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LETTERS

GUIDELINESLetters to the Editor, discussingmaterial recently published inthe Journal, are welcome. Theywill have the best chance of ac-ceptance if they are receivedwithin 8 weeks of an article’s pub-lication. Letters to the Editormay be published with a re-

sponse from the authors of the article being discussed.Discussions beyond the initial letter and response will notbe published. Letters submitted pertaining to publishedDiscussions of articles will not be printed. Letters to theEditor are not usually peer reviewed, but the Journal mayinvite replies from the authors of the original publication.All Letters are published at the discretion of the Editor.

Authors will be listed in the order in which they appear inthe submission. Letters should be submitted electronicallyvia PRS’ enkwell, at www.editorialmanager.com/prs/.

We reserve the right to edit Letters to meet requirementsof space and format. Any financial interests relevant to thecontent of the correspondence must be disclosed. Submis-sion of a Letter constitutes permission for the AmericanSociety of Plastic Surgeons and its licensees and asignees topublish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in theLetters to the Editor represent the personal opinions of theindividual writers and not those of the publisher, the Edi-torial Board, or the sponsors of the Journal. Any stated views,opinions, and conclusions do not reflect the policy of any ofthe sponsoring organizations or of the institutions with whichthe writer is affiliated, and the publisher, the Editorial Board,and the sponsoring organizations assume no responsibilityfor the content of such correspondence.

Letters

Reliable Option for SalvagePharyngoesophageal ReconstructionSir:

We read with interest the article entitled “ComplexSalvage of a Failed Pharyngoesophageal Recon-

struction with Impending Airway Disaster” (Plast Recon-str Surg. 2010;125:208e–210e) by Hsu and Yu. Althoughthe authors should be applauded for their successfulsalvage of such a complicated case, we would like topoint out several issues associated with their resectionand reconstruction plans.

A major problem of the resection included the pres-ervation of the posterior wall of the pharynx. If primaryclosure of the mucosal defect is not possible and a free flaptransfer is required, the resection should be circumfer-ential to simplify the reconstructive procedure. Althoughthe remaining mucosa may help to prevent stricture for-mation, the fistula rate for partial resections has beenshown to be higher than that for circumferential ones,regardless of the method of reconstruction.1,2

Flap selection is also an important consideration. In-dications for use of an anterolateral thigh flap for pharyn-

goesophageal reconstruction have recently expanded be-cause of low donor-site morbidity and good speechfunction with tracheoesophageal puncture.3 However,the safety of fasciocutaneous flaps in previously irradiatedpatients has not yet been established.1,4 In salvage cases,pharyngocutaneous fistulas, even minor ones, can lead tolife-threatening conditions, as seen in the described case,and prevention of fistula formation and secure woundclosure should take precedence over postoperative func-tion. Several reports have recommended the preferentialuse of enteric flaps for salvage pharyngoesophageal re-construction in patients able to tolerate a laparotomy,because of their excellent wound healing properties.1,5

Copyright ©2011 by the American Society of Plastic Surgeons

Fig. 1. Pectoralis major muscle flap to cover the transferred je-junum.

Fig. 2. Meshed skin graft on the pectoralis major muscle.

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In our opinion, the optimal reconstructive optionfor the patient was circumferential reconstruction withfree jejunum transfer and neck skin resurfacing with aregional flap. Although several regional flaps can beused (e.g., deltopectoral or pectoralis major myocuta-neous flaps), we prefer the pectoralis major muscle flapwith a skin graft on the muscle (Figs. 1 and 2). If a skindefect just cranial to the permanent tracheostoma isreconstructed with a skin island, even a thin flap willoverhang the stoma, resulting in prolonged endotra-cheal intubation. Using this method, the pectoralis ma-jor muscle becomes atrophic and patency of the stomais maintained. This method can be used safely, even infemale patients, with minimal breast deformity.DOI: 10.1097/PRS.0b013e31820a6432

Shimpei Miyamoto, M.D.

Minoru Sakuraba, M.D.

Shogo Nagamatsu, M.D.Division of Plastic and Reconstructive Surgery

National Cancer Center Hospital EastKashiwa, Japan

Correspondence to Dr. MiyamotoDivision of Plastic and Reconstructive Surgery

National Cancer Center Hospital5-1-1 Tsukiji, Chuo-ku

Tokyo 104-0045, [email protected]

DISCLOSUREThe authors have no financial interest to declare in re-

lation to the content of this communication.

REFERENCES1. Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ.

Morbidity after flap reconstruction of hypopharyngeal de-fects. Laryngoscope 2006;116:173–181.

2. Murray DJ, Novak CB, Neligan PC. Fasciocutaneous free flaps inpharyngolaryngo-oesophageal reconstruction: A critical reviewof the literature. J Plast Reconstr Aesthet Surg. 2008;61:1148–1156.

3. Yu P, Robb GL. Pharyngoesophageal reconstruction with theanterolateral thigh flap: A clinical and functional outcomesstudy. Plast Reconstr Surg. 2005;116:1845–1855.

4. Nakatsuka T, Harii K, Asato H, Ebihara S, Yoshizumi T, Sai-kawa M. Comparative evaluation in pharyngo-oesophagealreconstruction: Radial forearm flap compared with jejunalflap–-A 10-year experience. Scand J Plast Reconstr Surg HandSurg. 1998;32:307–310.

5. Patel RS, Makitie AA, Goldstein D, et al. Morbidity and func-tional outcomes following gastro-omental free flap recon-struction of circumferential pharyngeal defects. Head Neck2009;31:655–663.

Ischemic Optic Neuropathy as a Rare butPotentially Devastating Complicationof LiposuctionSir:

I t was with interest that we read the extremely didacticCME article by Iverson and Pao on liposuction pub-

lished in your Journal.1 Recently reviewing all cases of

nonarteritic anterior ischemic optic neuropathy fol-lowing any type of plastic, reconstructive, and aes-thetic surgery procedures,2 we found six cases3– 8 fol-lowing liposuction procedures. We would like to takethe opportunity to discuss some key points in thediagnosis and management of ischemic optic neu-ropathy as a severe though rare complication occur-ring after liposuction.

Perioperative anterior or posterior ischemic opticneuropathy is a rare entity occurring as consequenceof laminar or retrolaminar optic nerve infarctiondetermined by several injuries other than giant cellarteritis that produces ischemic damage to ganglioncell axons leading to axonal and visual field loss anddecreased visual acuity.9–11 Of six cases described(mean age, 39 years; range, 30 to 49 years) followingliposuction, three were bilateral anterior ischemic opticneuropathy,4,5,7 two were unilateral anterior ischemicoptic neuropathy,6,8 and one was unilateral posteriorischemic optic neuropathy3 (Table 1). The average vol-ume of aspirated fat was 7400 ml (range, 2800 to 22,000ml). Minagar and colleagues8 reported the case of a47-year-old woman with no atherosclerotic risk factorswho complained of postoperative hypotension and ane-mia after liposuction of the abdomen, thighs, and arms.Visual loss developed in her right eye 2 days after theprocedure, and a pallid optic disc edema was detectedby means of ophthalmoscopy. The left optic disc wasnot crowded, and had a normally sized cup. Becauseresults of magnetic resonance imaging and magneticresonance angiography of the brain were negative, theauthors8 stated that the patient had had a postoperativeanterior ischemic optic neuropathy precipitated byacute blood loss and hypotension. Interestingly, Sig-batullah et al.6 presented a very similar patient with leftanterior ischemic optic neuropathy, suffering an infe-rior altitudinal field defect on the second postoperativeday after liposuction, caused by hemodilution (the he-matocrit value was only 23.5 percent). A possible an-terior ischemic optic neuropathy also in the right eyewas presumed but not confirmed because of the visualfield depression and normal ophthalmoscopy. Foroo-zan and Varon7 described a case of bilateral anteriorischemic optic neuropathy after a high-volume lipo-suction procedure. The 30-year-old patient also devel-oped pulmonary embolism and dural venous sinusthrombosis with thrombocytopenia and anemia. Bilat-eral pallid optic disc edema and hemorrhages wereobserved during the examination. Although transversesinus thrombosis was disclosed on magnetic resonanceimaging, the intracranial pressure values were not re-ported. Postoperative severe anemia (hemoglobin of7.0 g/dl and a hematocrit of 21.6 percent) was re-ported. Ribeiro Monteiro et al.5 discussed a case inwhich visual loss was produced by bilateral anteriorischemic optic neuropathy in the setting of chronicpapilledema in idiopathic intracranial hypertension.Infarction of the optic disc already crowded and sub-mitted to an increased pressure of the cerebrospinalfluid was the result of hypotension caused by large-

Volume 127, Number 4 • Letters

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volume liposuction. The authors concluded that visualloss may have developed because of red blood cell loss,transient hemodilution, and hypotension. Moura et al.4managed a case of bilateral anterior ischemic opticneuropathy that arose 4 days after surgery. Cerebro-spinal fluid examination, lumbar pressure measure-ments, and magnetic resonance imaging of the brainwere all normal. An inferior altitudinal field defect andoptic disc edema in both eyes with a peripapillary hem-orrhage in the left eye did not improve with cortico-steroid therapy. Rath et al.3 reported a right posteriorischemic optic neuropathy in an otherwise uneventfulliposuction procedure combined with breast augmen-tation. Their 43-year-old patient presented 2 days aftersurgery with a best-corrected visual acuity of 20/200 inthe right eye, afferent pupillary defect, and red color

desaturation in the right eye. No neurologic disorderswere disclosed, whereas a homozygotic asset of pro-thrombin II variant was noted, suggesting a microem-bolism-related posterior ischemic optic neuropathy. Vi-sual acuity of 20/80 and cecocentral scotoma of theright eye persisted after 6 months.

