, MRI scanning. J. Forensic Sci. 50: 428, 2005. C. B. A virtual reality model of eustachian tube dilation and 29. Yasuda, T., Yokoi, S., Ohshita, H., and Toriwaki, J. 3D visu- clinical implications for cleft palate repair. Plast. Reconstr. alization of an ancient Egyptian mummy. IEEE Comput. Surg. 116: 236, 2005. Graph. Appl. 12: 13, 1992.

Online CME Collections This partial list of titles in the developing archive of CME article collections is available online at www. PRSJournal.com. These articles are suitable to use as study guides for board certification, to help readers refamiliarize themselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old can be taken for CME credit. Pediatric/Craniofacial The Use of Perioperative Corticosteroids in Craniomaxillofacial Surgery: A Survey—Themistocles L. Assimes and Lucie M. Lassard Endoscopically Assisted Reconstruction of Orbital Medial Wall Fractures—Chien-Tzung Chen et al. Subunit Principles in Midface Fractures: The Importance of Sagittal Buttresses, Soft-Tissue Reductions, and Sequencing Treatment of Segmental Fractures—Paul Manson et al. Maxillary Reconstruction: Functional and Aesthetic Considerations—Arshad Muzaffar et al. Cleft Lip: Unilateral Primary Deformities—James D. Burt and H. Steve Byrd Optimal Timing of Cleft Palate Closure—Rod J. Rohrich et al. Efficacy of Preoperative Decontamination of the Oral Cavity—Adam N. Summers et al. Primary Repair of Bilateral Cleft Lip and Nasal Deformity—John B. Mulliken Correction of Secondary Deformities of the Cleft Lip Nose—Samuel Stal and Larry Hollier Correction of Secondary Cleft Lip Deformities—Samuel Stal and Larry Hollier Common Craniofacial Anomalies: The Facial Dystoses—Jeremy A. Hunt and Craig Hobar Common Craniofacial Anomalies: Conditions of Craniofacial Atrophy/Hypoplasia and Neoplasia—Jeremy A. Hunt and Craig Hobar Subciliary versus Subtarsal Approaches to Orbitozygomatic Fractures—Rod J. Rohrich et al. Management of Craniosynostosis—Jayesh Panchal and Venus Uttchin The Management of Orbitozygomatic Fractures—Larry H. Hollier et al. Common Craniofacial Anomalies: Facial Clefts and Encephaloceles—Jeremy A. Hunt and Craig Hobar Velopharyngeal Incompetence: A Guide for Clinical Evaluation—Donnell F. Johns et al. Distraction Osteogenesis of the Craniofacial Skeleton—Jack C. Yu et al. Cleft Rhinoplasty—Allen L. Van Beek et al. The Management of Frontal Sinus Fractures—Reha Yavuzer et al. The Spectrum of Orofacial Clefting—Barry L. Eppley et al. The Pediatric Mandible I: A Primer on Growth and Development—James M. Smartt et al. The Pediatric Mandible II: Management of Traumatic Injury or Fracture—James M. Smartt et al. Two Hundred Ninety-Four Consecutive Facial Fractures in an Urban Trauma Center: Lessons Learned— Patrick Kelley et al. Aesthetic Management of the Nasal Component of Naso-Orbital Ethmoid Fractures—Jason K. Potter et al. Management of Mandible Fractures—David Heath Stacey et al.

1646 COSMETIC

Anatomy of the Corrugator Supercilii Muscle: Part I. Corrugator Topography

Jeffrey E. Janis, M.D. Background: Complete corrugator supercilii muscle resection is important for Ashkan Ghavami, M.D. the surgical treatment of migraine headaches and may help prevent postoper- Joshua A. Lemmon, M.D. ative abnormalities in surgical forehead rejuvenation. Specific topographic anal- Jason E. Leedy, M.D. ysis of corrugator supercilii muscle dimensions and its detailed association with Bahman Guyuron, M.D. the supraorbital nerve branching patterns has not been thoroughly delineated. Dallas, Texas; and Cleveland, Ohio Part I of this two-part study aims to define corrugator supercilii muscle topography with respect to external bony landmarks. Methods: Twenty-five fresh cadaver heads (50 corrugator supercilii muscles and 50 supraorbital nerves) were dissected to isolate the corrugator supercilii muscle from surrounding muscles. Standardized measurements of corrugator supercilii muscle dimensions were taken with respect to the nasion and lateral orbital rim. Results: Relative to the nasion, the most medial origin of the corrugator supercilii muscle was found at 2.9 Ϯ 1.0 mm; the most lateral origin point, 14.0 Ϯ 2.8 mm. The lateralmost insertion of the corrugator supercilii muscle measured 43.3 Ϯ 2.9 mm from the nasion or 7.6 Ϯ 2.7 mm medial to the lateral orbital rim. The most cephalic extent (apex) of the muscle was located 32.6 Ϯ 3.1 mm cephalad to the nasion–lateral orbital rim plane and 18.0 Ϯ 3.7 mm medial to the lateral orbital rim. There were no statistical differences noted between the right and left sides. Conclusions: The dimensions of the corrugator supercilii muscle are more extensive than previously described and can be easily delineated using fixed bony landmarks. These data may prove beneficial in performing safe, complete, and symmetric corrugator supercilii muscle resection for forehead rejuvenation and for effective decompression of the supraorbital nerve and supratrochlear nerve branches in the surgical treatment of migraine headaches. (Plast. Reconstr. Surg. 120: 1647, 2007.)

omplete resection of the corrugator super- tence of dynamic rhytides.1–3 All of these may cilii muscle has been advocated for both become exaggerated on forehead animation.1,4,5 forehead rejuvenation and in the surgical The cause of this may be related to the surgical C 1–3 treatment of migraine headaches. Unequal approach, specific technical execution, and/or corrugator supercilii muscle removal and/or in- the surgeon’s experience with a particular complete corrugator supercilii muscle resection technique.1,6,7 after forehead rejuvenation can lead to undesir- In a recent study, Walden et al.6 have shown that able sequelae such as dimpling, depressions, and the amount of corrugator supercilii muscle resec- residual corrugator activity, with resultant persis- tion can vary depending on the approach used, with as much as one-third of the transverse corru- From the Department of Plastic Surgery, The University of gator supercilii muscle head remaining after trans- Texas Southwestern Medical Center, and the Department of palpebral attempts at complete muscle removal. Plastic and Reconstructive Surgery, Case Western Reserve Although the senior author (B.G.) believes that University School of Medicine. 7,8 Received for publication April 13, 2006; accepted September this may largely be technique-related, familiarity 7, 2006. with normal corrugator supercilii muscle dimen- Gaspar W. Anastasi Award presentation at the American sions in reference to fixed bony landmarks can Society for Aesthetic Plastic Surgery Annual Meeting, in minimize this unpredictability and allow for a Orlando, Florida, April 23, 2006. more systematic approach to precise corrugator Copyright ©2007 by the American Society of Plastic Surgeons supercilii muscle myectomy. In addition, a compre- DOI: 10.1097/01.prs.0000282725.61640.e1 hensive understanding of the corrugator supercilii

www.PRSJournal.com 1647 Plastic and Reconstructive Surgery • November 2007 muscle dimensions may assist less experienced sur- while interdigitating with the orbicularis oculi geons in obtaining a successful outcome when per- muscle and frontalis muscles. The oblique head of forming any of the numerous surgical approaches the corrugator supercilii muscle is smaller, with its for forehead rejuvenation that have been de- fibers commonly running parallel to those of the scribed. depressor supercilii muscle after insertion into the Migraine headaches have been postulated to be medial brow. associated with peripheral nerve trigger points.9–14 Knize15 dissected 40 hemifacial cadaver heads The supraorbital/supratrochlear nerves have been to evaluate the detailed muscular anatomy of the implicated as one of four peripheral trigger sites forehead region. The origin of the corrugator su- that potentially account for migraine headache percilii muscle was found to be consistent and symptomatology.10 Improvement or complete located at the frontal bone near the superomedial amelioration of migraine headaches has been orbital rim, anterior and slightly cephalad to the demonstrated after chemodenervation of the cor- trochlea of the extraocular superior oblique rugator supercilii muscle by botulinum toxin type muscle.15 The corrugator supercilii muscle fibers A,9,10 which is theorized to act by decompression of then pass superolaterally “through” the frontalis the supraorbital nerve and supratrochlear nerve by and orbicularis oculi muscles before inserting into relaxation of the investing musculature.10,14 Long- the medial half of brow skin.15 The corrugator term success has been demonstrated in a vast ma- supercilii muscle also extends through the galeal jority of patients who have subsequently gone on to fat pad before giving off its dermal insertions.15 It have complete corrugator supercilii muscle is unclear from these and other descriptions myectomy.10 whether the corrugator supercilii muscle extends Based on extensive intraoperative observation, beyond the temporal fusion line, and exactly how the senior author (B.G.) postulates that the su- lateral the insertion point is.16,17 praorbital nerve branches demonstrate a more In a recent report that examined the efficacy significant investment pattern in relation to the of the transpalpebral, endoscopic, and open coro- corrugator supercilii muscle fibers, further sup- nal approaches to corrugator supercilii muscle reporting the necessity for safe and complete resection, the transverse head of the corrugator su- section of the corrugator supercilii muscle for percilii muscle was found to be incompletely supraorbital nerve decompression in migraine resected, mostly in the lateral region using the treatment. Although the investing topography of transpalpebral approach.6 The authors noted that other peripheral trigger points has been the transverse head of the corrugator muscle was described,9,11–13 the supraorbital nerve and its longer and thicker (average, 7.5 mm) than the close relationship to the corrugator supercilii oblique head (2.0 mm).6 More complete resection muscle fibers requires further anatomical inspec- of the corrugator, along with the depressor super- tion. A comprehensive understanding of corru- cilii and procerus muscles, was seen with the en- gator supercilii muscle dimensions and its rela- doscopic approach. In addition, the authors noted tionship with the supraorbital nerve branching the utility of visual cues such as muscle color to patterns may improve the safety and predictabil- differentiate between the various muscle fibers.6 ity of forehead rejuvenation and surgical treat- For example, the medial orbicularis oculi is su- ment for migraine headaches. In Part I of this perficial and a lighter pink than the vertically ori- study, the topographic dimensions of the corru- ented red depressor supercilii muscle fibers.6 Isse gator supercilii muscle with respect to fixed ex- and Elahi17 performed a smaller cadaver study and ternal bony landmarks are defined, whereas in found that in the lateral two-thirds of the brow, the Part II, the branching patterns of the supraor- corrugator supercilii muscle fibers pass through the bital nerve as they relate to the corrugator super- orbicularis oculi and frontalis muscles. This most cilii muscle fibers are described. lateral region of the corrugator supercilii muscle, although difficult to dissect, is important because RELEVANT ANATOMY it may largely account for lateral brow depressions The corrugator supercilii muscle is one of the seen postoperatively.17,18 three commonly described brow depressor muscle The motor nerve supply to the corrugator groups (including the medial orbicularis oculi supercilii muscle is from the frontal branch of and depressor supercilii) and is composed of two the temporal division of the facial nerve, heads. The transverse head originates from the whereas the zygomatic branch seems to inner- superomedial aspect of the orbital rim to insert vate the oblique head.2 Postoperative observation into the dermis at the middle third of the brow of corrugator supercilii muscle reactivation after lat-

1648 Volume 120, Number 6 • Corrugator Supercilii Muscle eral resection provides evidence that motor nerve ing the eyebrow arches. The frontalis and depres- fibers originating medially exist and are involved in sor supercilii muscles were dissected off of the reinnervation.1,2,15 This further supports the impor- corrugator supercilii muscle and elevated along tance of complete corrugator supercilii muscle resec- with the skin flaps. Once the full extent of the tion for supraorbital nerve/supratrochlear nerve de- transverse and oblique heads of the corrugator compression in the surgical treatment of migraine supercilii muscle were well delineated, the nasion headaches and for forehead rejuvenation, when in- and lateral orbital rim apex (most lateral bony dicated. point) were marked, and standardized measure- The association of the supratrochlear nerve ments of muscle dimensions were taken. with the corrugator supercilii muscle is well Because of the globe distortion and soft-tissue known, as it exits just lateral to the corrugator changes present in cadaver specimens, soft-tissue supercilii muscle origin, enters the muscle (where reference points were not used. In addition, use of it divides into three or four small branches), soft-tissue landmarks may result in great variability courses in a cephalad direction just deep to the in vivo. Therefore, fixed bony landmarks were anterior surface of the corrugator, and then pen- chosen as reference points. etrates the frontalis muscle.2,19 However, the inti- Vertical muscle dimensions were measured in mate relationship of the supraorbital nerve with reference to a horizontal line created to transect the corrugator supercilii muscle has not been spe- the lateral orbital rim and nasion points of refer- cifically elucidated. ence. Horizontal muscle dimensions were mea- Based on previous reports,15,20 the supraorbital sured relative to a vertical line bisecting the na- nerve does not seem to run within the corrugator sion, anterior nasal spine, and menton. Results are muscle mass. However, in a study by Knize,15 cross- listed as mean values with standard deviations. sectional histology performed in two cadavers re- Mean values between the right and left sides were vealed the presence of muscle fiber staining deep compared using paired t test analysis. to the supraorbital nerve (likely corrugator supercilii muscle fibers). This may suggest a more inti- RESULTS mate relationship between the supraorbital nerve There was no statistical difference seen be- and corrugator supercilii muscle fibers than pre- tween the right and left corrugator supercilii mus- viously thought. This intricacy is important and cle dimensions based on paired t test analysis (p Ͻ will be examined further in Part II of our study. 0.0001); therefore, right (n ϭ 25) and left (n ϭ 25) corrugator supercilii muscle measurements were MATERIALS AND METHODS added (total n ϭ 50) to improve the power of the Twenty-five fresh cadaver heads (50 corruga- study and are provided as mean values with cor- tor muscles and 50 supraorbital nerves) were dis- responding standard deviations. All measure- sected using a cross-shaped incision centered over ments were obtained using millimeters as the unit the radix, with the transverse component follow- of measurement (Figs. 1 and 2). Horizontal cor-

Fig. 1. Corrugator supercilii muscle (CSM) topography; cadaver dissection with average distances. Cadaver dissection of the corrugator supercilii muscle showing the major data points that delineate muscle dimensions with respect to the nasion (N) and lateral orbital rim (LOR).

1649 Plastic and Reconstructive Surgery • November 2007

Fig. 2. Comprehensive corrugator supercilii muscle dimensions. Artistic rendition (proportionate scale) of all the measured data points of the corrugator supercilii muscle in relation to the palpable bony anatomy [nasion (N) and lateral orbital rim (LOR)]. Note reﬂection of muscular inter- digitation required to delineate the lateral extent of the corrugator supercilii muscle. rugator supercilii muscle dimensions were mea- Table 2. Topographic Dimensions of the Corrugator sured first. The vertical midline connecting the Supercilii Muscle Lateral Orbital Rim Reference nasion and anterior nasal spine was used as the Points (Mean Values) reference landmark for all horizontal muscle di- Right (mm) Left (mm) Overall (mm) mension points (Table 1). LOR to apex 17.9 Ϯ 3.3 18.0 Ϯ 2.5 18.0 Ϯ 3.7 The nasion to lateral orbital rim distance mea- LOR to lateral sured 50.8 Ϯ 2.9 mm (range, 46 to 59 mm). The extent 6.9 Ϯ 2.6 8.3 Ϯ 3.2 7.6 Ϯ 2.7 most lateral insertion point of the corrugator su- LOR, the most medial palpable point of the lateral orbital rim. percilii muscle measured 43.3 Ϯ 2.9 mm from the nasion, which corresponds to a value that is 85 percent of the distance to the lateral orbital rim. cle was located 32.9 Ϯ 2.6 mm lateral to the nasion This is equivalent to a distance of 7.6 Ϯ 2.7 mm or 18.0 Ϯ 3.7 mm medial to the lateral orbital rim. medial to the lateral orbital rim (Table 2). Vertical dimensions were measured in reference The medial origin of the corrugator muscle to a straight horizontal plane that passes through was located 2.9 Ϯ 1.0 mm from the nasion, the nasion and lateral orbital rim (Table 3). whereas the lateral origin point measured 14.0 Ϯ The apex (most cephalad point) of the muscle 2.8 mm from the nasion. This corresponds to an was located at a mean distance of 32.6 Ϯ 3.1 mm average origin width of 11.1 mm. The apex (most from the horizontal plane. The vertical height of cephalad point) of the corrugator supercilii mus-

Table 3. Topographic Dimensions of the Corrugator Table 1. Topographic Dimensions of the Corrugator Supercilii Muscle Vertical Reference Points (Mean Supercilii Muscle Nasion Reference Points (Mean Values) Values) Right (mm) Left (mm) Overall (mm) Right (mm) Left (mm) Overall (mm) Plane to Nasion to lateral medial-inferior* 9.8 Ϯ 2.1 9.3 Ϯ 2.0 9.8 Ϯ 2.2 orbital rim 50.9 Ϯ 2.9 50.8 Ϯ 2.8 50.8 Ϯ 2.9 Plane to Nasion to medial medial-superior 18.6 Ϯ 2.4 18.2 Ϯ 2.5 18.7 Ϯ 2.4 origin 2.7 Ϯ 0.9 3.0 Ϯ 1.0 2.9 Ϯ 1.0 Plane to Nasion to lateral lateral-inferior 22.3 Ϯ 3.2 21.1 Ϯ 3.7 21.9 Ϯ 3.3 origin 13.8 Ϯ 3.0 14.2 Ϯ 2.6 14 Ϯ 2.8 Plane to Nasion to lateral lateral-superior 28.9 Ϯ 2.8 26.8 Ϯ 3.5 28.8 Ϯ 3.5 extent 44 Ϯ 2.6 42.7 Ϯ 3.5 43.3 Ϯ 2.9 Plane to apex 32.8 Ϯ 3.1 31.6 Ϯ 2.5 32.6 Ϯ 3.1 Ϯ Ϯ Ϯ Nasion to apex* 33.0 2.8 32.5 2.0 32.9 2.6 *Plane represents a straight horizontal reference line that passes *The most cephalad extent of corrugator supercilii muscle fibers. through the nasion and lateral orbital rim points.

1650 Volume 120, Number 6 • Corrugator Supercilii Muscle the most medial-inferior muscle origin was 9.8 Ϯ section to where the corrugator supercilii muscle 2.2 mm and 18.7 Ϯ 2.42 mm medial-superior. passes into the frontalis/orbicularis muscles lat- Lateral heights are 21.9 Ϯ 3.3 mm lateral-inferior erally, to prevent possible reinnervation from and 28.8 Ϯ 3.5 mm lateral-superior. other motor branches, such as the frontal branch of the facial nerve or from medial nerve fibers. DISCUSSION Although the endoscopic approach is the more Complete resection of the corrugator super- commonly described approach for surgical treat- cilii muscle has been advocated for both forehead ment of migraine headaches,10 multiple surgical rejuvenation1–3 and for the surgical treatment of techniques have been described for brow depressor migraine headaches.6,9 However, incomplete muscle excision and forehead rejuvenation. These and/or unequal corrugator supercilii muscle re- mainly include the transpalpebral, endoscopic, and section with simple, imprecise debulking proce- coronal approaches. Accuracy in brow depressor dures can have deleterious consequences. These muscle (including corrugator supercilii muscle) re- include forehead/brow asymmetries, skin dim- section has been clearly shown to be influenced by pling (particularly with animation), and recur- the surgical approach.6 Through this study, specific 1,2,15 rence of glabellar furrows and frown lines. In data regarding the most lateral, medial, superior, addition, aberrant reinnervation of residual mus- and inferior borders of the corrugator supercilii 1,2,4 cle can result in awkward forehead animation. muscle are now available and may increase the ac- Irregular “lateral horns” of reinnervated muscle curacy of performing more precise corrugator su- mass can become evident as early as 3 to 4 months 4 percilii muscle resection regardless of the surgical postoperatively. approach. In addition, information regarding su- The variability and unpredictability of com- praorbital nerve branching patterns provided in Part plete corrugator supercilii muscle resection may II of the current study will further refine our knowl- also hinder successful surgical treatment of mi- edge regarding the intimate relationship between graine headaches, as complete peripheral nerve (su- the supraorbital nerve and corrugator supercilii praorbital nerve and supratrochlear nerve) de- muscle. compression is mandatory.9,10 In our current Based on extensive intraoperative observation, report, we set out to further refine our under- the senior author (B.G.) has noted that corrugator standing of the average dimensions of the corru- supercilii muscle dimensions are more extensive gator supercilii muscle with respect to easily iden- than previously reported. Knize2 describes the cor- tifiable, fixed bony landmarks. To our knowledge, this is the largest cadaver study looking at corru- rugator supercilii muscle origin as being constant, gator supercilii muscle anatomy. This detailed to- with both a transverse and oblique head, whereas pographic information can assist the surgeon in the remainder of the muscle mass is variable. In- more accurate preoperative planning and im- adequate removal of the lateral portion of the transverse head of the corrugator supercilii mus- proved perioperative confirmation of complete 6 corrugator supercilii muscle resection. cle noted by Walden et al. suggests that the dis- Clinically, incomplete corrugator supercilii section of the most lateral insertion point of the muscle resection of up to 50 percent has been corrugator supercilii muscle is most unpredict- Ϯ reported with some techniques.6,8 In a recent de- able. We found this point to measure 43.3 2.9 tailed anatomical study, Walden et al.6 have dem- mm from the nasion (located 85 percent of the Ϯ onstrated that up to one-third (most lateral as- distance to the lateral orbital rim), or 7.6 2.7 pect) of the transverse corrugator supercilii mm medial to the lateral orbital rim. This point muscle head remained after transpalpebral resec- was not easily identifiable and required meticu- tion that was otherwise thought to be complete. lous dissection (using 3.8ϫ loupe magnification) Guyuron7 offers three plausible causes for subop- off of the interdigitating orbicularis oculi muscles, timal corrugator supercilii muscle resection: (1) frontalis muscle, and eyebrow dermis (Fig. 2). In interdigitations with the frontalis and orbicularis addition, this most lateral portion of the corruga- muscles may inhibit thorough visual assessment of tor supercilii muscle is thinner and more super- the superior aspect of the transverse head; (2) fear ficial; therefore, care must be taken to avoid in- of damage to the supraorbital nerve; and (3) the advertent frontalis and orbicularis oculi muscle full extent of the lateralmost portion of the cor- injury during resection. The improved under- rugator supercilii muscle is underestimated. standing of this ambiguous point of muscular in- Knize2 recommends complete avulsion of the cor- terdigitation allows for a more precise and tailored rugator supercilii muscle origin medially, and re- approach to corrugator supercilii muscle removal.

1651 Plastic and Reconstructive Surgery • November 2007

Fig. 3. Most clinically relevant dimensions. Patient photograph depicts the more clinically useful topographic data points. Horizontal data points: medialmost corrugator supercilii muscle origin (2.9 mm); lateralmost extension point (43.3 mm from the nasion and 7.6 mm from the lateral orbital rim); location of apex from lateral orbital rim (18 mm). Vertical data points (from nasion to lateral orbital rim plane): apex (32.6 mm) and lateralmost extent of corrugator supercilii muscle (28.8 mm).

We did not observe a clear delineation be- and symmetric between left and right sides. Al- tween the oblique and transverse head fibers, as though palpation of a contracted corrugator su- the fibers quickly paralleled each other within the percilii muscle on forehead animation may pro- mass of the corrugator supercilii muscle after the vide approximate muscle dimensions in the origin of the oblique head was no longer seen. clinical setting and should be a part of the pre- This may indicate that there is a singular corru- operative examination, objective topographic gator supercilii muscle mass, possibly with variable points based on fixed bony landmarks more ac- or accessory muscle fiber origins without well-de- curately define the extent of the corrugator su- fined and separate heads. percilii muscle mass to be resected. This infor- We found an average muscle origin width of mation can potentially be used to plan a more 11.1 mm, with the medialmost origin of the systematic approach to complete corrugator su- oblique head of the corrugator supercilii muscle percilii muscle removal by providing a “surgical located 2.9 Ϯ 1.0 mm from the nasion and 9.8 Ϯ roadmap” as to the anatomical limits required 2.2 mm cephalad to the horizontal plane and the for precise surgical excision of the corrugator lateralmost origin point located 14.0 Ϯ 2.8 mm supercilii muscle, regardless of the technique lateral to the nasion. The apex (most cephalad used (Fig. 3). point) of the corrugator supercilii muscle was lo- Although complete muscle resection is indicated 32.9 Ϯ 2.6 mm lateral to the nasion at a cated for migraine surgery, differential preserva- mean height of 32.6 Ϯ 3.1 mm from the horizontal tion of muscle and selective release of periosteum plane. This apex point is crucial for performing and brow retaining ligaments may be required for accurate and complete chemodenervation of the a more individualized approach to forehead corrugator supercilii muscle with botulinum rejuvenation.1,21–23 This should be based on the toxin. A comprehensive technical approach that surgeon’s preoperative evaluation of each pa- involves a more thorough chemodenervation of tient’s specific forehead morphology.1,21,23–25 all the corrugator supercilii muscle fibers is re- Knowledge of the corrugator supercilii muscle to- quired for both the diagnosis of frontal peripheral pography can further assist in selective retention trigger points and in the definitive surgical treat- of portions of the corrugator supercilii muscle ment of migraine headaches.10 If the most ceph- mass or retaining ligaments when indicated. alad extent of the corrugator supercilii muscle is Other glabellar muscles were not evaluated; how- not adequately treated, the successful treatment of ever, future studies using histologic analysis are migraine symptoms may suffer. needed to better define regional muscles such as The current report found the corrugator the medial portion of the orbicularis oculi muscle supercilii muscle dimensions to be consistent and depressor supercilii muscle.

1652 Volume 120, Number 6 • Corrugator Supercilii Muscle

CONCLUSIONS 5. Macdonald, M. R., Spiegal, J. H., Raven, R. B., Kabaker, S. S., and Mass, C. S. An anatomical approach to glabellar rhytids. The dimensions of the corrugator supercilii Arch. Otolaryngol. Head Neck Surg. 124: 1315, 1998. muscle were found to extend more lateral and 6. Walden, J. L., Brown, C. C., Klapper, A. J., Chia, C. T., and superior and displayed a greater width of origin Aston, S. J. An anatomical comparison of transpalpebral, than previously described. In addition, a clear dis- endoscopic, and coronal approaches to demonstrate expo- tinction between the oblique and transverse fibers sure and extent of brow depressor muscle resection. Plast. Reconstr. Surg. 116: 1479, 2005. was not seen. Complete corrugator supercilii re- 7. Guyuron, B. An anatomical comparison of transpalpebral, section for forehead rejuvenation (when indi- endoscopic, and coronal approaches to demonstrate expo- cated) and for supraorbital nerve (and su- sure and extent of brow depressor muscle resection (Dis- pratrochlear nerve) decompression in migraine cussion). Plast. Reconstr. Surg. 116: 1488, 2005. headache treatment can be safely and more pre- 8. Jelks, G. Transpalpebral corrugator/depressor resection. Presented at the Aesthetic Surgery of the Aging Face Symposium, cisely accomplished with the aid of external bony New York, N.Y., November 22, 2003. landmarks. By performing a more systematic ap- 9. Guyuron, B., Varghai, A., Michelow, B. J., Thomas, T., and proach to corrugator supercilii muscle resection, Davis, J. Corrugator supercilii muscle resection and migraine the risk of undesirable postoperative outcomes headaches. Plast. Reconstr. Surg. 106: 429, 2000. such as forehead irregularities, asymmetries, and 10. Guyuron, B., Kriegler, J. S., Davis, J., and Amini, S. B. Com- prehensive surgical treatment of migraine headaches. Plast. unequal muscle reactivation may decrease. In ad- Reconstr. Surg. 115: 1, 2005. dition, the learning curve for performing success- 11. Mosser, S. W., Guyuron, B., Janis, J. E., and Rohrich, R. J. The ful forehead rejuvenation and surgical treatment anatomy of the greater occipital nerve: Implications for the of migraine headaches by means of numerous sur- etiology of migraine headaches. Plast. Reconstr. Surg. 113: 693, gical approaches may be improved with more ac- 2004. 12. Dash, K. S., Janis, J. E., and Guyuron, B. The lesser occipital curate knowledge of the topographic information nerves and migraine headaches. Plast. Reconstr. Surg. 115: provided in this study. In Part II of this study, a 1752, 2005. more refined description of the supraorbital nerve 13. Totonchi, A., Pashmini, N., and Guyuron, B. The zygomat- branching patterns as they pertain to the corru- icotemporal branch of the trigeminal nerve: An anatomical gator supercilii muscle mass will be described. study. Plast. Reconstr. Surg. 115: 273, 2005. 14. Austad, E. D. Comprehensive surgical treatment of migraine Jeffrey E. Janis, M.D. headaches (Discussion). Plast. Reconstr. Surg. 115: 1759, 2005. Department of Plastic Surgery 15. Knize, D. M. An anatomically based study of the mechanism The University of Texas Southwestern Medical Center of eyebrow ptosis. Plast. Reconstr. Surg. 97: 1321, 1996. 1801 Inwood Road, WA4.240 16. Park, J. I., Hoagland, T. M., and Park, M. S. Anatomy of the Dallas, Texas 75390-9132 corrugator supercilii muscle. Arch. Facial Plast. Surg. 5: 412, [email protected] 2003. 17. Isse, N. G., and Elahi, M. M. The corrugator supercilii muscle revisited. Aesthetic Surg. J. 21: 209, 2001. ACKNOWLEDGMENT 18. Knize, D. M. The corrugator supercilii muscle revisited (Dis- The authors thank Rod J. Rohrich, M.D., for the cussion). Aesthetic Surg. J. 21: 214, 2001. generous donation of the cadaver specimens used in this 19. Williams, P. L., Warkwick, R., Dyson, M., and Bannister, L. H. study. (Eds.). Gray’s Anatomy, 37th Ed. London: Churchill Living- stone, 1989. P. 1100. 20. Knize, D. M. A study of the supraorbital nerve. Plast. Reconstr. DISCLOSURE Surg. 96: 564, 1995. None of the authors received financial benefits from 21. Sullivan, P. E., Salomon, J. A., Woo, A. S., and Freeman, M. B. The importance of the retaining ligamentous attachments of any commercial entity in support of this article. the forehead for selective eyebrow reshaping and forehead rejuvenation. Plast. Reconstr. Surg. 117: 95, 2006. REFERENCES 22. Moss, C. J., Mendelson, B. C., and Taylor, G. I. Surgical 1. Guyuron, B. Endoscopic forehead rejuvenation: Limitations, anatomy of the ligamentous attachments in the temple and flaws, and rewards. Plast. Reconstr. Surg. 117: 1121, 2006. periorbital regions. Plast. Reconstr. Surg. 105: 1475, 2000. 2. Knize, D. M. Transpalpebral approach to the corrugator 23. Abramo, C. A., and Dorta, A. A. Selective myotomy in fore- supercilii and procerus muscles. Plast. Reconstr. Surg. 95: 52, head endoscopy. Plast. Reconstr. Surg. 112: 873, 2003. 1995. 24. Freund, R. M., and Nolan, W. B., III. Correlation between 3. Guyuron, B., Michelow, B. J., and Thomas, T. Corrugator browlift outcomes and aesthetic ideals for eyebrow height supercilii muscle resection through blepharoplasty incision. and shape in females. Plast. Reconstr. Surg. 97: 1343, 1996. Plast. Reconstr. Surg. 95: 691, 1995. 25. Byrd, H. S., and Andochick, S. E. The deep temporal lift: A 4. Knize, D. M. Muscles that act on glabellar skin: A closer look. multiplanar, lateral brow, temporal, and upper face lift. Plast. Plast. Reconstr. Surg. 105: 350, 2000. Reconstr. Surg. 97: 928, 1996.

1653 COSMETIC

Versatility of Diced Cartilage–Fascia Grafts in Dorsal Nasal Augmentation

Martin H. Kelly, Background: Augmentation of the nasal dorsum using autologous cartilage F.R.C.S.(Plast.) remains an exacting task in rhinoplasty. Precise, long-term control over graft Neil W. Bulstrode, contour and alignment can be difficult to achieve. In an attempt to alleviate F.R.C.S.(Plast.) these problems, the use of diced cartilage wrapped in a supportive sleeve has Norman Waterhouse, recently seen a resurgence of interest. The Turkish delight technique uses F.R.C.S.(Plast.) Surgicel as the sleeve material, whereas Daniel and Calvert have proposed London, United Kingdom autologous fascia. Methods: The objective of this study was to assess the efficacy and reliability of diced cartilage–fascia grafts in the treatment of dorsal nasal volume deficiencies. Results: Over a 2-year period, 20 adult patients underwent nasal augmentation using diced cartilage–fascia grafts. The indications for dorsal grafting were congenital saddling, racial refinement, or iatrogenic or posttraumatic deformities. Apart from one infection, all of the hybrid grafts retained their original volume and had not undergone resorption by a mean time of 16 months postoperatively. A critical analysis of the radix-dorsum aesthetics led to a minor modification of the original technique. Conclusion: This series supports the use of diced cartilage–fascia grafts for the correction of difficult dorsal nasal defects with grafting in the 3- to 5-mm range in primary and secondary rhinoplasty. (Plast. Reconstr. Surg. 120: 1654, 2007.)

he use of cartilage grafts is an integral part to control its inherent curves. It tends to frag- of rhinoplasty surgery. Dorsal nasal grafts ment when crushed and may become misshapen Tpresent a specific challenge in that they by the cicatrix over time. Costal cartilage im- support the soft-tissue envelope of the nose at its poses a thoracic scar on the patient and must thinnest over the rhinion and are therefore also be splinted to prevent warping.2 In cases of more likely to produce visible contour defects if an important dorsal nasal deficiency, these re- they become warped or misplaced. spective limitations become all the more rele- A wide choice of donor cartilage exists (sep- vant, which rationalizes the opinion of many tum, concha, and costal), each with its own me- rhinoplasty surgeons that the “ideal” dorsal graft chanical advantages and limitations. The thin does not exist. nature of the quadrangular plate means that The use of cartilage micrografts wrapped in a stacking of septal grafts is often necessary to sleeve was developed to address these imperfec- recreate sufficient dorsal volume. Thin, sharp tions. Such a composite graft has no visible edges edges may become visible after several years and and might obviate the problem of warping that make displacement a real concern unless the follows the carving of a single fragment, which grafts are secured in correct alignment with the releases forces of torque that are inherently bal- brow lines cephalad and the tip-defining points anced in native cartilage tissue. Although the caudad. In addition, insufficient cartilaginous idea was developed in the 1940s,3 it gained new septal tissue may be available in patients under- attention after the publication by Erol of a per- going secondary rhinoplasty. Conchal cartilage sonal series of 2365 patients using a technique must be either scored or specifically contoured1 that he termed the Turkish delight.4 This involved a mixture of diced autologous cartilage From the Craniofacial Unit, Chelsea and Westminster Hos- and blood, wrapped in Surgicel (Johnson & pital. Johnson, Somerville, N.J.). However, the re- Received for publication October 12, 2005; accepted February ported favorable results in this single series (re- 10, 2006. sorption in only 11 patients) were not found to Copyright ©2007 by the American Society of Plastic Surgeons be easily reproducible. Animal studies reported DOI: 10.1097/01.prs.0000285185.77491.ab a lack of proliferation of cartilage grafts wrapped

1654 www.PRSJournal.com Volume 120, Number 6 • Diced Cartilage–Fascia Grafts in Surgicel.5 Our own clinical experience was operatively in one case early in the series. The disappointing, and Daniel and Calvert published “closed” version of the diced cartilage–fascia graft a clinical series which, albeit in a more modest thus aims to minimize extrusion of the diced car- sample of patients, clearly demonstrated an un- tilage and help maintain its desired position fol- acceptable rate of cartilage resorption when us- lowing placement and modeling once the nose ing the Turkish delight method,6 with recur- has been closed. rence of the deformity within a short time. The dorsum of the nose was accessed by an The technique was modified by Daniel and open rhinoplasty approach. In more extensive, Calvert in favor of using autologous fascia to reconstructive procedures, a bicoronal incision wrap the cartilage micrografts, which themselves was used for a transglabellar approach to the nasal were cleaned of blood.6 More stable results were dorsum. The receiving pocket was dissected to an observed, on the postulated basis that the cellu- extent only sufficient to accept the graft, to ensure lose in Surgicel resorbs within 24 hours, whereas its stable positioning and to reduce the risk of fascia is tissue with a high tensile strength and a misplacement. Adjustments to the final position proven track record as a durable graft material. and form of the graft were carried out by external In addition, it is known to have cell-supportive digital manipulation after the nose had been properties7 and serves as scaffolding for host closed. A 1:1 volume of graft–to-defect ratio was tissue incorporation.8 used, with no overcorrection. Soon after the report by Daniel and Calvert,6 Steri-Strips (3M, St. Paul, Minn.) and a mal- this form of hybrid grafting gained wider popu- leable aluminium splint were then placed over the larity. Its particular merits include its wide flexi- nasal pyramid to help maintain the graft in its bility of use to resurface irregular dorsal nasal position, and left in place for 1 week. The patient defects; its maximal graft efficiency, enabling was reviewed at 7 to 10 days, when it was still reuse of all cartilage fragments that are ordi- possible to effect minor changes in the dorsal con- narily discarded in rhinoplasty; and a unique tour by gentle digital pressure on the graft. This potential for the construct to be molded once it maneuver was well tolerated without anesthesia by is in place. It is particularly useful in congenital all patients in the outpatient setting. By 2 weeks dorsal deficiencies and in iatrogenic or posttrau- after surgery, the construct solidified, and further matic saddle deformities with a scarred soft- influence on its shape could not be gained. After tissue envelope. This study offers a critical anal- one infection early in the series, broad-spectrum ysis of the results from a series of 20 patients antibiotic prophylaxis was used during and for 5 treated with diced cartilage–fascia grafts and days after surgery in all cases. makes further observations to refine the technique in specific indications. RESULTS PATIENTS AND METHODS A total of 20 patients (16 women and four men) A total of 20 patients underwent diced carti- underwent diced cartilage–fascia grafting for dorsal lage–fascia grafting to the nasal dorsum between nasal defects between 2003 and 2005. The average 2003 and 2005. The technique we used closely follow-up was 18 months (range, 6 to 34 months). followed that previously published by Daniel and The average age was 27 years (range, 18 to 38 years). Calvert.6 Cartilage harvested from the septum, cos- The indications for surgery are listed in Table 1. The tal synchondrosis, or concha was diced into 0.5- to donor site for cartilage harvest was conchal in 13 1-mm cubes using two no. 11 blades, and packed patients, septal in six cases, and costal in one. Tem- into the cylinder of a 1-mm3 syringe with its hub amputated. A rectangle of deep temporal fascia Table 1. Indications for Grafting (approximately 2 ϫ 4.5 cm) was harvested by means of a single 3-cm incision overlying the tem- Indication No. poral fossa and was then wrapped and secured Saddle Congenital 2 around the syringe using 5-0 Vicryl (Ethicon, Inc., Racial 4 Somerville, N.J.) to form a sheath. A modification Iatrogenic 7 was made by placing an additional 5-0 Vicryl purse- Hypertelorism 2 Craniofacial 1 string suture around the open, caudal end of the Nasal cleft 1 fascial sleeve, to close the sheath when the syringe Binders 1 was removed. This was introduced after micrograft Posttraumatic 2 spillage into the nasal supratip was observed post- Total 20

1655 Plastic and Reconstructive Surgery • November 2007 poralis fascia was used in 19 cases and rectus fascia useful when attempting to improve volume defi- in one case. Complications were encountered in nition, projection, and faceting of the nasal tip. four patients. These included one spillage of micro- Alloplastic materials, however, are increasingly graft into the nasal supratip that required revision, recognized to have limited indications in rhino- one minor contour deformity, and one infection plasty, although they continue to find favor in that unfortunately led to resorption of the diced specific circumstances such as dorsal augmenta- cartilage–fascia construct. In 19 of the cases, the tion in the Asian nose. diced cartilage–fascia constructs have maintained The use of diced cartilage grafts, as reviewed their volume and shape throughout the postopera- by Daniel and Calvert,6 was reported in the early tive period. 1940s.3 It was subsequently used to form frameworks for ear reconstruction,9 repair nasal defects follow- CASE REPORTS ing leprosy,10 and in forming solid cartilaginous Case 1 masses for cranioplasty.11 Difficulty with controlling The first patient in this series developed supratip fullness the shape of an agglomerate of diced cartilage chips that was initially attributed to edema. However, by 3 weeks, a might be responsible for many following years of lump was palpable and visible in the supratip and the patient silence in the literature, until its resurgence as car- was returned to the operating room. A coalesced cartilage mass was obvious and was revised, with good result. On reviewing the tilage wrapped in Surgicel, the Turkish delight, pub- 4 case, it was evident that the distal end of the fascial sleeve was lished in 2000. However, others using the same not closed, allowing spillage of diced cartilage. This prompted method failed to reproduce the longevity of these modification to the technique in subsequent cases with the use results. Rather, a hybrid solution that made use of of a purse-string suture that was tightened after withdrawal of the plasticity of agglomerated cartilage chips and the the syringe. smooth surface and graft strength of autologous fas- Case 2 cia was proposed by Daniel and Calvert,6 which A female patient had a good initial result but injured her nose after a fall at 6 weeks. This resulted in a clinically apparent added a powerful new technique for treating dorsal dislocation of the diced cartilage–fascia construct from its pre- nasal deformities. The construct is ideal for improv- vious alignment with the nose. External manipulation both in ing both contour and volume of the dorsum and, the outpatient setting and under anesthesia failed to correct the although it cannot be used to give structural support deformity. Open rhinoplasty was required for access, and it was to the nose or improve its valvular function, it pro- possible to remove the whole construct en bloc with minimal dissection. By manipulating the construct without the need for vides a smooth and pliable graft, the ventral surface opening the fascial sheath, the diced cartilage was loosened of which absorbs any complex contour irregularity along its length. It was then replaced as normal, resulting in a rather than reflect through its dorsal surface. It also pleasing final result. allows the molding of a “soft” light-shadow interface Case 3 between the dorsal and lateral nasal subunits, which The seventeenth patient in this series (Fig. 1) presented the obviates any long-term concern with graft visibility. need for a complex nasal reconstruction after rhinoplasty 10 Results examined at over 2 years are stable and years previously at another institution. Multiple conchal and septal grafts were used to reconstruct the upper lateral and alar satisfactory, at which time the cartilage has coa- 6 cartilages and to restore the functioning of both external and lesced into a single mass. Our own experience internal valves. To avoid overly compressing the new fragile with the diced cartilage–fascia graft has been that subsurface framework, the overlying diced cartilage–fascia graft it is easy to assemble and straightforward to insert. was dressed with tape only. Although the final result was pleas- In addition, it optimizes graft management in rhi- ing to the patient, a subtle deviation to the right in the middle third was felt to be a direct consequence of failing to guide the noplasty (all cartilage fragments, e.g., alar ce- diced cartilage–fascia contour in this area. An offer of revision phalic trim, septal shavings, residual conchal frag- was declined by the patient. ments, can contribute to the agglomerate of cartilage within the fascia), which is highly rele- DISCUSSION vant in the secondary rhinoplasty, “graft-depleted” Aside from bone that is sometimes used in patient. Overall, the diced cartilage–fascia graft severe dorsal deficiencies, and fascia used in radix offers unparalleled flexibility in reconstructing augmentation, most dorsal nasal grafting uses au- difficult dorsal nasal deficiencies when compared tologous cartilage. Structural support can be with other existing methods. achieved with cartilage grafts to create columellar In all the cases reported in this series, the struts, dorsal augmentation grafts, or septal ex- diced cartilage was wrapped in fascia and not Sur- tension grafts. Functional grafts such as alar bat- gicel, so we are not able to comment as to the tens, septal spreader grafts, or alar spreader grafts differences observed in outcome between Erol4 are used to open and support the internal nasal and Daniel and Calvert.6 This series does demon- valve. Crushed, shaped, and scored cartilage is strate good long-term results, with no significant

1656 Volume 120, Number 6 • Diced Cartilage–Fascia Grafts

Fig. 1. Patient 4 with anterior, oblique, and lateral (left) preoperative views showingthepostrhinoplastychallenge.Thepostoperativeviews(right)show the deviation of the diced cartilage–fascia construct. The patient was happy with the result. graft resorption, and therefore supports Daniel the radix appears overgrafted in some patients. and Calvert’s proposition that the method is easily Although this phenomenon may be counteracted reproducible with satisfying outcome.6 by massaging the radix after closure, control over A critical analysis of the aesthetics of the nose the cephalad portion of the graft’s volume may following combined radix/dorsum augmentation further be achieved by suturing the sheath to itself with diced cartilage–fascia grafts might reveal that over 4 to 5 mm using absorbable sutures, restrict-

1657 Plastic and Reconstructive Surgery • November 2007

Fig. 2. Preoperative (left) and postoperative (right) views of a patient requiring differential augmentation with selective and diced cartilage–fascia construct of the dorsum and fascia only of the radix. ing the diced cartilage to specific portions of the grafting in the 3- to 5-mm range. The shape and length of the fascial sheath. Differential augmen- volume of the diced cartilage–fascia construct are tation along the length of the dorsum is thus pos- maintained. The simplicity and flexibility of this sible in cases where dorsum/radix disproportion method should see it rapidly integrated into routine is not a feature of the deformity (Fig. 2). The area rhinoplasty usage for dorsal nasal augmentation. requiring greater augmentation will have diced Martin H. Kelly, F.R.C.S.(Plast.) cartilage–fascia graft and a “fascia-only” portion in Craniofacial Unit areas requiring minimal augmentation as demon- Chelsea and Westminster Hospital strated in Figure 2. Fulham Road A nasal splint is essential for controlling nasal London SW10 9NH, United Kingdom width and maintaining alignment of the lateral bor- [email protected] ders of the graft. Antibiotic prophylaxis is routinely DISCLOSURE recommended, as the fascia initially forms a barrier One of the authors has a financial interest in the against revascularization of the cartilage grafts. products, drugs, and/or devices mentioned in this article. CONCLUSIONS REFERENCES In this heterogeneous cohort of patients with 1. Gruber, R., Pardun, J., and Wall, S. Grafting the nasal dorsum multiple indications and varying degrees of dorsal with tandem ear cartilage. Plast. Reconstr. Surg. 112: 1110, 2003. 2. Gunter, J., Clark, C., and Friedman, R. Internal stabiliza- nasal deficiency, we have observed pleasing long- tion of autogenous rib cartilage grafts in rhinoplasty: A term results and high patient satisfaction with the barrier to cartilage warping. Plast. Reconstr. Surg. 100: 161, diced cartilage–fascia technique for dorsal nasal 1997.

