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VIEWPOINTSGUIDELINES Viewpoints, pertaining to issuesof general interest, are welcome,even if they are not related toitems previously published. View-points may present unique tech-niques, brief technology up-dates, technical notes, and so on. Viewpoints will be published on

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table Authors will be listed in the order in which they appear

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quirements of space and format. Any financial interestsrelevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American So-ciety of Plastic Surgeons and its licensees and assignees topublish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the EditorialBoard, or the sponsors of the Journal . Any stated views,opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Edi-torial Board, and the sponsoring organizations assume noresponsibility for the content of such correspondence.

ViewpointsFacial Aesthetic Analysis in Beautiful PersianFemale Subjects Aged 13 to 30 Years by Meansof Photogrammetry Sir:

Facial analysis is of great importance for evaluationand planning in aesthetic surgery. 1 Numerous stud-ies have resulted in the vast array of reports available,the majority of which have been gathered from Amer-ican Caucasians, and there are few regarding the Per-sian population. 2–4 Porter reported the significant dif-ferences among various ethnicities and cited the needfor ethnic data.

Standard photogrammetry, using both anteroposte-rior and lateral views, incorporating a ruler or grid foradjustments, was performed (focal length, 95 cm; ob- ject distance to camera, 125 cm; zooming by means of Tele; real size printing).

Standard facial landmarks were represented by points on printed photographs of 197 Persian beau-

tiful female subjects, and measurements between fa-cial landmarks were obtained and depicted in charts(Figs. 1 and 2).

The criteria for being beautiful were based on theresearch committee’s opinion. Charts wereconstructedon the basis of information regarding North American

Caucasians.1

Findings were compared with those of Caucasians by using SPSS (SPSS, Inc., Chicago, Ill.)(one-sample t test, p 0.05; 95 percent confidenceinterval). The results are listed in Table 1.

All parameters regarding anterior and lateral viewsof face height were smaller compared with those of

Copyright ©2010by theAmerican Society of Plastic Surgeons

Fig. 1. Standard landmarks, frontal view.

Fig. 2. Standard landmarks, lateral view.

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Caucasians (statistically significant), except for n-sn(n-sn 59 mm versus 51 mm) and g-sn (g-sn 655 mmversus 63 4 mm), which were longer (statistically

significant). Therefore, the midfacewas a fewmillimeters

longer in the study group, and the lower third of the face was a bit shorter (sn-st and st-gn); however, the “canons”still rule the face. The height of the forehead was the

same, but the inclination and nasofrontal angle were

Table 1. Results and Basic Data Compared

MeasurementsBasic Data

MeasurementsTest Data

Measurements CommentsFacial heights for female subjects, mm

Upper tr-n 63 6 59 2 DecreasedMiddle n-sn 51 3 59 2 Increased

Lower sn-gn 64 4 58 2 DecreasedUpper tr-,gn 53 6 50 3 DecreasedMiddle g-sn 63 4 65 5 IncreasedLower sn-me 64 4 55 2 Decreasedsn-st 20 2 20 1 Withinst-gn 43 3 38 2 Decreased

ForeheadForehead height, cm 5–6 5.7 3 No change

Eyebrow, mmBrow-pupil 25 24 1.5 WithinBrow-crease 15 14 1.5 Within

Eyes, mmIntercanthal 30–34 32 2 No changeEye fissure 29–31 32 1 IncreasedUpper lid limbus 1–2 1.7 0.4 IncreasedScleral show 0 0.6 0.4 Increased

Nose, mm Alar base width 32 1 No change Ala-medial canthus 1–2 0.6 0.7

Lips, mmCommissure medial limbus Within limbus width Within limbus width No changeUpper lip length 20 2 20 1 WithinUpper lip vermillion 9 1.3 10 1 IncreasedLower lip vermillion 9 1.5 11 0.7 IncreasedLip strain Absent Absent No change

Tooth, mmIncisor show 1–4 2 1 WithinLateral view Lateral upper tr-n 63 6 59 2 DecreasedLateral middle n-sn 51 3 59 2 IncreasedLateral lower sn-gn 64 4 58 2 DecreasedLateral upper tr-gn 53 6 50 3 DecreasedLateral middle g-sn 63 4 65 5 IncreasedLateral lower sn-me 64 4 55 2 Decreasedsn-st 20 2 20 1 Decreasedst-gn 43 3 38 2 Decreased

Forehead, degreesInclination 6 5 7 2 IncreasedNasofrontal angle 134 7 135 3 Within

Eyes, mmSOR-cornea ( ) 8–12 ( ) 9.6 1.5 DecreasedIOR-cornea (–) 2–3 (–) 2 0.5 DecreasedLOR-cornea (–) 12–16 (–) 15 1 Within

Nosen-g (negative), mm (–) 4–6 (–) 4.5 0.7 DecreasedNasofacial angle, degrees 34 34 0.5 No change Ala-sn, mm ( ) 2 ( ) 1.5 0.5Nasolabial angle, degrees 105–108 106 1 No change

Lips, mmUpper lip length 20 2 20 1 Decreasedst-sl 18 5 15 2 Decreasedsl-gn 27 3 23 1.5 Decreased

Ching-sn sn-pg, degrees 11 4 15 1 IncreasedPerp to FH through sn, mm (–) 3 3 0.4 2 WithinPerp to FH through n, mm 0 2 0.4 1 No change

Facial convexity Inclination of Lieber line, degrees 1.6 2.5 5 1 Increased

Plastic and Reconstructive Surgery • June 2010

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higher. Surveying eyebrow and eye parameters showedreduced figures for eyebrow-pupil, eyebrow-crease, SOR,and IOR, and an increase for LOR, eye fissure, and upperlid-limbus. Although a statistical difference was reported,thestandard deviationsand meanswere within thevaluesfor Caucasians. However, clinically, eyes seemed to be

more prominent (Table 1).In contrast, there was minimal scleral show, yet theoverall beautiful appearance of the study group was not detrimentally affected (yet it is possible that otherwisethey would appear prettier). The sum of these factors ledto more prominent eyes in the study group. A review of nasal parameters showed statistical differences, but again,mean values and SD were within those of Caucasians.

Generally, lips were somewhat shorter but more prom-inent in the study group (vermilion parameters and liplength, sn-st, st-sl). Overall, chin height was a bit shorter,clinically justifiable and regarding sn-st and st-gn values(statistically significant). Facial convexity was greater inthe study group (g-sn sn-pg, perp to FH through sn,inclination of the Lieber line) (statistically significant).The inclination of the Lieber line was 5 1 degreescompared with 1.6 2.5 degrees in Caucasians.

In summary, the overall facies of the study group were as follows: small lower third of the face and chin,prominent eyes, prominent lips, and a more convexfacial profile, all denoting a “baby face” appearance. It is obvious that for a reasonable deduction, we are stillshort of data, but according to the presented informa-tion, it seems that although some figures of Caucasians were still applicable to the Persian population, many of them might be changed for Persians if optimal operativeresults are to be achieved (Table 1).DOI: 10.1097/PRS.0b013e3181cb6486

Mohammad Reza Farahvash, M.D. Jamshid Khak, M.D.

Department of Plastic Surgery Medical School of Tehran University of Medical Sciences

Maryam Jafari Horestani, D.D.S. Aesthetic and Operative Dentistry

Qazvin University of Medical SciencesFaculty of Dentistry

Qazvin, Iran

Yashar FarahvashMassachusetts College of Pharmacy

Boston, Mass.Benyamin Farahvash

Department of Dermatology Medical School of Boston University

Boston, Mass.

Correspondence to Dr. FarahvashB-10-1, Hafez Building, Hormozan Avenue, Shahrak Gharb

Tehran 14667, Islamic Republic of [email protected]

PATIENT CONSENT

The patientprovidedwritten consent for the use ofher image.

REFERENCES1. Mathes SJ. The head and neck: Part 1. In: Plastic Surgery . Vol.

2, 2nd ed. Philadelphia: Saunders Elsevier; 2006:4–5.2. Farkas LG, Bryson W, Klotz J. Is photogrammetry of the face

reliable? Plast Reconstr Surg. 1980;66:346–355.3. Chatrath P, De Cordova J, Nouraei SA, Ahmed J, Saleh HA.

Objective assessment of facial asymmetry in rhinoplasty pa-tients. Arch Facial Plast Surg. 2007;9:184–187.

4. Choe KS, Sclafani AP, Litner JA, Yu GP, Romo T III. TheKorean American woman’s face: Anthropometric measure-ments and quantitative analysis of facial aesthetics. Arch Facial Plast Surg. 2004;6:244–252.