The possible cause and pathophysiology are cur-rently unknown, although it seems more likely a tran-sient hypoperfusion of the optic nerve circulationrather than embolic lesions.12 Nevertheless, the devel-opment of ischemic optic neuropathy seems to belinked to perioperative hypotension and blood loss dur-ing the procedure, anemia, significant intraoperativedehydration, surgical trauma, shock, and lengthy timeof surgical procedure.2 Risk factors cause axonal edemathat is supposed to be the trigger of a compartment

Table 1. Characteristics of Ischemic Optic Neuropathy Cases after Liposuction Procedures

ReferenceAge(yr) Sex

Type ofSurgery

Aspirate(ml)

RiskFactor

PerioperativeComplications

Rath et al.,20093

43 F Breast augmentationand abdominalliposuction

2800 MTHFR(homozygous andheterozygous toprothrombin IIvariant)

None

Moura et al.,20064

49 F Liposuction of thethighs, dorsum,and hips; removalof breast nodules

3000 Small and “crowdedoptic discs”

Large amount of bloodloss during liposuction

RibeiroMonteiroet al., 20065

34 F Liposuction of thedorsum andgluteus regionbilaterally plusabdominoplasty

5500 Preexisting idiopathicintracranialhypertension

None

Sigbatullahet al., 20056

36 F Liposuction NA None Large amount of bloodloss during liposuction

Foroozan andVaron,20047

30 F High-volumetumescentliposuction andabdominoplasty

22,000 Obesity andhypothyroidism

Postoperative pulmonaryembolism and duralvenous sinus thrombosiswith thrombocytopeniaand anemia

Minagaret al., 20008

47 F Liposuction of theabdomen, thighs,and arms

3700 None Postoperative hypotension,tachycardia, and anemia(1295 cc of blood loss)requiring two units ofpacked red blood cells

F, female; AION, anterior ischemic optic neuropathy; PION, posterior ischemic optic neuropathy; IV, intravenously; QID, four times daily;OD, right eye; OS, left eye; OU, both eyes; BCVA, best-corrected visual acuity; MTHFR, methylenetetrahydrofolate reductase; VA, visualacuity.

Plastic and Reconstructive Surgery • April 2011

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syndrome in a structurally crowded optic disc with theresult of producing axonal degeneration and loss ofretinal ganglion cells by means of apoptosis.9 However,although anemia and hypotension have been reportedin most cases of postoperative visual loss, fortunately,patients do not display ocular damage so often, shiftingthe interest of the research onto other presumed riskfactors.2,9,10 It is likely that head-down or prone position(that itself significantly increases intraocular pres-sure12) rather than jugular vein ligation as presumed bysome authors is another risk factor leading to an in-creased orbital pressure that reduces arterial perfusionpressure. This may justify why this complication fre-quently follows neck dissection (even when jugularveins are spared)2 and spinal surgery.2,13 Alternatively,it has been shown that patient-specific susceptibility

such as optic disc morphology and a faulty autoregu-lation of the optic nerve circulation and defective au-tonomic variations in blood supply play a key role in thedevelopment of this disease,2,9–11 confirming the vul-nerability of the optic nerve blood supply to hemody-namic alterations.10

Management of ischemic optic neuropathy is pred-icated on early detection, with early ophthalmic assess-ment and referral. To prevent ischemic optic neurop-athy, some important preventive measures should betaken, including intraoperative head-up position, ade-quate hemoglobin concentration, and maintenance ofa low intraocular pressure. The administration of ac-etazolamide and retinal diuretics such as mannitol andfurosemide in combination with systemic corticoste-roids and antiplatelet agents is aimed at reducing optic

Table 1 (continued).

Latency andPresentationSymptoms Diagnosis Therapy

SuspectedCausingFactor(s) Outcome

Acute visual loss on day 2;BCVA 20/200 OD,afferent pupillarydefect, and red colordesaturation;cecocentral scotoma OD

Right PION Prednisone 1 mg/kgIV

MTHFR homozygousand heterozygousto prothrombin IIvariant

Visual acuity 20/80 andcecocentral scotoma OD atmonth 6 persisted

Blurred vision on day 4 inOD and a dark spot inthe inferior field ofvision OS; inferioraltitudinal field defectand optic disc edema inboth eyes with aperipapillaryhemorrhage in the OS

Bilateral AION Prednisone 1 mg/kgIV for 3 days andsubsequent oralcorticosteroids

Hypotension andblood loss fromthe surgeryassociated with thepostoperativehemorrhagiccomplication

2 mo later, visual acuity was20/25 in each eye; bilateraldense inferior altitudinaldefect

Second-day headache andblurred vision both eyes

Bilateral AION Acetazolamide 250mg orally QID anddexamethasoneorally 4 mg/day

Red blood cell loss,transienthemodilution, andhypotension

6 wk after surgery, VA hadimproved to fingercounting OD and 20/200OS; bilateral optic discpallor OU were present

Second-day blurred visionand dizziness

Left AION (andpossible butnot confirmedright AION)

Transfusion onpostoperative day17

Acute blood losscaused byliposuction(hematocrit,23.5%)

10 days later VA was 20/20 ODand 20/25 OS, with mildoptic disc swelling OS, mildvisual field constriction OD,and an inferior altitudinaldefect OS

Blurred vision in first day;6 days later, a nearvisual acuity of 20/70OU; bilateral pallidoptic disc edema andhemorrhages werepresent within theretinal nerve fiber layer

Bilateral AION Acetazolamide, 500mg twice daily

Anemia(hemoglobin of7.0 g/dl;hematocrit of21.6%) andhypotension

After 4 mo, VA was 20/50OD and 20/60 OS withsluggishly reactive pupilsand a left relative afferentpupillary defect; inferioraltitudinal and superiorarcuate visual field defectsbilaterally; both optic discswere pale

Visual loss developed ODon the secondpostoperative day andprogressed to no lightperception over theensuing 2 days; pallidoptic disc edema in OD

Right AION Oral prednisone 60mg/day for 2 days

Perioperativehypotension andanemia caused byacute blood loss

No light perception in theright eye


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nerve edema,2 and it seems to be effective, especially inthe acute phase.2 Recommendations should be to re-move and restore both predisposing and precipitatingfactors to reduce the risk of anterior ischemic opticneuropathy and, when already present, to avoid itsdevelopment in the contralateral eye and further epi-sodes in the same eye.

Ischemic optic neuropathy is a rare but potentiallydevastating complication of liposuction. Because thenumber of procedures of liposuction has increaseddramatically, physicians should be aware that anemia,hypotension, long duration of surgery, and significantintraoperative hydration may all be risk factors for thiscondition. Surgeons should inform all patients under-going liposuction about the risk of this possible thoughrare condition. During the procedure, every effortshould be made to maintain stable hemoglobin andmean arterial pressure and to avoid overhydration. In-quiring about transient visual obscuration and screen-ing for papilledema before proceeding with liposuctionon such patients should be considered preoperativelyby physicians.DOI: 10.1097/PRS.0b013e31820a657e

Tommaso Agostini, M.D.Department of Plastic and Reconstructive Surgery

University of FlorenceFlorence, Italy

Stefano Lazzeri, M.D.

Michele Figus, M.D.

Marco Nardi, M.D.Ophthalmology Unit

Hospital of PisaPisa, Italy

Marcello Pantaloni, M.D.

Davide Lazzeri, M.D.Plastic and Reconstructive Surgery Unit


Correspondence to Dr. Davide LazzeriPlastic and Reconstructive Surgery Unit

Hospital of PisaVia Paradisa 2

Cisanello 56100, Pisa, [email protected]

DISCLOSUREThere are no financial conflicts or interests to report in

association with the content of this communication.

REFERENCES1. Iverson RE, Pao VS. MOC-PS(SM) CME article: Liposuction.

Plast Reconstr Surg. 2008;121:1–11.2. Agostini T, Lazzeri D, Agostini V, Mani R, Shokrollahi K.

Ischemic optic neuropathy and implication for plastic sur-geons: Report of a new case and review of the literature. AnnPlast Surg. (in press).

3. Rath EZ, Falick Y, Rumelt S. Posterior ischemic optic neu-ropathy following breast augmentation and abdominal lipo-suction. Can J Ophthalmol. 2009;44:346–347.

4. Moura FC, Cunha LP, Monteiro ML. Bilateral visual loss afterliposuction: Case report and review of the literature. Clinics(Sao Paulo) 2006;61:489–491.

5. Ribeiro Monteiro ML, Moura FC, Cunha LP. Bilateral visualloss complicating liposuction in a patient with idiopathicintracranial hypertension. J Neuroophthalmol. 2006;26:34–37.

6. Sigbatullah M, Kupersmith MJ, Zerykier A, Volpe S. Ischemicoptic neuropathy after liposuction: Case report and review.J Neuroophthalmol. 2005;29:91–93.

7. Foroozan R, Varon J. Bilateral anterior ischemic opticneuropathy after liposuction. J Neuroophthalmol. 2004;24:211–213.

8. Minagar A, Schatz NJ, Glaser JS. Liposuction and ischemicoptic neuropathy: Case report and review of literature. J Neu-rol Sci. 2000;181:132–136.

9. Hayreh SS. Ischemic optic neuropathy. Prog Retin Eye Res.2009;28:34–62.

10. Murthy TVSP, Bathia P, Prabhakar T, Gogna RL. Postoper-ative visual loss. J Anaesth Clin Pharmacol. 2006;22:3–8.

11. Newman NJ. Perioperative visual loss after nonocular sur-geries. Am J Ophthalmol. 2008;145:604–610.

12. Hunt K, Bajekal R, Calder I, Meacher R, Eliahoo J, AchesonJF. Changes in intraocular pressure in anaesthetized pronepatients. J Neurosurg Anesthesiol. 2004;16:287–290.

13. Buono LM, Foroozan R. Perioperative posterior ischemicoptic neuropathy: Review of the literature. Surv Ophthalmol.2005;50:15–26.

Misleading Malrotation of the Natrelle Style510 ProsthesisSir:

I read the article by Schots et al. entitled “Malrotationof the McGhan Style 510 prosthesis.”1 I have been

using anatomical implants for 16 years and the extra-projection dual-gel 510 type implant manufactured byAllergan for 6 years.2,3 Malrotation occurred exception-ally. I recently wrote a chapter treating the overall fea-tures of 510 implant insertion, and it will soon be freelyavailable online by means of download.4 A consecutiveseries of 55 breast augmentations (110 prostheses) wasreported essentially adopting a dual-plane–like ap-proach. The mean age of the patients was 33.5 years(range, 18 to 52 years), mean follow-up was 12.5 months(range, 6 to 48 months), and mean implant weight was350 g, (range, 155 to 495 g). Unilateral malrotation wasrecorded for one patient 6 months after secondarysurgery (i.e., implant substitution with full-height510FX 310-g prosthesis), which requires surgical cor-rection. In another secondary case with secondary pexyplus submuscular substitution (full-height, 350 g), Iobserved some unilateral malrotation that the patientherself had never recognized (31 months’ follow-up)(Fig. 1). In contrast, none with primary augmentationcomplained except for one. A patient with full-height435-g prostheses described to me sporadic displace-ment with spontaneous rotation in the orthotopicposition. Schots calls it “dynamic rotation.”1 This oc-curred after 2 years in a large breast with hypoelasticskin and moderate ptosis; the follow-up has beenongoing for 5 years and has revealed some breast


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asymmetry without displacement, and the patient’sresults are still satisfactory.