1658 Volume 120, Number 6 • Diced Cartilage–Fascia Grafts

3. Peer, L. A. Diced cartilage grafts. Arch. Otolaryngol. 38: 156, during abdominal wall repair compared to dermal fibro- 1943. blasts. Wound Repair Regen. 12: 539, 2004. 4. Erol, O. The Turkish delight: A pliable graft for rhinoplasty. 8. Walter, A., Morse, A., Leslie, K., Hentz, J., and Cornella, J. Plast. Reconstr. Surg. 105: 2229, 2000. Histologic evaluation of human cadaveric fascia lata in a rabbit 5. Yilmaz, S., Erc¸o¨c¸en, A., Can, Z., Yenidu¨nya, S., Edali, N., and vagina model. Int. Urogynecol. J. Pelvic Floor Dysfunct. 17: 136, Yormuk, E. Viability of diced, crushed cartilage grafts and the 2006. effects of Surgicel (oxidized regenerated cellulose) on car- 9. Peer, L. A. Reconstruction of the auricle with diced cartilage tilage grafts. Plast. Reconstr. Surg. 108: 1054, 2001. grafts in a Vitallium ear mold. Plast. Reconstr. Surg. 3: 653, 1948. 6. Daniel, R., and Calvert, J. Diced cartilage grafts in rhinoplasty 10. Wintsch, K. Rhinoplasty in leprosy. Plast. Reconstr. Surg. 42: surgery. Plast. Reconstr. Surg. 113: 2156, 2004. 208, 1968. 7. Dubay, D., Wang, X., Kirk, S., Adamson, B., Robson, M. C., 11. Wilflingseder, P. Cranioplasties by means of diced cartilage and Franz, M. G. Fascial fibroblast kinetic activity is increased and split rib grafts. Minerva Chir. 38: 837, 1983.

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1659 DISCUSSION

Versatility of Diced Cartilage–Fascia Grafts in Dorsal Nasal Augmentation

Rollin K. Daniel, M.D. Newport Beach, Calif. elly, Bulstrode, and Waterhouse have written skin and the underlying osseocartilaginous Ka very important article pertaining to rhi- framework, whether to mask irregularities or to noplasty surgery and nasal reconstruction. suggest a slight natural transverse dorsal curva- They reviewed 20 consecutive cases in which ture. Long-term survival is not critical. Rather, it diced cartilage–fascia grafts were used for the functions as a temporary spacer during the ini- treatment of dorsal nasal volume deficiencies. tial healing period, preventing scar adherence As the patient photographs indicate, these between the skin and the underlying framework. were very difficult secondary rhinoplasty cases In contrast, augmentation requires both volume with major deficiencies and thin skin that and height that must be maintained for the rest would test any method of dorsal grafting. of the patient’s life. Kelly et al. state that the Their excellent results validate their conclu- grafts “have maintained their volume and shape sion that diced cartilage–fascia grafts provide a throughout their postoperative periods.” An in- relatively simple, efficient, and stable method teresting observation is provided in case 2. The of dorsal grafting in primary and secondary patient suffered a fall 6 weeks postoperatively, rhinoplasty cases. Therefore, an in-depth dis- causing a displacement of the graft. The nose cussion of their article followed by an analysis was reopened and the entire graft removed, ma- of the current status of diced cartilage–fascia nipulated, and replaced, with a pleasing final grafts appears warranted. result. I have removed a graft at 1 year after The technique used is rather simple: dice the insertion following its temporary placement in cartilage into 0.5- to 1.0-mm bits, wrap them in an Asian patient with an infected silicone im- autogenous fascia, and insert the moldable con- plant. At 1 year, the graft was smooth and semi- struct into the nose without overgrafting. The rigid and had a confluence of the diced cartilage five principal advantages of the surgical tech- within fibrous tissue.4 nique are the following: (1) wide flexibility to Several technical points raised in the article correct irregular dorsal defects, (2) maximal justify further comment. Most people using graft efficiency by incorporating excised carti- diced cartilage–fascia grafts tie off the graft once lage plus distant donor cartilage, (3) potential it is inserted to avoid spillage when manipulating for molding the graft in situ to achieve the de- the graft’s final shape. I use two sutures of 4-0 sired shape, (4) avoidance of warping, and (5) plain catgut to sew the fascial sleeve. The first absence of absorption with maintenance of dor- one closes the cephalic end and is retained as a sal augmentation. The most critical aspect of this percutaneous guide to place the graft, and the article is that it confirms that diced cartilage– second one runs the entire length of the sleeve fascia grafts are stable and that augmentation is and is then sutured once the excess diced carti- maintained. Readers of the Journal are undoubt- lage is milked out of the graft. These authors edly aware of the controversy surrounding diced used 19 fascial grafts from the deep temporal cartilage grafts wrapped in Surgicel.1,2 Histologic fascia and one from the rectus abdominis fascia. evidence indicates that Surgicel induces a for- The single use of rectus fascia probably occurred eign body reaction, which in turn causes absorp- in the one case where costal cartilage was har- tion of a significant amount of the enclosed vested. Similarly, I have taken rectus fascia dur- diced cartilage.3 It is my personal belief that ing a costal cartilage harvest and found it to be diced cartilage grafts wrapped in Surgicel can be incredibly contractile and thick, precluding its effective for concealment, but not for augmen- use as a wrapping tissue. Avoidance of overgraft- tation. What is the distinction? The goal of coning in the radix area is a very real problem that cealment is to provide a thin layer between the these authors have very neatly solved with their “fascia-only” extension of the diced cartilage– Received for publication March 12, 2006. fascia graft. The authors had one infection early Copyright ©2007 by the American Society of Plastic Surgeons in their series and then began routinely prescrib- DOI: 10.1097/01.prs.0000285186.10330.50 ing antibiotics in the perioperative period. Infec-

1660 www.PRSJournal.com Volume 120, Number 6 • Discussion tion is a very real concern, given the volume and experience. Ultimately, each new operative tech- surface area of the cartilage grafts. Although I nique will be accepted or rejected based on the have always given my rhinoplasty patients intra- surgeon’s experience in the operating room and operative and postoperative antibiotics, I added long-term patient follow-up. I suspect that diced antibiotics to the saline solution in which the cartilage–fascia grafting will become the tech- grafts are temporarily placed once I began using nique of choice for dorsal grafting because it diced cartilage–fascia grafts. solves one of the most difficult problems in all of What is the current status of diced cartilage– rhinoplasty surgery with simplicity and elegance. fascia grafts in rhinoplasty surgery? Perhaps the Rollin K. Daniel, M.D. most important point is that multiple surgeons 1441 Avocado Avenue, Suite 308 have now had success correcting volume defi- Newport Beach, Calif. 92660 ciencies in difficult primary and secondary rhi- [email protected] noplasty cases without any evidence of absorption in the intermediate-term follow-up period DISCLOSURE of 1 to 3 years. I have performed more than 150 The author has no financial interest in any of the diced cartilage and diced cartilage–fascia graft products, devices, or drugs mentioned in this article. procedures in which there has been no evidence of absorption. Histologic analysis of human spec- REFERENCES imens indicates that there is no significant dif- 1. Erol, O. O. The Turkish delight: A pliable graft for rhinoplasty. Plast. Reconstr. Surg. 105: 2229, 2000. ference between the patient’s septal cartilage, a 2. Daniel, R. K., and Calvert, J. C. Diced cartilage in rhinoplasty columellar strut, or a diced cartilage–fascia graft surgery. Plast. Reconstr. Surg. 113: 2156, 2004. at 1 year postoperatively.5 Obviously, there have 3. Brenner, K. B., McConnell, M. P., Evans, G. R. D., and Calvert, been technical problems that have had to be J. W. Survival of diced cartilage grafts: An experimental study. solved, especially the ones of overgrafting in the Plast. Reconstr. Surg. 117: 105, 2006. 4 4. Daniel, R. K. Diced cartilage grafts for rhinoplasty surgery. radix and undergrafting in the supratip area. J. Aesthetic Surg. (in press). Fortunately, these errors can be treated by minor 5. Calvert, J. C., et al. Diced cartilage grafts: A histological anal- revisions if they occur and are easily avoided with ysis. Plast. Reconstr. Surg. (in press).

Contacting the Editorial Office To reach the Editorial Office, please use the following contact information: Plastic and Reconstructive Surgery Rod J. Rohrich, M.D., Editor-in-Chief St. Paul’s Hospital 5909 Harry Hines Boulevard Room HD01.544 Dallas, Texas 75235-8820 Tel: 214-645-7790 Fax: 214-645-7791 E-mail: [email protected]

1661 COSMETIC

The Change of Maximum Bite Force after Botulinum Toxin Type A Injection for Treating Masseteric Hypertrophy

Ki Young Ahn, M.D., Ph.D. Background: A botulinum toxin type A injection into the masseter muscle has Seong Taek Kim, D.D.S., been used as a noninvasive treatment for masseteric hypertrophy. However, M.S.D. muscle atrophy inevitably causes a change of bite force. The aim of this study Daegu and Seoul, Korea was to evaluate the change in the maximum bite force after a botulinum toxin type injection for the treatment of masseteric hypertrophy. Methods: Seven patients who had presented for treatment of masseteric hypertrophy participated in this study. Twenty-five units of botulinum toxin type was injected into each masseter muscle, 50 units in total, at two to five points at the prominent portions of the mandibular angle. The bite-force measurement apparatus included a digital multimeter and a bite-force transducer. The maximum bite force between the maxillary and mandibular first molars was measured before injection and at 2, 4, 8, and 12 weeks after injection. Results: The difference in maximum bite force between the preinjection and 2-, 4-, and 8-week postinjection time points was statistically significant. However, there was no such difference between the preinjection and 12-week postinjection values (p Ͻ 0.05). Conclusions: The maximum bite force was significantly reduced after injection of botulinum toxin type A for the treatment of masseteric hypertrophy. How- ever, it gradually recovered by 12 weeks. (Plast. Reconstr. Surg. 120: 1662, 2007.)

he perception of beauty in Asians is differ- vealed atrophy of the hypertrophic muscles after ent from that of Caucasians. Asian women a botulinum toxin type A injection using clinical Ttend to prefer oval or almond-shaped faces photographs, ultrasound, electromyography, and dislike a square jaw, which they believe gives and computed tomography.4–10 To et al. evalu- them a masculine image. The cause of a square ated the effects of botulinum toxin type A on jaw might be overgrowth of the mandible, mas- masseteric hypertrophy using ultrasound and seteric hypertrophy, or fat accumulation. Among electromyography. All five patients in their study them, masseteric hypertrophy is known as the showed good responses, with a maximum effect asymptomatic enlargement of the masseter mus- of a 31 percent reduction in muscle bulk 3 cle and is commonly associated with abnormal months after treatment.5 Park et al. reported habits such as nocturnal bruxism and daytime serial measurements of the thickness of the mas- clenching. seter muscle using ultrasound and computed The treatment usually involves a surgical re- tomography before the injection and at 1 and 3 section of a portion of the mandibular angle or months thereafter.9 They reported the long-term masseter muscle. Recently, there have been clinical effects and the degree of patient satisfac- some reports showing that a botulinum toxin tion, and monitored any potential side effect type A injection into the masseter muscle can be during a 4- to 10-month follow-up period. Kim et used as an alternative noninvasive treatment for masseteric hypertrophy.1–5 These studies have real. evaluated the effects of two different doses of botulinum toxin type A on the thickness and From Dr. Ahn’s Aesthetic Clinic and the Department of Oral cross-sectional area using computed tomography Medicine, College of Dentistry, Yonsei University. and electromyography to determine the changes Received for publication February 28, 2006; accepted April in the masseter muscle.11 20, 2006. The mechanisms involved in the treatment of Copyright ©2007 by the American Society of Plastic Surgeons masseteric hypertrophy with a botulinum toxin DOI: 10.1097/01.prs.0000282309.94147.22 type A injection are somewhat different from

1662 www.PRSJournal.com Volume 120, Number 6 • Bite Force and Botulinum Toxin those for treating facial hyperkinetic wrinkles.12 constituted to a concentration of 5 units/0.1 ml An intramuscular injection of botulinum toxin with 2 ml of normal saline. By palpation of the type A leads to temporary partial denervation at masseter muscles, 25 units was injected into each the area of the neuromuscular synapses and side, 50 units in total, at two to five points at the eventually causes muscle atrophy. However, prominent portions of the mandibular angle. there are few reports showing a change in bite Intraoral stents were made individually for force after botulinum toxin type A injection for each patient before the injection to measure the masseteric hypertrophy. The aim of this study stable maximum bite force on a flat surface. The was to evaluate the change in the maximum bite bite-force measurement apparatus included a dig- force after botulinum toxin type A injection for ital multimeter (MPM-3000; Nihon Koudenshi treating masseteric hypertrophy. Co., Tokyo, Japan), and a bite-force transducer with a 17-mm-diameter plate at the end, and a PATIENTS AND METHODS block, 1 mm high and 3 mm in diameter, located A total of seven female patients who had pre- at the center. The block was placed on the occlusal sented for treatment of masseteric hypertrophy at surface of the first molar. The subject was then two medical centers were enrolled in this study. asked to bite on the block as hard as possible, and The mean age of the patients was 28.4 years the maximum digital readouts were measured and (range, 22 to 42 years). displayed in kilograms per centimeter squared. Botulinum toxin type A (Lanzhou Institute The maximum bite force between the maxillary of Biological Products, Lanzhou, China) was a and mandibular first molars was measured before freeze-dried powder of 100 units, and was re- the injection and at 2, 4, 8, and 12 weeks after

Fig. 1. Bite-force measuring method. (Above, left) The upper and lower stents. (Above, right) Intraoral view of the stents. (Below, left) Bite-force measuring machine (MPM 3000). (Below, right) Measuring bite force on the ﬁrst molar.

1663 Plastic and Reconstructive Surgery • November 2007

Fig. 2. Mean of bite forces of maximum voluntary clenching at each point (in kilograms per centimeter squared; n ϭ 14; *p Ͻ 0.05). There was an approximately 40 percent decrease in the bite force at 2 weeks after injection compared with that observed before injection, and there were statistically signiﬁcant differences between the bite force measured before injection and that measured at 2, 4, and 8 weeks after injection. However, there was no signiﬁcant difference between the preinjection and 12-week postinjection values. injection (Fig. 1). An analysis of variance test was Table 1. Mean Bite Forces of Maximum Voluntary (14 ؍ carried out to evaluate the influence of the dif- Clenching at Each Time Point (n ferent side (right and left) of botulinum toxin type Mean SD A on each masseter muscles. As a result of the Time Point (kg/cm2) (kg/cm2) p paired t test of both masseter muscles, the p Before injection 51.0 13.0 — value was not found to be significant. Therefore, After injection the number of samples was doubled by pooling. 2 weeks 30.7 11.6 0.0004* 4 weeks 33.6 12.7 0.0008* The data were analyzed using SAS version 8.1 8 weeks 36.4 16.3 0.0264* (SAS Institute, Inc., Cary, N.C.). l2 weeks 41.4 16.6 00884 *p Ͻ 0.05. RESULTS Mean values of bite forces of maximum vol- netic wrinkles such as crow’s feet and wrinkles untary clenching at each point are shown in on the glabellar and forehead area.12 The main Figure 2. There was an approximately 40 per- effect of botulinum toxin type A is the tempo- cent decrease in the mean maximum bite force rary effect of muscle atrophy, followed by che- at 2 weeks compared with that before the injec- modenervation caused by an acetylcholine block- tion. The maximum bite forces recovered grad- ade at the neuromuscular junction by the toxin. ually after 4 weeks and remained 20 percent In animal experiments,13 the muscle fibers be- lower at 12 weeks than that measured before the gin to show atrophy histologically within 10 to 14 injection. The difference between the maxi- days after the injection. This atrophy continues mum bite forces before injection and at 2, 4, and to develop over a 4- to 6-week period. It should 8 weeks after injection was statistically signifi- be noted that there is not only fiber atrophy, as cant. However, there was no such difference indicated by the generalized reduction in the between the preinjection and 12-week postin- fiber diameter, but also large variations in the jection values (p Ͻ 0.05) (Table 1). fiber size. Fiber atrophy is a reversible phenomenon and usually recovers within 4 to 6 months. DISCUSSION Seventeen orbicularis oculi muscle specimens In the case of contouring the lower face, the taken from patients during ptosis and myectomy mechanisms for treating masseteric hypertro- surgery were evaluated for their cholinesterase- phy with botulinum toxin type A are somewhat staining characteristics and fiber variability. different from those for treating facial hyperki- Diffuse cholinesterase activity was observed,

1664 Volume 120, Number 6 • Bite Force and Botulinum Toxin beginning at weeks 3 to 4, which was main- toxin type A injection and determine its potential tained for 3 to 4 months after injection. In all effects on patients with masseteric hypertrophy. patients studied, the staining pattern was similar to that observed in the control subjects after 6 CONCLUSIONS months.14 The maximum bite force was significantly re- The dosages used for masseter muscle were duced after injection of botulinum toxin type A for generally 25 to 30 units of botulinum toxin type treatment of masseteric hypertrophy. However, it A.3–5,8 The side effects of a botulinum toxin type gradually recovered by 12 weeks. A injection for masseteric hypertrophy, such as Seong Taek Kim, D.D.S., M.S.D. change in bite force, speech disturbance, mus- Department of Oral Medicine cle pain, facial asymmetry, and prominent zy- College of Dentistry goma, have been reported.8,11,15 Among them, Yonsei University the change in bite force is an inevitable side 134 Shinchon-dong, Seodamun-gu Seoul 120-752, Korea effect of muscle atrophy even though it is gen- [email protected] erally temporary. The bite force is a force generated by occlusal ACKNOWLEDGMENT contact between the opposing teeth and is also This study was supported by grants from Han All called the occlusal force. A number of appliances Pharmaceutical Co., Seoul, Korea. for measuring the bite force have been reported. These include a strain gauge transducer, a biting DISCLOSURE fork, and bite force dynamometers. The bite force Neither of the authors has a financial interest in any varies from individual to individual, and male sub- of the products, devices, or drugs mentioned in this article. jects generally have a larger bite force than female REFERENCES subjects.16 It has also been reported that the max- 1. Smyth, A. G. Botulinum toxin treatment of bilateral masse- imum bite force applied to a molar is several times teric hypertrophy. Br. J. Oral Maxillofac. Surg. 32: 29, 1994. stronger than that applied to an incisor. It was 2. Moore, A. P., and Wood, G. D. The medical management of reported that the maximum bite force applied to masseteric hypertrophy with botulinum toxin type A. Br. the first molar ranged from 91 to 198 pounds (41.3 J. Oral Maxillofac. Surg. 32: 26, 1994. to 89.8 kg/cm2), whereas the maximum force ap- 3. Mandel, L., and Tharakan, M. Treatment of unilateral masseteric hypertrophy with botulinum toxin: Case report. J. Oral plied to the central incisors ranged from 29 to 51 Maxillofac. Surg. 57: 1017, 1999. 2 17 pounds (13.2 to 23.1 kg/cm ). A bite force study 4. von Lindern, J. J., Niederhagen, B., Appel, T., et al. Type A using this MPM-3000 apparatus reported that the botulinum toxin for the treatment of hypertrophy of the mean maximum bite force of a 9-year-old girl was masseter and temporal muscles: An alternative treatment. Ϯ 2 18 Plast. Reconstr. Surg. 107: 327, 2001. 27 4.4 kg/cm . 5. To, E. W., Ahuja, A. T., Ho, W. S., et al. A prospective study In this study, the average maximum bite of the effect of botulinum toxin A on masseteric muscle force of the first molar before injection was 51 hypertrophy with ultrasonographic and electromyographic kg/cm2and there was no difference between the measurement. Br. J. Plast. Surg. 54: 197, 2001. right and left sides. There was an approximately 6. Choe, S. W., Cho, W. I., Lee, C. K., et al. Effects of botulinum toxin type A on contouring of the lower face. Dermatol. Surg. 40 percent decrease in the mean maximum bite 31: 507, 2005. force at 2 weeks compared with that recorded 7. Kim, N. H., Chung, J. H., Park, R. H., et al. The use of before injection. The bite force was restored to botulinum toxin type A in aesthetic mandibular contouring. its preinjection value by 12 weeks after injection Plast. Reconstr. Surg. 115: 919, 2005. Ͻ 8. Kim, H. J., Yum, K. W., Lee, S. S., et al. Effects of botulinum (p 0.05). Because of weakened muscle strength by toxin type A on bilateral masseteric hypertrophy evaluated atrophic change, some patients complained of mas- with computed tomographic measurement. Dermatol. Surg. ticatory difficulties when chewing hard food (but not 29: 484, 2003. when on a soft diet). 9. Park, M. Y., Ahn, K. Y., and Jung, D. S. Botulinum toxin type This study has some limitations. There were A treatment for contouring of the lower face. Dermatol. Surg. 29: 477, 2003. only seven patients, all of whom were female, and 10. Borodic, G. E., Ferrante, R., Pearce, L. B., and Smith, K. only the bite force of the molar was measured. Histologic assessment of dose-related diffusion and muscle Therefore, a further prospective long-term study fiber response after therapeutic botulinum A toxin injec- covering a large number of subjects from both tions. Mov. Disord. 9: 31, 1994. 11. Kim, J. H., Shin, J. H., Kim, C. Y., and Kim, S. T. Effects of two genders with measurements of the bite force of the different units of botulinum toxin type a evaluated by computed whole teeth should be carried out to fully estimate tomography and electromyographic measurements of human the change in the bite force after a botulinum masseter muscle. Plast. Reconstr. Surg. 119: 711, 2007.

1665 Plastic and Reconstructive Surgery • November 2007

12. Ahn, K. Y., Park, M. Y., Park, D. H., et al. Botulinum toxin A 15. Oshima, M., Middlebrook, J. L., and Atassi, M. Z. Antibodies for the treatment of facial hyperkinetic wrinkle lines in Ko- and T cells against synthetic peptides of the C-terminal do- reans. Plast. Reconstr. Surg. 105: 778, 2000. main (Hc) of botulinum neurotoxin type A and their cross- 13. Borodic, G. E., Ferrante, R. J., Pearce, L. B., et al. Phar- reaction with Hc. Immunol. Lett. 60: 7, 1998. macology and histology of the therapeutic application of 16. Brekhus, P. H. Stimulation of the muscles of mastication. botulinum toxin. In J. Jankovic and M. Hallett (Eds.), J. Dent. Res. 20: 87, 1941. Therapy with Botulinum Toxin. New York: Marcel Dekker, 17. Howell, A. H., and Manly, R. S. An electronic strain gauge for 1994. P. 119. measuring oral forces. J. Dent. Res. 27: 705, 1948. 14. Borodic, G. E., and Ferrante, R. Effects of repeated botuli- 18. Maki, T., Nishioka, A., Morimoto, A., et al. A study on the num toxin injections on orbicularis oculi muscle. J. Clin. measurement of occlusal force and masticatory efficiency in Neuroophthalmol. 12: 121, 1992. school age Japanese children. Int. J. Paediatr. Dent. 11: 281, 2001.

1666 COSMETIC

A Comparison of Face Lift Techniques in Eight Consecutive Sets of Identical Twins

Darrick E. Antell, M.D., Background: Selecting the “correct” face lift technique has always been a dif- D.D.S. ficult decision for the plastic surgeon. A technique that provides optimal aes- Michael J. Orseck, M.D. thetics for one patient may not provide the same result for another. The New York, N.Y. complexity of comparing these different results on patients with different facial features further confounds one’s ability to decide on a given technique. Even identical twins are often treated more appropriately with a different technique from one twin to the other because the character and severity of facial aging may differ between them. By comparing different superficial musculoaponeurotic system techniques on “less different” people (identical twins), perhaps the ideal technique may be determined. Methods: Between November of 1997 and April of 1999, eight sets of twins underwent face lift surgery by the senior author (D.E.A.), using one of four techniques. The charts and photographs of the eight consecutive pairs of twins (16 patients) were reviewed retrospectively. Results: No one face lift technique performed in this study produced a superior result as compared with another when performed on the appropriate patient. Conclusion: There exists no face lift technique suitable for every patient. As the current literature suggests, there is no one “best” face lift technique of those studied. (Plast. Reconstr. Surg. 120: 1667, 2007.)

he question “Which face lift technique is PATIENTS AND METHODS best?” is nearly as old as the operation itself. Between November of 1997 and April of 1999, TThis question becomes more difficult to an- eight consecutive pairs of identical twins (16 pa- swer than ever before, given the vast array of tech- tients) underwent facialplasty in an office surgery niques for facialplasty, and the variable effect of setting. Preoperative genetic analysis1 was per- gravity and other environmental effects on the skin formed to ensure that the twins were monozygotic and the deeper structures of the face. A more (identical) rather than dizygotic (fraternal) twins. effective comparison of these techniques may be Seven sets of twins were female and one set was male. obtained by decreasing the number of variables The twins were operated on the same day and in the between the patients. By using identical twins as order of their birth sequence. The patients ranged the subjects and one surgeon to perform his in age from 48 to 77 years, with a mean age of 60 choice of one of four techniques most commonly years. used in his practice, a more controlled comparison The choice of facialplasty technique was based is offered. Although many other excellent tech- on the patient’s anatomical findings at consultation niques for facialplasty are currently in wide use and at surgery. Because of these differences, in some today, this study compares the four techniques cases a different technique was used on one twin most commonly used by the senior author than on the other. The facialplasty techniques used (D.E.A.) during the time period in which the pro- in this study were as follows: no superficial muscu- cedures were performed. loaponeurotic system (SMAS) or skin only (four patients), conventional SMAS flap (dissection carried From the Manhattan Eye, Ear and Throat Hospital and just anterior to the parotid gland) (two patients), private practice. SMASectomy as described by Baker,2 (six patients), Received for publication March 24, 2006; accepted Novem- and SMAS plication (four patients). Adjuvant pro- ber 14, 2006. cedures, when performed, were performed on both Copyright ©2007 by the American Society of Plastic Surgeons twins. Interestingly, twins usually decide to have the DOI: 10.1097/01.prs.0000288016.24950.20 same adjuvant procedures to retain their similar ap-

www.PRSJournal.com 1667 Plastic and Reconstructive Surgery • November 2007 pearance. These procedures include one or more of One of two patients (50 percent) who had a the following: brow lift, blepharoplasty, and buccal conventional SMAS flap operation had an excel- fat pad excision.3 lent result. In the SMASectomy group (n ϭ 6), two Follow-up photographs (of the same hemi- (33 percent) had excellent results, one (17 per- face view from twin to twin) were obtained 13 cent) had a good result, and three (50 percent) to 60 months after surgery (mean, 23 months). had a fair result. In the plication group (n ϭ 4), The preoperative and postoperative results were two (50 percent) had excellent results, one (25 evaluated by four plastic surgeons blinded to the percent) had a good result, and one (25 percent) type of face lift and to the nature of the ancillary had a fair result. In the skin-only group (n ϭ 4), procedures. The face was divided into three an- two (50 percent) had an excellent result, one (25 atomical areas for evaluation: the cervicomental percent) had a good result, and one (25 percent) angle, the jawline, and the nasolabial fold. Each had a fair result. The patient with the lowest av- anatomical area was scored separately and erage score (4.25) had a skin-only lift that was graded as follows: 1, no improvement (poor); 2, evaluated at 18 months postoperatively. Clinical mild improvement (fair); 3, moderate improve- examples of excellent, good, and fair results are ment (good); 4, marked improvement (excel- shown in Figures 1 through 6. lent); and 5, perfect result. The average score by The anatomical region that showed the best the evaluators for each anatomical region was long-term improvement was the cervicomental an- added to achieve the total score (range, 3 to 15: gle (average, 3.42). The anatomical region that 3, no improvement (poor); 4 to 6, mild improve- showed the least long-term improvement was the ment (fair); 7 to 10, moderate improvement nasolabial fold (average, 2.45), similar to the find- (good); 11 to 14, marked improvement (excel- ings by Hamra.4 lent); and 15, perfect result). Complications Two patients (4a and 6a) (13 percent) had a were noted and analyzed. small neck hematoma that was percutaneously evacuated on the seventh and eighth postoperative days, respectively. Neither patient suffered RESULTS long-term problems from the hematoma. There Table 1 summarizes the face lift results. At were no patients who suffered a skin slough or follow-up, seven of the patients (44 percent) were facial nerve weakness in this study. found to have an excellent result, four (25 percent) had a good result, and five (31 percent) were DISCUSSION found to have a fair result. No patients had an In 2005, over 150,000 face lifts were performed outcome with a poor result or a perfect result. in the United States. This represents an increase

Table 1. Face Lift Results Average Score by Evaluators per Anatomical Region

Twin Type of Face Nasolabial Total Score Set Lift Adjuvant Procedures Neck Jawline Fold (range, 3–15) Result 1a SMAS flap None 2.75 3.25 3 9 Good 1b SMAS flap None 4 4 3.5 11.5 Excellent 2a SMASectomy Blepharoplasty 4 4 3.5 11.5 Excellent 2b Skin only Blepharoplasty 3.5 3 2 8.5 Good 3a SMAS plication Blepharoplasty 4 2.25 2 8.25 Good 3b SMASectomy Blepharoplasty 4 2.25 1.75 8 Fair 4a SMASectomy Coronal brow lift 2 1.5 1 4.5 Fair 4b Skin only Coronal brow lift 2 1.25 1 4.25 Fair 5a Skin only Blepharoplasty 4 4 3.25 11.25 Excellent 5b SMASectomy Blepharoplasty 4 4 3.5 11.5 Excellent 6a SMASectomy Blepharoplasty 3.75 2.5 2.25 8.5 Good 6b Skin only Blepharoplasty 4 4 4 12 Excellent 7a SMAS plication None 4 4 3 11 Excellent 7b SMAS plication None 4 4 3.25 11.25 Excellent 8a SMAS plication Blepharoplasty, BFE 2 1.75 1.25 5 Fair 8b SMASectomy Blepharoplasty, BFE 2.75 1.5 1 5.25 Fair Average anatomical score by region (range, 1–5) 3.42 2.95 2.45 BFE, buccal fat excision.

1668 Volume 120, Number 6 • Comparison of Face Lift Techniques

Fig. 1. Patient 5a (left) preoperatively and (right) 22 months postoperatively.

Fig. 2. (Left) Preoperative view of patient 5b, a 59-year-old woman with a long history of sun exposure. Note the advanced signs of aging as compared with her twin, shown in Figure 1. (Right) Postoperative view at 22 months. of 52 percent of the number of face lifts per- niques in managing the SMAS have been deformed in the year 1997.5 Along with the increase scribed. Today, many of these techniques are com- in the number of procedures, there is also an monly used. In a recent study by Matarasso et al.,7 increase in the number of the type of facialplasty of 570 plastic surgeons surveyed, 18 percent dis- techniques. Since the original work of Mitz and sected the SMAS over the parotid, 23 percent im- Peyronie6 on the SMAS, many excellent tech- bricated the SMAS, 15 percent performed a

1669 Plastic and Reconstructive Surgery • November 2007

Fig. 3. Patient 8a (left) preoperatively and (right) 18 months postoperatively.

Fig. 4. Patient 8b (left) preoperatively and (right) 18 months postoperatively.

SMASectomy, and 15 percent performed a skin- occur in the aging face. A careful selection of only procedure. In addition, 8 percent performed facialplasty technique and adjuvant procedures a deep/composite dissection, 16 percent per- should be chosen to provide the patient with a formed an extended SMAS flap dissection, and 5 harmonious result. percent performed a subperiosteal and/or an en- Using monozygotic twins as the subjects of doscopic lift. When considering the options, one study, major anatomical differences between pa- must realize that facial rejuvenation requires a tients are removed, allowing the comparison of complete analysis of the topographic changes that SMAS techniques to be more accurate. It is im-

1670 Volume 120, Number 6 • Comparison of Face Lift Techniques

Fig. 5. Patient 3a (left) preoperatively and (right) 16 months postoperatively.

Fig. 6. Patient 3b (left) preoperatively and (right) 16 months postoperatively. portant to obtain genetic marker analysis to en- soft-tissue ptosis and sun damage. These find- sure that the twins are indeed monozygotic rather ings are evident on analysis of split-face preop- than dizygotic. Monozygotic twins typically main- erative photographs (Fig. 8). In our patients tain their similar features throughout life, as op- with these findings, the same face lift technique posed to dizygotic twins, who can vary greatly in was used on both sides. However, one could appearance. However, it is not to say that even argue to use a different technique on one side monozygotic twins age in a similar fashion. Envi- of the face than the other to ultimately provide ronmental factors including cigarette smoking, a more symmetric face and a better overall sun exposure, and undue stress can cause one twin result. to age more than the other8 (Fig. 7). The results of our study essentially showed Not only does the aging process differ be- no difference between the face lift techniques tween twins and nontwins, but it may also differ on analysis of the postoperative results. Previous between the right and left sides of the face. One studies comparing superficial plane techniques upper eyelid may have more excess skin than the have shown similar results.9–11 Despite these other or one facial half may demonstrate more findings, it is impossible to draw any firm con-

1671 Plastic and Reconstructive Surgery • November 2007

Fig. 7. (Left) Twin with a 30-pack-year history of cigarette smoking. Note the advanced signs of aging as compared with her nonsmoking twin (right).

Fig. 8. Patient 5b. (Left) Mirrored image of the right side of the face. (Right) Mirrored image of the left side of the face. clusion for several reasons. The patients in this have recently undergone facialplasty that have study were not randomized to one technique or less than 1 year of follow-up that will be evalu- another. The senior author carefully chose one ated in the future. This increase in number will technique over the other based on the subject’s help—but not completely—eliminate a type II physical findings and his own experience. By error. Finally, the subjective nature of evaluat- choosing a technique based on the severity of ing cosmetic results allows for error. aging, a selection bias is inherently present. In The deep plane techniques were not evaluated addition, no statistical analysis was performed in this study but certainly have been used with because of the small number of patients en- great success. In addition, specific maneuvers to rolled in the study, and a type II error (not being improve the lid-cheek junction were not used. As able to show a difference when there actually is we are all aware, there exists much debate over the a difference) is possible given the small number superiority of superficial versus deep plane of subjects. There are currently many twins that techniques.12,13 Presently, both authors use both

1672 Volume 120, Number 6 • Comparison of Face Lift Techniques superficial and deep plane techniques14,15 and op- 3. Matarasso, A. Buccal fat pad excision: Aesthetic improve- erations to improve the lid-cheek junction16 but ment of the midface. Ann. Plast. Surg. 26: 413, 1991. are careful not to use an aggressive procedure 4. Hamra, S. T. A study of the long term effect of malar fat repositioning in face lift surgery: Short-term success but long where a more conservative approach is warranted. term failure. Plast. Reconstr. Surg. 110: 940, 2002. 5. American Society for Aesthetic Plastic Surgery. Cosmetic Sur- CONCLUSIONS gery National Data Bank, 2005. The clinical results of four of the superficial 6. Mitz, V., and Peyronie, M. The superficial musculoaponeu- plane face lift techniques are similar when per- rotic system (SMAS) in the parotid and cheek area. Plast. Reconstr. Surg. 61: 80, 1976. formed on the routine patient presenting for fa- 7. Matarasso, A., Elkwood, A., Rankin, M., and Elkowitz, M. cial rejuvenation. As newer techniques evolve, one National plastic surgery survey: Face lift techniques and com- should evaluate the results over the long term. plications. Plast. Reconstr. Surg. 106: 1185, 2000. Many techniques demonstrate improvement over 8. Antell, D., and Taczanowski, E. M. How environment and the short term but provide little or no improve- lifestyle choices influence the aging process. Ann. Plast. Surg. ment compared with the proven techniques over 43: 585, 1999. 9. Rees, T. D., and Aston, S. J. A clinical evaluation of the results time. of submusculoaponeurotic dissection and fixation in face Darrick E. Antell, M.D. lifts. Plast. Reconstr. Surg. 60: 851, 1977. American Board of Plastic Surgery 10. Webster, R. C., Smith, R. C., Papsidero, M. J., et al. Com- 850 Park Avenue parison of SMAS placation with SMAS imbrication in face New York, N.Y. 10021 lifting. Laryngoscope 92: 901, 1982. [email protected] 11. Prado, A., Andrales, P., Danilla, S., Castillo, P., and Leniz, P. A clinical retrospective study comparing two short-scar face ACKNOWLEDGMENTS lift: Minimal access cranial suspension versus lateral SMASec- tomy. Plast. Reconstr. Surg. 117: 1413, 2006. The authors thank Eva M. Taczanowski, P.A.-C., 12. Ivy, E. J., Lorenc, Z. P., and Aston, S. J. Is there a difference? and Viralkumar Patel, M.D., for assistance in the prep- A prospective study comparing lateral and standard SMAS aration of this article. face lifts with extended SMAS and composite rhytidectomies. Plast. Reconstr. Surg. 98: 1135, 1996. DISCLOSURE 13. Kamer, F. M., and Frankel, A. S. SMAS rhytidectomy versus Neither of the authors has a financial interest in any deep plane rhytidectomy: An objective comparison. Plast. of the products, devices, or drugs mentioned in this Reconstr. Surg. 102: 878, 1998. 14. Pitman, G. H. The Deep-Plane Demystified (Videotape). St. Lou- article. is: Quality Medical Publishing, 2000. 15. Stuzin, J. M., Baker, T. J., Gordon, H. L., and Baker, T. M. REFERENCES Extended SMAS dissection as an approach to midface reju- 1. Nichols, R. C., and Bilbro, W. C., Jr. The diagnosis of twin venation. Clin. Plast. Surg. 22: 295, 1995. zygosity. Acta Genet. Stat. Med. 16: 264, 1996. 16. Hamra, S. T. The role of the septal reset in creating a youth- 2. Baker, D. C. Lateral SMASectomy. Plast. Reconstr. Surg. 100: ful eyelid-cheek complex in facial rejuvenation. Plast. Recon- 80, 513. str. Surg. 113: 2124, 2004.