Direct Excision of Glabellar Furrows: An Alternative Treatment for SevereGlabellar RhytidesSir:

Treatment options for severe glabellar rhytides in-clude brow lifts with open resection of the corru-

gator muscle, botulinum toxin type A (Botox; Allergan,Inc., Irvine, Calif.) injections, intradermal fillers, top-ical creams, andendoscopic resection of thecorrugatormuscle. 1,2 For a select group of motivated patients withglabellar rhytides that are more severe than the poten-tial postoperative scarring, we believe that the direct excision of severe glabellar furrows is an effective sur-gical alternative to traditional approaches. It offers theadvantage of reduced downtime postoperatively, de-creased price, and potential permanency.

Thisprospectivestudy, conducted over a 4-year period,included 10 patients who met criteria for open or endo-scopic treatment of severeglabellar rhytides. Each patient underwent direct excision of glabellar rhytides, with theincision length, method of handling skin and soft tissue,and time of surgery kept as similar as possible betweenpatients. Patients underwent evaluation, along with pho-todocumentation, at 3 days, 1 week, 3 weeks, and 6 weekspostoperatively. Complications and revision rates werenoted. Outcome measures included brow ptosis, inci-sional erythema, suture marks, suture extrusion, woundinfections, hematoma, seroma, unacceptable scarring(hypertrophic scarring and scar unevenness), dehis-cence, and numbness. Patient satisfaction was assessedduring the 6-month postoperative visit.

In 10 patients, there were no cases of brow ptosis,

infections, hematomas, seromas, or wounddehiscencesobserved. Two patients had suture extrusion, and onehad mild hypertrophic scarring, requiring scar resur-facing. There were no cases of brow ptosis. All patientscomplained of numbness lasting for several weeks tomonths, and none reported numbness at the 6-monthfollow-up visit. At the 6-month follow-up visit, all pa-tients reported being very satisfied with their results.

There are significant data to suggest that the endoscopicbrow lift with corrugator resection is very effective. 3,4 How-ever, ourexperience hasbeen that manysurgeonsremaincautious during endoscopic and open brow lifts becauseof the potential risk for damage to the supratrochlear

neurovascular bundle. As a result, we have seen patients

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require multiple treatments (nonsurgical and surgical)for persistent glabellar frown lines (Fig. 1).

Direct excision is an excellent alternative to other tra-ditional procedures. The surgical effect is usually perma-nent after the initial treatment, and patients notice theresults instantly (Figs. 1 and 2). Direct excision is not

performed as frequently as other operations for glabellarfurrowing, and for this reason, few data are currently available. Disadvantages of this procedure include minorscarring that is typically unnoticeable in most cases.Numbness can affect initial patient satisfaction in ourstudy; however, all cases of numbness in this series of patients resolved within 6 months after surgery.

Decreasedpostoperative downtime,decreasedprice,and potential permanency all are important reasons toconsider direct excision as a useful and effective optionfor the treatment of glabellar furrows. We do not pur-port that direct excision should be a universal treatment but suggest that direct excision should be considered as

a viable option for suitable patients. In our experience,the results are as effective as other approaches, and scar-ring is typically minimal, creating favorable results forpatients with severe glabellar furrows.DOI: 10.1097/PRS.0b013e3181cb649e

Neil Tanna, M.D., M.B.A.

Arjun S. Joshi, M.D.Division of Otolaryngology–Head and Neck Surgery

George Washington University Washington, D.C.

Darshni Vira, M.D.Division of Head and Neck Surgery

David Geffen School of MedicineUniversity of California, Los Angeles

Los Angeles, Calif. William H. Lindsey, M.D.

Division of Otolaryngology–Head and Neck Surgery George Washington University

Washington, D.C.

Correspondence to Dr. TannaDepartment of Surgery

George Washington University 2475 Virginia Avenue NW, Apt. 907

Washington, D.C. [email protected]

DISCLOSUREThe authors have no commercial or financial interests to

disclose.

REFERENCES1. Frampton JE, Easthope SE. Botulinum toxin A (Botox Cos-

metic): A review of its use in the treatment of glabellar frownlines. Am J Clin Dermatol. 2003;4:709–725.2. Patel MP, Talmor M, Nolan WB. Botox and collagen for gla-

bellar furrows: Advantages of combination therapy. Ann Plast Surg. 2004;52:442–447; discussion 447.

3. Matarasso A, Matarasso SL. Endoscopic surgical correction of glabellar creases. Dermatol Surg. 1995;21:695–700.

4. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Endoscopicforeheadlift:Reviewof technique, cases, andcomplications. Plast Reconstr Surg. 2002;110:1558–1568; discussion 1569–1570.

A Simplified Lateral Canthopexy TechniqueSir:

Lateral canthopexy has become a routine part of cos-metic lower blepharoplasty to prevent lower lid mal-position, especially in those patients with laxity of thelower lid and negative vector anatomy. 1 All canthopexy techniques involvesecuring the lateral retinaculumto theperiosteum of the superolateral orbital rim with a suture.However, the surgical approach to identify the lateralretinaculumvaries, with sometechniques requiring moresurgicalexpertise thanothers.Perhaps the most challeng-ing technique is that of Jelks et al., 2 who dissect the lateralretinaculum from above through an upper blepharo-plasty incision. Dissection of the lateral retinaculumthrough the lateral extension of a lower blepharoplasty

incision is advocated by others.3,4

In this article, wedescribe

Fig. 1. In this preoperative view, the patient has a history of previous direct brow lift by another physician. Note the deepglabellar furrows.

Fig. 2. In a 3-year postoperative image, the longevity of directexcision of glabellar furrows is visible.


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a technical modification of the Hamra 5 transcanthal can-thopexy that involves percutaneous placement of the can-thopexy suture through the confluence of the superior andinferior gray lines at the lateral canthal angle.

An upper blepharoplasty is completed, but the lateralextent of the incision is not closed or, in the case in which

upper blepharoplasty is notperformed, a small incision ismade in the upper eyelid crease laterally. An 18-gaugeneedle (Fig. 1) is used to create a puncture wound at theconfluence of the superior and inferior gray lines at thelateralcommissure of theeye.One armof a double-armed5-0 Prolene suture (Ethicon, Inc., Somerville, N.J.) isplaced through the puncture wound, capturing the lat-eral retinaculum, and directed into the upper blepharo-plasty incision, below the orbicularis oculi muscle. Thesecond arm is subsequently placed through the samepuncture wound but on a slightly different path into theupper lid incision. These two sutures are secured to theperiosteum on theundersurfaceof thesuperolateral orbitalrim at a level just above the pupil or superior limbus, thustightening thetarsoligamentous sling.Thesutureis tied and

tension of the lower lid ischecked. ( SeeVideo,Supplemen-tal Digital Content 1, which demonstrates the lat eral can-thopexy technique, http://links.lww.com/PRS/A164 .)

The lateral canthopexy described here is a modifi-cation of the Hamra transcanthal canthopexy. In ourmodification, a needle is used to access the lateral ret-

inaculum and direct canthopexy suture placement. It is a minimally invasive technique that is simple to per-form, especially in the hands of a noviceblepharoplasty surgeon. An advantage of this technique is absoluteassurance of capturing the lateral canthal tendon. Ex-tensive dissection to identify the tendon is not required, which limitsoperative timeand postoperativeedema.Fur-thermore, recreation of the lateral retinaculum and can-thal angle as in canthoplasty (cantholysis) techniques isobviated. With this minimally invasive technique, resultshave been excellent, with few complications.DOI: 10.1097/PRS.0b013e3181d45d19

Mort Rizvi, M.D.

Michael Lypka, M.D., D.M.D.Mark Gaon, M.D.

Bradley Eisemann, B.A.Michael Eisemann, M.D.

Department of Plastic and Reconstructive Surgery Methodist Hospital and Weill Cornell Medical College

Houston, TexasMichael Lypka, M.D., D.M.D.

1 Hermann Museum Circle Drive, Suite 3070Houston, Texas 77004

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

REFERENCES1. Glat PM, Jelks GW, Jelks EB, WoodM,Gadangi P,LongakerMT.

Evolutionof the lateral canthoplasty: Techniquesandindications.Plast Reconstr Surg. 1997;100:1396–1405; discussion 1406–1408.

2. Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferiorretinacular lateral canthoplasty: A new technique. Plast Recon- str Surg. 1997;100:1262–1270; discussion 1271–1275.

3. Fagien S. Algorithm for canthoplasty: The lateral retinacularsuspension. A simplified suture canthopexy. Plast Reconstr Surg. 1999;103:2042–2053; discussion 2054–2058.

4. CodnerMA,Wolfli JN,Anzarut A. Primary transcutaneous lower

blepharoplasty with routine canthal support: A comprehensive10 year review. Plast Reconstr Surg. 2008;121:241–250.5. Hamra ST. The zygorbicular dissection in composite rhyti-

dectomy: An ideal midface plane. Plast Reconstr Surg. 1998;102:1646–1657.

Successful Replantation of an Almost- Amputated NoseSir:

Reconstructive methods to replace the nasal unitsdemand many surgical steps, sometimes with sub-optimal results. A case report of a 19-year-old patient

with a posttraumatic nearly complete amputation of the

Fig. 1. Needle placement.