I attempted similarities and divergences with my se-ries, including 67 percent of primary augmentations(24 percent with pexy) and 33 percent of secondaryaugmentations. The access was inframammary in 32cases. The pocket was partially subpectoral except forfour submuscular and two subglandular pockets. I sim-ilarly used electrocautery and no drains. The postop-erative protocol consisted of antibiotic/analgesic oraltherapy, moderately compressive bandages for 5 to 6days, local drainage only in secondary surgery withcapsulectomy, compression bra for 1 to 2 months in-stead of 3 weeks, and physical activities reduced for 3weeks but permitting moderate car driving. Two Bakergrade II contractures were detected.

In the meantime, my experience has reached ap-proximately 70 cases without further subglandular in-sertion or new malrotations. All 73 primary augmen-tations were performed in less than 2 years, weresubglandular, and recorded 12 displacements (com-

plication rate, 8.2 percent).1 On the basis of my study,the incidence of malrotation is, respectively, one and 60(�1.6 percent) in primary subpectoral augmentationswith and without pexy, zero and one in primary subg-landular augmentation, one and nine in secondary sub-pectoral substitution with and without pexy, and oneand one in secondary subglandular substitution. Thethree malrotations occurred within the first 25 cases atthe first 10 months of 510 prosthesis use in cosmeticsurgery. In 2004, I was able to start and test the appli-ance for reconstruction, but results were less satisfac-tory than those achieved by the style 410 devices be-cause of the highest extra projection and differentslope, and the use was discontinued, but malrotationwas never the reason. On the contrary, I believe the 510prosthesis is valid for cosmetic surgery but requiresrefined skill and patient selection limited by the pa-tient’s expectations, breast and thorax anatomy, soft-tissue thickness, skin resilience, and other factors.

Pocket preparation must be very accurate to pre-vent rotation, as presumed by Schots et al., because

Fig. 1. (Above, left) A 40-year-old woman is shown before correction after the other surgeon’s T-inverted pexy with 260-ccround implant augmentation. (Above, right and below) The patient is shown 2½ years after secondary vertical pexy andsubpectoral implant substitution using style 510FX 350-g prostheses. A certain grade of rotation appears in the rightbreast.


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the placement of the hyperprojected vertex cannotfail. The pocket must be a few millimeters wider thanthe device, at the lateral and lower limits above all.The envelope produced by dissection must bestretched after insertion to immobilize the prosthesisfor the next weeks.

In the cited series,1 I suppose there were some limits,such as the number of surgeons, shorter learning curve,subglandular pocket, and likely poor patient selection.The discussion was interesting but the following itemscould likely be true: (1) the subglandular pocket ismore exposed to excessive movements, (2) adherenceamong breast tissue and texture surface is protective,and (3) the double capsula can facilitate rotation butfirst produces shape distortion. I think that the cohesiveframe of the dual gel can be really injured when somesqueezing occurs during the insertion maneuver. Thehighly cohesive gel pole is not spherical inside and isscarcely deformable. In contrast, the surrounding lesscohesive gel can warp during insertion. A patient com-plained of inconstant shape alterations of one prosthe-sis at the lateral right side lasting 6 months. The onlyclinical sign was moderate rippling at the same level.

Moreover, I observed a patient after a car crash withsternal bone fracture whose magnetic resonance im-aging scan detected no inner displacement but only thedetachment of a small portion of the most cohesive gel(Fig. 2). Thus, I can presume that malrotation could berelated to incorrect manipulation and misplacement

during surgery, perhaps even minimal, which becomesevident after conclusion of the healing process or wors-ening the initial deformation/displacement.

This implant requires much more planning and sur-gical refinements than usual, the shape is special, andthe extra-projection highly cohesive vertex can pro-duce a side effect of unnatural shape when its place-ment is not accurately preserved. Nevertheless, if thesurgeon is able, the 510 prosthesis can guarantee long-lasting and consistent outcomes in both young andolder patients. That is principally true for the partiallysubmuscular, dual-plane, augmentation.DOI: 10.1097/PRS.0b013e31820a668e

Egidio Riggio, M.D.Unit of Plastic and Reconstructive Surgery

Fondazione Istituto Nazionale TumoriVia Venezian, 1

20133 Milano, [email protected]

DISCLOSUREThe author has no financial interest to declare in relation

of the content of this communication.

REFERENCES1. Schots JM, Fechner MR, Hoogbergen MM, van Tits HW. Mal-

rotation of the McGhan Style 510 prosthesis. Plast ReconstrSurg. 2010;126:261–265.

2. Riggio E. Extra projected breast implants in breast augmen-tation. Paper presented at: 2006 Aesthetic Surgery of theBreast: Safe Surgical Approach—Preop and Postop BreastDetection, 2nd European Symposium; Milan, Italy.

3. Riggio E. Extra projected anatomical implants. Paper pre-sented at: 2007 XX Congress de la Societe Francaise des Chiru-rgiens Esthetiques Plasticiens; Bordeaux, France.

4. Riggio E. Extra-projected dual cohesive silicone gel anatomicalimplants: Innovation for breast augmentation. In: Berhardt LV,ed. Advances in Medicine and Biology. Vol. 8. New York: NovaScience Publishers; 2010:273–295. Available at: https://www.novapublishers.com/catalog/product_info.php?products_id�14855; free download at: https://www.novapublishers.com/catalog/product_info.php?products_id�22172.

Dual-Plane Prosthetic Reconstruction Using theModified Wise Pattern Mastectomy in Womenwith MacromastiaSir:

We read with interest the recent article by Dr. Lo-sken and colleagues regarding alloplastic breast

reconstruction in women with macromastia that un-dergo skin-sparing mastectomy.1 In these patients, atype IV skin-sparing mastectomy is often required toachieve a more pleasant reconstruction than when ap-proached using the safer transverse incision. However,the risk of skin necrosis, especially at the T-junction, isnear 30 percent.1,2

The authors highlighted that a way of minimizingthis would be to use autologous tissue reconstruction.However, patients with macromastia are often over-

Fig. 2. Magnetic resonance imaging scan of a breast with a 510prosthesis showing the detachment of the upper part of the mostcohesive gel after car accident trauma with sternal bone fracture.The follow-up after the crash was 3 years without clinical prob-lems for the patient. Neither displacement nor deformation wasreported.


1740

weight or obese, and this can significantly raise the rateof complications and morbidity with this operation.

Skin necrosis at the T-junction following alloplasticdual-plane reconstruction using the recently intro-duced biological materials inferolaterally and pectora-lis major muscle superiorly3 would invariably result inimplant exposure and potential extrusion. In this set-ting, the authors feel that a technique already de-scribed, consisting of the use of the inferior deepithe-lialized mastectomy flap instead of the biologicalmaterial, should be readdressed.

Using this technique, the implant pocket is de-fined superiorly by the pectoralis major and inferi-orly by the deepithelialized lower pole mastectomyskin flap. So far, the dual plane consists of two vas-cularized flaps that would allow local wound care inthe setting of skin necrosis.1

We share with the authors the concepts of a Wisepattern with a more conservative angle and longer ver-tical limbs and not to use biological materials to defineimplant pocket inferolaterally. However, we use a dif-ferent approach (work in progress). In our technique,we do not create a dermal flap for lower pole implantcoverage, but the expander/implant is placed in thesubmuscular-subfascial pocket (Figs. 1 and 2).

At the inferior edge of the pectoralis major muscle,we undermine the superficial pectoralis fascia, in con-

tinuity with the pectoralis major muscle itself, up to theinframammary fold (Fig. 1). At this level, the inner sideof the superficial pectoralis fascia is cut to release thefascial tension.4,5 In this way, we define the conditionfor the major expansion in the lower pole.

Fig. 1. Intraoperative view of an immediate definitive implant recon-struction after bilateral type IV skin-sparing mastectomy. The mas-tectomy flaps are everted. The submuscular-subfascial pocketcontaining the definitive breast implant is shown. It has been dis-sected through the upper lateral border of the pectoralis major mus-cle (PM). The dotted line indicates the point of merging of the super-ficial pectoralis fascia (SPF) with the deep pectoralis fascia, whichdefines the pectoralis major muscle fascia. At this level, the pectoralismajor muscle fascia overlies and fuses with the axillary fascia, creatinga unique fascia that overlies the serratus anterior and obliquus exter-nus abdominis muscles. The submuscular-subfascial pocket space isentirely separated from the mastectomy plane.

Fig. 2. The inverted-T reduction pattern mastectomy flaps areshown after implant placement in the submuscular-subfascialpocket.


1741

The superficial pectoralis fascia represents the su-perficial layer of the pectoralis major muscle fascia,which overlies the pectoralis major muscle and contin-ues inferiorly and laterally to the pectoralis major mus-cle. At the lateral border of the pectoralis major muscle,the superficial and deep pectoralis fascia fuse them-selves and overlie the deeper axillary fascia, creatinga unique fascial system that covers the serratus an-terior and obliquus externus abdominis muscles.With our technique, no further coverage is neededinferolaterally, as this is anatomically provided by thethoracic fascias.

In skin-expander reconstructions, the skin at thelower pole will expand over time as the implant is filled.In case of skin-preserving mastectomy, when stagedskin expansion is unnecessary, the major expansion isimmediately gained at the lower pole when the defin-itive implant is placed.4,5

Using this technique, the expander/implant pocketis anatomically separated by the mastectomy space. Inconclusion, the thoracic fascias should be taken intoconsideration as valuable structures that allow an easyand pleasant breast reconstruction with a low compli-cation rate.5DOI: 10.1097/PRS.0b013e31820a66b8

Marzia Salgarello, M.D.

Giuseppe Visconti, M.D.

Liliana Barone-Adesi, M.D.Department of Plastic and Reconstructive Surgery

Catholic University of “Sacro Cuore”University Hospital “A. Gemelli”

Rome, Italy

Correspondence to Dr. SalgarelloVia Massimi 101

00136 Rome, [email protected]



REFERENCES1. Losken A, Collins BA, Carlson GW. Dual-plane prosthetic

reconstruction using the modified Wise pattern mastectomyand fasciocutaneous flap in women with macromastia. PlastReconstr Surg. 2010;126:731–738.

2. Carlson GW, Bostwick J III, Styblo T, et al. Skin sparing mas-tectomy: Oncologic and reconstructive considerations. AnnSurg. 1997;225:570–575; discussion 575–578.

3. Breuing KH, Warren SH. Immediate bilateral breast recon-struction with implants and inferolateral AlloDerm slings. AnnPlast Surg. 2005;55:232–239.