1673 COSMETIC

One-Stage Mastopexy with Breast Augmentation: A Review of 321 Patients

W. Grant Stevens, M.D. Background: One-stage mastopexy with breast augmentation is an increasingly Mark E. Freeman, M.D. popular procedure among patients. In the past 9 years, there has been a 506 David A. Stoker, M.D. percent increase in mastopexy procedures alone. Although some recommend Suzanne M. Quardt, M.D. a staged mastopexy and breast augmentation, there are currently no large Robert Cohen, M.D. studies evaluating the safety and efficacy of a one-stage procedure. Elliot M. Hirsch, M.D. Methods: A retrospective chart review was conducted of 321 consecutive pa- Marina del Rey and Los Angeles, tients who underwent one-stage mastopexy and breast augmentation. Data Calif. collected included the following: patient characteristics, implant information, operative technique, and postoperative results. Complication and revision rates were calculated to evaluate the safety and efficacy of the one-stage procedure. Results: No severe complications were recorded over an average of 40 months’ follow-up. The most common complication was deflation of a saline implant (3.7 percent), followed by poor scarring (2.5 percent), recurrent ptosis (2.2 percent), and areola asymmetry (2.2 percent). Forty-seven patients (14.6 percent) underwent some form of revision surgery following the one-stage procedure. Thirty-five (10.9 percent) of these were for an implant- related issue, whereas 12 patients (3.7 percent) underwent a tissue-related revision. This 10.9 percent implant-related revision rate is less than a previously documented 13.2 percent 3-year reoperation rate for breast augmentation alone. The authors’ 3.7 percent tissue-related revision rate also compares favorably to an 8.6 percent revision surgery rate in patients who underwent mastopexy alone. Conclusions: Although it has been stated that the risks of a one-stage procedure are more than additive, the results of our review suggest otherwise. Although a revision rate of 14.6 percent is significant, it is far from the 100 percent reoperation rate required for a staged procedure. (Plast. Reconstr. Surg. 120: 1674, 2007.)

lthough one-stage mastopexy with breast report that they commonly combine the proce- augmentation has received an increasing dures without adding additional risks.13 The goal Aamount of attention at plastic surgery meet- of this study was to review our experience with a ings, there is a dearth of literature documenting large number of combined, one-stage mastopexy outcomes of the procedure. The operation has and breast augmentation cases. The safety and been performed by surgeons for decades and was efficacy of the procedure were determined by first described1–6 by Gonzalez-Ulloa and Reg- evaluating our long-term complication and revi- nault in the 1960s. With the increasing amount sion rates. of breast surgery performed by plastic surgeons each year,1 the need for data regarding compli- PATIENTS AND METHODS cation and revision rates has become more press- A retrospective chart review of 321 consecutive ing. Several recent studies advocate the judicious one-stage breast augmentation with mastopexy use of the combined procedure,7–12 and others procedures was performed. All cases were completed at a single outpatient facility by one of two From Marina Plastic Surgery Associates and the Keck School surgeons (W.G.S. or D.A.S.) over a 14-year period of Medicine, University of Southern California. (1992 to 2006). The average follow-up period was Received for publication November 18, 2006; accepted Feb- 40 months, with a range of 6 months to 13 years. ruary 27, 2007. All patients had preoperative and postopera- Copyright ©2007 by the American Society of Plastic Surgeons tive photographs, general anesthesia, lower ex- DOI: 10.1097/01.prs.0000282726.29350.ba tremity sequential compression devices before in-

1674 www.PRSJournal.com Volume 120, Number 6 • Mastopexy with Breast Augmentation duction of anesthesia, and perioperative antibiotics. The average age of women in our study was During the procedure, extensive undermining of 39 years, the average body mass index was 22.7 mastopexy flaps was avoided when possible and no m/kg,2 184 patients (57 percent) had delivered drains were used. Patients were intermittently am- children, and of those, 161 (87 percent) had bulated the day of surgery and maintained on oral breast fed. Preoperative asymmetry was docu- pain medication. mented in 181 patients (56 percent), and 17 (5.3 All study patients were candidates for both percent) were diagnosed with tuberous breast breast augmentation and mastopexy, as defined by deformity. Twenty-eight patients (8.7 percent) having significant breast ptosis and hypoplasia. smoked cigarettes before surgery but agreed to Degree of breast ptosis was determined using the stop smoking at least 2 weeks before the proce- Regnault classification,14 and any preoperative dure. The average operation time was 128 min- asymmetry was recorded. Each patient’s age, body utes, which included 52 percent of patients hav- mass index, smoking status, and type of mastopexy ing concomitant procedures. (inverted-T, vertical, circumareolar, or crescent) Saline implants were used in 191 breasts (31 was recorded. Implant-related data such as fill (sa- percent) and silicone implants were used in 426 line versus silicone), shape, texture, volume, and (69 percent). Of the saline group, 13 patients position (submuscular versus subglandular) were received a Poly Implant prosthesis (Poly Im- also collected. Procedure-related data such as op- plant, La Seyne-sur-Mer, France) or prefilled erating surgeon, length of surgery, American So- implants bilaterally. The average volume of im- ciety of Anesthesiologists level, and concomitant plant was 317 cc for all types. The majority of procedures were noted. implants were textured and round, with only five Follow-up data including incidence of compli- patients (2 percent) receiving anatomically cations, treatment of complications, number of shaped implants and 37 patients (12 percent) revision procedures, reason for revision, and pa- receiving smooth implants. Two hundred eighty tient or surgeon dissatisfaction were also recorded. patients (87 percent) had the implant placed in Safety and efficacy were determined by measuring a submuscular pocket and 41 patients (13 per- complication and revision rates, which were calcu- cent) underwent subglandular placement. The lated retrospectively. To better understand their distribution of the techniques for mastopexy was cause, complications were divided into two catego- as follows: inverted-T, 60 percent; circumareo- ries: implant-related and tissue-related complica- lar, 21 percent; vertical, 15 percent; and cres- tions. Tissue-related complications included breast cent, 4 percent. and areola asymmetry, poor scarring, recurrent and There were no incidences of death, myocar- persistent ptosis, loss of nipple sensation, pseudop- dial infarction, pulmonary embolus, deep vein tosis, infection, hematoma, and depigmentation of thrombosis, or major flap or nipple loss in any the areola. Implant-related complications included patients. The most significant complications saline implant deflation, capsular contracture, im- were seen in four patients with submuscular implant malposition, and palpability. Statistical signif- plants who developed a postoperative infection, icance of the data was determined using chi-square three of which required implant removal (0.9 analysis and Fisher’s exact test. percent) and subsequent revision. Saline implant deflation was the most common complication, occurring in 12 patients (3.7 percent) RESULTS over 40 months, even though saline implants A total of 321 patients underwent one-stage were used in only 191 breasts (31 percent). Com- breast augmentation with mastopexy over the plications were divided into implant-related ver- 14-year period. There were 25 unilateral and 296 sus tissue-related categories, and their distribu- bilateral cases, leading to 617 individual breast tion is listed in Tables 1 and 2. procedures. Of these patients, 118 patients had undergone some form of previous breast surgery and 203 were primary cases. The most common previous procedure was breast augmentation Table 1. Implant-Related Complications alone, which accounted for 79 of the 118 pa- Complication No. (%) tients (67 percent). The majority of operations Deflation 12 (3.7) were for cosmetic concerns, whereas nine pa- Capsular contracture 6 (1.9) tients (3 percent) were undergoing reconstruc- Implant palpability 1 (0.3) tive procedures. Implant malposition 1 (0.3)

1675 Plastic and Reconstructive Surgery • November 2007

Table 2. Tissue-Related Complications deflations and the incidence of rippling and the Complication No. (%) patient’s desire to exchange for silicone implants. Of the 47 patients requiring a revision, 18 (38 Poor scarring 8 (2.5) Areolar asymmetry 7 (2.2) percent) had undergone a circumareolar mas- Recurrent ptosis 7 (2.2) topexy, although they made up only 21 percent of Breast asymmetry 5 (1.6) total mastopexies. Therefore, the revision rate in Significant infection 4 (1.2) Loss of nipple sensation 4 (1.2) circumareolar mastopexy patients (27 percent) Persistent ptosis 2 (0.6) was nearly twice as high as the overall revision rate Pseudoptosis 2 (0.6) of all patients (14.6 percent). Of the 28 patients Hematoma 2 (0.6) Partial areolar depigmentation 2 (0.6) who were smoking before surgery, eight (29 percent) required some form of revision procedure. Smokers made up 17 percent of all revision pro- Recurrent ptosis was defined as an acceptable cedures but accounted for only 8.7 percent of the initial result that bottomed-out months after sur- total patients in the study. gery. Patients with persistent ptosis had ptosis in DISCUSSION the early postoperative period. Capsular contracture was defined as Baker grade II or higher. Although it is understandable that most pa- In the 40-month follow-up period, 47 patients tients would prefer a combined procedure, recent literature raises the question of whether it may be (14.6 percent) underwent some form of revision 6 procedure. The most common indication for re- better to stage the procedures. Most of our pa- vision cited by patients was a desire to exchange tients prefer a one-stage operation even knowing their implants for a different size [n ϭ 14 (4.4 that a two-stage procedure may lead to a more percent)], followed by 11 patients (3.4 percent) predictable result. One-stage breast augmentation with saline implant deflations. Interestingly, im- with mastopexy is certainly a difficult operation, with numerous potential challenges, and it is un- plant-related revisions accounted for 74 percent of 6 all revision procedures. Thirty-five patients (10.9 derstandable that some say “surgeon beware!” However, the procedure is well-described by these percent) had a revision for an implant-related con- 8 cern and 12 patients (3.7 percent) had a revision same authors. The topic is further clouded by others who say that “simultaneous timing of these for a tissue-related complication. The incidence 10 and distribution of revision procedures is dis- operations does not add any additional risks.” played in Table 3. Spear et al. state that “complications after Several interesting and significant trends were augmentation and mastopexy combined are al- noted on further review of the data. The use of most certainly more frequent and potentially disastrous” and suggests a higher rate of “major saline implants, a circumareolar mastopexy, and a 6 history of smoking were all associated with a sta- disasters” such as skin flap or nipple loss. Al- tistically significant (p Ͻ 0.05) increase in the re- though we have no reason to doubt these may vision rate. Although saline implants were used occur, none of these severe complications were only 31 percent of the time, they accounted for 49 encountered in our series. The five most com- percent of the total revision patients (23 of 47). mon complications in our series were deflation This association is attributable to the number of of a saline implant (3.7 percent), poor scarring (2.5 percent), areola asymmetry (2.2 percent), recurrent ptosis (2.2 percent), and capsular con- Table 3. Indications for Revision tracture (1.9 percent). Of note, four patients (1.3 percent) developed a late infection, of Indications for Revision No. of Patients (%) which three (0.9 percent) later required im- Desire to change implant size 14 (4.4) Implant deflation 11 (3.4) plant removal. One patient (0.3 percent) also Recurrent/persistent ptosis 6 (1.9) developed superficial epidermolysis of the nip- Capsular contracture (grade III) 4 (1.2) ple-areola complex, with resultant depigmenta- Poor scarring 3 (0.9) Implant infection 3 (0.9) tion. The wound healed with local wound care Desire to remove implant for size 1 (0.3) and later underwent revision for hypertrophic Implant rippling 1 (0.3) scarring. Fortunately, no major disasters were Areola asymmetry 1 (0.3) Implant malposition 1 (0.3) encountered. Exchange for silicone implant 1 (0.3) The risks of a one-stage procedure have been Unilateral reduction for asymmetry 1 (0.3) described as potentially being greater than the risk Total 47 (14.6) of each procedure alone.8 To investigate this fur-

1676 Volume 120, Number 6 • Mastopexy with Breast Augmentation

Table 4. Comparison of Revision Rates unable to locate a large series concerning mas- Tissue-Related Implant-Related topexy alone. Therefore, we conducted our own Revisions Revisions review of 150 consecutive mastopexy-only patients Combined mastopexy 3.7% 10.9% at 3.5 yr during this same time period. Both populations and augmentation were found to have similar demographic informa- Mastopexy alone 8.6% tion. In the mastopexy-only patients, the average Augmentation alone 13% at 3 yr (SPS) 20% at 5 yr 3-year follow-up revealed a revision rate of 8.6 5 SPS, Mentor’s Saline Prospective Study. percent. This rate was more than twice the 3.7 percent revision rate for tissue-related complications in our combined augmentation with mas- ther, we compared our complication and revision topexy patients. data to that of mastopexy alone and breast aug- The most common indications for revision in mentation alone (Table 4). Although it is a pro- all patients were implant-related, as seen in the spective study, we chose to use Mentor’s Saline original study by Spear et al.7 Mentor’s Saline Pro- Prospective Study4 as a comparison for augmen- spective Study revealed a revision rate of 13.2 per- tation alone, as these numbers are frequently cent at 3-year follow-up for breast augmentation quoted in the literature. We were surprised to be alone,4 which is higher than our implant-related

Fig. 1. (Above) Preoperative views of patient 1, a 35-year-old mother with mild scoliosis and mild pectus excavatum. (Below) Postoperative views 5 weeks after one-stage mastopexy and augmentation with Mentor 200 cc Moderate Plus Proﬁle gel implants (Mentor Corp., Santa Barbara, Calif.) placed in a subpectoral pocket. Mastopexy scars are in an inverted-T pattern.

1677 Plastic and Reconstructive Surgery • November 2007

Fig. 2. (Above) Preoperative views of patient 2, a 45-year-old mother. (Below) Postoperative views 1 month after one-stage mastopexy and augmentation with Mentor 375 cc Moderate Plus Proﬁle gel implants (Mentor Corp., Santa Barbara, Calif.) placed in a subpectoral pocket. Mastopexy scars are in an inverted-T pattern. She also underwent an abdominoplasty and liposuction 2 weeks before the breast surgery. revision rate of 10.9 percent at 3.3 years. The im- significantly higher than what we have reported plant-related revision rate was inflated markedly previously.15,16 This rate is also high compared with by 14 patients (4.4 percent) desiring to exchange a 3 percent deflation rate at 3 years reported in their implants postoperatively for size concerns. Mentor’s Saline Prospective Study.4 Investigating Some may even argue that these patients should further, we discovered that a significantly higher not be included in a revision calculation, which number of our deflations occurred in patients would have led to an implant-related revision rate with Poly Implant Prostheses implants, which we of 6.5 percent. have documented previously.15 Four of the 11 pa- When one looks closely at Table 4, it is appar- tients (36.4 percent) who had a revision for a ent that the risks of our one-stage procedure are saline implant deflation had Poly Implant Pros- not more than additive. Our hypothesis is that a theses saline implants. The use of saline implants combined procedure may be performed with sim- in general was found to contribute significantly to ilar complications and revision rates to both pro- the chance of a revision procedure. If complica- cedures alone without adding the risks of a second tions unique to saline implants were excluded (de- anesthesia and recovery. flation, wrinkling, exchange for silicone), the total Of note, 12 patients (3.7 percent) developed revision rate for all patients would be 10.3 percent. a saline implant deflation over the average 40- This finding seems to favor the use of silicone month follow-up period. The large number of de- implants in combined augmentation and mas- flations contributed appreciably to both the com- topexy procedures. plication and revision rates, accounting for nearly In this study, we have only addressed the safety one-fourth of all revisions. When evaluated as a and efficacy of a combined mastopexy and breast percentage of saline implants used, this rate is augmentation procedure. We did not intend to

1678 Volume 120, Number 6 • Mastopexy with Breast Augmentation address technical concerns or aesthetic outcomes who would have at least a second operation for in this article. Patient satisfaction questionnaires a planned two-stage breast augmentation and would be an interesting focus for future study, as mastopexy. On the basis of data from this large seen in other reports. We have been pleased with retrospective study, we feel that one-stage mas- our aesthetic results from one-stage procedures topexy with breast augmentation is safe and ef- and have included some recent photographs as fective. representative samples (Figs. 1 and 2). W. Grant Stevens, M.D. Instead of patient surveys, we used calculated 4644 Lincoln Boulevard, Suite 552 revision rates to determine the efficacy of the com- Marina del Rey, Calif. 90292 bined procedure. Our overall revision rate of 14.6 [email protected] percent at 3.3 years compares favorably with Men- tor’s study, which showed reoperation rates of 13.2 DISCLOSURES percent at 3 years and 20 percent at 5 years for The authors have no financial interests in any of the augmentation alone.4 products mentioned in this article. They received no We have seen in our practice a five-fold in- funding from the manufacturers of any products men- crease in the number of one-stage augmentation tioned in this article and have no corporate or financial and mastopexy procedures, and we find that affiliations with the manufacturers. each case poses unique challenges. Although our review supports the idea that a one-stage REFERENCES procedure has acceptable complication and re- 1. Gonzalez-Ulloa, M. Correction of hypertrophy of the breast vision rates, we are not implying that it is a by exogenous material. Plast. Reconstr. Surg. 25: 15, 1960. simple procedure. Without a doubt, the one- 2. Regnault, P. The hypoplastic and ptotic breast: A combined operation with prosthetic augmentation. Plast. Reconstr. Surg. stage augmentation with mastopexy is one of the 37: 31, 1966. more challenging procedures we perform. The 3. American Society for Aesthetic Plastic Surgery. 2005 Cos- operative plan invariably requires a three-di- metic Surgery National Data Bank, 2005. mensional approach and a delicate balance be- 4. Mentor Corporation. Saline-Filled Breast Implant Surgery: tween the breast volume and contour in addi- Making an Informed Decision. Santa Barbara, Calif.: Mentor Corporation, updated January 2004. tion to the height and shape of the nipple-areola 5. Stevens, W. G., Stoker, D. A., Freeman, M. E., and Quardt, S. complex. Our current revision rate of 14.6 per- M. Mastopexy revisited: A review of 150 cases for safety and cent is not insignificant, and the possibility of a efficacy. Aesthetic Surg. J. 27: 150, 2007. secondary procedure should be explained to 6. Spear, S. Augmentation/mastopexy: “Surgeon beware.” each patient. However, by avoiding some iden- Plast. Reconstr. Surg. 112: 905, 2003. 7. Spear, S. L., Pelletiere, C. V., and Menon, N. One-stage tified risk factors such as saline implants, it is augmentation combined with mastopexy: Aesthetic results possible to obviate a second operation for over and patient satisfaction. Aesthetic Plast. Surg. 28: 259, 2004. 90 percent of patients who undergo combined 8. Spear, S. L., and Giese, S. Y. Simultaneous breast augmen- augmentation and mastopexy. tation and mastopexy. Aesthetic Surg. J. 20: 155, 2000. 9. Spear, S. L., Low, M., and Ducic, I. Revision augmentation CONCLUSIONS mastopexy: Indications, operations, and outcomes. Ann. Plast. Surg. 51: 540, 2003. This large retrospective review of consecu- 10. Puckett, C. L., Meyer, V. H., and Reinisch, J. F. Crescent mas- tive one-stage breast augmentation with mastopexy and augmentation. Plast. Reconstr. Surg. 75: 533, 1985. topexy procedures demonstrates several inter- 11. Elliott, L. F. Circumareolar mastopexy with augmentation. esting findings. Although further study is Clin. Plast. Surg. 29: 337, 2002. 12. Owsley, J. Q., Jr. Simultaneous mastopexy and augmentation needed to examine the cause of these findings, for correction of the small, ptotic breast. Ann. Plast. Surg. 2: a significant increase in the probability of a re- 195, 1979. vision was found to be related to the following 13. Karnes, J., Morrison, W., Salisbury, M., Schaeferle, M., Beck- three factors: a history of smoking, the use of a ham, P., and Ersek, R. A. Simultaneous breast augmentation saline implant, and the performance of a cir- and lift. Aesthetic Plast. Surg. 24: 148, 2000. 14. Regnault, P. Breast ptosis: Definition and treatment. Clin. cumareolar mastopexy. Although a one-stage Plast. Surg. 3: 193, 1976. procedure is technically difficult, in our series, 15. Stevens, W. G., Hirsch, E. M., Cohen, R., and Stoker, D. A. the complication and revision rates compare A comparison of 500 pre-filled saline breast implants versus 500 favorably with rates seen with either procedure standard textured saline breast implants: Is there a difference alone. Patients should be counseled that a sec- in deflation rates? Plast. Reconstr. Surg. 117: 2175, 2006. 16. Stevens, W. G., Stoker, D. A., Fellows, D. R., and Hirsch, E. ond-stage revision procedure is frequently M. Acceleration of textured saline breast implant deflation needed. However, this revision rate is substan- rate: Results and analysis of 645 implants. Aesthetic Surg. J. 25: tially smaller than the 100 percent of patients 37, 2005.

1679 COSMETIC

The Brava External Tissue Expander: Is Breast Enlargement without Surgery a Reality?

Ingrid Schlenz, M.D. Background: Controlled trials have shown that an external breast tissue ex- Alexandra Kaider, M.Sc. pander (Brava; Brava LLC Miami, Fla.) can effectively enlarge the breast without Vienna, Austria surgery. However, satisfaction with the results has varied among doctors and patients. The first author critically evaluated her clinical experience with Brava and attempted to identify factors associated with a successful outcome. Methods: Between May of 2003 and September of 2005, the first author supervised the treatment of 50 women. Volume measurements and standardized photographs of the breasts were obtained at the beginning of treatment and up to 12 months after treatment ended. At the final visit, women completed a satisfaction questionnaire. Results: Forty women were evaluated at an average of 10 months after discontinuation of treatment (range, 7 to 20 months). Reasons for drop-out were noncompliance with the treatment (n ϭ 6), unwillingness to attend follow-up visits (n ϭ 3), and more than 5 percent body weight change (n ϭ 1). The women used Brava 11 hours a day for a median period of 18.5 weeks (range, 14 to 52 weeks). The median volume increase was 155 cc (range, 95 to 300 cc). Thirty women (75 percent) were satisfied or very satisfied with the results, five (12.5 percent) acknowledged enlargement of their breasts but considered the treatment too bothersome, and five (12.5 percent) were disappointed because of little growth. Factors associated with poor growth included lesser intensity of wear (p Ͻ 0.002) and low body mass index (p ϭ 0.055). Conclusions: Long-term breast enlargement without surgery is possible with an external tissue expander. The more it is used, the more the breasts grow. To avoid disappointments and drop-outs, women have to be well informed about the time and lifestyle commitment. (Plast. Reconstr. Surg. 120: 1680, 2007.)

n 1999, an external breast tissue expander was forces. A small, battery-operated, microchip- introduced as a nonsurgical alternative to controlled minipump maintains 20 mm/Hg of breast augmentation when used consistently negative pressure inside the domes. This vacuum I 1 for 10 hours a day for a minimum of 10 weeks. effectively exerts an isotropic distractive force to The Brava device (Brava LLC, Miami, Fla.) con- the breast. The entire system is contained within sists of two semirigid polyurethane domes that fabric and worn like a brassiere (Fig. 1). are placed around the breasts and that interface Since 1999, several reports have confirmed with the skin through silicone gel–filled donut that the distractive force exerted on the breasts bladders. These bladder rims serve to maintain an by the device can stimulate tissue growth and airtight seal and to dissipate pressure and shear thereby effectively enlarge the breasts.2–5 How- ever, in the clinical experience, not all patients From the Department of Plastic and Reconstructive Surgery, achieved the promised one-cup enlargement, Wilhelminenspital, and the Core Unit for Medical Statistics and satisfaction with the results varied among and Informatics, Medical University Vienna. doctors and patients.2,4 This study was under- Received for publication October 16, 2005; accepted March taken to critically evaluate the clinical experi- 21, 2006. ence of a single plastic surgeon and to identify Presented at the 10th Congress of ESPRAS, in Vienna, Aus- tria, August 30 through September 3, 2005, and at the Joint factors associated with a successful outcome. Meeting of the Austrian and German Society of Plastic, Aesthetic, and Reconstructive Surgeons, in Munich, Ger- PATIENTS AND METHODS many, September 28 through October 1, 2005. From May of 2003 to September of 2005, the Copyright ©2007 by the American Society of Plastic Surgeons first author treated 50 women seeking breast en- DOI: 10.1097/01.prs.0000267637.43207.19 largement without surgery using the Brava device.

1680 www.PRSJournal.com Volume 120, Number 6 • The Brava External Tissue Expander

Fig. 1. Woman wearing the Brava system. Reprinted with permission from Brava LLC (Miami, Fla.).

Informed consent was obtained, and the need for treatment), or if their body weight changed more consistent wear and a minimum wear time of 10 than 5 percent. hours a day for a minimum of 10 weeks was ex- Univariate and multiple linear regression plained to the women. The women were also in- techniques were used to analyze the potential informed that average breast growth in other studies fluences on breast volume increase of several fac- had been 100 cc. All of the women stated that they tors, such as body mass index, children (yes versus would rather have little growth than undergo sur- no), initial breast volume, and intensity of wear gery for breast implants. Standardized photo- (total usage of the breast tissue expander, mea- graphs, a breast examination, measurements of sured in hours). In all statistical analyses, both chest circumference at the height of the nipple breast volume and breast volume increase were and the inframammary fold, and volume measure- considered using the mean of the right and left ments of the breasts with the Grossman-Roudner breasts. Due to their skewed distribution, log- device were obtained at the beginning of treat- transformed values were used for the variables ment, after 6 weeks of use, and periodically up to intensity of wear and breast volume increase. 14 months after the end of the treatment. Body weight was measured at the beginning of treatment and throughout the follow-up period. All RESULTS women under the age of 35 years had a pretreat- Of the 50 women enrolled, 40 (ages 17 to 53 ment sonogram of their breasts. All women older years) could be evaluated. Ten dropped out for the following reasons: loss of interest and non- than 35 years had a breast mammogram taken ϭ before starting. All women had a negative family compliance with the treatment protocol (n 6), unwillingness to come for the minimum follow-up history of breast cancer. ϭ At the final visit, women completed a question- visits required (n 3), and more than 5 percent naire to judge their results, any side effects, and their satisfaction with treatment (Table 1). The questions Table 1. Patient Questionnaire* were rated using a five-point scale, ranging from “not at all” to “very much.” Wear time was based on the Are you satisfied with the result? Was the effort worth the result? patient’s recollection and was not always corrobo- How much do you estimate that your breasts grew? rated by an objective measurement. How much did you increase in terms of bra size? Women were excluded from the study if they Grade any improvements (volume, lift, asymmetry). Grade any side effects (sweating, itching, skin rashes, pain). wore the Brava device for less than 8 hours a day, How much did Brava restrict your social life? if their total wear time was less than 10 weeks, if How much did Brava affect your sex life? they did not come for the minimum follow-up How uncomfortable was Brava to wear? Do you feel any change in your self-esteem? visits required (6 to 10 weeks after the beginning Would you recommend Brava to a friend? of the treatment, 4 weeks after the end of the *Rating according to a five-point scale, with 1 ϭ not at all, 2 ϭ a little, treatment, and 6 to 20 months after the end of the 3 ϭ moderate, 4 ϭ good, and 5 ϭ excellent/significant.

1681 Plastic and Reconstructive Surgery • November 2007 bodyweight weight change (n ϭ 1). As patient height of the nipple increased by a median of 4.4 selection improved, only one of the last 10 patients cm (range, 1 to 11 cm). Measurements taken 4 dropped out, compared with nine of the first 40 weeks after the end of the treatment remained patients (25 percent). constant until the latest follow-up (Fig. 2 and Ta- Seventy-two percent of the women who used ble 3). Breast growth from Brava use appears dif- Brava had completed high school or acquired a uni- ferent from that with implant enlargement. It is versity degree. Fifty percent had children and stated more subtle and involves the entire breast. The that they had suffered moderate to large breast vol- visible enlargement and the increase in nipple ume loss after pregnancy and breast feeding. Pa- circumference depended on the shape and diam- tients’ characteristics are summarized in Table 2. eter of the breast and, therefore, sometimes did The women used the Brava device on average not completely correlate with the volume increase for 11 hours a day for a median period of 18.5 measured with the Grossman-Roudner device (Ta- weeks (range, 14 to 52 weeks). Posttreatment fol- ble 3 and Figs. 3 through 7). low-up averaged 10 months (range, 7 to 20 All women admitted that the treatment was pain- months). The median volume increase measured less. The side effects included sweating, itching, and with the Grossman-Roudner device was 155 cc skin irritation (Table 4). With the exception of two (range, 95 to 300 cc). Chest circumference at the women, sweating and itching were limited to the

Table 2. Patient Characteristics Volume Change Sport Patient Age BMI Marital Status Education Children/BF after BF* (hr/wk) 1 34 21.5 Life partner Middle school 0 3 2 37 20 Married High school 2 3 3 3 43 20.8 Married Middle school 2 3 0 4 28 18 Single University 0 4 5 42 19.5 Married Middle school 2 3 2 6 40 18.5 Divorced Middle school 2 3 7 32 18.7 Married Middle school 2 3 3 8 27 18.5 Single High school 0 4 9 39 19 Married High school 2 3 4 10 21 19.2 Single University 0 4 11 26 17.7 Single High school 0 5 12 42 18 Single University 0 5 13 42 22 Married Middle school 2 2 2 14 20 21.2 Single High school 0 7 15 37 21.5 Married Middle school 2 2 12 16 37 18 Life partner University 0 3 17 24 23.5 Life partner University 0 0 18 53 22.5 Married High school 2 1 2 19 42 22.2 Single University 1 1 4 20 42 20.8 Married University 2 3 2 21 34 17.7 Single High school 0 3 22 33 19 Single High school 0 3 23 41 19.5 Married University 1 2 2 24 31 20 Single Middle school 1 3 3 25 41 21 Married High school 1 2 3 26 36 19.1 Divorced Middle school 0 7 27 30 19.5 Single University 0 5 28 21 17.5 Single University 0 4 29 42 18.5 Married High school 3 3 0 30 17 19.8 Single University 0 10 31 25 17.5 Single High school 0 7 32 44 21.8 Married High school 3 2 2 33 50 21 Single University 0 3 34 43 21.2 Divorced High school 3 3 5 35 29 17.2 Married Middle school 4 3 3 36 36 18.1 Married High school 1 3 4 37 24 18 Single University 0 5 38 31 21.5 Married Middle school 3 3 4 39 39 21.5 Married High school 2 1 3 40 20 15.5 Single University 0 5 Mean 34.4 19.7 3.8 BMI, body mass index; BF, breast feeding. *Volume change after breast feeding: 1 ϭ little, 2 ϭ moderate, 3 ϭ substantial.

1682 Volume 120, Number 6 • The Brava External Tissue Expander

Fig. 2. Breast volume change of the women with regular follow-up visits during Brava treatment; measurements were taken with the Grossman-Roudner device. Women who came only for the minimum follow-up visits are not included. summer months when the women used the Brava Factors associated with poor growth included device in nonacclimatized rooms. Skin rashes were lesser intensity of wear and low body mass index. the most common problem; they occurred either (Although this was not tested by statistical meth- within the first week, when women with sensitive skin ods due to the small sample numbers, it was strik- used the expander for more than 10 hours, or after ing that women with a body mass index Ͻ18 had 6 to 8 weeks, when the silicone rim was worn out or the least increase in volume.) The effect of total colonized with bacteria due to improper cleaning. wear time on breast growth was statistically signif- Ten women developed rashes when they used the icant in adjusted (p ϭ 0.02) and unadjusted mod- roll-on (part of the first-generation skin care by Brava els (p ϭ 0.005), while the influence of body mass LLC). With the second-generation skin care and the index was borderline significant in the adjusted development of a special dome cleanser, the skin model (p ϭ 0.055) (Table 5). rash problem was essentially resolved. Twenty women (50 percent) reported an im- Thirty women (75 percent) were satisfied or very provement in their self-esteem. Although most satisfied with the results (Figs. 3 through 6). They felt women stated that the Brava device was not com- that their breasts were fuller and firmer and that fortable to wear and that their social life was quite they filled up or even outgrew their brassieres. restricted during the treatment period, 85.5 per- Five women (12.5 percent) acknowledged en- cent would recommend it to a friend. largement of their breasts but considered the treatment too bothersome for the result. Two of DISCUSSION these women acknowledged the sizeable enlarge- Tissue expansion has well-established applica- ment only after being confronted with their be- tions in plastic and orthopedic surgery and is the fore-and-after photographs (Fig. 7). Five women only clinically applicable method of tissue gener- (12.5 percent) were disappointed because of little ation in adults.6–9 The mechanisms by which sus- growth. So far, two of the latter group have pro- tained gentle mechanical tension induces tissue ceeded to surgical augmentation. growth have recently been reviewed.10–12 Nonsur-

1683 Plastic and Reconstructive Surgery • November 2007

Table 3. Breast Growth and Brava Wear Time GRD Difference

Nipple Right Left Weeks Hours Worn Follow-Up Patient Difference (cm) Breast Breast Brava Worn per Day (days) 1 4.5 150 150 16 11 300 2 6 150 150 14 11.5 420 3 8.5 250 240 30 12 420 4 7 300 300 52 12 390 5 3 110 110 18 12 270 6 3 140 140 10 10 240 7 3 200 200 19 10 270 8 3.5 200 200 20 12 210 9 3.5 160 160 16 11 210 10 3 150 150 16 10 300 11 1 100 100 20 11 240 12 5 180 0 22 10 300 13 2.5 140 140 14 10 270 14 3 0 165 14 12 240 15 3.5 160 160 22 11.5 270 16 3 150 150 16 13 330 17 8 215 220 17 11 270 18 4 160 160 20 10 270 19 2.5 160 160 24 10 270 20 6.5 135 135 14 9 360 21 4 120 120 22 10 240 22 8 145 145 52 8 270 23 4 95 125 10 10 360 24 7 160 155 15 11 600 25 4.5 165 160 24 12.5 270 26 6 235 235 14 10 300 27 4.5 110 110 19.5 13 300 28 2 140 140 20 12 240 29 5.5 300 300 25 20 360 30 8 300 300 20 12 300 31 3 120 120 24 11.33 210 32 5.5 170 170 24 11 360 33 4 180 190 14 10 540 34 5 150 150 12 14 300 35 4 150 150 18 12 270 36 3 150 150 12 12 330 37 3.5 155 145 20 10 240 38 4 150 150 22 11 240 39 2.5 150 150 16 12.84 270 40 2.5 120 120 16 11 300 Mean 4.4 162 162 20 11 304 SD 1.9 56.8 55.9 8.7 1.9 81.6

gical breast enlargement with the Brava external who are able to wear it longer show statistically soft-tissue expander device is the latest develop- significantly better growth. For some women, this ment based on this principle. Several controlled does not seem to be a problem; they almost get studies have proven that it is effective.1–5 It is a addicted and work or study while wearing the de- good alternative for women looking for one-cup vice. The majority of women, however, have to enlargement of their breasts and who do not wish restrict their social life, spending their evenings at to undergo the risks of surgery and implants. home to manage 10 hours of wear per day. Since There are several factors, however, that make it they have to do that for several months, it is un- difficult for the patient and the doctor to achieve derstandable that some women lose interest or do the desired results.13 not manage to wear the device for enough hours. First, as an external tissue expander, the Brava Unfortunately, it is very difficult to foresee which device is compliance-dependent and only works patient will be compliant. Dependence on compli- well for women who are willing to put up with the ance to achieve results is unfamiliar to plastic sur- rigorous wear schedule. Ten hours per day is the geons, who are used to immediate postoperative minimum amount of time required, and patients gratification. The first author realized that the more

1684 Volume 120, Number 6 • The Brava External Tissue Expander

Fig. 3. An 18-year-old patient with no children at baseline (above) and at 13-month follow-up after 1 year of treatment and 200 cc of growth (below). Her breasts became fuller in the lower and upper quadrants. The relationship of the nipple level to the inframammary fold did not change.

Fig. 4. A 37-year-old patient with two children at baseline (above) and at 14-month follow-up after 14 weeks of treatment and 150 cc of growth (below). Her breasts are pseudoptotic before and after Brava treatment. The relationship of the nipple level to the inframammary fold did not change because of the treatment.

1685 Plastic and Reconstructive Surgery • November 2007

Fig. 5. A 44-year-old patient with three children at baseline (above) and at 12-month follow-up after 24 weeks of treatment and 170 cc of growth (below). Breasts became fuller in the lower and upper quadrants. The relationship of the nipple level to the inframammary fold did not change.

Fig. 6. A 39-year-old patient with two children at baseline (above) and at 9-month follow-up after 16 weeks of treatment and 150 cc of growth (below). Her breasts outgrew the biggest Grossman-Roudner device (425 cc) due to Brava treatment; therefore, her growth was more than what we could measure.

1686 Volume 120, Number 6 • The Brava External Tissue Expander

Fig. 7. A 39-year-old patient with two children at baseline (above) and at 7-month follow-up after 16 weeks of treatment and 160 cc of growth (below). The patient acknowledged enlargement only after being confronted with her before and after photographs.

Table 4. Side Effects* None Little Moderate Often Significant Total Sweating 14 10 12 2 2 40 Itching 16 6 8 4 6 40 Skin rashes 6 10 10 7 7 40 Pain 40 0 0 0 0 40 *According to patient questionnaires, n ϭ 40.

Table 5. Results of Univariate and Multiple Linear Regression Models Analyzing Breast Volume Increase (Log Transformed) Parameter 95% Confidence Variable Estimate (␤) Interval p Univariate regression models BMI 0.024 Ϫ0.024 to 0.073 0.320 Children (yes vs. no) Ϫ0.025 Ϫ0.198 to 0.148 0.769 Initial breast volume Ϫ0.0009 Ϫ0.0023 to 0.0004 0.172 Intensity of wear, total 0.306 0.097 to 0.516 0.005** usage in hours (log- transformed) Multiple regression model BMI 0.052 Ϫ0.001 to 0.105 0.055* Children (yes vs. no) Ϫ0.037 Ϫ0.204 to 0.130 0.657 Initial breast volume Ϫ0.001 Ϫ0.003 to 0.0005 0.180 Intensity of wear, total 0.267 0.044 to 0.490 0.020** usage in hours (log- transformed) BMI, body mass index. *Borderline statistically significant. **Highly statistically significant.

1687 Plastic and Reconstructive Surgery • November 2007 patients she supervised, the more rigorous she became in telling them what they had to endure during the treatment, which changed the drop-out rate from 25 percent for the first 40 patients to 10 percent for the last 10 patients. A 10 percent rate of noncompliance is actually very low compared with studies evaluating adherence to medication (range, 22 to 67 percent noncompliance),14,15 especially if one considers how much women have to do when they use Brava; other patients just have to swallow pills. To avoid disappointment, all women have to be very well informed about the wear protocol, and they have to consider whether they can manage to comply with it. For most women, this means a restricted social life during the treatment period. Second, it was difficult to keep the women motivated while they perceived that their breasts were not growing. Within 6 weeks, every woman had forgotten how small her breasts were originally. They kept comparing their deflated breasts in the evening to their swollen, edematous breasts in the morning after removing the domes. Tissue growth takes place very slowly, at about 1 to 1.5 ml per day of sustained use,1,15 and is not comparable with the amount of swelling observed during the first weeks. Even after 10 weeks, 50 percent of the volume increase is due to swelling.1,3 Therefore, it is important to have the women view their pretreatment photographs, to show them their progress and to keep them motivated. Some Brava women need a lot of attention. Fig.8. A39-year-oldwomanwithtwochildrenatbaseline Third, it is a problem to satisfy a woman with (above) and at 9-month follow-up after 16 weeks of treat- only 160 cc of growth after she has seen what her ment and 150 cc of growth (below). breasts look like with a 300-cc increase due to the swelling and she likes that better. Although all women were informed, before starting, that breast and when the overall metabolic balance is not per- enlargement with Brava is not comparable to that missive. with an implant, and they all stated that they would Another problem that made women complain be happy with just a little more volume, they always was the fact that they were led to believe by ad- wanted more once they had seen what their vertisements that they could grow one cup within breasts could look like. For the women with very 10 weeks. In the first author’s experience, it takes small breasts and a body mass index less than 18, 16 to 20 weeks and then depends on the shape and 100 to 150 ml of growth from Brava was still not size of the brassiere the woman wears. Almost all enough to fill a B-cup and did not satisfy them. women with small breasts in the first author’s of- Although they were adverse to surgery at the be- fice wear brassieres that are too big for them to ginning, two of these women ended up opting for make their breasts look bigger under clothes. Af- surgical augmentation. The first author believes ter the treatment, they complained that they still that they still had a benefit from the Brava treatment, wear the same brassieres, not considering that they since there was more breast tissue to cover the im- now fit them. If before-and-after photographs are plants, making the augmented breasts look more taken with the subject wearing the same brassiere, natural. From my experience, if the body mass index this can easily be demonstrated (Fig. 8). is less than 18, it is unlikely that women with AA Side effects such as sweating, itching, and skin breasts will grow to fit a B-cup, despite prolonged irritation were bothersome, but they were not Brava wear. It is difficult to generate substantial enough to make any of the women discontinue amounts of tissue when the initial mass is so limited wearing the Brava system. Good skin care and

1688 Volume 120, Number 6 • The Brava External Tissue Expander effective cleaning of the domes can prevent many replace implants, but it will bring women to the problems. Women with sensitive skin should only physician’s office who otherwise would have not gradually increase their wear time to allow their considered visiting a plastic surgeon. skin to adapt to the pressure. Ingrid Schlenz, M.D. Sleeping with the system was only uncomfort- Department of Plastic and Reconstructive Surgery able during the first week. After that time, most Wilhelminenspital women became used to it. Six women could not Montleartstrasse 37 sleep with it; four of them stopped wearing it and 1160 Vienna, Austria two stated that they would not have bought it if [email protected] they had known how bothersome it was. DISCLOSURE These difficulties and complaints must not The authors disclose any financial and personal make one overlook the fact that in the end 75 relationships with other people or organizations that percent of the women were satisfied or very satis- could inappropriately influence their work. fied with the result and 85 percent would recommend it to a friend. In comparison to patients REFERENCES 16 looking for breast implants, the women inter- 1. Khouri, R. K., Schlenz, I., Murphy, B., and Baker, T. J. Non- ested in Brava tended to have reached higher lev- surgical breast enlargement using an external soft-tissue ex- els of education and were much more aware and pansion system. Plast. Reconstr. Surg. 105: 2500, 2000. concerned about their bodies. They played sports 2. Greco, R. J. Nonsurgical breast enhancement: Fact or fiction? on a regular basis and stated that they ate healthy Plast. Reconstr. Surg. 110: 337, 2002. 3. Khouri, R. K., Rohrich, R. J., and Baker, T. J. Multicenter foods (Table 2). Most of them had been unhappy evaluation of an external tissue expander system (Brava) for with the size of their breasts for many years but breast enlargement. Plast. Surg. Forum 71: 168, 2002. would never consider implants because of their 4. Smith, C. J. Initial experience with the Brava nonsurgical knowledge and fear of possible side effects. All the system of breast enhancement. Plast. Reconstr. Surg. 110: 1593, women who had children and had lost volume 2002. 5. Baker, T. J., Schlenz, I., and Khouri, R. K. A new device for after breast-feeding stated that they just wanted to nonsurgical breast enlargement: Fifteen months follow-up. regain what they had before pregnancy; the others Plast. Surg. Forum 23: 113, 2000. also initially stated that they would rather have less 6. Neumann, C. A. The expansion of skin by a progressive growth than an implant in their healthy breasts. distension of a subcutaneous balloon. Plast. Reconstr. Surg. 19: The women were followed for up to 20 months 124, 1957. 7. Ilizarov, G. A. Clinical application of a tension-stress effect for after the end of the treatment and they had kept limb lengthening. Clin. Orthop. 238: 249, 1990. the volume growth observed at 1 month. Figure 2 8. McCarthy, J. G., Schreiber, J., Karp, N., Thorne, C. H., and shows that after the initial volume loss within the Grayson, B. H. Lengthening the human mandible by gradual first 3 weeks after the end of the treatment, the distraction. Plast. Reconstr. Surg. 89: 1, 1992. volume remained constant. This confirms what 9. Polley, J. W., and Figueroa, R. A. Management of severe maxillary deficiency in childhood and adolescence through Baker et al. found, that the remaining volume is distraction osteogenesis with an external, adjustable, rigid 5 real tissue growth and long-lasting. distraction device. J. Craniofac. Surg. 8: 181, 1997. 10. Ingber, D. E. Tensegrity: The architectural basis of cellular SUMMARY mechanotransduction. Annu. Rev. Physiol. 59: 575, 1997. The Brava system is a good solution for a 11. Sachs, F. Biophysics of mechanotransduction. Memb. Biochem. 6: 173, 1986. woman looking for a one-cup enlargement with- 12. DeFilippo, R. E., and Atala, A. Stretch and growth: The out changing the shape of her breasts and who molecular and physiologic influences of tissue expansion. does not wish to undergo the risks of surgery and Plast. Reconstr. Surg. 109: 2450, 2002. implants. To avoid disappointments and drop- 13. Khouri, R. K. Initial experience with the Brava nonsurgical outs, patients have to be closely screened with system of breast enhancement (Reply). Plast. Reconstr. Surg. 110: 1595, 2002. respect to their motivations and expectations, as 14. Claxton, A. J., Cramer, J., and Pierce, C. A systematic review well as informed about the rigorous wear schedule of the association between dose regimens and medication and the time realistically necessary to achieve a compliance. Clin. Ther. 23: 1296, 2001. one-cup enlargement. They should also be made 15. Osterberg, L., and Blaschke, T. Adherence to medication. N. aware that their social life will be restricted during Engl. J. Med. 353: 487, 2005. 16. Brinton, L. A., Brown, S. L., Colton, T., Burich, M. C., and the treatment period. Women with a body mass Lubin, J. Characteristics of a population of women with index less than 18 and very small breasts should breast implants compared with women seeking other types of not be considered Brava candidates. Brava will not plastic surgery. Plast. Reconstr. Surg. 105: 919, 2000.

1689 DISCUSSION

The Brava External Tissue Expander: Is Breast Enlargement without Surgery a Reality? Sumner A. Slavin, M.D. Brookline, Mass. ince its introduction in 1999 as a nonsurgical prescribed period? There were numerous Sbreast enhancer, the Brava external tissue problems with patient compliance, better de- expander (Brava LLC, Miami, Fla.)1 has stimu- scribed as noncompliance. At the outset, one- lated both researchers and clinicians to explain fifth of the study group had to be dropped how it works and who can benefit from its appli- for various reasons, including loss of interest, cation. Schlenz and Kaider delve further into failure to cooperate, or weight gain exceeding some of the mechanisms and mysteries of breast study guidelines. Despite this early high rate of enlargement induced by an externally worn de- attrition, 40 patients wore the device on their vice, providing answers to some, but hardly all, of breasts for up to 11 hours a day and a total of the controversial issues raised by it. 18.5 weeks. Their endurance was tested by the That two domes enveloping the breasts like a discomfort of constant negative pressure (a 20- brassiere can achieve real fibroglandular growth mmHg vacuum distraction force) and chronic is not yet a completely settled matter. Despite the skin irritation, sweating, and itching. Patients cited theories of tissue expansion, distraction- described a number of causes of discontent, induced cell growth, and angiogenesis, histolog- most notably disappointment with final median ical analysis of tissue specimens demonstrating volume accretion of 155 cc, with some gaining as true parenchymal proliferation has not been little as 95 cc. Additional sacrifices were also performed, and neither ultrasound examination necessary, including significant disruption of so- nor mammography is convincing proof. Al- cial activities, which were curtailed for as long as though the impracticality of obtaining confirm- 4 to 5 months by the necessity of either sleeping ing evidence by breast biopsy in a population of with the apparatus or wearing it during an entire patients who wish to avoid operation is appreci- day of work. ated, it should also be clear that breast hypertro- To the authors’ credit, 40 patients actually phy by a continuously applied mechanotransdu- completed the study and 75 percent expressed cive force has not attained universal acceptance satisfaction with the results. Unfortunately, those as scientific fact. with the smallest breast size and most in need of This study does not purport to prove or enlargement received the least benefit. Poor disprove the underlying mechanisms of breast growth of breast volume was observed in this enlargement using the Brava system. It does, group and in patients with a low body mass however, a thorough job explaining the limi- index. Problems with selection of optimal candi- tations of this device and the formidable prob- dates from the point of view of compliance were lems of compliance that must be overcome. As solved by a process of increased scrutiny of pa- compared with the earlier study by Khouri and tient backgrounds. Although the authors ex- colleagues,1 the authors studied a larger pa- pressed their preference for women with more tient population (40 versus 12) and followed advanced levels of education, they do not prove them for a longer period (18 weeks instead of why this factor should be critical and perhaps, 10). Arguably, their study does not completely unintentionally, introduce a source of bias into answer the question posed in the article’s title: the selection process. Is breast enlargement without surgery a real- This study provides a comprehensive review ity? However, their candid review of the prob- of the problems experienced by a patient pop- lems encountered in their study population ulation testing a new device, their disappoint- partially answers a different but important ments, and their satisfactions, and the adjust- question: Will women wear this device for the ments performed by the authors that ensured verifiable outcomes. However, it does not an- Received for publication April 19, 2006; accepted April 25, swer a question that I raised in 2000 when I 2006. discussed the original Brava article. Namely, Copyright ©2007 by the American Society of Plastic Surgeons do the effects last? A follow-up period of 10 DOI: 10.1097/01.prs.0000267577.74824.69 months after discontinuation of usage does

1690 www.PRSJournal.com Volume 120, Number 6 • Discussion not convincingly prove long-term efficacy. mations in an organ already prone to malignant Many patients will want to know whether their change. breast enlargement is sustained one or more Sumner A. Slavin, M.D. years later. 1101 Beacon Street Most importantly, two other issues remain un- Brookline, Mass. 02446 resolved. True parenchymatous hypertrophy, de- [email protected] [email protected] void of the edematous pseudoenlargement that most patients observed as accounting for up to DISCLOSURE 50 percent of their increased size, will have to be The author has no financial interests in any of shown conclusively. More information is needed the products, devices, or drugs mentioned in this regarding the biological mechanisms (growth article. factors and other cell-mediated processes) that contribute to the changes in breast size and REFERENCE shape. Finally, it must be proven that prolonged 1. Khouri, R. K., Schlenz, I., Murphy, B., et al. Nonsurgical breast mechanotransducive stimulation of the breast enlargement using an external soft-tissue expansion system. does not cause dangerous pathological transfor- Plast. Reconstr. Surg. 105: 2500, 2000.

Contribute to Plastic Surgery History The Journal seeks to publish historical photographs that pertain to plastic and reconstructive surgery. We are interested in the following subject areas: • Departmental photographs • Key historical people • Meetings/gatherings of plastic surgeons • Photographs of operations/early surgical procedures • Early surgical instruments and devices Please send your high-resolution photographs, along with a brief picture caption, via email to the Journal Editorial Office ([email protected]). Photographs will be chosen and published at the Editor-in- Chief’s discretion.