Video. Supplemental Digital Content 1 demonstrates the lat-eral canthopexy technique, http://links.lww.com/PRS/A164 .


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nasal dorsum after falling during a seizure is presented,causing an avulsion of the dorsum, the tip, and the right ala subunits. The flap remained connected to the nasalstructure by only a small left ala pedicle.

First, we considered completing the amputation andrepairing the receptor site with a conventional medio-

frontalis flap. Because of the presence of incipient cap-illary bleeding at the cranial part of the flap after dermalprick, and a cyanotic nuance when the nasal flap was set in place, we decided to preserve the pseudoavulsedtissue. Anesthesia was accomplished with propofol and dor-monid. The anesthesiologist also infiltrated the receptorsite with 1% lidocaine without epinephrine and admin-istered an infraorbitalis nerve block with 0.5% bupiva-caine withoutepinephrineto improvethe vascular supply by sympathetic blockade of the ala pedicle region. Theflap was then reattached over its original bed with 6-0 vertical mattress suture, despite the discrepancy betweenthe pedicle pattern and flap size (Fig. 1). The patient rested with their head at a 45-degree angle, in a warmroom (28 to 30°C), for 5 days. A nurse cleaned the reat-tached flap with warm saline every 4 hours, and the flap’scranial segment was pin-pricked followed by a smoothmassageto facilitatevenousdrainage. Cefazolin (1 g three

times per day), acetylsalicylic acid (100 mg two times perday), and the patient’s regular anticonvulsive drugs wereprescribed. On the fifth postoperative day, the flap hadsatisfactory vitality and the patient was discharged for am-bulatory follow-up (Figs. 2 and 3).

Facial angiosomes demonstrated abundant nutrition

around the neck, the face, and the nasal subunits.1

In ourpatient, the ala lateral nasal artery was responsible for the

Fig. 1. The nearly avulsed flap and the cyanosis after imme-diate reattachment.

Fig. 2. The flap on postoperative day 5.

Fig. 3. The flap on postoperative day25, showing complete tis-sue integration.


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arterial supply of the avulsed flap. Most successful re-planted noses have been reported to be possible without venous anastomosis. 2–5 Easingthevenous drainagecanbeeffectivein difficult situations as demonstrated in ourcasereport. Finally, the synchrony between the medical andparamedical staffmade a difference in flap survival in our

patient despite the minimal flap arterial pedicle supply without venous anastomosis.DOI: 10.1097/PRS.0b013e3181d45d87

Osvaldo Pereira, M.D.Universidade Federal de Santa Catarina

Jorge Bins-Ely, M.D., Ph.D.Giovanni S. Lobo, M.D.

Kuang H. Lee, M.D.Dante Eickhoff, M.D.

Clı́nica JaneUniversidade de Santa

Florianopolis, Santa Catarina, Brazil

Correspondence to Dr. PereiraFederal University of Santa Catarina

R. Dep. Antonio Edu Vieira, 1414Pantanal

Florianopolis, Santa Catarina 88040 001, [email protected]

PATIENT CONSENTThe patient provided written consent for the use of his

image.

REFERENCES1. Houseman ND, Taylor GI, Pan WR. The angiosomes of the

head and neck: Anatomic study and clinical applications. Plast Reconstr Surg. 2000;105;2287–2313.

2. Niazi Z, Lee TC, Eadie P, Lawlor D. Successful replantation of nose by microsurgical technique and review of literature. Br J Plast Surg. 1990;43:617–620.

3. Sánchez-Olaso A. Replantation of an amputated nasal tip withopen venous drainage. Microsurgery 1993;14:380–383.

4. Kayikçioüglu A, Karamürsel S, Keiçik A. Replantation of nearly total nose amputation without venous anastomosis. Plast Re- constr Surg. 2001;108:702–704.

5. Yao JM, Yan S, Xu JH, Li JB, Ye P. Replantation of amputatednose by microvascular anastomosis. Plast Reconstr Surg. 1998;102:171–173.

Management of Horse and Donkey Bite Wounds: A Series of 24 CasesSir:

Although horses are the animals most commonly involved with fatalities,1 reports about horse bites are very rare. Comparing animal bite wounds, cat bites result in punctured deep wounds, dog bites cause rather super-ficialabrasionandlaceration type wounds, 2 andhorse anddonkey bites provoke tissue loss wounds. 3

We have performed a retrospective evaluation of 24patients presenting with animal bites (19 horse and fivedonkey bites) and treated at the department of plastic

surgery from 2003 to 2009. Thehead andneck were the

most frequent bite sites (14 cases), followed by theextremities (eight cases) and the trunk (two cases).

All patients were operated on within 24 hours afteradmission. Wounds were first cleansed with only saline inall patients, because irrigation with antibiotic or iodinesolution may increase tissue irritation. Although half of

thepatients’ woundswere closedwith primarysutureaftersurgical débridement of crushed wound edges, the otherhalf required surgical treatment (Table 1). Besides thepatienttransferredfromanotherclinicon theseventhday after the event, in whose hand there was tissue necrosisand infection (Fig. 1),no other patient had infection. Onsubsequent follow-up, three patients developed minorscar complications on the cheek and the chin.

Our initial therapy in all animal bites includes co-pious irrigation with saline by means of a syringe witha 19-gauge needle, careful débridement of devitalizedtissues, antibiotic prophylaxis with amoxicillin and cla- vulanic acid, tetanus and rabies prophylaxis, and early repair.

Antimicrobial therapy is indicated for bite woundinfections, but the role of antibiotics in the treatment of uninfected animal bite wounds is still a subject of debate. Controversy exists regarding the use of antibi-

Fig. 1. Patient presented with the fifth finger of the right handamputated and tissue necrosis in the hypothenar area.

Table 1. Reconstructive Procedures in Patients withTissue Loss

ProceduresNo.

of PatientsDébridement and suturing 12Débridement and SSG 3

Débridement and FTSG 2Débridement and chondrocutaneousadvancement flap 2

Débridement, chondrocutaneous advancement flap, and FTSG 1

Débridement and reverse radialforearm flap 2

Débridement and pedicled groin flap 1Total ear reconstructions 1SSG, split skin graft; FTSG, full-thickness skin graft.


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otic prophylaxis in avoiding infections after an animalbite. The indications for antibiotic prophylaxis de-pend on the time between the bite and its medicaltreatment, the type of animal, the anatomical struc-tures involved, and the extent of the bite. 2 Although wounds on hands with exposed cartilage or delayedtherapy are considered at high risk for infection inanimal bites and delayed primary closure is recom-

mended, we preferred early repair by immediate pri-mary closure in horse and donkey bites, and no in-fection developed (Fig. 2).

A case of anaphylaxis after a horse bite is reported. 4 A deep lesion (crush injury) producing severe hema-toma, fat necrosis, and muscle rupture, without an ex-ternal wound, in a woman bitten on her thigh by a horsecould be diagnosed only through ultrasound examination, which can be useful for evaluating the extent of crush inju-ries after horse bites. 5 We have not seen such cases in ourseries.

Our experience shows the safety of primary closurefor horse and donkey bite wounds, provided that care-ful débridement and good cleansing with antibioticprophylaxis are also performed. An acceptable aes-thetic outcome can be achieved only with early primary repair and reconstructive procedures.DOI: 10.1097/PRS.0b013e3181d515dd

Rüştü Köse, M.D.Department of Plastic and Reconstructive Surgery

Ö zgür Söğüt, M.D.Department of Emergency Medicine

Cengiz Mordeniz, M.D.Department of Anesthesiology and Intensive Care

Harran University Medical School

Sanliurfa, Turkey

Correspondence to Dr. KöseDepartment of Plastic and Reconstructive Surgery

Harran University Hospital63300 Sanliurfa, Turkey

[email protected]

REFERENCES1. Lathrop SL. Animal-caused fatalities in New Mexico, 1993–

2004. Wilderness Environ Med. 2007;18:288–292.2. StefanopoulosPK, TarantzopoulouAD.Facialbite wounds:Man-

agement update. Int J Oral Maxillofac Surg. 2005;34:464–472.3. Shipkov CD. Nasal amputation due todonkeybite: Immediateand

latereconstruction witha foreheadflap. InjuryExtra 2004;35:85–90.4. Guida G, Nebiolo F, Heffler E, Bergia R, Rolla G. Anaphylaxis

after a horse bite. Allergy 2005;60:1088–1089.5. Vidal S, Barcala L, Tovar JA. Horse bite injury. Eur J Dermatol.

1998;8:437–438.