4. Salgarello M, Visconti G, Barone-Adesi L. Use of the subpectoralfascia flap for expander coverage in postmastectomy breast re-construction (Letter). Plast Reconstr Surg. 2011;127:1010.

5. Salgarello M, Visconti G, Barone-Adesi L. Nipple-sparing mas-tectomy with immediate implant reconstruction: Cosmeticoutcomes and technical refinements. Plast Reconstr Surg. 2010;126:1460–1471.

Management of Complicated FacialHemangiomas with Beta-Blocker(Propranolol) TherapySir:

We read with interest the article “Management ofComplicated Facial Hemangiomas with Beta-

Blocker (Propranolol) Therapy.”1 We have recentlytreated 31 consecutive patients with rapidly proliferat-ing hemangioma using propranolol as a first-linetreatment.2 We performed similar pretreatment car-diovascular workup and commenced administration ofpropranolol at 3 mg/kg/day. A rapid halt in heman-gioma proliferation was seen in 100 percent of patients,and significant regression was seen in 87 percent ofpatients. This treatment was well tolerated and had fewside effects.

We used a higher dosage of propranolol, as exper-imental studies have shown that the effect of propran-olol is dose-dependent. Recent in vitro studies hadsuggested that propranolol efficacy is dose-dependentin reducing proliferation of tumor stem cells3 and pla-cental endothelial cells.4

We do not use a weaning regimen for propranolol asin this study. All patients are followed up every 2 weeks,with monitoring of any adverse side effects, blood pres-sure, and pulse rate.

We also believe that to avoid rebound growth,optimum treatment should cover the majority if notall the proliferative phase (i.e., until the child is atleast 7 to 8 months old). We did not see any im-provement in patients in whom treatment was startedbeyond the proliferative phase, in contrast to someof the other studies.

There is as yet no consensus on the ideal treatmentregimen with propranolol, and we agree with the au-thors that further comparative studies are needed todetermine the most effective treatment dosage andoptimum treatment duration. It is also important todetermine the exact mechanism of action of pro-pranolol in future scientific studies, to exploit itspotential further.DOI: 10.1097/PRS.0b013e31820a656a

Anuj Mishra, M.R.C.S.

William Holmes, M.R.C.S.

Catherine Gorst, R.G.N., R.S.C.N.

Sehwang Liew, F.R.C.S.Plast.Vascular Birthmark Center

Alder Hey Children’s HospitalLiverpool, United Kingdom

Correspondence to Dr. MishraVascular Birthmark Centre

Alder Hey Children’s HospitalLiverpool L12 2AP, United Kingdom

REFERENCES1. Arneja JS, Pappas PN, Shwayder T, et al. Management of

complicated facial hemangiomas with beta-blocker (propran-olol) therapy. Plast Reconstr Surg. 2010;126:889–895.


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2. Holmes WJ, Mishra A, Gorst C, Liew SH. Propranolol as first-line treatment for rapidly proliferating infantile haemangio-mas. J Plast Reconstr Aesthet Surg. (in press).

3. O T, Waner M, Xu D, et al. Vandetanib and propranololinhibit infantile hemangioma (IH) and NICH cell growth invitro. Presented at: 18th International Workshop on VascularAnomalies; April 21–24, 2010; Brussels, Belgium.

4. Yang Q, Kumar S, Salalto V, Szabo S, North PE. Propranololinhibits proliferation and tube formation by purified placentalcapillary endothelial cells, an in vitro model for infantile hem-angioma (IH), and induces their apoptosis. Presented at: 18thInternational Workshop on Vascular Anomalies; April 21–24,2010; Brussels, Belgium.

Reply: Management of Complicated FacialHemangiomas with Beta-Blocker(Propranolol) TherapySir:

I thank the authors for their kind and thoughtfulcomments regarding our recently published article.1My colleagues and I applaud their recent publication2

and others3,4 that have illustrated remarkable resultswith the use of beta-blockers for infantile hemangiomawith limited deleterious sequelae. In contrast, there arereports of adverse events that cannot be ignored,5–7

because unrecognized hypoglycemia, bronchospasm,hypotension, or bradycardia could produce a disastrousoutcome. Furthermore, to date, propranolol has notbeen shown to be a panacea, and for a complicatedhemangioma producing functional problems, aggres-sive intervention may be requisite.8

Advances in a particular field of medicine ideallyoccur in a translational research model in which hy-pothesis-driven bench research can then be studied inwell-structured human trials. However, on occasion,medical advances are serendipitous in nature and con-trolled study occurs in reverse fashion, which is, ofcourse, the status of beta-blockers for the treatment ofinfantile hemangioma. Our goal as consultants is toprovide best practices of patient care through carefulscrutiny of evidence surrounding new innovation; adeparture from this tenet could lead to breach of thedictum primum non nocere. It is well acknowledged thatadvances are initially met with an excitement period,followed by an evaluative and reflective period, with theultimate arrival at a steady state of accepted clinicalutility. It can be argued that the “jury is still deliberat-ing” on the true place of beta-blockers in the treatmentalgorithm for infantile hemangioma because of ab-sence of a published controlled prospective trial; intime, the collective body of literature on this subject willdefine treatment indications, therapeutic regimen,clinical efficacy, complication profile, and mechanismof action.

Finally, I would be remiss if I did not congratulatetheir institution’s vascular birthmark center, becausethrough research, teaching, and multidisciplinary clin-ical care of patients with vascular anomalies, a futuregeneration of “next practices” will surely be cultivated.DOI: 10.1097/PRS.0b013e31820a65b9

Jugpal S. Arneja, M.D.University of British Columbia

British Columbia Children’s HospitalDivision of Plastic Surgery

A237 Shaughnessy Building, Box 1504480 Oak Street

Vancouver, British Columbia V6H 3V4, [email protected]

REFERENCES1. Arneja JS, Pappas PN, Shwayder TA, et al. Management of

complicated facial hemangiomas with beta-blocker (propran-olol) therapy. Plast Reconstr Surg. 2010;126:889–895.

2. Holmes WJ, Mishra A, Gorst C, Liew SH. Propranolol as first-line treatment for rapidly proliferating infantile haemangio-mas. J Plast Reconstr Aesthet Surg. Epublished ahead of printAugust 4, 2010.

3. Leaute-Labreze C, Dumas de la Roque E, Hubiche T, BoraleviF, Thambo JB, Taıeb A. Propranolol for severe hemangiomasof infancy. N Engl J Med. 2008;358:2649–2651.

4. Sans V, de la Roque ED, Berge J, et al. Propranolol for severeinfantile hemangiomas: Follow-up report. Pediatrics 2009;124:e423–e431.

5. Holland KE, Frieden IJ, Frommelt PC, Mancini AJ, Wyatt D,Drolet BA. Hypoglycemia in children taking propranolol forthe treatment of infantile hemangioma. Arch Dermatol. 2010;146:775–778.

6. Lawley LP, Siegfried E, Todd JL. Propranolol treatment forhemangioma of infancy: Risks and recommendations. PediatrDermatol. 2009;26:610–614.

7. Breur JM, de Graaf M, Breugem CC, Pasmans SG. Hypogly-cemia as a result of propranolol during treatment of infantilehemangioma: A case report. Pediatr Dermatol. Epublishedahead of print August 4, 2010.

8. Arneja JS, Mulliken JB. Resection of amblyogenic periocularhemangiomas: Indications and outcomes. Plast Reconstr Surg.2010;125:274–281.

Reconstruction of Extensive CompositeMandibular Defects Using Osseous orNonosseous Free Tissue TransferSir:

We read with great interest the article by Mosahebiet al. entitled “Reconstruction of Extensive Com-

posite Posterolateral Mandibular Defects Using Nonosse-ous Free Tissue Transfer” (Plast Reconstr Surg. 2009;124:1571–1577). The authors claim that the extensive soft-tissue defects cannot be reconstructed always with anosteocutaneous free tissue transfer, although it providesbony reconstruction.

The authors reviewed some osteocutaneous flapsthat are widely used in reconstruction and explainedwhy they do not like to use them. They prefer to usemusculocutaneous flaps such as the vertical rectus ab-dominis musculocutaneous flap for covering entirethrough-and-through defects of the mandible and oralcavity. By so doing, they claim to return patients tonormal life and oral alimentation more quickly thanwith other choices of reconstruction. The authors donot prefer osteomyocutaneous flaps, as their pediclelength and skin paddle will not be enough to cover the


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whole defect. They may be right on those aspects regard-ing the coverage of posterolateral defects and the oralcavity, but there are some points worth mentioning. First,the fibula osteocutaneous flap has a pedicle nearly 10 to12 cm long, and the skin coverage can be adequate formost defects. Moreover, if the soleus muscle is also in-cluded in the flap, it would be used in closing the oraldefect and providing bulk for contour reconstruction.1However, it is true that the cutaneous part of the flap maynot cover the entire posterolateral defect, which can besolved by local flaps alone. The iliac crest osteomyocuta-neous flap is also a very reliable flap in reconstruction ofbony defects of the mandible.2 It is very useful for con-touring and space-filling purposes. Although the pedicleis not as long as a fibular flap, it is nearly 10 cm long andreliable for a large skin island to cover the defect. Skinpaddle can be elevated to as large as 16 � 20 cm.3 Theinternal oblique muscle can be also included in the flapso that it can be used for closing intraoral mucosa defects.This flap has been used for bony reconstruction of oro-mandibular defects since Urken et al. popularized it in1998. The claimed donor-site morbidity is under 6 per-cent in most of the literature, and most of the com-plications can be avoided if care is taken during itsharvest.4 If closure of the defect is performed care-fully, no hernias will be seen, and if the anteriorsuperior iliac spine is preserved, no gait disturbancesor contour deformities of the hip will occur.4 We alsoperform this reconstruction very often and did notencounter any significant or persistent donor-sitemorbidities except for the incision scar.

The authors emphasize the importance of early main-tenance of oral intake and quality of life. A total of 39patients could have an oral diet, whereas only seven of 76patients could have a regular diet. We believe that resto-ration of oral intake for life quality is directly related to notonly swallowing but also chewing. Osteointegrated dentalimplants can be used after stabilization of the patient andthe reconstructed site. If we consider that the patientduring his or her remaining life has to eat, chew, talk, andso forth, dental restoration becomes an important issue.The restoration of quality of life is related more to thebony reconstruction if we consider that these patientshave to return to normal or nearly normal life and func-tion. Returning to normal oral nutrition does not meansolely having a soft diet in remaining life, but that mas-tication function has to be regained. Considering thatthese patients have oncologic diseases, their nutrition isfar more important and somewhat defines their progno-sis. From the date that bony flaps have been used formandibular reconstruction, dental implants have beenused.5,6 For this purpose, both fibular and iliac crestflaps can be used safely in selected cases. Althoughthe bony segment of the fibular flap is thinner, it isstill reliable for dental implants. If the defect is ex-tensive and cannot be covered with one osteomyo-cutaneous flap alone, combined flaps can be used forreconstruction of bone and soft tissue, although itextends the operative time. Considering these facts,we believe that bony reconstruction of the mandible

can be more appropriate even if the defect is exten-sive.DOI: 10.1097/PRS.0b013e31820a6668

Ersoy Konas, M.D.