1691 COSMETIC

Back Contouring in Weight Loss Patients

Berish Strauch, M.D. Background: Body contouring in the post–bariatric surgery patient has focused Christine Rohde, M.D. predominantly on the resulting tissue excesses of the abdomen, breasts, and Mitesh K. Patel, M.D. arms. The back, however, has not received the same attention and, although the Sameer Patel, M.D. skin folds on the back may sometimes be improved by addressing the previously New York, N.Y. mentioned areas, the result is usually unsatisfactory and leaves the patient with significant residual excess. Methods: The senior author (B.S.) has developed a classification system and surgical treatment for the excess back tissue that eliminates these folds. Results: Modifications of the senior author’s techniques of mammaplasty/mastopexy and circumferential abdominoplasty, in addition to direct excision, are used to improve the contour of the back. Conclusions: Contouring of the back roll deformities seen in post–bariatric surgery patients requires a systematic approach. With this approach, the authors have been able to achieve uniform patient satisfaction with low morbidity. Although patients are left with additional scarring, this tradeoff is accepted by nearly all patients for the dramatic improvement in body contour. (Plast. Reconstr. Surg. 120: 1692, 2007.)

ody contouring in the massive weight loss percent of our cases, a fifth roll was identified at patient has generated much interest in re- the axilla. Bcent years, primarily because of the increase in the number of patients undergoing PATIENT SELECTION AND weight-reduction surgery and being left with var- OPERATIVE PLANNING ious deformities of body contour. Although the Patients are usually referred for body contour- management of the abdomen, breasts, arms, ing after gastric bypass surgery, although some thighs, and buttocks in this group of patients has patients present after weight loss from nonsurgical received much attention, little has been written means. Body contouring is deferred until the pa- about the surgical approach to the back. tient’s weight is stable, generally at least 1 year after gastric bypass surgery. We approach body contouring in a staged fashion, addressing the ANATOMY OF THE BACK FOLDS circumferential abdominal excess as a first step. After massive weight loss, patients often de- The back tissue is contoured during several dif- velop back folds of excessive skin, fat, and fibrous ferent body contouring operations, depending on tissue. These “back rolls” can range in number the needs of each individual patient. from one to four on either side of the midline. The lower thoracic and hip rolls are flattened Depending on the patient’s prebypass anatomy in our standard circumferential abdominoplasty.1 and the amount of weight loss achieved, one or No undermining is used or needed. The lateral more of the usual four folds may be absent. breast roll is excised with the Wise-type breast pro- The highest fold is a posterolateral extension cedure to the posterior axillary line. The balance of the breast fold. In descending order, the next of the breast fold and the scapular fold is removed fold is the scapular roll. Next is the lower thoracic or flattened with an elliptical excision. roll, and the lowest is the hip roll (Fig. 1). In 1 The usual order of operations we plan for this population would start with mid-body contouring, From the Department of Plastic and Reconstructive Surgery, and then brachioplasty and breast surgery in one Albert Einstein College of Medicine and Montefiore Medical stage. If there are significant back folds left, we will Center. perform the residual back fold alone. The medial Received for publication January 30, 2006; accepted April thighs and face are performed in two subsequent 20, 2006. operations. Copyright ©2007 by the American Society of Plastic Surgeons To date, we have operated on 246 massive DOI: 10.1097/01.prs.0000282727.90788.39 weight loss patients. All of them had a stable

1692 www.PRSJournal.com Volume 120, Number 6 • Body Contouring after Weight Loss

Fig. 1. Drawing of back folds with nomenclature of the folds. Fig. 2. Drawing of back incisions. weight and had lost between 100 and 350 pounds. They were in the body mass index range from the low 20s to low 30s. Of the 246 patients who underwent mid-body contouring, 202 had circumferential abdominoplasties. The decision to go circumferential was largely based on the presence of a lower thoracic roll and a hip roll and descent of the buttock region.

SURGICAL TECHNIQUE The removal of the lower thoracic and hip rolls has previously been described by us.1 The lower thoracic and hip rolls serve as accurate markers for the upper and lower lines of resection in the circumferential abdominoplasty. The incisions are planned through the apex of these two rolls, respectively. By flattening the residual elements of the two rolls and bringing them together, the back is closed without any under- Fig. 3. Drawing of side incisions. mining. This limits the dead space and reduces the possibility of seroma formation. As noted in Figures 2 and 3, the incisions are planned cedure (Fig. 3). The patient is marked in a stand- through the apex of the lower two rolls to allow ing position with arms at the sides. An oblique for an easier closure. ellipse is developed. The superior margin en- The lateral breast fold is incorporated into the compasses the entire remaining breast fold; breast operation by extending the Wise-type pat- however, the lower margin goes only through tern laterally to the posterior axillary fold, remov- the apex of the scapular fold. The tissue is excised ing the lateral fold with the breast excision. This to fascia and the remaining portion of the scapular is performed in each patient who exhibits a sig- fold is elevated to the upper excision, achieving a nificant lateral fold excess. normal back contour with no undermining. A tu- The balance of the upper breast roll and scap- mescent fluid, consisting of one ampule of 1:1000 ular rolls are excised together in a separate pro- epinephrine and 50 cc of 1% lidocaine in 1 liter

1693 Plastic and Reconstructive Surgery • November 2007

Fig. 6. Postoperative view. Fig. 4. Drawing of ﬁnal closure of the back.

Fig. 5. Back of a 45-year-old woman, showing four major folds. Fig. 7. Back of a 38-year-old man, showing no breast fold but showing the remaining three folds. of lactated Ringer’s solution, is used before the brought out laterally before final closure (Figs. surgical excision. It is injected into the back rolls, 4 through 8). and the ellipse of tissue is incised sharply. Sharp dissection is used to remove excess skin and fat in RESULTS a suprafascial plane within the markings. No un- We have not experienced any seroma forma- dermining is necessary after the excess tissue is tion or necrosis of the posterior wound edges. We removed. The ellipse is then closed as a straight have had one minor dehiscence in the midline line using 2-0 chromic sutures for the deep layer, posteriorly. Spread scars posteriorly have been followed by closure of deep dermis with 4-0 run- seen in 32 patients, although this has not caused ning surgical steel and skin with surgical staples. concern in the patients. The combined tech- A Penrose drain is placed in the wound and niques give a very satisfactory back contour.

1694 Volume 120, Number 6 • Body Contouring after Weight Loss

should be avoided. Instead, only the lower two folds should be directly excised through an incision at the apex of these folds during the circumferential procedure. The upper back roll (i.e., the breast fold) extends posteriorly from the inframammary crease. This may be excised at the time of the mammaplasty.6 However, we prefer to incorporate only that part of the breast fold to the posteroaxillary line during the mammaplasty. The remainder of the breast fold is excised at a separate procedure with the patient supine at the time of the excision of the scapular fold. In our series, a total of 20 patients were operated on separately to remove the upper two folds of the back. As this procedure is generally deemed cosmetic by the insurance carrier, the number of patients has remained low. As early as 1975, Palmer et al.8 reported success in removing this fold using a mammaplasty, as described by McK- issock, combined with wide excision of the infra- Fig. 8. Postoperative view. mammary and lateral folds. Similarly, the senior author performs a Wise-pattern reduction with direct excision that closes as a lateral extension of the in- DISCUSSION framammary fold incision to the posterior axillary We continue to refine our approach to body line. Because of the fibrous nature of this tissue, contouring in the massive weight-loss patient. Af- liposuction alone yields less than satisfactory results. ter a circumferential abdominoplasty, many pa- A central fold frequently exists between the tients return to have their breasts, arms, and thighs upper breast and lower thoracic folds; we refer to contoured. However, troublesome areas of excess this as the scapular fold. Attempts to flatten out back tissue are usually not sufficiently addressed this fold by undermining the upper back flap dur- with standard procedures. We therefore catego- ing circumferential abdominoplasty often fail to rized the problems and set out to address the back completely eliminate the excess and lead to un- systematically. acceptably high rates of seroma formation. We In post–gastric bypass patients, the excess tissue believe direct excision of this fold with the breast must be excised. Liposuction is rarely indicated be- fold affords the best aesthetic outcome, with min- cause the skin and subcutaneous tissue remain in imal morbidity. excess in these patients. In addition, back tissue is dense and fibrous, making it less amenable to lipo- CONCLUSIONS suction. Therefore, scars must be created to achieve Contouring of back-roll deformities seen in a better contour. In the back, as in all areas of body post–bariatric surgery patients requires an ap- contouring in weight loss patients, the patients trade proach that allows for direct excision of the two scars for improved contour. lower folds (lower thoracic and hip rolls) during Although traditional abdominoplasty can im- the circumferential procedure, and of the two up- prove the anterior abdominal contour, it has been per folds (breast and scapular rolls) at a separate reported to accentuate the back rolls.2–5 Circum- procedure. Direct excision of each of these pairs ferential abdominoplasty can improve the appear- at separate sittings produces a well-contoured ance of the back.1 This approach is best used to back with the lowest morbidity. remove the lower thoracic roll and the hip roll. However, to address all of the back rolls through Berish Strauch, M.D. this approach at the time of the mid-body con- Department of Plastic and Reconstructive Surgery touring requires extensive undermining of the Albert Einstein College of Medicine/Montefiore Medical Center back flap. This type of undermining in the back 1625 Poplar Street, Suite 200 6,7 leads to excessively high rates of seroma formation. Bronx, N.Y. 10461 Therefore, undermining of the superior back flap [email protected])

1695 Plastic and Reconstructive Surgery • November 2007

DISCLOSURE 4. Carwell, G. R., and Horton, C. E. Circumferential torsoplasty. None of the authors has a financial interest in any Ann. Plast. Surg. 38: 213, 1997. 5. Hurwitz, D. J. Optimizing body contour in massive weight loss of drugs, devices, or products described in this article. patients: The modified vertical abdominoplasty (Discussion). Plast. Reconstr. Surg. 114: 1924, 2004. REFERENCES 6. Delay, E., Gounot, N., Bouillot, A., et al. Autologous latissimus 1. Strauch, B., Herman, C. K., Rohde, C., and Baum, T. Mid-body breast reconstruction: A 3-year clinical experience with 100 contouring in the post-bariatric surgery patient. Plast. Reconstr. patients. Plast. Reconstr. Surg. 102: 1461, 1998. Surg. 117: 2200, 2006. 7. Aly, A. S., Cram, A. E., and Heddens, C. Truncal body con- 2. Aly, A. S., Cram, A. E., Chao, M., et al. Belt lipectomy for touring surgery in the massive weight loss patient. Clin. Plast. circumferential truncal excess: The University of Iowa expe- Surg. 31: 611, 2004. rience. Plast. Reconstr. Surg. 111: 398, 2003. 8. Palmer, B., Hallberg, D., and Backman, L. Skin reduction 3. Van Geertruyden, J. P., Vandeweyer, E., De Fontaine, S., et al. plasties following intestinal shunt operations for treatment Circumferential torsoplasty. Br. J. Plast. Surg. 52: 623, 1999. of obesity. Scand. J. Plast. Reconstr. Surg. 9: 47, 1975.

English Language Assistance for Authors Appropriate use of the English language is a requirement for publication in Plastic and Reconstructive Surgery. Authors who have difficulty in writing English may seek assistance with grammar and style to improve the clarity of their manuscript. Many companies provide substantive editing via the Web. Website addresses for these companies include: • www.biosciencewriters.com • www.bostonbioedit.com • www.sciencedocs.com • www.prof-editing.com • www.journalexperts.com Please note that neither the American Society of Plastic Surgeons nor the Journal takes responsibility for, or endorses, these services. Their use does not guarantee acceptance of a manuscript for publication.

1696 IDEAS AND INNOVATIONS

Endoscopic Brow Lift, Upper and Lower Blepharoplasty, Retinacular Canthopexy: Personal Approach

James M. Stuzin, M.D. Coconut Grove, Fla.

he goals of periorbital rejuvenation empha- after it is released from the restraint of the size enhancing definition of the upper lid orbicularis retaining ligament. Tcrease, blending the contour of the lower 2. In performing an endoscopic brow lift, I lid and cheek, and often raising the lateral brow prefer to release the lateral brow through a and smoothing the glabella. My own personal transpalpebral subperiosteal approach via technique of upper and lower blepharoplasty the lateral upper lid, which accomplishes and foreheadplasty has evolved over the last 20 both lateral brow release and formation of years, and in my opinion, the introduction of the optical cavity within the frontal region. endoscopic techniques has allowed brow lifting It has been my experience that when the to become acceptable to more patients seeking subperiosteal forehead dissection is per- periorbital rejuvenation. formed through a lateral transpalpebral ap- My current approach to periorbital rejuvena- proach, there is little associated edema and tion is delineated in the Videoϩ segment of this ecchymosis and the dissection is technically article (see Video, Supplemental Digital Content simple. This approach is particularly suited 1, which shows my current approach to perior- for patients with a high forehead or reced- bital rejuvenation, http://links.lww.com/A133). A ing hairline (where it can be difficult to synopsis of the technique contained in the video visualize the supraorbital rim via a scalp is as follows: incision). After subperiosteal dissection of the forehead is performed, standard scalp 1. When performing an endoscopic brow lift, incisions are placed posterior to the hair- I typically approach corrugator resection line to allow introduction of the endoscope. through the upper lid, as it allows the sur- The endoscope is then utilized predomi- geon better control of medial brow position nantly for dissection along the temporal and provides direct access for corrugator line of fusion between the frontal bone and resection. In performing lower lid blepha- temporalis muscle, enhancing the sur- roplasty, I prefer to approach lower lid fat geon’s ability to protect the overlying fron- through a transconjunctival incision and tal branch of the facial nerve. My current utilize a skin flap to improve the appear- preference for fixation is to utilize the En- ance of the anterior lamella, thereby pre- dotine (Coapt, Inc.) device to stabilize the serving orbicularis innervation. Lower lid lateral brow postoperatively. shape is controlled utilizing a retinacular canthopexy, and the lateral orbicularis muscle is stabilized to the lateral orbital rim Video Plus content is available for this article. Received for publication July 13, 2007; accepted July 20, A direct URL citation appears in the printed 2007. text; simply type the URL address into any web Presented at the 41st Annual Baker Gordon Symposium on browser to access this content. Clickable links Cosmetic Surgery, in Miami, Florida, February 15 through to the material are provided in the HTML text 17, 2007. and PDF of this article on the Journal’s Web Copyright ©2007 by the American Society of Plastic Surgeons site (www.PRSJournal.com). DOI: 10.1097/01.prs.0000290691.15459.9e

www.PRSJournal.com 1697 Plastic and Reconstructive Surgery • November 2007

3. In approaching transpalpebral corrugator lateral commissure is secured to the lateral resection, the medial orbicularis is incised orbital rim, a small incision is made in the via the upper lid incision and the dissection lateral orbicularis muscle, inferior to the is continued superiorly within the subor- commissure, and the orbicularis is dissected bicular fat until the medial superior orbital from the orbicularis retaining ligament rim is visualized. Once the supraorbital rim along the lateral orbital rim and deep tem- is identified, the inferior aspect of the cor- poral fascia. In essence, this maneuver re- rugator becomes apparent, lying just ante- leases the superficial head of the lateral rior to the periosteum. The corrugator is canthal tendon and allows the lateral can- then grasped and its superior surface is dis- thus to be repositioned under less tension. sected from the overlying orbicularis and Suturing the lateral orbicularis to the lat- frontalis muscles. After the corrugator is eral orbital rim inferior to the canthoplasty adequately mobilized, it is resected in a seg- repositions the orbicularis in close proxim- mental fashion, with care taken to preserve ity to the orbit, which smoothes lower lid the intramuscular branches of the su- contour and helps to blend the lateral lid- pratrochlear nerve. cheek junction. 4. My preference in lower lid blepharoplasty is In summary, this approach to periorbital re- to utilize a skin flap, which allows substan- juvenation is associated with significant control of tial skin recruitment while preserving orbic- lateral brow and lower lid shape and is usually ularis innervation. Whenever I dissect a associated with a rapid recovery and little morbid- lower lid skin flap, I prefer to control lid ity. The need for lid lubrication in the early post- shape utilizing a retinacular canthopexy. operative period is common when utilizing a reti- My suture preference for canthoplasty is a nacular canthoplasty to stabilize the lower lid. A 4-0 Polydek (Deknatel) double-armed su- temporary suture tarsorrhaphy is helpful in lim- ture, with the needles inserted through the iting chemosis as well as preventing early postop- retinaculum of the lower eyelid just lateral erative lid malposition. to the lateral commissure. The double- armed needles are then visualized through the retinaculum of the upper lid, and the James M. Stuzin, M.D. periosteum of the lateral orbital rim is ex- 3225 Aviation Avenue, Suite 100 Coconut Grove, Fla. 33133 posed. Because the Polydek double-armed [email protected] needles are small and malleable, I typically remove them and substitute a very stout, nonmalleable needle (½-inch French eye DISCLOSURE cutting needle) before anchoring the can- The author has no financial interest in any of the thoplasty to the lateral orbital rim. After the devices, drugs, or products described in this article.

1698 CME

Surgical Cephalometrics: Applications and Developments

Craig A. Hurst, M.D. Learning Objectives: After studying this article, the participant should be able Barry L. Eppley, M.D., to: 1. Describe the historical origins of modern cephalometry. 2. Identify com- D.M.D. mon landmark points on the lateral cephalogram. 3. Describe multiple common Robert J. Havlik, M.D. clinical uses for cephalometry. 4. Exhibit knowledge of developments in imaging A. Michael Sadove, M.D. and analysis alternatives. Indianapolis, Ind. Background: Interest in the dimensions of the human head has been present since antiquity. Proportional analysis and measures from cadaveric specimens led to the development of radiologic image capture and analysis on living subjects. These techniques were originally applied to establishing normative values, documenting growth, and diagnosing dentofacial disharmonies. This article reviews the origins of cephalometric methodology and current developments and applications. Methods: The authors conducted a MEDLINE search and review of all English language articles using the keywords “cephalometric” and “cephalometrics.” Results: Cephalometrics have undergone substantial use and development since the introduction of radiologic imaging on living human subjects in 1931. Although frequently associated with orthognathic surgery, cephalometrics have been applied to a number of conditions involving altered craniofacial morphology. Advances in imaging and computing have led to increased interest in three-dimensional and non–x-ray–based assessment of the human head. Math- ematical models have been applied to standard cephalometric information to increase the descriptive accuracy of the complex shapes involved. Conclusions: Cephalometric techniques and analyses are versatile tools that can be applied to a wide variety of clinical scenarios involving the craniofacial region. New technologies and expanded applications promise to continue the development and use of this well-established methodology. (Plast. Reconstr. Surg. 120: 92e, 2007.)

ephalometrics is the subset of anthropomet- HISTORICAL DEVELOPMENT rics that deals with the quantification of the The scientific measurement of the skull was Cdimensions of the human head. Although first described by the Dutchman Petrus Camper in most frequently associated with the diagnosis and the late 1700s. As both an anatomist and painter, treatment of dentofacial disharmonies, cephalo- Camper sought to systematically define and com- metric techniques have been applied to multiple pare cranial dimensions of several species of pri- conditions presenting to a variety of clinicians. mates, including humans. Camper applied his mea- Cephalometric techniques and analyses have un- surement techniques to dried skulls and Greek and dergone significant changes since their introduc- Roman statues in an attempt to relate his work to the tion that have altered both the manner and scope ratio-based analysis of the ancients.1 Before this de- of their use. This article examines the historical tailed study, descriptions of skull dimensions rested origins of cephalometrics in addition to current solely on the use of proportions, most notably the 2 developments and applications. “divine proportion.” Camper’s methods led to a new era of anthropologic assessment of cadaveric From the Division of Plastic Surgery, Indiana University specimens. Researchers searched for relationships School of Medicine. between soft-tissue features and underlying skeletal Received for publication February 12, 2006; accepted July 7, landmarks in cadavers that could be transferred to 2006. the living. Copyright ©2007 by the American Society of Plastic Surgeons These approaches persisted until 1931, when DOI: 10.1097/01.prs.0000282728.97278.a2 radiographic cephalometry on live subjects was

92e www.PRSJournal.com Volume 120, Number 6 • Surgical Cephalometrics described simultaneously by both Hofrath in Ger- many and Broadbent in the United Sates. Broad- bent’s method consisted of standardized equipment and techniques that allowed for the comparison of measures both within subjects and between subjects. He performed serial cephalometric analysis on over 1700 patients every 3 to 6 months during an 18- month period and made important realizations regarding the growth of the face and its relation to the skull base.3 In 1939, Higley pioneered the application of filters to capture simultaneous images of the skeleton and the soft-tissue profile.4 This addition allowed for the quantification of the soft-tissue envelope and its relationship to the underlying skeleton. Usage expanded, and multiple sets of normative values were generated.5–8 Many authors developed analytical approaches to use cephalometric data for the investigation of facial growth, normative variations, and facial disharmonies.9 With the application of digital radiographic capture and computerized processing to cephalometric images in the mid 1980s, the science of craniofacial measurement entered the modern era. Presently, automated analysis can be performed rapidly and proposed interventions can be simulated easily.10 The maxilla and mandible are linked through the occlusal surfaces and their interrelationship Fig. 1. Angle classes of occlusion: (above) class I, (center) class II, rapidly became a central driving force for the de- and (below) class III. velopment and use of cephalometrics. In 1899, Edward Angle described three patterns of occlu- and cephalometric analysis is integral in the de- sion in children based on the relative positions of scription and treatment of the abnormal bite. the first molars.11 The Angle classification quickly became, and remains, the standard for description of occlusal patterns in adults and children. The BASIC TECHNIQUE Angle classes are as follows: In many ways, the basics of cephalometric technique have changed very little since the seminal Class I: The mesial (toward the anterior midline) work of Broadbent. The subject’s head is held in buccal cusp of the first maxillary molar sits in a fixed position by a device known as a cephalostat. the buccal groove of the first mandibular mo- This consists of bilateral rods placed in the exter- lar. The maxillary canine sits in between the nal auditory canals and a rest placed on the cheek canine and first premolar of the mandible (Fig. or forehead to restrict sagittal motion. The x-ray 1, above). source is then directed along the axis of the ear Class II: The mesial buccal cusp of the first max- rods onto a receiver. The head is held at a fixed illary molar sits mesial to the buccal groove of distance from the x-ray source and from the re- the first mandibular molar. The maxillary ca- ceiver. Absolute values for these distances are used nine is mesial to the mandibular canine (Fig. 1, to determine a magnification factor for the ar- center). rangement that needs to be incorporated into any Class III: The mesial buccal cusp of the first max- subsequent analyses. The first receivers consisted illary molar sits distal (away from the anterior of x-ray film, but as imaging technology pro- midline) to the buccal groove of the first man- gressed, digital capture devices have become com- dibular molar. The maxillary canine sits distal monplace. Regardless of the equipment configu- to the groove between the canine and first ration used to procure the images, technical premolar of the mandible (Fig. 1, below). consistency is of central importance12 if the infor- These occlusal relationships are the founda- mation is to be used in serial assessments or com- tion of orthodontic and orthognathic treatment pared with reference of norms.

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Table 1. Skeletal Landmarks Table 2. Soft-Tissue Landmarks Landmark Description Landmark Description S (sella) Center of the pituitary fossa G (glabella) Most anterior point on the N (nasion) Junction of the nasal and frontal bones forehead Or (orbitale) Most inferior point on the orbital rim N= (nasion) Most posterior portion of the Po (porion) Most superior point of the external nasofrontal junction auditory meatus Cm (columella Most anterior point on the ANS (anterior Most anterosuperior point on the point) columella nasal spine) anterior maxillary contour Sn (subnasale) Junction of columella and PNS (posterior Most posterior point on the upper lip nasal spine) hard palate Ls (labrale superius) Mucocutaneous border of the Point A Most posterior point on the anterior upper lip maxillary contour Stms (stomion Most inferior point on the Point B Most posterior point on the anterior superius) upper lip vermilion mandibular contour Stmi (stomion Most superior point on the Pg (pogonion) Most anterior point on the anterior inferius) lower lip vermilion mandibular contour Li (labrale inferius) Mucocutaneous border of the Me (menton) Most inferior point on the mandibular lower lip symphysis Pg= (pogonion) Most anterior point of the chin Go (gonion) Most inferior and posterior point at the Me (menton) Most inferior point of the chin mandibular angle C (cervical point) Point at which the neck transitions Co (condylion) Most posterior and superior point on from horizontal to vertical the condyle Gn (gnathion) Most anterior and inferior point on the symphysis the Frankfort horizontal plane, the natural head position, or the sella-nasion. The original refer- Landmark points and anatomical structures ence plane cited by Broadbent, the Frankfort hor- are identified on the output image that repre- izontal (Po-Or), was thought to represent the vi- sent important hard (Table 1 and Fig. 2) and soft sual axis. This was challenged by the description of (Table 2 and Fig. 3) tissue transitions. These the natural head position, which is the posture points are then joined to form lines and planes obtained by visually focusing on a distant object. (Table 3 and Fig. 4), which are subsequently de- The sella-nasion plane is the most commonly used scribed in terms of lengths, angles, and propor- reference for the anterior cranial base. tions (Table 4).12 Many of the relationships are This approach is commonly referred to as con- relative to a constructed reference plane such as ventional cephalometric analysis. The goal of this

Fig. 2. Skeletal landmarks. Fig. 3. Soft-tissue landmarks.

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Table 3. Planes The Downs analysis (Fig. 5) was derived from a Plane Description study of 20 boys and girls with a mean age of 14.5 years. It consists of a skeletal component and a den- S-N Sella-nasion plane Po-Or Frankfort horizontal plane (FH) tal component and uses the Frankfort horizontal as Go-Me Mandibular plane (MP) its reference plane. Downs used his constructed fa- N-Pg Facial plane (FP) hard tissue G-Pg Facial plane (FP=) soft tissue cial angle (N-Pg to FH; mean, 88 degrees), angle of ANS-PNS Palatal plane (PP) convexity (N-A-Pg; mean, 0 degrees), and the A-B plane angle (A-B to N-Pg; mean, Ϫ4.6 degrees) to describe the positions of the maxilla and mandible relative to the Frankfort horizontal reference plane. He also described the mandibular plane angle (FH to Go-Me; mean, 22 degrees) to further detail the inclination of the mandible. His dental analysis consisted of relating the central incisors to each other and the occlusal and mandibular planes.13,16,17 The Ricketts analysis (Fig. 6) and series of normative values were generated from the study of over 1000 children (mean age, 9 years), 60 percent of whom had class II occlusion. Ricketts also uses the Frankfort horizontal as its reference plane and borrows the facial angle of Downs (mean, 85.4 degrees). Ricketts’ method involved comparing points and planes to perpendicular lines running from the Frankfort horizontal. He defined and measured the facial contour by comparing the N-Pg plane to the FH-A perpendicular (mean, 4.1 mm). He also measured the distances of the upper incisor edge perpendicular (mean, 5.7 mm) and lower incisor edge perpendicular (mean, 0.5 mm) Fig. 4. Cephalometric planes. to the A-Pg plane to determine the positions of the maxilla and mandible. Ricketts also documented the inclination of the lower central incisor relative examination is to relate maxillary teeth to man- to the A-Pg line (mean, 20.5 degrees) along with dibular teeth, teeth to jaws, the jaws to each other, several other useful relations.15 and the jaws to the cranial base. Even though Alternatively, the Steiner analysis (Fig. 7) uses analytic methods have become more refined over the sella-nasion cranial base plane as its central time, most still use many of the basic relations reference. The most widely used component of described in early publications. Accordingly, sev- the Steiner analysis is the description of the angles eral of the better known analyses, such as Downs SNA, SNB, and ANB. Point A is the most posterior (1948),13 Steiner (1953),14 and Ricketts (1960)15 point on the anterior contour of the maxilla. Like- have persisted in some form since their develop- wise, point B is the most posterior point on the ment over 50 years ago. anterior curve of the mandible. The SNA (mean,

Table 4. Common Relationships Relationship Description Value (%) FH-SN Frankfort horizontal to cranial base 6 degrees SNA Cranial base to point A 82 Ϯ 3 degrees SNB Cranial base to point B 80 Ϯ 3 degrees ANB Point A to point B through nasion 2 degrees SN-MP Cranial base to mandibular plane 27 Ϯ 3 degrees FH-MP Frankfort horizontal to mandibular plane 21 Ϯ 3 degrees N-Me Total facial height 115 Ϯ 5.5 mm (100) N-ANS Upper facial height 50 Ϯ 2.5 mm (43) ANS-Me Lower facial height 65 Ϯ 4.5 mm (57)

95e Plastic and Reconstructive Surgery • November 2007

Fig. 5. Downs analysis. Fig. 7. Steiner analysis.

Fig. 6. Ricketts analysis. Fig. 8. McNamara analysis.

82 degrees) relates the horizontal position of the nasion (mean, 14 degrees). He also related the maxilla to the cranial base, whereas the SNB maxillary and mandibular central incisors to their (mean, 80 degrees) does the same for the man- respective bones in both linear and angular dible. The difference between the two is the ANB measures.14,18,19 (mean, 2 degrees), which describes the relation- More recent analyses such as those of Mc- ship between the maxilla and mandible. Steiner Namara,20 Grayson,21 and Ferraro22 use elements described the chin position relative to the man- of these early works supplemented with individual dible (N-B to Pg perpendicular) and the relation- innovations and relationships felt to be of impor- ship between the occlusal plane and the sella- tance. Regardless of which set of computations

96e Volume 120, Number 6 • Surgical Cephalometrics used, they all serve to describe the locations and sisted of two separate x-ray source and receiver sets interrelations of the maxilla, mandible, skull base, oriented at 90 degrees to capture both the lateral and dentition in both linear and angular means. and posteroanterior film simultaneously. Modern These values are then compared with established devices typically allow for the cephalostat to be norms to determine what imbalances exist and moved 90 degrees, permitting the use of a single which manipulations will create the desired oc- imaging system. Although the posteroanterior pro- clusal and aesthetic results. jection requires greater radiation exposure23 and has For example, in the McNamara analysis (Fig. greater potential for absolute error relative to the 8), the Frankfort horizontal is used for the refer- lateral film,24 important information for diagnosis ence plane and perpendiculars through the na- and treatment can be gained from this view. sion and point A are constructed in the manner of Posteroanterior cephalometric analysis is con- Ricketts. The sizes of the maxilla and mandible are ceptually very similar to evaluation of the lateral determined by measuring the distances from the film. Landmark points are identified (Table 5) condylion (the most posterior and superior posi- and lines are formed (Fig. 9). Distances and angles tion on the condyle) to point A (mean, 91.0 mm are measured and compared with norms to de- in women and 99.8 mm in men) and to the gna- termine the location and magnitude of facial thion (mean, 120.2 mm in women and 134.3 mm asymmetry present. Generally, a midsagittal plane in men), respectively. These values, and their dif- is identified that should connect the crista galli, ferences (mean, 29.2 mm in women and 34.5 mm anterior nasal spine, and dental and mandibular in men), are then compared with an atlas that midlines in the normal situation. This facial me- contains normative values of these measures. The ridian can be compared with constructed perpen- position of the maxilla relative to the cranial base diculars that bisect horizontal lines connecting is determined by measuring the linear distance bilateral structures. These horizontal lines can from point A to the nasion perpendicular (mean, also be compared with each other, with all being 0.4 mm in women and 1.1 mm in men). Likewise, parallel in the normal situation. The occlusal the position of the mandible relative to the cranial plane should be identified, as this is the most base is determined from measuring the distance clinically apparent manifestation of facial asym- from the pogonion to the nasion perpendicular metry. Common analytical approaches to the pos- (mean, –1.8 mm in women and –0.3 mm in men). teroanterior cephalogram have been published by The lower anterior facial height (ANS-Me) is mea- Ricketts et al.,25 Grummons and Kappeyne van de sured (mean, 66.7 mm in women and 74.6 mm in Coppello,26 and Athanasiou et al.27 men), as is the mandibular plane angle (relative to After the cephalometric analysis, prediction FH, 22.7 degrees in women and 21.3 degrees in tracings can then be constructed to map out men). The position of the upper central incisor planned interventions and predict the final oc- can be described relative to the maxilla in both clusal and aesthetic results. In the traditional horizontal (4 to 6 mm ahead of the point A per- method of prediction, elements of the cepha- pendicular) and vertical (2 to 3 mm of dental show logram, such as the maxilla or mandible, are on repose) directions. The lower central incisor traced on acetate sheets and relocated into their should lie 1 to 3 mm ahead of a line connecting ideal positions. Initially, the upper and lower point A and the pogonion and be covered with 1 central incisors are outlined and these tracings to 3 mm of overbite. Any discrepancies between are placed in their desired positions relative to these measurements and normative standards can the maxilla and mandible to simulate orthodon- be addressed using surgical and orthodontic tic manipulation. New tracings of the maxilla techniques.20 No specific approach is recognized and mandible, with the corrected incisor posi- as being superior to the others, but it is important tion, are then constructed. The maxilla is then that the clinician select a paradigm that is usable relocated into an appropriate position relative and gives predictable, understandable results. to the cranial base. The mandibular tracing is Facial asymmetry in the frontal plane induces then rotated about the condyle to meet the max- significant error in the assessment and evaluation illa, and adjustments are made to produce the of the lateral cephalogram. Bilateral structures best occlusion. The new construct with the rel- that are supposed to align or superimpose fail to evant facial elements in place is then traced and do so and lead to erroneous landmark identifica- compared with the original cephalogram to de- tion and distorted relationships. In these cases, the termine the magnitude and direction of any pro- posteroanterior cephalographic view is an impor- posed movements. This is coupled with the analysis tant adjunct. Broadbent’s original apparatus con- of dental models and the clinical examination to

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Table 5. Posteroanterior Points Point Description Ag (antegonion) Most superior point on the antegonial notch ANS (anterior nasal spine) Most superior point on the anterior maxilla Cd (condylar) Most superior point on the condylar head Iif (incision inferius frontale) Midpoint between central mandibular incisors at the incisal edge level Isf (incision superius frontale) Midpoint between central maxillary incisors at the incisal edge level Lpa (lateral piriform aperture) Most lateral aspect of piriform aperture M (mandibular point) Projection of mental spine on the lower mandibular border Lm (lower molar) Most lateral point on the first mandibular molar Um (upper molar) Most lateral point on the first maxillary molar Ma (mastoid) Most inferior point on the mastoid process Mx (maxillare) Intersection of the lateral maxillary alveolar process and the zygomaticomaxillary contour Za (zygomatic arch) Most lateral point on the zygomatic arch Tns (top nasal septum) Most superior point on the nasal septum Zfs (zygomaticofrontal suture) Medial extent of the zygomaticofrontal suture CG (crista galli) Most superior point of the crista galli

the aesthetic assessment of the human face, and surgeons continue to use many of the original principles in the evaluation of facial appearance.

Dysmorphology Many syndromes and diseases display craniofacial imbalances that can be objectively described using cephalometry. The characteristic appear- ances of patients with Prader-Willi,38 Down,39 Marfan,40,41 and other syndromes42–46 are well described in cephalometric terms. The cephalometric characteristics of osteogenesis imperfecta have been used to classify the various clinical subtypes and to document the altered growth patterns and cranial base morphology associated with this disease.47 Craniofacial growth restriction has also Fig. 9. Posteroanterior landmarks. been documented for epidermolysis bullosa.47,48 Although difficult to perform on young children, form the treatment plan. Soft tissues are also traced cephalometric techniques have been used to doc- and, based on the knowledge of their responses to ument the catch-up growth witnessed in patients particular skeletal movements,28–30 the aesthetics of with Pierre Robin sequence.49 Conversely, defi- the proposed intervention can then be evaluated. All cient growth has been documented in the maxilla of the point identifications, calculations, and ma- and lip of patients with van der Woude syndrome nipulations can be performed equally well with the when compared with sporadic cleft lip–cleft pal- appropriate computer software,31–37 with the final ate patients.50 The cranial base, which is of central goal being stable, functional occlusion coupled with importance when used as a reference plane in an optimal aesthetic appearance. conventional cephalometric analysis, has been found to be altered in acromegaly,51 Binder 52,53 54 55 APPLICATIONS syndrome, Cohen syndrome, thalassemia, Apert syndrome,56,57 and Crouzon syndrome.58,59 Cephalometric techniques and analyses have long enjoyed widespread use among orthodontists and orthognathic surgeons in the diagnosis and Temporomandibular Joint Assessment treatment of dentofacial disharmonies. However, The ability of cephalometrics to describe the other practitioners have used cephalometric tech- position of the mandible in relation to the skull base niques to investigate syndromic morphology, tem- has led to its application in the investigation of temporomandibular joint dysfunction, and obstructive poromandibular joint disorders. Skeletal imbal- sleep apnea. Cephalometry was originally applied to ances have long been implicated in the pathogenesis

98e Volume 120, Number 6 • Surgical Cephalometrics of temporomandibular joint dysfunction, but to date, no consistently reliable correlation has been found between temporomandibular joint disorders, anatomical variations, and magnetic resonance imaging studies.60–62 Cephalometric analysis has, however, demonstrated altered temporomandibular joint relations in patients with osteogenesis imperfecta types III and IV.47

Airway Assessment With the advent of digital radiography, clinicians gained the ability to easily adjust contrast levels on the cephalogram. This allowed for better visualization of soft-tissue structures, including those of the pharynx and airway. As a result, cephalometric analysis has been broadly used in the investigation of airway dimensions and obstructive sleep apnea. Anatomical variations among obstructive sleep apnea patients, snorers, and the obese have been compared with normal controls Fig. 10. Vertical proportions. in both the supine and erect positions.63–67 Al- though no definitive relationships have been discovered, it appears that obstructive sleep ap- trichion is the most anteroinferior point on the nea sufferers have lower set hyoid bones and midsagittal hairline and is so highly variable decreased anteroposterior pharyngeal airway among sexes and ages that it is of little routine use. lengths at the level of the soft palate.67–70 Ceph- Therefore, in situations of hairline recession or alometric characteristics have also been com- poor identification, the equal relationship between pared with the apnea-hypopnea index as a G-Sn and Sn-M remains useful. Similarly, the total means of correlating obstructive sleep apnea facial height can be defined as the distance from the severity with anatomical traits, but the results of these nasion to the menton. The midfacial portion (N-Sn) investigations are conflicting.67,68,71,72 Likewise, the re- constitutes 43 percent of this distance, whereas the lationship between obstructive sleep apnea and lower facial unit (Sn-M) constitutes 57 percent. The body mass index73,74 remains controversial. lower facial third can be further subdivided where Preoperative cephalometry has been advocated subnasale-stomion equals half the stomion-menton. in those undergoing surgery for obstructive sleep There should be 1 to 3 mm of upper incisor show in apnea75,76 and can be used to identify those who will repose. The thickness of the soft tissues of the lip and benefit from specific treatments77,78 such as mandib- chin should be equal along their course. ular advancement79 or uvulopalatopharyngoplasty.80 Soft-tissue relationships (Fig. 11) also can be Cephalometry has been applied in the evaluation of described in terms of several common angles avail- therapeutic interventions such as repositioning of able on the lateral cephalogram such as the na- the hyoid,81 mandible,82–86 and maxilla.87 sofrontal, nasofacial, nasolabial, nasomental, and mentofacial.88 The soft-tissue facial plane (FP=)is Soft-Tissue Analysis constructed by passing a line through the glabella The soft-tissue appearance depends heavily on and the pogonion. This line can be checked the underlying skeletal morphology, and this overt against the Frankfort horizontal with an accept- expression is what most patients and clinicians able junction measuring 80 to 95 degrees. The readily appreciate. Soft-tissue outlines captured nasofrontal angle is formed by comparing a line on the lateral cephalogram can be a useful adjunct connecting the glabella and the nasion with a line to photographs and clinical examination. The along the nasal dorsum. Normative values range profile can be assessed for proportionality by di- from 115 to 130 degrees. The line along the nasal viding the face into upper, mid, and lower facial dorsum also forms the nasofacial angle when com- thirds (Fig. 10). The distances from the trichion- pared with the facial plane (G=-Pg=) and should be glabella should equal the glabella-subnasale, 30 to 40 degrees. The nasolabial angle is con- which should equal the subnasale-menton. The structed by passing a line from the subnasale to the

99e Plastic and Reconstructive Surgery • November 2007

rate mathematical models for determining clinically relevant relations and dimensions. Fi- nally, issues relating to the radiologic forms of image capture have resulted in several techniques that derive similar data without exposure to radiation. The dependence of cephalometry on specific reference points and presumed bilateral symmetry becomes problematic when these factors are abnormal. Patients with hemifacial microsomia can have unequal positions of the external auditory canals, which will alter the head position in the cephalostat. Unilateral facial asymmetries will lead to difficulties in defining bilateral points on the lateral film. Bilateral structures that do not overlap require that the usable landmark point is averaged between the two outlines,21 thereby introducing error that is not present with midline landmarks (i.e., anterior nasal spine, pogonion, nasion). Fig. 11. Facial angles. Conventional analysis is limited by reliance on a reference plane (i.e., skull base) whose location may be inconsistent in certain populations such as most anterior point on the columella. A second syndromic patients. Similarly, the positioning of line running from the labrale superius to the sub- the head in the sagittal plane can alter the relative nasale intersects and forms the angle. Normal val- position of certain landmark points. For example, ues range from 90 to 105 degrees. The nasomental using the Frankfort horizontal or the natural head angle is formed by passing a line from the pogo- position can alter the position of point A and point nion to the nasal tip and comparing it to the nasal B,13 which may lead to potentially erroneous di- dorsal line. This angle serves to highlight the aes- agnoses of prognathia or retrognathia. thetic relationship between the nose and chin and The craniofacial region is a complex three- should ideally measure 120 to 135 degrees. With the nasofacial angle adjusted to the norm, the dimensional structure that undergoes change in a nasomental angle defines the relationship between nonuniform manner. When this structure is measured and analyzed by a two-dimensional tech- the lower face to the upper and mid facial masses. 94 Lip position is related to this nasomental line, with nique, a degree of accuracy is lost. In response, the upper lip falling twice as far behind the line as investigators have sought methods to acquire the lower lip. The cervicomental angle is con- three-dimensional information for a theoretically structed by comparing the soft-tissue facial plane more precise quantification and analysis. Early at- (G=-Pg=) to a line intersecting the cervical point tempts focused on combining anteroposterior and menton. The ideal range is 80 to 95 degrees. and lateral radiographic images and identifying 21,95 Other approaches are described to evaluate spe- structures in three planes. This approach has cific nasal aesthetics89–92 and chin positioning93 given way to the study of three-dimensionally re- with the aid of cephalometry. constructed computed tomographic scans of the head.96,97 Computed tomographic evaluation is particularly useful in young children who will not CRITICISMS cooperate with conventional cephalometric imag- The true utility of cephalometrics lies in its ing but require reconstructive procedures for syn- simplicity and versatility. There are, however, sev- dromic anatomy. As the quality of the computed eral criticisms of cephalometry that propel fur- tomographic images and the reconstructions has ther investigation into suitable corrections or improved, the disagreement with two-dimensional alternatives. Dissatisfaction with the two-dimen- cephalograms has diminished.98 Three-dimensional nature of cephalometric images has led to sional study of cranial dimensions has introduced the development of three-dimensional model- new reference points99 and relationships. This ap- ing. Disappointment with the analysis of ceph- proach may yield a more accurate quantification alometric data has prompted the use of elabo- of the anatomy, but widespread use is limited by

100e Volume 120, Number 6 • Surgical Cephalometrics a lack of an accepted evaluation scheme and the ated with diagnosis and treatment planning in pa- inability to obtain images in an office setting. tients with dentofacial disharmonies, cephalometric In an effort to limit radiation exposure and ob- techniques have been applied to a wide range of tain better cephalographic information, nonradio- maladies associated with altered craniofacial mor- graphic means of image acquisition have been de- phology. This expanded scope, coupled with new scribed. Surface mapping using portable scanners imaging modalities and data evaluation methods, has been developed to allow for capture of cepha- will add to an already rich history of technical inno- lometric soft-tissue data without traditional cepha- vation and clinical application. lometric equipment.100 Infrared photogrammetry Barry L. Eppley, M.D., D.M.D. produces three-dimensional soft-tissue measures 11725 North Illinois Street, Suite 140 that have been found to have a high degree of cor- Carmel, Ind. 46032 relation with underlying skeletal landmarks.101 Laser [email protected] scanning102 and sterolithographic103 techniques have also been used in attempts to obtain similar DISCLOSURE data without exposure to radiation or the incon- None of the authors has a financial interest in any venience of a cephalostat. of the products, devices, or drugs mentioned in this Cephalometric information expressed in article. lengths, angles, and proportions is used to describe the sizes and positions of the craniofacial REFERENCES structures. However, the craniofacial form is a 1. Trenmouth, M. J. Petrus Camper (1722–1789): Originator combination of both size and shape104 and the two of cephalometrics. Dent. Hist. 40: 3, 2003. parameters are difficult to isolate.105 The evalua- 2. Ricketts, R. M. 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of skeletal patterns in patients with and without internal de- parison of cephalometric variables. Int. J. Adult. Orthodon. rangement of the temporomandibular joint. Am. J. Orthod. Orthognath. Surg. 15: 139, 2000. Dentofacial Orthop. 107: 121, 1995. 79. Battagel, J. M., and L’Estrange, P. R. The cephalometric 62. Ahn, S. J., Kim, T. W., and Nahm, D. S. Cephalometric keys morphology of patients with obstructive sleep apnoea to internal derangement of temporomandibular joint in (OSA). Eur. J. Orthod. 18: 557, 1996. women with Class II malocclusions. Am. J. Orthod. Dentofacial 80. Woodson, B. T., and Conley, S. F. Prediction of uvulopala- Orthop. 126: 486, 2004. topharyngoplasty response using cephalometric radio- 63. Battagel, J. M., Johal, A., and Kotecha, B. A cephalometric graphs. Am. J. Otolaryngol. 18: 179, 1997. comparison of subjects with snoring and obstructive sleep 81. Rose, E., Lehner, M., Staats, R., and Jonas, I. E. Cephalo- apnoea. Eur. J. 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Cephalometric and polysomnographic analyses of Part I. diagnostic value. J. Orofac. Orthop. 63: 143, 2002. functional magnetic system therapy in patients with ob- 69. Johal, A., and Conaghan, C. Maxillary morphology in obstructive sleep apnea. Am. J. Orthod. Dentofacial Orthop. 120: structive sleep apnea: A cephalometric and model study. 169, 2001. Angle Orthod. 74: 648, 2004. 86. Fransson, A. M., Svenson, B. A., and Isacsson, G. The effect 70. Riha, R. L., Brander, P., Vennelle, M., and Douglas, N. J. A of posture and a mandibular protruding device on pharyn- cephalometric comparison of patients with the sleep ap- geal dimensions: A cephalometric study. Sleep Breath. 6: 55, nea/hypopnea syndrome and their siblings. Sleep 28: 315, 2002. 2005. 87. De Ponte, F. S., Brunelli, A., Marchetti, E., and Bottini, D. 71. Virkkula, P., Hurmerinta, K., Loytonen, M., Salmi, T., J. Cephalometric study of posterior airway space in patients Malmberg, H., and Maasilta, P. Postural cephalometric affected by Class II occlusion and treated with orthognathic analysis and nasal resistance in sleep-disordered breathing. surgery. J. Craniofac. Surg. 10: 252, 1999. Laryngoscope 113: 1166, 2003. 88. Powell, N., and Humphreys, B. Proportions of the Aesthetic Face. 72. Bates, C. J., and McDonald, J. P. The relationship between New York: Thieme-Stratton, 1984. severity of obstructive sleep apnoea/hypopnoea syndrome 89. Guyuron, B. Precision rhinoplasty: Part I. The role of life- (OSAHS) and lateral cephalometric radiograph values: A size photographs and soft-tissue cephalometric analysis. clinical diagnostic tool. Surgeon 3: 338, 2005. Plast. Reconstr. Surg. 81: 489, 1988. 73. Pae, E. K., and Ferguson, K. A. Cephalometric character- 90. Begg, R. J., and Harkness, M. A lateral cephalometric anal- istics of nonobese patients with severe OSA. Angle Orthod. 69: ysis of the adult nose. J. Oral Maxillofac. Surg. 53: 1268, 1995. 408, 1999. 91. Starck, W. J., and Epker, B. N. Cephalometric analysis of 74. Paoli, J. R., Lauwers, F., Lacassagne, L., Tiberge, M., Dodart, profile nasal esthetics: Part I. Method and normative data. L., and Boutault, F. Craniofacial differences according to Int. J. Adult. Orthodon. Orthognath. Surg. 11: 91, 1996. the body mass index of patients with obstructive sleep 92. Fruscella, P. Cephalometric analysis and postoperative re- apnoea syndrome: Cephalometric study in 85 patients. Br. sults in aesthetic rhinoplasty. Aesthetic Plast. Surg. 21: 79, J. Oral Maxillofac. Surg. 39: 40, 2001. 1997. 75. Lyberg, T., Krogstad, O., and Djupesland, G. Cephalomet- 93. Spear, S. L., and Kassan, M. Genioplasty. Clin. Plast. Surg. 16: ric analysis in patients with obstructive sleep apnoea syn- 695, 1989. drome: I. Skeletal morphology. J. Laryngol. Otol. 103: 287, 94. Ayoub, A. F., Wray, D., Moos, K., et al. Three-dimensional 1989. modeling for modern diagnosis and planning in maxillo- 76. Lyberg, T., Krogstad, O., and Djupesland, G. Cephalomet- facial surgery. Int. J. Adult. Orthodon. Orthognath. Surg. 11: ric analysis in patients with obstructive sleep apnoea syn- 225, 1996. drome: II. Soft tissue morphology. J. Laryngol. Otol. 103: 293, 95. Mori, Y., Miyajima, T., Minami, K., and Sakuda, M. An 1989. accurate three-dimensional cephalometric system: A solu- 77. Guilleminault, C., Riley, R., and Powell, N. Obstructive sleep tion for the correction of cephalic malpositioning. J. Orthod. apnea and abnormal cephalometric measurements: Impli- 28: 143, 2001. cations for treatment. Chest 86: 793, 1984. 96. Moss, J. P., Grindrod, S. R., Linney, A. D., Arridge, S. R., and 78. Tangugsorn, V., Krogstad, O., Espeland, L., and Lyberg, T. James, D. A computer system for the interactive planning Obstructive sleep apnea (OSA): A cephalometric analysis of and prediction of maxillofacial surgery. Am. J. Orthod. Dento- severe and non-severe OSA patients: Part I. Multiple com- facial Orthop. 94: 469, 1988.