Contact Dermatitis from DermabondSir:

2 -Octylcyanoacrylate, commonly known as Derma-bond (Ethicon, Inc., Somerville, N.J.), was ap-provedby theU.S. Food and Drug Administrationfor human use in 1998 as a topical skin adhesive. Therehave been few surgery reports on allergic phenomenarelated to the product. 1 We report two cases of contact dermatitis secondary to Dermabond application. A 47- year-old woman with no known drug allergies underwent uncomplicated bilateral breast reduction. Derma-bond was applied after her subcuticular suture closure.On day 6, the patient noted an enlarging nonpainfulbut significantly pruritic rash along the incision lines.She was afebrile. Physical examination at that time re- vealed a contiguous, nonblanching, and noninduratedexanthem extendingapproximately 6 cm on eithersideof all incisions. It was neither warm nor tender to pal-pation. The remainder of the breast tissue showed noabnormalities. The Dermabond was removed with di-lute acetone, and within 72 hours the pruritic rashresolved with no additional treatment. The second pa-tient is a 55-year-old woman with no known drug al-lergies who underwent scar revision of an abdomino-plasty. The final layer of closure included Dermabond.She re-presented on postoperative day 7 with pruriticerythema extending along the surgical scars bilaterally

(Figs. 1 and 2). There was no pain, swelling, or warmthon examination of the areas. She was afebrile. TheDermabond was removed and the rash was treated withtopical steroids only. Her symptoms dissipated withinseveral days. Three weeks after resolution of the ery-thema, she underwent a test patch application of Dermabond to her left forearm that resulted in a lo-calized erythematous pruritic reaction.

The presenting differential diagnosis of these pa-tients would include cellulitis, but the presentationof the patients was not consistent with an infectiouscause with, specifically, the lack of fever, induration,local discomfort, or increased warmth. Neither pa-

tient had a sense of malaise. Of significance in both

Fig. 2. Crush injury of the right ear.


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patients was the painless intense pruritic nature of the erythema, which is also not consistent with cel-lulitis.

2-Octylcyanoacrylate is a monomer in liquid form.On contact with tissueanions (e.g., tissue, blood, fluid),there is rapid polymerization and binding to epidermalkeratin in an exothermic reaction. 2,3 It is touted that thespeed of polymerization and high reactivity of the cy-anoacrylate compound should prevent the moleculefrom being a strong immunosensitizer. 1,3

The long-term treatment of contact dermatitis ide-ally is avoidance of the contact allergen. Short-term

treatment includes removal of the offending materialand possibly brief use of a topical steroid. 1 Applicationof 2-octylcyanoacrylate should be avoided on open wounds or incompletely closed surgical incisions toavoid immunosensitization and subsequent develop-ment of allergy to cyanoacrylates.

Although contact dermatitis secondary to Derma-bond is seemingly rare, plastic surgeons should be pre-pared to recognize the presence of 2-octylcyanoacrylateallergy and treat accordingly. The exanthem is hall-marked by intense painless pruritus. Treatment con-sists of removal of the Dermabond and considerationof short-term use of topical steroids.

DOI: 10.1097/PRS.0b013e3181d62a56

Brian K. Howard, M.D.North Fulton Plastic Surgery

Roswell, Ga.Susan E. Downey, M.D.

Department of Plastic Surgery University of Southern California

Los Angeles, Calif.

Correspondence to Dr. HowardNorth Fulton Plastic Surgery

1357 Hembree Road, Suite 200Roswell, Ga. 30076

DISCLOSURE Dr. Howard has not received any financial support from

and has no financial interest in Ethicon, Inc. Dr. Downey has been a paid consultant for Ethicon, Inc., in the past.

REFERENCES1. Hivnor CM, Hudkins ML. Allergic contact dermatitis after

postsurgical repair with 2-octylcyanoacrylate. Arch Dermatol.2008;144:814–815.

2. Ethicon, Inc. Dermabond packageinsert. Somerville, NJ:Ethi-con, Inc.

3. Tomb RR, Lepoittevin JP, Durepaire F, Grosshans E. Ectopiccontact dermatitis from ethyl cyanoacrylate instant adhesives.

Contact Dermatitis 1993;28:206–208.

Fig. 1. Focal rash at 7 days postoperatively.

Fig. 2. Focal rash at 7 days postoperatively.


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tional recipient vessel dissection is necessary. If these vessels had not been preserved in this case, salvage of the congested flap would have been more technically difficult.DOI: 10.1097/PRS.0b013e3181cb680f

Brian D. Cohen, M.D.

Nicholas Vendemia, M.D.Division of Plastic and Reconstructive Surgery

New York-Presbyterian HospitalNew York, N.Y.

Jason A. Spector, M.D.Division of Plastic and Reconstructive Surgery

Weill-Cornell Medical Center/New York-PresbyterianHospital

New York, N.Y.Christine H. Rohde, M.D.

Division of Plastic and Reconstructive Surgery Columbia University Medical Center/New York-Presbyterian

Hospital

New York, N.Y.Correspondence to Dr. Rohde

161 Fort Washington Avenue, Suite 607New York, N.Y. 10032

[email protected]

DISCLOSURENo financial support or benefits have been received by any

of the authors, by any member of their immediate families, or by any individual or entity with whom or with which the authors have a relationship from any commercial source that is related directly or indirectly to the scientific work reported in this article.

REFERENCES1. Park MC, Lee JH, Chung J, Lee SH. Use of internal mammary

vessel perforator as a recipient vessel for free TRAM breast reconstruction. Ann Plast Surg. 2003;50:132–137.

2. Saint-Cyr M, Chang DW, Robb GL, Chevray PM. Internalmammary perforator recipient vessels for breast reconstruc-tion using free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg. 2007;120:1769–1763.

3. Rohde C, Keller A. Novel technique for venous augmentationin a free inferior epigastric perforator flap. Ann Plast Surg.2005;55:528–530.

4. Niranjan NS, Khandwala AR, Mackenzie DM. Venous aug-mentation of the free TRAM flap. Br J Plast Surg. 2001;54:335–337.

5. Wechselberger G, Schoeller T, Bauer T, Ninkovic M, Otto A,Ninkovic M. Venous superdrainage in deep inferior epigastricperforator flap breast reconstruction. PlastReconstr Surg. 2001;1083:162–166.

Hyperbaric Oxygen and ReductionMammaplasty in the Previously Irradiated Breast Sir:

W ith expanding use of radiation therapy in treat-ing malignancy, managing complications of ra-diation therapy becomes more important. A princi-

pal clinical manifestation of delayed radiation injury is impaired wound healing. With the known risk of poor wound healing, elective surgery is relatively con-traindicated in areas of previous irradiation. Withlumpectomy/adjuvant radiation therapy becomingthe treatment of choice for early-stage breast can-

cer, there is an increasing population of post–radia-tion therapy women who have difficulty obtainingbreast reduction. There are few case reports describ-ing reduction mammaplasty after radiation therapy.Handel et al. 1 reported one case, with delayed heal-ing and an inferior cosmetic result. Spear et al. 2reported three cases using modified surgical tech-nique, with acceptable but again cosmetically infe-rior results. Hyperbaric oxygen therapy induces an-giogenesis and increases tissue oxygen content inirradiated tissue. 3 Previous studies have shown ben-efits of hyperbaric oxygen therapy in patients withdelayed radiation injury, including as a surgical adjuvant in multiple irradiated areas. 4

We conducted a retrospective chart review of fivepatients undergoing reduction mammaplasty in previously irradiated breasts along with adjuvant hyper-baric oxygen therapy at Virginia Mason Medical Cen-ter in Seattle. All were scheduled to receive 20preoperative hyperbaric oxygen therapy treatments,each consisting of 90 minutes of 100% oxygen at 2.36atm, followed by 10 similar postoperative treatments.Study approval and waiver of informed consent wasobtained from the Institutional Review Board of the Virginia Mason Medical Center/Benaroya ResearchInstitute. Initial Late Effects on Normal Tissue/Sub- jective, Objective, Management and Analytic breast symptom scores 5 measuring late effects of radiation were calculated based on clinical notes before initi-ation of preoperative hyperbaric oxygen therapy,and final Late Effects on Normal Tissue/Subjective,Objective, Management and Analytic scores werebased on the last recorded plastic surgery follow-up.

Case data are outlined in Table 1. To summarize,five women underwent bilateral reduction mamma-plasty 2 to 6 years after unilateral lumpectomy andpostoperative radiation therapy. Wound healing inall irradiated breasts was complete, with delayed heal-ing in two patients of 4 and 11 weeks. In the nonir-radiated breasts, delayed healing of 5 and 6 weeks

also occurred in two patients. In all cases, surgeonevaluation of the final cosmetic result was good. Allpatients expressed satisfaction with the final cosmeticresults. Representative preoperative and postopera-tive images for case 5 are included as Figures 1 and2. No significant complications of hyperbaric oxygentherapy occurred. One patient terminated postop-erative hyperbaric oxygen therapy treatment after 8of 10 planned treatments, because healing was al-ready complete.