Ebru Yoruk, M.D.

Serdar N. Nasır, M.D.Department of Plastic Reconstructive and Aesthetic

SurgeryHacettepe University Medical School

Samanpazarı, Ankara, Turkey

Correspondence to Dr. Konas38. Cad. 1470 Sok. Goktesehir Sitesi

No: 2B-59 Cukurambar CankayaAnkara, Turkey

[email protected]

REFERENCES1. Gabr EM, Kobayashi MR, Salibian AH, et al. Oromandibular

reconstruction with vascularized free flaps: A review of 50cases. Microsurgery 2004;24:374–377.

2. Safak T, Klebuc MJ, Mavili E, Shenaq SM. A new design of theiliac crest microsurgical free flap without including the “oblig-atory” muscle cuff. Plast Reconstr Surg. 1997;100:1703–1709.

3. Wei FC, Mardini S. Flaps and Reconstructive Surgery. Philadel-phia: Elsevier; 2009.

4. Valentini V, Gennaro P, Aboh IV, Longo G, Mitro V, IalongoC. Iliac crest flap: Donor site morbidity. J Craniofac Surg. 2009;20:1052–1055.

5. Urken ML, Buchbinder D, Costantino PD, et al. Oroman-dibular reconstruction using microvascular composite flaps:Report of 210 cases. Arch Otolaryngol Head Neck Surg. 1998;124:46–55.

6. Riediger D. Restoration of masticatory function by microsur-gically revascularized iliac crest bone grafts using enosseousimplants. Plast Reconstr Surg. 1988;81:861–877.

Patient Assessments of Scarring:Patient-Reported Impact of Scars Measure orPatient Scar Assessment Questionnaire?Sir:

I would like to commend Brown et al.1 for their rig-orous approach in developing the Patient-Reported

Impact of Scars Measure, a patient-reported outcomesmeasure on the impact of scarring; however, I wouldlike to challenge their assertion that this is “the firstscar-specific patient-reported outcome measure to as-sess the impact of scars from the patient’s perspectivefor use in clinical settings, research, and trials.” A com-prehensive review of the literature would have high-lighted our group’s own endeavors in producing a vali-dated patient-reported measure for scar, the Patient ScarAssessment Questionnaire (using an alternative butwidely accepted traditional technique based on classic testtheory) and the subsequent publication of that work inthis very Journal.2 It is important to assess in which situa-tions each of the two measures is more appropriate, ifinvestigators decide to use one or the other.

The Patient-Reported Impact of Scars Measure hasbeen derived by a robust interview-based methodology


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that continued until “theme-exhaustion”; however, amissing construct is the patient’s perception of scarappearance. Other themes of importance may havebeen elucidated had the sample of 34 interviewees beenmore reflective of different scar groups. The cause orsite of the scars in this sample group is not clearly stated,and it is accepted that such factors are important in scarperception. Further testing of the Patient-Reported Im-pact of Scars Measure in different scar populationgroups (from traumatic wounds and surgical popula-tions) will be important in demonstrating that it hasdiscriminative validity and can truly detect “knowngroup differences.”

The study does not present adequate evidence as yetthat the Patient-Reported Impact of Scars Measure canbe reliably applied to the many different scar popula-tions in clinical trials. The calibration of this scale hasbeen specific to scar types at the poor end of the spec-trum (the sample subjects for interview were selectedfrom a “specialist scar clinic,” and in the subsequentvalidation survey, 77 percent of the subjects rated theirscars as fair to very poor, nearly 60 percent hypertro-phic or keloid). Importantly, many trials will evaluatetherapies that may only improve certain aspects of thescar—appearance, symptoms, or psychological andfunctional impact. The ability to detect change alongthese separate domains will be an important attributeof a criterion standard multidimensional scale.

In conclusion, the Patient-Reported Impact of ScarsMeasure is likely to be more useful in evaluating ther-apeutic efficacy of interventions that improve the func-tional limitations related to scar symptoms (unlike theSymptoms subscale in the Patient Scar AssessmentQuestionnaire that requires further work) or psycho-logical impact—more relevant for the very poor, po-tentially disfiguring hypertrophic or keloid scars. Thereis no evidence to suggest the measure can detectchanges in scars caused by novel interventions thatspecifically change appearance in a wider range of scartypes. In this regard, the Appearance and Satisfactionwith Appearance subscales of the Patient Scar Assess-ment Questionnaire have already demonstrated anability to detect change. Both studies have strengthsand weaknesses, and an appreciation of the differenceswill highlight where further work and collaborationmay be useful to produce a truly comprehensive pa-tient-reported outcome measure instrument for scar-ring that covers all important domains.DOI: 10.1097/PRS.0b013e31820a667c

Piyush Durani, M.R.C.S.Department of Plastic Surgery

Leicester Royal InfirmaryInfirmary Square

Leicester LE1 5WW, United [email protected]

REFERENCES1. Brown BC, McKenna SP, Solomon M, Wilburn J, McGrouther

DA, Bayat A. The Patient-Reported Impact of Scars Measure:

Development and validation. Plast Reconstr Surg. 2010;125:1439–1449.

2. Durani P, McGrouther DA, Ferguson MW. The Patient ScarAssessment Questionnaire: A reliable and valid patient-re-ported outcomes measure for linear scars. Plast Reconstr Surg.2009;123:1481–1489.

Reply: Patient Assessments of Scarring:Patient-Reported Impact of Scars Measure orPatient Scar Assessment Questionnaire?Sir:

We thank Durani for his comments and welcome hiscall to distinguish between the Patient-Reported Im-pact of Scars Measure1 and the Patient Scar AssessmentQuestionnaire.2 We agree that both studies and instru-ments have strengths and weaknesses, and appreciationof these will highlight where further work and collab-oration may be useful. However, there are a number ofassertions made by the author that require clarification.

The Patient Scar Assessment Questionnaire reliedon classic test theory to establish its quality. With thisapproach, emphasis is placed on internal consistency,factor analysis, correlational analyses, and reliability. Inrecent years, classic test theory has been replaced by itemresponse theory and, specifically, Rasch analysis in instru-ment development and evaluation. To achieve funda-mental measurement, certain properties are required:

• The numerical properties of order (one mark on thescale represents more or less of the construct thananother).

• Addition (points on scales may be added together).• Specific objectivity (the calibration of the scale is

independent of the persons used to calibrate andvice versa) must be met.

Where data fit the Rasch model, these properties areconfirmed and fundamental measurement follows. In-ternal consistency and factor analysis do not determinewhether or not scales are unidimensional. However,where data collected with a scale fit the Rasch model,unidimensionality is possible and can be assessed. Inaddition to allowing item scores to be added together,Rasch analysis has several additional benefits for in-strument development:

1. It guides item reduction by identifying items thatmisfit the model (i.e., measure a different constructfrom the other items), are redundant, or exhibit biasrelated to extraneous variables such as age or sex.

2. It shows whether the chosen response format isworking.

3. Given that both patients and items are calibratedon the same underlying metric trait, it is possibleto see whether the items in a scale are matched tothe population being assessed. This allows endeffects to be avoided.

Although no measurement model for the PatientScar Assessment Questionnaire was provided by the


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authors, it is clear from its items that it predominantlymeasures impairment (symptoms). This reflects thereliance on literature and clinical experts in item gen-eration. Consequently, the questionnaire is equivalentto the Patient-Reported Impact of Scars Measure symp-tom scale. Such a scale is useful in that it may provideinformation on outcomes of interest to the clinician.

However, patients may not be concerned by the“symptoms” per se but rather by how their life is af-fected by the symptoms they experience. This is the roleof the Patient-Reported Impact of Scars Measure needs-based quality-of-life scale. Quality of life is the mostimportant patient-based outcome, and its measure-ment is fundamental to determining whether or notpatients benefit from interventions. The content of thePatient-Reported Impact of Scars Measure quality-of-life scale is derived entirely from patients—the onlyinformants capable of commenting on the impact ofscars on quality of life. Durani suggests that patients’perceptions of scar appearance are missing from themeasure. However, the issue was identified in the mea-sure’s development process and is actually covered byseveral quality-of-life items.3

He acknowledges that the Patient Scar AssessmentQuestionnaire was tested with patients who overwhelm-ingly had mild scars and that Patient-Reported Impactof Scars Measure content and testing was conductedwith patients with relatively severe scars. One of the keyrequirements of the Patient-Reported Impact of ScarsMeasure was that it should be relevant to patients whopresent to health services for treatment. It is unlikelythat patients with very mild scars will have impairedquality of life and, consequently, will not seek treatmentfor them. It is difficult to conceive of a clinical trial thatwould only be interested in patients with mild scars.Such a trial would not convince payers of the need toprescribe the tested product—especially if quality oflife was not measured.

Consideration of the classic test theory–based psy-chometric results for the Patient Scar Assessment Ques-tionnaire suggests that it is in need of refinement. Thetest-retest reliability (responsiveness) results are almostall below a level required for instruments to be used onan individual basis. This finding indicates that the Pa-tient Scar Assessment Questionnaire will produce highlevels of measurement error with low levels of respon-siveness. Furthermore, given that the measure assessessymptoms, the correlations observed with the ManchesterScale Score are surprisingly low. The only other test ofvalidity in the study was correlation between the ques-tionnaire and the visual analogue scale scores. However,the latter ranged from “excellent scar” to “poor scar,” andit is unclear what they actually measured.

Durani makes it clear that the Patient Scar Assess-ment Questionnaire is still in a development phase. Werecommend that subsequent data collected with themeasure be subjected to Rasch analysis in an attempt tosee whether it is possible to identify a single workingunidimensional symptoms scale from within its currentitems. The final scale would benefit from a simplified

response format and from having sufficient items to coverthe range of potential symptoms. Measures that consist ofseveral subscales make interpretation difficult. For exam-ple, if some symptoms improve and others deterioratewith treatment, is the intervention of value?