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97. Haffner, C. L., Pessa, J. E., Zadoo, V. P., and Garza, J. R. A 104. Sprent, P. The mathematics of size and shape. Biometrics 28: technique for three-dimensional cephalometric analysis as 23, 1972. an aid in evaluating changes in the craniofacial skeleton. 105. Hennessy, R. J., and Moss, J. P. Facial growth: Separating Angle Orthod. 69: 345, 1999. shape from size. Eur. J. Orthod. 23: 275, 2001. 98. Papadopoulos, M. A., Jannowitz, C., Boettcher, P., et al. 106. McIntyre, G. T., and Mossey, P. A. Size and shape measure- Three-dimensional fetal cephalometry: An evaluation of the ment in contemporary cephalometrics. Eur. J. Orthod. 25: reliability of cephalometric measurements based on three- 231, 2003. dimensional CT reconstructions and on dry skulls of sheep 107. Lavelle, C. L. Statistical methodology applied to facial stud- fetuses. J. Craniomaxillofac. Surg. 33: 229, 2005. ies. J. Craniofac. Genet. Dev. Biol. 9: 93, 1989. 99. Lagravere, M. O., and Major, P. W. Proposed reference 108. Lele, S., and Richtsmeier, J. T. Euclidean distance matrix point for 3-dimensional cephalometric analysis with cone- analysis: A coordinate-free approach for comparing biolog- beam computerized tomography. Am. J. Orthod. Dentofacial ical shapes using landmark data. Am. J. Phys. Anthropol. 86: Orthop. 128: 657, 2005. 415, 1991. 100. Nagasaka, S., Fujimura, T., and Segoshi, K. Development of 109. Halazonetis, D. J. Morphometrics for cephalometric diag- a non-radiographic cephalometric system. Eur. J. Orthod. 25: nosis. Am. J. Orthod. Dentofacial Orthop. 125: 571, 2004. 77, 2003. 101. Ferrario, V. F., Sforza, C., Puleo, A., Poggio, C. E., and 110. Chang, H. P., Liu, P. H., Chang, H. F., and Chang, C. H. Schmitz, J. H. Three-dimensional facial morphometry and Thin-plate spline (TPS) graphical analysis of the mandible conventional cephalometrics: A correlation study. Int. J. on cephalometric radiographs. Dentomaxillofac. Radiol. 31: Adult. Orthodon. Orthognath. Surg. 11: 329, 1996. 137, 2002. 102. McCance, A. M., Moss, J. P., Wright, W. R., Linney, A. D., 111. Sameshima, G. T., and Melnick, M. Finite element-based and James, D. R. A three-dimensional soft tissue analysis of cephalometric analysis. Angle Orthod. 64: 343, 1994. 16 skeletal class III patients following bimaxillary surgery. 112. Ferrario, V. F., Sforza, C., Poggio, C. E., D’Addona, A., and Br. J. Oral Maxillofac. Surg. 30: 221, 1992. Taroni, A. Fourier analysis of cephalometric shapes. Cleft 103. Bill, J. S., Reuther, J. F., Dittmann, W., et al. Stereolithog- Palate Craniofac. J. 33: 206, 1996. raphy in oral and maxillofacial operation planning. Int. 113. Lavelle, C. L. A study of mandibular shape. Br. J. Orthod. 11: J. Oral Maxillofac. Surg. 24: 98, 1995. 69, 1984.

104e SPECIAL TOPIC

Operating Room Fires: Optimizing Safety

Silvia Cristina Meneghetti, Background: This prospective study was undertaken to determine the safest M.D. means of supplemental oxygen delivery for patients undergoing facial cosmetic Mark M. Morgan, M.D. surgery under conscious sedation. Two common methods of oxygen delivery Janet Fritz, C.R.N.A. were used in 20 patients: (1) a nasal cannula and (2) a red rubber nasopha- Raymond G. Borkowski, M.D. ryngeal tube through which the cut ends of the nasal cannula were passed into Risal Djohan, M.D. the posterior pharynx. James E. Zins, M.D. Methods: The project was carried out in two parts. In part one, each subject was Cleveland, Ohio placed supine and oxygen supplementation at 3 liters/minute was applied through the nasal cannula. The oxygen concentration at 24 different set locations around the patient’s face was analyzed using the random access mass spectrometer unit, starting at the right and left alar rim and then at 2-cm intervals laterally, superiorly, and inferiorly. The procedure in part one was repeated with oxygen being delivered by passing the cut cannula end through a red rubber nasopharyngeal tube into the posterior pharynx. Results: Statistical analysis has showed that in all sites at or above the nasal area, the difference between the nasal cannula and red rubber nasopharyngeal tube is significantly greater than 0, indicating that higher concentrations are observed with the nasal cannula than with the red rubber nasopharyngeal tube (p ϭ 0.004). Conclusion: The authors’ study demonstrates a significant reduction in oxygen concentration, to levels consistent with ambient air, even at points extremely close to the oxygen source, when the nasopharyngeal tube system was used. (Plast. Reconstr. Surg. 120: 1701, 2007.)

lthough rare, operating room fires can be nasal cannula (i.e., turning off oxygen approxi- devastating. Approximately 100 operating mately 1 minute before use of the Bovie Aroom fires occur in the United States per device),5,6 and (3) a nasopharyngeal airway with year, resulting in significant patient morbidity the cut ends of the nasal cannula passed through and mortality.1–3 Common operating room in- the tube to provide a high flow of oxygen to the strumentation including fiberoptic lights and nasopharynx. This last system also prevents par- lighted retractors, lasers, paper drapes, and elec- tial upper airway obstruction caused by the trocautery have all been implicated in these tongue falling into the pharynx.17 events.1–16 The face is the second most common The use of the nasopharyngeal tube system surgical area injured by fire, with only the tonsils has been advocated to enhance maintenance of being more common. Approximately 78 percent the difficult airway in the awake pediatric popu- of all fires occur during facial, neck, and tonsil lation (patients with Pierre Robin sequence, chil- surgery.2,6,9,12,13 dren in developing countries with hypoxemia Suggested means of supplying supplemental caused by lower respiratory tract infection, and oxygen during facial plastic surgery procedures for children undergoing dental extractions).17–24 performed under conscious sedation vary con- Riefkohl and Kosanin described this technique siderably. These include (1) continuous oxygen in the plastic surgery literature in 1986 to pre- administration using a nasal cannula,14 (2) inter- vent hypoxemia and partial airway obstruction in mittent use of oxygen delivery by means of a the sedated patient and concluded that this system is usually well tolerated.17 At our institution, From the Department of Plastic Surgery and the Division of we have been using this nasopharyngeal tube Anesthesia, The Cleveland Clinic Foundation. system for over 15 years in deeply sedated facial Received for publication August 26, 2005; accepted Novem- plastic surgery patients. The rationale for this ber 17, 2005. study came from the senior author’s (J.E.Z.) ex- Copyright ©2007 by the American Society of Plastic Surgeons perience in maintaining difficult airways in the DOI: 10.1097/01.prs.0000282729.23202.da pediatric plastic surgery population. In extend-

www.PRSJournal.com 1701 Plastic and Reconstructive Surgery • November 2007

Fig. 1. Schematic representation of the grid superimposed on the face. Each point measured (asterisks) was located and reported by the intersection of the horizontal row (1 though 9) with a vertical column (1 through 12). ing this technique to the consciously sedated dom mass spectrometer unit (Marquette RAMS; facial plastic surgery patient, it was hypothesized Marquette Electronics, Milwaukee, Wis.). The accu- that this method of oxygen delivery might de- racy of the readings of this single-patient unit has crease oxygen concentration around the face been documented previously.25–28 Once these re- and thus reduce the possibility of fires in this cordings were completed, the nasal cannula was re- patient population. moved and a red rubber nasopharyngeal tube lu- The purpose of this prospective study there- bricated with lidocaine jelly was gently and slowly fore was to compare two commonly used meth- passed through one of the nares into the posterior ods of providing supplemental oxygen during pharynx.17 The oxygen and carbon dioxide cannulas facial cosmetic surgery procedures: (1) a nasal were then cut and passed down the nasopharyngeal cannula (MAC-SAFE Nasal Cannula; Unomedi- tube approximately 4 to 5 cm. This distance allowed cal, Inc., McAllen, Texas) and (2) a Ru¨sch (Tele- the cannulas to remain in the nasopharyngeal tube flex Medical, Limerick, Pa.) red rubber nasopha- while not being advanced into the posterior phar- ryngeal tube with the cut ends of the nasal ynx, thus avoiding occlusion of the cannulas by se- cannula passed through the center of the tube.17 cretions (Fig. 2). Oxygen concentration measure- Oxygen concentrations were compared at a va- ments were then repeated using the RAMS unit. riety of points about the face using these two Measurements were taken by placing the distal techniques. end of the tubing system connected to the RAMS unit directly on the skin and then moving the PATIENTS AND METHODS distal end over each of the respective points on the Twenty patients undergoing outpatient facial face that was measured. This system needs only cosmetic surgery under local anesthesia with con- several seconds to clear the gases in the tubing. scious sedation and oxygen supplementation were However, 1 minute was allowed to elapse between studied prospectively. Conscious sedation was ac- measurements to be precise and consistent from complished using an intravenous infusion of location to location. The RAMS unit displayed propofol and alfentanil. Sedation was determined oxygen, nitrogen, and carbon dioxide concentra- to be adequate when patients maintained sponta- tion for each patient, but only oxygen was re- neous respiration and were unresponsive to verbal corded in this study. stimuli but responsive to tactile stimulation. After adequate sedation, supplemental oxygen at a flow of 3 liters/minute was supplied using a nasal Statistical Analysis cannula. Oxygen concentration was then measured Oxygen concentration levels at each site were at 2-cm intervals around the nose, cheek, and lower summarized using medians and interquartile eyelids (Fig. 1) in a grid-like fashion using the ran- ranges, because means did not reflect the central

1702 Volume 120, Number 6 • Operating Room Fires

izontal) and column (vertical). Table 1 presents the median oxygen concentration at each site, and the 25th and 75th percentiles of the data. For example, row 5, column 8 represents the site under the patient’s left nostril. The median concentration when the nasal cannula was used was 76.95, whereas the median concentration was only 20.70 when the nasopharyngeal tube system was used. Contour plots for each of the methods and their difference are shown in Figures 3 through 5. The median differences in oxygen concentration by site are also listed in Table 1. For illustration purposes, the median difference between the nasal cannula and the nasopharyngeal tube system at the site below the patient’s left nostril (row 5, column 8) was 55.35 (p Ͻ 0.001). At all sites at the level of or superior to the nostrils, the oxygen concentration using the nasal cannula was significantly higher than when the nasopharyngeal tube Ͻ Fig. 2. (Above) MAC-SAFE Nasal Cannula is specially designed to system was used (p 0.001). The largest median provide supplemental oxygen while simultaneously sampling differences were observed at the nostril level (row end-tidal carbon dioxide. The cannula provides oxygen through 5, columns 5 and 8), where the differences ex- two bottom ports, and nasal prongs collect expired gases that ceeded 45. However, the median differences were can be tested through the gas sampling line. (Below) Nasopha- also greater than 10 for many observations near ryngeal tube system. Cut ends of the nasal cannula have been the eyelids (row 7, columns 3, 10, and 12; and row passed down the Ru¨sch tube. 9, columns 3 and 10). Repeated measure models showed a significant interaction between location and oxygen de- tendency of the data. Within patients, the differ- livery method. This means that the difference in ences in oxygen concentration levels between the oxygen concentration between methods was af- cannula and the nasopharyngeal tube system were fected by the location of the measurement, and calculated by site. To evaluate whether differences that differences between methods was evaluated existed between methods at each site, two-sided separately at each site. Wilcoxon signed rank tests were performed. The tests were each conducted using a Bonferroni- DISCUSSION corrected significance level of 0.05/24 ϭ 0.002, to Operating room fires are rare but devastating control the overall error level at 0.05. events. The literature has clearly documented and To evaluate an overall difference in oxygen surgeons and other operating room personnel are concentration between methods, a repeated mea- well aware of the fact that fiberoptic lights, lasers, sure model was fit using all measurements. A spa- and electrocautery devices may cause operating tial correlation structure was assumed for readings room fires.1–16 However, it has been our experi- within the same patient and method, because lo- ence that operating room personnel are less aware cations that were closer in proximity were ex- of the fact that supplemental oxygen delivered pected to have more similar concentration levels. during facial surgery performed under conscious Contour plots, which show areas of similar oxygen sedation poses a significant risk. This lack of aware- concentration by method, were created using the ness has led to significant injury both at our and R software package,29 using a linear interpolation at other institutions in our area in recent years. method30 to estimate the concentration in areas of Furthermore, guidelines in the plastic surgery lit- the plot between the measured locations. All other erature for the use of supplemental oxygen during statistical analyses were performed using SAS soft- facial cosmetic surgery are sparse, and suggested ware (version 8; SAS Institute, Inc., Cary, N.C.). means of minimizing the risk of fire are sometimes contradictory or ill advised.5,31 For example, in one RESULTS study addressing the issue of fire in the operating Figure 1 schematically depicts the data tabu- room during facial surgery, the authors recom- lated in Table 1, defining each point by row (hor- mend the use of a nasal cannula for the delivery

1703 Plastic and Reconstructive Surgery • November 2007

Table 1. Median and Interquartile Ranges at Each Site for the Nasal Cannula, the Nasopharyngeal Tube System, and the Difference between the Two* Site Difference *Row Column NC (IQR) NTS (IQR) (NC ؊ NTS) (IQR) p 1 1 20.75 (20.60–21.70) 20.50 (20.50–20.60) 0.25 (0.00–1.05) 0.008 1 3 20.70 (20.50–22.00) 20.50 (20.50–20.60) 0.15 (0.05–1.55) Ͻ0.001 1 5 20.70 (20.60–21.00) 20.55 (20.50–20.60) 0.20 (0.00–0.45) 0.026 1 8 20.95 (20.60–21.95) 20.50 (20.50–20.80) 0.40 (0.05–0.90) 0.004 1 10 21.10 (20.70–22.55) 20.60 (20.50–20.70) 0.50 (0.05–2.10) 0.008 1 12 21.55 (20.80–22.60) 20.55 (20.50–20.60) 1.00 (0.25–2.10) Ͻ0.001 3 1 20.80 (20.60–23.60) 20.50 (20.50–20.60) 0.25 (0.15–3.15) Ͻ0.001 3 3 22.75 (21.20–25.25) 20.60 (20.50–20.60) 2.25 (0.70–4.70) Ͻ0.001 3 10 23.00 (21.30–25.25) 20.60 (20.55–20.85) 1.95 (0.55–4.35) 0.003 3 12 21.65 (20.95–24.20) 20.50 (20.50–20.60) 1.00 (0.25–2.10) Ͻ0.001 5 1 34.60 (21.70–42.90) 20.50 (20.50–20.60) 14.10 (1.05–21.90) Ͻ0.001 5 3 51.25 (42.90–66.45) 20.60 (20.50–20.85) 29.70 (21.65–45.65) Ͻ0.001 5 5 71.05 (62.05–76.65) 21.00 (20.60–27.10) 45.85 (30.95–50.05) Ͻ0.001 5 8 76.95 (72.35–84.25) 20.70 (20.60–24.20) 55.35 (51.40–60.35) Ͻ0.001 5 10 45.10 (36.85–57.90) 20.70 (20.50–21.15) 24.30 (14.00–37.15) Ͻ0.001 5 12 34.55 (25.25–38.30) 20.60 (20.50–20.85) 14.00 (4.75–17.75) Ͻ0.001 7 1 25.60 (21.40–37.45) 20.55 (20.50–20.60) 5.05 (0.85–16.95) Ͻ0.001 7 3 35.60 (31.15–52.05) 20.50 (20.50–20.60) 15.05 (10.65–31.55) Ͻ0.001 7 10 34.55 (28.40–48.05) 20.55 (20.50–20.70) 13.75 (7.45–27.45) Ͻ0.001 7 12 35.10 (27.50–47.35) 20.55 (20.50–20.60) 14.55 (6.95–26.90) Ͻ0.001 9 1 26.50 (20.55–29.75) 20.50 (20.50–20.60) 5.85 (0.10–9.15) Ͻ0.001 9 3 30.65 (22.55–35.10) 20.50 (20.50–20.60) 10.05 (2.00–14.55) Ͻ0.001 9 10 33.85 (26.15–42.95) 20.50 (20.50–20.70) 13.35 (5.45–22.50) Ͻ0.001 9 12 30.00 (22.05–40.85) 20.65 (20.50–21.20) 9.35 (0.75–20.15) Ͻ0.001 NC, nasal cannula; NTS, nasopharyngeal tube system. *Two-sided Wilcoxon signed rank test of whether the difference equals 0.

Fig. 3. A contour plot is used to depict mean oxygen concentration over the face using the nasal cannula. Each colored area corresponds to a speciﬁc oxygen concentration range, depicted by a colored bar to the right of the oxygen plot. This average concentration represented by each colored area was calculated by interpolation as described in Patients and Methods. of supplemental oxygen with no mention at all ing electrocautery during facial surgery.6 Al- regarding oxygen flow while electrocautery is though perhaps safe in theory, this raises the used.14 In a second study addressing oxygen flow, possibility of human error. Should the surgeon the authors recommend turning off the supple- forget and fail to inform the anesthesia team to mental oxygen and waiting 60 seconds before us- turn off the supplemental oxygen or should the

1704 Volume 120, Number 6 • Operating Room Fires

Fig. 4. Contour plot of the mean oxygen concentration over the face with an oxygen ﬂow of 3 liters/minute using the nasopharyngeal tube system. Colored areas correspond to the mean oxygen concentration range, depicted by a colored bar to the right.

Fig. 5. A contour plot representing the difference in mean oxygen concentrations over the entire face between the nasal cannula and the nasopharyngeal tube system is presented. The key for the difference in concentrations is listed to the right of the graph. anesthesia team fail to turn off the oxygen when cial surgery.31 Using a fiberglass model, they dem- so instructed, the risk of fire is real. onstrated that the nasal cannula ignited at a min- For fires to occur, the classic triad must be imum coagulation level of 30 W, an oxygen flow of present: a spark, flame, or heat source to cause 2 liters/minute, and a linear distance of 5 cm from ignition; a fuel source (a flammable item); and an the oxygen source. The implications of these mea- oxidated material (i.e., oxygen).2,5,7,11,31 The like- surements as they apply to surgery around the face lihood of fire, therefore, relates not only to oxygen should be clear. Such conditions exist in a large level but also to the power of the ignition source number of facial cosmetic cases performed under (i.e., Bovie device)2,4,6,7,9–11 and the flammability of conscious sedation. the fuel source (paper drapes, cloth drapes, or This project was undertaken because of the preparation solution).6,7,11 Reyes et al. determined inconsistencies in the studies noted above. In par- the minimum conditions for combustion while ticular, could a safer means of delivering supple- supplemental oxygen was administered during fa- mental oxygen during facial surgery be delineated

1705 Plastic and Reconstructive Surgery • November 2007 so that accidents attributable to human error when a nasopharyngeal tube system was used. Fur- could be minimized?7 Based on our clinical expe- thermore, the significant reduction in oxygen con- rience, we believe that the red rubber nasopha- centration with the nasopharyngeal tube system ryngeal tube offers such a benefit. The idea for dropped the oxygen concentration to levels con- using the red rubber nasopharyngeal tube for pa- sistent with ambient air. This clearly adds safety, tients undergoing facial plastic surgery proce- increases the margin for human error (when the dures under conscious sedation was derived from surgeon forgets to say “oxygen off”), and expedites the senior author’s (J.E.Z.) experience with the performance of the operation under conscious use of the red rubber nasopharyngeal tube in sedation. Should surgeons and anesthesiologists awake pediatric patients with difficult airways to heed these recommendations, the risk of operat- reduce airway obstruction. It therefore seemed to ing room fires may well be reduced. be a logical technique to use in the facial plastic Although the above clearly documents the po- surgery patient when the need to reduce the ox- tential benefit of the red rubber nasopharyngeal ygen concentration around the operative field was system in reducing oxygen concentration in the required. Indeed, this nasopharyngeal setup has operative field of the patient undergoing facial been effectively used at our institution for con- plastic surgery under conscious sedation, poten- scious sedation for over 15 years, with no known tial complications of this system have not been major complications. We therefore chose two delineated. However, our clinical experience with common methods of oxygen delivery at our insti- the system has been quite favorable and problems tution for this study while keeping delivery con- negligible. Review of certain clinical nuances stant at 3 liters/minute. The data collected in our when using the system will be helpful to those who study show that supplemental oxygen levels are are unfamiliar with its setup. significantly higher at every point on the facial From a preoperative preparation stand- grid with a MAC-SAFE Nasal Cannula compared point, patients are prepared similar to those with the nasopharyngeal tube system. The differ- undergoing general anesthesia (i.e., nothing to ence in oxygen concentration between the deliv- eat or drink after midnight the night before ery methods was larger in locations at or superior to surgery). Under light sedation, the placement of the nose level, indicating that these areas may have the nasopharyngeal tube is somewhat uncom- added risks for fires when the nasal cannula is used. fortable and, once in place, patients frequently In particular, locations just below the nose and at the complain that there is “something in the back of lower lid level both showed significantly higher con- the throat.” Therefore, the patient is more com- centrations with use of the nasal cannula. fortable and the operation runs more smoothly Although the results of the repeated measure if the patient is deeply sedated during the inser- models confirmed the findings of the other fig- tion and maintenance phases of this technique. A ures and tests, the assumption that dependence Ru¨sch tube is used because its soft rubber allows within patients was based on the distance between easy, atraumatic placement into the nasal cavity measurements alone was not satisfied, because ar- and posterior pharynx. Although minor bleed- eas near the oxygen source were related differ- ing from passage of the tube can occur, there ently than those away from the nostrils. Model has been no instance of a major bleed from its results may be affected by this relationship, so the use in our experience. Occlusion of the Ru¨sch two-sided Wilcoxon signed rank tests were used to tube by mucus is theoretically possible. How- compare oxygen delivery methods at each site. ever, such an occurrence should be relatively The number of hypothesis tests comparing delivery obvious clinically. Either an increase in carbon methods was large, so some significant differences dioxide or a decrease in oxygen saturation will between methods would be expected by chance be evident, as both are separately and continu- alone. However, the fact that all locations at or su- ously monitored during surgery. Because these perior to the nostrils showed large, statistically sig- procedures are performed under conscious se- nificant differences confirms our belief that the na- dation, the patient theoretically should protect sopharyngeal tube system provides lower oxygen his or her airway, thus preventing aspiration. concentrations at nearly every location. The nasopharyngeal tube is significantly softer Although our study did not examine the other than both a nasogastric and an endotracheal two of the three variables of the classic triad (fuel tube. Therefore, iatrogenic creation of a false source or heat source), it did demonstrate a sig- passage in the nasopharynx or posterior phar- nificant reduction in oxygen concentration even ynx that can occasionally occur with a nasogas- at points extremely close to the oxygen source tric tube or with nasotracheal intubation is ex-

1706 Volume 120, Number 6 • Operating Room Fires tremely unlikely. We could find only one case 5. Greco, R. J., Gonzalez, R., Johnson, P., et al. Potential dangers report in the anesthesia literature demonstrat- of oxygen supplementation during facial surgery. Plast. Re- constr. Surg. 95: 978, 1995. ing dissection of the nasopharyngeal space by 6. Daane, S. P., and Toth, B. A. Fire in the operating room: 33 the red rubber tube. Although beyond the pur- Principles and prevention. Plast. Reconstr. Surg. 115: 73e, 2005. view of this article, it is the policy of our out- 7. Wald, D., Michelow, B. J., Guyuron, B., et al. Fire hazards and patient surgery center that all conscious seda- laser resurfacing. Plast. Reconstr. Surg. 101: 185, 1998. tion be administered by or under the direct 8. Chang, B. W., Petty, P., and Manson, P. N. Patient fire safety in the operating room. Plast. Reconstr. Surg. 93: 519, supervision of the anesthesia team. The anes- 1994. thesia team is composed of an anesthesiologist 9. Brechtelsbauer, B. P., Carroll, W. R., and Baker, S. Intraop- or nurse anesthetist under the direct supervi- erative fire with electrocautery. Otolaryngol. Head Neck Surg. sion of an anesthesiologist. We do not, however, 114: 328, 1996. claim that this represents the standard of care in 10. Bowdle, T. A., Glenn, M., Colston, H., et al. Fire following use of electrocautery during emergency percutaneous transtra- our locale or anywhere else. cheal ventilation. Anesthesiology 66: 697, 1987.

11. Rohrich, R. J., Gyimesi, I. M., Clark, P., et al. CO2 laser safety considerations in facial skin resurfacing. Plast. Reconstr. Surg. CONCLUSIONS 100: 1285, 1997. This prospective study documents a statisti- 12. Awan, M. S., and Ahmed, I. Endotracheal tube fire during tracheostomy: A case report. Ear Nose Throat J. 81: 90, 2002. cally significant reduction in oxygen concentra- 13. Matucci, K. F., and Militana, C. J. The prevention of fire tions in the operative field in facial plastic sur- during oropharyngeal electrosurgery. Ear Nose Throat J. 82: gery patients undergoing conscious sedation 107, 2003. when the cut ends of the nasal cannula are 14. Lowry, R. K., and Noone, R. B. Fires and burns during plastic passed down a red rubber nasopharyngeal tube surgery. Ann. Plast. Surg. 46: 72, 2001. 15. Toledano Fernandez, N., Garcia Saenz, S., Sanchez Cruz, J., into the posterior pharynx when compared with et al. Lower lip burn due to a fire during a blepharoplasty patients using a nasal cannula under similar cir- procedure. Arch. Soc. Esp. Oftalmol. 80: 297, 2005. cumstances. In those patients using this naso- 16. Weaver, J. M. Fire hazards with ambulatory anesthesia in the pharyngeal setup, oxygen concentrations in the dental office. Anesth. Prog. 51: 45, 2004. operative field were consistent with ambient air, 17. Riefkohl, R., and Kosanin, R. M. A practical method for oxygen administration during cosmetic facial surgery. Ann. even at points extremely close to the oxygen Plast. Surg. 16: 535, 1986. source. Experience with this nasopharyngeal sys- 18. Bagshaw, O. N., Southee, R., and Ruiz, K. A comparison of tem at our institution over the past 15 years has the nasal mask and the nasopharyngeal airway in paediatric documented excellent patient and physician ac- chair dental anesthesia. Anesthesia 52: 786, 1997. ceptance, with minimal morbidity. 19. Chhajed, P. N., Aboyoun, C., Malouf, M. A., et al. Prophy- lactic nasopharyngeal tube insertion prevents acute hypoxae- James E. Zins, M.D. mia due to upper-airway obstruction during flexible bron- Department of Plastic Surgery choscopy. Intern. Med. J. 33: 317, 2003. The Cleveland Clinic Foundation 20. Weber, M. W., Palmer, A., Oparaugo, A., et al. Comparison 9500 Euclid Avenue of nasal prongs and nasopharyngeal catheter for the de- Crile Building A60 livery of oxygen in children with hypoxemia because of a Cleveland, Ohio 44195 lower respiratory tract infection. J. Pediatr. 127: 378, 1995. [email protected] 21. Wilson, J., Arnold, C., Connor, R., et al. Evaluation of oxygen delivery with the use of nasopharyngeal catheters and nasal cannulas. Neonatal Netw. 15: 15, 1996. DISCLOSURE 22. Muhe, L., Degefu, H., Worku, B., et al. Comparison of nasal prongs with nasal tubes in the delivery of oxygen to children None of the authors has a financial interest in any with hypoxia. J. Trop. Pediatr. 44: 365, 1998. of the products, devices, or drugs mentioned in this 23. Wilson, J., Arnold, C., Connor, R., et al. Evaluation of oxygen article. delivery with the use of nasopharyngeal tubes and nasal cannulas. Neonatal Netw. 15: 15, 1996. 24. Chung, C. H., Sum, C. W., Li, H. L., et al. Comparison of nasal REFERENCES trauma associated with nasopharyngeal airway applied by 1. Joint Commission on Accreditation of Healthcare Organi- nurses and experienced anesthesiologists. Changgeng Yi Xue zations. Sentinel Event Alert 29: 1, June 24, 2003. Za Zhi 22: 593, 1999. 2. Podnos, Y. D., and Williams, R. A. Fires in the operating room. 25. Delaney, P. A., Barnas, G. M., and Mackenzie, C. F. Response American College of Surgeons, Committee of Perioperative time studies of a new portable mass spectrometer. J. Clin. Care. Bull. Am. Coll. Surg. 82: 8, 1997. Monitor. 13: 181, 1997. 3. Stouffer, D. J. Fires during surgery: Two fatal incidents in Los 26. PPG Biomedical Systems. SARA Service Manual. Pittsburgh, Angeles. J. Burn Care Rehabil. 13: 114, 1992. Pa.: PPG Biomedical Systems, 1987. 4. Howard, B. K., and Leach, J. L. Prevention of flash fires 27. Carlon, G. C., Kopec, I. C., Miodowik, S., et al. Frequency during facial surgery performed under local anesthesia. Ann. response of the peripheral samplings sites of a clinical mass Otol. Rhinol. Laryngol. 106: 248, 1997. spectrometer. Anesthesiology 72: 187, 1990.

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28. Lerou, J. G., and van Egmond, J. Mass spectrometry: Perfor- oxygen: Ensuring its safe delivery during facial surgery. Plast. mance of long tubes. J. Clin. Monit. 9: 68, 1993. Reconstr. Surg. 95: 924, 1995. 29. Akima, H. A method of bivariate interpolation and smooth 32. Wolf, G. L., Sidebotham, G. W., Lazard, J. L., et al. Laser surface fitting for irregularly distributed data points. ACM ignition of surgical drape materials in air, 50% oxygen, and Transactions on Mathematical Software (TOMS) 4: 160, 1978. 95% oxygen. Anesthesiology 100: 1167, 2004. 30. Ihaka, R., and Gentleman, R. R: A language for data analysis 33. Baumann, R. C., and MacGregor, D. A. Dissection of the and graphics. J. Comput. Graph. Stat. 5: 299, 1996. posterior pharynx resulting in acute airway obstruction. An- 31. Reyes, R. J., Smith, A. A., Mascaro, J. R., et al. Supplemental esthesiology 82: 1516, 1995.

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1708 SPECIAL TOPIC

50th Anniversary Plastic Surgery Research Council Panel on the Future of Academic Plastic Surgery

R. Barrett Noone, M.D. Robert M. Goldwyn, M.D. Mary McGrath, M.D. Scott Spear, M.D. Gregory R. D. Evans, M.D. Philadelphia, Pa.; Brookline, Mass.; San Francisco, Calif.; Washington, D.C.; and Orange, Calif.

INTRODUCTION AND COMMENTS–- thoughts, authored by Cobb and Warner and R. BARRETT NOONE, M.D. published in the Journal of the American College of he members of the panel and I are hon- Surgeons, was titled “Challenges and a New Vision ored to receive an invitation to speak about for Academic Surgery.”1 Many of my thoughts Tthe future of academic plastic surgery. The are borrowed from that editorial, and I recom- topic of our panel in your program book is mend it to you. “The Future of Academic Medicine,” and I The academic surgeon has a number of re- decided to paraphrase this to “The Future of sponsibilities. The responsibilities basically can Academic Plastic Surgery” to focus on our own be broken down to what the academic surgeon specialty. We have a distinguished panel that is traditionally does and traditionally has done: quite diverse. I am Barry Noone, and I am • Educate students and residents. clinical professor of surgery at the University • Test new ideas through research. of Pennsylvania and executive director of the • Contribute to the administrative infrastruc- American Board of Plastic Surgery (ABPS). ture of the medical school and one’s hospital. Our other panelists need no introduction, but • Develop a clinical practice. I am going to introduce them anyway. Dr. We face a number of challenges in academic Robert Goldwyn is clinical professor of surgery plastic surgery. For my part this morning, what I at Harvard Medical School, and, as everyone would like to do is present the challenges, and knows, is the longest serving editor of the jour- then let everyone else come up with the solutions. nal Plastic and Reconstructive Surgery. Dr. Mary I thought about some of the factors that are im- McGrath is a professor of surgery in the Divi- pacting the academic surgeon at the present time. sion of Plastic Surgery at the University of These are not all inclusive. Those that I would like California, San Francisco. Dr. Scott Spear is to focus on today, to at least start us off on our the professor and chairman of the Department discussions and our interactive panel, are listed in of Plastic Surgery at Georgetown University Table 1. and is currently the president of the American Plastic surgery has, as you all know, many Society of Plastic Surgeons (ASPS). different training models. Is this good; is this In preparing for this morning’s panel, I relied bad; is this indifferent? John Persing, who is on literature and personal experience. An excel- currently chair of the ABPS and immediate past lent article that assisted me in organizing my chair of the Association of Academic Chairmen of Plastic Surgery, sent out a questionnaire to Presented at the Plastic Surgery Research Council 50th An- the academic chairs in plastic surgery and niversary Meeting, in Toronto, Ontario, Canada, May 21, achieved a fairly high response rate for the ques- 2005. tionnaire, at 76 percent. Many of you are aware Received for publication April 19, 2006; accepted April 18, of this questionnaire, and the conclusion was 2007. that he demonstrated a decrease in research Copyright ©2007 by the American Society of Plastic Surgeons opportunities in the independent programs, sig- DOI: 10.1097/01.prs.0000282308.47851.54 nificantly more of a decrease than in the inte-

www.PRSJournal.com 1709 Plastic and Reconstructive Surgery • November 2007

Table 1. Factors Impacting the Academic Surgeon independent departments. As I said before, this The practice of surgery is not an exhaustive list. I present these to you Increasing clinical demands just to get the ball rolling. Less time for other academic pursuits Must increase clinical volume, decrease costs, and THE FUTURE OF PLASTIC SURGERY–- increase efficiency Must develop new clinical programs, often “boutique,” ROBERT M. GOLDWYN, M.D. to attract specialty patients Dr. Noone: We will start off with Dr. Goldwyn Disease-focused patient care who has a very good perspective on the entire Multidisciplinary team concept, with decision-making conferences specialty over a period of time and has read more Time demands on plastic surgery, a specialty with many, clinical and research articles than anyone I know. varied “diseases” Dr. Goldwyn. Danger of plastic surgeon becoming only a technician Endangered status of the surgeon as a scientist Dr. Goldwyn: It is a great pleasure for me to be Research has always been a critical aspect of academic here at this 50th Anniversary of the Plastic Surgery surgery Research Council. At a certain age, it is a pleasure Now, pursuit of science is changing (i.e., genome to be anywhere above the sod. sequencing may revolutionize surgical diagnosis and therapy) I want to emphasize that I shall be speaking of The single-investigator model is changing to an the future not of academic surgery and research integrated multidisciplinary team; mirrors the but specifically of plastic surgery, academic plastic disease-focused clinical team surgery. I will probably say some things that pos- Clinical responsibilities leave little time for bench research and grant writing sibly will provoke discussion. Finances I am comfortable in asserting that, in the fore- Decreasing insurance reimbursements seeable future, there will be plastic surgery and Increasing overhead: surgery department, dean, plastic surgeons within academia. More difficult to malpractice insurance Increasing need for cosmetic surgery fees to support predict, however, is who they will be and under faculty, perhaps impacting the overall curriculum whose auspices and what conditions they will work. Economic relationship of plastic surgery to the The first point and one that should be obvious hospital/medical center Patient safety issues but is too often forgotten in these discussions is Response to external forces that plastic surgery, unlike physics, physiology, New layer of complexity biochemistry, and chemistry, is not primarily a Less continuity of care by residents may have impact basic science even though it involves basic science. here Post-GME responsibilities Plastic surgery, like general surgery, internal med- Role of the academic center in continuing education of icine, urology, neurosurgery, and orthopedics, to the plastic surgeon mention a few, is primarily clinical. As such, cli- Leadership role in assessing core competencies of faculty nicians vastly outnumber those doing any kind of Participation in MOC program research. This will likely be true for many decades Changes in resident education as it has been in the past. The clinician-scientists The 80-hour work week: attendings work harder, have always been a minority, a valuable minority to stressing an already fragile system Shift from service-based learning to focus on the core be sure, but their scarcity has remained despite the competencies advent of various M.D./Ph.D. programs. Developing a “shift-based” mentality toward patient care A critical factor for a young person in any field Probable erosion of current physician work ethic Diversity of training models is the encouragement and direction he or she re- Good, bad, or indifferent for plastic surgery? ceives from role models and mentors. Someone who ABPS task force to study: with RRC and program has the best interests of his or her student or resident directors Effect on status as division/department or young staff member must be sure not to push that GME, graduate medical education; MOC, maintenance of certifica- person into a trivial project just for a presentation at tion; RRC, Residency Review Committee. a meeting or an article for a journal. In addition to worthwhile mentors, for someone to succeed in academic plastic surgery, he or grated programs. In the questionnaire, there she needs opportunities, not just in the abstract was a decrease in travel opportunities in the but in the specifics, such as a good laboratory independent programs as compared with inte- properly staffed, sufficient and continuing fund- grated programs. When he looked at depart- ing, and the paramount ingredient, in addition to ment versus division status, there was a signifi- those personal qualities I have outlined, time. cant decrease in research and travel for the Time to do research. Too often, the young doctor divisions of plastic surgery versus those that were begins in an investigative setting but because the

1710 Volume 120, Number 6 • Future of Academic Plastic Surgery division or department wants to generate money, addressing this issue in depth, but permit me a few he or she is forced into overwhelming clinical more thoughts on this matter. commitments. Although patient care is an area of As I am getting older, I still entertain a dream, obvious importance, it consumes time and, unless not so noble as that of Martin Luther King—a one is vigilant, may squelch—not stimulate—the dream of seeing plastic surgery flourish as depart- investigative spirit and dampen or obtund creativ- ments. But I, like Moses, have labored long in the ity. Dr. Joseph Murray used to remark to me many desert and will never myself enter the promised times that he was fortunate that at the beginning land! of his career, he had only a few patients but the I seriously believe that having the status of a time and the opportunity, which he certainly took department will give plastic surgery a greater pres- advantage of, to conduct his pioneering research ence within the medical school; more prominence in organ transplantation. in the curriculum; more ability and autonomy to Tip O’Neill, former speaker of the house, hire staff, to pay them, and to direct their activities; made the memorable remark that all politics are and more opportunity to raise our own money for local. This is true also for what plastic surgeons do research without the burden of making forced in a community setting and within a university contributions to the chief of surgery. A young hospital or a medical school. How is plastic surgery person should not have to contend with two chiefs, viewed? From my past, I would like to share some one in plastic surgery and another overchief, usu- observations and reminiscences. When I trained ally a general surgeon. The change in what we now in general surgery at the then Peter Bent Brigham have will help us avoid what Henry Thoreau called Hospital from 1956 to 1961, Dr. Murray was the “a life of quiet desperation,” and it is not so quiet. only plastic surgeon, and initially there was no Plastic surgeons who join together in a private division of plastic surgery. In fact, he had difficulty group or as a division or department and who are in presenting a plastic surgical topic at our surgical able to raise and control their own money are grand rounds. I was the first Brigham resident to likely to have more control over their destiny, greater security, and more respect from others in go into plastic surgery, and when I told Dr. Francis academia and more self-respect. D. Moore, the chief of surgery, about my decision, With the emergence of younger people who he leaned back in his chair, and asked: “Bob, why will become younger chiefs of surgery and would you want to go into the backwaters of med- younger faculty members, there will be more re- icine?” I politely replied that I did not believe that alization of the wisdom and inevitability of plastic Dr. Murray was in the “backwaters of medicine.” surgery being an independent department and Dr. Moore’s answer, “Well, Dr. Murray is really a not an island within the medical school and its general surgeon.” hospitals. The days of general surgery as supreme At the moment the Brigham and Women’s above everything and everyone is gone, even Hospital combined with the Massachusetts Gen- though all who think that way have not left the eral Hospital as partners, it still did not have a scene. Department of Plastic Surgery, despite the fact For people to conduct research and to remain that it did have a Nobelist as its former chief of academic plastic surgeons, they must guarantee plastic surgery. that those within their department or division ex- As chief of plastic surgery at the Beth Israel perience equality, tangible and intangible. Why Hospital from 1972 to 1996, I was in private prac- labor in the laboratory and make one-quarter or tice and so called part-time, a peculiar designation one-fifth of the income of those performing clin- because I spent three-quarters of my life in the ical work, particularly aesthetic surgery? It is not hospital. I was chief of the division and that unit enough to write an article and see it published, or continues to be a division. At Harvard Medical to be a good, token scientist trotted out at a meet- School, I am clinical professor of surgery, not plas- ing like this and to be only marginally compen- tic surgery. Until I retired, I was part-time and in sated. We who are or have been primarily clini- private practice, as were most of us in those days, cians wanted financial security for ourselves and including Dr. Murray when he conducted his im- our families. We should not deny it to anyone else portant investigations. and certainly not to younger colleagues engaged I am presenting this perspective because plas- primarily in research. tic surgery is long overdue to become departments What you have heard during the past few days within the medical schools and its hospitals should give anyone confidence that there is a tre- throughout the country. I know Dr. Spear will be mendous future in plastic surgery; specifically, in

1711 Plastic and Reconstructive Surgery • November 2007 research. The only ones who can stop this, and it the single most important and pressing problem would be unfortunate if it happened, would be has to do with workforce and numbers. Let me try ourselves if we lost sight of our goals in the frenzy to develop this thought for you a bit. At a forum of the marketplace and if we failed to maximize sponsored by the American Society of Plastic Sur- our abilities and our opportunities. geons on plastic surgery strategic issues last March, Finally, those who are senior and who have there was a subgroup that sat down and talked taken no part in the laboratory research should about academics (Table 3). not be among the authors. I once wrote an edi- Note that many of these have a financial basis, torial about a person I knew and who had put his and this grows ever more acute as costs escalate name at the end of a research paper. I doubt that and the demand, nearly all unfunded mandates, he knew where the laboratory was, and I com- continues for greater compliance and reporting to mented that he was as likely to go to the laboratory groups ranging from quality assurance commit- as he was to go to Albania on a Sunday for a picnic. tees to the Accreditation Council for Graduate I have known too many instances of younger per- Medical Education. In addition, there are issues sons in a laboratory not finishing their research or that are specific to plastic surgery, and I would not completing a paper because they did not be- identify three for special mention. lieve that they would receive proper credit, if any. There is a perception that we have a limited Good research requires honesty not only in the value, because of the less essential nature of the work but among those who supposedly perform it. services that we provide in the academic situation. Thank you very much. We lack departmental status, to which Dr. Gold- Dr. Noone: Thank you Dr. Goldwyn. That was wyn just alluded, with regard to competing spe- stimulating and inspiring. Dr. McGrath will now cialties, but—and here is the crux of the prob- address some of the challenges. lem—we do not have the means to strengthen our position. We can be as aggressive as we want de- THE FUTURE OF PLASTIC SURGERY–- manding to become departments, but how will MARY H. MCGRATH, M.D., M.P.H. that be actualized unless we have the power to bring it about? And nowadays, clout is determined I was asked to talk about the future of plastic largely by income: clinical income and research surgery as a specialty. We are uneasy about the dollars. The underlying problem is that we are not future and focus a lot of concern on our practice mission-critical to the medical center, either in environment and the pressing problems of reim- terms of income or in terms of our ability to hold bursement, regulation, and liability. However, our own with the competition. these are immediate problems. When I started to The abstract of a very interesting paper pre- organize my thoughts about what our specialty sented at the American Surgical Association is re- needs to survive and prosper in the years to come, produced in Table 4. In a study conducted at the I decided that the key element is what is happen- University of Pennsylvania, the researchers looked ing in the academy. The six issues in Table 2 are going to drive whether or not our discipline, our specialty, will still be here in 50 years. As a consequence, I firmly believe that plastic Table 3. Forum on Academic Plastic Surgery’s surgery as a specialty will survive or not survive Strategic Issues, March 18, 2005 depending on what happens in the academy. Inadequate funding, rigid regulations There are some very grave problems in our aca- Inadequate compensation for administrative activity Increased work duty hours (expect crisis) demic centers today, but for plastic surgery I think Economic appeal of private practice over a career in academics Inadequate concern and strategic support from the rest of Table 2. Driving Forces for the Survival of Plastic plastic surgery Surgery over the Next 50 Years Increase in unfunded mandates Increased costs (malpractice, education mission) Hypothesis: The future of plastic surgery is an academic issue Reliance on practice income for support* The future depends on a healthy environment in Perception of limited value because of the “less essential” academic plastic surgery for: nature of our services Educating practitioners Lack of department status with regard to competing Maintaining scientific credibility specialties (and no means to strengthen our position) Stimulating and supporting innovation Not “mission-critical” to the medical center Validating with outcomes analysis Income Forging professional identity Competition Planning for the future *Specific to plastic surgery.