These cases illustrate that with adjuvant hyperbaricoxygen therapy, elective reduction mammaplasty is asafe option for some patients who have previously

undergone breast irradiation. Our patients ranged in


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T a b l e 1

. S u m m a r y o f C a s e D a t a

H B O

2

S O M A /

L E N T

O u t c o m e s

C a s e

A g e

( y r )

C a n c e r S u r g e r y

I r r a d i a t i o n

C h e m o t h e r a p y

B M I

S m o k e r

P r e

P o s t P r e

P o s t I r r a d i a t e d B r e a s t

N o n i r r a d i a t e d B r e a s t

1

3 8

L e f t l u m p e c t o m y 5

y r p r e v i o u s l y

Y e s ; d o s e u n k n o w n

( r a d i a t i o n t h e r a p y

p e r f o r m e d o u t s i d e

o u r s y s t e m )

Y e s

2 6 . 7

N e v e r

2 0

8

3

1

P r i m a r y h e a l i n g ,

c o m p l e t e

w o u n d c l o s u r e

D e l a y e d h e a l i n g 6 w k ,

c o m p l e t e w o u n d

c l o s u r e

2

5 4

R i g h t l u m p e c t o m y

w i t h e x c i s i o n o f

n i p p l e - a r e o l a

c o m p l e x a n d

s e n t i n e l n o d e

d i s s e c t i o n 2 y r

p r e v i o u s l y

5 0 4 0 c G y w h o l e r i g h t

b r e a s t , 1

0 0 0 c G y

b o o s t l u m p e c t o m y

s i t e

Y e s

3 2 . 7

N e v e r

2 0

1 0

2

1

D e l a y e d h e a l i n g

4 w k , c o m p l e t e




c l o s u r e

3

5 3

L e f t l u m p e c t o m y

w i t h e x c i s i o n o f

n i p p l e - a r e o l a

c o m p l e x 4 y r

p r e v i o u s l y

4 6 8 0 c G y w h o l e l e f t

b r e a s t , 5

4 0 c G y


s i t e

N o

3 0 . 9

R e m o t e f o r

5 y r

2 0

1 0

1

1


c o m p l e t e


D e l a y e d h e a l i n g 5 w k ,


c l o s u r e

4

5 7

L e f t l u m p e c t o m y

w i t h a x i l l a r y

n o d e d i s s e c t i o n

6 y r p r e v i o u s l y

5 0 4 0 c G y w h o l e l e f t

b r e a s t , 1

0 0 0 c G y


s i t e

N o

2 3 . 6

N e v e r

2 0

1 0

6

2


c o m p l e t e




c l o s u r e

5

5 7

L e f t l u m p e c t o m y 5

y r p r e v i o u s l y

6 6 4 0 c G Y w h o l e l e f t

b r e a s t

N o

3 9 . 5

2 0 y r p r

e v i o u s l y

,

f o r 1 0 y r

2 0

1 0

1 0

2

D e l a y e d h e a l i n g

1 1 w k ,

c o m p l e t e




c l o s u r e

H B O

2 , h y p e r b a r i c o x y g e n t h e r a p y ; L E N T

, L a t e E f f e c t s o n N o r m a l T i s s u e ; S O M A

, S u b j e c t i v e , O b j e c t i v e , M a n a g e m e n t a n d A n a l y t i c ; B M I , b o d y m a s s i n d e x ; P r e , p r e o p e r a t i v e l y ; P o s t ,

p o s t o p e r a t i v e l y .


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age from 38 to 57 years. All but one patient we treatedshowed improvement in their Late Effects on NormalTissue/Subjective, Objective, Management and An-alytic symptom scales for late effects of radiation.This series benefits from internal controls, as all pa-tients underwent surgery on one previously irradi-ated and one nonirradiated breast. Complicationrates were equal, with two each of the irradiated andnonirradiated breasts demonstrating delayed woundhealing. In conclusion, it is our hope that awarenessof these positive results will make the combination of hyperbaric oxygen and reduction mammaplasty more widely available to an appropriate population.DOI: 10.1097/PRS.0b013e3181cb67d0

Sean M. Snyder, M.D.General Internal Medicine

Kevin M. Beshlian, M.D.

Section of Plastic and Reconstructive Surgery

Neil B. Hampson, M.D.Center for Hyperbaric Medicine Virginia Mason Medical Center

Seattle, Wash.

Correspondence to Dr. Snyder806 NW 83rd Street

Seattle, Wash. [email protected]

Presented at the Northwest Society of Plastic SurgeonsMeeting, February of 2009.

DISCLOSUREThis was an author-initiated chart review study. Neither

the study nor its authors received any financial support. No author has any conflict of interest to disclose.

REFERENCES1. Handel N, Lewinsky B, Waisman JR. Reduction mammaplasty

following radiation therapy for breast cancer. Plast Reconstr

Surg. 1992;89:953–955.2. Spear SL, Burke JB, Forman D, Zuurbier RA, Berg CD. Ex-perience with reduction mammaplasty following breast con-servation surgery and radiation therapy. Plast Reconstr Surg.1998;102:1913–1917.

3. Marx RE, Ehler WJ, Tayapongsak P, Pierce LW. Relationshipof oxygen dose to angiogenesis induction in irradiated tissue.Am J Surg. 1990;160:519–524.

4. Feldmeier JJ, Hampson NB. A systematic review of the liter-ature reporting the application of hyperbaric oxygen preven-tion and treatment of delayed radiation injuries: An evidencebased approach. Undersea Hyperb Med. 2002;29:4–30.

5. Pavy JJ, Denekamp J, Letschert J, et al. EORTC Late Effects Working Group: Late effects toxicity scoring. The SOMA scale. Radiother Oncol. 1995;35:11–15.

Lipid Rescue in Resuscitation of Local Anesthetic–Induced Cardiac Arrest in Aesthetic Surgery Sir:

Cardiac toxicity with local anesthetics such as bupiv-acaine and ropivacaine has long been recognizedby anesthesiologists and surgeons. Despite publishedreports in the literature, the exact mechanism of actionof lipid emulsion for prompt reversal of bupivacainetoxicity remains unexplained. 1,2 Of all the amide local

anesthetics, bupivacaine exhibits the most cardiotox-icity, which is often the result of a sudden increase of its concentration in the plasma. There is increasingevidence in the anesthesia literature supporting the useof lipid therapy to treat bupivacaine- and ropivacaine-induced toxicity after failure of established resuscita-tion measures. 3 However, published reports regardingthe use of intravenous lipid emulsion in successful re-suscitation of localanesthetic–induced cardiac collapsein aesthetic surgery are rare. We draw attention to theefficacy of lipid rescue therapy in reversing local anes-thetic–induced cardiac arrest and set the stage for anintriguing and emerging topic in the aesthetic surgery

literature.

Fig. 1. Preoperative view of the patient in case 5.

Fig. 2. Postoperative view of the patient in case 5.


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operating room for all aesthetic procedures as a pre-cautionary plan.

This awareness and availability of a protocol (Fig.1) in resuscitation is of utmost importance. This pro-tocol presents significant knowledge of the clinicaleffectiveness of lipid emulsion infusion on reversal of

cardiac arrest in an aesthetic surgical procedure. Asin the case with other clinical scenarios, lipid rescueresuscitation should be used as soon as signs of localanesthetic–induced toxicity manifest, to attenuateprogression of anesthetic-induced toxic conditions.The communication of this topic provides not only a clear understanding of intraoperative emergenciesin aesthetic surgery but also a learning curve forscientific education.DOI: 10.1097/PRS.0b013e3181cb671b

Daniel Man, M.D. Vinod K. Podichetty, M.D., M.S.

Dr. Man Aesthetic Plastic Surgery CenterBoca Raton, Fla.

Correspondence to Dr. Podichetty Dr. Man Aesthetic Plastic Surgery Center

851 Meadows Road, Suite 222Boca Raton, Fla. 33486

[email protected]

DISCLOSUREThe authors have no financial interests to disclose.

REFERENCES1. Albright GA. Cardiac arrest following regional anesthesia with

etidocaine or bupivacaine. Anesthesiology 1979;51:285–287.

2. Weinberg GL. Current concepts in resuscitation of patients with local anesthetic cardiac toxicity. Reg Anesth Pain Med.2002;27:568–575.

3. Corcoran W, Butterworth J, Weller RS, et al. Local anesthetic-induced cardiac toxicity: A survey of contemporary practicestrategies among academic anesthesiology departments.Anesth Analg. 2006;103:1322–1326.

4. Groban L, Butterworth J. Lipid reversal of bupivacaine tox-icity: Has thesilver bullet been identified? RegAnesth Pain Med.2003;28:167–169.

Hand Rejuvenation Using RadiesseSir:

Youthful hands are easier to create, as advances inthe reduction of skin laxity, wrinkling, and masksfor underlying bone structure become more availableand less painful. Hand augmentation can add volumeand increase the youthful appearance of the hand with-out disrupting hand function. These qualities, along

Fig. 1. (Left ) Bilateral hands before injection and ( right ) after injection.