There is, of course, additional work that can be per-formed to evaluate the value of the Patient-ReportedImpact of Scars Measure. In particular, it is importantto test its responsiveness, although measures with goodreproducibility are likely to be responsive. If changesare made to the Patient Scar Assessment Questionnaireas outlined above, it would be helpful to compare it tothe Patient-Reported Impact of Scars Measure symp-toms scale to see which is more useful in measuring scarsymptoms. However, the Patient-Reported Impact ofScars Measure quality-of-life scale remains the onlymeasure available for assessing the impact of scars fromthe patient’s perspective.DOI: 10.1097/PRS.0b013e31820a65e0

Benjamin C. Brown, M.B.Ch.B.Plastic and Reconstructive Surgery Research

Manchester Interdisciplinary BiocenterUniversity of Manchester

Stephen P. McKenna, Ph.D., C.Psychol., A.F.B.Ps.S.Galen Research Ltd.

Enterprise House

Ardeshir Bayat, Ph.D., M.R.C.S.Plastic and Reconstructive Surgery Research

Manchester Interdisciplinary BiocenterUniversity of Manchester, and

Manchester Academic Health Science CenterSouth Manchester University Hospital Foundation Trust

Wythenshawe HospitalManchester, United Kingdom

Correspondence to Dr. BayatPlastic and Reconstructive Surgery Research

Manchester Interdisciplinary BiocenterUniversity of Manchester

131 Princess StreetManchester M1 7DN, United Kingdom

[email protected]

REFERENCES1. Brown BC, McKenna SP, Solomon M, Wilburn J, McGrouther

DA, Bayat A. The patient-reported impact of scars measure: De-velopment and validation. Plast Reconstr Surg. 2010;125:1439–149.

2. Durani P, McGrouther DA, Ferguson MW. The Patient ScarAssessment Questionnaire: A reliable and valid patient-re-ported outcomes measure for linear scars. Plast Reconstr Surg.2009;123:1481–1489.

3. Brown BC, McKenna SP, Siddhi K, McGrouther DA, Bayat A.The hidden cost of skin scars: Quality of life after skin scarring.J Plast Reconstr Aesthet Surg. 2008;61:1049–1058.

Nerve Lengthening for Nerve Substance DefectsSir:

We read with great interest the research article bySharula et al. entitled “Repair of the Sciatic

Nerve Defect with a Direct Gradual Lengthening of


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Proximal and Distal Nerve Stumps in Rabbits.”1 Inthe article, the authors describe a novel techniquefor repairing nerve substance defects of 20 mm inperipheral nerve in rabbit by nerve lengthening per-formed with an external device. Nerves were ex-tended for 3 weeks at a rate of 1 mm/day followed byend-to-end coaptation. Nerve regeneration was thenevaluated by electrophysiologic and histologic exam-ination at 16 weeks. It is worth mentioning that forthe lengthening process no anesthesia was necessary.

We ask why the distal nerve stump was distractedas well. Usually, after the lengthening time of 22 days,the distal stump undergoes Wallerian degeneration.The advantage of stretching both ends is not fullyclear to us. When the axon is severed by nerve injury,the axon dies back 1 or 2 mm from the injury site andthe distal segment degenerates, a feature known asWallerian degeneration.2 The myelin debris is phago-cytized by macrophages. Whereas the axon segmentdistal to the injury site degenerates, the Schwanncells proliferate, typically within the basal lamina,and form a column of Schwann cells within a basallamina or band of Bungner. Does the distraction ofthe distal segment lengthen connective tissue andallow for greater Schwann cell proliferation?

Moreover, the study by Kroeber et al. showed neu-roma formation after the duration of the distraction ofthe proximal nerve end.3 After a delay of 1 or 2 days,the proximal stump of the cut nerve gives rise to axonalsprouts that will extend either on the surface ofSchwann cells or to the inner laminin-rich surface ofthe basal lamina of the Schwann cell columns (bandsof Bungner). If the regenerating axon sprouts do notreach and elongate through the trophic distalSchwann cell tube, they will grow in a more randommanner and can form a neuroma.4 This is often thecase after traumatic peripheral nerve injury, includ-ing limb amputation. The axonal sprouts within thebulbous neuroma show increased mechanosensitivityand chemosensitivity. It would be interesting ifstretching itself could prevent neuroma formationafter peripheral nerve injury, and this observationshould be highlighted in this interesting study.DOI: 10.1097/PRS.0b013e31820a6655

Christine Radtke, M.D.

Peter M. Vogt, M.D., Ph.D.

Kerstin Reimers, Ph.D.Department of Plastic, Hand, and Reconstructive Surgery

Hannover Medical SchoolHannover, Germany

Correspondence to Dr. RadtkeDepartment of Plastic, Hand, and Reconstructive Surgery

Hannover Medical SchoolCarl-Neuberg Strasse 1

30625 Hannover, [email protected]

REFERENCES1. Sharula, Hara Y, Nishiura Y, Saijilafu, Kubota S, Ochiai N.

Repair of the sciatic nerve defect with a direct gradual length-ening of proximal and distal nerve stumps in rabbits. PlastReconstr Surg. 2010;125:846–854.

2. Waller A. Experiments on the glossopharyngeal and hypo-glossal nerves of the frog and observations produced therebyin the structure of their primitive fibers. Phil Trans R Soc Lond.1850;140:423–429.

3. Kroeber MW, Diao E, Hida S, Liebenberg E. Peripheral nervelengthening by controlled isolated distraction: A new animalmodel. J Orthop Res. 2001;19:70–77.

4. Ramon Y, Cajal S. Degeneration and Regeneration in the NervousSystem. London: Oxford University Press; 1928.

Capsular Contracture and Genetic Profile of icaGenes among Staphylococcus epidermidis Isolatesfrom Subclinical Periprosthetic InfectionsSir:

We read with great interest the article by Tamboto,Vickery, and Deva in the September of 2010 issue

of the Journal on the role of subclinical infection andbiofilm in capsular fibrosis.1 The methods used and theanimal model developed are very interesting and arecertainly an approximation of use in humans. We areinterested in the fact that for the first time someone hasshown a direct causal link between the presence ofbiofilm and capsular contracture in vivo in an animalmodel. However, our experience in humans showsquite different results.

We performed a study aimed to genotype Staphylo-coccus epidermidis isolates from subclinical peripros-thetic infections with samples taken in a sterile fieldfrom four different foci: capsule, intraprosthetic liquid,periprosthetic liquid, and prothesis. The implants re-moved were textured surface expanders in 10 patientssubjected to a second heterologous breast reconstruc-tion. All samples were plated onto selective media(blood agar/colistin–nalidixic acid blood agar, Mac-Conkey agar), nonselective media (blood agar, choc-olate) in aerobic atmosphere or carboxyphylia, and inanaerobic conditions (Centers for Disease Control andPrevention agar); the genotypic analysis was performedby polymerase chain reaction to detect the presence oficaA and icaD genes, as a part of the ica operon, essentialamong S. epidermidis isolates in the biofilm formation.In particular, this operon encodes for different en-zymes, including N-acetylglucosamine transferase, essen-tial for the production of the biofilm.

A total of three of 10 S. epidermidis isolates studiedshowed both icaA and icaD genes (30 percent), whereasthe remaining seven strains were polymerase chain re-action–negative for both of these genes (70 percent).

The three icaA-negative and icaD-positive strainswere isolated from three patients, two of whom had aBaker grade II capsular contracture and one of whomhad a Baker grade III capsular contracture. The sevenstrains negative for ica were isolated from patients whohad a Baker grade II capsular contracture (n � 4), a


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Baker grade III capsular contracture (n � 2), or a Bakergrade IV capsular contracture (n � 1) (Table 1).

Although the limited number of cases analyzed (10cases) makes any speculation difficult to be inferred, it isinteresting to notice a likely random distribution betweenthe Baker grade of capsular contracture and the geneticprofile of icaA and icaD, responsible for the biofilm for-mation, among S. epidermidis isolates surveyed in thisstudy, with only three S. epidermidis strains positive for bothicaA and icaD genes. According to our results, we mayconclude that the grade of capsular fibrosis seems to beindependent of the production of biofilm.DOI: 10.1097/PRS.0b013e31820a6592

Paolo Persichetti, M.D., Ph.D.

Giuseppe Angelo Giovanni Lombardo, M.D.

Giovanni Francesco Marangi, M.D.

Giovanni Gherardi, Ph.D.

Giordano Dicuonzo, M.D., Ph.D.“Campus Bio-Medico di Roma” University

Rome, Italy

Correspondence to Dr. MarangiPlastic and Reconstructive Surgery Unit

“Campus Bio-medico di Roma” UniversityVia Alvaro del Portillo 200

00128 Rome, [email protected]

REFERENCE1. Tamboto H, Vickery K, Deva AK. Subclinical (biofilm) infection

causes capsular contracture in a porcine model following augmen-tation mammaplasty. Plast Reconstr Surg. 2010;126:835–842.

Reply: Capsular Contracture and Genetic Profileof ica Genes among Staphylococcus epidermidisIsolates from Subclinical Periprosthetic InfectionsSir:

I thank Dr. Perischetti et al. for their analysis of thedistribution of the icaA and icaD operons in relation tothe presence of capsular contracture in patients un-dergoing second-stage breast reconstruction.

The ica cluster contains all the genes necessary forthe production of the polysaccharide intercellular ad-hesin, one of two polysaccharides produced by Staph-ylococcus epidermidis that help it to accumulate biofilmonce initial attachment has occurred to a surface.There are four open reading frames (icaA, icaD, icaB,and icaC) and a regulator (icaR) located upstreamfrom the start codon that contribute to the successfulproduction and activation of polysaccharide inter-cellular adhesin.1

Initial studies did show a competitive advantage inthat strains with ica activity were more capable of form-ing attachment to medical prosthetics and more likelyto cause invasive infection.2,3 More recent analysis, how-ever, has shown that ica-negative strains are able toovercome their disadvantage and are also responsiblefor clinical infection. Investigation in knockout mu-tants has revealed no conclusive result, with three offour reports demonstrating no significant reduction invirulence in ica-inactive strains.4 Furthermore, recentstudies examining isolates from prosthetic joints andpatients with neurosurgical meningitis have shownthat ica-negative strains are also capable of causinginvasive biofilm infection.5,6 These observations havebeen attributed to the presence of alternative polysaccha-ride intercellular adhesion–independent mechanisms ofbiofilm accumulation such as the biofilm-associated pro-tein that may be able to overcome deficiencies in icaexpression.