1712 Volume 120, Number 6 • Future of Academic Plastic Surgery

Table 4. Abstract from the Article “Surgeon Table 5. Finances of Surgery Departments with Contribution to the Hospital Bottom Line: Not All Are Plastic Surgery Divisions: Reserves and Deﬁcits* Created Equal”* Reserve Status No. of Departments Objective: We hypothesized that surgeon productivity is Deficit accounts† 5 directly related to hospital profitability but significant None (zero balance) 19 variation in margin contribution exists among the Ͻ14 various specialties. 1–2 5 Methods: Surgeon total relative value units (RVUs), a 3–5 7 measure of productivity, were collected from operating 6–10 3 Ͼ10 2 room (OR) logs. Annual hospital profit which reflects all payments received, less all direct and indirect costs, was From Richardson, J. D. The current status of academic surgery de- provided for each specialty by Hospital Finance. Hospital partments in the South. Ann. Surg. 239: 575, 2004. *In millions of dollars. profit or hospital profit per OR hour for each †Department owes money to university, hospital, or bank (range, specialty was plotted as a function of total RVUs or $1–$5 million). RVUs per OR hour. Results: Thoracic ($577 hospital profit/surgeon RVU), Transplant ($340.64/RVU) and Cardiac ($170.11/RVU) were the most profitable followed closely by GI/Colon estingly, it is a division in more departments than Rectal and Vascular. Trauma ($2.26/RVU), Gyn ($8.05/ any other of the surgical specialties, including car- RVU) and Plastics ($9.73/RVU) contributed least to hospital profitability. When hospital profitability per OR diac, which was somewhat surprising to me. Look- hour was calculated by RVU/OR hour. Transplant ing at orthopedics and otolaryngology, our com- slightly exceeded Thoracic ($3,800 vs. $3,450). petitors in many areas of overlapping practice, we Conclusions: Surgeons contribute significantly to hospital see they are divisions in a quarter or fewer of the profitability with certain specialties responsible for departments. This contributes to the imbalance of greater profits than others. Payer mix, the penetration of managed care and negotiated contracts as well as a resources and influence we have with these spe- number of other factors all have an impact on an cialties. individual hospital’s profitability. Surgeons should be The finances of the surgery departments in aware of their significant influence in the marketplace. which we are member divisions are not uniformly From Kaiser, L. R., Resnick, A. S., Corrigan, D. P., and Mullen, J. L. sturdy. As seen in Table 5, in millions of dollars, Surgeon contribution to hospital bottom line: Not all are created equal. Ann. Surg. 242: 530, 2005. five of them are running deficit accounts, mean- *American Surgical Association April 15, 2005. P. 66. ing that the department already owes somewhere between $1 and $5 million to the university, the at surgeon relative value units, a measure of pro- hospital, or the bank. Nineteen of the depart- ductivity, and the hospital profit for each surgical ments are running a net zero balance, and the rest relative value unit. are working on a tight margin, with only approx- Seeing this information, it is not hard to un- imately one-quarter of the departments having a derstand why plastic surgeons have so little clout strong endowment or large reserve fund. in departments where the thoracic surgeons are I think this is an absolutely key concept. You filling beds and bringing into the hospital $600 for need critical mass to succeed. Richardson’s article every $9 that we are. The conclusion in this study goes on to say, “It is striking to me that almost every is that surgeons contribute significantly to hospital department head had nearly every subspecialty profitability, and they should be aware of this program” and “Unless our primary hospitals are when engaged in marketplace negotiations. To huge, it is often difficult to develop successful whom is this message being delivered? It is being programs.” “Many programs might do better to delivered to thoracic surgeons and transplant sur- focus on those done well rather than having every geons. Unfortunately, we as a specialty are not program, particularly if there is no educational empowered much by this advice. imperative to have the additional program.” In addition to looking at information about Given the information we have just reviewed, our economic importance within medical centers, we see that plastic surgery is not an economically let us look at the current status of plastic surgery important specialty within our medical centers. As within surgical departments. Recently, Dr. David divisions, we have little autonomy and are not Richardson surveyed surgical departments in the equal to our competing surgical and medical spe- southern part of the United States and collated cialties that are stronger by virtue of their orga- data from 45 surgical departments about their nizational status; and we are small in numbers, economic condition. with the inherent weaknesses of being small eco- The survey showed that in the 45 departments, nomic units lacking the means to grow our busi- plastic surgery was a division in 39 of them. Inter- ness by expanding. Recognizing that this situation

1713 Plastic and Reconstructive Surgery • November 2007

Table 6. Number of Plastic Surgery Training riod of time that we have been downsizing our Programs by Year numbers. Year No. We have been steadily downsizing for the past 1993 102 12 years. Strategically, it is proving to have been 1995 97 the worst mistake plastic surgery could have made. 1998 92 Past predictions of a physician surplus and over- 2000 88 2005 87* production of specialists have not been borne out. *There are now 38 medical schools without a plastic surgery training Arising with the enthusiasm for managed care in program. the early 1990s, workforce planners called for increases in the number of primary care physicians Table 7. Total Number of Plastic Surgery Diplomates and advanced these initiatives with financial in- Certiﬁed by Year centives that supported the training of generalists at the expense of specialists. As it happens, pre- Year No. dicting the future is a hazardous enterprise and we 1995 200 1996 194 are, in fact, facing a shortage of physicians in the 1997 220 United States. 1998 205 Data published in Health Affairs in 2002 on 2000 227 2001 182 economic and demographic trends in physician 2002 192 numbers take into account the growth in the 2003 173 American population, retirement trends of practicing physicians, adjustments attributable to reduced work hours seen with younger physicians and female physicians, and other factors.2 The has been developing for years, one can ask how the analysis predicts a shortage in the United States of specialty of plastic surgery has responded to these 50,000 physicians by 2010; by 2020, the shortage factors. will reach 200,000.3 This has prompted a state- We have responded by cutting back on the number of people we are training.Tables 6 and 7 ment from the American Association of Medical list the numbers. Since 1993, we have diminished Colleges Center for Workforce Studies that was re- the number of training programs by 15, and there leased on February 22, 2005. This statement called are now 38 medical schools in the United States for an increase in the total enrollment in U.S. med- without a plastic surgery training program. ical schools by 15 percent over 2002 levels over the Note that the decrease in the number of pro- next 10 years. It also calls for measures to facilitate grams has not resulted in an increase in the size of individual choice of specialty, with relevant informa- the remaining programs. We just are not training tion on current and future opportunities. The latter as many plastic surgeons. suggests that the American Association of Medical Also, how does the number of our plastic sur- Colleges recognizes that the physician workforce gery training programs compare with those in will have to change with evolving medical practices other specialties? We have significantly fewer pro- rather than respond to overarching plans to over- grams than do the specialties whose practices are haul the system of health care delivery by limiting similar to ours. It is notable in Table 8 that der- training in certain specialties. Even as these new matology has instituted 22 new programs in pro- data have emerged, we in plastic surgery have con- cedural dermatology during the same 10-year pe- tinued to downsize, and I think we have done it for all of the wrong reasons (Table 9).

Table 8. Numbers of Training Programs in the United States Table 9. Downsizing of Plastic Surgery No. The specialty of plastic surgery has continued to downsize Current academic year (ending June of 2005) Based on faulty demographic data suggesting market No. of medical schools 125 oversaturation Otolaryngology 102 Based on practitioner demand to limit intraspecialty Dermatology 112 competition Procedural dermatology 22 Based on academic hubris allowing “quality” to be case Plastic surgery 89 numbers Withdrawn programs effective June 30, 2005 Based on faulty analysis and strategy Plastic surgery 2 We do not have a monopoly

1714 Volume 120, Number 6 • Future of Academic Plastic Surgery

A strong impetus to our downsizing has been It is simple economics. When faced with in- a response to the concerns voiced by plastic sur- creasing competition and lower income, one can geons in practice that there are too many plastic reduce supply to hold the price structure. How- surgeons coming into their community. This ques- ever, cutting down on the number of units that you tion of competition is an important one if we are produce will work only if you are the sole maker going to talk about workforce numbers. Because of the product. this can be an emotional issue, it is useful to look Downsizing has not protected plastic surgery at some data. Periodically, ASPS conducts a mem- because, as we have pulled back, the competing ber needs survey, the most recent one being con- specialties have continued to train greater num- ducted last November. Several thousand plastic bers of people. With these increases in workforce surgeons responded to a question about the most have come their aggressive efforts to broaden the challenging issue facing them (Table 10). scope of practice in the university and community. All of the answers are interesting, but two are The competition is across the board—aesthetic relevant to the workforce issue. The percentages and reconstructive. Patients with skin cancers, pa- of plastic surgeons rating competition as a most rotids, nasal fractures, lid ptosis, hand surgery, and important issue were as follows: so forth are no longer referred to us. As we grow • Competition from nonplastic surgeons, 26 per- less identified with these clinical conditions, the cent. patients go to dermatologists, oral surgeons, and • Competition from other plastic surgeons, 1 ophthalmologists. Every time that we choose the percent. strategy of saying, “We’ll shrink back; we’ll drop our numbers; we will not have so many in the commu- These answers are a striking illustration of why nity; we’ll protect our interests,” we produce more our downsizing efforts have been so misguided. room for our external competitors (Table 11). Our efforts have been based on faulty analysis and Also, as the scope of practice for our compet- strategy because, the fact is, we do not have a itors expands, plastic surgery is being left without monopoly. Therefore, reducing the number of an identity. Everybody is tearing off pieces of our people we are training has been a poor economic specialty. strategy for preserving market share. The root cause of the problem is our dimin- ishing numbers. It takes an increased, not a decreased, presence in the community to engender Table 10. Most Challenging Issues for Plastic Surgery more work. This is true in private practice and in in the Next 3 Years the university. At the 38 university medical schools Percentage of Members without a plastic surgery training program, new Rating Item as generations of medical students and residents, One of the Most Issue Important Issues who will be future referring doctors, never meet Medical malpractice/tort plastic surgery residents to form relationships or reform 52 learn what we do. The best and brightest students Reimbursement for go into otolaryngology or dermatology—drawing reconstructive procedures 49 talent away from plastic surgery. We are not there in Competition from nonplastic surgeons 26 tumor boards, multidisciplinary conferences, re- Increased overhead costs 24 search seminars, and other gatherings where we can Organizational issues 11 educate other practitioners about the specialty. Regulatory compliance 8 Marketing/market share 7 Maintaining/improving quality of care 6 Growth of practice 4 Table 11. Consequences of Decreasing Numbers of Continuing education/staying Plastic Surgeons current 4 Retirement 4 Results in more external competitors Public perception/media and Results in expanded scope of practice for competitors (oral advertising 2 surgeons and facial fractures) Uncompensated care 2 Leaves the specialty without a clinical identity Competition from other plastic Fragments the market surgeons 1 Draws talent away from plastic surgery Becoming more of a cosmetic Diminishes exposure of students/residents who will be surgery practice 1 future referring physicians

1715 Plastic and Reconstructive Surgery • November 2007

Also, our existing training programs are be- Table 12. Workforce Issues for sieged with problems, almost all of which arise Otolaryngology–Head and Neck Surgery from small size. With only a handful of faculty and RESULTS: The current and predicted workforce supply four or six total residents, plastic surgery divisions and demographic data support a geographic are increasingly irrelevant to the university. This and proportionate increase in the number of relative insignificance tips the balance of power otolaryngologists practicing and entering the workforce with other competing surgical specialties; the Demographic findings represent a stable age distribution of 40- to 49- and 50- to 59-year-old otolaryngologists, small numbers make it difficult to provide cover- with a noted increase in the number of women entering age for all the clinical areas within our specialty, the field. Empiric data reflect the continuous, diverse and thus results in further narrowing of the scope and dominant role otolaryngologists maintain in the of plastic surgery’s clinical effort. Many of our treatment and care of patients with otolaryngologic and training programs today are struggling; their head and neck disease. weakness will lead to ever more attrition. As the From Cannon, C. R., Giaimo, E. M., Lee, T. L., and Chalian, A. Special report: Reassessment of the ORL-HNS workforce. Perceptions and number of our programs drop, we are demon- realities. Otolaryngol. Head Neck Surg. 131: 1, 2004. strating to the universities that they do not need us. The 38 that do not have plastic surgery programs are providing good clinical care; otolaryn- ers, purchasing consortia, and government agen- gology is picking up the slack. Dermatology is fill- cies . . .. Payments have been declining steadily and ing the void. And, frankly, we can argue that we steeply, and the volume of adult cardiac surgery in should all have departmental status, but there is many institutions is threatened by advances in inno strong case for independence if there are not terventional cardiology. Hospital support for cardiac numbers, if there is not a critical mass, if there is surgery programs has therefore become much less not an enterprise. generous. It is no surprise that our specialty has lost Before we start to look at what corrective ac- some of its desirability as a career choice, and some tions are open to the specialty of plastic surgery, residency positions have not filled in the initial it is helpful to recognize that strategy and work- match.”7 force are top priority issues in every specialty. Pe- Not all specialties are facing such debilitating diatric surgeon Moritz Ziegler writes “. . . never problems. It is interesting that two of our com- before have so many simultaneous internal and petitors have an optimistic outlook on workforce external forces appeared on the horizon that have planning and are seeing increased opportunities. the collective potential of influencing the quality Otolaryngology predicts the need for increasing of future pediatric surgeons.” And he goes on to the numbers of otolaryngologists and expects to propose “. . . the beginnings of a strategy to con- play the dominant role in the treatment of head trol the destiny.”4 and neck disease (Table 12). Planning for the future and the need to effect In dermatology, a workforce publication asks change is being stressed by many surgical special- “Why is Mohs surgery currently so popular?” and ties. Vascular surgeon Richard Green points out, questions how the increasing number of Mohs “For the 10 years between 1992 and 2002, some- surgery fellowships will impact workforce econom- where between 0 and 6 positions were unmatched ics. The article points out that it is hard to deter- annually. This year 23 positions were unmatched . . .. mine the optimal supply of Mohs surgeons be- The trends are ominous.”5 He also states “We can no cause of the growing number of non-Mohs longer moan and whine over encroachments into surgical procedures they are performing and our turf by nonsurgeons. We must make our own teaching. It continues, “Many Mohs surgeons per- opportunities. Changes in our attitude, our identity, form a significant number of cosmetic and other and our structure will be necessary to do so. Our surgical procedures. A sampling of 10 Mohs sur- ability to make change will depend upon our values, geons who belong to the American Society of Der- defined as the judgment as to whether we remain a matologic Surgery showed that the individual derivative of our general surgery roots . . . or em- practices offered on average 11 different cosmetic brace the disruptive technology of endoluminal services.”8 therapy as the next iteration of vascular surgical prac- It is not only that we are relinquishing our tice. We are at a crossroads . . ..”6 traditional areas of practice to others as we grow At a planning conference in 2003, cardiotho- smaller. In addition, we are overlooking areas of racic surgeons outlined the problems facing their shortage and areas left uncovered that could be specialty. “The specialty of adult cardiac surgery developed. One such area is burn surgery. A study faces unprecedented pressures from third-party pay- published in 2004 characterized the current and

1716 Volume 120, Number 6 • Future of Academic Plastic Surgery future need for burn surgeons in the United There needs to be a support network for our States. With 29 percent of burn centers presently program directors. They are beleaguered by de- attempting to recruit a burn surgeon and 89 per- mands, requirements, and regulations. They are cent expecting difficulty with manpower in the bound by decisions of the Residency Review Com- future, a severe shortage is expected in the im- mittee about accreditation and the American mediate future.9 Board of Plastic Surgery about certification. Similarly, shortages of head and neck surgeons We need to help our ailing programs. The are emerging along with higher disease preva- plastic surgery community outside the university lence in an aging population. The surgery is de- setting has to be informed about the situation. manding and the hours long, and it is feared that Once informed, our nonacademic plastic sur- surgical treatment will be threatened by an inad- geons are going to have to work on this problem equate number of surgeons practicing in the also. The ASPS and the American Society for Aes- field.10 thetic Plastic Surgery have not been involved with Data on the state of emergency department long-term planning about workforce, and the Plas- coverage by plastic surgery also point to a vacuum tic Surgery Educational Foundation has cut back waiting to be filled. Growing out of a forum held on resources that support educational program- by the American College of Emergency Physicians ming. in 2002, data were collated for the percentage of Perhaps most importantly, we have to organize hospital emergency departments in California re- and develop solidarity and be mutually supportive. porting trouble with on-call physicians. This was We have all been very individualistic. Our aca- presented by specialty for those having trouble demic programs have always functioned in isola- greater than or equal to 50 percent of the time. tion, and this would be a good time to reexamine The specialty most likely to be unavailable half or that strategy and consider novel ways of interact- more than half of the time was plastic surgery. ing and sharing resources. Fully 35 percent of the hospitals reported this, In closing, my hypothesis has been that the whereas neurosurgery was problematic at 22 per- future of plastic surgery as a specialty depends on cent of the hospitals and orthopedics at somewhat the health of our academic sector. We are not less than 20 percent. The four most problematic strong enough and do not have sufficient numbers specialties were plastic surgery; ear, nose, and to maintain our specialty into the future if we throat; neurosurgery; and orthopedics. Problems simply maintain the status quo. We have allowed on the call panels occurred at universities, health our workforce numbers to drift downward and maintenance organizations, and county and com- seen the consequences of this approach. Now, we munity hospitals but were most prevalent at uni- need to rescue our training programs, correct our versity hospitals and approximately one-half as decreasing workforce numbers, and promote clin- prevalent at community hospitals. ical depth and breadth within the specialty. Ex- What corrective actions can the specialty of pansion and growth need enterprising men and plastic surgery take to address our dwindling num- women, and an enhanced presence in the univer- bers (Table 13)? First, it will take a purposeful sity will mean greater success in the practice com- effort to come together to analyze our present munity. Thank you. position and decide that action needs to be taken. Dr. Noone: Thank you very much Dr. McGrath. Our last speaker before we go into open discussion Table 13. Where Plastic Surgery Needs to Go is going to be Scott Spear who, as we all know, is Make growth a strategic priority a professor of plastic surgery at Georgetown and Purposeful effort to increase numbers president of ASPS. Increase number of programs Increase number of faculty THE FUTURE OF PLASTIC SURGERY–- Support program directors Cooperation from the RRC, ABPS, and AACPS SCOTT L. SPEAR, M.D. Help for ailing programs (not eliminate them) I am going to talk a little about vision, and I am Warn and engage the plastic surgery community and organizations really here with some news. Not so much talking Resources about what the problems are, but, believe it or Research funding not, some news and maybe some calls to action, Get organized, develop solidarity, and become mutually and in many ways this sort of keyed things up for supportive me because we have been part of these discus- RRC, Residency Review Committee; ABPS, American Board of Plastic Surgery; AACPS, Association of Academic Chairmen in sions and, actually, I have some plans to do Plastic Surgery. things to help.

1717 Plastic and Reconstructive Surgery • November 2007

I really did enjoy all of the presentations that I think we have to create some seed money for that I heard before me, but I am going to give you a foundation one way or the other. We have to get couple of different perspectives because I do wear a critical mass of dollars started. a couple of different hats in terms of how I am Julia Terzis put a new idea in my head at a going to speak this morning, as president of ASPS, recent meeting in Puerto Rico. She suggested that as a program director like some of you, as a chair we need to have a strategy vis-a`-vis the National of a department like just a few of you, but there are Institutes of Health, to develop a concerted strat- a couple here who are departments. egy to develop a study section for funding of plastic Well, I will tell you that there is a sort of sea surgery. There is one for dermatology, for exam- change going on within the American Society of ple. There is one for dentistry, but there is cer- Plastic Surgeons that has been going on for the tainly not one for plastic surgery. past year or two, maybe three. We are beginning There is a global problem affecting all of ac- to see that our job is not just to be responsible for ademic medicine, not just plastic surgeons, by the ASPS but, actually, be responsible for the health of way, namely, how to make a living and still teach, the specialty. Part of that includes a recognition perform research, contribute to the literature, that we have to advance the state of the art and perform administrative duties, and yet avoid going science. We recognize that for whatever reason, to jail, getting divorced, or dying a pathetic, lonely, without pointing fingers, we have failed to develop boring person. The problem is compounded in a significant financial platform for research. Al- academic plastic surgery. Dr. McGrath has alluded though we obviously have an interest in research, to some of this. We have a minimal opportunity for we do not invest a lot of money in research. We extramural funding. We do not have a National have a Plastic Surgery Educational Foundation, Institutes of Health study section. We are not con- and we have an endowment. Although we should sidered critical to the mission of academic medical all feel very proud that the endowment has ulti- centers, unlike surgery, medicine, pediatrics, ob- mately developed a pot of money of approximately stetrics, and so forth. We really are not even on the $5 million over 10 years or so, it is, in reality, pretty radar screen for your hospital or academic med- pathetic. If you think about Georgetown specifi- ical center (Table 14). cally, if I was going to have an endowment at So, what is the future on a local level? Review Georgetown that would allow me to fulfill my mis- your local situation. You have to have a long-term sion as I see it for the next century, I would prob- strategic plan and short-term goals that will allow ably need a $10 million endowment just for you to be successful. Georgetown. So, the idea that, specialty-wide, we Regarding the financial model for success, you have been able to come up with $5 million for have to provide product lines. Just think of your- research is great. It is better than zero dollars but, self as Macy’s. You have the building, the square frankly, it probably should be the annual budget, feet. You have to make money out of that square not the endowment. So, we have a long way to go. footage. If you do not, you die. I mean, nobody is But remember, the possible sources of money going to give you a gift at the end of the year and are industry, government, other endowments, and say, “Gee wiz, we feel bad. Plastic surgery did not member surgeons. Also, I have to tell you some- have a good year. We need to give you a bag of thing. Realistically, member surgeons are not go- money that we are going to take out of medicine ing to be a great source of money. The big money or pediatrics or surgery.” No, you have to generate is (A) the government and (B) industry. Member revenue. doctors are going to give a little bit but, unless We have been successful at Georgetown doing some of them have struck it rich, we are not going this because we have product lines. They include to get a lot of money out of our member doctors. microsurgery, wounds, hands, feet, burns, trauma, So, what are the possible strategies for ASPS? cosmetic, and cutaneous cancers. We have grants Well, I think we have to create a foundation that really targets industry and other foundations for money. Member surgeons are great, but we really Table 14. Solutions for Plastic Surgery have to go after the big dollars. Those are where Recognize that no one else is going to help you: not your industry and the other foundations such as the dean, not your department chair, not your hospital Robert Woods Johnson Foundation, and the president, not your other university faculty, not your Howard Hughes Foundation are. I mean, these volunteer faculty, and not your patients groups give out millions and billions of dollars, Recognize that you will have to come up with a solution, you know, and our $5 million just does not count. or be frustrated, fail miserably, or give up and leave

1718 Volume 120, Number 6 • Future of Academic Plastic Surgery and endowments, and anywhere else we can gen- cipient of funds or resources. You are a source of erate income to help us with our mission. We are money. You are never a valuable destination for not snobby about it. Frankly, it is a battle because, money. There will always be a more compelling you know, those of you who run programs know, place for investment other than plastic surgery. that you look around and there is no one else that Always. I remember when we had a chief of surgery seems to understand what you are trying to do. You come from Hopkins, and he said, “Well, you know, have got staff and assistants and administrators, we are going to put this money together in a pot. but most of them do not really get the big picture, And, then every year, we will all sit down together which is that you are trying to generate enough and decide where we ought to invest it.” You know, money, because it is about money, unfortunately, the plastic surgery money, the cardiac money, the to accomplish your mission. thoracic money. Now, did he think I was stupid, You have to recruit faculty with a business plan that plastic surgery would ever be a place that we with generous but fair incentives but plans for debt would all vote to put the money? It would always recovery. I actually drew up a recruitment plan for be the lowest thing on the list. We would always our institution that I had to fight with the lawyers need a transplant surgeon or a thoracic surgeon or for 2 years to allow me to set up. They did not like a gastrointestinal surgeon or a colon/rectal sur- it. I had to fight with that same chair who was the geon more than a plastic surgeon and, frankly, I vice president of the university about putting it in could not even argue with that. Of course, those place. He did not like it. It’s now being considered things, from a hospital point of view, have a higher for adoption by the entire eight-hospital consor- value. What that is, is the kiss of death for the tium for how to recruit faculty because it is a good development of plastic surgery (Table 15). business plan, a good business model. Universities It increases your visibility and contacts within and hospitals run miserably. I mean, they are fi- your institution and with other departments. One nancial disasters because they do not understand of the unanticipated benefits is that the resident business, often particularly in terms of the faculty support from that increased mass allows you to recruitment and faculty retention. We, at least, recruit more faculty to grow your critical mass, insisted that all of the faculty be profitable within which means you have to have some vision about 3 years. Now, you can make everybody profitable what plastic surgery can contribute to your med- by how much you pay them. So, the point is, you ical center. You have to fight. The way I set this up start people off by recruiting them to a certain at Georgetown is I had to begin to make some salary. You give them a couple of years to get there. logical arguments that everybody else had to ac- If they do not get there, then their salaries go cept. One of the logical arguments I made was, I down. I mean, that’s realistic. On the other hand, see no rational distinction between divisions and if they get there and do better, their salaries go up. departments in our university hospital, in that Now, we tax ourselves. Since we became a de- urology with a training program and a specialty partment, we taxed ourselves. But, interestingly, and orthopedics with a training program and a even before we became a department, we taxed specialty are departments. However, plastic sur- ourselves separately for ourselves. So, within our gery with a training program and a specialty is not. division, we had a divisional tax that was specifi- There is no logical reason why one is and one is cally for reinvestment in plastic surgery. And now not. The budgets are the same, the number of the last thing, which is the most painful for me as surgeons is the same, and the number of residents a chair, is you have to earn your own salary. You is the same. My opinion was that it does not matter have to lead by example. If you expect your other whether we are a department or a division pro- faculty members to pay you, they may in the short run, but they will resent you every year. So, ultimately, you have to earn your own salary one way Table 15. How to Become a Department or the other. An integrated plastic surgery training program is a huge Why departmental status for plastic surgery? In and unappreciated big step because it: a nutshell, no one else in academic medicine se- Increases your number of residents (i.e., spokespeople) by riously values plastic surgery. I can tell you that a factor of 2, 3, or even 4 (we went from 4 to 18) they can be our friends. They can come to us as Increases your visibility and contacts within your institution and with other departments patients. They can enjoy the revenue that it gen- Provides more resident support to allow you to recruit erates for them, but nobody seriously values it. more faculty to grow your critical mass Period. Therefore, plastic surgery under outside Provides parity with other surgical programs (e.g., control will always be a source rather than a re- neurology; ear, nose, and throat; orthopedics; urology)

1719 Plastic and Reconstructive Surgery • November 2007 vided that we are the same, treated fairly and Table 16. Reasons to Become a Department evenly like everybody else. Now, where it comes Being your own department, allows you to into real play is in the area of subsidies. So, in other Establish your own budget words, now Dr. McGrath talked about the depart- Set your own priorities ments of surgery around the country not doing Choose your own recruits Have all of your resources available for investment in well, and she said “a big number were actually in plastic surgery, so it is not a question of “if” but “where” a deficit mode.” So, if your whole department is in a deficit mode and you develop a clinical surplus, obviously that money is going to be used to cover has a multiplier effect on your ability to be effec- the deficit in your department of surgery. So, tive, grow, and fund programs. When you become when our department of surgery was losing your own department, not only have you had to money, which it often was, and they asked me how build something to get there, but now that you got I felt about supporting it, I always said, “You know, there you can build more and faster because you I think that I should. I think it’s great. We all need have more money and more independence. It al- to support the department of surgery. What I do lows you, if you want to, to fund your own research. not understand is why all of the other surgical Now, Dr. McGrath went over this a little bit, specialties in addition to plastic surgery do not also actually it is amazing that with the four presenta- support the department of surgery. So, that if it’s tions, we did not overlap more, but I’m also going a worthy thing for the hospital to do, it ought to to give you a little bit from the ASPS Strategic be worthy enough for all of the other surgical Planning Session in 2005. When we were asked to specialties as well. So, all I am asking for is parity look at the things we could actually have an impact and rational thinking. So, if we are all going to on, there were only four: pitch in and reach in our pockets and help the department of surgery, that should include ortho- • Measures or basically how we can measure out- pedics, urology, and neurosurgery.” I asked them comes or things like that or quality how they felt about that. They did not want to do • Ethics and the public perception that. So, I said, “Well, if they do not want to do that, • Academics why should I to do that?” It’s interesting how that • Community or the integration of the specialty works. These are the four things we thought we could The other argument I made was that the move- influence. The long-term viability of academic ment of dollars should be a two-way street. In other plastic surgery is threatened by the items listed in words, plastic surgery had no problem supporting, Table 17. putting money into the department of surgery We have to make it mission-critical to the hos- treasury but, occasionally, money from the depart- pital or health system. We have to create financial ment of surgery treasury ought to go to plastic independence, which is large amounts of clinical surgery. Because we are putting it in, some of it revenue, or indirect cost recoveries from research ought to come out, so I eventually staked out the or endowments or something. We need to push money that we put in there as our money. We put for departmental status. We need a critical mass in money in, but it ought to be used for our recruits. number of faculty, and, we need optimal, auton- I was pretty aggressive about it. If we put in omous training pathways. $100,000 in a given year, I would say, “Well next year, I have $100,000 worth of investment going into plastic surgery. It seems to be obvious that we Table 17. Long-Term Academic Issues ought to be able to go into that money we put in.” The long-term viability of academic plastic surgery is So very aggressively fight for the money. If you threatened by keep track of the money that goes in, you should Inadequate funding, rigid regulations, and increased be able to pull some of the money out. Obviously, duty hours your chair certainly does not like that. Once you Perception of limited value and “less essential” nature of service can identify the money and begin to track it, you Economic appeal of private practice over academics have to invest it wisely in recruits and infrastruc- Inadequate concern and support from the profession ture. You cannot afford to throw money away, The lack of departmental status Increase in unfunded mandates particularly on recruits. The degradation of academic plastic surgery programs will Being your own department allows you to do Restrain the profession’s ability to educate practitioners the things listed in Table 16. The other lesson, in when demand and competition are increasing terms of a local thing, is that being a department Adversely affect the credibility of the specialty

1720 Volume 120, Number 6 • Future of Academic Plastic Surgery

ASPS is trying to get involved with this by did take approximately 15 or 20 years to make adopting a consensus statement for attaining de- happen. However, I do think that successive gen- partmental status. We want to get organized plastic erations will find it easier to do this if the model surgery, which is ASPS, to support ABPS, the res- I shared. Thank you. idency review committee, and training program Gregory R. D. Evans, M.D. directors in establishing optimum training envi- Aesthetic and Plastic Surgery Institute ronments. Regarding the workforce study, I think 200 Manchester Avenue, Suite 650 we are committed to doing that. I think Dr. Orange, Calif. 92868 McGrath was right that we probably need to look [email protected] at that again. ASPS is going to commit itself to the specialty DISCLOSURES and the academic world. So, these are the strate- None of the authors has a financial interest in any gies of ASPS: of the products, devices, or drugs mentioned in this • Develop a workforce assessment for future article. Dr. Spear declares that he is a paid consultant to needs. Ethicon, Inamed, and LifeCell. • Initiate a consensus process to develop a statement regarding academic status. REFERENCES • Engage the residency review committee, ABPS, 1. Cobb, J. P., and Warner, B. W. Challenges and a new vision academic chairs in a conference to determine for academic surgery. J. Am. Coll. Surg. 200: 605, 2005. program criteria/standards and responsibilities 2. Cooper, R. A., Getzen, T. E., McKee, H. J., et al. Economic needed to optimize the vitality of the specialty. and demographic trends signal an impending physician • shortage. Health Aff. 21: 140, 2002. Arrange for an ASPS representative on the 3. Cooper, R. A. Weighing the evidence for expanding physi- Residency Review Committee (I do not know cian supply. Ann. Intern. Med. 141: 705, 2004. whether we can do that, but we can try). 4. Ziegler, M. M. Pediatric surgical training: An historic per- • Organized plastic surgery will engage the spective, a formula for change. J. Pediatr. Surg. 39: 1159, 2004. 5. Green, R. M. What changes are needed to keep vascular American College of Surgeons to support de- surgery alive and vigorous? Vascular 12: 15, 2004. partmental status. 6. Boncheck, L. I., Harley, D. P., Wilbur, R. H., et al. The STS In other words, ASPS is really going to try to future planning conference for adult cardiac surgery. Ann. take an active part, if not the lead role, in helping Thorac. Surg. 76: 2156, 2003. 7. Nguyen, J. C., Jacobson, C. C., Rehmus, W., and Kimball, A. to make some things happen to help support ac- B. Workforce characteristics of Mohs surgery fellows. Derma- ademic plastic surgery. So, to sum up: as ASPS tol. Surg. 30: 136, 2004. president, what I am telling you is that this is a sea 8. Faucher, L. D. Are we headed for a shortage of burn sur- change, with the Society getting much more ac- geons? J. Burn Care Rehabil. 25: 464, 2004. tively involved in trying to revitalize the training 9. York, A. Shortage of head and neck surgeons could threaten treatment. Lancet Oncol. 5: 582, 2004. pathways and the academic status within the med- 10. Rudkin, S. E., Oman, J., Langdorf, M. I., et al. The state ical centers. Also, I have tried to share with you my of ED on-call coverage in California. Am. J. Emerg. Med. 22: own personal experience at Georgetown, which 575, 2004.

Membership in the American Society of Plastic Surgeons For information regarding membership in the American Society of Plastic Surgeons, contact: American Society of Plastic Surgeons 444 E. Algonquin Road Arlington Heights, Ill. 60005 Tel: 847-228-9900 Fax: 847-228-9131

1721 SPECIAL TOPIC

Bridging the Gap: The 34th Varaztad H. Kazanjian Memorial Lecture

Robert M. Goldwyn, M.D. Brookline, Mass.

wish first to thank Dr. James May and my feel at home and by his behavior conveying to colleagues at the Massachusetts General Hos- the patient the truth: that she was the most Ipital and the residents and the Kazanjian fam- important person in the room. After having care- ily for the unique distinction and great privilege fully taken her history and after having exam- of being this year’s Kazanjian Lecturer. I am well ined her, he thoughtfully discussed her with us. aware of the caliber of those who have preceded He reassured her, but not in a cavalier fashion. me. To be associated even in name with Dr. His reassurance to us also meant a great deal. He Kazanjian is a profound honor for which I am agreed with our plan and fortunately she had the very grateful. I am grateful also to see so many expected outcome. friends here. I am reminded of what Bob Hope I need no reminding that the greatest compli- said about Bing Crosby: “Bing is my best friend ment is to be invited to be heard by one’s col- and there is nothing I wouldn’t do for him and leagues in one’s own city. It seems easier to there is nothing he wouldn’t do for me. We went journey to a distant place to learn than to make through life together—doing nothing for each the psychologically long trip across town. I re- other.” member Dr. Francis Moore telling me that when At the outset, I wish to acknowledge my in- he was chief resident of surgery at the Massachu- debtedness to two people in particular who have setts General Hospital, he surprised, truly influenced my career and especially my life. Un- shocked, his fellow residents and the senior staff fortunately, both could not be here this morn- by going periodically to the Peter Bent Brigham ing—Dr. Bradford Cannon and Dr. Joseph Mur- to see, as he said, what Dr. Cutler and his service ray. Dr. Murray has long been a mentor and it were doing that might be new. was because of him that I became a plastic sur- Some may think that I have chosen this cryptic geon. I would not be here in this capacity if it title “Bridging the Gap” because it allows me to were not for him. talk about almost anything. Perhaps there is I recall that when I was a senior resident at the some truth to that. I did think the title might be Brigham and on Dr. Murray’s service, a woman sufficiently intriguing to prompt some to come in her twenties, a clinic patient, had an amelo- who otherwise might not. I am not going to blastoma of her lower jaw. Dr. Murray advised discuss the retail clothing giant Gap. I am not wide excision with an immediate iliac bone graft. speaking about the federal deficit or the dispar- He suggested, however, that we consult Dr. Ka- ity between the rich and the poor or the chasm zanjian. Although I had heard of him, I had only between those with insurance and those without glimpsed him at a couple of Harvard Medical it. I am not talking about the Big Dig, and I shall Alumni reunions. Knowing of my desire to go leave to others the Herculean task of bridging into plastic surgery, Dr. Murray wanted to give the gap between the inhabitants of Venus and me the opportunity to meet Dr. Kazanjian. He those of Mars. drove the patient and me to Dr. Kazanjian’s My topic is the inherent differences that exist office in Kenmore Square. Unhurriedly, Dr. Ka- between the physician and the patient, which in zanjian talked to us and the patient, making us many ways are necessary. But my message is that Received for publication September 6, 2005; accepted Sep- these differences or points of separation need tember 6, 2005. not constitute an unbridgeable gap preventing Presented at the 34th Varaztad H. Kazanjian Memorial the physician and the patient from coming to- Lecture, Massachusetts General Hospital, Harvard Medical gether meaningfully to their mutual benefit. School, in Boston, Massachusetts, May 25, 2005. This is probably the first time a Kazanjian Lec- Copyright ©2007 by the American Society of Plastic Surgeons ture is without audiovisual or PowerPoint accom- DOI: 10.1097/01.prs.0000282307.37913.4f paniment, and it could very well be the last.

1722 www.PRSJournal.com Volume 120, Number 6 • Bridging the Gap

I have interspersed a few medical pleasantries ally is not blamed for being sick but will be because I believe that humor bridges the gap not blamed for not trying to overcome that sickness. just between speaker and audience but between Although society or individuals or groups within physician and patient. An appropriate witticism— society may disapprove of how a patient becomes and I emphasize the word “appropriate”— ill (such as someone having been injured from acknowledges some of the unpleasant realities drunken driving), society through its physicians that might arise in a therapeutic setting. Humor and hospitals has dedicated considerable re- lightens the moment although, admittedly, it sources to help the ill become well again. Al- does not eliminate the problem. I believe, how- though the patient’s incapacity legitimately ex- ever, that when doctors and patients can laugh empts him or her from normal obligations, only together, even (and especially) in a stressful sit- under extreme circumstances does it allow the uation, it brings them closer together. Tension, patient to become permanently disabled to the anxiety, and anger decrease; confidence and point of being alienated from society. If, indeed, hope take their place, facilitating recovery and all the sick people somehow banded together perhaps even healing. and generated a belief or doctrine within society I have chosen this subject of the relationship that being ill is better than being well, that soci- between physician and patient in preference to ety could not function. It is to everyone’s benefit, talking about techniques, which come and go, therefore, to restore that individual to health. and happily, and usually inevitably, are replaced The doctor and the patient in an ideal relation- by something better. Also, I confess that I am ship work toward that end. more comfortable talking about what I have ob- In contrast to the reconstructive patient, the served and learned than what I have done. No patient for cosmetic surgery least fulfills the tra- matter what happens in our lifetime and no ditional sick role. Aesthetic patients have chosen matter what happens to what we call medicine or to make themselves ill in the short-term and to surgery or plastic surgery, the constant is that place themselves at risk, possibly to obtain an people will become ill and will need help from enhancement that will make them feel happier, those whom society has trained, has designated which can be an elusive goal. to help, and now expects to receive that help Though a commonplace phenomenon, it is from. noteworthy and when one ponders it, even a A few remarks first about the anatomy of the doctor-patient relationship. Some of what I have surprising one, that a person whom we physi- to say is not original. This calls to mind what cians have met just a few minutes previously— Samuel Johnson wrote to an author: “Your someone perhaps of an opposite gender, of a manuscript is both original and good; unfortu- different age, socioeconomic status, race, or nately what is original is not good and what is from another culture and country—is expected good is not original.” to speak to us frankly, even undress before us, My reflections here about the relationship be- permits us to examine him or her in a way that is tween the patient and doctor within the social not permitted to anyone else, and asks us and context is based partly on what I learned from trusts us in the hope of getting better or cured to my teacher at Harvard College, Talcott Parsons, do something to their body, to the point of professor of sociology, from his lectures and sticking a knife into it when that individual may from his book, The Social System, which, though be unaware, unconscious, under anesthesia. All published in 1950, contains insights that are still this is possible today because for centuries phy- valid, still helpful. sicians have generally done their work well in The patient and the physician each has his or ameliorating or eradicating a condition or dis- her role that society defines not just in general ease, and in working for the good of the patient, terms but in specific ones as well. Society counts though there certainly have been and unfortu- on, even mandates, that an individual who is nately will always be instances of poor perfor- sick—I am not talking about a cosmetic patient— mance or frank negligence. The Hippocratic tra- seek help in order no longer to be sick. In es- dition does live on as a reality. sence, society wants and needs to reintegrate Through its institutions, society has provided that person back into his or her preillness status training of those whom we call healers or physi- to perform his or her preillness functions— cians, and it is presumed that the physician is necessary to that person and to society. The sick competent, and it is hoped though not necessar- person has an obligation to get help and gener- ily guaranteed that the physician is not only

1723 Plastic and Reconstructive Surgery • November 2007 committed to the well-being of the patient but reality of having a lot of knowledge but in a also compassionate and empathetic. narrow range. We must never forget that knowl- Professor Parsons, whom I cited earlier, edge is not the same as wisdom. pointed out the paradox that it is in the doctor’s “My doctor is such a specialist that he will not self interest not to act only or primarily in his or even make hospital calls.” Note the criticism of her self-interest. Doctors are supposed to put the the specialist, setting himself or herself apart patient’s interests above their own and will be from the traditional doctor who used to make a rewarded for this behavior. house call, certainly a hospital visit but, as we Patients usually trust and believe their doctors. have seen recently these visits by the admitting Someone with a macabre sense of humor re- physician have been supplemented and even marked: “I trust my doctor. If he treats you for a supplanted by hospitalists. broken arm, that’s what you die of.” “A specialist is a doctor whose patients can The patient, although he or she may at the only be sick during office hours.” Here the focus moment be weaker physically and less in charge again is on the presumed lifestyle of the special- than the physician, has a power, albeit a different ist who does not deal with emergencies. Remem- kind of power. Society and its laws dictate that ber that even though that may not be true, the the patient cannot be exploited according to the perceived reality becomes the reality in the whim of the physician for the purpose of re- minds of many patients and the inevitable issues search, money, sex, or any other reason. The concerning money: patient’s dignity must always be honored and preserved. We should never forget that there are “A specialist is a doctor with a smaller practice many more patients in the world than there are but a bigger home.” or will be doctors, testifying to the truth of Oscar “The difference between a regular doctor and a Wilde’s remark that “The only tyranny that lasts specialist is $100 a visit.” is the weak over the strong.” “My doctor is a specialist and has magic hands. Undoubtedly the physician is an authority fig- Each time he touches me, $50 disappears.” ure. The following story illustrates this. A variant is: “My doctor is better than Houdini; A man goes to see his doctor, who takes him when he asks me to cough, money flies out of into the examining room and tells him to un- my wallet.” dress completely. The doctor then says, “Go to “My doctor is a specialist and he is a wonderful the window,” and the patient does. specialist. When I told him I could not afford “Pull-up the blinds.” The patient does. the surgery, he retouched my radiographs.” “Turn toward me and bend down and spread Milton Berle commented when he got his bill: your buttocks.” The patient does. “Now I know why surgeons wear masks.” “Now turn around, face the window, stick out He said also that “Doctors are amazing. They your tongue, and thumb your nose.” cure poor people faster.” The patient does but then asks the doctor, “Why did you have me do all that?” In these jokes, the focus is on the money gap, The doctor replies, “I hate my neighbor.” the presumption that doctors, particularly special- This obviously is not the way to bridge the gap, ists, are rich and, in contrast to the average Amer- but it does emphasize that generally doctors are ican, physicians, and certainly specialists, are in in charge of the patient’s treatment although, of the upper echelon of income earners in this coun- course, the patient owns his or her body and if try. Just as the former United States Congressman he or she is in good mental or physical health, and Speaker of the House, Thomas P. “Tip” that individual must give permission for the pro- O’Neill enunciated the verity that “all politics are posed treatment. From what I have observed local,” so all medicine becomes financial, espe- during many years as a physician and even be- cially when something goes wrong. In fact, the fore as a medical student and resident, please patient’s ultimate recourse—the legal one—cen- permit me to offer specific suggestions to bridge ters around money. When a patient experiences a the gap between the patient and the physician. complication, he or she has to pay something, if In this context, the physician is the plastic sur- not to the doctor, and if not to the hospital, then geon and is moreover a specialist. Here is what certainly that individual loses money and has in- some have said about specialists: creased fiscal problems because of time out of “A specialist is a doctor who is ignorant in all work or time spent during recovery, which may subjects but one.” Note the comment on the never be complete.