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with other intrinsic properties, make soft-tissue fillers auseful method for the rejuvenation of the hand. 1–5 Thepurpose of this article is to demonstrate our techniqueand the results of using calcium hydroxylapatite(Radiesse; BioForm Medical, San Mateo, Calif.) forhand rejuvenation.

The patient extends and flexes the digits to iden-tify hypotrophic areas (Fig. 1). Next, 0.5 cc of lido-caine is injected in the areas of the dorsal hand in twoplaces where the filler will be placed. The Radiesseis injected just above the fascia plane and below thesubcutaneous tissue (Fig. 1). Usually, a second injection is given between the second and third meta-carpals for easier distribution of the filler. Limitinginjections to one or two decreases the chance of irritation to subcutaneous nerves.

The filler is introduced into the hand using a bolustechnique (0.5 to 1.3 ml per injection), with one ortwo injections to each hand. The bolus is then dig-

itally manipulated throughout the dorsal hand untileven distribution of the hydroxylapatite occurs whilethe patient makes a tight fist. Pinching and tentingthe dorsal skin during injection will help avoid in-tramuscular injections. The filler remains in the sub-dermal and subfascial plane but dorsal to the musclefascia, where it can be moved in the subcutaneousplane through gentle pressure.

Patients mayreturn to normalactivities of daily livingas soon as they feel comfortable. There may be mildswelling and bruising in the injected area that usually recedes in 1 to 2 weeks. A follow-up appointment isscheduled for 14 days after the original injections forrechecks and more volume if needed.

This article displays a method for hand rejuvena-tion. The Radiesse filler provides the patient with amore youthful physical appearance without affectingfunction. Although some bruising and swelling may occur, the effect of the filler provides the patient withquick recovery time and immediate results.DOI: 10.1097/PRS.0b013e3181d45d9e

Scott S. Gargasz, M.D., J.D.Michael C. Carbone

Advanced Hand and Plastic Surgery CenterTampa, Fla.

Correspondence to Mr. Carbone Advanced Hand and Plastic Surgery Center, Suite 251

Tampa, Fla. [email protected]

DISCLOSURENeither of the authors has any financial interest, includ-

ing but not limited to patent licensing arrangements, consul- tancies, or stock ownership, in Radiesse.

REFERENCES1. Busso M, Appelbaum D. Hand augmentation with Radiesse

(calcium hydroxylapatite). Dermatol Ther. 2007;20: 385–387.2. Butterwick KJ. Rejuvenation of the aging hand. Dermatol Clin.

2005;23:515–527.

3. Jacovella PF, Peiretti CB, Cunille D, Salzamendi M, Schech-tel SA. Long-lasting results with hydroxylapatite (Radi-esse) facial filler. Plast Reconstr Surg. 2006;118(3 Suppl.):15S–21S.

4. Mann J, Rao J, GoldmanM. A double-blind, comparative study of nonanimal-stabilized hyaluronic acid versus human colla-gen for tissueaugmentationof thedorsalhands. DermatolSurg.

2008;34:1026–1034.5. Bergeret-Galley C, Latouche X, Illouz YG. The value of new

filler material in corrective and cosmetic surgery: DermaLiveand DermaDeep. Aesthetic Plast Surg. 1994;18:13–17.

Lessons from the Mexican Axolotl: AmphibianLimb Regeneration and Its Impact onPlastic Surgery Sir:

A major task of plastic surgery is the improvement of extensivescarsandproblematicwounds. With theexception of fetal scar-free healing, the possibilities forregeneration within humans are limited. A wound that exceeds the basement membrane results in scar forma-tion, which means a rapid and firm butoften unsatisfying wound closure. Scar tissue is less resilient and functional,keeping it questionablewhetherhuman wound healing isan evolutionarily optimized process.

Among amphibians, regeneration in the sense of neoplasm of identical tissue is a common event. TheMexican axolotl ( Ambystoma mexicanum ) is able to re-generate whole limbs after amputation (Fig. 1) andshows scar-free healing throughout its life. Dedifferenti-ation of resident cells, initiated and maintained by a limb

blastema, leads to a perfect restoration of lost tissue. Thisprocess, called epimorphic regeneration, uses mecha-nisms similar to developmental limb formation. 1

What leads to these regenerative processes? Oncloser examination, the similarities between fetal andamphibian wound healing seem to concern adaptiveimmunity. The axolotl lacks adaptive immunity and

Fig. 1. The Mexican axolotl ( Ambystoma mexicanum ) after ex-perimental amputation. (Image courtesy of Bjoern Menger.)


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therefore shows minimal inflammatory response to injury, which also applies to the fetus, whereas adult hu-man skin tends to undergo a rapid restoration by rigidconnective tissue accompanied by a strong inflamma-tory reaction. Recent studies showed the ambivalent role of the immune system in healing processes. 2

An interesting consideration would be about whichtype of wound was liable to evolutionary selection at all.Definitely, it was more the small and medium contami-nated wound, because larger injuries surely resulted indeath presently. This was a demand for a strong immu-nologic response and firm closure of wounds. The mod-ern wound (e.g., generated by surgical incision or dé-bridement) often suffers from inflammation, scarring,and fibrosis, as it heals under molecular mechanisms ini-tially selected for the environment of our ancestors.

The deprivation of regenerative competence causedby evolutionary demands was presumablyaccompaniedby major variances concerning adaptive immunity. Isthis reversible? Consolidated findings suggest that mod-ern wound healing is a conserved, evolutionarily adapted rather than an optimized program. The stud-ies of Odelberg et al. 3 showed that dedifferentiation of adult mammalian cells is possible and therefore may beinitiated in humans. A similar composition of media-tors and signaling pathways raises the hope of usingregenerative mechanisms to the good of our patients. Actually, the process of wound healing can be influ-enced by even minor changes of the composition of growth factors, as the reduced scar formation afterexperimental use of transforming growth factor- iso-forms has already displayed. 4

We can assume that further characterization of themolecular mechanisms underlying amphibian limb re-generation might facilitate the development of thera-peuticconcepts in wound therapy. The lesson taught by the Mexican axolotl potentially gives direction to com-pelling advances in plastic and reconstructive surgery.DOI: 10.1097/PRS.0b013e3181d45e16

Bjoern Menger, Cand.med., M.D.Kerstin Reimers, Dr.rer.nat., Ph.D.

Joern W. Kuhbier, Cand.Med, M.D.Peter M. Vogt, Prof. Dr. med., M.D.

Clinic for Plastic, Hand, and Reconstructive Surgery Replantation and Burn Center of Lower Saxony

Hannover Medical SchoolHannover, Germany

Correspondence to Dr. MengerLaboratory of Experimental Plastic Surgery

Hannover Medical SchoolPodbielskistraße 380

30659 Hannover, Germany [email protected]

DISCLOSUREThe authors have no financial interest to declare in re-

lation to the content of this article.

REFERENCES1. Gardiner DM, Endo T, Bryant SV. Themolecularbasis of limb

regeneration: Integrating the old with the new. Cell Dev Biol.2002;13:345–352.

2. Martin P, Leibovich SJ. Inflammatory cells during wound re-pair: The good, the bad and the ugly. Trends Cell Biol. 2005;15:599–607.

3. Odelberg SJ, Kollhof A, Keating MT. Dedifferentiation of mammalian myotubes induced by msx1. Cell 2000;103:1099–1109.

4. Shah M, Foreman DM, Ferguson MW. Neutralisation of TGF-beta 1 and TGF-beta 2 or exogenous addition of TGF-beta 3to cutaneous rat wound reduces scarring. J Cell Sci. 1995;108:985–1002.

A Modified Lead Oxide Cadaveric InjectionTechnique for Embalmed Contrast Radiography Sir:

In the past four decades, plastic surgery has enjoyedan anatomical renaissance in which old techniques

have been revived and refined and new proceduresevolved. The two most detailed studies of thecutaneouscirculation were performed by Manchot in 1899 1 andSalmon in 1936. 2 In 1986, Rees and Taylor developedan improved protocol. 3 There have been many at-tempts to use the Rees-Taylor technique on embalmedcadaveric tissue but, until recently, without success. 4

Four upper limbs were harvested. The cadavers hadbeen treated with Genelyn Solution (Anatomical Seriesnonflammable S6; Genelyn Pty. Ltd., South Australia, Australia) and stored in vacuum plastic bags in the coolroom (4°C) for up to 1 year.

A suitable sized cannula was inserted directly intothe subclavian or axillary vessels at the disarticulatedlevel. Heavy silk or linen was used to tie the cannulaein place. Then, 50 ml of 6% hydrogen peroxide(Orion Laboratories Pty. Ltd., Western Australia, Australia) was injected. The cannula was closed usingsurgical forceps to leave the solution in the vessels forup to 3 hours. Leaks were checked and secured onthe cut surfaces.