In summary, the presence or absence of ica operonactivity does not necessarily impact on the ability of S.epidermidis to cause clinical biofilm disease. It is there-fore not possible to draw conclusions about the appar-ent random distribution of icaA/icaD activity in patientswith capsular contracture from this patient sample.DOI: 10.1097/PRS.0b013e31820a65f2

Anand K. Deva, M.D.Macquarie Cosmetic and Plastic Surgery

Macquarie University ClinicSuite 301, Level 3

2 Technology PlaceMacquarie University

New South Wales 2109, [email protected]

REFERENCES1. Heilman C, Schweitzer O, Gerke C, Vannitanakom N, Mack

D, Gotz F. Molecular basis of intercellular adhesion in thebiofilm forming Staphylococcus epidermidis. Mol Microbiol. 1996;20:1083–1091.

2. Ziehbur W, Heilman C, Gotz F, et al. Detection of the inter-cellular adhesion gene cluster (ica) and phase variation inStaphylococcus epidermidis blood culture strains and mucosalisolates. Infect Immun. 1997;65:890–896.

3. Frebourg NB, Lefebvre S, Baert S, Lemeland JF. PCR basedassay for discrimination between invasive and contaminat-ing Staphylococcus epidermidis strains. J Clin Microbiol. 2000;38:877–880.

4. Rohde H, Mack D, Christner M, Burdelski C, Franke G,Knobloch JKM. Pathogenesis of staphylococcal device-re-

Table 1. Strains Divided on the Positive Gene andClinical Outcome*

Strains Studied(n � 10)

PCR-PositiveStrains (n � 3)

PCR-NegativeStrains (n � 7)

GradeI/II

GradeIII/IV

GradeI/II

GradeIII/IV

2 1 4 3PCR, polymerase chain reaction.*Baker grade assessment.


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lated infections: From basic science to new diagnostic, ther-apeutic and prophylactic approaches. Rev Med Microbiol.2006;17:45–54.

5. Stevens NT, Tharmabala M, Dillane T, Greene C, O’Gara JP,Humphreys H. Biofilm and the role of the ica operon and aapin Staphylococcus epidermidis isolates causing neurosurgicalmeningitis. Clin Microbiol Infect. 2008;14:719–722.

6. Koskela A, Nilsdotter-Augustinsson A, Persson L, SoderquistB. Prevalence of the ica operon and insertion sequence IS256among Staphylococcus epidermidis prosthetic joint infection iso-lates. Eur J Clin Microbiol Infect Dis. 2009;28:655–660.

Distally Based Superficial Sural Artery FlapExcluding the Sural NerveSir:

We read with great interest the article entitled “Vas-cular Supply of the Distally Based Superficial

Sural Artery Flap: Surgical Safe Zones Based on Com-ponent Analysis Using Three-Dimensional ComputedTomographic Angiography” by Mojallal et al.1 andwould like to congratulate the authors on their impres-sive work.

The possibility of excluding the sural nerve duringthe dissection of distally based superficial sural arteryflaps was first reported by Hyakusoku et al.2 in 1994.This concept was further supported by a cadaver studyby Aoki et al.3 In our hospital, we have been usingdistally based superficial sural artery flaps without suralnerve for the reconstruction of distal leg defects sincethe late 1980s (Figs. 1 and 2) and have already pre-

sented a clinical series,3 as Mojallal et al.1 also referredto in their article.

The three-dimensional computed tomographicangiography data presented by Mojallal et al.1 in theirarticle are largely consistent with the data presentedpreviously by Aoki et al.3 Moreover, Aoki et al.3 havedocumented that the diameters of extrinsic vesselsaround the sural nerve were larger than those aroundthe lesser saphenous vein; however, the sural nervehad fewer intrinsic vessels. A very close connection inbetween the extrinsic vessels of the sural nerve andthe lesser saphenous vein was also observed onangiography.3 The results of the study by Mojallal etal.1 together with our previous data2,3 verify our clin-ical hypothesis that the sural nerve itself is not soimportant in terms of survival of distally based su-perficial sural artery flaps and can be spared duringflap elevation.

However, the prediction of the flap survival area andappropriate design are still challenging. We believe itis important to determine the suprafascial perforatordirectionality4 using multidetector-row computed to-mographic analysis. Multidetector-row computed to-mographic analysis might be used to reveal the char-acteristics of suprafascial perforator directionality inall parts of the body.4,5 Our results from previousmultidetector-row computed tomographic studieshave suggested that the direction of the blood flowin peripheral perforators is toward the central por-tion. In contrast, the perforators originating near themedian line of the body have laterally directed blood

Fig. 1. The sural nerve can be seen in the donor site.

Fig. 2. The flap survived without any complications.


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flow. In other words, blood flow of lower limb per-forators after penetrating fascia tends to flow prox-imally. Thus, we now believe the distally based su-perficial sural artery flap is the reasonable design ofthe flap.DOI: 10.1097/PRS.0b013e31820a6551

Hakan Orbay, M.D.

Rei Ogawa, M.D., Ph.D.

Shimpei Ono, M.D., Ph.D.

Shimpo Aoki, M.D., Ph.D.

Hiko Hyakusoku, M.D., Ph.D.Department of Plastic and Reconstructive Surgery

Nippon Medical School HospitalTokyo, Japan

Correspondence to Dr. OgawaDepartment of Plastic and Reconstructive Surgery

Nippon Medical School HospitalTokyo, Japan

[email protected]



REFERENCES1. Mojallal A, Wong C, Shipkov C, et al. Vascular supply of the

distally based superficial sural artery flap: Surgical safe zonesbased on component analysis using three-dimensional com-puted tomographic angiography. Plast Reconstr Surg. 2010;126:1240–1252.

2. Hyakusoku H, Tonegawa H, Fumiiri M. Heel coverage with aT-shaped distally based sural island fasciocutaneous flap. PlastReconstr Surg. 1994;93:872–876.

3. Aoki S, Tanuma K, Iwakiri I, et al. Clinical and vascular an-atomical study of distally based sural flap. Ann Plast Surg.2008;61:73–78.

4. Ono S, Ogawa R, Hayashi H, Takami Y, Kumita S, HyakusokuH. Multidetector-row computed tomography (MDCT) analy-sis of the supra-fascial perforator directionality (SPD) of theoccipital artery perforator (OAP). J Plast Reconstr Aesthet Surg.2009;63:1602–1607.

5. Ono S, Hayashi H, Ogawa R, Hyakusoku H. MDCT analysis ofsystemic suprafascial perforator directionality (SPD) for per-forator flaps designing: The possibility of application for up-per limb reconstruction. Paper presented at: 2010 Meeting ofthe Federation of European Societies for Surgery of the Hand;June 2010; Bucharest, Romania.

Reply: Distally Based Superficial Sural ArteryFlap Excluding the Sural NerveSir:

We would like to thank Drs. Orbay, Ogawa, Ono,Aoki, and Hyakusoku for their pertinent comment onour recent publication on the vascular anatomical basisof the distally based sural flap.1 The notion that thesural nerve is not indispensable for the vascularizationof the distally based sural flap was shown in severalreports1–3 and supported by our clinical study.4 This

would mean that the distally based sural flap could beconsidered as a perforator flap rather than a neurocu-taneous flap, based on distal peroneal perforators (andtibialis posterior artery perforators to a lesser extent).In this sense, as for all perforator flaps, two questionsarise: (1) What would be the territory vascularized by asingle perforator? (2) What would be the direction ofthe blood flow from this perforator? These questionscan be answered only after static and dynamic assess-ment of the blood supply using three-dimensional/four-dimensional computed tomographic angiographyin a cadaveric model or using multidetector-row com-puted tomography in an in vivo model as mentioned byOrbay et al.

To give answers to these questions, we have per-formed anatomical studies and have recently presentedthe “perforasome theory,”5 which is based on four ma-jor principles concerning the suprafascial distributionof the perforator vascular branches. A perforasome wasdefined as a suprafascial territory supplied by a singleperforator and its vascular network.5

According to the first principle of the perforasometheory, adjacent perforasomes are connected by meansof both direct and indirect linking vessels. According tothe second principle, flap design and skin paddle ori-entation should be based on the direction of the linkingvessels, which is axial in the extremities and perpen-dicular to the midline in the trunk. This coincides withthe suggestions of Ono et al. and their study on theoccipital artery perforators and corresponding flaps.6The third principle suggests that preferential filling ofperforasomes occurs within perforators of the samesource artery first, followed by perforators of otheradjacent source arteries.

Furthermore, vascularity of a perforator found ad-jacent to a joint is directed away from that same joint[e.g., the direction of the blood flow of the distallybased sural flap is away, that is, proximal from the anklejoint (fourth principle of the perforasome theory)].This supports the statement of Ono et al. that “theblood flow of lower limb perforators after penetratingfascia tends to go proximally,” which makes them “be-lieve that the distally based superficial sural artery flapis the reasonable design of the flap.” However, if theperforator is located near a proximal joint (e.g., a suralperforator distal to the knee joint), the flow will belongitudinal but distally directed. We thank Orbay et al.again for their comment, which will add further detailsin understanding of the vascularization of the distallybased sural flap.DOI: 10.1097/PRS.0b013e31820a65ca

Ali Mojallal, M.D., Ph.D.Department of Plastic, Reconstructive, and Aesthetic

Edouard Herriot HospitalUniversity of Lyon, and

Department of Plastic SurgeryUniversity of Texas Southwestern Medical Center

Dallas, Texas


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Christo Shipkov, M.D., Ph.D.Department of Plastic, Reconstructive, and Aesthetic

Edouard Herriot HospitalUniversity of Lyon

Lyon, France

Corrine Wong, M.R.C.S.

Spencer Brown, Ph.D.

Rod J. Rohrich, M.D.

Michel Saint-Cyr, M.D.Department of Plastic Surgery

University of Texas Southwestern Medical CenterDallas, Texas

Correspondence to Dr. MojallalDepartment of Plastic, Reconstructive, and Aesthetic

SurgeryEdouard Herriot Hospital

Hospices Civils de LyonUniversity of Lyon5 Place d’Arsonval

69437 Lyon, Cedex 03, [email protected]

REFERENCES1. Mojallal A, Wong C, Shipkov C, et al. Vascular supply of the

distally based superficial sural artery flap: Surgical safe zonesbased on component analysis using three-dimensional com-puted tomographic angiography. Plast Reconstr Surg. 2010;126:1240–1252.

2. Hyakusoku H, Tonegawa H, Fumiiri M. Heel coverage with aT-shaped distally based sural island fasciocutaneous flap. PlastReconstr Surg. 1994;93:872–876.

3. Aoki S, Tanuma K, Iwakiri I, et al. Clinical and vascular an-atomical study of distally based sural flap. Ann Plast Surg.2008;61:73–78.

4. Mojallal A, Shipkov C, Braye F, Breton P. Distally based adi-pofascial sural flap for foot and ankle reconstruction. J AmPodiatr Med Assoc. 2011;101:41–48.

5. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ.The perforasome theory: Vascular anatomy and clinical im-plications. Plast Reconstr Surg. 2009;124:1529–1544.

6. Ono S, Ogawa R, Hayashi H, Takami Y, Kumita SI, HyakusokuH. Multidetector-row computed tomography (MDCT) analy-sis of the supra-fascial perforator directionality (SPD) of theoccipital artery perforator (OAP). J Plast Reconstr Aesthet Surg.2010;63:1602–1607.

The Versatility of the Distally Based PeroneusBrevis Muscle FlapSir:

We had the great pleasure of reading the extremelyinteresting article by Schmidt and Giessler enti-

tled “The Muscular and the New Osteomuscular Com-posite Peroneus Brevis Flap: Experiences from 109Cases.”1 We congratulate the authors for the exhaustiveand complete description of their experience concern-ing the use of this flap for restoration of small to me-dium defects around the ankle, foot, and distal lowerleg.1 We would like to take the opportunity to furtherdiscuss indications and advantages of the reverse-flowperoneus brevis flap from our experience.2

Since its first clinical application by Eren et al.,3 thedistally based peroneus muscle flap has been indicatedas a convincing alternative in small to moderate defectcoverage of the distal third of the lower limb. Althoughthere has been some criticism,4 its versatility and itsadvantages have been confirmed by numerousinvestigations.2,5–10 Primary tension-free closure of thedonor site results in a cosmetically acceptable scar overthe lateral aspect of the leg2,3; with its arc of rotation,it allows coverage of more anterior defects of the ankle,the Achilles tendon, the heel area, and the lateral andmedial malleolus areas.1–3,7,10 Because of its vascularsupply, the reverse-flow peroneus brevis muscle flaprepresents a better choice when dealing with soft-tissueand bone infections rather than other local fasciocu-taneous flaps1,2,10; moreover, its reliability is not grosslyinfluenced by associated comorbidities that are ex-pected in both old and posttraumatic patients.2,10

The article by Schmidt and Giessler1 offers a furtheradvantage by describing the osteomuscular variant ofthis flap obtained by raising the peroneus brevis flapwith a semicircular lateral fibula vascularized segmentfirmly attached to the muscle origin. In its compositeform, it allows for optimal and complete restorations ofa bone-deficient recipient site either to achieve fullreconstruction of a defect or to add stability and volumeto a hollowed-out recipient bone.1 Moreover, becauseharvesting this flap is associated with very low donor-sitemorbidity, the German authors suggest its use as a freeflap, proposing more investigations to prove the feasi-bility of the microsurgical peroneus brevis muscle.1

In our experience,2 we adopted the distally basedperoneus brevis flap, as we believe it offers many ad-vantages compared with other reconstructive options.Although the size of the flap makes it suitable only forsmall or moderate sized defects, it is a quick and safereconstructive surgical procedure that allows reliablesoft-tissue coverage of bone and tendons and preser-vation of major arteries of the leg. In particular, we havestudied the effect of raising this flap on plantar flexionand foot eversion.2 By assigning clinical demerit pointsaccording to the Weber demerit score and giving aclinical grade according to the Olerud-Molander AnkleScore in which subjective parameters such as pain, stiff-ness, and swelling and the functions of stair climbing,running, jumping, squatting, and work or activities ofdaily life were scored, we compared preoperative andpostoperative ankle function and stability.2 Neitherscore was observed to be worsened, because no differ-ences have been found between presurgical and post-surgical reconstruction procedures. Thus, the success-ful healing of all defects obtained with the peroneusbrevis flap and the absence of functional impairment ofthe ankle lead to a very high rate of patient satisfactionwith the outcomes. The resolution of major complaintsof the patients, mainly pain and stiffness, was perceivedas was the negligible morbidity because of the preser-vation of ankle functionality (plantar flexion and footeversion) ensured by the preservation of the peroneuslongus muscle.


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Because of its almost constant vascularity, the distallybased peroneus muscle flap is a useful option for mod-erate size defects in the distal third of the lower leg, andis often preferable to the use of free flaps. Coverage ofdefects of the ankle, the Achilles tendon, heel, andlateral and medial malleolus areas is allowed by its arcof rotation. Its versatility is attributable to its simple andquick elevation and its easy transposition within thewound without further dissection. Ankle instability isavoided by preservation of the peroneus longus.DOI: 10.1097/PRS.0b013e31820a65a6

Fulvio Lorenzetti, M.D., Ph.D.Plastic and Reconstructive Surgery Unit

Tommaso Agostini, M.D.Burn Center Unit

Marcello Pantaloni, M.D.

Davide Lazzeri, M.D.Plastic and Reconstructive Surgery Unit


Correspondence to Dr. LazzeriPlastic and Reconstructive Surgery Unit

Hospital of PisaVia Paradisa 2

Cisanello, 56100 Pisa, [email protected]



REFERENCES1. Schmidt AB, Giessler GA. The muscular and the new osteo-

muscular composite peroneus brevis flap: Experiences from109 cases. Plast Reconstr Surg. 2010;126:924–932.

2. Lorenzetti F, Lazzeri D, Bonini L, et al. Distally based per-oneus brevis muscle flap in reconstructive surgery of thelower leg: Postoperative ankle function and stability evalua-tion. J Plast Reconstr Aesthet Surg. 2010;63:1523–1533.

3. Eren S, Ghofrani A, Reifenrath M. The distally pedicledperoneus brevis muscle flap: A new flap for the lower leg.Plast Reconstr Surg. 2001;107:1443–1448.

4. Barr ST, Rowley JM, O’Neill PJ, et al. How reliable is thedistally based peroneus brevis muscle flap? Plast Reconstr Surg.2002;110:360–362.

5. Saydam M, Yilmaz S, Seven E. Distal peroneus brevis muscleflap. Plast Reconstr Surg. 2002;110:351.

6. McHenry TP, Early JS, Schacherer TG. Peroneus brevis ro-tation flap: Anatomic considerations and clinical experience.J Trauma 2001;50:922–926.

7. Koski EA, Kuokkanen HO, Tukiainen EJ. Distally-based per-oneus brevis muscle flap: A successful way of reconstructinglateral soft tissue defects of the ankle. Scand J Plast ReconstrSurg Hand Surg. 2005;39:299–301.

8. Yang YL, Lin TM, Lee SS, Chang KP, Lai CS. The distallypedicled peroneus brevis muscle flap anatomic studies andclinical applications. J Foot Ankle Surg. 2005;44:259–264.

9. Fansa H, Frerichs O, Schneider W. Distally pedicled pero-neus brevis muscle flap for defect coverage on the lower leg(in German). Unfallchirurg 2006;109:453–456.

10. Bach AD, Leffler M, Kneser U, Kopp J, Horch RE. Theversatility of the distally based peroneus brevis muscle flap inreconstructive surgery of the foot and lower leg. Ann PlastSurg. 2007;58:397–404.

Reply: The Versatility of the Distally BasedPeroneus Brevis Muscle FlapSir:

It was with great pleasure that we read the commentof Lorenzetti et al. on our article describing the clinicalexperience with 109 peroneus brevis flaps in variousversions and about their own use of this flap as a muscleflap. They describe their experience in using the dis-tally pedicled muscular flap as one of their standardflaps.1 We congratulate the authors for their interestingand very recent study and are delighted to hear thatthey also describe very positive results of this relativelysimple flap for many small and medium defects aroundthe ankle. This exactly parallels our experience if somedetails during dissection are followed, as described inour original article.2

We are grateful that Lorenzetti et al. reinforce ourpositive experience with the very low donor-site mor-bidity of the flap with objective data they have gatheredevaluating postoperative foot and ankle mobility withboth the Weber Demerit and the Olerud-MolanderAnkle Scores. No deterioration in either score was ob-served after having harvested the peroneus brevis flap.Using these scores on our compound osteomuscularflap cases would certainly be very interesting as soon aswe have a larger number of those skeletal reconstruc-tion cases. In providing us their experience here, theycombine the clinical experiences from both our bothgroups with a considerable number of flaps and willsurely encourage more reconstructive surgeons tochoose the peroneus brevis flap for defects in its typicalarc of rotation.DOI: 10.1097/PRS.0b013e31820a66a6

Goetz A. Giessler, M.D., Ph.D.

Andreas B. Schmidt, M.D.Department of Plastic, Hand, and Reconstructive

MicrosurgeryBG Trauma Center Murnau

Murnau, Germany

Correspondence to Dr. GiesslerDepartment of Plastic, Hand, and Reconstructive

MicrosurgeryBG Trauma Center Murnau

Professor-Kuentscher-Strasse 8Murnau 82418, Germany

REFERENCES1. Lorenzetti F, Lazzeri D, Bonini L, et al. Distally based pero-

neus brevis muscle flap in reconstructive surgery of the lowerleg: Postoperative ankle function and stability evaluation.J Plast Reconstr Aesthet Surg. 2010;63:1523–1533.

2. Schmidt AB, Giessler GA. The muscular and the new osteo-muscular composite peroneus brevis flap: Experiences from109 cases. Plast Reconstr Surg. 2010;126:924–932.


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Correction: Freestyle Pedicle Perforator Flaps:Clinical Results and Vascular Anatomy

In the article by Lecours et al. entitled “Freestyle Pedi-cle Perforator Flaps: Clinical Results and Vascular

Anatomy,” published in the November 2010 issue of theJournal (Plast Reconstr Surg. 2010;126:1589–1603), thenames of the fifth and sixth authors are spelled incor-rectly. The correct spelling of the fifth author’s name

is Emilie Mailhot, and that of the sixth author’s name isMichele Tardif (corrections in italics).

REFERENCELecours C, Saint-Cyr M, Wong C, Bernier C, Mailhot E, TardifM, Chollet A. Freestyle pedicle perforator flaps: Clinical re-sults and vascular anatomy. Plast Reconstr Surg. 2010;126:1589 –1603.

Plastic and Reconstructive Surgery PodcastsInstructions for Downloading PRS Podcasts

1) Download iTunes for free from www.apple.com/itunes/overview/.

2) After iTunes is installed, subscribe to the podcast show:• Click on Advanced on the top.• Then pick “Subscribe to Podcast.”• You will be prompted to enter a Web address. Enter this address:

http://feeds.feedburner.com/PlasReconSurgPodcast.

3) The podcast will appear under the name American Society of Plastic Surgeons.

4) Click the triangle symbol to the left of the title to see the full listing of all episodes.


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Capsular Contracture and Genetic Profile of ica Genes among Staphylococcus epidermidis Isolates from...

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