1724 Volume 120, Number 6 • Bridging the Gap

In circumstances stressful to the patient par- unduly, you go out to the waiting room—appro- ticularly but in all situations, bridging the gap priately named. Do not just send your secretary to requires not forgetting that a good doctor, sur- explain and apologize, although that is better than geon or specialist or whoever, must never become nothing. It is good for strengthening your char- detached—not just being physically unavailable acter to make the lonely walk yourself. It might but being emotionally disconnected. It would be- teach you a valuable lesson. I should caution you, hoove us to keep in mind what was said by Dr. J. however, you might be as welcome as President Englebert Dunphy, an outstanding surgeon who Bush at a Democratic fundraiser. began his remarkable career at the then Peter Also, do not keep a patient waiting excessively Bent Brigham Hospital—and some in the front to the point of frustration, desperation, and anger row remember him very well. I had the privilege for the results of any test you have ordered. The of knowing him but unfortunately only briefly. He patient should be informed almost as soon as you remarked: “Why cannot a patient be a friend?” are. Nobody should have to call repeatedly, often That simple question underpins what I am saying to deal with someone irritable and uncaring, to this morning but in addition, the necessary ques- obtain information that you, the doctor, should tion is: “Why cannot a physician be a friend?” The have transmitted and interpreted rather than hav- bridge goes both ways. ing it done by an untrained assistant who might In general, patients desire more than having a not even have known the patient. service performed. Seneca, the eminent Roman Another simple thing—really just an instance statesman and philosopher of the first century AD, of proper manners—can help bridge the gap. It wrote: “If, therefore, a physician does nothing should not have to be said that you should greet more than feel my pulse and put me on the list of the patient warmly and that if you are seated, stand those whom he visits on his rounds, instructing me up. Those fundamentals should have been what to do and what to avoid without any personal learned during childhood. feeling, I owe him nothing more than his fee, When Dr. Robert F. Loeb, who from 1947 to because he does not see me as a friend but as a 1960 was the Bard professor of medicine, chair- client.” Seneca had in mind this quality of caring man of medicine, and chief of the Presbyterian on the part of a physician, not just technical com- Medical Service at Columbia, was asked when he petence meted out perfunctorily. shook hands with a patient on rounds at Bellevue Now I will mention a few simple observations Hospital in 1962 whether he was doing so to de- and suggestions about bringing the patient and the physician closer together. Specialists and non- termine the temperature, moisture, or strength of specialists—all doctors—should keep in mind that the arm, he replied simply: “Gentlemen, the thing patients resent waiting a length of time they con- that I am doing is greeting another human being.” sider unfair—a phenomenon that is too common And one should do so with a smile. in the offices of most doctors. Sometimes, of Oliver Wendell Holmes, the nineteenth cen- course, not being on time is unavoidable, but tury poet and great physician, and also dean of many patients who are kept waiting believe that Harvard Medical School, expressed it well in verse: the doctor has placed his or her time above theirs And last, not least, in each perplexing case, and may correctly or incorrectly interpret the doc- Learn the sweet magic of a cheerful face; tor as being behind and overbooking his or her Not always smiling, but at least serene, schedule as a lack of consideration rather than the When grief and anguish cloud the anxious scene. doctor’s desire to be a good doctor to more peo- Each look, each movement, every word and tone, ple. Nobody—patient or physician, rich or poor— Should tell your patient you are all his own; can ever recover 1 nanosecond. The story is told Not the mere artist, purchased to attend, about the doctor who was so late that it took hours But the warm, ready, self-forgetting friend, finally to get to Mr. Smith. The doctor apologized Whose genial visit in itself combines to the elderly man by saying, “I hope you did not The best of cordials, tonics, anodynes. mind waiting so long.” Mr. Smith replied, “It’s a shame you could not have seen my illness in its With regard to smiling, I must say that there early stages.” are some people who never smile, whether they Another patient also spent inordinate time— be doctors or patients, and certainly patients several hours—waiting to be examined. Finally, have less to smile about when they are ill. My the patient called it quits and went home to die of Uncle Harris once remarked that some individ- natural causes. If you have kept a patient waiting uals go to a pet store not to buy a dog or a cat or

1725 Plastic and Reconstructive Surgery • November 2007 a canary but a bat—some realities one can never He was a tree surgeon, and Groucho asked: change. “Doc, did you ever fall out of a patient?” It does no harm but considerable good to I have seen many changes in medicine and I spend a few minutes inquiring about the patient hope I will see many more. However, not every- as a person, about what is happening in his or thing new is necessarily good, at least at first her life and in the family. This should not be a consideration. What I am thinking of is robotic police interrogation or one conducted peremp- telerounding. I quote from a recent article by torily without true interest. Ellison et al. in the October of 2004 issue of the With a patient who comes for a postoperative Journal of the American College of Surgeons: “Tele- visit, there is a difference in the following greet- rounding patients were seen once at the bedside ings: “Hi (name)! How are you doing?” Com- by the attending, and then again by the attend- pared with, “How’s your hand doing?” Or worse, ing using the Web-based video conferencing sys- “How’s your cast?” I have heard this said to a tem during usual resident afternoon rounds. postoperative patient as the initial greeting: The video conferencing system was brought to “How’s your breast?” the patient’s room, where the vital signs and The person started as a whole human being fluid measurement from the nursing flow sheet and how quickly he or she is reduced to a body were relayed. The attending, from a geographi- part or part of a part. I tremble to think what cally remote office, then conversed with the pa- could happen in the office of those who work in tient for three to five minutes and visually exam- the nether regions of the body: urologists, proc- ined the incisions and drain effluent. Alterations tologists, or gynecologists. in postoperative management were relayed to Remember the patient is a person who hap- the resident or nursing staff, and the encounter pens to be a patient at this particular time in his concluded.” Note the word “encounter.” Ah, the or her life and the doctor is a person who is in warmth of it all. If I have to get sick and I will, I the role of a doctor at this moment in his or her hope it will be before robots have replaced phy- life but, of course, who can also become a pa- sicians as we know them today. tient within seconds. It takes years to become a I have talked a great deal about the relation- doctor but sometimes only a moment to become ship between patients and physicians—plastic a patient. surgeons—between others and us. However, a One of life’s unforgettable moments, for me relationship that receives too little attention is and my parents, was when I received my medical one that we have with ourselves—the intraper- degree. But another, for me, was when, because sonal relationship. We must think of ourselves of a kidney stone, I suddenly became a patient not in a selfish way but in a self-assessing way sharing the room with someone on whom 2 days even though our work and our profession re- before I had operated for cancer of the parotid. quire that we are committed to the well-being of Although death is the greatest leveler, illness others. Admittedly, we all can do better with runs a close second. regard to helping patients, but we also have to be Most of us here at Harvard have heard about aware of our own needs. This does not mean Dr. Francis W. Peabody, who lived from 1881 to becoming totally egocentric or narcissistic, but it 1927. In the year of his death from cancer, when does mean that we have to heed the injunction he was just 46, he gave a memorable talk to of Luke: “physician, heal thyself.” However, be- students and medical school faculty—it was en- fore we can heal ourselves, we have to be aware titled “The Care of the Patient.” Its most famous of ourselves, understand ourselves, and recog- passage was this: “One of the essential qualities nize our problems. This requires the capacity to of the clinician is interest in humanity, for the be sufficiently comfortable with ourselves to per- secret of the care of the patient is in caring for mit introspection. The Socratic injunction the patient.” “know thyself” has never gone out of style and, in However, what is not often repeated but this busy world, it is perhaps more important should be is what Dr. Peabody further remarked: than ever. The French have an expression: “to be “The treatment of a disease may be entirely im- comfortable in one’s own skin.” This is the first personal; but the care of the patient must be step to being comfortable with somebody else completely personal.” Although a disease may be (namely, a patient) and having that person com- an “it,” the disease does not happen to an “it.” fortable with you. This quality is not just a pro- Having said that, I remember Groucho Marx’s fessional asset but a personal one because its remark to someone who appeared on his show. presence or absence may affect all the physi-

1726 Volume 120, Number 6 • Bridging the Gap cian’s relationships, including those that suppos- whether this is true—have received proper ther- edly should be closest. Life without emotional apy or instruction to become less dangerous to sharing—love—is dour, drab, and joyless. We themselves and to others. We also should do should not use our profession as a means to more than discharge a patient from our care, not avoid appropriate intimacy by becoming overly just help the individual regain his or her health busy either by choice or chance, consciously or but also maintain it to the best of his or her unconsciously. This is an occupational hazard capacity and our ability. If, for example, we have among physicians, probably because of the grat- a patient whom we have treated for injuries re- ifications we receive in a professional setting: sulting from drunken driving, we should at least respect, authority, power, praise, and money. try to arrange for consultations with those who However, at some point, we doctors have to leave might help him or her break the habit. We are or our office, the operating room, or the hospital to should be physicians and plastic surgeons and go home or whatever we call home. What then? remember that the patient is much more than Learning to live a full life in the greatest sense the sum of his or her parts. of the phrase is not an automatic accomplish- A point that too few doctors keep in mind is ment. It takes study of oneself and may even that although the word “patient” is derived from require professional help. There are too many pati, which is Latin for “to suffer,” the word physicians who are unhappy, and an unhappy “doctor” comes from the Latin “to teach.” It is doctor does nobody any good. There are too interesting that a doctor, when you really think many physicians who have emotional and physi- about it, not only has to relieve pain but also has cal problems, such as addiction to drugs, alco- to instruct or teach the patient how to take care hol, gambling, sex, or work, who do not or are of himself or herself and, more importantly, how unable to ask for professional assistance. A re- to maintain well-being—not getting sick again or cent Harvard study showed the remarkable in- as frequently. There is no better solution to a creased rate of suicide by physicians compared problem than its prevention. with the general public. More astounding, at In preparing for this lecture, I came across a least to me, was the fact that female physicians few observations that resonated with me and that committed suicide at twice the rate of their male I thought were worthy of sharing with you. One counterparts. was by Santayana (he was a Harvard philosopher, It is a tremendous and sorrowful waste for not a Mexican general), who said: “Never have I someone who is bright and who has worked hard enjoyed youth so thoroughly as I have in my old and achieved much to become self-destructive— age.” and there are various ways of exhibiting it. Ann Landers made this statement: “Inside ev- Sooner or later, such behavior interferes with per- ery 70 year old is a 35 year old asking, ‘what sonal fulfillment and health and the optimal care happened?’” Mark Twain always had something of those who have entrusted themselves to us. wise and humorous to say: “I am an old man and We are fortunate that we have chosen medi- I have known many troubles but most of them cine as a career. Lawrence Sterne, the eigh- have never happened.” teenth century English novelist, remarked with My mother’s favorite author and one to whom humor: “There are worse occupations in the I was introduced when I was very young was world than feeling a woman’s pulse.” Colette, and in the great style of the French That aspect aside, I, now approaching my 75th writer-philosopher stated: “What a wonderful life birthday, am glad that I have had my kind of I have had; I only wish I had realized it sooner.” career rather than, for example, doing what I That obviously has meaning for those who are heard the other day on the radio—namely, a younger, but even some of us with more years lawyer saying that he has devoted his life to and less hair would do well to remember it. helping drunken drivers regain their licenses. In Finally, I want to say that one can display a curious way, he is probably doing good, but I courage in many ways, in many areas of life, but shudder to think whom he would put back on not all of them have to be on a battlefield. Just the road. Yet, when I thought about it further, getting up in the morning can be a tour de force, we physicians should not make value judgments especially if we are tired and things are not going on whom we have put back on the road. The as well as we would like. We all know that Sunday difference is that the attorney was presumably nights are not as good as Friday or Saturday attempting to restore suspended licenses to nights. The prospect of a comparatively free those who might not—and I do not know weekend will be, as long as there is human life in

1727 Plastic and Reconstructive Surgery • November 2007 a technologically driven culture, much more en- “I do not wanna. The teachers do not like me, joyable than the thought of a full work week. At and all the kids make fun of me.” least, I would hope so, because if it were not that The mother advances on the bed, whips the way, we would be workaholics beyond redemp- blanket back and says, “Bernie, you don’t have tion. Oscar Wilde, who seemed to have had any choice. You have to go to school.” something to say about everything, expressed Bernie says, “Give me a good reason!” the thought that “Work is a colossal waste of “You’re 52 years old and you’re the time.” Although he might have believed that was principal.”1 true for himself, he did work prodigiously and After all the discourse—this long discourse, was grateful to his many physicians who attended perhaps overly long—we have reached a conclu- him during his many illnesses. However, over- sion that is basic but Einsteinian in its elegant work—the so-called treadmill living—is not op- simplicity but one that antedates Einstein by a timal for most of us and woe to the patient whose few millennia. Permit me the paraphrase: Do doctor believes he or she is bionic. unto your patient as you would wish your physi- In closing, there is a story relating to the phe- cian to do unto you or your loved ones. nomenon of getting up daily to go to work as did Robert M. Goldwyn, M.D. all of you coming here so early and in the rain— 54 Willow Crescent going to work is an act of courage so universal, so Brookline, Mass. 02445 expected that what it entails is underappreciated. [email protected] Mrs. Schultz heard the 7-o’clock alarm ring for the fourth time in her son’s room and, knowing DISCLOSURE of his reluctance to get up, she opened the door The author does not have a financial interest in any and said: “Bernie, it’s 7-o’clock and you have to of the products, devices, or drugs mentioned in this get out of bed to go to school.” article. Bernie pulls the blanket over his head. “I do not want to go to school.” REFERENCE “You have to go,” his mother says. 1. Telushkin, J. Jewish Humor. New York: Quill, 1992. P. 38.

Future Meetings of the American Society of Plastic Surgeons The following are the planned sites and dates for future annual meetings of the American Society of Plastic Surgeons: 2008 Chicago, Ill. October 31 to November 4 2009 Seattle, Wash. October 23 to 28 2010 Toronto, Canada October 1 to 6 2011 Denver, Colo. September 23 to 28 2012 Washington, D.C. November 1 to 7

1728 EDITORIAL

The Lagging U.S. Health Care Information Technology Infrastructure: Parallel Challenges for Plastic Surgery

Rod J. Rohrich, M.D. Dallas, Texas

recent USA Today article reported that the ing clinical standards. Financial incentives are United States trails other nations in high- being designed and implemented for practice Aspeed Internet access, and warned that redesign, emphasizing the following items: catching up to the rest of the world may not happen unless governmental policy implements • Improved information technology systems change.1 According to this article, the median • Improved team approaches to patient care download speed in the United States is 1.97 • Patient safety, as achieved through better use megabits per second, far behind that of many of technology other countries (Table 1). The Federal Commu- • Increased sharing of patient data and coordi- nications Commission has designated that down- nation among health-care providers load speeds of 200 kb per second or faster are • Patient-centered medical care and record “high speed,” but this speed would not be rec- keeping ognized as “broadband” in many countries. That • Efficiency through improved speed and dimin- the country with the largest economy in the ished redundancy world has one of the slowest Internet speeds is alarming. Diversity in the way insurance pays for patient Equally alarming are the findings of a study care is noted. The United Kingdom pays for care commissioned by The Commonwealth Fund. on a capitation basis, in which the patient pays The 2006 Commonwealth Fund International little or no fee for primary health care. The Neth- Health Policy Survey of Primary Care Physicians erlands has a mixed system, based on capitation reported wide gaps between the leading and and fee for service. Canada covers doctor visits lagging countries in clinical information systems entirely, but the patient is responsible for his or and payment incentives.2 The study shows that her medication costs to varying degrees. Australia, U.S. primary care physicians are among the least Germany, and New Zealand have mixed systems. likely to have extensive clinical information sys- Of concern, in the United States alone, a high tems or incentives targeted on quality and the percentage of the population has no insurance; most likely to report that their patients have when patients do have insurance, they often bear difficulty paying for care. In a similar fashion to high deductible fees and other costs for health the USA Today article, this study concludes that care. sweeping policy changes in the U.S. health-care system may be necessary to overcome the documented performance gaps. INFORMATION TECHNOLOGY, SHARING, AND PATIENT RECORD DETAILS OF THE REPORT COORDINATION The report focuses on primary care physicians Primary care practices’ use of information in seven countries: Australia, Canada, Germany, technology and information-sharing systems The Netherlands, New Zealand, the United King- showed major discrepancies among the seven dom, and the United States. It begins by reporting countries studied. The most widespread use of that many countries are instituting public health information technology and data sharing was policies that hold primary care practices account- found in Australia, The Netherlands, New Zea- able for managing chronic conditions and meet- land, and the United Kingdom. Germany ranked in the middle, with Canada and the United States Copyright ©2007 by the American Society of Plastic Surgeons far behind. Fully 98 percent of primary care prac- DOI: 10.1097/01.prs.0000287532.22699.f4 tices in The Netherlands utilize an electronic med-

www.PRSJournal.com 1729 Plastic and Reconstructive Surgery • November 2007

Table 1. Download Speeds by Country or State After-hours coverage arrangements again showed Country/State Download Speed the Canadian and U.S. practices lagging behind. (megabits/sec) Half of Canadian practices and three of five U.S. United States 1.97 practices indicated they had no after-hours cov- Alaska 0.545* erage arrangements, in contrast to fewer than 25 California 1.520 percent of practices in the other countries studied. Florida 2.368 New York 3.436 Not surprisingly, use of local emergency rooms Texas 1.509 was highest among Canadian and U.S. patients for Rhode Island 5.011* care that could have been provided had a regular Canada 7 France 17 doctor been available. South Korea 45 The United States, the only country studied Japan 61 among the group of seven without universal *Alaska and Rhode Island represent the slowest and fastest download health insurance and with increasingly high de- speeds, respectively, in the United States. ductible payments for patients with insurance, stands out in regard to medication costs. More ical records system, whereas only 28 percent do in than half of the U.S. primary care physicians re- the United States. These systems: ported that their patients “often” had difficulty paying for medications. They also indicated that • Automatically alert doctors to potential drug many of their patients experienced difficulty pay- dosage interactions; ing for care. • Automatically prompt doctors to provide test Nonfinancial incentives to improve patient results to patients; and care and safety—in the form of physicians rou- • Automatically send patient follow-up and ap- tinely receiving patient survey data and results of pointment reminders. clinical outcomes trials—were mixed. A majority of doctors in the United Kingdom, Germany, and In the four leading countries, between 50 and New Zealand indicated they did receive results of 90 percent of primary care physicians have elec- patient surveys as well as clinical outcomes results. tronic medical records systems implemented to The U.K. doctors led the group in this regard; provide the above data; by contrast, fewer than 25 nearly all doctors reported receiving such data, percent of U.S. and Canadian practices have sys- evidence of the national efforts to include pa- tems in place to provide these functions. More tients’ experiences as outcome indicators. As a than 60 percent of U.S. and Canadian practices result, the United Kingdom has developed a bat- have no system (manual or otherwise) to provide tery of evidence-based clinical guidelines and pa- these functions for their patients. tient surveys. In parallel with the findings about electronic As of yet, the United States and Canada do not medical records systems and information technol- have financial payment initiatives in place that ogy implementation, U.S. and Canadian doctors focus on physicians and primary care. Instead, the reported the highest incidence of not hearing the United States has relied on private insurance, em- results of referrals to other doctors. Also, U.S. and ployer, and state initiatives to explore and imple- Canadian doctors reported the greatest incidence ment payment incentives and payment methods. of medical records sometimes or often not being available at the time of the patient’s appointment. IMPLICATIONS FOR PLASTIC SURGERY It is important to emphasize that the Com- CHRONIC ILLNESSES, ACCESS TO monwealth study is limited in that it focuses on PRIMARY CARE, PRESCRIPTIONS, AND primary care physicians in a limited number of QUALITY INCENTIVES countries. Data from this study cannot be directly The United States and Canada were the least transferred to the plastic surgery community be- prepared among the seven countries to provide cause it differs in fundamental ways from primary optimal care for chronically ill patients with mul- care physicians. The report does indicate, how- tiple illnesses, with only 68 percent of U.S. prac- ever, that U.S. medicine lags behind other coun- tices indicating the ability to do so. Providing writ- tries in terms of overall information technology ten self-care instructions to patients with multiple infrastructure, cohesiveness of patient data trans- illnesses was conducted most effectively by Ger- fer, and an overall policy of improving physician man practices (63 percent) but much less fre- performance and patient payment structures. quently among the other six countries studied. These are important points to consider. Both the

1730 Volume 120, Number 6 • Editorial

United States and Canada lag in information ca- ical technology in the United States are among the pacity; interestingly, both countries have relied best in the world. However, as all of you are aware, primarily on market-driven, individual care sys- the practice of medicine and plastic surgery is tems or individual physician investment to build more than time in the operating room! Effective information technology capability. In the other medical care and plastic surgery are situated in a countries studied, collective efforts to support pri- larger medical infrastructure context, which is, sad mary care have provided increases in information to say, falling behind. Until (or unless) govern- technology capacity to a broad range of solo and ment-led initiatives change this landscape, it falls small group practices. Of note, only the United to the individual plastic surgery practices, institu- States appears to lack a national plan to support tions, and societies to invest in the hardware, soft- expanded primary care information technology ware, training, and management skills necessary to development. implement effective change. Evidence-based pa- Of the countries studied, the United States tient outcomes instruments for evaluating physi- outspends the rest in per capita health-care costs cian performance will also assist in the improve- (Table 2). Despite this, primary care physicians in ment of patient safety and enhance effectiveness the United States are more limited than those in overall. Such metrics and instruments are already other leading countries in information capacity, being developed. That is all the more reason for shared performance reporting, and development our major national society—the American Society of evidence-based quality metrics. Despite having of Plastic Surgeons—to provide a streamlined among the best-trained and skilled doctors in the pathway for day-to-day patient outcome manage- world, the United States lags behind in overall ment and guidelines for optimizing electronic provision of primary health care. Additional evi- medical records systems that can be used by all dence of this is that the United States is not a practicing plastic surgeons. If we are to advance in leader in clinical outcomes and often ranks low our specialty of plastic surgery, we need the in- among industrialized countries for mortality rates formation technology infrastructure to do so in in diseases that are amenable to medical care. In our offices, in our research, and in our country. a 2005 survey, the United States often ranked last The time to start is long overdue! or tied for last on issues of patient safety, access, 3 Rod J. Rohrich, M.D. and care efficiency. Editor-in-Chief For the U.S. plastic surgeon, development of Plastic and Reconstructive Surgery information technology infrastructure is critical University of Texas Southwestern Medical Center for the advancement of our specialty. Surgical 5323 Harry Hines Boulevard, HD01.544 training and technique and innovations in med- Dallas, Texas 75390-8820 [email protected]

Table 2. Per Capita Health-Care Spending REFERENCES 1. Caule, L. U.S. net access not all that speedy. USA Today June Per Capita Spending 26, 2007. P. A1. Country on Health Care 2. Schoen, C., Osborn, R., Hyunh, P. T., Doty, M., Peugh, J., and New Zealand $1886 Zapert, K. On the front lines of care: Primary care doctors’ United Kingdom $2231 office systems, experiences, and views in seven countries. Australia $2876 Health Aff. (Millwood) 25: w555, 2006. Available at www. Germany $2996 healthaffairs.org. Accessed December 18, 2006. The Netherlands $2976 3. Hussey, P. S., Anderson, G. F., Osborn, R., et al. How does the Canada $3003 quality of care compare in five countries? Health Aff. (Millwood) United States $5635 23: 89, 2004.

1731 EDITORIAL

Appropriate Prophylactic Antibiotic Use in Plastic Surgery: The Time Has Come

John G. Hunter, M.D., M.M.M. New York, N.Y.

urgical site infections are the second most poorly timed use and unsuitable agent selection. common type of nosocomial infection to- Despite the rapid proliferation, since 2003, of Sday. The appropriate use of prophylactic patient safety and appropriate antibiotic use– antibiotics has been demonstrated to reduce dominated surgical quality improvement initia- surgical site infection rates, as well as infec- tives (such as the Surgical Care Improvement tion-related morbidity rates and health-care Project8), which have been embraced by other costs, for a number of surgical procedures. surgical specialties, plastic surgeons still engage Prevention of surgical site infections is a na- in such practices with unfortunate regularity. tional patient safety goal.1 Suggestions for the appropriate use of prophy- Unfortunately, as a group, plastic surgeons lactic antibiotics, relevant for essentially all plas- tend to use prophylactic antibiotics inappropri- tic surgery procedures, are listed in Table 1.7 ately. There is no debate about this. It has been A major health-care quality initiative, directed repeatedly documented by surgeon practice sur- not at hospitals but, for the first time, at all veys, literature reviews, and critiques in this Jour- physicians, should ultimately force change in nal and elsewhere.2–6 Although authoritative, our prophylactic antibiotic use practices. widely accepted, evidence-based guidelines for The nascent reengineering of health-care de- appropriate prophylactic antibiotic agent selec- livery and financing in the United States became tion and administration timing and duration “real” for physicians (including plastic surgeons) exist,7 many plastic surgeons ignore (or are un- on July 1, 2007, with implementation of Medi- aware of) them. We generally use prophylactic care’s Physician Quality Reporting Initiative. Al- antibiotics too often and for too long. Over the though voluntary, the Initiative is clearly a first past several decades, the use of prophylactic an- step toward mandatory quality reporting by indi- tibiotics in plastic surgery, especially for aesthetic vidual physicians; it is essentially a pay-for- procedures, has increased dramatically, yet there performance program “with training wheels.” is no scientific evidence demonstrating changes The Initiative requires that participating phy- in infection rates or antibiotic efficacy.2 sicians choose three quality measures (from a The continued anecdotal use of prophylactic menu of 74) on which they will report for rele- antibiotics by plastic surgeons has often been vant services or procedures performed on their defended by the contention that the necessary Medicare patients between July 1 and December scientifically valid data to provide evidence-based 31, 2007. Physicians meeting an 80 percent re- guidelines for appropriate prophylactic antibi- porting rate for the chosen measures during the otic use for most plastic surgery procedures do 6-month period will receive a 1.5 percent bonus not exist.2 Although this assertion perhaps can payment for all allowed Medicare charges during 9 be used to rationalize the dubious administra- that time period. For surgical procedures, the tion of a prophylactic antibiotic for a clean pro- quality measures that have been developed (a cedure such as blepharoplasty, there is abso- collaborative effort in which the Surgical Quality lutely no justification for prolonged and/or Alliance, of which the American Society of Plastic Surgeons is a member, participated) From the Division of Plastic Surgery, Weill Medical College and approved by the National Quality Forum of Cornell University and New York–Presbyterian Hospital, constitute the Perioperative Care Measure Set. and Department of Surgery, New York Methodist Hospital. The measure set contains three prophylactic Received for publication July 8, 2007; accepted July 19, antibiotic use performance measures relevant 2007. to plastic surgeons: selection of prophylactic Copyright ©2007 by the American Society of Plastic Surgeons antibiotic agent, timing of antibiotic prophy- DOI: 10.1097/01.prs.0000280567.18162.12 laxis administration, and discontinuation of

1732 www.PRSJournal.com Volume 120, Number 6 • Editorial

Table 1. Suggestions for Prophylactic Antibiotic Use in Plastic Surgery DOs ● Consider not using prophylactic antibiotics for clean procedures not involving implants ● Cefazolin is the primary antibiotic choice for virtually all plastic surgery procedures ● For beta-lactam allergic patients, clindamycin is generally preferable to vancomycin ● Always administer the antibiotic before making the incision (1 hour or less; 2 hours for vancomycin) ● For long (Ͼ3.5 hours) or bloody procedures, consider an intraoperative (second) dose of cefazolin ● Use vancomycin only when absolutely indicated (high methicillin-resistant Staphylococcus aureus rate, and so on; one dose only) ● Consider not administering additional antibiotic doses after wound closure (no additional benefit has been observed in many studies) ● Additional DOs to reduce surgical site infections: maintain intraoperative normothermia (Ͼ36°C); maintain normovolemia; consider supplemental oxygen administration DON’Ts ● Do not use newer, broad-spectrum antibiotics (therapeutic choices) ● Do not continue prophylactic antibiotics for more than 24 hours after surgery end time, ever ● Do not start prophylactic antibiotics after wound closure; there is no benefit (there is a limited benefit if antibiotics are started after the incision is made) ● Do not order antibiotic “on call” to the operating room; it is often administered too early before the incision (give in the holding area or operating room) ● The presence of implants, drains, and so on does not justify prolonged prophylactic antibiotic administration; there is no additional benefit ● Additional DON’Ts to reduce surgical site infections: do not shave operative sites with razors (or have patients shave them); if hair removal absolutely required, use clippers immediately before the procedure prophylactic antibiotics. Compliance requires the health-care policy wonks championing surgical the use of a first- or second-generation cephalo- quality improvement. Accepting and complying sporin antibiotic (unless the patient has a beta- with prophylactic antibiotic-related performance lactam allergy), antibiotic administration within measures is relatively easy; other existing measures 1 hour before the incision is made (2 hours for (such as appropriate venous thromboembolism vancomycin), and discontinuation of antibiotics prophylaxis, also part of the Perioperative Care within 24 hours of surgery end time.9,10 Measure Set), and those yet to come our way, will So how will the Physician Quality Reporting undoubtedly be more difficult for plastic surgeons Initiative change the prophylactic antibiotic uti- to widely accept and comply with. It is time to lization patterns of those surgeons who do not accept the “new realities” of health care. Plastic participate? The collected data will undoubtedly surgeons can–-and must–-begin by appropriately be used by the Centers for Medicare and Med- using prophylactic antibiotics. icaid Services to create performance bench- John G. Hunter, M.D., M.M.M. marks for each quality indicator. The informa- 47 East 63rd Street tion will be publicly reported; it will be New York, N.Y. 10021 scrutinized by consumers, businesses, insurance [email protected] [email protected] carriers, medical societies, hospitals, and regula- [email protected] tory agencies. “Best practices” will be established, and practice guidelines will be promulgated. In- DISCLOSURE dividual physicians will receive performance The author has no financial interests to disclose. feedback comparing their performance with that of their peer groups. REFERENCES Quality and performance measures are here 1. Burke, J. P. Infection control: A problem for patient safety. to stay and will continue to proliferate. They will N. Engl. J. Med. 348: 651, 2003. ultimately affect every one of us, even if we never 2. Lyle, W. G., Outlaw, K., Krizek, T. J., et al. Prophylactic set foot in a hospital or participate in any insur- antibiotics in plastic surgery: Trends of use over 25 years of an evolving specialty. Aesthetic Surg. J. 23: 177, 2003. ance plans. In the near future, maintenance of 3. Grunebaum, L. D., and Reiter, D. Perioperative antibiotic licensure and board certification will, in part, re- usage by facial plastic surgeons. Arch. Facial Plast. Surg. 8: 88, quire quality and performance measure reporting 2006. and compliance. Physician practice patterns will 4. Perrotti, J. A., Castor, S. A., Perez, P. C., and Zins, J. E. become much more transparent. Have no miscon- Antibiotic use in aesthetic surgery: A national survey and literature review. Plast. Reconstr. Surg. 109: 1685, 2002. ception, we will be evaluated, and judged! 5. Peled, I. J., Gur, D., Berger, J., et al. Prophylactic antibiotics Achieving appropriate prophylactic antibiotic in aesthetic and reconstructive surgery. Aesthetic Plast. Surg. use in surgery represents “low-hanging fruit” for 24: 299, 2000.

1733 Plastic and Reconstructive Surgery • November 2007

6. Rohrich, R. J., and Rios, J. L. The role of prophylactic anti- 8. Surgical Care Improvement Project (SCIP). Available at biotics in plastic surgery: Whom are we treating? Plast. Re- http://www.medquic.org/scip. Assessed July 7, 2007. constr. Surg. 112: 617, 2003. 9. Center for Medicare and Medicaid Services. Medicare Phy- 7. Bratzler, D. W., and Houck, P. M. Antimicrobial prophy- sician Quality Reporting Initiative (PQRI). Available at laxis for surgery: An advisory statement from the National http://www.cms.hhs.gov/pqri. Assessed July 7, 2007. Surgical Infection Prevention Project. Clin. Infect. Dis. 38: 10. Harris, J. A. Medicare’s Physician Quality Reporting Initia- 1706, 2004. tive. Bull. Am. Coll. Surg. 92: 8, 2007.

PRS is ‘‘Media Choice” in Medical Marketing and Media Magazine David C. Watts, M.D., medical director of the Plastic and Cosmetic Surgery Institute of Vineland, New Jersey, selected Plastic and Reconstructive Surgery as his Media Choice in the August 2007 issue of Medical Marketing and Media magazine. “PRS is the gold standard of journals for plastic surgery as the official journal of the American Society of Plastic Surgeons. The ‘White Journal,’ as it is known, is sectioned to address surgical areas such as breast, experimental, reconstructive, hand/peripheral nerve, pediatric/craniofacial, and cosmetic. PRS provides the latest operative techniques along with the basic science that supports advances occurring in the field. A discussion often accompanies articles to provide an opportunity to critique the article and make comments. Each issue contains an online CME article with questions that are pertinent and also provide CME credit. I consider PRS a ‘must read’ for any practicing plastic surgeon.”

1734 REVIEWS

s a service to our readers, Plastic and Recon- though Dr. Feldman and I do not share the same Astructive Surgery® reviews books, DVDs, prac- surgical approaches, our concepts and goals are tice management software, and electronic media the same. Clearly, his technique works well for items of educational interest to reconstructive him. and aesthetic surgeons. All items are copyrighted In the chapter on subplatysmal surgery, I was and available commercially. The Journal actively pleased to read Dr. Feldman state, “I don’t per- solicits information in digital format (e.g., CD- form digastric shaves very often, a few times a ROM and Internet offerings) for review. year at most.” The chapter on resecting subman- Reviewers are selected on the basis of relevant dibular salivary gland bulges is very thorough interest. Reviews are solely the opinion of the and honest. After reading the descriptions of the reviewer; they are usually published as submit- complexities and potential complications, I was ted, with only copy editing. Plastic and Reconstruc- convinced I would never resect a submandibular tive Surgery® does not endorse or recommend gland for cosmetic reasons. any review so published. Send books, DVDs, and Neck Lift is certainly Dr. Feldman’s master- any other material for consideration to: Jack A. piece, and reading it was truly stimulating. As I Friedland, M.D., Review Editor, Plastic and Recon- have stated at several national meetings, this is a structive Surgery, UT Southwestern Medical Cen- book for resident, young, and seasoned plastic ter, 5323 Harry Hines Boulevard, HD1.544, Dal- surgeons alike. Even if you never perform corset las, Texas 75390-8820. platysmaplasty, you will be educated and enlight- Jack A. Friedland, M.D. ened by the book. It should be in every cosmetic Review Editor surgeon’s library. DOI: 10.1097/01.prs.0000291396.88230.f5 Neck Lift Daniel C. Baker, M.D. By Joel J. Feldman. Pp. 450. Quality Medical Publishing, St. Reoperative Aesthetic and Reconstructive Louis, Mo., 2006. Price: $395. eck Lift is the culmina- Plastic Surgery, 2nd Edition Ntion of Joel Feldman’s By James C. Grotting. Pp. 2063. Quality Medical Publish- 30 years of experience per- ing, St. Louis, Mo., 2007. Price: $525. forming both reconstruc- hen the first edition tive and cosmetic surgery Wof Reoperative Aesthetic on the neck. The entire and Reconstructive Plastic book is a testimony to his Surgery by James Grotting clear thinking and analysis was published in 1995, it of a complicated, often represented a landmark confusing subject. The il- textbook. Before that pub- lustrations by Amanda lication, there was no Behr are superb, simple, good comprehensive re- and precise. source that focused on re- The 12 chapters discuss basic concepts, anat- operative plastic surgery. omy, surgical technique, and the more compli- The success of the first edi- cated and controversial subplatysmal surgery, at tion prompted the publi- which Dr. Feldman is a master. One of the best cation of the second. The impetus was to capture chapters covers anatomy. It is the most thorough many of the novelties and changes that have and clear description of aesthetic neck anatomy occurred in our specialty over the past several I have ever read. The chapter’s exhaustive bibli- years. Thus, the second edition, in two volumes, ography of 163 references is invaluable and has 23 more contributors, 401 more pages, and shows the time, thought, and effort put into this six more chapters than the first. Improvements book. I especially enjoyed the chapters on inci- include a series of review questions at the end of sions and earlobe shaping, two critical areas of- each chapter covering the salient concepts and ten overlooked in rhytidectomy. principles, illustrations that have been colorized, In his Preface, Dr. Feldman admits that his and references that have been annotated. Ten approach to neck lifting is unconventional. Al- new chapters emphasize reoperative aesthetic surgery of the face and body as well as reopera- Copyright ©2007 by the American Society of Plastic Surgeons tive reconstructive surgery of the trunk and

www.PRSJournal.com 1735 Plastic and Reconstructive Surgery • November 2007 nerves. Some of the old chapters have been to- Attar provide a practical and useful review of reop- tally rewritten, and others have been modified. erative peripheral nerve surgery of the trunk and Included with the second edition are two DVDs. extremities. The illustrations and intraoperative The first focuses on implant removal and vertical photographs are highly effective and will enable mastopexy and the second on secondary face lift the reader to better understand the intricacies of using dermal fat grafts. Both are composed of reoperative peripheral nerve surgery. photographs, movie clips, and commentary by Overall, this is well-written, nicely detailed, Dr Grotting. and highly illustrated text with more than 3000 Of the new chapters, three have been selected photographs and schematics. All of the chapters for comment. Drs. Aly and Capella provide an are prepared by recognized experts in their excellent review of secondary body-contouring fields. Most plastic surgeons will identify with the procedures following massive weight loss in men many clinical scenarios that are reviewed and and women. Examples of reoperative breast, covered in each chapter. Valuable insights and trunk, and extremity procedures are provided, technical pearls are provided that will be bene- with many preoperative and postoperative pho- ficial to residents in training as well as to novice tographs. Dr. Coleman has elegantly reviewed and seasoned plastic surgeons. Adding this book revisional fat grafting of the cheek and lower to one’s library is recommended, especially for eyelid. His techniques for fat harvesting, prepa- those who do not own the first edition. For those ration, transfer, and placement are described. who do, there is new information that will nicely The preoperative, intraoperative, and postopera- complement one’s library. tive photographs are useful and beneficial for the DOI: 10.1097/01.prs.0000291397.65359.aa practitioner. Finally, Drs. Ducic, Dellon, and Al- Maurice Y. Nahabedian, M.D.