During this time, the lead oxide mixture was pre-pared: 36 g of milk powder (Nuture, Toddlers; HeinzLtd., Victoria, Australia) and 200 g of lead oxide (P 3O4Red lead; Ajax Chemicals, Australia) mixed with 40 ml

of tap water and ground into a fine, smooth paste witha pestle and mortar. Finally, 80 ml of boiling water wasadded to the paste and stirred thoroughly.

A 50-cc syringewith 35 to 55 ml of mixture was injectedin a pulsatile fashion and stopped when greatest resis-tance occurred. The limbs were stored in the cool room.The mixture solidified in the small vessels after 24 hoursand in large vessels (brachial artery) after up to 10 days.

Whole limbs were radiographedat a distanceof 150cmbetween digital cassette (Fuji FCR IP CC; Fiji Film Corp.,Tokyo, Japan) and x-ray source (Linear x-ray CollimatorMC 200C; Progeny, Inc., BuffaloGrove, Ill.). We used 100kV, 0.32 second, and 85 mA for the shoulder; 75 mA for

the upper arm; and 65 mA for the forearm (Fig. 1).


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The integument and muscle were removed and ra-diographed (55 mA, 100 kV, 0.32 second; and 60 mA,100 kV, 0.32 second, respectively) (Fig. 2).

This study was successful because (1) the cadavershad been embalmed using the Genelyn solution,leaving the tissue more pliable; (2) hydrogen peroxide

was usedbefore the leadoxide injection; and (3) the leadoxide injectant had been modified. 5 It is thought that wecan apply more pressure during injection, as the vessel walls in embalmed cadavers are tougher than in freshcadavers. Therewere no vessel rupturesin ourfour upperarm injections. Smaller syringes (5 or 10 ml) contributeto higher pressure. With limited access to fresh cadaverictissue, this technique broadens the application of cadav-eric radiography to unembalmed tissue.

We have reported an embalmed cadaveric injectionusing a modified lead oxide mixture. It provides resultsequal to those obtained from the unembalmed (fresh)cadaveric injection.DOI: 10.1097/PRS.0b013e3181d45eb4

Wei-Ren Pan, M.D.Nicholas M. Cheng

Fatima Vally The Jack Brockhoff Reconstructive Plastic Surgery

Research Unit Department of Anatomy and Cell Biology

University of MelbourneParkville, Victoria, Australia

Correspondence to Dr. Pan Jack Brockhoff Reconstructive Plastic Surgery Research

Unit Room E533

Department of Anatomy and Cell Biology University of Melbourne

Grattan Street Parkville, Victoria 3050, Australia

[email protected]

The second and third authors are equivalent secondauthors; their names are listed in alphabetical order.

ACKNOWLEDGMENTSThe authors thank Prue Dodwell, G. Ian Taylor,

Chris Briggs, Susan Kerby, and Lauren Richardson for invaluable support.

REFERENCES1. Manchot C. In: Ristic J, Morain WD, eds. The Cutaneous Arteries

of the Human Body. New York: Springer-Verlag; 1983:149.2. Salmon M. In: Taylor GI, Tempest M, eds. Arteries of the Skin .

London: Churchill Livingstone; 1988.3. Rees MJ, Taylor GI. A simplified lead oxide cadaver injection

technique. Plast Reconstr Surg . 1986;77:141–145.4. Taylor GI, Palmer JP. The vascular territories (angiosomes) of

the body: Experimental study and clinical applications. Br J Plast Surg . 1987;40:113–141.

5. Suami H, Taylor GI, Pan W-R. A new radiographic cadaverinjection technique for investigating the lymphatic system.Plast Reconstr Surg. 2005;115:2007–2013.

Fig. 2. Inverted radiograph showing the details of the bloodsupply of the deltoid.

Fig. 1. Inverted radiograph of a rightupperarm(embalmed) in- jectedwith leadoxidemixtureshowingthedetailsof thevascularanatomy.


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Umbilicoplasty for Types of UmbilicalDeformitiesSir:

M any methods have been reported for umbilico-plasty. However, although umbilical deformitieshave many variations, no report has described the se-lection of umbilicoplasty method for each umbilicaldeformity. In this article, we report the most suitableumbilicoplasty method for each type of umbilical de-formity.Three methods of umbilicoplasty were used for various types of umbilical deformities.

In method 1, we elevated a pair of long flaps opposingobliquely and having their bases at the left and right sides

of the umbilical position 1,2 (Fig. 1, left ). After closing thehernia orifice, the right and left skin flaps were suturedtogether to make a skin pouch. The pouch was turnedinside out and the median line of the dermal side wassutured to themedian line of theabdominal wall. Finally,the cranial and caudal ends of the flap donor sites were

closed. This method was adapted to umbilical defects andlow-grade umbilical protrusions.In method 2, we elevated a pair of fan-style flaps on

bilateral sides of the umbilical protrusion and excised ex-cessive tissue on the cranial and caudal sides (Fig. 1, center ). After closing the hernia orifice, a skin pouch was created,turned inside out, and fixed the same as in method 1. Thismethod was adapted to large umbilical protrusions.

In method 3, we divided the umbilical protrusion vertically to create a pair of skin flaps based laterally (Fig. 1, right ). After closing the hernia orifice, the flaps were sutured together and fixed on the median line of the abdominal wall in manner similar to that used in

methods 1 and 2. This method was adapted to tall andnarrow umbilical protrusions and small umbilical pro-trusions in the umbilical depression.

We performed umbilicoplasty for 31 patients be-tween 1998 and 2006: five umbilical defects, 20 low-grade umbilical protrusions, three large umbilical pro-trusions, one tall and narrow umbilical protrusion, andtwo small umbilical protrusions in depression. All typesof umbilical deformities were well corrected, and nat-ural vertically long and deep umbilical depressions without conspicuous scars were shown.

A 3-year-old boy presented with a low-grade 5-mmumbilical protrusion, which was round and 15 mm in

diameter. A small hernia orifice, 5 mm in diameter, waspalpable in the umbilicus (Fig. 2, left ). The umbilicalprotrusion was corrected using method 1 (Fig. 2, cen-

Fig. 1. Schematic depiction of the three methods for umbilico-plasty. Inmethod 1,a pairof long flapswithlateralbases iselevatedfrom the cranial and caudal sides of a umbilical position ( left ). In

method2, a pair of fan-styleflaps is elevatedfrom bilateral sides of a large umbilical protrusion ( center ).In method3, a pairof skinflapsis created by verticaldivisionof a umbilical protrusion ( right ).

Fig. 2. Method1 wasused in a 3-year-oldboy with a low-gradeumbilical protrusion ( left ). The patient underwent umbilicoplastyusing our method 1 ( center ). The natural vertically long and deep umbilicus without conspicuous scar is shown 2 years postoper-atively (right ).


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ter ). A natural vertically long and deep umbilical de-pression facing forward without conspicuous scars isshown at 2 years postoperatively (Fig. 2, right ).

Many surgical methods of umbilicoplasty using suturefixation methods and local flaps have been reported. 3–8However, the conventional methods often result in an

unnatural, wide, and shallow umbilical depression withconspicuous scarring. To resolve these problems andform a cosmetically pleasing umbilicus, we devised a new umbilicoplasty method with an S-shaped skin incision. 1,2This method enables us to create a vertically long anddeep umbilical depression facing forward at the correct umbilical position without conspicuous scars. However,there are many variations of umbilical deformities, andsome cases do not need this method. Therefore, we devised two more methods of umbilicoplasty to correct alltypes of umbilical deformities.

Method 1 is suited to the umbilicoplasty for umbilicaldefects and low-grade umbilical protrusions that do not

have enough surplus skin for umbilicoplasty. In thismethod, we elevate a pair of long flaps from the cranialand caudal sides of the umbilical position to create a skinpocket without waste of skin. The skinclosure of the donorsites and the lateral location of the flap bases enable us toform a longitudinal umbilical depression. 1,2 Method 2 isbetter adapted to large umbilical protrusions that have sur-plusskinforumbilicoplasty.Inthismethod,itiseasytocreatea longitudinal deep umbilicus with a pair of fan-style flaps, which is laterally based and distallywide. Method3 isbestfortall andnarrow umbilical protrusions and small protrusionsin the umbilical depression. These umbilical deformitieshave just size ofskin forumbilicoplasty.This methodisa type

ofsuturefixationmethod, but inselectedcases, itcan createa vertically long and deep umbilical depression the same asthe other methods. We called this method “method 3” as amatter of convenience.

Although our three methods have different designs,they have thecommonpolicy ofmakinga pair ofskin flapslaterally based. Using the best choice of the three meth-ods, a natural vertically long and deep umbilical depres-sion can be created in any type of umbilical deformity.

We studied the best method of umbilicoplasty foreach type of umbilical deformity. Using the best choiceof our three methods, it is easy to create a natural, vertically long and deep umbilical depression without

conspicuous scars in any type of umbilical deformity.DOI: 10.1097/PRS.0b013e3181d62a6a Akiyoshi Kajikawa, M.D., Ph.D.

Kazuki Ueda, M.D., Ph.D.Takao Sakaba, M.D.

Masaki Momiyama, M.D. Yoko Katsuragi, M.D.

Department of Plastic and Reconstructive Surgery Fukushima Medical University

Fukushima, Japan

Correspondence to Dr. Kajikawa

Department of Plastic and Reconstructive Surgery

Fukushima Medical University 1, Hikarigaoka

Fukushima 960-1295, [email protected]

DISCLOSURENone of the authors has a financial interest to declare in

relation to the content of this article.

REFERENCES1. Kajikawa A, Ueda K, Suzuki Y, Ohkouchi M. A new umbili-

coplasty for children: Creating a longitudinal deep umbilicaldepression. Br J Plast Surg. 2004;57:741–748.

2. Kajikawa A, Ueda K, Narushima M, et al. Umbilicoplasty forchildren: Creating a longitudinal deep umbilical depressionfacing forward at the correct position. J Jpn Plast Reconstr Surg.2005;25:788–796.

3. Onizuka T, Kojima K. Reconstruction of the navel. Jpn J Plast Surg. 1970;13:248–254.

4. Hodgkinson DJ. Umbilicoplasty: Conversion of “outie” to “in-nie.” Aesthetic Plast Surg. 1983;7:221–222.

5. Itoh Y, Arai K. Umbilical reconstruction using a cone-shapedflap. Ann Plast Surg. 1992;28:335–338.

6. de Lacerda DJ, Martins DM, Marques A, Brenda E, de Moura Andrews J. Umbilicoplasty for the abdomen with a thin adi-pose layer. Br J Plast Surg. 1994;47:386–387.

7. Onishi K,YangYL, MaruyamaY. A newlunch box-typemethodin umbilical reconstruction. Ann Plast Surg. 1995;35:654–656.

8. Yotsuyanagi T, Nihei Y, Sawada Y. A simple technique forreconstruction of the umbilicus, using two twisted flaps. Plast Reconstr Surg. 1998;102:2444–2446.

Triangulation for Abdominoplasty Sir:

The symmetry of an abdominoplasty scar is essential,and if it is not achieved, it is something often com-mented on by patients postoperatively. It can be difficult

Fig. 1. With thepatient lying squarely on the table (or preoper-atively),an approximate incision marking is drawn. In this case, apreviouscesarean delivery scar formed theinitial marking of thecentral part. Long sutures areplaced at thesymphysis pubis andxiphisternum. The abdominal meridian may be marked.


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to achieve, however, especiallyearly in one’s practice, andmay only come with experience. Presented here is a

method that simplifies the marking of abdominoplasty incisions and that should ensure symmetry. As for all abdominoplasties, the patient should be

assessed lying and standing. Crude assessment of over-all body habitus/body symmetry should be performed,including relative heights of the anterior superior iliacspines and symmetry of the chest. This is important because these will be points of reference for markingthe incision when the patient is lying down, and asym-metry when standing may not then be apparent. Dis-cussion about length and height of the scar is of courseappropriate at this stage.

With the patient on the operating table, care is taken

to ensure theyarelying squarely.An approximateincision

line is marked on the lower abdomen before draping.Once thepatient hashadskin preparation andthedrapeshave been laid inplace, thepointof thexiphisternumandthe center of the symphysis pubis are identified. A 2-0 silk(75 cm) stitch is placed at each of these points. This stitchis also useful for securing drapes, particularly if nonad-herent drapes are used. The sutures are cut long to allow them to be used for the triangulation.

Using the sutures to join the two points of attachment allows marking of the meridian or central line of the abdo-men. This should pass through the umbilicus and allow marking of the position of the new umbilicus (Fig. 1).

Altering the relative lengths of the two sutures andholding them together with an artery clip allows accu-rate measurement on each side of the midline. A point on the previously marked incision line is chosen, andthe sutures are aligned to that point. Holding the su-tures together, they are then transferred to the oppo-site side of the abdomen and a mark is made. This isrepeated with several points along the line until themarks canbe joined to createan even, symmetricalscar.The silk sutures are removed at the end of the proce-dure (Figs. 2 through 4).

This is a simple but reliable method of marking andchecking markings for abdominoplasty to ensure sym-metry of the resulting scar.DOI: 10.1097/PRS.0b013e3181d62a7e

J. Alexa Potter, M.R.C.S.Philip A. Griffin, F.R.A.C.S.

Flinders Medical CenterBedford Park

Adelaide, South Australia, Australia

Correspondence to Dr. PotterSuite 605

Flinders Private HospitalBedford Park

Adelaide, South Australia 5042, Australia

[email protected]

Fig. 2. The twomarkingsuturesarealignedso that they meet atan identified point on the marked incision line. They are heldtogether with artery forceps.

Fig. 3. Keeping the forceps holding the marking sutures to-gether, they are moved across to the opposite side of the abdo-men, and thepoint where the forceps reach is marked. This pro-cess is repeated for several points along the original markedincision line, until the corresponding marked points can be joined to form the symmetrical incision l ine on the other side.

Fig. 4. The same process may also be used for contoured/geo-metric incisions.


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DISCLOSURENeither of the authors has a financial interest to declare

in relation to the content of this article.

How We Teach Tendon Repairs Outside the

Operating RoomSir:

At our institution, we have been successful in teach-ing residents how to repair a tendon using a sim-ple, efficient, and inexpensive simulation. Developingthe fine motor skills needed to repair a tendon by means of surgical simulation while removed from thestress of the operating room is ideal and should en-hance the trainee’s ability to focus on and combinethose other aspects of being a well-rounded surgeon when in the operating room.

The simulated tendon is a white, round, flexible, syn-theticbaitworm10 mmin diameter and 6 cmlong (Gary

Yamamoto Custom Baits, Page, Ariz.). This is pinned to afoam board taped securely to the underlying table, andthe model is transected at its midpoint (Fig. 1). Residentsare first taught how to perform a four-strand cruciateflexor tendonrepair 1 bywatchinga 5-minuteinstructional video created by the authors in which the repair is drawnin a stepwise fashion and then demonstrated on themodel. The residents are then free to practice and im-prove on repairs with the simulator. A diagram is madeavailable for reference during therepairs.We have foundthat surgical residents from all levels benefit from thisapproach and that 10 repairs is a reasonable initial goal.Should assessment of resident progress be desired, the

repairs canbe timed andalso graded using a global ratingscale (Fig. 2) that is similar to a previously validated grad-

ing system. 2 Standardsurgical instrumentsand 4-0mono-filament suture are used.

The importance of simulation in today’s surgicalresidencies is well recognized. 2–4 To our knowledge, weare the first to report a surgical simulator designed toteach flexor tendon repairs. 5 A rubber bait worm serves

as a good tendon simulator in its general appearanceand feel. It is inexpensive and simple to set up. Themodel tendon readily shows damage from heavy han-dling; this is advantageous in assessing for unnecessary or improper use of forceps, for example. Our goal wasto provide a safer, more productive, and more efficient interface between the surgical resident and their first flexor tendon repair on a real patient. Indeed, resi-dents who trained with the simulated tendon have sub-sequently reported good confidence and less anxiety inperforming their first true operative repair.DOI: 10.1097/PRS.0b013e3181d5172d

John M. Ingraham, M.D.

Scott & White Memorial HospitalTexas A&M Health Science Center College of MedicineRobert A. Weber, III

Temple High SchoolRobert A. Weber, M.D.

Scott & White Memorial HospitalTexas A&M Health Science Center College of Medicine

Temple, Texas

Correspondence to Dr. IngrahamDivision of Plastic Surgery

Scott & White Memorial Hospital2401 South 31st Street

Temple, Texas 76508

Portions of this article have previously been published inHand (DOI no. 10.1007/s11552-009-9184-9).

DISCLOSUREThe authors have no conflicts of interest to disclose.

REFERENCES1. McLarney E, Hoffman H, Wolfe SW. Biomechanical analysis

of the cruciate four-strand flexor tendon repair. J Hand Surg (Am.) 1999;24:295–301.

2. Wanzel KR, Matsumoto ED, Hamstra SJ, Anastakis DJ. Teach-ing technical skills: Training on a simple, inexpensive, andportable model. Plast Reconstr Surg. 2002;109:258–264.

3. Leach DC. Simulation and rehearsal. In: Philibert I, ed.ACGME Bull. 2005;December:1–10.

4. Grober ED, Hamstra SJ, Wanzel KR, et al. Laboratory basedtraining in urological microsurgery with bench model simu-lators: A randomized controlled trial evaluating the durability of technical skill. J Urol. 2004;172:378–381.

5. Ingraham JM, Weber RA III, Weber RA. Utilizing a simulatedtendon to teach tendon repair technique. Hand (NY.) 2009;4:150–155.

Fig. 1. Simulated tendon repair setup with transected baitworm pinned to the foam base.


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Fig. 2. Simulated tendon repair global rating scale.


a modified lead oxide cadaveric injection

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