Advertising in Plastic and Reconstructive Surgery® Please direct all inquiries regarding advertising in Plastic and Reconstructive Surgery® to: Christopher J. Ploppert Advertising Representative Lippincott Williams & Wilkins 530 Walnut St. Philadelphia, PA 19106 Tel: 215-521-8429 Fax: 215-827-5809 Email: [email protected]

1736 LETTERS

GUIDELINES (maggots tested for safety and effectiveness and ren- Letters to the Editor, discussing dered germ-free). Maggot therapy is defined as a material recently published in “controlled, therapeutic myiasis.”2,3 In the United the Journal, are welcome. They States, the Food and Drug Administration regulates will have the best chance of ac- medicinal maggots as prescription-only medical de- ceptance if they are received vices, given that many of the wounds treated with within 8 weeks of an article’s publication. Letters to the Editor maggot debridement therapy are quite serious and may be published with a re- require close medical attention. In most other coun- sponse from the authors of the article being discussed. tries, maggot debridement therapy is performed or Discussions beyond the initial letter and response will not regulated similarly. be published. Letters submitted pertaining to published After confusing self-inflicted myiasis with maggot de- Discussions of articles will not be printed. Letters to the bridement therapy, the author then suggests that the Editor are not usually peer reviewed, but the Journal may maggots were responsible for the patient’s demise. invite replies from the authors of the original publication. While invasive myiasis can be deadly, no identification All Letters are published at the discretion of the Editor. was provided to demonstrate that these maggots were Authors will be listed in the order in which they appear in an invasive species. It has previously been shown that the submission. Letters should be submitted electronically most cases of wound-associated myiasis (although gen- via PRS’ enkwell, at www.editorialmanager.com/prs/. 4 We reserve the right to edit Letters to meet requirements erally not self-induced) are benign. of space and format. Any financial interests relevant to the We know the patient must have had a wound, but content of the correspondence must be disclosed. Submis- no other history was presented. We are only told that sion of a Letter constitutes permission for the American when the maggots were removed, the wound ex- Society of Plastic Surgeons and its licensees and asignees to tended through the cranium and into the brain. It is publish it in the Journal and in any other form or medium. then implied that the single batch of larvae, placed The views, opinions, and conclusions expressed in the on the wound 7 days earlier, must have been respon- Letters to the Editor represent the personal opinions of the sible for this destruction. After the maggots were individual writers and not those of the publisher, the Edi- removed and the patient had spent a week in the torial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of hospital, the patient became septic and died. We are the sponsoring organizations or of the institutions with which asked to believe that this, too, was a result of the the writer is affiliated, and the publisher, the Editorial Board, maggot infestation. and the sponsoring organizations assume no responsibility I would contend that someone desperate enough for the content of such correspondence. to put maggots on his or her scalp wound is suffering from either a serious and long-standing wound or cognitive impairment. The reported patient likely Putting Wild Maggots on Your Head Is Not suffered from both. He likely had a long-standing “Maggot Therapy,” but It Does Suggest tumor or other invasive wound that had extended Pre-Existing Pathology through his skull and into his brain by the time he applied maggots to his head. Sir: To claim that the maggots were responsible for all was surprised and disappointed to see Dr. Emsen’s of this pathology, along with the sepsis a week after poorly documented and inappropriately titled re- I they were removed, without presenting any informa- port of myiasis in the April 15, 2007, issue of this fine tion about the wound before infestation or the mag- Journal.1 The misleading title, “Fatal Side Effect of gots themselves, is irresponsible at best and mislead- Maggot Treatment on Wound Healing” does not ac- ing at worst. Let us call this report what it really is: a curately reflect the two fundamental facts about the terrible outcome in someone who attempted inap- case: (1) what was reported was not “maggot therapy” propriate treatment of his own wound with uniden- but rather an uncontrolled maggot infestation (“my- tified, nonmedicinal maggots. Let us title our com- iasis”); and (2) no evidence was presented to support munications more honestly and responsibly, since the contention that the maggots caused the reported many readers will look no further to glean their pathology. “take-home message.” What Dr. Emsen actually described was self-in- DOI: 10.1097/01.prs.0000284669.88359.f0 flicted myiasis with wild, nontherapeutic fly larvae (maggots). These were not medicinal maggots, and what the patient did, without medical supervision, Ronald Sherman, M.D., M.Sc., D.T.M.&H. contradicts the current principles and practice of University of California, Irvine maggot therapy. BioTherapeutics, Education and Research Foundation The term maggot therapy should be applied only Irvine, Calif. to the medical use of specific, medical-grade larvae Correspondence to Dr. Sherman Copyright ©2007 by the American Society of Plastic Surgeons 36 Urey Court Irvine, Calif. 92617 DOI: 10.1097/01.prs.0000291616.67831.68 [email protected]

www.PRSJournal.com 1737 Plastic and Reconstructive Surgery • November 2007

DISCLOSURES Ilteris Murat Emsen, M.D. The BioTherapeutics, Education, and Research Department of Plastic and Reconstructive Surgery Foundation supports patient care, therapist education, Numune State Hospital and research in maggot therapy, leech therapy, phage Erzurum, Merkez, Turkey therapy, and other modalities that use live organisms to Correspondence to Dr. Emsen treat disease. The author is a cofounder and laboratory Ataturk Universitesi Logmanlari 4 Blok, No. 30 director of Monarch Laboratories, which produces med- Erzurum, Merkez 25240, Turkey ical-grade maggots in North America. [email protected] REFERENCES 1. Emsen, I. M. Fatal side effect of maggot treatment on wound REFERENCE healing. Plast. Reconstr. Surg. 119: 1624, 2007. 1. Emsen, I. M. Fatal side effect of maggot treatment on wound 2. Sherman, R. A., Hall, M. J., and Thomas, S. Medicinal mag- healing. Plast. Reconstr. Surg. 119: 1624, 2007. gots: An ancient remedy for some contemporary afflictions. Annu. Rev. Entomol. 45: 55, 2000. 3. Sherman, R. A. Maggot therapy for foot and leg wounds. Int. J. Low. Extrem. Wounds 1: 135, 2002. Maggot Debridement Therapy 4. Sherman, R. A. Wound myiasis in urban and suburban United States. Arch. Intern. Med. 160: 2004, 2000. Sir: n his communication entitled “Fatal Side Effect of IMaggot Treatment on Wound Healing” (Plast. Re- constr. Surg. 119: 1624, 2007), Dr. Ilteris Murat Emsen Reply describes a 75-year-old man with an infected scalp wound that was infested with maggots. The patient Sir: apparently used maggots on his chronic wound without Dr. Sherman mentions in his letter that the case I opening the dressing for a week. When he arrived at the presented was not maggot treatment but uncontrolled clinic he was in a semicoma, his scalp had been invaded maggot infestation. He mentions that these were not by maggots, and his cranial bone tissue was nonexistent. medicinal maggots; that in the United States, maggot The patient died soon after from septicemia. It is con- therapy is performed with medical-grade larvae (i.e., cluded that the uncontrolled use of maggot therapy can maggots that are tested for safety and effectiveness and be dangerous. rendered germ-free); and that such therapy should be In his report, Dr. Emsen does not give any details carried out by experienced hands. All of this is true. as to what kind of maggots the patient used and how However, my report is from Turkey, not the United he purchased them. To the best of my knowledge, States. There are no medicinal maggots in this region. there is only one place in Turkey, the GATA Military The history of the patient is more important. He had Hospital in Ankara, where maggot therapy is being a nonhealed scalp wound and had found and used used. This method was introduced in Turkey in 2002, nonmedical, nonsterile maggots on his scalp. The pa- and since that time, several patients have been tient had a very low socioeconomic status and cultural treated.1 According to those responsible for maggot situation. People like him are rare in the United States. treatment at GATA Military Hospital, the patient was This does not mean that these people are not living in not treated by them (M. Tanyuksel, M.D., personal countries other than the United States. The author who communication). It is most likely that the patient makes this critique should understand this point. The exposed himself, willingly or unwillingly, to flies in patient had heard something about using maggot treat- his environment. It is known that different kinds of flies ments from his friends. My communication does not are attracted by the strong odor emanating from chronic discuss the use of medical maggots, and I am not op- wounds and usually lay their eggs on the dressing covering posed to medical or sterile maggots.1 There is a very fine the wound; this causes a natural infestation under non- point in my communication: only sterile or tested or sterile conditions. The hatched maggots migrate to the medical maggots have a beneficial effect on nonhealed wound and start eating either necrotic tissue (e.g., spe- or infected wounds. We must be very careful if these cies of Lucilia, Calliphora, and Fannia, which are the agents are not sterile or medical. Infection with these causative agents of facultative myiasis) or living tissue nonsterile or nonmedical maggots can cause more ag- (e.g., Wohlfahrtia magnifica, which causes obligatory gressive tissue destruction. The point is this: it is not myiasis).2 These maggots have little to do with maggot known where he found these nonsterile maggots. How- therapy, which utilizes sterile larvae of the greenbottle ever, in rural regions of Turkey, some places (especially fly, Lucilia sericata. The maggots are left on the wound barns) are potent maggot sources (nonsterile and non- for 24 to 72 hours; they are then removed and replaced medical). In summary, maggots must be used by expe- with a new lot if necessary.3 rienced hands in patients with high sociocultural situ- In the described case, the cranial bone tissue was ations. most probably destroyed by bacteria and not by mag- DOI: 10.1097/01.prs.0000291398.72982.7e gots, as to the best of my knowledge, maggots cannot

1738 Volume 120, Number 6 • Letters eat bone tissue. The maggots are representative of Ilteris Murat Emsen, M.D. either facultative myiasis, in which case they partially Department of Plastic and Reconstructive Surgery cleaned the wound (granulotic tissue is visible in Dr. Numune State Hospital Emsen’s figure), or obligatory myiasis, in which case Erzurum, Merkez, Turkey they did even more damage to the existing wound. Correspondence to Dr. Emsen In conclusion, there is no indication whatsoever Ataturk Universitesi that maggot therapy can be dangerous, and it is Logmanlari 4 Blok, No. 30 certainly not fatal. More than 20,000 patients world- Erzurum, Merkez 25240, Turkey wide have been treated with maggots in the last 15 [email protected] years and nothing similar has been reported. In addition, it would be unimaginable that someone would REFERENCE think of putting maggots directly onto the exposed 1. Emsen, I. M. Fatal side effect of maggot treatment on wound brain of a patient. healing. Plast. Reconstr. Surg. 119: 1624, 2007. DOI: 10.1097/01.prs.0000291399.11101.d3 Kosta Y. Mumcuoglu, Ph.D. Department of Parasitology Hebrew University–Hadassah Medical School Surgical Treatment of Partial Defects of the P.O. Box 12272 External Ear Jerusalem 91120, Israel [email protected] Sir: was both surprised and concerned when I read the Iarticle by Abenavoli et al. entitled “Surgical Treat- REFERENCES ment of Partial Defects of External Ear” (Plast. Reconstr. 1. Tanyuksel, M., Araz, E., Dundar, K., et al. Maggot debride- Surg. 119: 434, 2007). I had described this technique in ment therapy in the treatment of chronic wounds in a military this Journal in 1985 (“Ear Reconstruction with Rotation hospital setup in Turkey. Dermatology 210: 115, 2005. Advancement in Composite Flap”)1, and I described a 2. Sherman, R. A., Hall, M. J., and Thomas, S. Medicinal mag- modification of the technique (“Reconstruction of the gots: An ancient remedy for some contemporary afflictions. Ear after Skin and Cartilage Loss”) in Clinics in Plastic Annu. Rev. Entomol. 45: 55, 2000. Surgery in 2002.2 I would appreciate it if the credit can 3. Mumcuoglu, K. Y. Clinical applications for maggots in wound be given to the original author. care. Am. J. Clin. Dermatol. 2: 219, 2001. DOI: 10.1097/01.prs.0000291401.18725.3d Nabil I. Elsahy, F.R.C.S. Cairo Plastic Surgery Center 2 Road 18 Maadi Sarayat Reply Cairo, Egypt Sir: [email protected] Dr. Mumcuoglu mentions in his letter that maggots are not the cause of cranial bone erosion or destruc- REFERENCES tion. In addition, he inquired about which kind of 1. Elsahy, N. I. Ear reconstruction with rotation-advancement maggots were used in the case I described. The patient composite flap. Plast. Reconstr. Surg. 75: 567, 1985. in this case had a low sociocultural status. He had been 2. Elsahy, N. I. Reconstruction of the ear after skin and cartilage living in a very poor village in a rural region and had loss. Clin. Plast. Surg. 29: 201, 2002. been advised, correctly or incorrectly, by his friends. The wound in his scalp was a nonhealed wound and he had used the maggots to heal it. Neither he nor his friends, however, knew what kind of maggot was used.1 Reply It is not known where he found them. In a rural region, Sir: some places (especially barns) are potential sources of I apologize to Dr. Elsahy for neglecting to include his maggots (nonsterile and nonmedical). The most im- article in the references, but according to the rules of portant factor in my communication is that maggots the editor-in-chief of Plastic and Reconstructive Surgery, can have beneficial effects on nonhealed or infected only a limited number of articles can be included. In wounds. However, one cannot predict what nonsterile reality, the technique used by Dr. Elsahy and published and nonmedical maggots will do. The history of the in 19851 as a case report and in 20022 as a review utilizes patient is important. As a result, maggots must be used principles that are similar to my technique, but con- by experienced hands, even if the maggots are medical- sidering that the area treated is very small, a few details grade and have been tested. In contrast, infection with can make a difference that is worth presenting. For or without maggots can be dangerous or fatal in some example, Dr. Elsahy uses a rotation-advancement flap, cases. whereas I use a simple advancement flap; this could be DOI: 10.1097/01.prs.0000291400.11101.9f a difference. Nevertheless, I believe that Dr. Elsahy’s

1739 Plastic and Reconstructive Surgery • November 2007 approach is extremely useful and worthy of consider- Michael T. Yen, M.D. ation in cases of external ear defects. Cullen Eye Institute DOI: 10.1097/01.prs.0000291402.95853.f9 Department of Ophthalmology Fabio M. Abenavoli, M.D. Baylor College of Medicine 6565 Fannin, NC-205 “San Pietro” Hospital Houston, Texas 77030 Rome, Italy [email protected] Correspondence to Dr. Abenavoli Via Savoia 72 REFERENCES 00198 Rome, Italy 1. Oh, Y. W., Seul, C. H., and Yoo, W. M. Medial epicanthoplasty [email protected] using the skin redraping method. Plast. Reconstr. Surg. 119: 703, 2007. 2. Yen, M. T., Jordan, D. R., and Anderson, R. L. No-scar Asian REFERENCES epicanthoplasty: A subcutaneous approach. Ophthal. Plast. Re- constr. Surg. 18: 40, 2002. 1. Elsahy, N. I. Ear reconstruction with rotation-advancement 3. Jordan, D. R., and Anderson, R. L. Epicanthal folds: A deep composite flap. Plast. Reconstr. Surg. 75: 567, 1985. tissue approach. Arch. Ophthalmol. 107: 1532, 1989. 2. Elsahy, N. I. Reconstruction of the ear after skin and cartilage loss. Clin. Plast. Surg. 29: 201, 2002.

Augmentation Mentoplasty with Diced High-Density Porous Polyethylene Medial Epicanthoplasty Using the Skin Sir: Redraping Method e read the article by Gu¨rlek et al., entitled “Aug- Sir: Wmentation Mentoplasty with Diced High-Density read with interest the article entitled “Medial Epi- Porous Polyethylene,”1 with interest. The method they Icanthoplasty Using the Skin Redraping Method” by present for augmentation mentoplasty is ingenious and Oh et al.1 Creation of a double eyelid is the most may become an additional technique in the surgical common cosmetic procedure performed in Asia, and armamentarium. several different surgical procedures have been de- Our concern, however, is that the authors may not scribed to address the epicanthal fold. Many of these have delivered the appropriate diagnoses and conse- procedures are complicated by their complexity as quent treatment to this cohort of 20 patients, as re- well as noticeable medial canthal scar formation, flected in the following aspects of their article: which may be undesirable and unacceptable. The The authors’ analysis of and clinical work-up of the authors have eloquently described their technique of cases treated, as reported in the Methods section, are addressing the Asian epicanthal fold with minimal absent. They do not state on what clinical and radio- visible scarring. However, this technique still places graphic bases their decisions were made, other than an incision on the eyelid, and though the authors saying in the introduction that “the Frankfort position have reported excellent results, they fail to recognize in particular is very useful in evaluating the chin” and that the most effective way to avoid undesirable scar- that “radiographs must be used for evaluating cepha- ring in this area is to avoid creating a skin incision lometric dimensions.” altogether. No mention is made of carrying out a detailed soft- Since the majority of patients requiring epican- tissue, skeletal, and dental analysis in 20 patients thoplasty also undergo concurrent double eyelid- treated with one surgical combination, namely, aug- plasty, an alternative technique for addressing the mentation mentoplasty and rhinoplasty, on facial pro- epicanthal fold that should be considered is the sub- files that appeared to us to have more than just mic- cutaneous approach.2,3 This approach avoids a skin rogenia. incision in the medial canthal region by utilizing the The photographs of the two patients shown demon- medial end of the eyelid crease incision that was strate that in addition to the “chin retrusion” (micro- created for the upper eyelid blepharoplasty. This genia) the authors mention, these patients have mi- procedure also emphasizes separation of the skin of crognathia. The authors do not state why they did not the epicanthal fold and excision of the underlying consider such pathology or why they did not entertain orbicularis. The skin is then fixated with buried ab- correction of the micrognathia. Had a detailed soft- sorbable sutures to eliminate or soften the epicanthal and hard-tissue clinical analysis, oral and orthodontic fold. Since creating the double eyelid is primarily a assessment, and cephalometric radiographic analysis cosmetic procedure, the aesthetics of the epicantho- been reported, the full extent of this and other under- plasty should also be considered a priority. I ask the lying pathologies would have been revealed, making all readers to consider the subcutaneous approach as other surgical options available for their consideration. another technique for maximizing the aesthetics in Was this done? Asian epicanthoplasty. We suspect there were diagnostic errors, as reflected DOI: 10.1097/01.prs.0000291403.03478.31 by the statement that “none of our patients had mal-

1740 Volume 120, Number 6 • Letters occlusion.” Looking at the photographs provided, it is or opportunity for cephalometric analysis, so we did not possible that these patients did not present with a not use cephalometric analysis. Patients with maloc- malocclusion at some point, with such severe class II clusal deformities are referred to other centers that skeletal deformities. It is a basic orthognathic principle can perform cephalometric analysis. that these skeletal deformities have a malocclusion. We also agree with Dr. Heliotis and Dr. Messiha The only possible explanation is that these cases were about performing cephalometric analysis. In the pres- poorly treated years earlier with extractions and orth- ence of opportunities for performing cephalometric odontics to align teeth, with disregard to the underlying analysis for patients with occlusal deformities, we be- skeletal and soft-tissue problems, but all 20? lieve in its quantitativeness and imperativeness.1 The treatment options for these patients are many DOI: 10.1097/01.prs.0000291405.41595.60 and varied and should be examined and discussed in a Ali Gurlek, M.D. multidisciplinary clinic, with an orthodontist and a sur- Cemal Firat, M.D. geon to give the patient all possible options. The authors resorted to correcting complex dentofacial and Go¨ktekin Tenekeci, M.D. skeletal problems with a rhinoplasty and a single soft- Ahmet T. Eren, M.D. tissue procedure to camouflage a skeletal problem, by Department of Plastic Surgery dismissing such a problem with the statement that I˙nonu University Medical School “none of our patients had malocclusion.” Physicians T. O¨ zal Medical Center undertaking these cases must be surgeons with the full Malatya, Turkey complement of diagnostic and surgical skills, including Correspondence to Dr. Gurlek not only soft-tissue and rhinoplasty but also orthog- Department of Plastic Surgery nathic expertise. I˙nonu University Medical School DOI: 10.1097/01.prs.0000291404.03478.ff T. O¨ zal Medical Center Manolis Heliotis, F.D.S.R.C.S., F.R.C.S. 44069 Kampus, Malatya, Turkey [email protected] Ashraf Messiha, M.F.D.S., M.R.C.S. Department of Maxillofacial Surgery REFERENCE North West London Hospitals NHS Trust London, United Kingdom 1. Gu¨rlek, A., Firat, C., Aydog˘an, H., et al. Augmentation mentoplasty with diced high- density porous polyethylene. Plast. Correspondence to Dr. Heliotis Reconstr. Surg. 119: 684, 2007. Department of Maxillofacial Surgery North West London Hospitals NHS Trust Northwick Park Hospital Watford Road Securing Nasal Tip Rotation through Harrow HA1 3UJ, London, United Kingdom Suspension Suture Technique [email protected] [email protected] Sir: e thank Dr. Guyuron and appreciate his Discus- REFERENCE Wsion of our article entitled “Securing Nasal Tip 1. Gu¨rlek, A., Firat, C., Aydog˘an, H., et al. Augmentation men- Rotation through Suspension Suture Technique,” toplasty with diced high- density porous polyethylene. Plast. which was published in the May 2006 issue of the Journal Reconstr. Surg. 119: 684, 2007. (Plast. Reconstr. Surg. 117: 1750; discussion 1756, 2006). We would like to explain some facts which may not have been clear enough in context. Reply First, we are not trying to deny the existence of Sir: effective techniques to obtain satisfactory results for tip We thank Dr. Heliotis and Dr. Messiha, for their rotation through the closed method in rhinoplasty. We attention and contribution to our article, “Augmenta- decided to describe this method because with it we can tion Mentoplasty with Diced High-Density Porous obtain precise and long-lasting results. Although we are Polyethylene.”1 not trying to say that this is the best or only method, it Of course they are very right about measuring is an alternative technique that can be useful in certain the facial dimensions using cephalograms. We agree cases, such as long or projecting noses. with them on this issue. As we point out in the article, It is true that we work in the subcutaneous plane; our patients had no malocclusion deformity, only a however, in cases where it is necessary to modify the deformity of the chin. Patients with malocclusal de- cartilage structure (removal of the cephalic margin of formities were excluded from the study and other the lower lateral cartilages or application of intradomal osteotomy techniques were performed or those pa- sutures), we perform it in a manner similar to that used tients were referred to another center. We evaluated for the traditional closed method, being careful not to the patients according to Frankfort horizontal posi- leave irregularities. tion using lateral head radiographs and lateral Although trimming of the cephalic margin of the lower photographs.1 In our city, there was no orthodontist lateral cartilages can deter the suspensory ligament of the

1741 Plastic and Reconstructive Surgery • November 2007

Fig. 1. (Left) Preoperative view of a 28-year-old woman with nasal tip ptosis. We used the closed approach, with dorsal exposure by intercartilaginous incision, minimal dorsal reduction rasp of the hump, cephalic lateral crura resection, and excision to the upper anterior border of the caudal septum. (Right) At 18 months postoperatively, the tip suspension suture technique has proven to be effective. tip, our dorsal suture definitely replaces it. In our descrip- Follow-up ranged from 3 to 24 months. Although tion, we mention that we make a stab incision in the skin these periods were not very long, we think that there on each side of the nasal dorsum at the level of the was enough time to observe the persistence of the re- osteocartilaginous junction and then pass a no. 21 hypo- sults. We have reached up to 4 years of follow-up in dermic needle. We emphasize that we use a nonabsorb- some cases and we still find that the results have re- able thread that connects the nasal tip (the medial side of mained stable. The lack of more clinical examples in the domes) to the upper part of the cartilaginous dorsum our article was due to the editor’s decision, even though (i.e., the upper part of the upper lateral cartilages or we sent four cases (Fig. 1). osteocartilaginous junction), trying to keep it near the In performing our technique, we recommend using dorsal line to avoid intranasal exposure of the thread. a hook after passing the no. 21 needle, to hold the skin Although the scar tissue helps maintain the desired away from the cartilage, and using backward and for- shape, the thread itself secures the permanent result. This ward movements with the suture to release it in cases factor is especially useful in projecting noses in which the where the dermis could be caught, to avoid dimples in tip tends to drop with the passage of time. The distance the outer appearance. Finally, we think our technique between the entrance and exit points in the dorsal car- offers good results in cases where it can be appropriate tilage is usually similar to or slightly longer than that (in long or projecting noses) and that it can be repro- between the domes. Consequently, it does not affect the duced by any surgeon, assuring long-lasting, beautiful interdomal distance or the internal valve function. This results. In addition, it is another alternative to solving technique does not exclude the wide variety of possibil- a difficult problem in rhinoplasty. ities in rhinoplasty, such as spreader grafts, columellar DOI: 10.1097/01.prs.0000291608.43175.ec strut, correction of cartilage tip asymmetries, reduction of excessive caudal septum, and so on. Juan Carlos Cardenas, M.D. This type of anchor suture does not flatten the col- Jenny Carvajal, M.D. umella. That aspect was the main reason for developing this technique. In the majority of cases where we tried Alvaro Ruiz, M.D. to rotate the tip by anchoring it to the caudal border SURATEP of the septum, the consequence was flattening or dis- Medellı´n, Antioquia, Colombia tortion of the columella. We think that it is more logical Correspondence to Dr. Cardenas to lift the tip from the distal extreme. This resembles Calle 15 sur #48-130 anchoring the tip from the dorsum with a piece of tape Medellı´n, Antioquia 574, Colombia on the outer skin. [email protected]

1742 Volume 120, Number 6 • Letters

Reply Conor P. Barry, M.F.D.(R.C.S.I.), M.B. Sir: William J. Ryan, F.R.C.S., M.A. I appreciate the elaborate reply that Dr. Cardenas Leo F. Stassen, F.R.C.S., R.D.S.(R.C.S.I.), M.A. and his colleagues have provided in response to my Department of Oral and Maxillofacial Surgery Discussion of their article entitled “Securing Nasal Dublin Dental Hospital Tip Rotation through Suspension Suture Technique” Dublin, Ireland (Plast. Reconstr. Surg. 117: 1750; discussion 1756, 2006). I thank the authors for clarifying many of the Correspondence to Dr. Barry issues that were unclear or not elaborated on suffi- Department of Oral and Maxillofacial Surgery ciently in their article. Dublin Dental Hospital Lincoln Place There is always more than one way of achieving the Dublin, Dublin2, Ireland intended goals. The goal of every operation, however, [email protected] should be to utilize the simplest and most effective [email protected] means to achieve these objectives. DOI: 10.1097/01.prs.0000291609.43175.a5 REFERENCES Bahman Guyuron, M.D. 1. Hollier, L. H., Jr. Anatomical study of factors contributing to Division of Plastic Surgery zygomatic complex fracture instability in human cadavers Case Western Reserve University (Discussion). Plast. Reconstr. Surg. 119: 641, 2007. 29017 Cedar Road 2. Rowe, N. L. Fractures of the zygomatic complex and orbit. In Cleveland (Lyndhurst), Ohio 44124 N. L. Rowe and L. I. Williams (Eds.), Maxillofacial Injuries. [email protected] Edinburgh: Churchill Livingstone, 1985. Pp. 460–462. [email protected] 3. Dal Santo, F., Ellis, E., III, and Throckmorton, G. S. The effects of zygomatic complex fracture on masseteric muscle force. J. Oral Maxillofac. Surg. 50: 791, 1992. Anatomical Study of Factors Contributing to 4. Gillies, H. D., Killner, T. P., and Stone, D. Fractures of the malar-zygomatic complex, with a description of a new x-ray Zygomatic Complex Fracture Instability in position. Br. J. Surg. 14: 651, 1927. Human Cadavers 5. Stassen, L. F., and Kerawala, C. Peri- and intraorbital trauma Sir: and orbital reconstruction. In P. Ward Booth, S. A. Schendel, e thank Dr. Hollier for his Discussion1 of our and J. E. Hausamen (Eds.), Maxillofacial Surgery. London: Warticle, “Anatomical Study of Factors Contrib- Churchill Livingstone, 1999. Pp. 177–193. uting to Zygomatic Complex Fracture Instability in Human Cadavers” (Plast. Reconstr. Surg. 119: 637, 2007). It appears, however, that he has misunder- stood the main contention of the article. We do not Reply advocate fixation or indeed any treatment for non- Sir: displaced zygomatic complex fractures. Zygomatic I would agree with the authors’ conclusion that all complex fractures have been classified into “stable” zygomatic complex fractures requiring reduction or “unstable” depending on their likelihood for early should be fixated, regardless of how stable they ap- postreduction displacement.2 pear after reduction. It would be unusual now for a Our hypothesis was as follows: surgeon to bring a patient to the operating room and openly expose and reduce a fracture and yet not • The forces acting on the zygomatic complex are place a plate, at least on the zygomaticomaxillary more vertical than previously thought. • After fracture, these forces are reduced3 and are buttress. It is my impression that, in the past, reduc- unlikely to cause displacement of a reduced frac- tion alone was more common because internal fix- ture, but they may cause distraction at the frontozy- ation was not as readily available or as user-friendly. gomatic suture. I would, however, dispute that there is necessarily a • Fractures that were previously thought to be ade- prominent role for the temporalis muscle in causing quately treated by Gillies elevation alone (clinically displacement of reduced fractures. Certainly this stable fractures)4 may benefit from fixation to pre- study provides no firm basis for this assumption. vent long-term relapse due to new bone formation Nonetheless, these authors are to be congratulated at the frontozygomatic suture.5 on better characterizing the anatomy in this region. DOI: 10.1097/01.prs.0000291611.44961.b8 Our conclusions might be better worded as fol- Larry Hollier, M.D. lows: We suggest fixation for all zygomatic fractures 6621 Fannin Street, Suite 620.10 that have required reduction, even those previously Houston, Texas 77030 classified as clinically stable. [email protected] DOI: 10.1097/01.prs.0000291610.37337.0f [email protected]

1743 Plastic and Reconstructive Surgery • November 2007

The Double Opposing Periareola Flap: A Novel Minimally Invasive Surgery for the Treatment Concept for Nipple-Areola Reconstruction of Focal Axillary Hyperhidrosis Sir: Sir: e read with great interest the article by Shestak he February 2007 article by Arneja et al., entitled Wand Nguyen entitled “The Double Opposing T“Axillary Hyperhidrosis: A 5-Year Review of Treat- Periareola Flap: A Novel Concept for Nipple-Areola ment Efficacy and Recurrence Rates Using a New Ar- Reconstruction” (Plast. Reconstr. Surg. 119: 473, throscopic Shaver Technique” (Plast. Reconstr. Surg. 2007). We have been using this “novel” concept for 119: 562, 2007), contained interesting and promising nipple reconstruction since it was first described by data about a new surgical therapy–-the arthroscopic Thomas and colleagues1 in 1996, and we have made shaver technique–-for patients with focal axillary hy- minor modifications to improve long-term nipple perhidrosis. Given our considerable experience with projection.2,3 different treatment options for focal hyperhidrosis, When we first started using this technique, we with a primary focus on surgical strategies, we would found remarkable changes in nipple height during like to contribute some comments, information, and the first postoperative year that were similar to those experiences. 1 described Thomas et al., who reported a projection Arneja et al. showed a success rate of 94 percent loss of about 44 percent after an average follow-up of with their surgical technique. However, efficacy was 14 months. When wound closure is performed as only assessed by the patients themselves, who esti- described by Thomas et al., the nipple’s side walls are mated the percentage of sweat reduction.1 Even sutured to skin margins created by elevation of the though this evaluation may be convenient for a clin- flap. The nipple is left as a cylinder without any ical routine, for scientific studies we propose that ground or foundation plate. We suspected that the efficacy of surgical procedures for axillary hyperhi- connection of nipple cavity fat to subcutaneous fat drosis should be evaluated with at least one objective causes a “slipping out” of nipple volume tissue, lead- measure (e.g., iodine starch test or gravimetry).2 This ing to a collapse and the discussed projection loss. would facilitate considerably the comparability of Therefore, our intention was to create a firm foun- different surgical procedures. In particular, the ques- dation plate for the new nipple, which we achieved tion of whether surgery is successful or not can be by a modification of the donor-site wound closure better answered using gravimetry. In our experience, 3 using deepithelialized skin. The cylinder walls are it can be difficult to distinguish between ineffective sutured onto deepithelialized skin without leaving surgery and the opinion of the so-called “pseudohy- any connection of the nipple cavities to the subcu- perhidrosis patient,” who is typically dissatisfied by 3 taneous fat of the breast. We think this minor mod- the operative result, even though postoperative ification has had a major effect on nipple projection gravimetry and minor starch test results are normal. and aesthetic outcomes. In addition, if only subjective parameters, such as a DOI: 10.1097/01.prs.0000291612.22090.ea numerical rating scale, are used, a telephone inter- Gottfried Wechselberger, M.D. view is less than ideal for evaluating the long-term results of axillary skin texture after surgery. Heinrich M. Schubert, M.D. In the Surgical Technique section, Arneja et al. Petra Pu¨lzl, M.D. mention that all patients were given general anes- Thomas Schoeller, M.D. thesia. We read this passage with some surprise, as in our departments, most surgical treatment options for Department of Plastic and Reconstructive Surgery Innsbruck Medical University axillary hyperhidrosis are performed using tumes- Innsbruck, Austria cence anesthesia. In a retrospective overview of approximately 500 patients treated with focal axillary Correspondence to Dr. Wechselberger hyperhidrosis, no single case of general anesthesia Department of Plastic and Reconstructive Surgery was necessary. Particularly in an outpatient setting, Innsbruck Medical University general anesthesia is associated with significantly Anichstra␤e35 A-6020 Innsbruck, Austria higher costs compared with local anesthesia. Con- [email protected] sidering the surgical technique, hydrodissection induced by tumescence anesthesia is a welcome side effect that is missing when general anesthesia is used. REFERENCES In addition, using the cartilage shave, an extensive 1. Thomas, S. V., Gellis, M. B., and Pool, R. Nipple reconstruction training curve would seem to be necessary to avoid with a new local tissue flap. Plast. Reconstr. Surg. 97: 1053, 1996. any perforation of axillary skin, compared with man- 2. Oehlbauer, M., Schoeller, T., Piza-Katzer, H., and ual techniques such as liposuction-curettage, super- Wechselberger, G. One-stage breast reduction and nipple- areolar reconstruction. Ann. Plast. Surg. 49: 553, 2002. ficial liposuction, and curettage. 3. Schoeller, T., Schubert, H. M., Pu¨lzl, P., and Wechselberger, Although the results of the technique described ap- G. Nipple reconstruction using a modified arrow flap tech- pear convincing, the costs of a cartilage shave unit nique. The Breast 15: 762, 2006. are considerable. The average cost of the Dyonics EP1

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Arthroscopy Shaver unit (Smith & Nephew, Andover, 4. Bechara, F. G., Sand, M., Sand, D., Altmeyer, P., and Hoff- Mass.) with special handpiece is about $4000 to $6000 mann, K. Suction-curettage as a surgical treatment of focal U.S., and the unit is probably not standard equipment axillary hyperhidrosis: Recommendation for an aggressive ap- for physicians performing surgery for axillary hyperhi- proach. Plast. Reconstr. Surg. (in press). drosis. In contrast, most dermatologists and plastic sur- 5. Lawrence, C. M., and Lonsdale Eccles, A. A. Selective sweat gland removal with minimal skin excision in the treatment of geons possess a liposuction unit, preferring liposuction- axillary hyperhidrosis: A retrospective clinical and histological curettage as the surgical treatment option. review of 15 patients. Br. J. Dermatol. 155: 115, 2006. To summarize, Arneja et al. describe an effective and sophisticated procedure enabling a permanent reduction of axillary hyperhidrosis. Nevertheless, similar results are achievable using other minimally Reply invasive procedures, such as liposuction-curettage, Sir: with a considerably more favorable cost-benefit I thank Dr. Bechara et al. for their comments as well 2–5 However, if a cartilage shaver unit is already ratio. as their valuable contributions to the literature on the available, the method presents an interesting alter- treatment of this disabling condition. I appreciate the native to other minimally invasive treatment options. opportunity to respond, and I believe the comments DOI: 10.1097/01.prs.0000291613.22090.a3 found herein are pertinent to this discussion. Falk G. Bechara, M.D. Department of Dermatology and Allergology 1. It is certainly possible to quantify the total Ruhr University Bochum amount of sweat production; however, the Bochum, Germany amount of sweat production does not necessarily Michael Sand, M.D. correlate with symptom severity. Axillary hyper- Department of General and Visceral Surgery hidrosis can be compared with hypermastia in Augusta Kranken Anstalt that disease severity is subjective in nature. It is Academic Teaching Hospital suggested that the volume of breast tissue re- Ruhr University Bochum moved during reduction mammaplasty does not Bochum, Germany influence symptom relief, and removal of small Pejman Boorboor, M.D. amounts of breast tissue has had profound effects 1 Department of Plastic and Reconstructive Surgery on symptom reduction. Axillary hyperhidrosis Hannover Medical School treatment outcomes should be considered simi- Hannover, Germany lar, as symptom reduction should be the end- Peter Altmeyer, M.D. point rather than a sweat volume change. The patients in the study expressed a decrease from Klaus Hoffmann, M.D. 9.8 to 2.3 on a numerical rating scale (scale of 1 Department of Dermatology and Allergology to 10), at a mean follow-up interval of 1½ years. Ruhr University Bochum Furthermore, I would enjoy learning about the Bochum, Germany entity of “pseudohyperhidrosis,” as the term was Correspondence to Dr. Bechara not found in a MEDLINE search, nor have I Department of Dermatology and Allergology come across this entity. Ruhr University Bochum 2. With regard to technique, as my coauthors and I Gudrunstrasse 56 described in our article2 and as shown in Figure 44791 Bochum, Germany 1, an essential component of our technique is [email protected] palpation of the flaps to appreciate the change of DISCLOSURE the flap texture from that of a pebbly consistency None of the authors has any commercial associations to that of a smooth consistency. The endpoint of surgical therapy would become more difficult that might pose or create a conflict of interest with in- with a large-volume, tumescent-style infiltration formation presented in this communication. of fluid, purportedly as described for tumescent liposuction by Klein.3 To limit patient discom- REFERENCES fort, our patients received general anesthesia (a 1. Arneja, J. S., Hayakawa, T. E. J., Singh, G. B., et al. Axillary majority via laryngeal mask airway), and a small hyperhidrosis: A 5-year review of treatment efficacy and re- amount (20 cc) of local anesthesia was infiltrated currence rates using a new arthroscopic shaver technique. into the hair-bearing axilla. Furthermore, tumes- Plast. Reconstr. Surg. 119: 562, 2007. cence would certainly allow a dermatologist to 2. Bechara, F. G., Sand, M., Sand, D., Altmeyer, P., and Hoffmann, K. Surgical treatment of axillary hyperhidrosis: A perform our technique in an office setting with- study comparing liposuction cannulas with a suction-curet- out general anesthesia, but the outcomes might tage cannula. Ann. Plast. Surg. 56: 654, 2006. be jeopardized due to difficulty with palpating 3. Perng, C. K., Yeh, F. L., Ma, H., et al. Is the treatment of axillary the skin flaps. Small perforations of the axillary osmidrosis with liposuction better than open surgery? Plast. flap are indeed possible, although they are min- Reconstr. Surg. 114: 93, 2004. imized with low-speed debridement (500 rpm)

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sured treatment outcomes. It should be considered as a preferred surgical option for treating primary hyperhidrosis of the axilla. DOI: 10.1097/01.prs.0000291614.29714.54 Jugpal S. Arneja, M.D. Section of Plastic Surgery Children’s Hospital of Michigan Wayne State University 3rd Floor Carls Building Detroit, Mich. 48201 [email protected]

DISCLOSURE The author has no conflict of interest associated with the preparation or submission of this communication.

REFERENCES 1. Wagner, D. S., and Alfonso, D. R. The influence of obesity and volume of resection on success in reduction mammaplasty: An outcomes study. Plast. Reconstr. Surg. 115: 1034, 2005. 2. Arneja, J. S., Hayakawa, T. E., Singh, G. B., et al. Axillary hyperhidrosis: A 5-year review of treatment efficacy and recurrence rates using a new arthroscopic shaver technique. Plast. Reconstr. Surg. 19: 562, 2007. 3. Klein, J. A. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast. Reconstr. Surg. 92: 1085, 1993.

Perforator-Plus Flaps or Perforator-Sparing Fig. 1. Arthroscopic shaver handpiece with 4.0-mm blade can- Flaps: Different Names, Same Concept nula tip (above); manual traction and placement of shaver into Sir: theaxilla,withdebridement(500rpm)andaspiration(50mmHg) e congratulate Dr. Mehrotra on his thoughtful of the undersurface of the axillary flap. Treatment is terminated Warticle (Plast. Reconstr. Surg. 119: 590, 2007). We with direct visual confirmation and palpable change in consis- have independently described a flap of very similar 1,2 tency of the flap from “pebbly” to “smooth” (below). design that we call the perforator-sparing flap, and we would like to share our experience in light of this article. The first issue pertains to that of terminology, which with a “blade” rather than a “serrated” shaver tip. has caused considerable confusion in the era of perfora- Drains are routinely used, and in fact, small per- tor flaps.3 Calling these flaps perforator-plus flaps has the forations produce an additional pathway for the advantage of stressing their additional blood supply from egress of fluid. the preserved perforator. However, it may potentially add 3. A majority of North American plastic surgeons to the current terminological confusion. We have called work in multispecialty hospital operating rooms our flaps perforator-sparing flaps because this is essen- or day-surgery centers. I extrapolate the use of an tially what they do, spare the perforator encountered at orthopedic arthroscopic shaver with standard the tip of the flap and mobilize it to its origins to allow it blade tip, routinely utilized for joint surgery; this to move freely with transposition or rotation of the flap. equipment can be borrowed from our orthope- Terminology aside, our philosophy for this flap design is dic colleagues. Certainly, liposuction and curet- in line with that proposed in this article: the sacrifice of tage tools are also readily available equipment muscle such as the soleus in the lower limb is associated and can produce acceptable results; however, this with definite functional impairment. For this reason, use technique combines these two separate modali- of the fasciocutaneous flap is preferable. However, the ties with a single, readily available device, allow- vascularity of the fasciocutaneous flap in the leg is unre- ing a definitive endpoint to therapy via palpation liable. Thus, the perforator-sparing flap is the logical so- of the axillary flap. In addition, resource utiliza- lution (Fig. 1).1 tion was at a minimum, with only 46 minutes of In cadaveric specimens and clinical cases, we surgical time required. found that it is technically feasible to raise such flaps In conclusion, my coauthors and I view our technique in most instances, except in some areas, such as the as minimally invasive, with excellent subjectively mea- distal third of the leg. It has better vascularity com-

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Fig.1. Theevolutionoflocalskinflapsinthelowerlimb.(Left)Earlylocalflapswererandomflapsraisedwithoutregardtoanyknown blood supply. These flaps had limited reach because they were guided by strict length-to-width ratios and were unreliable because they depended solely on the subdermal plexus. (Second from left) Ponten introduced and popularized the concept of fasciocutaneous flaps that stress inclusion of the deep fascia, preserving cutaneous perforators at the base of the flap when possible, and inclusion of sensory nerves and veins with the flap. His flaps had a longer survival than could be predicted for random flaps of comparable size. In essence, this flap has evolved into a neurovenocutaneous flap, with its axiality based on these structures. (Second from right) Local perforator island-type flaps based solely on the skin perforator were developed with the advent of perforator flaps. (Right) The perforator-sparing local fasciocutaneous flap is a hybrid flap designed with the intention of creating a local flap with an optimal blood supply. In addition to raising the flap as described by Ponten, the preserved perforator located near the tip of the flap increases the reliability of this flap. It has better vascularity than the local island-type perforator flap because it has a “dual” supply from the incorporated perforator as well as a neurovenocutaneous circulation. pared with conventional flaps of similar design with- should perhaps be more appropriately described as out the “extra” perforator. The concept of favorable, simply a muscle perforator flap. neutral, and unfavorable configurations pertains to DOI: 10.1097/01.prs.0000291615.67831.b3 the ease of transposing the flap without tension on Chin-Ho Wong, M.R.C.S.(Ed.) the preserved perforator and should be borne in Bien-Keem Tan, F.R.C.S.(Ed.) mind when using this flap.1 Some maneuvers can be used to increase success, such as full mobilization of Department of Plastic, Reconstructive, and Aesthetic Surgery the perforator to its origin to maximize length. If Singapore General Hospital necessary, one can also create a more direct path Singapore from the vessel’s origin to the flap by cutting a trough in the muscle. In rare cases, however, this design Correspondence to Dr. Wong cannot be used successfully and one can either divide Department of Plastic, Reconstructive, and Aesthetic the perforator or island the flap to convert it into a Surgery Singapore General Hospital pure perforator flap. Outram Road We agree that one of the main problems with Singapore 169608 island perforator flaps in the lower limb, particularly [email protected] in the setting of trauma, is venous congestion. Dopp- ler ultrasonography can reliably locate the position DISCLOSURE of sizable perforators but gives little information The authors did not receive any funding for this work about the adequacy and even the integrity of the and declare no conflict of interest in the work presented. venae comitantes that accompany the perforator. The perforator-sparing flap is a safer flap in this REFERENCES respect. Furthermore, its better vascularity also has 1. Wong, C.-H., and Tan, B.-K. Perforator-sparing transposition the advantage of better promoting healing and fight- flap for lower limb defects: Anatomic study and clinical ap- ing infection in infected wounds. plication. Ann. Plast. Surg. (in press). Mehrotra has successfully extended this concept to 2. Wong, C.-H., Tan, B.-K., and Song, C. Perforator-sparing but- muscle flaps. However, one important anatomical fea- tock rotation flap for coverage of pressure sores. Plast. Reconstr. ture distinguishes skin from muscle flaps. The subder- Surg. 119: 1259, 2007. mal plexus, which is a significant component of the 3. Blondeel, P. N., Van Landuyt, K. H., Monstrey, S. J., et al. The “duality” of the blood supply in skin flaps, is absent in Gent consensus on perforator flap terminology: Preliminary muscle flaps. The soleus flap described in the article definitions. Plast. Reconstr. Surg. 112: 1378, 2003.

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Reply available regional and free tissue transfers were con- Sir: sidered and the perforator-plus flap appeared to be I appreciate the comments and observations of Drs. relatively less morbid. With circumferential degloving, Wong and Tan. It appears that their approach has its a fasciocutaneous free flap would have been impracti- beginnings in raising random flaps with perforator cal. A free muscle flap would also have resulted in sparing contributing an additional source of blood sup- sacrifice of a functioning muscle elsewhere. The use of 2 ply. My approach, however, was conversely developed islanded soleus flaps is well described. Since the tibial from raising islanded perforator flaps in lower extrem- fracture in the lower third could be covered by rotating ity trauma. Utilizing the “cut as you go” approach for the soleus based on its available perforator without flap margins, I spared part of the flap base if insetting detaching the distal insertion, the term muscle perfo- was possible after perforator dissection and flap mobi- rator-plus flap was used. lization. In most cases, it is possible to retain a flap base The concept of favorable, neutral, and unfavorable of varying length. The flap is primarily surviving on the options in perforator-“sparing” flaps would be a prac- perforator in most cases, and the retained base is the tical addition to developing these flaps. A nomencla- 1 additional and secondary supply.1 Hence the term per- ture for perforator-plus flaps has been proposed. As it forator plus would emphasize that the perforator is the was true then, even now it would require a concerted primary source of blood supply. effort to have a holistic classification. It may be perti- The flaps raised by the perforator-plus approach nent to let the froth settle on the issue. would be reasonably assumed to undergo significant DOI: 10.1097/01.prs.0000291616.67831.68 necrosis if based only on the random blood supply from Sandeep Mehrotra, M.S., D.N.B., M.Ch. the base. Completely islanding the flap would still en- Reconstructive Surgery Centre sure survival, albeit with venous congestion and edema. Command Hospital (Eastern Command) The base possibly acts not so much as an important Alipore, Kolkata source of arterial input but rather as a source for venous West Bengal, India and lymphatic drainage. The relative contribution of [email protected] the perforator and the retained base to the overall vascular input of the flap is based on flap design, axiality DISCLOSURE along the vascular source, the retained flap base, and The author declares that there is no potential or perforator dimensions and is a contentious issue. How- actual personal, financial, or political interest in the ever, it is the concept of raising flaps with preservation communication being submitted. of dual or maximum possible vascular inputs that is important and the key to a successful outcome. REFERENCES I fully agree with the philosophy of preserving 1. Sharma, R. K., Mehrotra, S., and Nanda, V. The perforator muscle in lower extremity trauma. In an already trau- “plus” flap: A simple nomenclature for locoregional perfora- matized limb, all attempts should be made to retain tor-based flaps. Plast. Reconstr. Surg. 116: 1838, 2005. residual functional tissue. I used the soleus perforator- 2. Yajima, H., Tamai, S., Ishida, H., and Fukui, A. Partial soleus plus flap because no other regional option was avail- muscle island flap transfer using minor pedicles from the able. A hemisoleus perforator-plus flap was raised after posterior tibial vessels. Plast. Reconstr. Surg. 96: 1162, 1995.

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